overcoming barriers and limitations – why this new journal is needed editorial overcoming barriers and limitations – why this new journal is needed winfried rief a, cornelia weise a [a] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2019, vol. 1(1), article e32600, https://doi.org/10.32872/cpe.v1i1.32600 published (vor): 2019-03-29 corresponding author: cornelia weise, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. e-mail: weise@uni-marburg.de highlights • introducing the new journal clinical psychology in europe (cpe). • overcoming artificial barriers by focusing on evidence instead of traditions. • bridging the gap from basic experimental to treatment-related research. • supporting open science recommendations. • covering a broad variety of research efforts. • full open access but no publication fees. we warmly welcome you to the reading of our newly founded journal clinical psychology in europe – cpe! most of us receive requests to submit a manuscript to some obscure new journal just about every day. and today you are holding another new journal in your hands and may – with good reason – be wondering whether it is really necessary to launch a new jour‐ nal given the numerous existing options for submissions. our resounding answer is: yes, we need this journal “clinical psychology in europe” (cpe). not because we feel the need to add another obscure new journal to the field, but because we are keen to have a journal that is committed to encouraging a modern and self-critical discussion in the scientific community, to have a journal that is open-minded about topics considered for publication, to have a journal that increases the visibility of our field of research and to have a journal that provides innovative ideas for future re‐ search in clinical psychology. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i1.32600&domain=pdf&date_stamp=2019-03-29 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ cpe aims to face several challenges in the field of clinical psychology: a first challenge stems from the past, when clinical psychology limited its power and potential to influence society with tensions and artificial barriers between traditions, es‐ pecially between traditions of psychotherapy (“schools”). to face this challenge, cpe is clearly committed to evidence-based treatments, inde‐ pendent of their traditional roots. we encourage all innovations that attempt to overcome these kinds of barriers, we aim to integrate different approaches, and to find a common language in clinical psychology. although science thrives on critical debates, we should aim to have these constructive debates inside our community – while acting as one pow‐ erful group for societal aims. secondly, it is all too often forgotten that clinical psychology is not limited to treat‐ ment. the fruitful exchange between basic approaches, mechanistic and experimental re‐ search, diagnostics and classification, epidemiology and interventional research is the ba‐ sic motor of our science. interventions without links to basic sciences are isolated appli‐ cations, but not serious fields of research. relating the different fields of clinical psychol‐ ogy to each other, but also with the progress of other areas such as neuroscience, emo‐ tion regulation, learning, social interaction, and many others, creates the cross-links that characterize top scientific fields. accordingly, in cpe we aim to provide a balanced ratio of articles reporting on basic, mechanistic, and experimental research in clinical psychology, research from associated areas, such as neuroscience, behavioral medicine, or health psychology and articles pre‐ senting treatment-related issues. our goal is to stimulate interdisciplinary exchange and understanding. a third critical challenge (not only for clinical psychology, but for science in general) is the risk of disseminating false positive results. clinical psychology, and in particular intervention research, is particularly prone to this threat. many psychotherapy research‐ ers are strongly identified with their favorite approaches and theories, and sometimes tend to disrespect one major rule of “good research practice”: distrust your own re‐ search, and cross-check every result critically before you attempt to publish it. this disre‐ spect is problematic as the dissemination of false positive results misleads other research‐ ers, deceives society, and leads to misallocation of resources. to face this challenge, cpe supports open science endeavors. we do not consider cur‐ rent proposals for open science as the final result of these discussions, but as a process during which we should try and evaluate different approaches to continuously improve the validity of published results. our supporting publisher “leibniz institute for psychol‐ ogy information (zpid)” provides several tools to improve open science, for example lit‐ erature databases, archives for data-sharing, repositories, support for study planning or pre-registration (https://www.leibniz-psychology.org/en/). fourth, it is our impression that there is extensive knowledge around, but this knowl‐ edge does not always reach the scientific community. given the pressure to 'publish or overcoming barriers and limitations 2 clinical psychology in europe 2019, vol.1(1), article e32600 https://doi.org/10.32872/cpe.v1i1.32600 https://www.leibniz-psychology.org/en/ https://www.psychopen.eu/ perish', many researchers focus on submitting empirical research articles. journals wel‐ come these manuscripts and only rarely allow for updates or general overviews. accord‐ ingly, there are limited opportunities for experts to share knowledge they have accumu‐ lated over several years of work in a specific field. to reflect the broad variety of research efforts, cpe provides the opportunity to sub‐ mit different types of articles. for empirical research, the typical research articles can be submitted. however, we also encourage submitting scientific updates on the current knowledge of a field in which experts can share their current summaries with all of us. the same holds true for the publication of other expertise or events, such as inaugural speeches or keynote lectures, which are characterized by thorough preparation. cpe can help to further disseminate this knowledge using the format of state-of-the-art over‐ views. to meet our goal of providing a platform of exchange, cpe further encourages au‐ thors to report latest developments (such as new technical applications or recently devel‐ oped questionnaires) as well as topics related to politics and education in the field of clini‐ cal psychology. for example, the description of different legal regulations for clinical psy‐ chology and psychological interventions might inform and stimulate the development of such regulations in different countries. and finally, we face a challenge in meeting the major societal aim of research: dis‐ seminate it for the benefit of others and let others make use of it. this is why journals exist and why we meet at conferences. however, many journals have developed a life of their own with financial benefit becoming more and more relevant. as we are convinced that the decision about publication should not depend on whether authors can afford to pay substantial article processing charges we are delighted that – thanks to the support of leibniz institute for psychology information – our aim of not charging any publica‐ tion costs for articles has become reality! we welcome your submissions at https://cpe.psychopen.eu and we are looking for‐ ward to collaborating with you! now enjoy reading the first issue of cpe and get in‐ spired. winfried rief, editor in chief, and cornelia weise, managing editor rief & weise 3 psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. www.leibniz-psychology.org https://cpe.psychopen.eu https://www.leibniz-psychology.org/ https://www.psychopen.eu/ competences of clinical psychologists politics and education competences of clinical psychologists eaclipt task force on “competences of clinical psychologists” clinical psychology in europe, 2019, vol. 1(2), article e35551, https://doi.org/10.32872/cpe.v1i2.35551 received: 2019-04-18 • accepted: 2019-06-07 • published (vor): 2019-06-28 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: winfried rief, ph.d., professor of clinical psychology and psychotherapy, university of marburg, marburg, germany. e-mail: rief@uni-marburg.de abstract background: politicians, societies, stakeholders, health care systems, patients, their relatives, their employers, and the general population need to know what they can expect from clinical psychologists. even more, for our self-definition as a professional group, we should share a common understanding of the competence profile that characterises our qualifications. this understanding of the competence profile of clinical psychology leads directly to the content that should be taught in university curricula and postgraduate trainings for clinical psychology. the following discussion paper attempts to offer a general european framework for defining the competence profile of clinical psychologists. method: a group of european specialists developed this discussion paper under the umbrella of the european association of clinical psychology and psychological treatment (eaclipt). representatives with different treatment orientations, of basic science and clinical applications, and from east to western european countries, were part of the group. results: we present a list of competences that should be acquired during regular studies of psychology with a clinical specialisation. additionally, further competences should be acquired either during studying, or during postgraduate trainings. conclusion: clinical psychologists are experts in mental and behavioural disorders, their underlying psychological, social and neurobiological processes, corresponding assessments/ diagnostic tools, and evidence-based psychological treatments. while we provide a list with all competences of clinical psychologists, we do not consider this proposal as a final list of criteria, but rather as a living discussion paper that could be updated regularly. therefore, we invite our colleagues to contribute to this discussion, and to submit comments via email to the corresponding author. keywords competences, clinical psychology, psychotherapy, mental disorders this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i2.35551&domain=pdf&date_stamp=2019-06-28 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • people need to know what they can expect from clinical psychologists. • we present a list of competences that clinical psychologists acquire during their training. • this list of competences was developed by colleagues representing different treatment orientations, different european countries, and basic versus clinical scientists. • this competence list can represent a basis for optimising education and training programmes for clinical psychologists, and for informing the public. competence lists are increasingly important for the self-definition of a profession, for the planning of study and training curricula, and for the public view on a professional field. politicians, societies, stakeholders, health care systems, patients, their relatives, their em‐ ployers, and the general population need to know what they can expect from clinical psychologists. for our self-definition as a professional group, we should share a common understanding of the competence profile that characterises our qualifications. this un‐ derstanding of the competence profile of clinical psychology leads directly to the content that should be taught in university curricula and postgraduate training for clinical psy‐ chology. therefore, competence lists can be considered as an interactive aspect of the progress of a profession: first, they are developed based on current understanding, reality, experiences, and concepts, but vice versa, the list of competences can be used to develop and improve existing training curricula to better focus on an optimised education of these necessary competences. this interaction is outlined in figure 1. figure 1. how competence profiles, current practice and education inform each other. competences of clinical psychologists 2 clinical psychology in europe 2019, vol.1(2), article e35551 https://doi.org/10.32872/cpe.v1i2.35551 https://www.psychopen.eu/ how competence profiles stimulate the progress of a profession many activities exist to develop and improve competence lists for clinical psychologists and psychotherapists. however, many of them are limited to specific nations (bartolo, 2005) or to specific psychotherapeutic orientations (sburlati, schniering, lyneham, & rapee, 2011). in the context of the iapt programme in uk, the university college of london developed competence frameworks for specific treatment modalities and their supervision (roth & pilling, 2008). they also provided competence profiles for different clinical groups, and clinical contexts (ucl.ac.uk/core/). these kinds of competence lists serve to quality assurance, but also to ethical evaluations (lane, 2011). some attempts used qualitative methods to approach the field (nodop & strauß, 2014), and differentiated scientific-conceptual competences, personal, and interpersonal competences. compe‐ tence lists also play a role in the development of national legal regulations for psycholo‐ gists and psychotherapists (willutzki, fydrich, & strauß, 2015). the aim of this article was to develop and present a european framework of compe‐ tence profiles for clinical psychologists that should be valid for all evidence-based treat‐ ment orientations in all european countries. therefore, we used the framework of the european association of clinical psychology and psychological treatment (eaclipt) to establish a work group representing different european countries and their national spe‐ cialties, different treatment orientations, the broad range from basic to applied science, but also further aspects of diversity. the proposal was further evaluated and approved by the eaclipt board members. here we present the first version of the european compe‐ tence list of clinical psychologists. competences of clinical psychologists clinical psychologists are experts in mental and behavioural disorders, the continuum from mental health to disease, psychological and psychobiological mechanisms of mental and behavioural disorders and physical diseases, epidemiological and health economic relevance of mental and behavioural disorders, vulnerability and resilience factors of psy‐ chological health, and evidence-based treatments for mental disorders and psychological factors of physical diseases. clinical psychologists are engaged in diagnosing, treating and scientifically investigating mental and behavioural disorders and psychological fac‐ tors of physical diseases within a bio-psycho-social and developmental framework. they plan, conduct, and evaluate activities to promote mental and behavioural health on a sci‐ entific basis in prevention, treatment and rehabilitation. they do not only apply current scientific knowledge, but they are also able to work with new complex problems and pro‐ fessional challenges, in a permanently changing environment. they have the competence eaclipt task force on “competences of clinical psychologists” 3 clinical psychology in europe 2019, vol.1(2), article e35551 https://doi.org/10.32872/cpe.v1i2.35551 https://www.psychopen.eu/ to support the scientifically-driven progress of the field, and to permanently integrate the latest scientific findings into their work. list of competences more detailed competences of clinical psychologists are: a) general psychological processes in health and disease clinical psychologists are experts in identifying and describing psychological, psychosocial, psychobiological and neuroscientific aspects of normal and abnormal human behaviour and experiences, hereby considering the whole life span. they have expertise in analysing the role of cognitive processes such as perception, learning, memory, language, of emotional and motivational processes, in developmental psychology and developmental psychopathology of the whole life span, of the biological basis of human experiences and behaviour, individual differences and dimensions of personality, and they can identify the social and cultural influences on normal and abnormal behaviour and experiences. they are familiar with scientifically sound models to better understand normal and abnormal behaviour, and can apply them to understand and treat psychological problems across life span. b) mental and behavioural disorders and psychological processes in physical disorders clinical psychologists are experts in informing the public, political stakeholders, institutions, affected people and their relatives about psychological problems and mental disorders, their varying appearances, and how to classify them. they can also identify psychological and psychosocial aspects of physical diseases. they are able to detect, diagnose, classify and describe mental disorders and psychological processes of physical diseases, using observational techniques, self-rating scales, expert ratings and other evaluated assessment tools. clinical psychologists reflect on cultural, societal and historical relativism in diagnosing mental and behavioural disorders and continually contribute to the development of international classification systems. c) psychological diagnostics clinical psychologists are able to develop, evaluate, employ, analyse, and report results of diagnostic tools to improve the objectivity, reliability and validity of diagnosing psychological, psychosocial and neurobiological aspects of mental and behavioural disorders and psychological mechanisms relevant in physical diseases. in their diagnostic work, they consider the continuum between healthy and clinically relevant processes, ageand socioeconomically relevant aspects, and other environmental and cultural determinants of psychological well-being and dysfunctional processes. they employ best-evidence self-rating scales, scientifically evaluated interview techniques, and other assessment tools, both for clinical competences of clinical psychologists 4 clinical psychology in europe 2019, vol.1(2), article e35551 https://doi.org/10.32872/cpe.v1i2.35551 https://www.psychopen.eu/ purposes, but also to assess personality characteristics, performance profiles, deficits, skills, and resources. d) intervention: general aspects clinical psychologists know about the different evidence-based psychological interventions, their historical development and current evidence-based evaluation. they can critically think about different treatments and can inform the public about scientifically based treatment guidelines and typical treatment characteristics, hereby considering disorder-, personand sociocultural-relevant aspect. they use scientifically-based interventions to enhance resources of the patients and clients to improve psychological well-being, and to reduce vulnerability and risk factors for psychological problems and mental and behavioural disorders. clinical psychologists can inform patients, their relatives, public institutions, stakeholders and others about the potential and risks of psychological treatments, based on a current critical scientific evaluation of them. e) prevention, rehabilitation: general academic expertise clinical psychologists are able to inform about prevention and rehabilitation programmes, their scientific evidence, and their potential use for society and specific target groups. they can develop, apply and evaluate such programmes. clinical psychologists can promote mental and behavioural health and develop mental health literacy in various settings. f) scientific methodology clinical psychologists can use qualitative and quantitative approaches to investigate psychological, psychobiological and psychosocial processes and clinical applications to better understand normal and abnormal behaviour and experiences. they are able to plan, conduct and analyse the results of studies using modern criteria for scientific evaluations and advanced statistical modelling. in particular, clinical psychologists are able to plan, conduct, analyse, report and explain clinical trials and their results, to evaluate psychological interventions according to modern scientific standards. they are also able to understand and use methods and results from developmental, cognitive and experimental psychology, or from any other field related to scientific psychology important for the understanding of the aetiology, maintenance and treatment of mental and behavioural disorders. they know methods and central elements of psychotherapy and psychological intervention research, and how to incorporate that knowledge into their clinical practice. they actively take part in psychological intervention and psychotherapy research by developing research questions, designs and treating patients in clinical trials. g) ethical and legal aspects clinical psychologists consider and respect current ethical standards and legal regulations for their professional work. clinical psychologists are sensible regarding cultural diversity and respect it in their work with clients. eaclipt task force on “competences of clinical psychologists” 5 clinical psychology in europe 2019, vol.1(2), article e35551 https://doi.org/10.32872/cpe.v1i2.35551 https://www.psychopen.eu/ depending on national regulations, the following skills are either acquired dur‐ ing university studies, or during postgraduate trainings often connected to the term psychotherapy: h) skills for psychological interventions: meta-competences • clinical psychologists are able to provide psychological interventions that follow treatment aims and a treatment plan, based on current scientific knowledge about mental and behavioural disorders and interventions. major competences to provide interventions have been acquired according to current standards of learning how to practise these interventions. • clinical psychologists are able to motivate patients to engage in psychological interventions, and to foster and maintain a good alliance with their clients/ patients, their relatives and significant others. they can explain the intervention rationale to patients, other health care specialists, and further involved people. • clinical psychologists have the competence for perspective taking, empathy and mentalisation. they have professional skills to identify the diversity of verbal and nonverbal communication signals of others. they have professional competences to communicate with others, based on a broad variety of acquired communication skills, even during difficult communication sequences, or with patients with difficult communication patterns. they can verbally address emotional, cognitive, behavioural and interactive aspects of the patient’s/client’s behaviour. • clinical psychologists have an advanced ability to regulate their own emotions and behaviour, and to reflect their own emotions, cognitions, and behaviour during professional encounters. they can reflect the consequences of past learning and socialisation processes on current behaviour and experiences, not only in others, but also in themselves. they can cope with professional stressful situations, but are able to relax and plan their life according to an adequate work-life-balance. • clinical psychologists are able to evaluate on-going interventions of themselves or of others, to detect unfavourable or unexpected events, and to react adequately in the event of occurring risks (e.g., suicidality). they are able to address treatment problems (e.g. adherence problems of patients) and problems of the therapeutic relationship accordingly. they are able to use the patient’s/client’s feedback to adapt intervention processes. • when confronted with new problematic professional situations, they have concepts about how to develop new problem-solving strategies, based on a profound framework theory how to plan interventions. • clinical psychologists are able to end interventions in a planned manner, to plan for long-term maintenance of treatment gains, and to reduce the risk of relapse after the intervention. competences of clinical psychologists 6 clinical psychology in europe 2019, vol.1(2), article e35551 https://doi.org/10.32872/cpe.v1i2.35551 https://www.psychopen.eu/ • clinical psychologists aim to continuously improve their professional abilities. they are able to learn from their own and other experiences, from supervision and intervision, and to transfer current scientific knowledge to clinical practice and to integrate recommendations of others (e.g. supervisors) in their clinical work. • clinical psychologists are able to communicate with other health-professionals, and to coordinate their diagnostic and intervention plans with other experts involved in the overall treatment plan. i) skills for psychological interventions: disorder-, person-, and contextspecific diagnostics and interventions following recommendations of official scientifically based guidelines, clinical psychologists can select evidence-based diagnostic tools and evidence-based psychological interventions for specific mental and behavioural disorders and psychological aspects of physical diseases. for treatment planning, they consider the different severity degrees and courses of mental and behavioural disorders, the comorbidity profiles, further associated problems, the patient’s and setting’s resources, as well as cultural aspects. j) skills for psychological interventions: prevention, rehabilitation clinical psychologists are able to prepare, conduct, and evaluate clinical prevention and rehabilitation programmes according to current scientific standards. they have public relation skills to present programmes and persuasive skills to promote the relevance of the programmes to significant stakeholders. k) skills for psychological interventions: setting-specific interventions, modern technologies clinical psychologists are able to provide professional, scientifically based work with individuals, with couples, with families, and in groups. they can provide expert knowledge and they have the ability to work in complex systems (e.g., hospitals, occupational health services, political institutions). they are aware of options to increase effectivity, reachability, and benefit-cost-ratios for providing clinical psychological interventions also by using modern technologies. l) skills for psychological interventions: documentation, evaluation clinical psychologists continuously document and evaluate their work. they consider aspects of quality insurance. conclusion we provide a first list with the characterising competences of clinical psychologists that aims to cover the needs of all european nations, but also of representatives of different specialisations and orientations of clinical psychology. however, we do not consider this proposal as an exhaustive list of criteria, but as a living discussion paper that could be eaclipt task force on “competences of clinical psychologists” 7 clinical psychology in europe 2019, vol.1(2), article e35551 https://doi.org/10.32872/cpe.v1i2.35551 https://www.psychopen.eu/ updated regularly. therefore, we invite our colleagues to contribute to this discussion, and to submit comments via email to the corresponding author. funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. author note: members of the eaclipt task force on “competences of clinical psychologists” and the eaclipt board which has approved this proposal are: gerhard andersson, natasa jokic begic, claudi bockting, roman cieslak, celine douilliez, thomas ehring, philipp kanske, andreas maercker, agnieszka popiel, winfried rief, chantal martin soelch, svenja taubner. references bartolo, p. a. (2005). regulating the psychology profession in malta. european psychologist, 10(1), 76-77. https://doi.org/10.1027/1016-9040.10.1.76 lane, d. (2011). ethics and professional standards in supervision. in t. bachkirova, p. jackson, & d. clutternuck (eds.), coaching and mentoring supervision: theory and practice (pp. 99–104). maidenhead, united kingdom: open university press. nodop, s., & strauß, b. (2014). kompetenzbereiche in der psychotherapeutischen ausbildung. zeitschrift für klinische psychologie und psychotherapie, 43(3), 171-179. https://doi.org/10.1026/1616-3443/a000272 roth, a. d., & pilling, s. (2008). a competence framework for the supervision of psychological therapies. retrieved august, 18, 2011 from www.ucl.ac.uk/core/. sburlati, e. s., schniering, c. a., lyneham, h. j., & rapee, r. m. (2011). a model of therapist competencies for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders. clinical child and family psychology review, 14(1), 89-109. https://doi.org/10.1007/s10567-011-0083-6 willutzki, u., fydrich, t., & strauß, b. (2015). aktuelle entwicklungen in der psychotherapieausbildung und der ausbildungsforschung. psychotherapeut, 60(5), 353-364. https://doi.org/10.1007/s00278-015-0048-1 competences of clinical psychologists 8 clinical psychology in europe 2019, vol.1(2), article e35551 https://doi.org/10.32872/cpe.v1i2.35551 https://doi.org/10.1027/1016-9040.10.1.76 https://doi.org/10.1026/1616-3443/a000272 https://doi.org/10.1007/s10567-011-0083-6 https://doi.org/10.1007/s00278-015-0048-1 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. eaclipt task force on “competences of clinical psychologists” 9 clinical psychology in europe 2019, vol.1(2), article e35551 https://doi.org/10.32872/cpe.v1i2.35551 https://www.psychopen.eu/ competences of clinical psychologists (introduction) how competence profiles stimulate the progress of a profession competences of clinical psychologists list of competences conclusion (additional information) funding competing interests acknowledgments author note references the european association of clinical psychology and psychological treatment (eaclipt): a new organization for the future! editorial the european association of clinical psychology and psychological treatment (eaclipt): a new organization for the future! gerhard andersson ab [a] department of behavioural sciences and learning, linköping university, linköping, sweden. [b] department of clinical neuroscience, karolinska institute, stockholm, sweden. clinical psychology in europe, 2019, vol. 1(1), article e33241, https://doi.org/10.32872/cpe.v1i1.33241 published (vor): 2019-03-29 corresponding author: gerhard andersson, department of clinical neuroscience (cns), k8, cpf kcp, liljeholmstorget 7b plan 6 117 63 stockholm, sweden. e-mail: gerhard.andersson@liu.se the european association of clinical psychology and psychological treatment (eaclipt) was founded in 2017 with representatives of many european countries. at its launch, many people were surprised to hear that such an organization did not already exist given the role of clinical psychology both as a branch of psychology and psycholog‐ ical research, but also as a renowned profession. we knew several national organizations existed for clinical psychologist practitioners and researchers across europe, as well as european and international organizations for various subdisciplines of psychology and forms of psychotherapy. but we regarded the absence of a targeted organization for europe as a serious omission. thus, the eaclipt aims to strengthen science, practice and political representation in relation to clinical psychology. in this editorial we will briefly describe the aims of the eaclipt and also our ach‐ ievements to date. finally, we will outline our wishes for the future. the eaclipt’s aims are broad. we want to foster research, education and dissemina‐ tion of scientifically evaluated findings, and address the following topics: • diagnostics and classification of mental health conditions • psychological and psychobiological mechanisms of health and disease • psychological treatments, psychotherapy • prevention and rehabilitation • healthcare issues in mental health conditions this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i1.33241&domain=pdf&date_stamp=2019-03-29 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ • dissemination and implementation of evidence-based psychological treatments • education in clinical psychology • representation of clinical psychology in politics across europe. although the eaclipt focuses on clinical psychology, we are also dedicated to both re‐ search and practice. it is, however, by no means an organization exclusively for clini‐ cians, since we also have a strong interest in the status of clinical psychology as a re‐ search area and as an important profession from a policy perspective. thus, policy and research are regarded as more urgent areas for eaclipt to focus on than the actual prac‐ tice of clinical psychology. the latter has many national and international organizations and, when it comes to psychotherapy brands, also several psychotherapy organizations. the eaclipt is needed right now for several reasons. first, we believe that clinical psychology is more than psychotherapy. second, the world, and indeed europe, is shrink‐ ing as practitioners and patients move across borders. this requires european-wide standards both in research and in clinical practice, and also cross-border collaboration. the profession of clinical psychology is also expanding into medicine and healthcare in general. this necessitates research into disorders and health problems that have often been regarded as extraneous to psychology. good practice in research and clinical tasks demand that we define quality criteria for training in and provision of clinical psycholog‐ ical healthcare, and that we improve comparability of training programs in european countries. what have we done so far? following our initial gathering in amsterdam, the nether‐ lands, in 2017, we arranged a small closed inaugural conference in linköping, sweden, in 2018. in between those two meetings we formed a board which then convened in am‐ sterdam. we also had regular monthly board meetings by phone and developed a website www.eaclipt.org. and, as you can see, the journal was initiated and launched its first is‐ sue in 2019. the board has also actively sought to recruit members, find national representatives and attend important meetings at eu-level (e.g., parliament). we have also had to deal with numerous practical matters that accompany an organization’s launch. we have also initiated a newsletter. although the exact number of our members is unknown at this ed‐ itorial’s publication, membership topped 400 at the time of writing. we have also began planning for our first conference. the first european congress of the eaclipt will be held in germany, dresden, 31 oct 02 nov 2019, under the topic: “no health without mental health: european clinical psychology takes responsibility”. finally we should mention our expectations. we hope that the eaclipt will help ad‐ vancing the field of clinical psychology and all connected academic and clinical fields in europe. we expect clinical psychology to be even more relevant in the future than it is today. clinical psychology has already had a favourable impact on the treatment of men‐ tal health conditions and, increasingly, other health problems too. this has been driven the eaclipt: a new organization for the future! 2 clinical psychology in europe 2019, vol.1(1), article e33241 https://doi.org/10.32872/cpe.v1i1.33241 http://www.eaclipt.org https://www.psychopen.eu/ by progress in research. but it is not enough just to know what works when it comes to clinical problems (including both assessment and treatment procedures). we also need to make an effort to disseminate that knowledge, not least at policy level. finally, we hope that the profession of both researchers and clinicians (sometimes the same person serv‐ ing in both functions) will benefit from the eaclipt and that we will manage to develop policy documents and research collaborations across europe. gerhard andersson, president eaclipt further board members: claudi bockting, roman cieślak, céline douillez, thomas ehring, andreas maercker, winfried rief andersson 3 psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. www.leibniz-psychology.org https://www.leibniz-psychology.org/ https://www.psychopen.eu/ education and training in clinical psychology and psychological psychotherapy in switzerland politics and education education and training in clinical psychology and psychological psychotherapy in switzerland marius rubo a, chantal martin-soelch b, simone munsch a [a] clinical psychology and psychotherapy, department of psychology, university of fribourg, fribourg, switzerland. [b] clinical psychology and health psychology, department of psychology, university of fribourg, fribourg, switzerland. clinical psychology in europe, 2020, vol. 2(3), article e2991, https://doi.org/10.32872/cpe.v2i3.2991 received: 2020-03-24 • accepted: 2020-07-15 • published (vor): 2020-09-30 handling editor: anton-rupert laireiter, university of vienna, vienna, austria corresponding author: marius rubo, clinical psychology and psychotherapy, department of psychology, university of fribourg, 2, rue de faucigny, ch-1700 fribourg/ switzerland. tel.: +41 26 300 76 61. e-mail: marius.rubo@unifr.ch abstract switzerland offers education in clinical psychology in the german and french language and training in psychotherapy in german, french and italian. both education and training are structured along centralized guidelines and recognized at a federal level. after finishing one’s studies, becoming a psychological psychotherapist requires between two and six years of postgraduate training and a financial investment of tens of thousands of swiss francs. historically, it is quite common for swiss psychotherapy trainings to incorporate a mix or combination of several psychotherapy schools such as cognitive behavioral, psychodynamic, systemic and humanistic. foreign degrees obtained in eu countries are generally recognized, and the fulfillment of criteria is evaluated on an individual basis. graduates find a diverse job market with opportunities to work in clinics and psychotherapeutical practices, but the absence of direct reimbursement via mandatory health insurance plans for psychological psychotherapists (not psychiatrists) lead many to work on patients’ private payments or as a psychiatrist’s employee. the ordering model, a potential new regulation allowing for the direct reimbursement of psychological psychotherapists’ work, is planned to be decided upon throughout 2020. keywords education in clinical psychology, psychotherapy training, switzerland, employment models, reimbursement, ordering model this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i3.2991&domain=pdf&date_stamp=2020-09-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • switzerland offers education in clinical psychology in german and french. • trainings in psychological psychotherapy often incorporate content from various psychotherapy schools. • degrees obtained in eu countries can be acknowledged. • several employment models exist for psychological psychotherapists, and the profession hopes to see improvements in the reimbursement situation throughout this year. education in clinical psychology goals in switzerland – a federal parliamentary republic consisting of four broad geographic and language regions and of 26 cantons – private and state universities as well as universities of applied sciences are centrally evaluated by the governmental institution swissuniversities (www.swissuniversities.ch). altogether 12 universities are currently ac‐ credited and fulfill the criteria of the federal higher education law (hochschulförderungsund koordinationsgesetz, hfkg) and six of them (universities of basel, bern, fribourg, geneva, lausanne and zurich, but also the zurich university of applied sciences) offer education programs in clinical psychology in german or french language. the universi‐ ty in fribourg furthermore offers a bilingual curriculum (german-french) with courses in english. similar to most countries in europe, the swiss education in clinical psychology includes a three years’ bachelor and a two years’ master program. the bachelor pro‐ gram includes basics of psychology such as human cognition, experimental psychology, personality, development, emotions, and psychopathology. subsequent master programs in clinical psychology focus on psychopathological and related biological processes, knowledge on evidence-based diagnostic and interventions and more strongly emphasize the ability to critically assess and process the scientific literature in the field. these skills allow students to pursue careers both in clinical settings (and particularly to pursue a federally accredited postgraduate training in psychotherapy or health psychology) as well as in research. a master diploma in psychology leads to the title “psychologist” that is recognized at federal level. contents, structure and costs the contents of bachelor programs in psychology and master programs in clinical psy‐ chology are similarly structured and comparable across all swiss universities according to the guidelines of the konferenz der schweizer psychologie-institute (k-psych), which will be updated in june 2020. bachelor programs include three years of studies and training in psychotherapy in switzerland 2 clinical psychology in europe 2020, vol.2(3), article e2991 https://doi.org/10.32872/cpe.v2i3.2991 http://www.swissuniversities.ch https://www.psychopen.eu/ 180 ects, while master programs consist of two years of studies and 120 ects. a two-month full time practical experience which is mandatory in master programs can be completed in clinical settings, but also in research groups. evaluation the bachelor program in psychology includes three consecutive years of studies. after the first year, students are required to pass written propaedeutic exams (except at the fernuni, zhaw and fhnw). subsequent examinations during the second and third year are individually organized by the universities and include oral and written exams as well as written essays or presentations. costs swiss universities open all their education programs for a semester fee from chf 500 up to chf 1300 (swissuniversities, n.d.). granting of studentships depends on the parental income and eligibility is usually organized by the canton of domicile of the student. legal framework swiss education in psychology, clinical psychology and psychotherapy in 2013, the law on psychology professions (bundesamt für gesundheit [bag], 2020a, psyg/lpsy) was introduced with the overall purpose of reinforcing public health and protecting customers and people in need for psychological opinion, counseling or treat‐ ment from fraud. with the new law, the title “psychologist” is now protected in switzer‐ land. obtaining a master degree in clinical psychology in switzerland qualifies students to enter accredited postgraduate specialized trainings in neuropsychology, psycholog‐ ical psychotherapy, health psychology, clinical psychology and children and youth psychology. these are the 5 specialized post-graduate titles defined in the psyg/lpsy. all swiss postgraduate trainings are evaluated and accredited by the federal commission on psychology professions (bag, 2019b). this commission also evaluates and decides the recognition of foreign degrees. following the implementation of the psyg in 2013 and until end of 2018, all existing training programs in psychological psychotherapy from different stakeholders in switzerland underwent an evaluation process, which is required to be repeated every seven years, under the lead of the commission of psychology professions. rubo, martin-soelch, & munsch 3 clinical psychology in europe 2020, vol.2(3), article e2991 https://doi.org/10.32872/cpe.v2i3.2991 https://www.psychopen.eu/ recognition of foreign degrees relying on the swiss-eu bilateral agreement on the free movement of persons (afmp), switzerland has adopted the eu’s system of mutual recognition of professional qualifica‐ tions (state secretariat for education, resarch and innovation [seri], n.d.), in which a university degree or a degree from a university of applied science from abroad is recognized if it is acknowledged in the country of origin. nonetheless, each application is evaluated on an individual basis and additional requirements may be determined before a title is validated as equivalent. requests from countries outside of europe are processed equally. as switzerland is relatively unique in europe in requiring 5 years of advanced training, additional parts of training regularly have to be caught up here. register of psychology professions psychologists with a title in psychological psychotherapy (and any other postgraduate training accredited by the federal department of health as e.g. child and youth psychol‐ ogist, neuropsychologist, health psychologist and clinical psychologists) are obliged to enlist in the register of psychology profession (bag, 2020b). in the case of psychological psychotherapists, the list includes information about whether the person is entitled to autonomously offer psychotherapeutic treatment. the register aims at increasing the transparency of offers across cantons and to ensure the quality of treatment offers to the swiss inhabitants. the completion of the register is currently still ongoing. training in psychological psychotherapy diverse options for therapy trainings in switzerland, different institutions offer training programs in psychological psycho‐ therapy. in 2013, after the introduction of the psyg/lpsy, a total of 62 postgraduate curricula in psychological psychotherapy were accredited temporarily until 2018, which means that these diplomas were recognized by the government independent of an evalu‐ ation according to the before mentioned conditions. these psychotherapy training offers were diverse and encompassed cognitive-behavioral, humanistic, psychodynamic and systemic approaches. until 2019, 41 of these initial programs have been accredited by the federal department of health. currently, three german universities, two french uni‐ versities, one german/french university and the zhaw university of applied sciences from switzerland offer a total of 12 postgraduate psychotherapy trainings for applicants holding an accredited master's degree. the remaining 29 postgraduate psychotherapy trainings are offered outside the university. of the 41 psychotherapy trainings, the following therapy schools are represented: (1) 8 in cognitive behavioral therapy; (2) 11 in psychoanalytic therapy; (3) 10 in systemic therapy; (4) 4 in humanistic methods; (5) training in psychotherapy in switzerland 4 clinical psychology in europe 2020, vol.2(3), article e2991 https://doi.org/10.32872/cpe.v2i3.2991 https://www.psychopen.eu/ 8 in various mixed forms and integrative approaches. notably, it is common for the abovementioned programs to incorporate content from other “schools”. in switzerland, adult and child/adolescent psychotherapy are currently not consid‐ ered to be separate psychological professions by law. therefore, a postgraduate diploma in psychological psychotherapy entitles psychotherapists to offer treatment to the full age range. nevertheless, some training programs focus more on adults whereas others focus explicitly on children, adolescents and young adults. goals postgraduate trainees are expected to have established a profound understanding of human experience and behavior as well as their biological underpinnings during the bachelor and master program in clinical psychology. they are already skilled to assess and evaluate complex human experience and behavior in diverse developmental stages and psychosocial contexts. building on these skills, postgraduate trainings in psychologi‐ cal psychotherapy (ppt) then teach to autonomously offer and evaluate psychotherapeu‐ tic treatment. specifically, trainees learn to employ evidence-based psychotherapeutic theories, techniques and methods, reflect professional activities based on theoretical and practical expertise and reflecting societal and legal aspects, cooperate with other health experts, respect cost-efficiency in their professional activities, and others. contents and structure altogether, obtaining the title of a psychological psychotherapist requires between four and six years of fulltime postgraduate training and is prolonged if the training is executed in part time. resulting in a sum of 5430 units (one unit equals 45 minutes), the training consists of theory and competences (500 units), supervision (at least 150 units, 50 of which in a single setting), self-experience (at least 100 units, 50 of which in a single setting), individual and practical experiences under supervision (at least 500 units, with at least 10 case reports), and altogether at least 2 years of fulltime practical experiences in an institution of primary psychosocial health care, with at least one year in psychotherapeutic or psychiatric primary health care (edi, 2016). in case of part time employment, the duration is automatically prolonged. no less than 50% part time employment is allowed. these are basic and mandatory requirements. most institutions offering psychotherapeutic training ask for more hours than legally required, especially for more units of theory and practical competence training. evaluation at the end of postgraduate trainings in psychological psychotherapy, the responsible teaching and supervising experts of the program examine the trainees’ theoretical and clinical competences and evaluate whether all units have been acquired. during the rubo, martin-soelch, & munsch 5 clinical psychology in europe 2020, vol.2(3), article e2991 https://doi.org/10.32872/cpe.v2i3.2991 https://www.psychopen.eu/ training process, supervisors and experts repeatedly comment on the trainee’s professio‐ nal development and their patients’ therapeutic processes and discuss the trainees’ case reports examination procedures during or at the end of the program depend on the individual institute offering the postgraduate training and may include oral or written theoretical exams and oral exams on case reports of the trainees. costs the total costs of postgraduate psychotherapy training vary strongly, ranging from a minimum of 35200 chf to a maximum of 91700 chf. number of psychologists and psychotherapists according to the most recent representative survey initiated by the swiss federation of psychologists (fsp, https://www.psychologie.ch; stettler, stocker, gardiol, bischof, & künzi, 2013) in 2012, switzerland counted 15 000 psychologists or 1.8 psychologists per 1000 inhabitants, while there were 0.4 fulltime working psychological psychotherapists per 1000 inhabitants. in 2012, 32% of all psychological psychotherapists reported working according to the psychoanalytic, 19% to the cognitive-behavioral, 17% to the humanistic and 12% to the systemic orientation, and an additional fraction reported to adhere to multiple schools (grosse holtforth, kramer, & dauwalder, 2015). in 2019, around 8600 (79% female) students were enrolled in psychology at a swiss university (not including phd students and persons pursuing postgraduate trainings (bundesamt für statistik, 2019). after the implementation of the law on psychology professions, from april 2013 until december 2019, a total of 2218 degrees in psychology and 359 degrees in psychotherapy from abroad have been accredited. altogether 80% of these candidates had pursued their education and psychotherapy training in italy, germany, france, portugal and in austria. the remaining 20% applications came from south america and from mid and eastern europe (bag, 2020c). advanced training for psychotherapists after receiving a diploma in psychological psychotherapy from an accredited training program, psychotherapists are obliged to participate in regular advanced trainings in order to refresh and renew their theoretical and practical competences. nevertheless, up to date, neither contents nor hours of advanced training have been defined. trainings in other specialization titles for neuropsychology, there is one accredited curriculum in french and one accredi‐ ted training in german, offered in collaboration between universities and the swiss training in psychotherapy in switzerland 6 clinical psychology in europe 2020, vol.2(3), article e2991 https://doi.org/10.32872/cpe.v2i3.2991 https://www.psychologie.ch https://www.psychopen.eu/ society of neuropsychology. neuropsychologist are the only specialized psychologists reimbursed by the mandatory health insurance. for health psychology, there is at the moment only one french-speaking curriculum offered by french-speaking universities (fribourg, geneva and lausanne, leading house fribourg) in collaboration with the swiss society for health psychology under the insti‐ tutional cover of the rector conference of french-speaking universities in switzerland (the so-called triangle azur). the delivered title is a mas in health psychology, the accreditation process will begin soon. for clinical psychology, there is one french-speaking curriculum offered by 3 frenchspeaking universities (geneva, lausanne and fribourg, leading house geneva) in col‐ laboration with the swiss association of clinical psychologists, also under the institu‐ tional cover of the rector conference of french-speaking universities in switzerland (the so-called triangle azur). the delivered title is a mas in clinical psychology, the accreditation process will begin soon. the swiss association of clinical psychologists offer a complete curriculum in german and one in italian, leading the title of specialist in clinical psychology recognized by the swiss federation of psychologists, but not accredi‐ ted by the federal commission on psychology professions yet. the clinical psychology specialization is particularly aimed at the employment in mental health hospitals with in-patients. for children and youth psychology, there is only one training option offered by the swiss association of children and youth psychologists, that is not accredited yet. employment situation for psychological psychologists in switzerland psychotherapy in the swiss health system the total annual costs for health services which are reimbursed by mandatory insurances in switzerland amount to chf 9,86 billion of which 11% (chf 1,08 billion) are generated in the field of psychiatry (including psychological psychotherapy). specifically, 2.9% of the total annual health costs covered by mandatory insurances (chf 286 million) are generated by psychological services (grosse holtforth, kramer, & dauwalder, 2015). these numbers do not include the costs of psychological psychotherapy covered by private insurances or paid by patients personally. according to a study by the schweizerisches gesundheitsobservatorium, around 470,000 individuals (7% of the population above 15 years of age) sought psychotherapeutic treat‐ ment in 2009, 88% of who were treated in an outpatient and 12% in an inpatient setting (rüesch, baenziger, & juvalta, 2013). psychological psychotherapists in particular, treat 259 000 of these patients each year (stettler et al., 2013). on average, each psychological psychotherapist treats 84 patients per year, and each patient receives 29 sessions within 17 months of treatment. a majority of psychological psychotherapists reports having rubo, martin-soelch, & munsch 7 clinical psychology in europe 2020, vol.2(3), article e2991 https://doi.org/10.32872/cpe.v2i3.2991 https://www.psychopen.eu/ a wait list (59%). 43% therapists report that they do not have any current availability (stettler et al., 2013). quantitative research on treatment gaps in psychotherapy in swit‐ zerland is relatively scarce. estimates of the percentage of individuals suffering from a mental disorder who do not receive even minimal treatment range from 40% to 65% (stocker et al., 2016). the reimbursement of psychological psychotherapy in the swiss health-care system is divided into three main financing sources. firstly and most importantly, 67% of the psychotherapeutic services are reimbursed by the mandatory health insurance plans. secondly, 29% of the psychotherapeutic services are paid by the patients themselves or by their private complementary insurances, and, thirdly, 4% of the psychotherapeutic services are financed by public social services. (stettler et al., 2013). employment models for psychological psychotherapists the fact that there is so far no direct reimbursement of psychological psychotherapy by the mandatory health insurances influences the current employment models. about a third of all psychological psychotherapists work in private practice, where their patients privately pay for psychotherapeutic treatment or receive partial reimbursement via a private insurance plan. another group of psychological psychotherapists of about 40% work in so-called “delegated” practice (stettler et al., 2013). as a “delegated psychothera‐ pist” the psychological psychotherapist is an employee of and works in the rooms of a psychiatrist. according to the current legislation, this means that the psychiatrist “delegates” psychotherapy and that the psychological psychotherapist works under the psychiatrist’s legal responsibility and supervision. the psychiatrist gets reimbursed for the psychotherapy provided by the psychologist via mandatory basic insurance plans. the payment of the psychological psychotherapists varies from employer to employer (psychiatrist). strikingly, the reimbursement for delegated psychotherapy is only around two thirds of that for psychotherapy offered by psychiatrists. psychological psychotherapists further work in outpatient clinics within larger insti‐ tutions, where patients either pay privately (if a psychological psychologist is head of the unit), or the patients get reimbursed for their psychotherapies (if a psychiatrist is head of the clinic). finally, around 13% of psychological psychotherapists work in psychiatric hospitals and provide primary mental health care as well as psychotherapy. (possibly) better working conditions in the future the system of delegated psychotherapy is highly controversial in switzerland. it was originally implemented as a temporary solution to improve access to mental health care until the psychological profession were regulated in detail and – again supposedly temporarily treats psychological psychotherapists as auxiliary employees of psychia‐ trist-psychotherapists receiving a lesser payment. although the rationale behind the training in psychotherapy in switzerland 8 clinical psychology in europe 2020, vol.2(3), article e2991 https://doi.org/10.32872/cpe.v2i3.2991 https://www.psychopen.eu/ delegated model has become obsolete with the „law on psychology professions“ intro‐ duced in 2013, adaption has been postponed until today. remarkably, the delegation model has remained unchanged despite clearly standing at contrast with psychological psychotherapists’ official authorization to execute their profession independently and to their own full responsibility (www.psyeg.admin.ch). the law however changed the situation of neuropsychologists who are now reimbursed by the mandatory law. recently, a potential new regulation called the “ordering model” is being discussed and evaluated by the government. in the ordering model, a psychological psychotherapist would work self-employed and in his/her own office, and a physician’s prescription would suffice for the reimbursement of a limited number of psychotherapy sessions by mandatory health insurance plans. after a period of more than 7 years of internal evaluations, the federal council opened a consultation phase regarding the planned new legal regulations in july 2019 (bag, 2019a). while the federal department of health supports the new regulation, there have been heated debates since the consultation phase has been opened, most prominently between psychologists, psychiatrists and politics. as a result, the decision on the implementation of the ordering model, which was originally scheduled for early 2020, has been post‐ poned and seems unlikely to be processed in due time. funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors thank alexander ariu for his help in collecting information. references bundesamt für gesundheit (bag). 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(n.d.). semestergebühren hochschulen-2019/2020. retrieved january 16, 2020, from https://www.swissuniversities.ch/fileadmin/swissuniversities/dokumente/lehre/ hochschulraum/gebuehren.pdf training in psychotherapy in switzerland 10 clinical psychology in europe 2020, vol.2(3), article e2991 https://doi.org/10.32872/cpe.v2i3.2991 https://www.bag.admin.ch/bag/de/home/das-bag/organisation/ausserparlamentarische-kommissionen/psychologieberufekommission-psyko.html https://www.bag.admin.ch/bag/de/home/das-bag/organisation/ausserparlamentarische-kommissionen/psychologieberufekommission-psyko.html https://www.bag.admin.ch/bag/de/home/berufe-im-gesundheitswesen/psychologieberufe/faq-psyg.html https://www.bag.admin.ch/bag/de/home/berufe-im-gesundheitswesen/psychologieberufe/faq-psyg.html https://www.bag.admin.ch/bag/de/home/berufe-im-gesundheitswesen/psychologieberufe/psychologieberuferegister-psyreg.html https://www.bag.admin.ch/bag/de/home/berufe-im-gesundheitswesen/psychologieberufe/psychologieberuferegister-psyreg.html https://www.bag.admin.ch/bag/de/home/zahlen-und-statistiken/statistiken-berufe-im-gesundheitswesen/statistiken-anerkennungen-psychologieberufe.html https://www.bag.admin.ch/bag/de/home/zahlen-und-statistiken/statistiken-berufe-im-gesundheitswesen/statistiken-anerkennungen-psychologieberufe.html https://www.bfs.admin.ch/bfs/de/home/aktuell/neue-veroeffentlichungen.assetdetail.7746943.html https://www.bfs.admin.ch/bfs/de/home/aktuell/neue-veroeffentlichungen.assetdetail.7746943.html https://www.admin.ch/opc/de/classified-compilation/20132533/index.html#app1ahref2 https://doi.org/10.7202/1036093ar https://www.sbfi.admin.ch/sbfi/en/home/bildung/recognition-of-foreign-qualifications.html https://www.swissuniversities.ch/fileadmin/swissuniversities/dokumente/lehre/hochschulraum/gebuehren.pdf https://www.swissuniversities.ch/fileadmin/swissuniversities/dokumente/lehre/hochschulraum/gebuehren.pdf https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. rubo, martin-soelch, & munsch 11 clinical psychology in europe 2020, vol.2(3), article e2991 https://doi.org/10.32872/cpe.v2i3.2991 https://www.psychopen.eu/ training in psychotherapy in switzerland education in clinical psychology goals contents, structure and costs evaluation costs legal framework swiss education in psychology, clinical psychology and psychotherapy recognition of foreign degrees register of psychology professions training in psychological psychotherapy diverse options for therapy trainings goals contents and structure evaluation costs number of psychologists and psychotherapists advanced training for psychotherapists trainings in other specialization titles employment situation for psychological psychologists in switzerland psychotherapy in the swiss health system employment models for psychological psychotherapists (possibly) better working conditions in the future (additional information) funding competing interests acknowledgments references clinical psychology in lithuania: current developments in training and legislation politics and education clinical psychology in lithuania: current developments in training and legislation evaldas kazlauskas a, neringa grigutyte a [a] center for psychotraumatology, institute of psychology, vilnius university, vilnius, lithuania. clinical psychology in europe, 2020, vol. 2(1), article e2835, https://doi.org/10.32872/cpe.v2i1.2835 received: 2019-10-19 • accepted: 2020-02-13 • published (vor): 2020-03-31 handling editor: anton-rupert laireiter, university of vienna, vienna, austria corresponding author: evaldas kazlauskas, center for psychotraumatology, institute of psychology, vilnius university, ciurlionio 29-203, vilnius, lt-01300 lithuania. e-mail: evaldas.kazlauskas@fsf.vu.lt abstract this paper presents an overview of the current status in training and legislation of clinical psychology in lithuania. clinical psychology training at the university level in lithuania started soon after the collapse of the soviet union in the 1990s and was influenced by the social context and historical-political situation in the country. currently, legislation for clinical psychology in lithuania is in progress, and several promising regulations for psychology in health care were introduced in the last decade. however, psychologists, including clinical psychologists, are not licensed in lithuania. the lack of legislation for psychology is the main obstacle for the recognition and establishment of clinical psychology in the country. in health care, the title ‘clinical psychologist’ is not common; ‘medical psychologist’ is the title used instead to refer to both clinical psychologists and health psychologists. we conclude that while the development of clinical psychology in lithuania is promising, there is still a long way to go to establish clinical psychology as an important profession in lithuania. keywords lithuania, clinical psychology, legislation, training, education, policy this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i1.2835&domain=pdf&date_stamp=2020-03-31 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • university training in clinical psychology started in the 1990s after the collapse of the soviet union. • legislation for clinical psychology in lithuania is in progress and issues regarding the title and licensing of clinical psychologists are associated with the lack of regulation of psychology in the country in general. • in lithuania, the title ‘clinical psychologist’ is not used in health care, and the titles of psychologists or clinical psychologists are not protected by law. clinical psychology in the baltic states remains unknown and somewhat of a ‘white zone’ on the global map of psychology. this paper aims to present the status of clinical psychology in one of the baltic states – lithuania, with a brief overview of the training and legislation for clinical psychology in the country. the current paper is an update of the previous reports on the history of lithuanian psychology (bagdonas, pociute, rimkute, & valickas, 2008), and is an extension of the overview of lithuanian clinical psychology published two decades ago (gailiene, 2000) with a focus on current national developments in clinical psychology. grounded on the development of clinical psycholo‐ gy in lithuania this paper is informative in understanding the challenges and diverse pathways of establishing clinical psychology at a national level in different countries. historical background lithuania is a country with a population of around three million, situated in the northeastern part of europe. it has been an eu member state since 2004, together with the other two baltic states – latvia and estonia. lithuania’s history is marked by occupa‐ tions and fights for freedom. established as the independent republic of lithuania after world war i in 1918, lithuania was occupied by the soviet army in 1940-1941, followed by nazi occupation in 1941-1944, and soviet occupation again in 1944-1990 (eidintas, bumblauskas, kulakauskas, & tamošaitis, 2015). lithuania was one of the republics of the former soviet union until 1990. the political situation in the country during the soviet regime was very restrictive and oppressive. political violence and oppression that lasted for decades during the soviet regime resulted in a loss of a large proportion of the population (eidintas et al., 2015). narratives of historical traumas are still vivid in the majority of families living in the country (kazlauskas, gailiene, vaskeliene, & skeryte-kazlauskiene, 2017; kazlauskas & zelviene, 2016). furthermore, the memory of occupation and fights for freedom continue to have a profound impact on politics, socioeconomic situation, science, and culture in the country up to this day. the development of clinical psychology in lithuania was closely related to the political situation of 20th century europe. in lithuania, as well as in other post-com‐ munist countries in the region, particularly in the former soviet republics, psychology clinical psychology in lithuania 2 clinical psychology in europe 2020, vol.2(1), article e2835 https://doi.org/10.32872/cpe.v2i1.2835 https://www.psychopen.eu/ was restricted and oppressed by the soviet regime (gailiene, 2000). despite negative attitudes held by the soviet regime towards psychology, the growing interest in psychol‐ ogy resulted in the establishment of the lithuanian psychological association (lpa) in 1958 (bagdonas et al., 2008), with almost 300 founding members. the first professional five-year psychology diploma-training program in lithuania was opened at vilnius uni‐ versity in 1969, producing the first graduates of this psychology program in 1974. this program was focused on engineering and work psychology, as it was the only way it could be deemed acceptable by the soviet regime (gailiene, 2000). officially, when psychology training was launched in 1969, it was not possible to study or practice clinical psychology. however, since the very start of the psychology program at the university, psychology students were interested in clinical psychology and first psychologists managed to get positions and started to work in psychiatric hospitals in the 1970s (bagdonas et al., 2008). during the 1970s and the 1980s, the field of clinical psychology was evolving through the initiatives of local professionals, as well as with the assistance of lithuanian expats from the united states. during the soviet era, u.s. psychology professors managed to sneak across the ‘iron curtain’ into lithuania often under the pretense of visiting relatives and delivered clinical psychology training workshops and supervisions (bieliauskas, 1977; gailiene, 2000) which was a significant contribution to the development of clinical psychology at that time. training in clinical psychology the start of clinical psychology training a turning point in clinical psychology in lithuania was a two-year master’s degree program in clinical psychology launched at vilnius university in 1994, which marked the start of professional training of clinical psychologists’ in lithuania. this ambitious aim to start the training of clinical psychologists was initiated by a group of psychologists from the department of psychology at vilnius university who had previous interest in clinical psychology and psychotherapy and had relevant clinical experience. the master’s degree in clinical psychology program aimed to fulfill the needs of society to have professionally trained clinical psychologists. soviet legacy significantly impacted the training of clinical psychologists in lithua‐ nia and the start of clinical psychology training was challenging. clinical psychology research in lithuania was almost non-existent during the soviet occupation. moreover, research methods and psychological assessment measures were not compatible with international standards due to the ‘iron curtain’ preventing the circulation of knowledge between the former soviet union and the rest of the world until the 1990s. lithuania as part of the soviet union experienced even more restrictions in comparison to other eastern and central european post-communist countries outside of the soviet union kazlauskas & grigutyte 3 clinical psychology in europe 2020, vol.2(1), article e2835 https://doi.org/10.32872/cpe.v2i1.2835 https://www.psychopen.eu/ (gailiene, 2000). access to international scientific knowledge of psychology, scientific papers, books, or modern assessment measures was restricted in the country until the 1990s. thus, training in clinical psychology, especially in clinical psychological assess‐ ment, was significantly influenced by the soviet approach to psychopathology and psychiatry. for example, psychological assessment training was focused on the use of soviet cognitive assessment instruments, which were available at the time but not used outside of the soviet union. current clinical psychology training psychology training is currently regulated by the ministry of education and science of the republic of lithuania which approved standards for training of psychology in 2015 (ministry of education and science of the republic of lithuania, 2015). the nation‐ al education standards in psychology are in line with the standards of the other eu member states and in accordance with the european certificate in psychology (europsy) which was approved by the european federation of psychologists’ associations (efpa) (european federation of psychologists' associations [efpa], 2019; lunt, peiró, poortinga, & roe, 2014). furthermore, the training of psychologists in lithuania is based on bologna regulations for higher education across europe (laireiter & weise, 2019) and includes three cycles: bachelor’s degree, master’s degree, and doctoral degree. psychologists are trained at six universities in lithuania. bachelor’s degree programs in psychology take 3.5-4 years and master’s degree programs take two years to complete with a focus in various areas of psychology, such as clinical, health, educational, work and organizational, and forensic. psychology degree programs offered at the universities are evaluated and accredited by the national agency responsible for the accreditation of all study programs in the country. lpa does not accredit psychology study programs; however, it was closely involved in the development of the national regulations for the training of psychologists. the clinical psychology master’s degree program in lithuania is a two-year program with 120 european credit transfer and accumulation study (ects) credits. content of the program allows students to develop core competencies of clinical psychologists listed by the european society for clinical psychology and psychological intervention (eaclipt) task force on ‘competences of clinical psychologists’ (eaclipt task force on “competences of clinical psychologists”, 2019). the majority of the study credits (67 ects credits) are dedicated to clinical psychology courses. additionally, the master’s the‐ sis research project is 30 ects credits, and supervised practice is 23 ects credits, which is a 4-month full-time internship in a clinical setting outside the university. the core courses of the curriculum are all clinical and include counselling skills training; adult and child clinical psychological assessment; introduction to the diversity of approaches in clinical psychology, with psychodynamic, existential, cognitive-behavioral and biopsy‐ clinical psychology in lithuania 4 clinical psychology in europe 2020, vol.2(1), article e2835 https://doi.org/10.32872/cpe.v2i1.2835 https://www.psychopen.eu/ chosocial approaches equally covered; developmental psychopathology; trauma and crisis psychology; and research methods in clinical psychology. in lithuania, around 30 students are admitted to the master’s program in clinical psychology annually, and the competition to enter the program is high. the admission numbers to master’s degree programs are regulated by the government, but the universi‐ ty and study program committees have the flexibility of establishing admission quotas based on the available resources each year. the majority of students in the clinical psychology program are funded by the state, with up to 30% of students being self-fun‐ ded. by 2020, more than 400 clinical psychologists have graduated from the clinical psychology program in lithuania. for over 25 years, the master’s degree program in clinical psychology at vilnius university remained the only training program for clinical psychologists in lithuania. however, over the past few decades, other psychology master’s degree programs in the field of clinical and health psychology were launched in addition to the aforementioned clinical psychology program at a number of lithuanian universities. master’s study programs in health psychology were launched at vilnius university, vytautas magnus university and the lithuanian university of health sciences. furthermore, the master’s degree program in counselling psychology was recently launched at klaipeda university. there are two four-year doctoral study programs in psychology in lithuania, one at vilnius university, and the other is a joint ph.d. program of mykolas romeris university and vytautas magnus university. up to 10 ph.d. students are admitted annually to both of these programs. around one-third of all ph.d. students choose to conduct research in the clinical psychology field. however, as ph.d. studies in lithuania are research-based, ph.d. students are expected to conduct research and publish papers, and no clinical training is included in the program. legislation for clinical psychology issues with the use of the title ‘clinical psychologist’ due to negative attitudes by the soviet regime towards clinical psychology and psycho‐ therapy, psychologists were labeled ‘medical psychologists’ (gailiene, 2000) since they started to work in health care institutions in the 1970s. all psychologists in national health care are still referred to as ‘medical psychologists’. surprisingly, the term ‘medical psychologist’ persisted in lithuania, and resulted in the title ‘clinical psychologist’ not existing. thus, according to official statistics, there are zero clinical psychologists in lithuania, but this is only because the term ‘clinical psychology’ is not used in the country’s health care system. there are, in fact, many graduates of clinical and health psychology programs who work in health care institutions or private practice across the country. kazlauskas & grigutyte 5 clinical psychology in europe 2020, vol.2(1), article e2835 https://doi.org/10.32872/cpe.v2i1.2835 https://www.psychopen.eu/ this attitudinal legacy from the soviet era adds to the confusion in the legislation of clinical psychology in lithuania. despite the fact that the masters’ degree program in clinical psychology has existed for over 25 years, the profession of clinical psychology is not yet fully recognized or established in lithuania. the titles ‘clinical psychologist’ and ‘psychologist’ in contrast to many other european countries are not protected. furthermore, the title of clinical psychology is not used in psychology practice but only in training and education. introduction of regulation there was no regulation for psychologists in health care in lithuania until 2012 (ministry of health of the republic of lithuania, 2011). moreover, there were no minimal training standards set in the field of clinical and health psychology prior to 2012. for decades, it was up to the employer to decide what training standards were considered as training standards to apply for psychologists in health care until the regulation was introduced. when it came to medical psychologists, health care institutions mostly used to employ psychologists with a five-year psychology diploma or master’s degree in any area of psychology, but occasionally psychologists with no more than a 4-year bachelor’s degree or even ‘professionals’ without a diploma could be employed before 2012. it was only in 2012 that psychologists were included in the system of the lithuanian national accreditation agency for health professions. consequently, health care institu‐ tions could only hire registered medical psychologists with a master’s degree in health or clinical psychology. this new regulation was introduced with collaborative efforts between the ministry of health and lpa, which insisted that a bachelor’s degree in psy‐ chology and master’s degree with a specialization in health or clinical psychology should be a minimum requirement for psychologists to practice in health care. several years of a transition period ensured that psychologists who started work before clinical and health psychology training became available in lithuania and had substantial experience in clinical work could be registered as psychologists eligible to work in the health care setting. this regulation did not include psychologists working outside the public health care setting, which is why psychologists providing psychological counselling or psychothera‐ py in private practice are not yet registered or regulated. psychological services of regis‐ tered medical psychologists in licensed health care institutions are reimbursed by the national health care insurance. however, due to the lack of staff and resources, access to psychologists’ services is restricted and there are long waiting lines. psychologist’s services in private practice outside of health care institutions are not reimbursed by the national health care insurance. in reality, even non-professionals can declare themselves psychotherapists or clinical psychologists and start delivering services in private practice without any formal training in psychology in lithuania. this is because law in lithuania clinical psychology in lithuania 6 clinical psychology in europe 2020, vol.2(1), article e2835 https://doi.org/10.32872/cpe.v2i1.2835 https://www.psychopen.eu/ regulates neither the psychologist’s profession nor psychological services nor does it protect the psychologist’s title. debates about the regulation of psychology legislation for clinical psychologists is part of the national regulation of psychology. until 2020, psychology in lithuania was not regulated by national laws and not included in the list of the licensed professions, except for school psychologists working in the national education system (european parliament, 2016). debates about the standards for professional psychologists have been intense for over a decade. there are conflicting opinions among psychologists regarding the mini‐ mal training standards or regarding which institutions should license psychologists in lithuania. over the past decade, several proposals for a new law have been brought in the lithuanian parliament. these proposals included various requirements for minimal training, ranging from licensing psychologists for independent practice with only a bachelor’s degree in psychology to requirements of holding bachelor’s and specialized master’s degree in addition to having one-year experience of supervised practice in the field of intended practice, such as clinical and health psychology, educational psychology, or work and organizational psychology, which would be in line with the efpa’s europsy regulations (european federation of psychologists' associations [efpa], 2019). while most psychologists in lithuania agreed that at least a master’s degree is needed to be granted a psychologist’s license, debates on the licensing agency still are ongoing. proposals as to which organization should play the role of the licensing agency ranged from self-regulation of professionals by lpa to the establishment of a new chamber of psychologists or choosing one of the governmental institutions. regulation of psychologists in health care despite the lack of regulation on the national level, an important step for psychologists working in public health care was the document ‘medical norm’ issued by the ministry of health of the republic of lithuania in 2018 (ministry of health of the republic of lithuania, 2018). this document defined the aim, the area of practice, and the meth‐ ods of psychologists who work in the national health care system under the title of ‘medical psychologists’. however, the professional title ‘clinical psychologist’ was not included in this document. up until 2020, there has been no clear distinction between health and clinical psychology in terms of regulation and fields of practice in health care. current legislation in lithuania allows for graduates of either health or clinical psychology master’s programs to work in health care in positions of psychologists in primary care, mental health care, prevention, rehabilitation, or in hospitals with patients who have somatic diseases. the regulation of medical psychologists in health care does not include differentiation between a child and adult psychologists, psychologists who kazlauskas & grigutyte 7 clinical psychology in europe 2020, vol.2(1), article e2835 https://doi.org/10.32872/cpe.v2i1.2835 https://www.psychopen.eu/ provide assessment and those who mostly provide psychological counselling or use various methods of psychotherapy. clinical psychology, psychotherapy, and psychiatry the present work focused solely on training and legislation for clinical psychology, therefore, it does not extend to the situation of psychotherapy in lithuania. there are multiple psychotherapy schools that offer post-diploma training in various psychothera‐ py approaches in lithuania, such as cognitive-behavioral, psychodynamic, child psycho‐ dynamic, group analysis, existential, gestalt, jungian analysis, family therapy, and others. training in specialized psychological therapies for posttraumatic stress disorder (ptsd), such as eye movement desensitization and reprocessing (emdr), is also available in the country (schäfer et al., 2018). majority of psychologists who work in health care or private practice pursue psychotherapy training after having obtained a master’s degree from the university. however, there are no statistics available on how many psycholo‐ gists have had additional psychotherapy training after the completion of psychology studies at university. the legal distinction between psychotherapy and clinical psychol‐ ogy remains unclear since law in lithuania does not yet regulate psychotherapy. the relationship between psychiatry and clinical psychology is also not part of this paper. while these fields share a mutual interest in psychopathology and treatment of mental disorders, they also have a history of diverse interactions. future directions this brief report presented struggles in establishing clinical psychology as a profession in lithuania, a post-communist eu country. our review demonstrated that the development of clinical psychology in lithuania has been rather successful with a history of over 25 years of clinical psychology training available at the university level. furthermore, regulations and standards for psychologists in health care have recently been introduced in lithuania. however, our review also revealed controversies surrounding the use of the title ‘clinical psychologist’ and difficulties in establishing clinical psychology as an important field and profession in lithuanian society. several future directions could be identified for further progress of clinical psycholo‐ gy in lithuania: • the term ‘clinical psychologist’ should be used officially to identify psychologists who provide services in health care and have training in clinical psychology. • continuing education in clinical psychology is needed to constantly update the knowledge of psychologists who work in lithuania. legislation and licensing of psychological practice should include a formal requirement for continuing education in the field of clinical psychology after university graduation. clinical psychology in lithuania 8 clinical psychology in europe 2020, vol.2(1), article e2835 https://doi.org/10.32872/cpe.v2i1.2835 https://www.psychopen.eu/ • training of clinical psychologists should be more focused on research. potentially this could be achieved by more intense international collaboration and learning from countries that have more expertise in research and training in clinical psychology. the staff of clinical psychology programs could focus more on staff exchange with other international institutions to modernize training in lithuania. funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. references bagdonas, a., pociute, b., rimkute, e., & valickas, g. 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(2018). trauma and trauma care in europe. european journal of psychotraumatology, 9(1), article 1556553. https://doi.org/10.1080/20008198.2018.1556553 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. clinical psychology in lithuania 10 clinical psychology in europe 2020, vol.2(1), article e2835 https://doi.org/10.32872/cpe.v2i1.2835 https://doi.org/10.32872/cpe.v1i1.34406 https://doi.org/10.1027/00438-000 https://www.skvc.lt/uploads/lawacts/docs/229_19635725da19d5b0c50a341a3d08ea4a.pdf https://e-seimas.lrs.lt/portal/legalact/lt/tad/tais.404693 https://e-seimas.lrs.lt/portal/legalact/lt/tad/c0c8f68164c911e8b7d2b2d2ca774092?jfwid=2r1mprf1 https://e-seimas.lrs.lt/portal/legalact/lt/tad/c0c8f68164c911e8b7d2b2d2ca774092?jfwid=2r1mprf1 https://doi.org/10.1080/20008198.2018.1556553 https://www.psychopen.eu/ clinical psychology in lithuania (introduction) historical background training in clinical psychology the start of clinical psychology training current clinical psychology training legislation for clinical psychology issues with the use of the title ‘clinical psychologist’ introduction of regulation debates about the regulation of psychology regulation of psychologists in health care clinical psychology, psychotherapy, and psychiatry future directions (additional information) funding competing interests acknowledgments references evidence of a media-induced nocebo response following a nationwide antidepressant drug switch research article evidence of a media-induced nocebo response following a nationwide antidepressant drug switch kate mackrill a, greg d. gamble b, debbie j. bean a, tim cundy b, keith j. petrie a [a] department of psychological medicine, university of auckland, auckland, new zealand. [b] department of medicine, university of auckland, auckland, new zealand. clinical psychology in europe, 2019, vol. 1(1), article e29642, https://doi.org/10.32872/cpe.v1i1.29642 received: 2018-09-10 • accepted: 2018-12-05 • published (vor): 2019-03-29 handling editor: winfried rief, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany corresponding author: keith j. petrie, psychological medicine, faculty of medical and health sciences, university of auckland, private bag 92019, auckland, new zealand. e-mail: kj.petrie@auckland.ac.nz abstract background: in 2017, patients on a generic or branded antidepressant venlafaxine were switched to a new generic formulation (enlafax). in february and april 2018, two major nz media outlets ran stories about the new generic being less effective and causing specific side effects. this study aimed to examine the effect of the media coverage on drug side effects reported to the national centre for adverse reactions monitoring (carm) and whether the specific symptoms reported in the media increased compared to side effects not reported in the media. method: we analysed monthly adverse reaction reports for enlafax to carm from october 2017 to june 2018 and compared adverse reports, complaints of decreased therapeutic effect and specific symptom reports before and after the media coverage using an interrupted time series analysis. results: we found the number of side effects and complaints of reduced therapeutic effect increased significantly following the media stories (interruption effect = 41.83, 95% ci [25.25, 58.41], p = .003; interruption effect = 15.49, 95% ci [7.01, 23.98], p = .012, respectively). the specific side effects mentioned in the media coverage, including suicidal thoughts, also increased significantly compared to other side effects not mentioned in the media. conclusions: in the context of a drug switch, media reports of side effects appear to cause a strong nocebo response by increasing both the overall rate of side effect reporting and an increase in the specific side effects mentioned in the media coverage, including reduced drug efficacy and heightened suicidal thoughts. keywords media, nocebo effect, venlafaxine, side effects, generic medicines this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i1.29642&domain=pdf&date_stamp=2019-03-29 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • the study provides further evidence that media coverage of side effects can induce a nocebo effect. • this is the first study to look at media coverage of an antidepressant brand switch. • the increase in reported adverse events was higher for those symptoms mentioned in the media reports. switches from branded to generic medicine formulations have become more frequent in recent times as health funders seek to reduce costs. these switches to generic medical and psychotropic medications have from time to time caused an increase in reported ad‐ verse events (desmarais, beauclair, & margolese, 2011; leclerc et al., 2017), and this is likely to be due to negative attitudes towards generic medicines rather than pharmaco‐ logical differences between the branded and generic versions of the medication (colgan et al., 2015). this phenomenon is known as the nocebo effect and research using inert medicines has shown that people report a reduced therapeutic effect and more side effects from a generic-labelled placebo compared to a branded placebo (faasse, martin, grey, gamble, & petrie, 2016). similarly, the process of switching from one placebo tablet to another is as‐ sociated with reports of side effects and reduced drug efficacy (faasse, cundy, gamble, & petrie, 2013). the nocebo effect can also occur in active medications and there is recent evidence that media coverage about drug side effects can create a nocebo response by highlighting negative reactions to a particular medication and prompting an increase in symptom complaints and drug discontinuation (faasse & petrie, 2013). in 2017, 45,000 new zealand patients prescribed the antidepressant venlafaxine were switched to a new funded generic (enlafax xr) from either the branded originator or a different generic version. in february 2018, two major print and online media outlets in new zealand ran stories on patients’ complaints that the new generic was less effective and causing an increase in various symptoms, including heightened suicidal thoughts. a few months later, another media report was released, again discussing patients’ reports of ineffectiveness and side effects from enlafax. based on previous research, we tested two hypotheses: firstly, that media coverage of the complaints following the venlafaxine switch would be associated with an increase in adverse drug reactions reported to the new zealand centre for adverse reactions monitoring (carm); and secondly, that the specific side effects reported in the media would increase compared to other side effects not reported in the coverage. media-induced nocebo response 2 clinical psychology in europe 2019, vol.1(1), article e29642 https://doi.org/10.32872/cpe.v1i1.29642 https://www.psychopen.eu/ method newspaper articles on february 28 2018, two leading new zealand media outlets, the new zealand herald (nzme) and stuff (fairfax media), published newspaper and online articles on the venla‐ faxine brand switch. the new zealand herald ran a story titled “patients say generic pharmac-funded version of antidepressant venlafaxine left them depressed, anxious” (henry, 2018), while stuff’s article was titled “anti-depressant swap: sufferers claim ge‐ neric drug is harming their condition” (maude, 2018). these articles described the per‐ sonal experience of two patients when they switched from their original brand efexor to enlafax. the reports stated that the new, cheaper generic version was not as efficacious in managing the patients’ depression and they were also experiencing side effects. the new zealand herald article specifically mentioned that patients were reporting suicidal thoughts, nausea, fatigue, headaches and anxiety. in april, stuff released another online article, which continued on the subject of the previous media coverage. this media report, “fight over pharmac’s switch to generic an‐ ti-depressant brand continues” (steele, 2018), again stated that the new generic was not as effective and noted that various adverse events had been reported specifically head‐ aches, anxiety and suicidal thoughts. of the two websites, stuff is the most viewed with approximately 161,600 unique views per day, while the new zealand herald has 94,800 views (https://www.siteprice.org). neither of these stories suggested patients report side effects to their doctor or to carm. adverse drug reactions a report of all adverse reactions to venlafaxine was obtained from carm through med‐ safe, new zealand’s medicines monitoring agency. the carm database collects adverse reactions to medicines and vaccines, the majority of which are submitted by healthcare professionals. reporting is usually made online and carm reporting forms can be ac‐ cessed on the website https://nzphvc.otago.ac.nz. reports were obtained from october 2017 to july 2018 and included the month the report was received, the patients’ age and gender, and up to five symptoms attributed to the medicine. as the data was anonymous and publicly available, the study did not require ethical approval. measures the number of reports of decreased therapeutic response was calculated for each month. decreased therapeutic response is an adverse reaction category on the carm database equivalent to a reduced efficacy of the medicine. mackrill, gamble, bean et al. 3 clinical psychology in europe 2019, vol.1(1), article e29642 https://doi.org/10.32872/cpe.v1i1.29642 https://www.siteprice.org https://nzphvc.otago.ac.nz https://www.psychopen.eu/ the total number of side effects reported each month was also calculated as was the number of times the five specific side effects mentioned in the new zealand herald arti‐ cle were reported. the side effects were matched to the corresponding adverse reactions in the carm database with headaches, nausea and anxiety being matched exactly. two of the media-mentioned side effects were considered broad enough to cover a range of carm adverse reactions. as such, reports of fatigue, lethargy and tiredness were grou‐ ped under the broader side effect of fatigue, while suicidal thoughts were matched with reports of suicidal tendencies, suicidal ideation and impulses to self-harm. the five most common adverse reactions not mentioned in the media reports were identified from the carm database and used as control symptoms. these were dizziness, drug withdrawal syndrome, irritability, sleep disturbance and a fuzzy head. statistical analyses interrupted time series analyses were conducted to investigate whether the february and april media reports on the venlafaxine brand switch were associated with an increase in the carm reporting of decreased therapeutic response, total number of side effects and the specifically mentioned side effects in the months directly after the media reports compared to the five months before. an autoregressive integrated moving average (ari‐ ma) model with an autoregression term of 1 and moving average term of 1 was used for all analyses. as the three media reports were a one-off interruption to the normal time series, a binary independent variable was created to indicate their presence by month. march and may were given the value of 1 as these were the periods directly after the feb‐ ruary and april media reports and all other months were coded 0. the analysis produces an estimated interruption effect, which is the change in the rate of adverse event report‐ ing from the months coded 0 and 1, and indicates whether this change is significantly different. this is a more conservative analysis as the adverse event reports in march and may are averaged together to calculate the general effect of the three media stories rather than both months being compared separately to the pre-media rate. analyses were con‐ ducted in sas (v9.4 sas institute inc., cary, nc) using the sas proc arima procedure. an alpha level of .05 was considered significant. results in total, there were 100 adverse event reports from october 2017 to july 2018. the aver‐ age age of reporters was 43.7 years old and 70.0% were female. in the five months prior to the first newspaper articles, the average number of adverse event reports to carm was 6.00 (sd = 1.23) per month. in march and may, the two months directly after the release of the articles, the average number of carm reports significantly increased to 25.50 media-induced nocebo response 4 clinical psychology in europe 2019, vol.1(1), article e29642 https://doi.org/10.32872/cpe.v1i1.29642 https://www.psychopen.eu/ (sd = 12.02; interruption effect i.e. difference between the pre-media average and march + may average = 19.45, 95% confidence interval (ci) [10.77, 28.13], p = .005). the newspaper articles also had a significant effect on side effect reporting with the pre-media average of 7.00 reports (sd = 4.18) a month increasing to 49.00 (sd = 26.63) in march and may, see figure 1. similarly, the rate of decreased therapeutic response re‐ porting significantly increased from 4.00 (sd = 2.12) during the previous months to an average of 17.00 (sd = 9.90) over march and may. the interruption effect of the media on side effect reporting = 41.83, 95% ci [25.25, 58.41], p = .003. interruption effect for de‐ creased therapeutic response reports = 15.49, 95% ci [7.01, 23.98], p = .012. figure 1. number of reports of side effects and decreased therapeutic response before and after the media reports. mackrill, gamble, bean et al. 5 clinical psychology in europe 2019, vol.1(1), article e29642 https://doi.org/10.32872/cpe.v1i1.29642 https://www.psychopen.eu/ a further analysis investigated whether the reports to carm of the specific side effects mentioned in the february new zealand herald article increased in march and may com‐ pared to the five previous months. figure 2 shows the rate of reporting for the mediamentioned side effects and table 1 shows the interruption effects and corresponding p values. figure 2. numbers before and after media reports for the specific side effects reported in the media and control symptoms not in media reports. media-induced nocebo response 6 clinical psychology in europe 2019, vol.1(1), article e29642 https://doi.org/10.32872/cpe.v1i1.29642 https://www.psychopen.eu/ prior to the media coverage, suicidal thoughts were reported an average of 0.40 times (sd = 0.55) per month but following the media report this significantly increased to 7.00 (sd = 1.41) across march and may. there were no adverse event reports of nausea before the media coverage, but reporting significantly increased to 2.00 (sd = 1.41) during the post-media months. the average rate of reporting per month of headache was 0.60 (sd = 0.55) before the media focus, which significantly increased to 4.00 (sd = 2.83) reports in march and may. fatigue was reported 0.80 times (sd = 1.10) over the five pre-media months but this did not change significantly after the media coverage (m = 4.00, sd = 4.24). similarly, the reporting of anxiety did not change, going from an average of 0.40 (sd = 0.89) before the media coverage to 1.00 (sd = 1.41) after the focus. the side effects most frequently reported to carm that were not mentioned in the newspaper article were investigated to determine the effect on other adverse events. diz‐ ziness, sleep disturbance, irritability and fuzzy head were all reported an average of 0.20 times (sd = 0.45) per month before the media focus. following the coverage, there was a significant increase in the reporting of dizziness (m = 3.00, sd = 1.41) and sleep disturb‐ ance (m = 1.00, sd = 1.41). there was no change in the post-media rate of reporting for irritability and fuzzy head (both m = 1.00, sd = 1.41). before the media articles, drug withdrawal syndrome was reported an average of 0.40 times (sd = 0.55) a month, which did not change after the media coverage (m = 2.00, sd = 0). table 1 estimated interruption effects of the newspaper articles on carm reports for specifically mentioned side effects and control side effects variable interruption effect 95% ci p side effects mentioned in article suicidal thoughts 6.64 [4.60, 8.68] < .001 nausea 1.95 [0.62, 3.28] .029 fatigue 1.63 [-1.45, 4.71] .339 headache 3.62 [1.05, 6.19] .034 anxiety 0.39 [-2.34, 3.11] .791 side effects not mentioned in article dizziness 2.70 [1.72, 4.60] .002 drug withdrawal syndrome 2.96 [0.53, 5.39] .055 sleep disturbance 0.75 [0.20, 1.30] .036 irritability 0.50 [-0.91, 1.91] .507 fuzzy head 0.88 [-0.30, 2.06] .190 mackrill, gamble, bean et al. 7 clinical psychology in europe 2019, vol.1(1), article e29642 https://doi.org/10.32872/cpe.v1i1.29642 https://www.psychopen.eu/ discussion main findings this study found that reports by the two largest new zealand media outlets highlighting the side effects and lack of efficacy of a new generic antidepressant were followed by a significant increase in reports to carm of similar side effects. the increase in reported adverse events was largely limited to those mentioned in the media reports. while two of the control symptoms, dizziness and sleep disturbance, did also increase, this was at a lower rate than the symptoms mentioned in the media stories. the results are consistent with a nocebo response driven by the media coverage, whereby patients’ expectations of particular side effects result in an increase in those specific symptoms. a pharmacologi‐ cal explanation for this effect is very unlikely as the side effects highlighted in the media stories and the control side effects were mentioned at a similar rate prior to the media coverage. following the media coverage, it was those symptoms mentioned in the media stories that were mostly affected. a particular concern in the findings is the mirroring of reports of decreased therapeu‐ tic efficacy, which could potentially drive non-persistence with antidepressant therapy. also of public health relevance is the increase in reports of suicidal ideation which is likely due to the highlighting of suicidal thoughts and behaviour by patients discussed in the media stories in february and again in april. comparison with other studies previous studies have shown that information about likely side effects from medication can result in a significant increase in reports of those specific effects. patients who were told about sexual side effects when starting finasteride or beta-blocker medication were significantly more likely to report these symptoms than patients who were not told of these side effects (cocco, 2009; mondaini et al., 2007). similarly, in the context of a clini‐ cal trial, those patients warned of gastrointestinal side effects in one research site were more likely to complain of this as a side effect and withdraw from the study due to these complaints (myers, cairns, & singer, 1987). seeing another person in a media story report side effects from a medication can also increase the expectations of a similar response (faasse & petrie, 2016). in an earlier study by our group, media reporting on a change in the formulation and appearance of thyro‐ xine replacement therapy that led to a dramatic increase in adverse reaction reports (faasse, cundy, & petrie, 2009), found side effect complaints increased significantly after television news stories. the largest increases concerned symptoms mentioned in the me‐ dia reports. this was strongest for the initial coverage and weakened with successive sto‐ ries (faasse, gamble, cundy, & petrie, 2012). this occurred in the current study, as the may adverse event reporting was not as large as in march. research on side effects from media-induced nocebo response 8 clinical psychology in europe 2019, vol.1(1), article e29642 https://doi.org/10.32872/cpe.v1i1.29642 https://www.psychopen.eu/ electromagnetic fields has also shown that alarmist media reports, which emphasise ad‐ verse effects, exacerbate the nocebo effect and lead to greater symptom reporting and a perceived sensitivity to the supposedly harmful substance (verrender, loughran, dalecki, freudenstein, & croft, 2018; witthöft & rubin, 2013). switches to generic medicine provide potential for a nocebo response to be strongly influenced by negative media coverage as non-adherence, patient reports of decreased ef‐ ficacy and increased side effects are more common following switches (boone et al., 2018; weissenfeld, stock, lüngen, & gerber, 2010). a nocebo response induced through media reports can have a detrimental effect. recent work has shown that negative stories in the media about statins have led to an increase in the rate of patients discontinuing statins in the united kingdom (matthews et al., 2016) and this early discontinuation has been linked to an increase in myocardial infarction and death from cardiovascular disease in denmark (nielsen & nordestgaard, 2016). the likely mechanisms of the nocebo response found in this study are social trans‐ mission and the misattribution of common symptoms to the effects of the new medica‐ tion (petrie & rief, 2019). previous research has found that seeing another person report side effects after receiving a treatment increases the likelihood of side effects’ complaints after receiving the same treatment, especially if the observer can empathise with the per‐ son reporting the side effects (faasse, parkes, kearney, & petrie, 2018). studies have also found that individuals with higher levels of psychological distress also report a greater number of physical symptoms (watson & pennebaker, 1989). this is likely to be of more relevance in this group of patients taking an antidepressant and thus allowing more symptoms to be misattributed to the effects of the new generic medicine. while generic switches are now commonplace in new zealand, a recent general population survey found 38% still preferred taking branded medication compared to a generic or no prefer‐ ence (kleinstäuber, mackrill, & petrie, 2018). following a switch to a generic medicine more side effects are reported by patients who are older, female and by those who have been on their previous branded medicine longer (mackrill & petrie, 2018). strengths and limitations while this study drew on adverse reports to a national database, it is likely that the rates are a substantively low estimate of the true effect of the nocebo effect caused by the me‐ dia coverage. studies estimate that reports to a national adverse database represent less than 10% of detected adverse drug reactions (mcgettigan, golden, conroy, arthur, & feely, 1997; smith et al., 1996). it is further likely that many patients would not have sought medical assistance for symptoms due to the perception that there was little that could be done by their gp. the study is limited by the non-experimental design and restricted in outcomes to the specific side effect categories recorded by carm. as such, it is possible that patients may have experienced other side effects that the carm database does not measure. although mackrill, gamble, bean et al. 9 clinical psychology in europe 2019, vol.1(1), article e29642 https://doi.org/10.32872/cpe.v1i1.29642 https://www.psychopen.eu/ patients can make direct reports using online forms this makes up only a small percent‐ age of carm reports. the behavioural outcomes of the adverse event reporting are also unknown. it is not known whether there was an increase in suicidal behaviour following the stories or whether patients stopped venlafaxine or changed to another medication. in conclusion, we found media coverage of reports of a lack of efficacy and side ef‐ fects following a switch to a generic version of venlafaxine were likely responsible for an increase in similar reports to a national centre for adverse drug reactions. of particular concern is how media reports of increases in suicidal thoughts and loss of drug efficacy following a drug switch can be readily converted in similar complaints across the wider community. more research is also required on how such media reports are associated with increases in non-adherence and non-persistence with medication, as well as possible increases in suicidal behaviour. future work may also be needed to develop 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(2010). the nocebo effect: a reason for patients’ non-adherence to generic substitution? die pharmazie, 65(7), 451-456. witthöft, m., & rubin, g. j. (2013). are media warnings about the adverse health effects of modern life self-fulfilling? an experimental study on idiopathic environmental intolerance attributed to electromagnetic fields (iei-emf). journal of psychosomatic research, 74(3), 206-212. https://doi.org/10.1016/j.jpsychores.2012.12.002 media-induced nocebo response 12 psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. www.leibniz-psychology.org https://doi.org/10.1111/j.1743-6109.2007.00563.x https://doi.org/10.1038/clpt.1987.142 https://doi.org/10.1093/eurheartj/ehv641 https://doi.org/10.1146/annurev-psych-010418-102907 https://doi.org/10.1111/j.1365-2125.1996.tb00004.x https://www.stuff.co.nz https://doi.org/10.1016/j.envres.2018.06.032 https://doi.org/10.1037/0033-295x.96.2.234 https://doi.org/10.1016/j.jpsychores.2012.12.002 https://www.leibniz-psychology.org/ https://www.psychopen.eu/ media-induced nocebo response (introduction) method newspaper articles adverse drug reactions measures statistical analyses results discussion main findings comparison with other studies strengths and limitations (additional information) funding competing interests acknowledgments references psychoneuroendocrinology and clinical psychology scientific update and overview psychoneuroendocrinology and clinical psychology susanne fischer a, ulrike ehlert a [a] institute of psychology, clinical psychology and psychotherapy, university of zurich, zurich, switzerland. clinical psychology in europe, 2019, vol. 1(2), article 33030, https://doi.org/10.32872/cpe.v1i2.33030 received: 2019-01-11 • accepted: 2019-03-01 • published (vor): 2019-06-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: susanne fischer, university of zurich, institute of psychology, clinical psychology and psychotherapy, binzmuehlestrasse 14 / box 26, 8050 zurich, switzerland. e-mail: s.fischer@psychologie.uzh.ch abstract background: hormones impact on cognition, emotions, and behaviour. given that mental disorders are defined by abnormalities in these very same domains, clinical psychologists may benefit from learning more about alterations in endocrine systems, how they can contribute to symptoms commonly experienced by patients, and how such knowledge may be put to use in clinical practice. method: the aim of the present scientific update was to provide a brief overview of endocrine research relevant to the aetiology, diagnostics, and treatment of mental disorders, including some of the latest studies in this area. results: hormones appear to be intrinsic to the development and maintenance of mental disorders. oxytocin is involved in social cognition and behaviour and as such may be relevant to mental disorders characterised by social deficits (e.g., autism spectrum disorder and schizophrenia). stress and sex steroids exert demonstrable effects on mood and cognition. in patients with depression and anxiety disorders, initial attempts to lower/enhance such hormones have thus been undertaken within conventional therapies in order to improve outcomes. finally, hunger and satiety hormones may be involved in the vicious circle of dysfunctional eating behaviours and weight loss/gain in anorexia or bulimia nervosa. conclusion: three conclusions can be drawn from this review: first, endocrine research should be considered when patients and clinicians are developing multidimensional illness models together. second, endocrine markers can complement conventional assessments to provide a more comprehensive account of a patient’s current state. third, endocrine testing may guide treatment choices and inform the development of novel treatments. keywords anxiety, cognition, depression, hormones, mental disorders, mood, psychological therapy this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i2.33030&domain=pdf&date_stamp=2019-06-28 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • hormones are intrinsic to the development and maintenance of mental disorders • endocrine research should be incorporated into multidimensional illness models • endocrine markers can complement conventional diagnostic assessments • endocrine testing may guide treatment choices and inform the development of new treatments psychoneuroendocrinology is an interdisciplinary research area dedicated to the interac‐ tion between the mind, brain, and hormonal system (wolf & saucier, 2013). stress and lifestyle behaviours (e.g., diet, physical activity) are the most frequently studied psycho‐ logical factors exerting shortand long-term effects on hormones. conversely, a number of hormones are known to impact on psychological domains, such as cognition, emotions, and behaviour. among these are hormones involved in social interaction (e.g., oxytocin), stress hormones (e.g., noradrenaline and cortisol), sex hormones (e.g., testosterone, oes‐ tradiol, and progesterone), and hormones involved in hunger and satiety (e.g., ghrelin, leptin, or insulin). given that mental disorders are characterised by abnormalities in cog‐ nition, emotions, and behaviour, clinical psychologists may benefit from learning more about alterations in endocrine systems, how they may contribute to symptoms common‐ ly experienced by patients, and how such knowledge may be put to use in clinical prac‐ tice. the aim of the present scientific update was therefore to provide a brief overview of endocrine research relevant to the aetiology, diagnostics, and psychopharmacological and psychotherapeutic treatment of mental disorders, including some of the latest studies in this area. findings will be presented separately for each of the aforementioned domains and summarised in the final part of the manuscript alongside recommendations for clini‐ cal applications. how hormones affect social interaction the most prominent hormone regulating social interaction is oxytocin (meyerlindenberg, domes, kirsch, & heinrichs, 2011). although oxytocin is available in the pe‐ riphery (e.g., in reproductive organs), its central origin is in the hypothalamus, and oxy‐ tocin receptors are widely expressed in numerous areas of the brain, including the frontal cortex, amygdala, and olfactory nucleus. oxytocin has demonstrable effects on social cognition and behaviour, such as enhanc‐ ing theory of mind, emotional recognition, empathy, social exploration, and attachment psychoneuroendocrinology and clinical psychology 2 clinical psychology in europe 2019, vol.1(2), article 33030 https://doi.org/10.32872/cpe.v1i2.33030 https://www.psychopen.eu/ (see also ditzen et al., 2009; heinrichs, baumgartner, kirschbaum, & ehlert, 2003). as such, it has attracted the interest of researchers studying mental disorders characterised by social deficits, including autism spectrum disorders and schizophrenia. there is now evidence to suggest that oxytocin may be an aetiological factor in autism spectrum disor‐ der, since several polymorphisms within the gene encoding its receptor (oxtr) have been found to be risk-inducing (kranz et al., 2016; loparo & waldman, 2015). on the oth‐ er hand, peripheral levels of oxytocin are often found to be unaltered in the same patients as well as in patients with psychotic disorders (rutigliano et al., 2016). these null-find‐ ings need to be interpreted with caution, however, since the bioavailability of oxytocin in blood, urine, or saliva does not necessarily reflect its centrally circulating levels (valstad et al., 2017), which are of greater importance considering the clinical features of these ill‐ nesses. importantly, central levels are only quantifiable in humans via access to the cere‐ brospinal fluid by means of lumbar puncture. thus, although it is unlikely that oxytocin levels will be used as a diagnostic illness marker in the near future, their potential role in the pathophysiology of disorders characterised by social deficits can be incorporated into psychoeducation delivered to patients and their next of kin. another line of research has examined the effects of intranasally administered oxyto‐ cin in patients with autism spectrum disorder and schizophrenia (keech, crowe, & hocking, 2018), with findings of small but significant improvements in theory of mind (but not in emotion recognition or empathy). in other words, patients receiving exoge‐ nous oxytocin showed an increased ability to attribute mental states to others, thus pro‐ viding ex juvantibus evidence for an involvement of the oxytocin system in the patho‐ physiology of these disorders. importantly, numerous open questions need to be an‐ swered before oxytocin can be considered as an adjunct treatment for autism spectrum disorder or schizophrenia, including its precise mechanisms of action in the brain, its long-term efficacy, and potential adverse effects (e.g., increased irritability). interestingly, more recent research has explored the role of endogenous oxytocin as a modulator of treatment outcomes. a pilot study was able to demonstrate that the lower depressed patients’ pre-treatment oxytocin levels, the lower their degree of change in a self-report measure of depression over the course of psychological therapy (jobst et al., 2018). this finding aligns well with another study in patients with depressive disorders, which showed that oxytocin levels fluctuated during therapy sessions, and in parallel with subtle changes in the therapeutic alliance (i.e., ruptures; zilcha-mano, porat, dolev, & shamay-tsoory, 2018). together, these studies suggest that oxytocin levels may also be a useful prognostic tool as well as a means to monitor treatment progress. fischer & ehlert 3 clinical psychology in europe 2019, vol.1(2), article 33030 https://doi.org/10.32872/cpe.v1i2.33030 https://www.psychopen.eu/ how hormones affect cognition, mood, and sexual function up to now, the largest share of clinical neuroendocrine research has been dedicated to the stress hormones noradrenaline and cortisol. the catecholamine noradrenaline (na) is available in the brain and in several other body tissues (fischer & nater, 2015). its central origin is the locus coeruleus, with αand β-adrenergic receptors expressed in numerous other brain areas, such as the cortex, thalamus, hippocampus, amygdala, and hypothala‐ mus. in the periphery, na, together with adrenaline, is the main end product of the sym‐ pathetic nervous system, and its receptors are present in all major organs and cells of the immune system. noradrenaline has effects on multiple domains of psychological functioning, includ‐ ing cognition, affect, arousal, and pain perception. it is thus unsurprising that 1) cogni‐ tive symptoms (e.g., deficits in working memory), as experienced, for instance, by pa‐ tients with depressive disorders (maletic, eramo, gwin, offord, & duffy, 2017), 2) anxiety and hyperarousal, representing key clinical features of panic disorder and post-traumatic stress disorder (bandelow et al., 2017), and 3) bodily symptoms such as fatigue and pain, which feature prominently in somatic symptom disorders (nater, fischer, & ehlert, 2011), are all paralleled by altered na functioning. notably, findings are highly complex; de‐ pending on the tissue (i.e., different areas within the brain, blood), both elevated and attenuated concentrations of na are observed, sometimes within the same patient co‐ hort. drugs targeting the na system (e.g., venlafaxine) constitute effective antidepressants and anxiolytics (e.g., bandelow et al., 2014; dgppn et al., 2015), thus adding further evi‐ dence to the assumption that the na system is instrumental in the pathophysiology of depressive and anxiety disorders. clinicians administering such drugs are advised to ex‐ plain the role of na to patients before initiating treatment. by contrast, in somatic symp‐ tom disorders and in physical diseases, it is mainly the peripheral actions of na (e.g., its effects on the musculoskeletal or cardiovascular system) which are critical. interestingly, in patients undergoing coronary artery bypass graft surgery, it was recently shown that preoperative psychological interventions led to significantly lower (i.e., more adaptive) levels of adrenaline after surgery when compared to standard medical care (salzmann et al., 2017). this finding highlights the value of catecholamines as markers of therapeutic efficacy. notably, na activity can also be determined non-invasively, namely via salivary alpha-amylase, an enzyme involved in the digestion of starch, thus facilitating its use in clinical practice (nater & rohleder, 2009). the glucocorticoid cortisol, the other major stress hormone, is the end point of the hypothalamic-pituitary-adrenal (hpa) axis (ehlert, 2011). although cortisol is synthe‐ sised in the adrenal cortex, both central (e.g., the hippocampus) and peripheral tissues (e.g., lymphocytes) are densely populated by mineralocorticoid and glucocorticoid recep‐ psychoneuroendocrinology and clinical psychology 4 clinical psychology in europe 2019, vol.1(2), article 33030 https://doi.org/10.32872/cpe.v1i2.33030 https://www.psychopen.eu/ tors. apart from the gluconeogenetic and anti-inflammatory effects of cortisol, one of its main effects lies in influencing cognition. akin to the findings on na, cortisol concentrations have been found to be abnormal in a number of patients presenting with cognitive problems (e.g., difficulty concentrat‐ ing), as is the case in affective disorders (belvederi murri et al., 2016; stetler & miller, 2011). moreover, abnormal cortisol concentrations have been demonstrated in patients with post-traumatic stress disorder, where they may contribute to re-experiencing of trauma via constant retrieval of the fear memory (morris, compas, & garber, 2012), and in somatic symptom disorders, where they may contribute to bodily complaints (tak et al., 2011). interestingly, while patients with affective disorders are characterised by com‐ parably elevated levels of cortisol (i.e., hypercortisolism), patients with posttraumatic stress disorder or somatic symptom disorders mostly exhibit diminished levels (i.e., hy‐ pocortisolism; ehlert, gaab, & heinrichs, 2001; heim, ehlert, & hellhammer, 2000). these differences may be attributable to different genetic predispositions and/or different amounts of stress experienced during the lifespan (ehlert, 2013). together, these findings underline the potential of cortisol for improving differential diagnostics. these findings have been extended by clinical studies, where a similar dichotomy ap‐ pears to prevail. in depression, the current state of research suggests that the higher a pa‐ tient’s pre-treatment cortisol levels, the lower their chances of responding to psychologi‐ cal therapy (fischer, strawbridge, herane vives, & cleare, 2017). in addition, initial at‐ tempts to improve memory performance in these patients have been undertaken using agents which act on glucocorticoid receptors (e.g., mifepristone) or influence cortisol synthesis (e.g., ketoconazole; soria et al., 2018). in anxiety disorders, the pattern seems to be reversed, insofar as lower cortisol levels predict worse treatment outcomes (fischer & cleare, 2017), although importantly, this only appears to be true for stimulated cortisol as measured during exposure sessions. this has been interpreted as an implication that a certain amount of cortisol is a prerequisite for patients to form an extinction memory, which is one of the key mechanisms underlying successful treatment for fear-related ill‐ nesses. more recent research suggests that this knowledge may be utilised to optimise ex‐ posure-based psychological therapy for anxiety disorders. for instance, meuret et al. (2016) were able to demonstrate that early-day exposure sessions (i.e., when endogenous cortisol levels are highest) led to greater clinical improvement in patients with panic dis‐ order and agoraphobia when compared to sessions held later on during the day. sex hormones, such as testosterone, oestradiol, and progesterone, are end products of the hypothalamic-pituitary-gonadal (hpg) axis (melcangi, giatti, & garcia-segura, 2016). they are mainly produced in the testes in men and in the ovaries in women, and their key function is to orchestrate reproduction and sexual functioning. however, sex steroids also act as neurosteroids (e.g., fostering neurogenesis and differentiation) in various parts of the brain, such as the hippocampus and prefrontal cortex. fischer & ehlert 5 clinical psychology in europe 2019, vol.1(2), article 33030 https://doi.org/10.32872/cpe.v1i2.33030 https://www.psychopen.eu/ in terms of mental disorders, the bulk of research to date has studied the role of sex steroids in sexual dysfunctions. testosterone, for instance, is lowered in men with erec‐ tile disorder (isidori et al., 2014), and hormonal (replacement) therapy has been proven to be useful in enhancing erectile function in hypogonadal men (corona et al., 2017; elliott et al., 2017) and sexual function in post-menopausal women (elraiyah et al., 2014). how‐ ever, long-term follow-up studies are scarce and potential adverse effects of exogenous testosterone (e.g., acne) need to be carefully weighed against the benefits. similarly, oes‐ trogens and combined oestrogen/progestogen treatments appear to enhance sexual func‐ tion in some post-menopausal women (nastri et al., 2013), but again, side effects need to be considered. these findings are important for any clinical psychologist advising pa‐ tients with sexual dysfunctions in terms of adjunct treatments. a burgeoning literature also demonstrates the involvement of sex hormones in other mental disorders, which is attributable to the aforementioned central expression of ste‐ roid receptors. in schizophrenia, it was shown that oestradiol and selective oestradiol re‐ ceptor modulators (e.g., raloxifene) can enhance memory and executive functions (soria et al., 2018). in addition, recent research suggests that sex steroids may exert positive ef‐ fects on mood. for instance, longer lifetime exposure to endogenous and exogenous oes‐ tradiol was found to be linked to fewer depressive symptoms during the menopausal transition (marsh et al., 2017), whereas greater fluctuations in endogenous oestradiol during the menopausal transition predicted more depressive symptoms in women report‐ ing high amounts of stress (gordon, rubinow, eisenlohr-moul, leserman, & girdler, 2016). these findings not only contribute to a more profound understanding of the symp‐ toms pertaining to psychotic and mood disorders, but may ultimately be put to use in or‐ der to guide (sex-oriented) treatment choices. how hormones affect hunger and satiety a number of hormones regulating hunger and satiety, such as ghrelin, leptin, or insulin, have been related to different mental disorders (drobnjak & ehlert, 2011). whereas the orexigenic hormone ghrelin is produced in the stomach, the anorexic hormones leptin and insulin are produced in adipose tissue and in the pancreas, respectively. all three hormones are capable of crossing the blood-brain barrier and thus directly influence en‐ ergy homoeostasis by acting on the hypothalamus. ghrelin, leptin, and insulin have, for the most part, been objects of research into eat‐ ing disorders. for instance, enhanced baseline ghrelin levels were reported in patients with eating disorders (prince, brooks, stahl, & treasure, 2009), likely as a consequence of restrained eating. importantly, elevated levels of ghrelin may in turn facilitate other dys‐ functional behaviours, such as hoarding food in anorexia nervosa or binge eating in buli‐ mia nervosa or binge eating disorder. furthermore, patients with anorexia nervosa have been found to present with increased insulin sensitivity, whereas patients with bulimia psychoneuroendocrinology and clinical psychology 6 clinical psychology in europe 2019, vol.1(2), article 33030 https://doi.org/10.32872/cpe.v1i2.33030 https://www.psychopen.eu/ nervosa or binge eating disorder exhibit decreased insulin sensitivity (ilyas et al., 2018). similar to ghrelin, these findings have been interpreted as being the result of dietary re‐ striction and weight loss/weight gain, respectively, while at the same time further contri‐ buting to dysfunctional eating patterns by affecting appetite regulation in the brain (i.e., diminishing/enhancing appetite). this is important knowledge when trying to make sense of the vicious circles that perpetuate eating disorders. evidence is now also accumulating that hunger and satiety hormones are abnormal in other mental disorders, mainly those presenting with metabolic symptoms and/or comor‐ bid metabolic diseases (e.g., diabetes mellitus). findings include elevated levels of leptin and insulin resistance in patients with psychotic disorders (greenhalgh et al., 2017; pillinger et al., 2017; stubbs, wang, vancampfort, & miller, 2016) and depressive disorders (kan et al., 2013). notably, these seem to be independent of bmi and intake of antipsy‐ chotic medication (which are known to have several metabolic side effects). this suggests that these hormonal abnormalities are not a mere consequence of lifestyle behaviours as‐ sociated with suffering from a chronic illness, but may be antecedents of highly debilitat‐ ing ancillary symptoms pertaining to psychotic and depressive disorders. importantly, recent studies support the notion that endogenous ghrelin and leptin may also influence treatment outcomes: whereas increases in ghrelin predicted non-re‐ sponses to treatment with lithium-augmented antidepressants in patients with depres‐ sion (ricken et al., 2017), leptin was positively linked to increases in bmi (ricken et al., 2016). in terms of ghrelin, the observed increases in non-responders could be interpreted as being secondary to reduced appetite, a core symptom of severe depression. in terms of leptin, synergistic actions with lithium on the serotonergic system could have resulted in an attenuation of leptin’s anorexic effect, but more research is warranted to investigate the intricate interplay between the two systems. these findings are important to consider by clinicians prescribing psychoactive drugs, and will hopefully allow the adjusting of treatments to the needs of the individual patient in the future. summary and integration it is evident from this brief overview that hormones are intrinsic to both the development and maintenance of mental disorders, and there are several conceivable ways in which this knowledge may be useful to clinical psychology. first, neuroendocrine research should find its way into clinical practice when clinicians and patients are developing multidimensional illness models together, such as at the beginning of psychological ther‐ apy. this is important given that mental disorders are still stigmatised by a large propor‐ tion of the general population due to lay concepts about their origins (e.g., depressive dis‐ orders being seen as a lack of willpower). second, endocrine markers may be used to aid the (differential) diagnostics of mental disorders. this is important in light of the fact that not all aspects of mental health are accessible by means of introspection, let alone by in‐ fischer & ehlert 7 clinical psychology in europe 2019, vol.1(2), article 33030 https://doi.org/10.32872/cpe.v1i2.33030 https://www.psychopen.eu/ dividuals who suffer from deficits in detecting and reporting signs of psychological dis‐ tress (e.g., those scoring high on alexithymia). similarly, hormones may be used to assess treatment outcomes above and beyond self-report symptom measures or clinical rating scales. these ideas align well with the us national institute of mental health (nimh) re‐ search domain criteria (rdoc), which aim to provide more precise characterisations of a patient by integrating biological and psychological research (e.g., insel et al., 2010). to this end, a matrix combining five psychological domains (social processes, arousal/regu‐ lation, negative valence, positive valence, and cognition) with different units of analysis (genes, molecules, cells, neural circuits, physiology, behaviour, self-reported information, and paradigms) has been proposed. this allows for a particular state of mental illness to be described by deficits in different psychological domains, which map on to specific bio‐ logical substrates (e.g., neuroendocrine abnormalities). third, the results of neuroendo‐ crine testing may guide treatment choices, that is, they may support clinicians in finding out what is likely to work for whom and why. this resonates well with the central tenet of precision psychiatry, which advocates the tailoring of treatments to the needs of the individual patient by integrating data from multiple levels of information (e.g., biological, personality, and behavioural measures). on a related note, alternative or additional treat‐ ments for mental disorders may be developed that are based on a more in-depth account of patients’ pathophysiology (e.g., hormonal substitution as an augmentation to psycho‐ logical therapy). in the foreseeable future, clinical psychology is likely to benefit from a number of emerging trends in psychoneuroendocrinological research. elucidating the genetic and epigenetic underpinnings of endocrine functioning will be crucial to fully comprehend its role in mental disorders. as both the distribution and sensitivity of endocrine receptors are governed by genetic variation as well as by the individual’s epigenetic make-up (e.g., dna methylation), this could ultimately enable the identification of patients who run the risk of developing mental illnesses. similarly, learning more about the cross-talk between different endocrine systems and between endocrine and other bodily systems (e.g., cen‐ tral monoaminergic systems) should allow for a more accurate description of how, pre‐ cisely, endocrine disturbances contribute to the onset of mental disorders – and provide more precise targets for additional or alternative treatment options. finally, the advent of novel methodologies to assess hormones in a reliable, non-invasive manner (e.g., finger‐ nail cortisol) holds the promise to translate neuroendocrine knowledge into clinical prac‐ tice – and hopefully to the benefit of patients and clinical psychologists alike. funding: the authors received no financial support for the research, authorship, and/or publication of this article. competing interests: the authors declare no conflicts of interest. acknowledgments: the authors have no support to report. psychoneuroendocrinology and clinical psychology 8 clinical psychology in 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(2013). psychoneuroendocrinology. in m. d. gellman & j. r. turner (eds.), encyclopedia of behavioral medicine. new york, ny, usa: springer. https://doi.org/10.1007/978-1-4419-1005-9 zilcha-mano, s., porat, y., dolev, t., & shamay-tsoory, s. (2018). oxytocin as a neurobiological marker of ruptures in the working alliance. psychotherapy and psychosomatics, 87(2), 126-127. https://doi.org/10.1159/000487190 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. fischer & ehlert 13 clinical psychology in europe 2019, vol.1(2), article 33030 https://doi.org/10.32872/cpe.v1i2.33030 https://doi.org/10.1016/j.neubiorev.2017.04.017 https://doi.org/10.1007/978-1-4419-1005-9 https://doi.org/10.1159/000487190 https://www.psychopen.eu/ psychoneuroendocrinology and clinical psychology (introduction) how hormones affect social interaction how hormones affect cognition, mood, and sexual function how hormones affect hunger and satiety summary and integration (additional information) funding competing interests acknowledgments references symptom perception from a predictive processing perspective scientific update and overview symptom perception from a predictive processing perspective giovanni pezzulo a, domenico maisto b, laura barca a, omer van den bergh c [a] institute of cognitive sciences and technologies, national research council, rome, italy. [b] institute for high performance computing and networking, national research council, naples, italy. [c] health psychology, university of leuven, leuven, belgium. clinical psychology in europe, 2019, vol. 1(4), article e35952, https://doi.org/10.32872/cpe.v1i4.35952 received: 2019-05-06 • accepted: 2019-08-13 • published (vor): 2019-12-17 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: giovanni pezzulo, institute of cognitive sciences and technologies, national research council, via san martino della battaglia 44, 00185 rome, italy. e-mail: giovanni.pezzulo@istc.cnr.it abstract background: bodily symptoms are highly prevalent in psychopathology, and in some specific disorders, such as somatic symptom disorder, they are a central feature. in general, the mechanisms underlying these symptoms are poorly understood. however, also in well-known physical diseases there seems to be a variable relationship between physiological dysfunction and self-reported symptoms challenging traditional assumptions of a biomedical disease model. method: recently, a new, predictive processing conceptualization of how the brain works has been used to understand this variable relationship. according to this predictive processing view, the experience of a symptom results from an integration of both interoceptive sensations as well as from predictions about these sensations from the brain. results: in the present paper, we introduce the predictive processing perspective on perception (predictive coding) and action (active inference), and apply it to asthma in order to understand when and why asthma symptoms are sometimes strongly, moderately or weakly related to physiological disease parameters. conclusion: our predictive processing view of symptom perception contributes to understanding under which conditions misperceptions and maladaptive action selection may arise. keywords somatic symptom disorder, medically unexplained symptoms, symptom perception, predictive coding, active inference this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i4.35952&domain=pdf&date_stamp=2019-12-17 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • there is a variable relationship between physiological dysfunction and selfreported symptoms. • we conceptualize symptom perception (and misperception) within a predictive processing perspective. • in this view, symptom perception integrates sensations and predictions about these sensations. • failures of such integration can produce misperceptions and maladaptive action selection. • we use the perception (and misperception) of asthma symptoms as an example. new developments in the conceptualization of how the brain works have recently emerged. these conceptualizations emphasize the predictive nature of the brain, hence are known as predictive coding or predictive processing views (clark, 2013; friston, 2010; hohwy, 2013). although the basic ideas underlying this conceptualization have been de‐ veloped by von helmholtz in the late 19th century, a strong impetus in recent years has been given by the thorough study of perception, especially of visual illusions. many per‐ ceptual phenomena can only be understood by assuming that meaningful perception is not just a matter of processing incoming information, but that it is also largely reliant on pre-existing (prior) information: often the brain unconsciously and compellingly assumes (or infers) non-given information to construct a meaningful percept. predictive processing views and their implications are currently explored in an in‐ creasing number of scientific areas. in neuroscience, the theory of "predictive coding" (friston, 2005; rao & ballard, 1999) describes how sensory (e.g., visual) hierarchies in the brain may combine prior knowledge and sensory evidence, by continuously exchanging top-down (predictions) and bottom-up (prediction error) signals. besides, interest in cre‐ ating intelligent systems enhanced the need to extend the predictive processing perspec‐ tive beyond perceptual processing, to address also action and planning (aka active infer‐ ence). pioneering work towards this goal has been done by karl friston and colleagues (friston et al., 2016; friston, fitzgerald, rigoli, schwartenbeck, & pezzulo, 2017; friston et al., 2015; friston, samothrakis, & montague, 2012; pezzulo, rigoli, & friston, 2018). in the present paper, we will first introduce some basic concepts of the predictive processing view of perception (called "predictive coding") and its extension to the action domain (called "active inference"). next, we will briefly describe their implications for symptom perception. the remainder of this paper will sketch a formal model of symptom percep‐ tion as viewed from a predictive processing perspective. symptom perception and predictive processing 2 clinical psychology in europe 2019, vol.1(4), article e35952 https://doi.org/10.32872/cpe.v1i4.35952 https://www.psychopen.eu/ predictive processing during perception (predictive coding) and action (active inference) a basic task of the brain is to construct an adaptive model of the (external and internal) world, while its only source of information to do so is the spatial and temporal patterning of its own neural activity. in order to achieve this goal, the brain uses information from neural activity that is triggered by peripheral input (sense organs and receptors in the peripheral body), but also from neural activity that is generated by the brain itself (aka spontaneous dynamics), reflecting previous experiences and “built in” information. this leads to two counterflowing streams of neural activation across several hierarchical lev‐ els of the brain: stimulation by peripheral input (called “likelihood” in the context of bayesian inference) interacts with activations generated by the brain that act as modelbased predictions of the input (“priors”) within a specific context. for example, if one is waiting for jeff in a crowded street, the brain generates neural patterns acting as priors that will facilitate spotting jeff in the crowd. the theory of "predictive coding" specifies how the brain may mechanistically imple‐ ment this kind of bayesian inference. according to predictive coding, input at each hier‐ archical level that is predicted is cancelled out (“explained away”), while unpredicted in‐ put creates prediction errors that are relayed to the next hierarchical level where it meets priors generating new prediction errors. prediction errors are thus propagated through the brain from very basic and concrete to higher abstract levels of representation to even‐ tually settle on a "posterior" belief (to be understood in the technical sense of a neural probability distribution, not as a conscious belief) that accounts for the stimulation with the least overall prediction errors. the posterior belief can subsequently act as prior for new input leading to further adaption in an iterative process. in the case of waiting for jeff: the benefit of having an a priori belief in the brain representing jeff is that it helps to quickly recognize him and to prime a network of related information for further interac‐ tion. obviously, there is also a downside of having highly active priors about jeff arriving soon: whenever input is downgraded to some extent, any person that resembles jeff will easily be mistaken for jeff. in sum, the theory of "predictive coding" postulates that the brain continuously strives to minimize its prediction error (and the difference between predictions and sensations). it does so by accommodating the prior hypothesis (or belief) and/or the model producing such hypothesis, to fit unpredicted information. for exam‐ ple, if jeff was expected but a female appears, the brain can revise the prior belief. fur‐ thermore, if jeff is wearing a fancy new cap and sunglasses which is discrepant infor‐ mation compared to previous encounters the model of jeff in the brain may be adapted (for example, by reducing the weight given to these aspects of visual input). the theory of "active inference" extends this view to also account for active compo‐ nents of perceptual processing (active perception) and goal-directed behavior. in this per‐ pezzulo, maisto, barca, & van den bergh 3 clinical psychology in europe 2019, vol.1(4), article e35952 https://doi.org/10.32872/cpe.v1i4.35952 https://www.psychopen.eu/ spective, the brain does not passively wait for sensory stimulations, but it can initiate ac‐ tivity to produce input that is consistent with its adaptive model. waiting for jeff may prompt the person to move towards a location providing a better overview of the passing crowd and/or to increase the scanning rate generating more detailed information to help spotting him; or even going to jeff's house, if he does not appear. as these examples of active inference illustrate, acting is just another way to reduce prediction error. in other words, while in predictive coding one reduces prediction errors by changing the prior be‐ lief to fit the world, in active inference one reduces prediction errors by changing the world to fit the prior belief (e.g., that one will encounter jeff). as this latter example illus‐ trates, in active inference the prior belief is much more than a prediction: it can play the role of a cognitive goal that triggers a goal-directed plan (e.g., a plan to go to jeff's house). the importance of precision control priors and prediction errors (pe’s) can be thought of as probability distributions of neural activity capturing statistical regularities associated with a specific input. these distribu‐ tions are characterized by a variance, or its inverse: precision. highly precise priors and prediction errors reflect that a neural pattern has a high probability of being associated with a particular input, and conversely for low precise priors and pe’s. if jeff is unusually tall, both priors and pe’s representing jeff’s height are highly precise, resulting in a quick and reliable recognition of jeff. repeated encounters will also generate precision expecta‐ tions, that is: not only is the perceptual information related to jeff’s “height” highly pre‐ cise, the brain will learn to consider “height” as a highly precise prior for recognizing jeff. precision parameters of both pe’s and priors are used as weighting factors in bayesi‐ an inference and predictive coding: they determine the relative contributions of prior in‐ formation and sensory evidence to the brain's "posterior belief" and thus the content of perception. highly precise priors and low precise pe’s will shift the posterior belief to‐ wards the prior, while the reverse is true with low precise priors and highly precise pe’s (see figure 1 for a graphical illustration of integration of prior and sensory evidence in bayesian inference). for example, when it is dark, there is a high probability to recognize jeff in any tall person, reflecting a strong effect of the prior on the eventual perception. conversely, on a sunny day it is less likely to take any tall person for jeff and this likeli‐ hood is even further reduced if one is not waiting for jeff. symptom perception and predictive processing 4 clinical psychology in europe 2019, vol.1(4), article e35952 https://doi.org/10.32872/cpe.v1i4.35952 https://www.psychopen.eu/ figure 1. integration of prior knowledge and sensory evidence (likelihood) in bayesian inference. note. the top panel shows that if prior and likelihood have the same precision (i.e., inverse variance of the gaussian distribution), the posterior belief is in between. the second and third panels show that higher precision prior and likelihood "attract" the posterior, respectively. note that in all cases, the precision of the posterior increases compared to the prior. see the main text for explanation. precision parameters of sensory events play an additional role in (active) perceptual in‐ ference and information gathering. information sources that are assumed to bring more precise information are preferentially sampled, while those that are assumed to bring im‐ precise information can be ignored (e.g., looking for jeff in the total dark is useless and thus avoided). in sum, perception can be considered a dynamic constructive process balancing exter‐ nal input and pre-existing information: under some conditions, the eventual percept closely reflects the external input, while in other conditions it may more closely reflect pre-existing information that act as (implicit) prior expectations. perceptual illusions can be considered extreme cases where the percept is (almost) entirely determined by prior expectations (pezzulo, 2014; sterzer et al., 2018). furthermore, perception has active (in‐ formation gathering) components that permit sampling information from the most pre‐ cise information sources but can lead to inattention or even neglect when precision pa‐ rameters are not set correctly (parr & friston, 2018). pezzulo, maisto, barca, & van den bergh 5 clinical psychology in europe 2019, vol.1(4), article e35952 https://doi.org/10.32872/cpe.v1i4.35952 https://www.psychopen.eu/ predictive processing and symptom perception one of the research areas for which these new conceptualizations are particularly fruitful is interoception, which is considered to play an important role in the experience of the self, agency, emotion and psychopathology (allen, levy, parr, & friston, 2019; barca & pezzulo, 2019; iodice, porciello, bufalari, barca, & pezzulo, 2019; pezzulo, barca, & friston, 2015; pezzulo, maisto, barca, & van den bergh, 2019; pezzulo, rigoli, & friston, 2015; seth, 2013; tsakiris & preester, 2018). the embodied predictive interoception cod‐ ing model (epic; barrett & simmons, 2015) describes the neural architecture and func‐ tional characteristics of interoception, suggesting a critical role for active inference: vis‐ ceromotor cortices generate autonomic, hormonal and immunological predictions to ade‐ quately deal with anticipated demands while pe’s are fed back to the brain to adapt and modify subsequent predictions. because visceromotor cortices are overall relatively in‐ sensitive to somatic input, interoception is largely dominated by prior expectations (“a construction of beliefs that are kept in check by the actual state of the body”, barrett & simmons, 2015, p. 424). being critical for symptom perception, this account of interocep‐ tion allows and suggests important variability in the relationship between symptoms and peripheral bodily dysfunction. this has tremendous conceptual and practical implications for medicine. indeed, while the relationship between self-reported symptoms and parameters of pe‐ ripheral bodily dysfunction is generally strong in acute monosymptomatic health condi‐ tions, it becomes typically much weaker in chronic multisymptomatic conditions (janssens, verleden, de peuter, van diest, & van den bergh, 2009). in a substantial num‐ ber of cases no relationship with physiological dysfunction can be found at all. hence, the latter are often called “medically unexplained symptoms” (mus). the prevalence of mus in primary care consultations is estimated around one third, while prevalence rates in secondary care are even higher (de waal, arnold, eekhof, & van hemert, 2004; nimnuan, hotopf, & wessely, 2001). in secondary care general medicine, the symptoms often appear as functional syndromes, such as chronic fatigue, fibromyalgia, irritable bowel disease, multiple chemical sensitivity, bodily distress disorder, while in psychiatry they are labeled as somatic symptom disorder, somatization disorder, conversion disorder, etc. however, also placebo and nocebo phenomena which are abundantly present in ev‐ eryday medicine are difficult to understand within a strict biomedical disease model. the predictive processing perspective allows to describe the conditions moderating the relationship between symptoms and bodily dysfunction (van den bergh, witthöft, petersen, & brown, 2017), to explain pseudoneurological symptoms and conversion (edwards, adams, brown, pareés, & friston, 2012), persistent physical symptoms (henningsen et al., 2018), placebo effects (büchel, geuter, sprenger, & eippert, 2014) and pain perception (wiech, 2016). however, most current models appeal to the mechanisms of predictive coding, while disregarding action components (or active inference) that are equally important to understand symptoms and psychopathological conditions. symptom perception and predictive processing 6 clinical psychology in europe 2019, vol.1(4), article e35952 https://doi.org/10.32872/cpe.v1i4.35952 https://www.psychopen.eu/ below, we discuss a worked example of symptom perception in terms of underlying predictive coding and active inference dynamics. our example focuses on asthma percep‐ tion. asthma relies on a well-known physiological dysfunction but often the symptoms do not clearly relate to that dysfunction, which is a rather prevalent clinical problem (de peuter et al., 2005; janssens et al., 2009). our example describes the conditions for a strong, weak or absent relationship between symptoms and bodily input. a worked example of symptoms and the body: the case of asthma perception consider the simplified case of an asthmatic person who feels two bodily sensations (e.g., wheezing, breathlessness) that sometimes indicate the beginning of an asthma episode. the person has to infer whether it is an asthma episode (hypothesis 1) or not (hypothe‐ sis 2), based on what he currently feels (e.g., wheezing, breathlessness) and his prior be‐ lief (e.g., the fact that he/she is in the bedroom where he usually has asthma episodes). generative model and inference from the formal perspective of predictive coding (and more broadly, bayesian inference), the brain makes this inference using a so-called "generative model" of how its sensations are generated. the "generative model" has two essential components. the first one ("like‐ lihood model") describes the probabilistic mapping between sensations (e.g., wheezing, breathlessness) and the two competing hypotheses (hypothesis 1: this is an asthma epi‐ sode; hypothesis 2: this is not) which in this context are also called "hidden" states, be‐ cause they cannot be directly observed but need to be inferred. for example, a good like‐ lihood model of asthma may represent the fact that under hypothesis 1 (this is an asthma episode), the probability of feeling wheezing is high (e.g., 0.8). however, under hypothe‐ sis 2 (this is not an asthma episode), the probability of feeling wheezing is very low (e.g., 0.05). in other words, the person should expect to feel wheezing (only) if he is experienc‐ ing an asthma episode. furthermore, the likelihood model may represent the fact that breathlessness has the same probability (e.g., 0.6) under hypotheses 1 and 2 (and more broadly, that one can feel breathless for many other reasons, such as because one has done physical exercise). a consequence of having this particular likelihood model is that while wheezing is very informative (i.e., feeling wheezing tells me with high probability that hypothesis 1 is true; and not feeling wheezing tells me with high probability that hypothesis 2 is true), breathlessness is not, as it cannot disambiguate between hypothe‐ ses 1 and 2. the second component of the generative model is the person’s "prior belief" about the two hypotheses 1 and 2. for example, if the asthmatic person is in the bedroom where he frequently experienced asthma episodes in the past, he may have a high prior pezzulo, maisto, barca, & van den bergh 7 clinical psychology in europe 2019, vol.1(4), article e35952 https://doi.org/10.32872/cpe.v1i4.35952 https://www.psychopen.eu/ belief (e.g., 0.7) for hypothesis 1. if we assume for simplicity that hypotheses 1 and 2 are mutually exclusive, and there are no alternative hypotheses, then the prior probability of hypothesis 2 is just one minus the prior probability of hypothesis 1; that it, 0.3. we can use these figures to calculate the (posterior) probability of the two (mutually exclusive) hypotheses 1 and 2, according to bayes' rule: posterior of hyp1 = prior of hyp1 * likelihood of hyp1 prior of hyp1 * likelihood of hyp1 + prior of hyp2 * likelihood of hyp2 posterior of hyp2 = 1  −  posterior of hyp1 imagine the person is currently experiencing wheezing and is in the bedroom where he frequently experiences asthma episodes. we can use the numbers above to calculate the posterior probability (or belief) about hypotheses 1 and 2, as follows: posterior of hyp1 = 0.7 * 0.8 0.7 * 0.8  + 0.3 * 0.05   =   0.9739 therefore, in this example, the posterior probability of hyp1 is 0.9739 and the posterior probability of hyp2 is one minus 0.9739, that is, 0.026. this means that in this situation, the person would have a very strong belief (in probabilistic terms) about an asthma epi‐ sode. it is possible to use the same formula to simulate other possible situations. imagine that the same person is in the same room but does not feel any wheezing or breathless‐ ness. in this second example, the belief about an asthma episode would be much smaller (0.474 for hyp1) and the person should conclude that hypothesis 2 is correct. from bayes' rule to predictive coding note that we have illustrated our two examples in terms of bayesian inference, which cannot be directly computed by the brain. however, the theory of predictive coding sug‐ gests that the brain solves something analogous to the above bayes' formula, using a hi‐ erarchical neural architecture1. in this architecture, predictions (derived from prior beliefs) are propagated in a top-down manner, and they are compared with perceptual and inter‐ oceptive evidence (via the likelihood model). the result of the comparison is called pre‐ diction error, and is propagated bottom-up in the hierarchy, to help updating the (posteri‐ or) probability of the initial hypothesis. in our first example above, the brain would propagate a strong top-down prediction about an asthma episode (as the prior of hypothesis 1 is high); and because the intero‐ ceptive evidence (wheezing) is largely compatible with this hypothesis, the resulting pre‐ diction error that is propagated bottom-up would be relatively low. iterating this top1) note that predictive coding uses continuous probability distributions (e.g., gaussian) rather than the discrete distri‐ bution that we considered in the example of bayes' rule. for simplicity, we ignore this difference here. symptom perception and predictive processing 8 clinical psychology in europe 2019, vol.1(4), article e35952 https://doi.org/10.32872/cpe.v1i4.35952 https://www.psychopen.eu/ down (prediction) and bottom-up (prediction error) message passing would permit refin‐ ing the initial hypotheses, setting the posterior probability of hyp1 to a value where pre‐ diction error is minimized which in this case is (close to) 0.9739. in our second example above, the brain would propagate a strong prediction about an asthma episode, too. however, because the interoceptive evidence (not wheezing) is in‐ compatible with this hypothesis, the resulting prediction error would be very high and after some iterations, the inference would settle to a (posterior) probability of 0.474 for hyp1. precision weighting and its mis-regulation in psychopathology yet there is another aspect of bayesian inference and predictive coding that we have ig‐ nored for now but is central to theories of psychopathologies. all the aforementioned top-down and bottom-up signals are weighted by their precision. technically, precision is the inverse variance of a probability distribution (e.g., a continuous distribution, such as a gaussian) and it can be used as a weight to each of the elements (priors and likelihoods) of the above bayes' rule with the effect that the more precise information has a stronger effect on the computations of the posterior probability, see figure 1. precision weighting is a convenient way to give more credit to the most reliable information sources and dis‐ card noisy evidence. for example, there may be conditions in which i cannot be sure about my sensory or interoceptive evidence (e.g., i don't know how i feel); in these cases, the evidence has to be down-weighted and thus the prior dominates the inference. trusting the prior is of course something sensible to do when evidence is scarce or unreliable. however, there are other and more pathological cases in which the prior may acquire a very high precision and dominate the inference, even if this is not optimal; and this may constitute a route to mus. let's expand our second example above (i.e., the case when one has a strong prior but no evidence for an asthma episode) by also considering that both the prior and the likelihood are weighted according to some precision value. if the precision of the prior is (for some reason) excessively high, one can obtain posterior probabilities for hyp1 that are much higher than our previous example (i.e., very close to prior probabilities, as in the central panel of figure 1). the person would thus conclude incorrectly that he/she is experiencing an asthma episode. furthermore, given that the predictive coding architecture continuously generates predictions about what it expects, the same person may also predict or "hallucinate" the wheezing that he is not experienc‐ ing (because it is highly compatible with the winning hypothesis 1). this example illustrates that priors that have acquired an excessively high precision may dominate the inference and fail to be correctly updated based on empirical evidence thus potentially producing mus. how can priors acquire unwarrantedly high precision? while accurate predictive coding requires the precision of top-down and bottom-up sig‐ nals to be optimized (and would thus not produce mus), there may be various pathologi‐ cal conditions that can lead to their mis-regulation. these may include deficits of neuro‐ pezzulo, maisto, barca, & van den bergh 9 clinical psychology in europe 2019, vol.1(4), article e35952 https://doi.org/10.32872/cpe.v1i4.35952 https://www.psychopen.eu/ modulators like dopamine and noradrenaline, which in predictive coding are carriers of precision signals; or the exposure to the "wrong" environmental statistics, like when growing up with a chronically ill or health-anxious parent. these and other condition may lead to the formation of excessively precise priors that resist updating; and it is un‐ der these conditions that mus may emerge. a second possible way mus (or similar phenomena) may emerge is the converse of the above example; and namely, when likelihoods have excessively (pathologically) low precision. some pathologies may be related to deficits of interoceptive processing, in which one "does not know how he/she feels" (e.g. alexithymia, affective agnosia; lane, weihs, herring, hishaw, & smith, 2015) or cannot easily attribute some interoceptive sensation (e.g., wheezing) to some cause (e.g., an asthma episode). in these cases, because the interoceptive signals are assigned a vanishingly small precision, they would be large‐ ly ignored during the inference and again, the prior would dominate it. from predictive coding to active inference we discussed how, under a predictive coding scheme, deficits of precision weighting in either the prior or the likelihood (or both) can lead to maladaptive perceptual inference and mus. the theory of active inference expands this view, by introducing additional ways these deficits may hinder correct inference and action selection. here we focus on just one aspect of active inference: the fact that it induces an active sampling of informa‐ tion that is expected to have informative value, i.e., to gather relevant evidence. when describing the asthmatic person's generative model, we have considered that wheezing is more informative than breathlessness, as the presence or absence of the for‐ mer (but not the latter) disambiguates between hypotheses 1 and 2. active inference as‐ sumes that informative evidence is not passively gathered (as in predictive coding) but actively sampled; for example, by monitoring or directing attention to the relevant infor‐ mation sources (e.g., "attention to bodily signals"). active inference would thus predict that under normal conditions, the asthmatic person should preferentially monitor and di‐ rect attention to its most informative signal: wheezing. yet, one can imagine a degenerate (technically, high-entropy) likelihood function, in which wheezing as a source of interoceptive evidence has degraded to a sensation that has exactly the same probability under both hypotheses 1 and 2. in this case, monitoring wheezing would be useless, as it would bring exactly the same evidence for the two hy‐ potheses. if a person's (likelihood) model of his bodily signals were degenerate, not only he would fail to recognize asthma symptoms, but he would also cease to attend to them and more broadly, to pay attention to his bodily signals, similar to a form of "neglect" (parr & friston, 2018). in this case, he would only be able to infer asthma from the prior belief or other, non-bodily sources of information (e.g., what the others around me be‐ lieve about my asthma) that may not be particularly reliable. ignoring bodily signals symptom perception and predictive processing 10 clinical psychology in europe 2019, vol.1(4), article e35952 https://doi.org/10.32872/cpe.v1i4.35952 https://www.psychopen.eu/ would thus render this person prone to mus, as well as to deficits of body schema and self-representations that may have a strong bodily basis (pezzulo, 2014; seth, 2013). a degenerate (likelihood) model of bodily signals may arise from neurological or pe‐ ripheral disorders that make bodily signals noisier. however, it can also be the conse‐ quence of a poor learning and developmental processes, which can lead to the acquisition of internal models that are insufficiently differentiated and do not permit to appropriate‐ ly categorize one's own interoceptive signals (petersen, schroijen, mölders, zenker, & van den bergh, 2014). conclusions we discussed symptom perception and mus from the perspective of predictive coding and active inference. our examples illustrate the fact that there are various ways by which the components of a person's generative model (prior and likelihood) can be as‐ signed too high or too low precision or become "unbalanced". this, in turn, may produce (momentary) incorrect inference or action selection or (more chronic) psychopathologi‐ cal conditions. formal theories like predictive coding and active inference can help dissecting these possibilities and identifying their markers during development. however, these conceptu‐ al models also imply important challenges to test and validate them. one way is to flesh out a computational version of the model involving a clear mechanistic description of the critical variables and their interactions, to run simulations and compare the results with evidence from real life (friston et al., 2017; petzschner, weber, gard, & stephan, 2017; stephan et al., 2016). funding: the authors received no financial support for the research, authorship, and/or publication of this article. competing interests: the authors declare no conflicts of interest. acknowledgments: the authors have no support to report. references allen, m., levy, a., parr, t., & friston, k. j. 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(2018). the predictive coding account of psychosis. biological psychiatry, 84(9), 634-643. https://doi.org/10.1016/j.biopsych.2018.05.015 tsakiris, m., & preester, h. d. (2018). the interoceptive mind: from homeostasis to awareness. oxford, united kingdom: oxford university press. van den bergh, o., witthöft, m., petersen, s., & brown, r. j. (2017). symptoms and the body: taking the inferential leap. neuroscience and biobehavioral reviews, 74(pt a), 185-203. https://doi.org/10.1016/j.neubiorev.2017.01.015 wiech, k. (2016). deconstructing the sensation of pain: the influence of cognitive processes on pain perception. science, 354(6312), 584-587. https://doi.org/10.1126/science.aaf8934 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. symptom perception and predictive processing 14 clinical psychology in europe 2019, vol.1(4), article e35952 https://doi.org/10.32872/cpe.v1i4.35952 https://doi.org/10.1016/j.biopsych.2018.05.015 https://doi.org/10.1016/j.neubiorev.2017.01.015 https://doi.org/10.1126/science.aaf8934 https://www.psychopen.eu/ symptom perception and predictive processing (introduction) predictive processing during perception (predictive coding) and action (active inference) the importance of precision control predictive processing and symptom perception a worked example of symptoms and the body: the case of asthma perception generative model and inference from bayes' rule to predictive coding precision weighting and its mis-regulation in psychopathology from predictive coding to active inference conclusions (additional information) funding competing interests acknowledgments references perceived criticism and family attitudes as predictors of recurrence in bipolar disorder research articles perceived criticism and family attitudes as predictors of recurrence in bipolar disorder claudia lex 1,2 , martin hautzinger 3 , thomas d. meyer 4 [1] department of psychiatry, villach general hospital, villach, austria. [2] department of psychology, university klagenfurt, klagenfurt, austria. [3] department clinical psychology and psychotherapy, eberhard karls university tuebingen, tuebingen, germany. [4] mcgovern medical school, louis a. faillace, md, department of psychiatry and behavioral sciences, university of texas hsc at houston, houston, tx, usa. clinical psychology in europe, 2022, vol. 4(1), article e4617, https://doi.org/10.32872/cpe.4617 received: 2020-10-29 • accepted: 2021-12-02 • published (vor): 2022-03-31 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: thomas d. meyer, mcgovern medical school, louis a. faillace, md, department of psychiatry and behavioral sciences, university of texas hsc at houston, 1941 east road (bbsb 3118), houston, texas 77054, usa. e-mail: thomas.d.meyer@uth.tmc.edu abstract background: bipolar disorder (bd) is a highly recurrent psychiatric condition. while combined pharmacological and psychosocial treatments improve outcomes, not much is known about potential moderators that could affect these treatments. one potential moderator might be the quality of interpersonal relations in families, for example, familial attitudes and perceived criticism. method: to explore this question we conducted a post-hoc analysis that used an existing data set from a previous study by our group that compared cognitive behavioral therapy (cbt) and supporting therapy (st) in remitted bd. in the present study, we used cox proportional hazard models. results: we found that the relatives’ ratings of criticism predicted the likelihood of depressive recurrences, especially in the st condition. the patients’ ratings of negative familial attitudes predicted the risk of recurrences in general, irrespective of the therapy condition. conclusion: these results suggest that it might be important to assess perceived criticism and familial attitudes as potential moderators of treatment outcome in bd. keywords bipolar disorder, cognitive behavioral therapy, expressed emotion, perceived criticism, illness course, family, psychotherapy this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4617&domain=pdf&date_stamp=2022-03-31 https://orcid.org/0000-0003-4523-3580 https://orcid.org/0000-0001-6082-2602 https://orcid.org/0000-0003-4236-7778 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • patients with bd had an increased risk for depressive recurrences when their relatives had rated themselves as highly critical towards the patients. this was only true for patients who attended an unspecific therapy instead of cbt. • patients with bd had an increased risk for depressive recurrences when they thought that their relatives had negative attitudes towards them. • there was no significantly increased risk for manic recurrences in relation or criticism or negative familial attitudes. bipolar disorder (bd) is a mental health condition characterized by depressive and hypo­ manic or manic episodes. while individuals experiencing bd can remit, it is considered a life-long condition and over 50% of patients with bd suffer at least one recurrence within two years (perlis et al., 2006; tohen et al., 2003). furthermore, functional impairments at work, home, or school, and in interpersonal relations often persist beyond sympto­ matic states of the disorder and despite medication (gitlin & miklowitz, 2017). these findings on long-term outcomes of bd have encouraged experts to develop and evaluate psychosocial and psychological therapies adjuvant to medication. the combination of psychological and pharmacological treatments overall improves the long-term outcome in bd (miklowitz & scott, 2009; swartz & swanson, 2014) but the evidence is mixed. a recent network analysis showed that the evidence is stronger for some therapies such as family focused therapy (fft) or cognitive behavior therapy (cbt) than others, but that these findings should be balanced against evidence that dropping out of cbt is more likely than for fft, and that efficacy varies depending on the outcome such as recurrence, depressive or manic symptoms (miklowitz et al., 2021). for example, fft seems to protect against recurrences, especially in families with greater levels of impairment (kim & miklowitz, 2004). cbt, however, was specifically associated with stabilizing depressive symptoms (miklowitz et al., 2021). in general, more studies are needed to determine under what circumstances which form of psychological therapy is most effective. one potential factor or moderator of outcome in bd could be the quality of interper­ sonal relations, because similar to other psychiatric disorders (e.g. grover & dutt, 2011; hooley & teasdale, 1989; weintraub et al., 2017) it has been suggested that characteristics of familial relations may also predict outcome in bipolar depression (johnson et al., 2016). in regard to bd, criticism expressed by families when interacting with their ill relative predicted hospital admissions (scott et al., 2012) and relapse (rosenfarb et al., 2001). also, high expressed emotion, which is a construct that is characterized by critical com­ ments, hostility, and emotional over-involvement that family members express towards an affected relative (kavanagh, 1992; vaughn & leff, 1976), predicted relapses as does a communication style called ‘negative affective style’ (miklowitz et al., 1988; o’connell et al., 1991). finally, two studies found that perceived criticism and expressed emotion predictors of expressed emotion 2 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ were specifically associated with depressive rather than with manic recurrences (kim & miklowitz, 2004; yan et al., 2004). most of the before mentioned studies looked at the natural course of bd. in order to examine if perceived criticism and hostile/critical attitudes influence the effect of cbt on recurrences in bd, we reanalyzed data previously collected in a randomized controlled trial (meyer & hautzinger, 2012). in this study individual cbt and supportive therapy (st) were administered to patients with remitted bd. cbt was manual-based including cognitive and behavioral strategies, techniques to prevent relapse, and coping strategies for symptoms (basco & rush, 1996). st was less structured and followed a client-centered approach. in the original study (meyer & hautzinger, 2012), it was found that the relapse rates did not significantly differ between the two therapy groups in the long run. however, a higher number of prior mood episodes and a lower number of attended therapy sessions were associated with less time to relapse in both groups, indicating that other potential factors shared by both groups influenced outcome. based on the evidence cited above, we hypothesized that higher levels of negative familial attitudes and perceived criticism expressed by the patients with bd and their relatives could be such a moderator of outcome. method participants initially, 141 individuals who were interested to participate in a study of psychological treatment for bd contacted our study team. they were either referred by local hospitals, psychiatrists or were self-referrals due to public information in newspapers, brochures, or radio. sixty-five individuals were excluded (figure 1), therefore, the present paper reports data relating to clinical course and attitudes of 76 participants who were random­ ized for a study on psychotherapy for bd (meyer & hautzinger, 2012). inclusion criteria were a diagnosis of bd, age between 18 and 65, informed consent to the present study, and adherence to their usual psychiatric treatments. participants with severe manic or depressive symptoms, i.e. scores > 20 on the bech-rafaelsen melancholia scale (brms; bech, 2002) or > 20 on the bech-rafaelsen mania scale (brmas; bech et al., 1978), were excluded. also, participants with comorbid substance dependency requiring detoxification and/or the presence of current psychotic symptoms could not participate in the present study. we obtained informed consent that included the consent to send a questionnaire to their spouse, or if single or divorced to their partner or closest relative (e.g. mother). lex, hautzinger, & meyer 3 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ figure 1 flow chart of the recruitment process note. not bd = individuals who were not diagnosed with bd. predictors of expressed emotion 4 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ procedures and measurements first, the participants were in a baseline screening session. they gave informed consent, were administered clinical interviews (e.g., scid-i and scid-ii), and completed selfand observer-rated measures (see for further details: meyer & hautzinger, 2012). then they were randomized either to an individual cbt or supportive therapy (st), which both contained individual 20 sessions over 9 months. the cbt followed a structured manual similar to the manual by basco and rush (1996), which included relapse prevention plans, coping strategies, and interpersonal skills. in the st a client centered approach was adopted focusing on whatever topics the individuals brought into the sessions. all ses­ sions were video-taped. qualified therapists who were at least in a 1-year postgraduate training led the sessions. in addition, all therapists attended a 2-day workshop relating to cbt and st therapy. raters who were blind to group allocation assessed conducted assessments at month 0, 3, 6, 9, 12, and 24 during the trial. information on recurrences was obtained by using repeatedly the scid-i modules for mood episodes during the follow-up but also by monitoring hospitalizations, clinical notes, and mood diaries of the participants. family attitude scale (fas) the fas (kavanagh et al., 1997) contains 30 items covering 4 key aspects of critical attitudes among close family members: criticism, hostility, anger, and warmth. the items are rated on a 5 point scale ranging from always (4) to never (0), therefore scores may range between 0 to 120. higher scores reflect higher levels of critical familial attitudes. we used two versions of the fas, one for patients (fas-p; e.g., “he/she thinks, that i am a real burden”) and one for relatives (fas-r; e.g., “he/she is a real burden”). the fas-p, therefore, reflects how the patient perceives the attitudes of his/her relative, while the relative reports in the fas-r how he/she feels about the patient and what he/she thinks about the patient. in order to obtain a german version, the senior author translated the original english version, and then a native english speaker did the backtranslation. the inconsistencies were discussed and finally removed. to our knowledge, the german fas has not been formally validated, but we published high internal consistencies for the fas-p (cronbach's α = 0.94) and for the fas-r cronbach's α = 0.95; lex et al., 2019). perceived criticism measure (pcm) the rating on a 10 point scale of the question "how critical is your relative of you?" has been used as a valid indicator of overall criticism in families (hooley & miklowitz, 2017; renshaw, 2007). therefore, in the pcm-p (hooley & teasdale, 1989) we asked the patients to rate the question “how critical has he/her been of you?”. parallel, the relatives self-rated their level of criticism with the question “how critical have you been of him/ her?” (pcm-r). although there is no recommended cutoff, higher scores reflect higher levels of criticism and a score above 6 raises concern about an increased relapse risk lex, hautzinger, & meyer 5 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ (masland & hooley, 2015). information about correlates of the german pcm scale can be found in lex et al. (2019). beck depression inventory (bdi) the bdi (beck et al., 1961) is a self-report questionnaire measuring the severity of depression. participants rate 21 items that correspond to depressive symptoms on a four-point scale from 0 to 3. scores above 9 reflect mild, and scores above 18 reflect moderate depression. in the present study, we used the validated german version with comparable psychometric properties compared to the english version (brieger et al., 2007; hautzinger et al., 1994). self rating mania inventory (srmi) the srmi (shugar et al., 1992) is a 47-item self-rating instrument that assesses manic and hypomanic symptoms. it can be used to assess acute symptoms or residual symptoms in remitted states. in the present study, we asked the participants to focus on the previous month when rating their (hypo)manic symptoms. scores above 14 reflect a high probability of acute mania. the srmi shows a good internal consistency (cronbach's α = 0.94) and high retest reliabilities between 0.79 and 0.93 (shugar et al., 1992). bech rafaelsen melancholia scale (brms) the observer-based brms (bech, 2002; smolka & stieglitz, 1999) has 11 items that relate to depressive symptoms and is used to rate the severity of depression. the rating for each items ranges from 0 (no symptom) to 4 (severe). a sum score ≤ 14 indicates no or doubtful depression, scores between 15 and 20 indicate mild depression, 21–28 indicate moderate depression, and scores above 28 reflect severe depression (lam et al., 2005). bech rafaelsen mania scale (brmas) the brmas (bech et al., 1978) has 11 items and the observer rates the presence of manic symptoms on a scale from 0 (not present) to 4 (severe). parallel to the brms, scores range between 0 and 44, and scores < 14 suggest no or doubtful mania, scores between 15 and 20 indicate mild mania, and scores above 20 are interpreted as moderate to severe mania (lam et al., 2005). the brmas shows good interrater reliabilities between 0.80 and 0.95 (e.g., bech, 2002). the brmas is often combined with the brms to cover the full range of bipolar symptoms (rossi et al., 2001). statistical methods hierarchical cox proportional hazard models were used to assess the relapse risk for depression in relation to the patients’ and the relatives’ assessments of familial attitudes and perceived criticism. the potential covariates were therapy condition (cbt vs. st; predictors of expressed emotion 6 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ block 1), attitudes (fas or pcm scores; block 2), and the interaction between therapy and attitudes (block 3). when looking at the recurrence risk for (hypo)manic events, srmi scores were entered at block 1, the subsequent blocks were the same as before. srmi scores were included, because in a previous analysis we found that the only baseline clinical variable that predicted recurrence of manic episodes was the level of subthreshold self-reported manic symptoms (bauer et al., 2017). with less than 5% of the corresponding z-scores being greater than 1.96, there were no outliers for the fas and pcm measures. there were no substantial bivariate correlations between predictors (see table 1) indicating that there was no problem with multicollinearity (field, 2013). in addi­ tion, bivariate listwise correlations and independent t-tests were used. the significance level was set at 5% for all statistical procedures, exact p values and effect size values will be displayed. table 1 bivariate listwise pearson correlations between predictors, fas, and pcm measures n = 76 fas-p pcm-p fas-r pcm-r therapy condition .05 .19 .17 .04 fas-p .48** .47** .29* pcm-p .30* .49** fas-r .40** note. fas-p = family attitude scale rated by patients; fas-r = family attitude scale rated by relatives; pcm-p = perceived criticism scale rated by patients; pcm-r = perceived criticism scale rated by relatives. *p < .05. **p < .01. results demographics the participants’ mean age was 43.96 (sd = 11.81) and included 38 women. thirty-two individuals were single, 31 were married, and 13 were divorced. sixty individuals were diagnosed with bd-i, and 16 were diagnosed with bd-ii. based on the scid-i, all partici­ pants were in full remission; looking at rating scales, most patients had scores below 15 on the brms (93.4%) and the brmas (98.7%). table 2 displays demographical and clinical data of the participants. the participants of cbt and st did not differ significantly on age, gender, clinical course of bd, and time until first relapse (meyer & hautzinger, 2012). also, conducting independent t-tests revealed that scores on the fas-p, t(66) = -.66, p = .51 and the pcm-p, t(66) = -1.47, p = .15, for the patients did not differ significantly between the two treatment conditions. similarly, the scores in the fas-r, t(62) = -.90, p = .37 and the pcm-r, t(61) = -.18, p = .85, were not significantly different in relatives of the patients who had been randomly assigned to cbt and st. lex, hautzinger, & meyer 7 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ table 2 means (m) and standard deviations (sd) of patients with bd who received either cbt or st variable cbt st m sd m sd age 44.40 11.00 43.53 12.72 bdi 13.53 9.23 11.03 7.60 brms 6.08 4.70 5.55 5.24 srmi 17.65 10.98 19.00 11.19 brmas 2.34 3.69 1.03 2.56 n of prior episodes 11.18 15.17 10.13 10.61 age of onset 26.63 9.24 29.84 12.44 weeks until relapse 54.95 46.36 50.08 51.64 patient fas 39.63 19.58 40.10 15.58 patient pcm 4.69 2.49 5.47 1.81 relative fas 33.08 15.99 36.68 16.18 relative pcm 4.88 2.31 4.97 1.64 note. bdi = beck depression inventory; brms = bech rafaelsen melancholia rating scale; brmas = bech ra­ faelsen mania rating scale; fas = family attitude scale; pcm = perceived criticism scale; srmi = self-rating mania inventory (meyer & hautzinger, 2012). cox proportional hazards models the cox proportional hazards model included the two measures of interest (fas and pcm), the therapy condition (cbt and st), and their interaction. first, the outcome was defined as recurrence of a depressive episode. table 3 contains the relevant outcome values of these analyses. two separate models were calculated: one for patients’ and one for relatives’ scores. although, the overall model for the patients was not significant; χ2 = 7.65, p = .18, the fas-p predicted significantly more recurrences of depressive episodes. the overall model for relatives was also not significant, χ2 = 6.27, p = .28, but pcm-r significantly interacted with therapy group in predicting depressive recurrences. specifically, increased pcm-r predicted a higher number of depressive recurrences in the st group but not in the cbt group (figure 2). predictors of expressed emotion 8 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ table 3 cox proportional hazards models testing fas and pcm as predictors of depressive recurrence variable b wald p hr 95% ci for hr χ2 pll ul patients model 1 0.16 .69 therapy .14 0.16 .69 1.15 0.57 2.31 model 2 6.38 .09 therapy .07 0.04 .84 1.08 0.53 2.19 fas-p .03 5.89 .01 1.03 1.01 1.06 pcm-p -.14 1.53 .22 0.87 0.70 1.08 model 3 7.65 .18 therapy -.74 0.54 .46 0.47 0.06 3.49 fas-p .04 2.94 .09 1.04 1.00 1.08 pcm-p -.28 2.63 .10 0.76 0.54 1.06 fas-p x therapy -.01 0.16 .69 0.99 0.94 1.04 pcm-p x therapy .24 1.16 .28 1.27 0.82 1.97 relatives model 1 0.36 .55 therapy .22 0.36 .55 1.25 0.61 2.57 model 2 2.27 .52 therapy .27 0.51 .48 1.32 0.62 2.80 fas-r .01 1.19 .28 1.01 0.99 1.04 pcm-r .03 0.06 .81 1.03 0.83 1.27 model 3 6.27 .28 therapy 1.82 2.12 .15 6.19 0.53 71.92 fas-r -0.01 0.27 .61 0.99 0.96 1.03 pcm-r 0.40 3.52 .06 1.50 0.98 2.28 fas-r x therapy 0.03 1.68 .20 1.03 0.98 1.09 pcm-r x therapy -0.52 4.43 .03 0.59 0.37 0.97 note. b = regression coefficient; fas-p = family attitude scale rated by patients; fas-r = family attitude scale rated by relatives; pcm-p = perceived criticism scale rated by patients; pcm-r = perceived criticism scale rated by relatives; hr = hazard ratio; srmi = self rating mania scale; wald = wald test. lex, hautzinger, & meyer 9 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ figure 2 percentage of participants with a depressive recurrence whose pcm-r scores were below/on and above the median note. cbt = cognitive behavioral therapy; pcm-r = perceived criticism scale rated by relatives; st = supportive therapy. when the outcome was defined as recurrence of (hypo)manic episodes, the overall models for patients (χ2 = 11.89, p = .07) and for relatives (χ2 = 7.34, p = .29) were not significant. in both models, the score of the srmi was the only significant predictor of manic recurrences (table 4). table 4 cox proportional hazards models testing fas and pcm as predictors of (hypo)manic recurrence variable b wald p hr 95% ci for hr χ2 pll ul patients model 1 5.11 .02 srmi .04 4.92 .03 1.04 1.01 1.08 model 2 6.01 .05 srmi .04 5.00 .03 1.04 1.01 1.08 therapy .44 1.05 .31 1.55 .67 3.56 predictors of expressed emotion 10 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ variable b wald p hr 95% ci for hr χ2 pll ul model 3 10.01 .04 srmi .05 6.63 .01 1.05 1.01 1.09 therapy .37 .74 .39 1.45 .62 3.37 fas-p -.01 .66 .42 .99 .95 1.02 pcm-p -.12 1.10 .29 .88 .70 1.11 model 4 11.89 .07 srmi .06 8.12 .004 1.07 1.02 1.11 therapy -.30 .05 .82 .74 .06 9.18 fas-p -.05 3.23 .07 .95 .90 1.01 pcm-p .05 .07 .77 1.05 .73 1.51 fas-p x therapy .06 2.56 .11 1.06 .99 1.13 pcm-p x therapy -.29 1.26 .26 .75 .45 1.24 relatives model 1 4.24 .04 srmi .04 4.13 .04 1.04 1.00 1.08 model 2 4.86 .09 srmi .04 4.25 .04 1.04 1.00 1.08 therapy .37 .70 .40 1.44 .61 3.40 model 3 6.50 .17 srmi .05 4.93 .03 1.05 1.00 1.08 therapy .41 .85 .36 1.51 .63 3.64 fas-r .001 .01 .95 1.00 .97 1.03 pcm-r -.13 1.38 .24 .88 .70 1.09 model 4 7.34 .29 srmi .04 4.48 .03 1.05 1.00 1.09 therapy 1.27 .86 .35 3.58 .24 52.50 fas-r .004 .02 .89 1.00 .95 1.06 pcm-r -.03 .02 .90 .97 .58 1.62 fas-r x therapy -.01 .06 .80 .99 .93 1.06 pcm-r x therapy -.12 .18 .67 .89 .51 1.55 note. b = regression coefficient; fas-p = family attitude scale rated by patients; fas-r = family attitude scale rated by relatives; pcm-p = perceived criticism scale rated by patients; pcm-r = perceived criticism scale rated by relatives; hr = hazard ratio; srmi = self rating mania scale; wald = wald test. discussion the present study explored whether negative familial attitudes and perceived criticism predicted recurrences in euthymic individuals with bd who attended individual cbt or lex, hautzinger, & meyer 11 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ st. in general, there was no significant difference in risk of recurrence between the two groups (meyer & hautzinger, 2012), but the present post-hoc exploration showed that the relatives’ rating of their own perceived criticism towards the patient influenced the likelihood of depressive recurrences to a greater extent in the st than in the cbt condi­ tion. in addition, the patients’ perception of the family climate was related to the risk of depressive recurrences. there was no significant link between indicators for the familial climate and the risk for manic recurrences. these results are in line with previous studies that report familial criticism was linked to depressive relapse and symptoms but not to mania (kim & miklowitz, 2004; yan et al., 2004). at first sight, the interaction between treatment condition and self-rated perceived criticism of the relatives towards the patient (pcm-r) remains puzzling. however, the wording of the item for relatives refers to how much they see themselves being critical of the patients. the data therefore suggests that admitting more critical comments on side of the relatives increased risk for depressive recurrences specifically in the st group, while it did not make a difference in the cbt group. one goal of the manual-based cbt was to help patients to differently communicate and solve problems which often includes how to react to perceived criticism. although this is speculative, this perhaps helped to protect against being criticized or differently to react to perceived criticism. for example, the patients might learn to attribute critical remarks to their relatives’ mood or the specific situation instead to their own person. in st, the patients did not specifically learn communication or coping skills, therefore pre-treatment differences in actual or perceived criticism by the relative might still have had the same effect on risk of recurrence as having had no treatment, while cbt helped to attenuate the effect of this factor. while the latter is a potential explanation of the differential effect, it remains unclear why the relatives’ but not the patients’ perception of criticism had an impact on recurrence rates. this is puzzling because a) pc measures were administered at baseline, i.e. before the therapy sessions started, b) the pc of patients and relatives were positively correlated at baseline, and c) both therapies were done in an individual and not in a couple or family setting. in addition, while it is an intriguing idea that individual cbt might be effective in families with a hostile and critical climate, it is important to keep mind that these conclusions are exploratory and based on post-hoc analyses. regardless of the condition, patients who perceived their familial climate as more hostile had an increased risk for depressive recurrences. this is in line with previous studies that found that expressed emotions were linked to more depressive symptoms (kim & miklowitz, 2004) and recurrences (yan et al., 2004). those studies, however, used observer-based assessments based on frequency counts of critical and hostile behavior while we assessed the familial climate with questionnaires. the mostly used version of the fas is self-rated by the patient and asks for specific thoughts, behaviors and feelings expressed by the relative towards the patient (e.g., “he/she loses his/her temper with me”; “he/she thinks i am real burden”; “he/she feels very close to me”). the pa­ predictors of expressed emotion 12 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ tient-rated fas was found to be related to relapse in patients with psychosis (pourmand et al., 2005), and its content rather taps into hostility and criticism than to emotional overinvolvement, which is considered as one of the key factors of expressed emotion (kavanagh et al., 1997). in the present study, we also used a relatives’ version of the fas, and we found that it did not significantly predict the risk of recurrences. although observer-rated measures, e.g., the camberwell family interview (leff & vaughn, 1985), are regarded as the gold standard to assess the familial climate (hooley & parker, 2006), our results suggest that the patient-rated fas could be a sensible instrument to tap intrafamilial hostility and criticism and to predict depressive recurrences in bd. it is essential to keep in mind that in the fas the patient reports his/her perception of the family member’s attitudes and feelings, while the relative reports how he/she actually feels and what he/she thinks. interestingly, the relatives’ one-item measure pcm interacted with therapy group to predict relapses, while the patients’ fas predicted relapses regardless of the treatment condition. first, this result emphasizes the importance to assess criticism and hostility in both interaction partners, because it is still not clear how the reciprocity of interactions relate to hostility, criticism and expressed emotion (hooley & gotlib, 2000). for example, hostility expressed by a relative’s remark could be escalated or descaled depending on the response by the patient. second, patients’ actual perceptions of the attitudes are important, because the patient might or might not identify the hostility and criticism expressed by the relative (yan et al., 2004). while the fas and pcm share variance, they do not assess identical constructs (lex et al., 2019). while perceived criticism, whether rated by the patient or relative, is fairly specific, the fas encompasses more general negative attitudes within the family beyond critical comments. possibly, in patients this perception of criticism can be better measured by ratings of a range of specific behaviors, feelings and thoughts, i.e., fas, while in relatives the one-item measure pcm might be sufficient. this is one of the few studies in which criticism and hostile familial attitudes, two key elements of expressed emotion, were rated by the affected individuals and their relatives themselves instead by observers. although the pcm and the fas have empirical evidence to predict relapse similar to the more time consuming interviews or observations of actual family interactions (chambless & blake, 2009; hooley & parker, 2006; kavanagh et al., 1997), relying solely on self-reports is a limitation of the study. also, emotional overinvolvement as a key factor of expressed emotion was not assessed. we also received information from only one relative who might not be the one who necessarily was the most critical or most relevant person for the patient. some studies suggest that the kind of relation between the relative and patient might play a crucial role (hooley, 2007). finally, as mentioned before, these were post hoc analyses, therefore the study was probably not powered to test for these interactions which is probably reflected in the non-significant overall models. lex, hautzinger, & meyer 13 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://www.psychopen.eu/ conclusions despite this limitations, we found preliminary evidence that perceived criticism and familial attitudes in individuals with bd and their relatives were associated with an increased risk for depressive recurrences. specifically, the relatives’ self-rated own criti­ cism towards the patient affected outcome in the st group more that in the cbt group, and an overall negative family climate as perceived by patients predicted outcome regardless of the therapy conditions, when it referred to depressive recurrences. the different results for the one-item measure pcm and the fas support the idea that these instruments share some variance but do not assess identical constructs. while this was a first step to explore the usefulness of self-ratings of family attitudes and expressed emotion in bd, our results encourage the idea to use such questionnaires that are easy to administer in clinical practice to assess the familial climate (chambless & blake, 2009; masland & hooley, 2015). these preliminary results also stress the need for future studies to explore in more detail the potential moderating role of expressed emotions in different psychological therapies (miklowitz & chambless, 2015) and specifically in different stages of bd. funding: this research was supported by a series of grants provided from the german research foundation (deutsche forschungsgemeinschaft [dfg] me 1681/6-1 to 6.3). acknowledgments: we are indebted to all the interviewers and therapists involved in the baseline assessments of our study, especially, dr. katja salkow and dr. peter peukert (in memoriam), as well as, research assistants for their enormous work, support, and help. competing interests: the authors have declared that no competing interests exist. references basco, m., & rush, a. 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(2004). expressed emotion versus relationship quality variables in the prediction of recurrence in bipolar patients. journal of affective disorders, 83(2-3), 199–206. https://doi.org/10.1016/j.jad.2004.08.006 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. lex, hautzinger, & meyer 17 clinical psychology in europe 2022, vol. 4(1), article e4617 https://doi.org/10.32872/cpe.4617 https://doi.org/10.1111/j.1545-5300.2001.4010100005.x https://doi.org/10.1016/s0165-0327(00)00228-7 https://doi.org/10.1016/j.jad.2012.04.005 https://doi.org/10.1016/0010-440x(92)90040-w https://doi.org/10.1016/s0165-0327(98)00150-5 https://doi.org/10.1176/appi.focus.12.3.251 https://doi.org/10.1176/appi.ajp.160.12.2099 https://doi.org/10.1192/bjp.129.2.125 https://doi.org/10.1111/famp.12208 https://doi.org/10.1016/j.jad.2004.08.006 https://www.psychopen.eu/ predictors of expressed emotion (introduction) method participants procedures and measurements statistical methods results demographics cox proportional hazards models discussion conclusions (additional information) funding acknowledgments competing interests references body exposure, its forms of delivery and potentially associated working mechanisms: how to move the field forward scientific update and overview body exposure, its forms of delivery and potentially associated working mechanisms: how to move the field forward andrea s. hartmann 1 , eva naumann 2, silja vocks 1 , jennifer svaldi 2, jessica werthmann 3 [1] institute of psychology, osnabrück university, osnabrück, germany. [2] department of psychology, eberhard-karls university tübingen, tübingen, germany. [3] institute of psychology, albert-ludwig university freiburg, freiburg, germany. clinical psychology in europe, 2021, vol. 3(3), article e3813, https://doi.org/10.32872/cpe.3813 received: 2020-06-04 • accepted: 2021-05-18 • published (vor): 2021-09-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: andrea s. hartmann, osnabrück university, institute of psychology, knollstr. 15, 49069 osnabrück, germany. telephone: +495419696349, fax: +49541969402. e-mail: andrea.hartmann@uos.de abstract background: body image disturbance (bid) is a hallmark feature of eating disorders (eds) and has proven to be involved in their etiology and maintenance. therefore, the targeting of bid in treatment is crucial, and has been incorporated in various treatment manuals. one of the most common techniques in the treatment of bid is body exposure (be), the confrontation with one’s own body. be has been found to be effective in individuals with eds or high body dissatisfaction. however, be is applied in a multitude of ways, most of which are based on one or a combination of the hypothesized underlying working mechanisms, with no differential effectiveness known so far. method: the aim of this paper is to selectively review the main hypothesized working mechanisms of be and their translation into therapeutic approaches. results and conclusion: specifically, we underline that studies are needed to pinpoint the proposed mechanisms and to develop an empirically informed theoretical model of be. we provide a framework for future studies in order to identify working mechanisms and increase effectiveness of be. keywords body exposure, eating disorders, body image disturbance, working mechanisms, intervention this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3813&domain=pdf&date_stamp=2021-09-30 https://orcid.org/0000-0002-6251-3763 https://orcid.org/0000-0001-8498-9466 https://orcid.org/0000-0002-2312-1249 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • body exposure (be) is an effective intervention for body image disturbance in eating disorders. • ways of delivery vary depending on assumed underlying working mechanisms. • impact of attention focus, verbalization, therapist presence, and dosage should be investigated. • research on working mechanisms will improve be and maximize results for specific patients. body image disturbance (bid) is a distinct risk factor for the development and mainte­ nance of eating disorders (eds), and potentially contributes to relapse after treatment (e.g., glashouwer et al., 2019). furthermore, targeting body dissatisfaction is associated with better overall treatment outcome (wilson et al., 2002). thus, the improvement of body image should be a key element of ed treatment, e.g. in the form of body exposure (be), alongside the normalization of nutrition and eating behaviors. this paper aims to selectively review the theoretical rationales underlying potential working mechanisms of be, the empirical evidence for these rationales, and the corresponding therapeutic application of be. another aim is to review future research ideas on mechanisms, be delivery, and moderators of be effects in order to foster clinicians’ use of be as an effective intervention strategy. efficacy of body exposure a meta-analytical review indicated that be is effective as stand-alone intervention for bid (alleva et al., 2015). the analysis included 62 original studies on the effectiveness of stand-alone interventions to improve body image that had a control group, random allocation to conditions, and at least one preand posttest measure. two interventions that can be broadly viewed as be namely exposure exercises and guided imagery exercises showed significant intervention effects on body image. the meta-analysis further demonstrated that effects were stronger when targeting individuals with body concerns as compared to unselected groups (alleva et al., 2015). in an extension of this finding, a more recent review (griffen et al., 2018) focused on summarizing the effects of be in distinct groups of individuals with various ed diagnoses separately and mixed, as well as individuals with obesity, body dysmorphic disorder, and non-clinical individuals. their search yielded a total of 15 studies evaluating be. for all participant groups, at least preliminary effectiveness of be was shown. however, due to a scarcity of studies no differential effectiveness of various forms of be could be determined (griffen et al., 2018). notably, some individuals do not benefit from be, as evidenced by findings that on certain measures, between-group effects are significant while group by time interaction mechanisms of body exposure 2 clinical psychology in europe 2021, vol. 3(3), article e3813 https://doi.org/10.32872/cpe.3813 https://www.psychopen.eu/ effects are not (e.g., delinsky & wilson, 2006). research and reports on symptom deterio­ ration or treatment dropouts are rare. in a randomized controlled trial by hildebrandt and colleagues (2012), self-injurious behaviors and subsequent study dropout occurred in the be condition but not the control condition. in a study by delinsky and wilson (2006), the only dropouts occurred in the be condition (without significant attrition differences between conditions), and the participants who dropped out also had higher depression scores at the outset. accordingly, while be might deteriorate symptoms in emotionally unstable patients, frequency of symptom deterioration or treatment discontinuation can­ not be extrapolated from current data. in sum, be seems to be effective for the majority of patients. a common characteristic of be procedures is a systematic examination of one’s own body by the patient – in a mirror or through recorded videos – over a varying number of sessions. however, different be versions exist in which the specific be approach varies in several aspects, and the (clinical) decision for the specific be approach often relies on the hypothesized underlying working mechanism. hypothesized working mechanisms: theoretical ideas on how be reduces body image disturbance the theoretical accounts of be show distinct differences, resulting in a variety of specific intervention approaches. here, we will briefly review four theoretical ideas that have previously been proposed. moreover, where available, we present empirical evidence and the respective treatment implications. of note, the field is only just beginning to develop a comprehensive understanding of how exposure might work, and an integrated model of these rationales is lacking. thus, while in the following the theoretical ideas are discussed as discrete working mechanisms, it might very well be that they all work alongside each other or interact (lass-hennemann et al., 2018). furthermore, there may also be a general working mechanism, e.g., the generally structured preoccupation with one’s body without avoidance or safety behaviors. first, a hypothesis derived from exposure research in anxiety disorders posits that habituation to negative emotion and distress on psychological and biophysiological processing levels is responsible for the positive effects of be. from a theoretical perspec­ tive, repeated and prolonged exposure to the conditioned stimulus ‘‘seeing one’s own body’’ (cs) is assumed to induce decreases in the conditioned negative reaction (cr) by preventing negative reinforcement, e.g., avoidance (benito et al., 2018; craske et al., 2014). indeed, there is evidence for a reduction of self-reported negative affect between and within exposure sessions (e.g., trentowska et al., 2017). while these findings are supported by some studies assessing physiological parameters (e.g. emotional arousal measured by means of voice stress analysis; baur et al., 2020), other findings, e.g. from hartmann, naumann, vocks et al. 3 clinical psychology in europe 2021, vol. 3(3), article e3813 https://doi.org/10.32872/cpe.3813 https://www.psychopen.eu/ studies assessing heart rate as a physiological measure of change in distress during be, are more ambiguous (trentowska et al., 2017; vocks et al., 2007). one reason for this inconsistency might be that be elicits a multitude of emotions in individuals with bid (e.g., naumann et al., 2013). for instance, in individuals with eds, disgust has been shown to play a more important role than anxiety (e.g., von spreckelsen et al., 2018). moreover, disgust seems more resistant to psychological and physiological habituation processes in other disorders (olatunji et al., 2009), and is influenced more likely by coun­ terconditioning (e.g., engelhard et al., 2014). recently, potential working mechanisms of exposure (in anxiety research) have been overhauled by the so-called inhibitory learning approach. accordingly, the working mechanism of exposure lies in the development and strengthening of nonthreat associations in memory during exposure (e.g., craske et al., 2008; foa & mclean, 2016). thus, within an exposure framework of be, three potential working mechanisms have been suggested: habituation, counterconditioning, and inhibitory learning. while all three approaches are based on an exposure rationale, each offers a distinct and differ­ ential therapeutic application of be in a clinical context. treatment manuals postulating habituation as a working mechanism recommend that patients mainly focus on their negatively valenced body parts over an extended period of time in order to activate negative affect, which consequently can be reduced (vocks et al., 2018). treatment man­ uals based on the counterconditioning mechanisms should aim to change the unwanted reaction (negative affect) when confronted with the stimulus (body). thus, they might suggest to rather focus on positively valenced body parts, coupled with an instruction to do something positive for/with one’s body (e.g., use body lotion) or, to focus on negatively valenced body parts while instructing to elicit positive thoughts about the body and/or remember what the body already has achieved (e.g, vocks et al., 2018). and lastly, treatment manuals using inhibitory learning as a rationale would aim to use as many different exposure exercises as possible in order to maximize the possibilities to create nonthreat associations. another theoretical rationale of be is based on the idea of attention bias modification. the hypothesis was derived from data demonstrating a negative attentional bias to subjectively unattractive body parts when confronted with one’s own body in individuals with eds (e.g., bauer et al., 2017). it was hypothesized that a change in this dysfunc­ tional attention pattern might alter the associated negative affect. some studies have demonstrated that a focus on positively valenced body parts leads to an improvement on measures of body image (glashouwer et al., 2016; krohmer et al., authors’ unpublished data; smeets et al., 2011), and some (krohmer et al., authors’ unpublished data) but not all (glashouwer et al., 2016) have reported a concurrent change in attention patterns. however, one study did not find differential effects between a negative and a positive focus condition on body dissatisfaction, body-related checking, body concerns, and neg­ ative mood from preto post-be (e.g., jansen et al., 2016). this contradicts the idea mechanisms of body exposure 4 clinical psychology in europe 2021, vol. 3(3), article e3813 https://doi.org/10.32872/cpe.3813 https://www.psychopen.eu/ of attention bias modification as the only working mechanism of be. following this rationale, corresponding therapeutic be approaches asked patients to focus on positively valenced body parts only (jansen et al., 2016; vocks et al., 2018) or to state their emotion­ al connotations of the respective body parts while distributing their attention evenly (svaldi & tuschen-caffier, 2018). a third theoretical rationale of be is based on the hypothesis of reduction of body perception distortion in individuals with eds. most individuals with eds overestimate the dimensions of their own body (e.g., mohr et al., 2016; volpe et al., 2018). furthermore, there is some (norris, 1984), but also contrasting (lewer et al., 2017; vocks et al., 2007) evidence that distorted body perception might change over the course of be. more recently, a systematic review suggested that the construct of distorted perception may be misleading as the distortion may rather stem from a dysfunctional cognitive-evaluative component of body image than from perceptual deficits (mölbert et al., 2017). following this rationale, one would advise an even distribution pattern and the use of non-judg­ mental language (hildebrandt et al., 2012) during be. a fourth theoretical rationale suggests that central dysfunctional cognitions (e.g., interpretation and memory biases, e.g., korn et al., 2020) of bid are changed through (implicit) cognitive restructuring in the course of be. such cognitive restructuring can be achieved by inducing cognitive dissonance (e.g., between the dysfunctional belief “my stomach looks fat” and the behavior of describing the stomach neutrally), which may in turn reduce body-related negative schemata (williamson et al., 2004). in addition to the above-mentioned induction of cognitive dissonance and cognitive restructuring, therapeutic approaches of be derived from this hypothesis instruct patients to either focus on positively valenced body parts or to focus on all body parts evenly, while describing their body positively or neutrally (i.e., with the therapist present; e.g., jansen et al., 2016; klimek et al., 2016; luethcke et al., 2011). all of these aspects are noteworthy, as be seems, in general, a promising tool to address body image disturbances in clinical and non-clinical populations (alleva et al., 2015), even though with only small effect sizes as a stand-alone technique in the latter. accordingly, there is a need to refine the theoretical rationale as well as (experimental) research on working mechanisms in order to improve the technique and potentially individualize it in the future to maximize outcome in specific patients. suggested foci in future research it is important for future research to focus on factors that determine its positive effects. in the following, we describe variables that require systematic examination. hartmann, naumann, vocks et al. 5 clinical psychology in europe 2021, vol. 3(3), article e3813 https://doi.org/10.32872/cpe.3813 https://www.psychopen.eu/ where should one look during be? as briefly reviewed above, depending on the theoretical rationale, be approaches dif­ fer in whether patients are instructed to focus selectively on positively or negatively valenced body parts, or evenly on all body parts. given that these foci might elicit emotions that may or may not be necessary to reach the intervention goal, it is essential to understand individual needs and differences. in one study, interventions with a focus on exclusively positive or negative body parts successfully reduced body dissatisfaction, body-related checking, body concerns, and negative mood in women with high levels of body dissatisfaction (jansen et al., 2016). moreover, the negative focus condition yiel­ ded a stronger decrease in body-related avoidance behavior over the follow-up period. for comparison studies, we propose to consider another effective form of be, which comprises instructions to focus on all body parts from head to toe, successively, in order to correct distorted body perception and alter viewing patterns. furthermore, we suggest testing a form in which body parts are clustered by their indication of weight gain or status (e.g., thighs, bottom, stomach vs. knees, ankles, forearms), instead of by their subjective valence. this might be of particular interest if the hypothesized working mechanism is dissolution of the conditioned association, as it allows for exposure to the most fear-inducing body parts, given that fear of weight gain is a central concept of individuals with eds (e.g., rodgers et al., 2018). how should verbalization be instructed during be? another large difference between previous studies lies in the type of body-related descriptions provided by participants, i.e. whether they purely describe their body, or the associated emotions and cognitions, or both. while a negatively toned description might strengthen the experience of be (in the sense of a stronger habituation effect), subsequently leading to a more effective dissolution of negative body-related affect, a mainly positive or neutral, non-judgmental description might strengthen the decrease in negative affect by correcting distorted perception, thus altering dysfunctional attention processes or cognitive dissonance processes (rather like inhibitory learning). so far, only two studies have compared different forms of instructed verbalizations. in the first study, the authors compared two neutral versions of be to a cognitive dissonance version in which participants were instructed to describe body parts using positive verbalizations. while all three forms led to improvements on measures of ed and body image, only the cognitive dissonance version of be yielded an increase in body satisfaction (luethcke et al., 2011). in the second study, a positive and a negative full-body verbalization con­ dition were compared in healthy individuals. both interventions yielded improvements in emotional arousal and body satisfaction between sessions. however, within sessions, the negative but not the positive verbalization condition led to a decrease in positive affect and body satisfaction and an increase in negative affect (tanck et al., authors’ mechanisms of body exposure 6 clinical psychology in europe 2021, vol. 3(3), article e3813 https://doi.org/10.32872/cpe.3813 https://www.psychopen.eu/ unpublished data). to further disentangle different forms of verbalisation, we propose to compare a neutral description of what patients see, and a description of positive or negative aspects of each body part in future studies. thereby, while manipulating the form of verbalization, the attentional focus should be controlled (e.g., by asking patients to describe every part of their body from head to toe). is a therapist needed in be? to the best of our knowledge, there are no studies comparing be with and without a therapist present. such investigations would be highly relevant, as the presence of a therapist could impact the effectiveness of the intervention, particularly when consid­ ering cognitive dissonance as a working mechanism. comparative studies have looked at differences in the effectiveness of guided vs. unguided be (díaz-ferrer et al., 2015; díaz‐ferrer et al., 2017; moreno-domínguez et al., 2012). for example, women with body dissatisfaction and subclinical eds underwent either an unguided version, in which they freely explored self-chosen body parts and were instructed to verbalize associated emotions and cognitions, or a guided version, in which they focused on all body parts and had to describe them using neutral words. both conditions were found to be effective in reducing bid, with a slight superiority of the unguided condition. however, heart rate and skin conductance observed within sessions indicated that the two techniques might act through different mechanisms (díaz‐ferrer et al., 2017), with a stronger increase in both indicators in the unguided condition. notably, the conditions in the comparison studies varied not only with respect to therapists’ active guidance during be, but also regarding the body parts which were focused on and the way in which body parts were described. thus, in order to understand the impact of therapist presence and guidance during be, future research should compare guided and unguided versions of be while controlling for focus and type of verbalization. how much be is needed? the ideal intensity of be remains unclear. on the one hand, intensity can be captured as frequency of sessions. in anxiety disorder research, the frequency of exposure is assumed to be a major factor in treatment effectiveness (wolitzky-taylor et al., 2008). in eds, sev­ eral findings highlight that therapeutic effects might occur mostly between rather than within sessions (e.g., hilbert et al., 2002). thus, multiple sessions are necessary, which is further underlined by the finding that short-term exposure leads to an activation and deterioration of body satisfaction and negative affect (veale et al., 2016). findings from studies investigating the effects of different numbers of sessions are important, because they may, for instance, allay clinicians’ fears of overwhelming the patient when delivering multiple be sessions. hartmann, naumann, vocks et al. 7 clinical psychology in europe 2021, vol. 3(3), article e3813 https://doi.org/10.32872/cpe.3813 https://www.psychopen.eu/ on the other hand, intensity can also be captured as duration of single sessions, thus the length of a be therapy session, be sessions over a whole day, or exposure until a reduction in anxiety to a certain predefined extent is realized. in intensive exposure (“flooding”), aversive stimuli are presented at the highest level of intensity, while gradual exposure follows a stepwise approach starting at a low level of intensity. previous research in the area of obsessive-compulsive disorder suggests that intensive exposure might lead to a stronger short-term reduction of anxiety symptoms. by contrast, gradual exposure might be more helpful for reducing emotions that habituate more slowly, such as disgust (olatunji et al., 2009). more recent studies in the area of anxiety disorders ad­ vocate for variability in the exposure hierarchy in order to maximize inhibitory learning (e.g., knowles & olatunji, 2019). future research should test whether variations in inten­ sity impact be effects on bid. besides frequency and duration of sessions, potentially relevant moderating variables in the context of intensity of be may relate to the setting (e.g., mirror size, light, distance to mirror) or clothing (everyday vs. tight clothes vs. underwear). who benefits or does not benefit from be? evidence of differential effectiveness of be in specific groups is limited by the low diversity of the groups researched so far. men have been overlooked in body image research, including be interventions (burlew & shurts, 2013), and be in individuals with comorbidities remains to be investigated. additionally, as alleva et al. (2015) highlighted, individuals of middle to older age have also been neglected in past be research. furthermore, for body dysmorphic disorder, another mental illness with the core symptom of bid, be (mirror retraining), also represents an essential part of the cbt protocol (e.g., wilhelm et al., 2013). however, to date, no study has examined the effec­ tiveness of this technique detached from the overall cbt treatment. further research into the effectiveness of be in mental disorders potentially associated with bid, namely borderline personality disorder, posttraumatic stress disorder, or social anxiety disorder (dyer et al., 2013; dyer et al., 2015) is also lacking. lastly, a comprehensive evaluation of be effectiveness should also include the sys­ tematic assessment of side effects, adverse events, or predictors of non-responders, and a subsequent trade-off between positive effects and negative aspects for single patient groups. as looking at oneself in a mirror can lead to significant distress and a worsening of negative affect (veale et al., 2016; walker et al., 2012; windheim et al., 2011), be might destabilize some patients. eventually, extending research to subgroups will help to formulate diagnosisand patient group-specific treatment guidelines, which will move us closer to establishing individualized evidence-based treatments. mechanisms of body exposure 8 clinical psychology in europe 2021, vol. 3(3), article e3813 https://doi.org/10.32872/cpe.3813 https://www.psychopen.eu/ what might further influence the efficacy of be? several potential moderators may be worthy of further investigation, because they may have confounded previous research results. moderating factors may also influence practi­ tioner’s decision to implement be. given the scarcity of previous research, we are not able to quantify the impact of, for example, current weight, genderand weight-match between patient and therapist, current status of treatment, chronicity of symptoms, level of habitual checking and avoidance, and the delivery in groups vs. alone on the effectiveness of be. we suggest that all of these factors should be assessed in future studies to provide information regarding their impact on be effects and on clinician’s decision to implement be. tools for evaluating be mechanisms and efficacy past studies varied regarding outcome and process variables. to understand the differen­ tial effectiveness of be on various levels of experience, a comprehensive set of process and outcome measures needs to be considered. first, we suggest that different facets of body image should be assessed in order to capture processes and outcomes on all levels of bid (i.e. perceptual, cognitive-affective, and behavioral). second, we advocate for the adoption of a multi-method approach encompassing selfand expert-report measures, as well as objective measures in order to elucidate mechanisms of be on as many process­ ing levels as possible. the former might include selfand external report measures on body dissatisfaction and disorder-specific symptomatology. the latter might consist of psychobiological indicators of emotional activation indexing fearand anxiety-related differences in the autonomic nervous system, e.g., such as fear-potentiated startle and heart rate, but also indices of attention allocation and information processing as well as the very recent approach of vocal arousal. conclusion despite findings regarding the effectiveness of be in intervention studies, it is still largely unknown which version works best for whom. thus, first, lab-based experimental studies need to be conducted to isolate the effect of potential working mechanisms and test their impact within the different proposed forms of be on bid outcomes (glashouwer et al., 2020). current studies from our workgroups target this research gaps by setting out to differentiate attention foci and verbalization forms measuring self-reported, peripherphysiological, and eye-tracking outcomes. findings from these and other studies can then inform theory-based and empirically based models on key processes, and can advance refined etiological models of bid. in the future, interventions based on these models can then be tested in larger randomized controlled trials including additional analyses of moderators to identify which specific be procedure is maximally hartmann, naumann, vocks et al. 9 clinical psychology in europe 2021, vol. 3(3), article e3813 https://doi.org/10.32872/cpe.3813 https://www.psychopen.eu/ successful (or unsuccessful) for a specific patient subsample. of further relevance, re­ search needs to prove that the positive effects of be outweigh the fact that this technique can be strenuous for patients, as they are confronted with the very thing they fear the most. funding: the writing of this paper was funded by a scientific network grant (body exposure and attention modification [beam-] net) awarded to the first author by the german research foundation (ha 8589/2-1). acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. twitter accounts: @ashartmann, @siljavocks data availability: data sharing is not applicable to this article as no new data were created and analyzed in this study. references alleva, j. m., sheeran, p., webb, t. l., martijn, c., & miles, e. 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(2008). psychological approaches in the treatment of specific phobias: a meta-analysis. clinical psychology review, 28(6), 1021-1037. https://doi.org/10.1016/j.cpr.2008.02.007 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. mechanisms of body exposure 14 clinical psychology in europe 2021, vol. 3(3), article e3813 https://doi.org/10.32872/cpe.3813 https://doi.org/10.1371/journal.pone.0198532 https://doi.org/10.1016/j.bodyim.2012.06.001 https://doi.org/10.1177/0145445503259853 https://doi.org/10.1037/0022-006x.70.2.267 https://doi.org/10.1016/j.brat.2011.05.003 https://doi.org/10.1016/j.cpr.2008.02.007 https://www.psychopen.eu/ mechanisms of body exposure (introduction) efficacy of body exposure hypothesized working mechanisms: theoretical ideas on how be reduces body image disturbance suggested foci in future research where should one look during be? how should verbalization be instructed during be? is a therapist needed in be? how much be is needed? who benefits or does not benefit from be? what might further influence the efficacy of be? tools for evaluating be mechanisms and efficacy conclusion (additional information) funding acknowledgments competing interests twitter accounts data availability references integrating metta into cbt: how loving kindness and compassion meditation can enhance cbt for treating anxiety and depression scientific update and overview integrating metta into cbt: how loving kindness and compassion meditation can enhance cbt for treating anxiety and depression simona stefan ab, stefan g. hofmann a [a] boston university, department of psychological and brain sciences, boston, ma, usa. [b] department of clinical psychology and psychotherapy, babes-bolyai university, cluj-napoca, romania. clinical psychology in europe, 2019, vol. 1(3), article e32941, https://doi.org/10.32872/cpe.v1i3.32941 received: 2019-01-08 • accepted: 2019-06-11 • published (vor): 2019-09-20 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: stefan g. hofmann, 900 commonwealth avenue, boston, ma, usa. e-mail: shofmann@bu.edu abstract background: loving kindness meditation and compassion meditation are traditional buddhist practices that have recently been introduced and investigated in psychotherapy with promising results. both meditation practices emphasize metta, a mental state of positive energy and kindness towards oneself and other beings, as opposed to the anger, hostility, or self-loathing that often accompany emotional problems. method: we conducted a qualitative review of the literature to produce an integrative review. results: metta meditation appears to be particularly useful for treating depression and social anxiety, both characterized by low positive affect and negative attitudes and core beliefs about the self. conclusion: metta meditation can aid therapy by promoting more adaptive self-images, social connectedness, and emotional experiences. keywords meditation, cbt, depression, anxiety, loving kindness, compassion this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i3.32941&domain=pdf&date_stamp=2019-09-20 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • loving kindness and compassion meditation (metta) have been recently introduced in psychotherapy. • metta addresses shame, anger, and hostility, and promotes an accepting attitude towards oneself. • metta meditation increases positive affect. • metta meditation can be particularly useful in social anxiety and depression. loving kindness and compassion meditation in psychotherapy initially derived from buddhist practices, the concept of mindfulness, briefly defined as the non-judgmental, accepting experience of the present, as it unfolds moment by mo‐ ment, has nowadays become ubiquitous in the fields of psychotherapy and mental health, as well as in self-help and popular psychology. psychotherapy interventions, such as mindfulness-based stress reduction (mbsr; [kabat-zinn, 1982] and mindfulness based cognitive therapy (mbst; [segal, williams, & teasdale, 2002] are considered established interventions for conditions such as chronic stress and depression (hofmann, sawyer, witt, & oh, 2010). furthermore, mindfulness has become an integral part of various psy‐ chological interventions, such as acceptance and commitment therapy (act; hayes, 2004) and dialectical behavioral therapy (dbt; linehan et al., 1999). more recently, oth‐ er forms of meditation inspired by buddhist philosophy, especially loving kindness and compassion meditation, have been introduced and investigated in mental health inter‐ ventions (hofmann, grossman, & hinton, 2011; zeng, chiu, wang, oei, & leung, 2015). although the term was originally associated with loving kindness, we will refer to both as metta interventions, as both types of interventions instill a sense of positive energy (metta) directed at oneself and other beings. taking a mindful stance, they further en‐ courage a kinder view on oneself and others, which is central to addressing many emo‐ tional intra and interpersonal problems (e.g., anger, hostility, depression, anxiety). due to the warmth and sense of connection they provide, metta interventions increase positive affect, particularly emotions related to calmness and safety. in this article, we will explore how metta-derived practices can help build a healthier view and a warmer attitude to‐ wards oneself, and how we can combine them with more traditional intervention techni‐ ques, specifically cognitive-behavioral therapy (cbt), when treating depression and so‐ cial anxiety. according to the buddhist tradition, loving kindness (metta) and compassion (karuna) are two of the four brahma viharas, or sublime states, which also include sympathetic joy (mutida; feeling joy when others are joyful) and equanimity (upekkha; tranquility, equi‐ distance, calmness) (hofmann et al., 2011). they are centered on the idea of universal and metta and cbt 2 clinical psychology in europe 2019, vol.1(3), article e32941 https://doi.org/10.32872/cpe.v1i3.32941 https://www.psychopen.eu/ unconditional kindness and interconnection among human beings, as opposed to the harshness and isolation which often accompany the experience of emotional suffering. whereas loving kindness meditation promotes an attitude of warmth and positive energy directed at oneself and all other beings, compassion entails the drive and commitment to alleviate suffering (graser & stangier, 2018). thus, compared to loving kindness, the ex‐ perience of compassion encompasses a warm feeling of sadness. self-compassion (i.e., an attitude of compassion directed towards the self), as defined by (neff, 2003) has emerged as a somewhat separate concept made up of three components: mindfulness (as opposed to over-identifying with one’s own suffering), common humanity (as opposed to isola‐ tion), and self-kindness (a kind attitude towards the self, as opposed to harshness and self-criticism). an alternative conceptualization promoted by gilbert describes compas‐ sion (and self-compassion implicitly) as a positive affect motivational system, with evolu‐ tionary roots and specific neurobiological underpinnings, channeled on soothing and providing care, safety, and empathy (gilbert, 2005; macbeth & gumley, 2012). studies have shown self-compassion to be consistently inversely related to psychopathology measures (e.g., depression, anxiety, stress), pointing to its potential role in preventing negative, dysfunctional emotions (see macbeth & gumley, 2012). in practice, loving kindness meditation (lkm) involves the mental repetition of phra‐ ses directed at others’ and one’s well-being and relief from suffering, in a non-judgmen‐ tal and observing mental stance (e.g., “may you be well”, “may you be happy”, “may we be safe”). as lkm progresses, kindness is directed towards more and more challenging recipients, starting with oneself or a friend, continuing with a neutral person, and ending with the entire universe (hofmann et al., 2011). the purpose is to experience a wish for universal well-being with a kind and tender mindset. compassion meditation is similar to lkm, but encompasses the acknowledgement of suffering (e.g., “this is a moment of suf‐ fering”), recognizing the communality of suffering (e.g., “suffering is a part of life) and committing to a position of kindness to oneself or others (e.g., “may i be kind to myself”), often accompanied by compassionate imagery – imagining a compassionate person, character, or any other entity evoking features of wisdom, empathy, and understanding (gilbert & procter, 2006; neff, 2011). however, there are multiple techniques for deliver‐ ing lkm and compassion meditation (see finlay-jones, 2017 for a review) and many exer‐ cises actually combine the two, generating some conceptual overlap in the field (shonin, van gordon, compare, zangeneh, & griffiths, 2015). so far, previous results have shown that lkm and compassion meditation interven‐ tions are effective in reducing depression, and increasing mindfulness, compassion, and self-compassion (against passive control conditions), as well as positive emotions (against relaxation) (galante, galante, bekkers, & gallacher, 2014). evidence suggests that these meditation interventions are useful for both clinical and healthy populations, in address‐ ing psychological distress, positive and negative affect, the frequency and intensity of positive thoughts and emotions, interpersonal skills, and empathic accuracy (shonin et stefan & hofmann 3 clinical psychology in europe 2019, vol.1(3), article e32941 https://doi.org/10.32872/cpe.v1i3.32941 https://www.psychopen.eu/ al., 2015). a recent review (graser & stangier, 2018) also evidenced that, looking at randomized trials only, compassion-based interventions are effective for psychotic disor‐ ders, depression, eating disorders, and patients with suicide attempts, while loving kind‐ ness interventions are effective in treating chronic pain, and a combination of both is useful for borderline personality disorder. still, there are few randomized trials and even fewer that compared compassion and loving kindness interventions with active control conditions. therefore, it is not certain whether these related strategies bring a unique, unshared contribution to relieving distress or promoting positive affect. also, results are difficult to summarize because of the divergent conceptualizations of metta interven‐ tions; using very similar terminology, studies refer to compassion and/or loving kindness interventions as 1. single sessions consisting of brief exercises (e.g., feldman, greeson, & senville, 2010), 2. several sessions of meditation (e.g., carson et al., 2005; hofmann et al., 2015), 3. specific interventions which include, but are not restricted to compassion/loving kindness meditation, such as compassion-focused therapy (e.g., gilbert & procter, 2006) or cognitively-based compassion training (e.g., mascaro, rilling, tenzin negi, & raison, 2013), or 4. combining these interventions with cbt (e.g., beaumont, galpin, & jenkins, 2012). loving kindness and self-compassion in depression and social anxiety disorder negative self-views, self-criticism, and shame in depression and social anxiety conceptually, due to their focus on promoting a kind, accepting view of oneself and oth‐ ers, these interventions particularly resonate with disorders characterized by self-criti‐ cism and shame (gilbert & procter, 2006), anger, and hostility (hofmann et al., 2011). the experience of shame and self-criticism is transdiagnostic, prevalent in disorders such as depression, social anxiety disorder, psychotic disorders, ptsd, eating disorders, and per‐ sonality disorders (gilbert, pehl, & allan, 1994; thompson & waltz, 2008). for instance, in depression, the classical cognitive-behavioral model (beck & alford, 2009) emphasizes the role of negative core beliefs related to oneself (worthlessness/ help‐ lessness, unlovability), which further lead to a strain of negative automatic thoughts sup‐ porting the depressed, negative affect. depressed individuals thus often have a harsh, critical attitude towards themselves, which is difficult to change. in this sense, studies have found that self-coldness (i.e., the reverse of self-compassion, including self-judg‐ ment, isolation, and over-identification) is a strong predictor of depressive symptoms in the general population both cross-sectional and longitudinally, over a period of 1 year (lópez, sanderman, & schroevers, 2018). also, depressed outpatients score lower on selfcompassion as compared to never-depressed participants, even when controlling for de‐ metta and cbt 4 clinical psychology in europe 2019, vol.1(3), article e32941 https://doi.org/10.32872/cpe.v1i3.32941 https://www.psychopen.eu/ pression levels, with symptom-focused rumination and behavioral avoidance mediating the relation between self-compassion and depression (krieger, altenstein, baettig, doerig, & holtforth, 2013). self-compassion also predicts subsequent depressive symp‐ toms in clinical patients, while depression does not predict self-compassion (krieger, berger, & holtforth, 2016), and the relation between self-compassion and depression ap‐ pears to be mediated by emotion regulation skills (diedrich, burger, kirchner, & berking, 2017). additionally, personality traits such as dependency (the tendency to rely exces‐ sively on other people and their approval) and self-criticism are related to depression se‐ verity scores in clinical (luyten et al., 2007) and remitted depressives (mongrain & leather, 2006), and constitute independent predictors (luyten et al., 2007). similarly, socially anxious individuals display low self-esteem, high self-criticism, and dependency, with self-criticism as the strongest predictor of social anxiety symptoms (iancu, bodner, & ben-zion, 2015). also, people with social anxiety disorder show lower levels of self-compassion when compared to healthy controls, and within group, selfcompassion is related to fear of negative and positive evaluation (werner et al., 2012). additionally, shame and shame-proneness (the tendency to experience shame frequently) are particularly important in social anxiety disorder, being associated with social anxiety symptoms even after controlling for levels of depression and guilt (fergus, valentiner, mcgrath, & jencius, 2010). following psychological intervention, changes in social anxi‐ ety symptoms are further associated with decreases in shame proneness (fergus et al., 2010). emotion regulation and negative self-schemas emotions can be regulated intrapersonally (hofmann, sawyer, fang, & asnaani, 2012) or interpersonally (hofmann, 2014; hofmann & doan, 2018). strategies that involve other people are interpersonal emotion regulation and include strategies such as soothing and social modeling (hofmann, carpenter, & curtiss, 2016). these strategies appear to en‐ hance emotions by targeting the social self (hofmann & doan, 2018). an example of an intrapersonal emotion regulation is cognitive reappraisal (e.g., hofmann, 2016), a strategy aimed to cognitively modify one’s perspective as to elicit an alternative emotional re‐ sponse (as conducted in the process of cognitive restructuring). it is usually less effective‐ ly used by currently depressed participants (visted, vøllestad, nielsen, & schanche, 2018). possibly, this is because cognitive reappraisal is demanding on the executive functions, which are sometimes impaired in depression, or because cognitive change is incongruent with the depressive mood and its subsequent negative and ruminative thinking style (gotlib & joormann, 2010). alternative accounts posit that depressive thinking is hard to change because although patients may logically understand that their thinking is distor‐ ted, they cannot embrace kinder, healthier views of themselves if they lack the emotional experience of being cared for. many depressed patients report having been abused, bul‐ lied, or heavily criticized during childhood, and experienced little parental warmth. selfstefan & hofmann 5 clinical psychology in europe 2019, vol.1(3), article e32941 https://doi.org/10.32872/cpe.v1i3.32941 https://www.psychopen.eu/ criticism thus becomes a sort of inner voice, towards which the patient often assumes a submissive position (gilbert, clarke, hempel, miles, & irons, 2004). therefore, in these cases, the motivational system related to soothing and safeness appears to be “malfunc‐ tioning”. usually, the activation of the soothing system (i.e. prompted by affection and safety signals perceived from others or oneself) deactivates defensive emotions (e.g., anxiety) and behaviors, and also turns off behaviors related to goal seeking, achieving, and acquiring, instead eliciting a state of calmness and connectedness. however, with de‐ pressed individuals, this system seems to be suppressed, possibly because its develop‐ ment was impaired at critical times in the past (gilbert, 2005). in other words, depressed people have difficulty soothing themselves because the experience of being cared for is affectively foreign. this is why metta interventions could be particularly useful, since they do not aim to merely restructure negative self-views, but to create an inner experi‐ ence of warmth and peace by promoting a qualitatively different kind of attitude towards oneself. furthermore, self-criticism is highly prevalent in social anxiety disorder com‐ pared to other anxiety disorders, and remains at elevated levels even in people with his‐ tory of social anxiety only (cox, fleet, & stein, 2004). also, people with social anxiety often have high levels of perfectionism and unrealistic social standards (hofmann, 2007), intrusive self-deprecating thoughts, and hostility and paranoia (hofmann & otto, 2018), which combine with poor cognitive and emotion regulation strategies in the face of per‐ ceived threats and challenges, further complicating treatment (flett & hewitt, 2014). cog‐ nitive models of social anxiety disorder also emphasize maladaptive self-beliefs (clark & wells, 1995; farmer, kashdan, & weeks, 2014) as central to symptom development, like high standard self-beliefs, conditional self-beliefs (e.g., “if people see i’m anxious, they’ll think badly of me”), and unconditional beliefs (e.g., “i’m weak”). similarly to depressed patients, individuals with social anxiety disorder also have diminished levels of positive affect due to lack of normative positive biases, unusual processing of positive events in the form of dampening positive affect, and lack of positive self-evaluations, which also contribute to living in a cold, harsh inner world (farmer et al., 2014). efficacy of metta interventions in depression and social anxiety. can we change the inner experience (qualia) in relation to oneself? compassion-based (metta) interventions have been found to be effective in treating de‐ pression, anxiety, and shame, although the conceptualizations and treatment approaches are diverse (finlay-jones, 2017; kirby, 2017). for instance, compassion-focused therapy (gilbert & procter, 2006) is itself a form of psychotherapy, including the functional analy‐ sis of self-criticism and safety behaviors, explicitly training clients in decentering from their inner self-critical voice, and using experiential techniques such as compassion im‐ agery, compassionate letter writing, or the two-chair technique. compassion-focused therapy has been found to be effective in increasing happiness and mindfulness and de‐ metta and cbt 6 clinical psychology in europe 2019, vol.1(3), article e32941 https://doi.org/10.32872/cpe.v1i3.32941 https://www.psychopen.eu/ creasing worry and emotional suppression in the general population (jazaieri et al., 2014), as well as in schizophrenic, anxious, depressed, and disordered eating populations (see graser & stangier, 2018 and kirby, 2017). another type of compassion intervention, mindfulness-based compassionate living was administered online and was found to be ef‐ fective in reducing depressive and anxiety symptoms in participants with high levels of self-criticism, thus pointing to its potential as a transdiagnostic intervention (krieger et al., 2019). as an emotion regulation strategy, self-compassion is similarly effective as reapprais‐ al and acceptance in reducing depressed mood following a mood induction task in de‐ pressed participants, but the effect seems to be moderated by baseline levels of depres‐ sion, in the sense that self-compassion appears to be more effective than reappraisal for more severely depressed participants (diedrich, grant, hofmann, hiller, & berking, 2014). also, even a short, 7-minute lkm exercise (i.e., imagining two loved ones sending their love to the participants) can increase explicit and implicit positivity towards strang‐ ers and implicit positivity towards the self, as well as positive affect (calm, happy, loving) when compared to a control condition (hutcherson, seppala, & gross, 2008). regarding social anxiety, a recent study (cȃndea & szentágotai-tătar, 2018) examined self-compassion as an emotion regulation strategy (i.e., for people with social anxiety) comparing self-compassion to cognitive reappraisal and waitlist. they found no differen‐ ces at posttest between the groups, although the self-compassion group had significantly lower levels of shame-proneness and fear of negative evaluation at posttest compared to the pretest levels. also, shame-proneness decreased from pre to posttest only in the selfcompassion and cognitive reappraisal groups. similar results had been previously ob‐ tained, showing that self-compassion and cognitive reappraisal as emotion regulation strategies are similarly effective in reducing self-conscious negative emotions (a combi‐ nation of shame, embarrassment, shyness, guilt, and regret), and more effective than re‐ sponsibility reattribution and control condition (arimitsu & hofmann, 2017). all these results suggest that metta interventions can qualitatively change the inner experience of oneself, thus fostering feelings of warmth, acceptance, and peace. positive affect and its role in depression and social anxiety: how metta interventions can help the data previously presented suggest that being overly self-critical and exhibiting an in‐ flexible vision of oneself are at the core of depression and social anxiety disorder. there‐ fore, metta-focused interventions may be particularly beneficial for treating these prob‐ lems. according to the emotion dysregulation model of mood and anxiety disorders (hofmann et al., 2012), apart from the enduring negative affect, both depression and so‐ cial anxiety are characterized by deficiencies in positive affect (brown, 2007), which are less specifically targeted by cbt protocols, potentially with the exception of behavioral activation. increasing positive affect is especially important in depression and social stefan & hofmann 7 clinical psychology in europe 2019, vol.1(3), article e32941 https://doi.org/10.32872/cpe.v1i3.32941 https://www.psychopen.eu/ anxiety since, apart from increasing well-being as proposed by the broaden and build theory (fredrickson, 2001), it enhances behavioral repertoires, promoting approach be‐ haviors to relevant situations (e.g., social situations, pleasant activities, new contexts and challenges), instead of the typical withdrawal and avoidance behaviors. essentially, posi‐ tive emotions extend the behavioral spectrum in reverse to negative emotions, which are associated with more circumscribed responses (e.g., withdrawal associated with sadness). when it comes to loving kindness and compassion specifically, the action tendencies that follow are those of interactional and interpersonal engagement, even if the emotional re‐ sponses may differ between the two (happiness versus compassion), thus pointing to their unique contribution in alleviating depression and social anxiety (hofmann et al., 2011). metta meditation has the potential to increase positive affect, especially since it does not rely on transient, hedonic values, but fosters a deeper sense of kindness and connectedness (hofmann et al., 2011, 2012). in this sense, meta-analytic results show that loving kindness increases the level positive emotions, potentially more so the peaceful and prosocial emotions, to a larger extent compared to compassion interventions (zeng et al., 2015). this is not surprising, given the fact that compassion and self-compassion interventions stem from the experience and acceptance of suffering. also, in a proof-ofconcept study, loving kindness meditation, administered as a 12-session group interven‐ tion, was found to be effective for symptoms of dysthymia and depression, as well as for increasing positive affect (hofmann et al., 2015). including metta interventions into cbt apart from using them as independent interventions, metta interventions can be used adjunctively to cbt protocols in order to increase positive affect levels and to create an appropriate emotional climate for clients to easily accept the cognitive restructuring of negative self-schemas. metta meditation can be time restricted as to accommodate typical cbt sessions, with the advantage of facilitating cognitive restructuring and potentially also increasing the level of positive affect. metta interventions can be delivered as exerci‐ ses in individual and group psychotherapy, practiced in the beginning or at the end of the cbt session, and then also as homework. we can also design interventions which in‐ clude one or two sessions of metta interventions, then maintain the interventions as homework while the protocol proceeds as usual. some authors also designed protocols where compassion-based sessions are introduced at the end of treatment, following the first standard cbt sessions (e.g., asano et al., 2017). however, given that both loving kindness and self-compassion meditation are, like mindfulness, abilities acquired in time, it is essential to practice them continually. nowadays, we can find various types of loving kindness and self-compassion exercises online, which is a useful resource for both pa‐ tients and practitioners. although we believe these interventions can be easily practiced by cbt trained therapists (with no additional credentials), exercising these abilities one‐ self, as well as advanced reading and practical training are important prerequisites. so metta and cbt 8 clinical psychology in europe 2019, vol.1(3), article e32941 https://doi.org/10.32872/cpe.v1i3.32941 https://www.psychopen.eu/ far, few studies have tested the combination of cbt and metta interventions in clinical trials. to date, experimental data has shown that adding a preparatory self-compassion ex‐ ercise prior to a cognitive reappraisal task increases the efficacy of the latter in depressed individuals, thus providing encouraging results (diedrich, hofmann, cuijpers, & berking, 2016). that is, participants who practiced a self-compassion exercise (seeing oneself as from outside with a compassionate mindset) showed afterwards a greater reduction in negative emotions during cognitive reappraisal, following a negative mood induction task. these results point to the usefulness of metta interventions in facilitating cognitive restructuring, thus providing another argument for incorporating them into cbt. similarly, one of our ongoing studies aims to investigate how group cbt plus positive affect training (including mindfulness and loving kindness meditation) fares for people with low positive mood, irrespective of disorder. in this study, the protocol (12 sessions) introduces the concept and practice of mindfulness as an adjunct to forthcoming loving kindness meditation in the first two sessions, while the concept of loving kindness is in‐ troduced and practiced starting with session 3 (approximately 40 minutes). the following group sessions (4-12) begin with a brief 10-minute mindfulness exercise, then classic cbt techniques and exercises (e.g., thought record, cognitive restructuring, behavioral activa‐ tion) are introduced, and followed by metta meditation (10 minutes) and debriefing (10 minutes), each time promoting a more challenging target of loving kindness (e.g., beloved friend, then someone neutral, etc.). participants are also instructed to practice the medita‐ tion exercises at home. other studies have investigated the use of compassion-based interventions (i.e., not only meditation, but also exercises such as letter writing) in combination with cbt. for instance, a single group feasibility study tested the combination of cbt with compassion intervention sessions in depressed participants with good results (asano et al., 2017). the protocol (10 sessions) used standard cbt and, in the last three sessions approached shame and self-criticism, memories of compassion, and compassion letters. combining cbt with compassionate mind training in 12 sessions (combining imagery exercises with other techniques, like letter writing and grounding) was also shown to be effective for people referred to therapy as victims of traumatic incidents, with the cbt plus compas‐ sionate mind training scoring higher on self-compassion post-therapy (beaumont et al., 2012). finally, we have to keep in mind the fact that some barriers may restrict the useful‐ ness of metta interventions. for instance, individuals high on self-criticism often show a fear of compassion and self-compassion, because these states are experienced as unfami‐ liar and sometimes, as a sign of weakness (gilbert, mcewan, matos, & rivis, 2011). also, precisely because metta interventions foster a sense of calm and soothing rather than a more energetic kind of positive affect, they may appeal less to some people who value the latter kind of emotions more (galante et al., 2014). in these cases, introducing other stefan & hofmann 9 clinical psychology in europe 2019, vol.1(3), article e32941 https://doi.org/10.32872/cpe.v1i3.32941 https://www.psychopen.eu/ compassion-based techniques besides meditation could be helpful (e.g., two-chair techni‐ que with the critical and the criticized self). conclusion metta interventions have been shown to be effective for a wide range of emotional prob‐ lems, reducing shame and self-criticism, and also increasing positive affect. this allows for conversions into promising interventions especially for disorders characterized by harsh, critical, inflexible self-views and low positive affect, with depressive and social anxiety disorders as the most prevalent. precisely because loving kindness and compas‐ sion are experienced less by these patients, metta interventions appear to be particularly useful; whether they really succeed, however, is still an empirical question (e.g., they may be difficult to practice by these participants again, because they lack these abilities in the first place). more data are needed in clinical populations, as well as for comparisons with active control groups. nonetheless, so far it seems that metta interventions are effective as independent interventions, as well as emotion regulation strategies, and potentially as adjuncts to cbt protocols as well. future research should look into the added benefits of combining loving kindness and compassion interventions with established treatment protocols and address their mechanisms of change. funding: dr. hofmann receives financial support from the alexander von humboldt foundation (as part of the humboldt prize), nih/nccih (r01at007257), nih/nimh (r01mh099021, u01mh108168), and the james s. mcdonnell foundation 21st century science initiative in understanding human cognition – special initiative. he receives compensation for his work as editor from springernature and the association for psychological science, and as an advisor from the palo alto health sciences and for his work as a subject matter expert from john wiley & sons, inc. and silvercloud health, inc. he also receives royalties and payments for his editorial work from various publishers. competing interests: 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(2015). the effect of lovingkindness meditation on positive emotions: a meta-analytic review. frontiers in psychology, 6, article 1693. https://doi.org/10.3389/fpsyg.2015.01693 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. stefan & hofmann 15 clinical psychology in europe 2019, vol.1(3), article e32941 https://doi.org/10.32872/cpe.v1i3.32941 https://doi.org/10.1007/s12671-014-0368-1 https://doi.org/10.1002/jts.20374 https://doi.org/10.3389/fpsyg.2018.00756 https://doi.org/10.1080/10615806.2011.608842 https://doi.org/10.3389/fpsyg.2015.01693 https://www.psychopen.eu/ metta and cbt loving kindness and compassion meditation in psychotherapy loving kindness and self-compassion in depression and social anxiety disorder negative self-views, self-criticism, and shame in depression and social anxiety emotion regulation and negative self-schemas efficacy of metta interventions in depression and social anxiety. can we change the inner experience (qualia) in relation to oneself? positive affect and its role in depression and social anxiety: how metta interventions can help including metta interventions into cbt conclusion (additional information) funding competing interests acknowledgments references repetitive negative thinking and interpretation bias in pregnancy research articles repetitive negative thinking and interpretation bias in pregnancy colette r. hirsch a § , frances meeten b §, calum gordon a, jill m. newby cd, debra bick e, michelle l. moulds c [a] institute of psychiatry, psychology and neuroscience, king’s college london, london, united kingdom. [b] school of psychology, university of sussex, sussex, united kingdom. [c] school of psychology, university of new south wales, sydney, australia. [d] black dog institute, hospital road randwick, new south wales, sydney, australia. [e] warwick clinical trials unit, university of warwick, coventry, united kingdom. §these authors contributed equally to this work. clinical psychology in europe, 2020, vol. 2(4), article e3615, https://doi.org/10.32872/cpe.v2i4.3615 received: 2020-04-26 • accepted: 2020-11-01 • published (vor): 2020-12-23 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: colette r. hirsch, department of psychology, institute of psychiatry, psychology and neuroscience, king’s college london, de crespigny park, london se5 8af, uk. phone: +44 207 848 0697. e-mail: colette.hirsch@kcl.ac.uk supplementary materials: materials [see index of supplementary materials] abstract background: repetitive negative thinking (rnt; e.g., worry about the future, rumination about the past) and the tendency to interpret ambiguous information in negative ways (interpretation bias) are cognitive processes that play a maintaining role in anxiety and depression, and recent evidence has demonstrated that interpretation bias maintains rnt. in the context of perinatal mental health, rnt has received minimal research attention (despite the fact that it predicts later anxiety and depression), and interpretation bias remains unstudied (despite evidence that it maintains depression and anxiety which are common in this period). method: we investigated the relationship between rnt, interpretation bias and psychopathology (depression, anxiety) in a pregnant sample (n = 133). we also recruited an age-matched sample of non-pregnant women (n = 104), to examine whether interpretation bias associated with rnt emerges for ambiguous stimuli regardless of its current personal relevance (i.e., pregnancy or nonpregnancy-related). results: as predicted, for pregnant women, negative interpretation bias, rnt, depression and anxiety were all positively associated. interpretation bias was evident to the same degree for material that was salient (pregnancy-related) and non-salient (general), and pregnant and nonpregnant women did not differ. rnt was associated with interpretation bias for all stimuli and across the full sample. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i4.3615&domain=pdf&date_stamp=2020-12-23 https://orcid.org/0000-0003-3579-2418 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: our findings highlight the need to further investigate the impact of interpretation bias in pregnant women, and test the effectiveness of interventions which promote positive interpretations in reducing rnt in the perinatal period. keywords perinatal mental health, repetitive thinking, worry, interpretation bias, pregnancy highlights • a tendency to make negative interpretations was investigated in pregnant women for the first time. • negative interpretation bias was associated with repetitive negative thinking. • interpretation bias extended to pregnancy related information for pregnant and non-pregnant women. • reducing negative interpretation bias in pregnant women could be useful. repetitive negative thinking (rnt) plays a role in the onset and maintenance of depres‐ sion (nolen-hoeksema et al., 2008), and is transdiagnostic such that it is evident in a range of disorders, including anxiety (ehring & watkins, 2008). rnt refers to thinking that is negative, perseverative and difficult to control, whether about the past (rumina‐ tion) or future (worry) (samtani & moulds, 2017). perinatal depression and anxiety are common. one in four pregnant women report mental health problems (howard et al., 2018), the most common being anxiety and depression, and they commonly persist into early motherhood. given the role of rnt in predicting and maintaining both anxiety and depression, it is surprising that rnt in the perinatal period has only recently received research attention (e.g., dejong et al., 2016; moulds et al., 2018; newby et al., 2019). consistent with the broader rnt literature, there is growing evidence that antenatal rnt predicts perinatal mental health problems. schmidt et al. (2016) reported that rnt in the first trimester predicted depression and anxiety in the third trimester (schmidt et al., 2016), and that rnt interacts with other factors (e.g., level of social functioning; o’mahen et al., 2010; perfectionism; egan et al., 2017) to predict postnatal depression. in another longitudinal study, rnt in late pregnancy (i.e., third trimester) predicted change in depression symptoms from the third trimester to 8 weeks postpartum, an association that was not moderated by initial levels of depression (barnum et al., 2013). building on correlational findings, there is experimental evidence that rnt maintains postnatal difficulties. in a sample of new mothers, rnt impaired problem-solving ability and reduced confidence in problem-solving capacity (o’mahen et al., 2015). similarly, in women with postpartum gad, rnt reduced responsivity to infants – suggesting a key role for rnt in mother-infant bonding (stein et al., 2012). taken together, these findings highlight that rnt plays a key detrimental role in the perinatal context. repetitive negative thinking and interpretation bias in pregnancy 2 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ interpretation bias – the tendency to draw negative conclusions from ambiguous information is a transdiagnostic cognitive process evident across emotional disorders (hirsch et al., 2016). interpretation bias often focuses on an individual’s core clinical concern. for example, individuals with panic disorder (stopa & clark, 2000) and social anxiety disorder (amin et al., 1998) demonstrated a more negative interpretation bias for ambiguously threatening information which was central to their clinical problem (i.e., panic and socially-related material, respectively) relative to both individuals with other forms of anxiety, and non-clinical control participants. this content specificity is also evident in children who experience higher levels of anxiety specific to particular fears (e.g. social anxiety, separation anxiety, fear of spiders; mobach et al., 2019). relatedly, everaert et al. (2017) hypothesized that the personal relevance of material may be key to observing interpretation bias, such that the material has to relevant the person them‐ selves in order to be processed in a biased manner. interpretation bias is associated with different forms of rnt (krahé et al., 2019) across the population, and individuals with gad and depression demonstrate particular‐ ly high levels of this bias. there is evidence that targeting (i.e., reducing) a negative interpretation bias has the downstream effect of reducing rnt. for example, training individuals with gad to interpret ambiguous information as benign (rather than nega‐ tive) reduced worry frequency (hayes et al., 2010). in addition, there is evidence that training in generating positive interpretations leads to reduced rnt and anxiety in individuals with high levels of rnt (hirsch, krahé, whyte, bridge, et al., 2020), as well as those with clinical anxiety and/or depression (hirsch et al., 2018; hirsch, krahé, whyte, krzyzanowski, et al., 2020). moreover, improvements in worry, rumination, anxiety and depression are mediated by decreases in interpretation bias, consistent with it being the mechanism of change (hirsch, krahé, whyte, krzyzanowski, et al., 2020). to date, no research has investigated interpretation bias in the perinatal context. it is therefore unknown whether women in the perinatal period have a tendency to draw negative conclusions when presented with ambiguity and if such a bias does exist whether it is associated with levels of depression and anxiety, as well as rnt. further, if such a bias is indeed present, it will be both theoretically and clinically informative to establish whether this mechanism also applies to pregnancy-related ambiguous stimuli (e.g., the outcome of a foetal scan) which would be particularly salient and personally relevant for pregnant but not non-pregnant women. this speaks to a wider conceptual question regarding the nature of interpretation bias underlying rnt: is it a general mechanism that applies to any ambiguity, whether or not it is personally relevant and salient? in order to answer this question, we recruited a sample of matched non-pregnant women and examined whether this general bias also operates for ambiguous material that is not likely to be personally relevant (i.e., is pregnancy-related). that is, if interpre‐ tation bias that is associated with rnt is reduced by lack of current personal relevance, pregnancy-related material would elicit a weaker bias in non-pregnant women with high hirsch, meeten, gordon et al. 3 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ levels of rnt compared to pregnant women with high levels of rnt. alternatively, if such an interpretation bias operates on ambiguously threatening material irrespective of current personal relevance, we would predict an association between rnt and this bias regardless of pregnancy status or personal relevance of the material (i.e., pregnancy-rela‐ ted versus general ambiguity). in sum, extant findings confirm that interpretation bias and rnt are interrelated, and there is emerging evidence that rnt is a key cognitive process in the context of perinatal mental health. however, it remains unknown whether negative interpretation bias is associated with depression and anxiety in the perinatal period. furthermore, the possibility that rnt is correlated with interpretation bias in this period has not been examined to date. accordingly, our first goal was to investigate associations between interpretation bias, rnt (as a trait tendency, as well as specific types of rnt including depressive rumination and worry), as well as symptoms of psychopathology (anxiety, depression) in a community sample of pregnant women. we hypothesised significant positive relationships between rnt, interpretation bias, depression and anxiety symp‐ toms. second, we were interested in whether interpretation bias associated with rnt emerges for ambiguous stimuli regardless of its current personal relevance. we recruited a sample of age-matched women who were not pregnant, and thus for whom pregnan‐ cy-related materials were not likely to be personally relevant. we then examined the association between levels of rnt and interpretation bias for pregnancy-related and general (non-pregnancy-related) materials in samples of both pregnant and non-pregnant women. this enabled us to establish whether interpretation bias underlying rnt oper‐ ates on all ambiguously threatening material, irrespective of personal relevance. method participants we recruited 140 pregnant and 107 non-pregnant female participants who were 25-40 years of age, fluent in english and based in the uk. pregnant participants were eligible to take part if they were at least 16 weeks gestation, and had not previously experienced a stillbirth. non-pregnant participants were eligible if they were not currently trying to fall pregnant, and had not experienced a stillbirth in the past. participants were recruited through social media, online message boards, and the king’s college london research circular. the final sample was comprised of 133 pregnant and 104 non-pregnant women1. see table 1 for participant demographics. 1) nine participants were removed from analysis with a score on the recognition test comprehension questions 2.5 standard deviations below the group mean. an additional participant was removed from analysis for having repetitive negative thinking and interpretation bias in pregnancy 4 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ table 1 demographic characteristics baseline characteristic pregnant sample (n = 133) non-pregnant sample (n = 104) statistical test and significance value m sd m sd t (235) = 5.04, p < .001 age 32.64 3.68 30.12 4.0 nationality % n % n % χ2 (2) = 15.94, p < .001 british 123 92.5 77 74.0 other european 4 3.0 16 15.4 world 6 4.5 11 10.6 highest level of education n % n % χ2 (4) = 4.61, p = .33 secondary 26 19.5 13 12.5 bachelor 52 39.1 37 35.6 master 33 24.8 37 35.6 doctoral 7 5.3 7 6.7 other 15 11.3 10 9.6 marital status n % n % single, never married 2 1.5 24 23.1 χ2 (3) = 56.63, p < .001 in a relationship 30 22.6 46 44.2 married /domestic partnership 100 75.2 31 29.8 separated, divorced, widowed 1 0.8 3 2.9 number of children n % n % χ2 (3) = 24.63, p < .001 none 46 34.6 66 63.5 one 65 48.9 19 18.3 two 16 12.0 14 13.5 three or more 6 4.5 5 4.8 english as a native language 123 92.5 84 80.8 χ2 (1) = 7.24, p = .007 materials and measures demographic questions participants completed a number of demographic questions regarding age, nationality, level of education, relationship status, number of children and english fluency. partici‐ pants were also asked whether they were currently pregnant, and if they responded yes, asked to indicate number of weeks gestation, and whether they had previously experienced a stillbirth. interpretation measures scrambled sentences test (sst) — this task was employed by hirsch et al. (2018) and hirsch, krahé, whyte, bridge, et al. (2020), adapted from wenzlaff and bates (1998, no grammatically correct sentences in the scrambled sentences test. seven pregnant and three non-pregnant partici‐ pants were removed from analysis. hirsch, meeten, gordon et al. 5 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ 2000). participants unscramble six words presented in a random order into a grammati‐ cally correct sentence of either positive or negative valence. participants were given 20 sentences, equally divided between worry themes and depressive rumination themes, and asked to unscramble as many as possible in five minutes whilst holding a six-digit number in mind (which increased cognitive load; see wenzlaff & bates, 1998, 2000)2. an index of interpretation bias was created by dividing the number of grammatically correct positively unscrambled sentences by the total number of grammatically correct unscrambled sentences. index scores range from 0 to 1, higher scores denote a more positive interpretation bias. the sst had good internal consistency α = .86, which is comparable to that reported in a recent validation paper where two sst lists of worry and depression items were examined with α = .77 and α = .92 respectively (krahé et al. 2020). recognition test (rt) — this test was based on that used by mathews and mackintosh (2000). materials included items related to two themes – pregnancy related and general (non-pregnancy) related. general materials were drawn from worry and rumination recognition test materials used by hirsch, krahé, whyte, & bridge, et al. (2020), while the pregnancy materials were developed for the current study from interviews with four pregnant women3. the rt has two phases: in the first, participants read 21 ambiguous scenarios and answered a comprehension question after each scenario. in the second section, after all scenarios had been read, participants were presented with the title of each scenario, followed by four statements presented in a random order. participants rated how similar each statement was to the scenario they read on a 4-item likert scale from 1 (very different in meaning) to 4 (very similar in meaning). two of these statements resolved the previously read ambiguous scenario in either a positive or negative way, consistent with the story (targets). the remaining two statements were positively and negatively valenced, but were not realistic interpretations of the story (foils; included as filler items). twenty-one scenarios were equally split between worry and rumination themes, and themes relating to pregnancy. worry and rumination items were a subset of those used by hirsch, krahé, whyte, bridge, et al. (2020). an interpretation bias index was created for each participant by subtracting mean ratings for negative targets from mean ratings for positive targets, with a higher score denoting a more positive interpretation bias. pregnancy interpretation bias index (7 items), general interpretation bias index (14 items) and total interpretation bias index (including both pregnancy and general items) were computed. split half reliability was high, spearman-brown coefficient for negative targets and positive targets respectively was .83 and .85. 2) see appendix a in the supplementary materials for sample items. 3) see appendix b in the supplementary materials for sample items. repetitive negative thinking and interpretation bias in pregnancy 6 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ questionnaire measures repetitive thinking questionnaire (rtq-t [trait]) — the 10-item rtq-t (trait) (mcevoy, thibodeau, & asmundson, 2014) measures trait repetitive negative thinking. participants rate the extent to which each item (e.g., ‘i have thoughts or images about all my shortcomings, failings, faults, mistakes’) is true for them when they are distressed or upset. the rtq possesses good internal consistency, convergent and divergent validity (mahoney, mcevoy, & moulds, 2012). present sample cronbach’s α = .92. penn state worry questionnaire (pswq) — the 16-item pswq (meyer, miller, metzger, & borkovec, 1990) measures worry (example item: ‘my worries overwhelm me’). participants rate the extent to which each item is typical of their experience. the pswq has good test-retest reliability (meyer et al., 1990) and good convergent and discriminant validity (brown, antony, & barlow, 1992). present sample cronbach’s α = .83. ruminative response scale (rrs) — depressive rumination was assessed using the 22-item measure rrs (nolen-hoeksema & morrow, 1991). participants rate the extent to which they engage in a range of responses when they feel sad, down or depressed (e.g., ‘think about how alone you feel’). the rrs has good internal consistency (treynor, gonzalez, & nolen-hoeksema, 2003) and test-retest reliability (just & alloy, 1997). present sample cronbach’s α = .94. generalized anxiety disorder 7-item scale (gad-7) — the 7-item gad-7 (spitzer et al., 2006) questionnaire measures anxiety symptoms over the past 2 weeks (example item: ‘feeling nervous, anxious, or on edge?). the gad-7 is a reliable and valid measure of anxiety in the general population (löwe et al., 2008). present sample cronbach’s α = .92. patient health questionnaire 9 — the 9-item phq-9 (kroenke & spitzer, 2002) meas‐ ures depression symptoms in the previous 2 weeks. the phq-9 is a reliable and valid measure of depression severity (kroenke, spitzer, & williams, 2001). present sample cronbach’s α = .88. perinatal anxiety screening scale — pregnant participants completed the 31-item pass (somerville et al., 2014), which measures anxiety in antenatal and postpartum women. participants indicate how often they experience each item (e.g., ‘fear that harm will come to the baby’) in the past month. the pass has good reliability and validity (somerville et al., 2014). present sample cronbach’s α = .95. edinburgh postnatal depression scale (epds) — the 10-item epds (cox, holden, & sagovsky, 1987) was used to assess depression symptoms in pregnant participants. it possesses a high level of test-retest reliability (kernot, olds, lewis, & maher, 2015), hirsch, meeten, gordon et al. 7 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ and good validity (gibson, mckenzie-mcharg, shakespeare, price, & gray, 2009). present sample cronbach’s α = .89. procedure the survey was hosted on the qualtrics platform. participants were asked to complete the survey in one sitting, at a time they could be free from distractions. both groups of participants completed the same core survey (questionnaires, sst, rt), pregnant participants completed two additional pregnancy-specific questionnaires (pass, epds). the survey took 35-40 minutes to complete. upon completion participants received a £5 amazon voucher. the study was approved by the king’s college london research ethics committee (approval number: hr-17/18-5735). participants provided consent elec‐ tronically. results mean questionnaire scores by group are presented in table 2. table 2 descriptive statistics for questionnaires and bias measures by group measures pregnant group (n = 133) non-pregnant group (n = 104) t-test and significance valuem sd m sd questionnaire rtq 29.78 9.53 30.14 9.44 t (235) = 0.29, p = .77 gad7 7.04 5.32 6.84 6.22 t (202.894)a = 0.26, p = .79 phq9 8.09 5.66 7.56 6.41 t (206.795)a = 0.67, p = .51 pswq 52.16 14.02 53.57 14.90 t (235) = 0.75, p = .46 rrs 45.61 13.24 51.53 14.60 t (235) = 3.27, p = .001 pass 30.23 18.25 – – epds 9.26 5.77 – – interpretation bias measures rt pregnancy items 0.42 0.78 0.36 0.77 t (235) = 0.57, p = .57 rt general items 0.68 0.66 0.60 .73 t (235) = 0.85, p = .39 rt all items 0.59 0.65 0.52 0.68 t (235) = 0.82, p = .42 sst 0.72 0.20 0.69 0.23 t (235) = 1.17, p = .24 note. pswq = penn state worry questionnaire; rrs = ruminative response scale; rtq = repetitive thinking questionnaire; gad7 = generalised anxiety disorder questionnaire; phq9 = patient health questionnaire; pass = perinatal anxiety screening scale; epds = edinburgh postnatal depression scale; rt = recognition test; sst = scrambled sentences test. aequal variances not assumed. repetitive negative thinking and interpretation bias in pregnancy 8 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ mean scores on questionnaire measures (rtq, gad7, phq9, pswq) did not differ be‐ tween groups (ps > .05), except on the rrs, where the non-pregnant group reported significantly higher levels of rumination, t(235) = 3.27, p = .001, r = .21. is there an association between interpretation bias and repetitive negative thinking, and anxiety and depression in a sample of pregnant women? to examine whether levels of rnt, worry and rumination were associated with a more negative interpretation bias in pregnant women, we examined correlations between the rnt measures and the behavioural measures of interpretation bias (sst, rt pregnancy items, rt general items, and all rt items collapsed)4 (see table 3 for correlations by group). trait repetitive thinking (measured by the rtq) was significantly negatively correlated with sst index (r = -.61, p < .001). anxiety (measured by the gad7; r = -.63, p < .001), worry (measured by the pswq; r = -.67, p < .001), depression (measured by the phq9; r = -.62, p < .001), and depressive rumination (measured by the rrs; r = -.72, p < .001) were also significantly negatively correlated with the sst. table 3 correlations between rnt and interpretation bias measures (rt, sst) in pregnant and non-pregnant participants questionnaires rt index sst indexpregnancy items worry items all items pregnant group rtq -.24** -.25** -.27** -.61** gad7 -.14 -.24** -.22* -.63** phq9 -.24** -.29** -.30** -.62** pswq -.16 -.24** -.23** -.67** rrs -.09 -.21* -.18* -.72** non-pregnant group rtq -.18 -.22* -.22* -.56** gad7 -.12 -.12 -.13 -.61** phq9 -.15 -.18 -.18 -.68** pswq -.23* -.24* -.26** -.64** rrs -.25* -.21* -.24* -.66** note. rtq = repetitive thinking questionnaire; gad7 = generalised anxiety disorder questionnaire; phq9 = patient health questionnaire; pswq = penn state worry questionnaire; rrs = ruminative response scale; rt = recognition test; sst = scrambled sentences test. *p < .05. **p < .01. 4) in the pregnant sample, the two interpretation bias measures, the rt (all items) and the sst were significantly correlated (r = .33, p < .001). hirsch, meeten, gordon et al. 9 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ for the recognition test (rt), trait repetitive thinking (rtq) was significantly negatively correlated with rt index (all items) (r = -.27, p = .002). anxiety (r = -.22, p = .01) and worry (r = -.23, p = .008), depression (r = -.30, p = .001), and depressive rumination (r = -.18, p = .04) were also significantly negatively correlated with rt. to investigate bias specificity, we calculated the rt index for general and pregnancy-related items separate‐ ly and examined correlations between both of these indices and self-report measures. the rt index for general items was significantly negatively correlated with rnt (r = -.25, p = .003), anxiety (r = -.24, p = .005), worry (r = -.24, p = .005), depression (r = -.29, p = .001), and depressive rumination (r = .21, p = .02). for the rt index comprised of pregnancy items, there was a significant negative correlation between rnt (r = -.24, p = .006) and depression (r = -.24, p = .006). no other associations were significant. does interpretation bias associated with rnt emerge for ambiguous stimuli regardless of its current personal relevance? to examine whether interpretation bias associated with rnt emerges for ambiguous stimuli regardless of its current personal relevance, we examined interpretation bias for pregnancy-related and general stimuli in samples of pregnant and non-pregnant women. we conducted a 2 group (pregnant vs. non-pregnant) x 2 rt material type (pregnancy-related vs. general) mixed model ancova with repeated measures on the second factor and interpretation bias as the dependent variable. to examine whether trait rnt was associated with interpretative bias irrespective of group, rtq-trait scores were included as a covariate. there was no significant main effect of group, f(1, 234) = 0.52, p = .47, ηp2 = .002. there was no significant main effect of material type, f(1, 234) = 3.60, p = .06, ηp2 = 0.02, however this effect approached significance, but with a small effect size. examination of the means suggested that regardless of group (pregnant vs. non-pregnant), when rtq was included in the model as a covariate, the rt positivity index was higher for general items (m = 0.64, se = 0.04) than for pregnancy-related items (m = 0.40, se = 0.05). there was no interaction of group and material type, f(1, 234) = 0.06, p = .81, ηp2 < .001. trait repetitive negative thinking (rtq) was a significant covariate, indicating that trait rnt had a significant relationship with positivity index ratings (as measured by the rt) regardless of group or material type, f(1, 234) = 14.92, p < .001, ηp2 = .065. 5) we re-ran the ancova with rrs ratings included in the model as a covariate alongside rnt. the effects remain as described above and the rrs was not a significant covariate in the model (p = .36). however, we interpret this result with caution given significant group differences on rrs scores between the two groups at baseline (field, 2009). repetitive negative thinking and interpretation bias in pregnancy 10 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ discussion we sought to establish whether there are associations between negative interpretation bias, rnt and symptoms of depression and anxiety in the perinatal period. furthermore, if an interpretation bias is present, we sought to examine whether pregnant and nonpregnant women exhibit similar levels of interpretation bias for both general (likely to be personally salient for both groups) and pregnancy-related (likely to be only salient for pregnant but not pregnant women) ambiguous stimuli. clarifying this would speak to the question of whether interpretation bias is lower for non-personally relevant information. in pregnant women, we found negative associations between two behavioural measures of interpretation bias, rnt, and psychopathology symptoms; that is, the more negative one’s interpretation bias, the higher their levels of rnt and symptoms of depression and anxiety. regarding personal relevance, pregnant and non-pregnant women did not differ in their negative interpretation bias, irrespective of material type (pregnancy-related or general). rather, trait rnt predicted interpretation bias regardless of pregnancy status or personal relevance of material focus. it is noteworthy that mean scores on the self-report measures were relatively high in the current sample. importantly, however, (with the exception of the rrs), the pregnant and non-pregnant groups were nonetheless matched. thus, whilst our findings emerged in the context of high levels of psychopathology and rnt for a community sample, the fact that our groups were comparable nonetheless renders our between-group com‐ parisons meaningful. that said, we acknowledge that the pregnant participants reported significantly lower levels of depressive rumination relative to their non-pregnant coun‐ terparts. our findings are theoretically informative, demonstrating that a bias to negatively interpret ambiguous stimuli also extends to women in the perinatal period, and that this bias is associated with psychological symptoms and rnt. moreover, the bias is not influenced by personal relevance such that it was elicited by both pregnancy-related and general non-pregnancy-related material for women irrespective of pregnancy status. this suggests that the tendency to generate negative interpretations for those with higher levels of rnt may be applied to whatever ambiguity an individual encounters; the negative interpretation then has the potential to trigger further negative thoughts which may encompass other ambiguity and as such trigger new bouts of rnt which can then be perpetuated via further negative interpretations (hirsch & mathews, 2012; hirsch et al., 2016). furthermore, if these findings are replicated in those suffering from generalised anxiety disorder, it may help explain how these individuals end up worrying about so many new topics as soon as they encounter them, given that negative interpretations will trigger and maintain worry about a wide range of topics. these results also have implications for the prevention of perinatal depression and/or anxiety, and suggest the potential clinical utility of offering interventions which effec‐ tively reduce cognitive biases, including cognitive behavioural therapy (cbt) and antide‐ hirsch, meeten, gordon et al. 11 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ pressant medication. in addition, the findings suggest the potential utility of offering cbm-i targeting interpretation bias to vulnerable pregnant women (i.e., those with a history of psychopathology) in order to reduce rnt and associated psychological symp‐ toms in the antenatal period. given the generalised (i.e., rather than pregnancy-specific) nature of interpretation bias observed in our sample, such preventive interventions could utilise cbm-i materials employed in our previous work (e.g., hirsch et al., 2018; hirsch, krahé, whyte, bridge, et al., 2020) to train pregnant women to generate positive interpre‐ tations, without the need for adaptation. however, if multi-session cbm-i training is undertaken, ensuring personal relevance of materials is likely to increase engagement and prevent attrition. in addition to potentially reducing rnt and psychological distress, given evidence that rnt predicts postnatal depression (e.g., egan et al., 2017; o’mahen et al., 2010) and predicts increases in depression from the last trimester of pregnancy to 28 weeks postpartum (barnum et al., 2013), a further possibility that awaits testing in future research is that reducing antenatal rnt may prove effective in reducing the likelihood of suffering from postnatal depression and anxiety. the study has some limitations. first, we cannot rule out the possibility that some participants in the non-pregnant group were trying to conceive, had recently miscarried, or were unknowingly pregnant at the time of participation. whilst possible, given our large sample, we reason that the number of such participants is likely to be a very small proportion of the sample, and as such, do not expect that they would influence our findings. second, framing the pregnancy-related scenarios in the first-person (common practice in the interpretation literature) may have inadvertently resulted in them being processed as personally relevant/salient by non-pregnant participants, despite the lack of relevance of the content (i.e., pregnancy) to their real day-to-day lives. future studies which include self-relevant, non-self-relevant (presented in the first person) and nonself-relevant (referring to other) scenarios are needed to clarify this issue (see wisco & nolen-hoeksema, 2010, for this distinction). third, although our pregnant and non-preg‐ nant samples were matched on levels of trait rnt and worry, groups differed on levels of self-reported rumination. furthermore, mean levels of worry were higher than those reported in the general population, with a community sample of adults scoring 42.67 on the pswq (startup & erickson, 2006), compared to 52.78 in the current sample. thus, we acknowledge that our sample may not be representative of the general population. critically, however, this difference does not prevent us from answering our key research question. fourth, whilst we checked that non-pregnant participants were not currently trying to fall pregnant, it is possible that for some of them, pregnancy may have in fact been personally relevant (e.g., if a close family member was pregnant). however, if this were the case it is likely that it only applied to a sub-group of the non-pregnant sample, and as such is unlikely to account for the current findings. in any case, such limitations are balanced by notable strengths; for example, we con‐ ducted ppi with pregnant women to ensure that our pregnancy-related materials were repetitive negative thinking and interpretation bias in pregnancy 12 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ relevant to the concerns of pregnant women, and thus maximise the ecological validity of the results. furthermore, our findings are broadly replicated across two measures of interpretation bias, and demonstrate associations with different forms of repetitive negative thinking, as well as anxiety and depressed mood in pregnant women. an interesting direction for future research in this area would be to investigate the possibility that pregnancy – a period characterised by uncertainty and ambiguous information for many women exacerbates interpretation biases which were present prior to falling pregnant. for example, prospectively examining a sample of women of child-bearing age and re-assessing them during pregnancy would establish whether pre-existing biases are amplified during pregnancy, as well as shed light on the extent to which interpretation biases potentially interact with other cognitive processes (e.g., the tendency to attend to threat), as well as with life events more broadly. in sum, this study is the first to investigate the interrelationship of negative interpre‐ tation bias, rnt, depression and anxiety in the perinatal period, and found positive associations between all of these variables. for pregnant women, interpretation bias was evident to the same degree for both material that was likely to be salient (pregnan‐ cy-related) and material that was general, and did not differ from that of non-pregnant women. our finding that trait rnt is associated with interpretation bias for all ambigu‐ ous material, and across the full sample, underscores the need for novel interventions to target negative interpretations and reduce rnt in those at risk of developing clinical disorders characterised by unhelpful rnt. given the wider impact of perinatal mental health problems on children, partners and the unborn child, we consider pregnant wom‐ en a priority for rnt-focused preventive interventions. funding: ch receives salary support from the national institute for health research (nihr), mental health biomedical research centre at south london and maudsley nhs foundation trust and king’s college london. competing interests: the authors have declared that no competing interests exist. acknowledgments: we are very grateful to the pregnant women who helped us develop the pregnancy related materials, as well as those who took part in the study. supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • appendix a: example of materials in scrambled sentences test • appendix b: example of a pregnancy specific materials in the recognition test hirsch, meeten, gordon et al. 13 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://www.psychopen.eu/ index of supplementary materials hirsch, c. r., meeten, f., gordon, c., newby, j. m., bick, d., & moulds, m. l. 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(2010). interpretation bias and depressive symptoms: the role of self-relevance. behaviour research and therapy, 48, 1113-1122. https://doi.org/10.1016/j.brat.2010.08.004 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. hirsch, meeten, gordon et al. 17 clinical psychology in europe 2020, vol.2(4), article e3615 https://doi.org/10.32872/cpe.v2i4.3615 https://doi.org/10.1001/archinte.166.10.1092 https://doi.org/10.1037/a0026847 https://doi.org/10.1016/s0005-7967(99)00043-1 https://doi.org/10.1023/a:1023910315561 https://doi.org/10.1037/0022-3514.75.6.1559 https://doi.org/10.1177/0146167200262003 https://doi.org/10.1016/j.brat.2010.08.004 https://www.psychopen.eu/ repetitive negative thinking and interpretation bias in pregnancy (introduction) method participants materials and measures procedure results is there an association between interpretation bias and repetitive negative thinking, and anxiety and depression in a sample of pregnant women? does interpretation bias associated with rnt emerge for ambiguous stimuli regardless of its current personal relevance? discussion (additional information) funding competing interests acknowledgments supplementary materials references there are no short-term longitudinal associations among interoceptive accuracy, external body orientation, and body image dissatisfaction research articles there are no short-term longitudinal associations among interoceptive accuracy, external body orientation, and body image dissatisfaction raechel e. drew ab, eszter ferentzi cd, benedek t. tihanyi cd, ferenc köteles d [a] institute of psychology, elte eötvös loránd university, budapest, hungary. [b] centre for infant cognition, department of psychology, university of british columbia, vancouver, canada. [c] doctoral school of psychology, elte eötvös loránd university, budapest, hungary. [d] institute of health promotion and sport sciences, elte eötvös loránd university, budapest, hungary. clinical psychology in europe, 2020, vol. 2(2), article e2701, https://doi.org/10.32872/cpe.v2i2.2701 received: 2019-04-16 • accepted: 2020-01-11 • published (vor): 2020-06-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: ferenc köteles, institute of health promotion and sport sciences, elte eötvös loránd university, 1117-budapest, bogdánfy ödön u. 10, budapest, hungary. e-mail: koteles.ferenc@ppk.elte.hu abstract background: objectification theory assumes that individuals with low level of interoceptive accuracy may develop an external orientation for information concerning their body. past research has found associations between interoceptive accuracy and body image concerns. we aimed to explore temporal relationships between the tendency to monitor one's body from a third-party perspective, body image dissatisfaction, and interoceptive accuracy. method: in a short longitudinal research, 38 hungarian and 59 norwegian university students completed the schandry heartbeat tracking task and filled out baseline and follow-up questionnaires assessing private body consciousness, body surveillance, and body image dissatisfaction 8 weeks apart. results: interoceptive accuracy and indicators of external body orientation did not predict body image dissatisfaction after controlling for gender, nationality, and body image dissatisfaction at baseline. similarly, body surveillance was not predicted by baseline levels of interoceptive accuracy and body image dissatisfaction. conclusion: contrary to the tenets of objectification theory, body image dissatisfaction and body surveillance are not predicted by interoceptive accuracy over a short period of time among young individuals. keywords interoceptive accuracy, body image, self objectification, body surveillance, public body consciousness, body image dissatisfaction this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i2.2701&domain=pdf&date_stamp=2020-06-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • past research suggests that an individual's ability to detect their own internal signals may have important implications for body monitoring and body image. • we did not find the expected temporal associations among interoceptive accuracy and body image-related variables. • culture and gender were predictors of body image dissatisfaction, an important consideration when designing interventions targeting body image concerns. interoception, the perception of sensations originating from within the body, is related to many aspects of daily functioning, including subjective emotional experience, decision making, and our sense of self (craig, 2002; damasio, 1999; tsakiris, 2017). in the insular cortex, interoceptive and exteroceptive information converge, are processed and integra‐ ted, and provide us with a sense of the physiological status of our entire body, or a feeling of embodiment (craig, 2015; herbert & pollatos, 2012; tsakiris, 2017). interocep‐ tive accuracy (iac) is the dimension of interoception that specifically describes accurately detecting one’s own bodily signals (ceunen, van diest, & vlaeyen, 2013; garfinkel, seth, barrett, suzuki, & critchley, 2015). it is typically measured via behavioral test, as opposed to self-report. individuals with low levels of iac seem to have more difficulties maintain‐ ing a healthy body image and may be more likely to experience body dissatisfaction and eating disorders (badoud & tsakiris, 2017; cash & deagle, 1997; herbert & pollatos, 2012; pollatos et al., 2008), although this is not always the case (pollatos & georgiou, 2016). body image as a concept refers to the mental representation of one's own body, but is multifaceted in that it includes perceptual, affective, and cognitive components (badoud & tsakiris, 2017; cash & pruzinsky, 1990, 2002; gaudio & quattrocchi, 2012; tiggemann & lynch, 2001). past research has approached body image concerns from several different perspectives (i.e., body image dissatisfaction, internalized thin ideals); thus, body image has been widely used as an umbrella term for several related constructs (badoud & tsakiris, 2017). in light of an absence of a clear definition, badoud and tsakiris (2017, p. 7) have defined body image very simply as “the conscious, predominantly visual, mental representation of one’s own body and of our perceptual, cognitive and affective attitudes towards it”. it is considered the product of a complex aggregation of bottom up and top down information signals originating from within and outside of the body (craig, 2015; eshkevari, rieger, longo, haggard, & treasure, 2012; suzuki, garfinkel, critchley, & seth, 2013). it is proposed that the balance between processing of interoceptive and exteroceptive cues is central to the stability and health of our body image (badoud & tsakiris, 2017; tsakiris, 2017). predictive coding models suggest that individuals who do not perceive interoceptive signals accurately may learn to rely more on external cues when assessing the body's status due to the imprecision of predictions (i.e., top-down interoceptive accuracy and body image dissatisfaction 2 clinical psychology in europe 2020, vol.2(2), article e2701 https://doi.org/10.32872/cpe.v2i2.2701 https://www.psychopen.eu/ representations) based on prior inaccuracies (ainley, apps, fotopoulou, & tsakiris, 2016). in line with this idea, tsakiris and colleagues (2011) found that individuals with low iac were more likely to assume ownership of a false body part, highlighting the level of disembodiment and body image distortion that can occur when accurate perception of internal signals is dampened. objectification theory (fredrickson & roberts, 1997) in‐ dicates that when the psychological experience of the body (i.e., embodiment) is predom‐ inantly informed by external sources of information, there will be greater exposure to negative cultural cues (i.e., unattainable beauty ideals, objectifying media imagery). this, in turn, contributes to discrepancies between the idealized body image and perceived actual appearance of the body, through further internalization of ideals and making salient any existing discrepancies (mckinley & hyde, 1996). furthermore, discrepancies between the perceived self and an internalised ideal self (i.e., evaluation), plus a high level of importance placed on matching that ideal (i.e., investment) can produce body image dissatisfaction (cash, 2012; cash & pruzinsky, 2002). concerning healthy young individuals, women with attenuated iac exhibit higher levels of body image dissatisfac‐ tion (emanuelsen, drew, & köteles, 2015). similarly, duschek and colleagues (2015) found that individuals with greater iac had a more positive body image. self objectification is the acculturated tendency to view one's own body as an object, to evaluate it based on appearance rather than functionality, and to experience oneself from a third-party perspective (ainley & tsakiris, 2013; calogero, tantleff-dunn, & thompson, 2010; fredrickson & roberts, 1997). habitual self-monitoring, an integral aspect of self objectification, is referred to in the literature as body surveillance (calogero et al., 2010; grippo & hill, 2008; mckinley & hyde, 1996). body surveillance is accepted as the behavioural manifestation of self objectification, and as such it is measured inde‐ pendently from other facets of the original self objectification construct (i.e., body shame and control beliefs), but also used synonymously (moradi & huang, 2008; tiggemann, 2013). it is important to note that body surveillance and iac (or other aspects of intero‐ ception) are different constructs; the former includes an external perspective and evalua‐ tion, whereas the latter refers to internal body related sensations. research has indicated a relationship between body surveillance and negative body image or distortion in both clinical (i.e., eating disorders, depression) and non-clinical samples (calogero, davis, & thompson, 2005; dakanalis, timko, clerici, riva, & carrà, 2017; fitzsimmons-craft et al., 2012; moradi & huang, 2008; peat & muehlenkamp, 2011; tiggemann & kuring, 2004). self objectification is proposed to predict body image problems, and body surveillance has mediated the relationship between internalised thin ideals and body image dissatis‐ faction in previous research (fitzsimmons-craft et al., 2012; fredrickson & roberts, 1997; knauss, paxton, & alsaker, 2008; myers & crowther, 2007; tiggemann & williams, 2012). more recently, fitzsimmons-craft and colleagues (2015) found that a higher level of body surveillance was moderately associated with increased body dissatisfaction. other drew, ferentzi, tihanyi, & köteles 3 clinical psychology in europe 2020, vol.2(2), article e2701 https://doi.org/10.32872/cpe.v2i2.2701 https://www.psychopen.eu/ research suggests that less external body orientation is important for maintaining a positive body image (avalos & tylka, 2006; homan & tylka, 2014). we suggest that objectification theory (fredrickson & roberts, 1997) may provide insight into previous findings that individuals with diminished iac express higher body image dissatisfaction; while those with improved iac demonstrate a more positive body image (duschek et al., 2015; emanuelsen et al., 2015). we believe that diminished accura‐ cy in perceiving one’s internal signals may lead a person to rely on external sources of information concerning the bodily self, or vice versa. miller and colleagues (1981, p. 404) define public body consciousness, another concept of external orientation concerning one's appearance, as “a chronic tendency to focus on and be concerned with the external appearance of the body”. individuals who are high in public body consciousness typically view themselves from an outsider's perspective, monitoring their appearance and behaviour to facilitate social interaction (ainley & tsakiris, 2013; miller et al., 1981). although distinct constructs, one could argue that public body consciousness is closely related to body surveillance, insofar as both con‐ structs concern viewing oneself as a social object, an external orientation for information concerning one's body, and a preoccupation with appearance (miner-rubino, twenge, & fredrickson, 2002). body surveillance, however, primarily differs from public body consciousness in that the individual takes on the perspective of the observer, as opposed to merely being aware of it (miller et al., 1981; miner-rubino et al., 2002). in this way, it is likely a more disembodied experience than the awareness of self from a public perspective (miner-rubino et al., 2002). our aim was to investigate how internal orientation (i.e., interoception) and external orientation (i.e., public body consciousness and body surveillance) influence body im‐ age dissatisfaction. research investigating similar associations (ainley & tsakiris, 2013; duschek et al., 2015; emanuelsen et al., 2015) has not included these constructs in one empirical study. additionally, as this previous work investigated cross-sectional data, spontaneous fluctuation cannot be excluded; thus, we have used a short-term longitudi‐ nal study to explore their relation. based on the aforementioned theoretical considerations and empirical findings, low level of iac and the proclivity to assess one's body from an outsider's perspective should predict a negative body image. in the present research, we expected that iac, body surveillance and public body consciousness at baseline (t1) would predict body image dissatisfaction 8 weeks later (t2) (hypothesis 1). we also considered the possibility that low iac and high levels of body image dissatisfaction may increase the tendency to view oneself from a third party perspective. therefore, alternately, we expected that iac and body image dissatisfaction at t1 would predict body surveillance at t2 (hypothesis 2). interoceptive accuracy and body image dissatisfaction 4 clinical psychology in europe 2020, vol.2(2), article e2701 https://doi.org/10.32872/cpe.v2i2.2701 https://www.psychopen.eu/ material and method participants assuming α = .05, 1-β = .80, and a medium effect size (.15; in the lack of empirical data, this estimation was based on theoretical considerations), the minimum sample size for a multiple linear regression analysis with 6 predictor variables is 97 (faul, erdfelder, lang, & buchner, 2007). participants in this research were norwegian (n = 59, 74.6% female, 24.8 ± 5.09 yrs) and hungarian (n = 38, 65.8% female, 21.3 ± 1.60 yrs) students enrolled at a university in hungary. norwegian students were enrolled in an english language international program. the research was approved by the research ethics committee of the institution. participation was voluntary, and all participants signed an informed consent form before the measurements. the english versions of the questionnaires were administered for the norwegian students and the hungarian version for the hungarian participants. measures the body surveillance subscale of objectified body consciousness scale the scale was developed by mckinley and hyde (1996) to assess negative body experi‐ ence from a social constructionist point of view. the questionnaire measures the experi‐ ence of the body as an object to be viewed by others and the beliefs underlying this experience. for the purpose of this research, we have chosen to use only the 8 item body surveillance subscale, which uses a 7 point likert-scale. higher values indicate higher surveillance tendency. cronbach's alpha in the present study was .75 at t1, and .70 at t2. the public body consciousness scale the scale was developed by miller and colleagues (1981) as part of the body conscious‐ ness questionnaire, and it consists of 5 items rated on a 5 point likert-scale. higher scores indicate more importance placed on individual appearance. cronbach's alpha for the public body consciousness subscale in the present study was .71 at t1. the body image ideals questionnaire the questionnaire was developed by cash and szymanski (1995) to provide a reliable assessment of participants' evaluation of their own physical appearance, and asks two questions with regard to each of 11 physical characteristics, including muscle tone, hair texture, complexion and various physical abilities (e.g., coordination, strength). respon‐ ses are indicated on a 4 point likert-type scale. the first question asks participants to what extent they feel that they match their physical ideals; the second question asks how important it is to the participant that their actual attributes match their ideals. higher drew, ferentzi, tihanyi, & köteles 5 clinical psychology in europe 2020, vol.2(2), article e2701 https://doi.org/10.32872/cpe.v2i2.2701 https://www.psychopen.eu/ scores on the scale indicate a greater overall level of body image dissatisfaction. in the current study, the internal consistency of the questionnaire was .65 at t1, and .69 at t2. the mental heartbeat tracking method interoceptive accuracy was assessed using the mental tracking method (schandry, 1981), a widely used paradigm. in healthy individuals, there is a correspondence between the performance on the schandry-task and the mean amplitude of heartbeat evoked potential (pollatos & schandry, 2004), an eeg potential associated with the heartbeat, which is also higher during the schandry-task than during periods of rest (schulz et al., 2015). during the task, participants were asked to count their perceived heartbeats silently. they were not allowed to monitor their pulse (e.g., palpating the wrist or neck artery) or use any other physical techniques that might help them to count more accurately. they were further instructed to count uncertain sensations but to refrain from guessing. upon hearing a “start” cue, participants began to silently count their own heartbeats until a “stop” cue was given, at which point they reported the number of heartbeats counted to an experimenter. at the same time, the experimenter counted and recorded the participants’ heartbeats using a polar watch (model rs-400) with a chest strap. this procedure was administered for one 15 second warm-up trial followed by three subsequent intervals (30, 40, and 100 seconds) presented in random order, with a 10 second break in between. following the initial trial, participants were asked to indicate how they arrived at the reported number of heartbeats. subjects who reported guessing or counting seconds were encouraged to count only the perceived heartbeats for the remaining three trials. the experimenter explained that accuracy is regarded as neither positive nor negative. subjects were not aware of the length of the intervals and no feedback about performance was given. iac is the mean score of the formula: 1 – [(| recorded heartbeats – counted heartbeats|)/recorded heartbeats] calculated for each of the three time trials. cronbach’s alpha coefficient for the index was .924. procedure participants filled out an on-line test battery one day prior to a scheduled meeting with the experimenter (t1). at the meeting, participants were seated in a quiet room. after a brief introduction to the mental tracking method, participants were asked to relax, breath normally, and focus on the beating of their heart. participants completed the on-line self report battery a second time 8 weeks later (t2). this period of time appears long enough to capture short-term fluctuations and fits within a typical 12-week university semester, while avoiding the inclusion of the stressful first and final 2 weeks of the semester. this research was part of a larger study, thus participants took part in other measure‐ ments as well. concerning the variables used in the present paper, only baseline intero‐ ceptive accuracy values were included in another research (ferentzi, drew, tihanyi, & köteles, 2018). interoceptive accuracy and body image dissatisfaction 6 clinical psychology in europe 2020, vol.2(2), article e2701 https://doi.org/10.32872/cpe.v2i2.2701 https://www.psychopen.eu/ statistical analysis statistical analysis was conducted using the jasp v0.8.5.1 software (jasp team, 2019). based on the results of normality analysis (shapiro-wilk tests), parametric statistical methods were used throughout the analysis. differences between groups with respect to age and sex were checked using student t-test and chi-square test, respectively. concern‐ ing the assessed psychological variables, the two national groups were compared using student t-test. cross-sectional associations among variables at t1 were checked using pearson correlation. longitudinal associations (hypothesis 1 and 2) were investigated using multiple linear regression analysis. in step 1 the baseline value of the respective criterion variable was entered; in step 2, group affiliation (hungarian = 1; norwegian = 2), gender (male = 1; female = 2), t1 values of interoceptive accuracy, body surveillance, and (only for body image dissatisfaction) public body consciousness were stepped in. results descriptive statistics, group level comparisons, and baseline correlations are presented in table 1 and table 2, respectively. a statistically significant difference between groups in age, t(95) = -4.104, p < .001, d = -0.854, but not in sex ratio, χ2(1) = 0.869, p = .351, was found. the two groups showed significant differences with respect to body surveillance and public body consciousness at t1, and body image dissatisfaction at t2. concerning baseline measures, a significant negative medium level association between body sur‐ veillance and iac was found in the hungarian group. in the norwegian group, body surveillance was moderately associated with body image dissatisfaction and weakly with public body consciousness, and public body consciousness was negatively associated with iac (for details, see table 2). table 1 descriptive statistics (mean ± standard deviation) of the assessed variables split by group, and results of student t-tests comparing the two groups variable hungarians n = 38 norwegians n = 59 t(95) p cohen‘s d body surveillance at t1 36.04 ± 5.174 33.05 ± 7.454 2.159 .033 0.449 body surveillance at t2 33.68 ± 5.132 32.03 ± 6.465 1.322 .189 0.275 body image dissatisfaction at t1 1.58 ± 1.327 1.41 ± .883 0.757 .451 0.157 body image dissatisfaction at t2 1.96 ± 1.292 1.33 ± .797 3.015 .003 0.627 public body consciousness at t1 24.16 ± 2.937 21.00 ± 3.634 4.492 < .001 0.934 iac at t1 .46 ± .249 .52 ± .269 -1.087 .280 -0.226 note. iac = interoceptive accuracy; t1 = baseline; t2 = 8 weeks later. drew, ferentzi, tihanyi, & köteles 7 clinical psychology in europe 2020, vol.2(2), article e2701 https://doi.org/10.32872/cpe.v2i2.2701 https://www.psychopen.eu/ table 2 pearson’s correlations among variables at baseline variable 1 2 3 4 1. body image dissatisfaction .14 -.07 .11 2. body surveillance .44** – .18 -.40* 3. public body consciousness .11 .32* – -.18 4. iac -.11 -.11 -.33* – note. upper triangle = hungarians (n = 38); lower triangle = norwegians (n = 59); iac = interoceptive accuracy. *p < .05. **p < .01. in the multiple linear regression analysis predicting body image dissatisfaction at t2 (hypothesis 1), baseline biq score explained 23.1% of the total variance (p < .001) in step 1. in step 2, the regression equation explained 32.6% of the total variance (p < .001). predictors of body image dissatisfaction at t2 were baseline body image dissatisfaction, group, and gender (p < .1), but not iac, body surveillance, and public body consciousness (for details, see table 3). group association was negative, while gender had a positive association; thus, all other factors being equal, hungarian nationality and female gender predicted higher levels of body image dissatisfaction at t2. table 3 results of the multiple linear regression with body image dissatisfaction at t2 as the dependent variable step b seb β 95% ci (ll, ul) p zero-order correlation partial correlation step 1: r2 = .231, p < .001 body image dissatisfaction at t1 0.474 0.089 0.481 0.298, 0.650 < .001 .481 .481 step 2: r2 = .326, p < .001 body image dissatisfaction at t1 0.439 0.091 0.446 0.259, 0.619 < .001 .481 .455 group -0.622 0.210 -0.288 -1.038, -0.205 0.004 -.296 -.298 gender 0.371 0.214 0.159 -0.055, 0.797 0.087 .202 .179 iac at t1 -0.147 0.382 -0.036 -0.905, 0.611 0.701 -.100 -.041 body surveillance at t1 -0.005 0.015 -0.035 -0.036, 0.025 0.725 .191 -.037 public body consciousness at t1 -0.006 0.029 -0.019 -0.064, 0.053 0.851 .140 -.020 note. iac = interoceptive accuracy; t1 = baseline; t2 = 8 weeks later. the regression equation predicting body surveillance at t2 (hypothesis 2) explained 49.7% of total variance in step 1, and 51.7% in step 2. the only significant predictor was baseline body surveillance score (for details, see table 4). interoceptive accuracy and body image dissatisfaction 8 clinical psychology in europe 2020, vol.2(2), article e2701 https://doi.org/10.32872/cpe.v2i2.2701 https://www.psychopen.eu/ table 4 results of the multiple linear regression with body surveillance at t2 as dependent variable step b seb β 95% ci (ll, ul) p zero-order correlation partial correlation step 1: r2 = .497, p < .001 body surveillance at t1 0.624 0.064 0.705 0.496, 0.752 < .001 .705 .705 step 2: r2 = .517, p < .001 body surveillance at t1 0.640 0.071 0.724 0.499, 0.781 < .001 .705 .687 group -0.069 0.927 -0.006 -1.911, 1.773 .941 -.134 -0.008 gender 1.571 1.021 0.119 -0.458, 3.600 .128 .206 .159 iac at t1 2.468 1.770 0.108 -1.049, 5.985 .167 -.073 .145 body image dissatisfaction at t1 -0.327 0.431 -0.059 -1.184, 0.529 .450 .179 -.079 note. iac = interoceptive accuracy; t1 = baseline; t2 = 8 weeks later. discussion this study investigated the temporal relationships among the external orientation toward the body, body image, and interoceptive accuracy (heartbeat tracking ability) assessing a general student sample of young hungarians and norwegians. dissatisfaction with body image 8 weeks later was predicted by baseline dissatisfaction, hungarian nationality, and female gender, but not by interoceptive accuracy or external body orientation. body sur‐ veillance was predicted only by baseline body surveillance but not by gender, nationality, interoceptive accuracy, or dissatisfaction with body image. based on past research, we expected that interoceptive accuracy (iac) and constructs representing an external body orientation (public body consciousness and body surveil‐ lance) would predict body image dissatisfaction (ainley & tsakiris, 2013; emanuelsen et al., 2015; fitzsimmons-craft et al., 2012; fredrickson & roberts, 1997). whereas these hypotheses were not supported by our data, nationality and gender were predictors of change. nationality related findings are difficult to explain as (1) the size of the two samples was not equal and (2) there was a significant difference between the two groups with respect to age. generally, hungarian adolescents experience higher levels of body concerns when compared to other european nationalities (papp, urbán, czeglédi, babusa, & túry, 2013); this tendency, along with their younger age, might have made the temporal fluctuations of body image dissatisfaction more marked. the result that female gender predicted (although only at a trend level) greater change in body image dissatisfaction was not surprising, as empirical evidence shows that females generally experience higher levels of body image dissatisfaction (grabe, ward, & hyde, 2008; grogan, 2016; tiggemann, 2004). in past studies, both norwegian and hungarian adolescent females have shown higher levels of body image dissatisfac‐ tion than their male counterparts (meland, haugland, & breidablik, 2007; papp et al., drew, ferentzi, tihanyi, & köteles 9 clinical psychology in europe 2020, vol.2(2), article e2701 https://doi.org/10.32872/cpe.v2i2.2701 https://www.psychopen.eu/ 2013). even at very young ages, girls are more likely to exhibit body concerns, and be more dissatisfied with their bodies (grogan, 2016), perpetuated by the internalised ideals promoted by modern western culture and media (grabe et al., 2008; myers & crowther, 2007). although a previous cross-sectional study revealed a medium level reverse correlation between iac and self objectification (ainley & tsakiris, 2013), this was replicated only in the hungarian sample in the present study. moreover, results of our second regression model indicate that iac does not explain variance in changes of body surveillance. according to our results, the only predictor of self objectification at t2 was the baseline self objectification score; the strong association between the two (β = 0.705) indicates high temporal stability. therefore, temporal associations with iac are difficult to detect if the effect size of iac is low and additional factors are controlled for. temporal sta‐ bility of body image dissatisfaction was lower (β = 0.481); still, low to medium level associations between body image dissatisfaction and iac reported in cross-sectional studies (duschek et al., 2015; emanuelsen et al., 2015) might have been too weak to detect in the current study. moreover, the instruction used in the schandry-task was more strict than usual with respect to allowing estimation. this might have resulted in lower iac scores with less variance than in other studies and possibly influenced participants’ response tendencies (for more detail, see the limitations section). overall, the lack of predictive associations among self-objectification, body image dissatisfaction, and iac indicates that the ability to accurately sense our bodily signals is not among the significant factors that influence how we monitor and envision our body’s appearance. for example, self-reported (i.e., conscious) aspects of interoception (e.g., interoceptive sensibility and body awareness) might play a more important role in these processes. additionally, as tiggemann (2004) has pointed out, body surveillance and body image dissatisfaction do not necessarily go hand-in-hand, especially considering the multi-face‐ ted complexity of the body image dissatisfaction construct and individual differences in the internalised-ideal used as a comparator between the perceived body and ideal body. the current study is not without limitations. first, an 8 week time frame might not be sufficient to reveal on complex time-related associations among multiple variables. second, internal consistency for the body image ideals questionnaire and public body consciousness scores were acceptable but low when compared to previous research (ainley & tsakiris, 2013; dakanalis et al., 2017; miller et al., 1981). third, although widely accepted, the mental tracking paradigm (schandry, 1981) has received some criticism for the potential that participant responses could be influenced by previous knowledge about their own heart rate, or expectations concerning their ability to detect their heart rate accurately (ring, brener, knapp, & mailloux, 2015). instruction given to participants can also bias the measurement (desmedt, luminet, & corneille, 2018). for example, participants with the tendency to please others may produce lower overall iac scores when given strict instructions that do not allow guessing, but produce inflated iac interoceptive accuracy and body image dissatisfaction 10 clinical psychology in europe 2020, vol.2(2), article e2701 https://doi.org/10.32872/cpe.v2i2.2701 https://www.psychopen.eu/ scores when given permissive instructions that do allow for guessing. individuals with a desire to please others could also be likely to aspire to social norms and experience body image dissatisfaction, which may provide some explanation for why we did not find an expected relationship between increased body image dissatisfaction and lower iac at baseline. finally, although norwegian students in the present research have a high level of proficiency and study in english on a daily basis, the questionnaires were neither translated into norwegian nor validated for use with a norwegian population. there may be subtle variations in responses due to second language understanding. in summary, culture and gender differences should be considered when designing interventions for improving body image, as subgroups of the population may show disparate patterns of association among related constructs. funding: this work was supported by the hungarian national scientific research fund (k124132). the sponsor had no other involvement in the current study. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. references ainley, v., apps, m. a. j., fotopoulou, a., & tsakiris, m. 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(2017). the multisensory basis of the self: from body to identity to others. quarterly journal of experimental psychology, 70(4), 597-609. https://doi.org/10.1080/17470218.2016.1181768 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. drew, ferentzi, tihanyi, & köteles 15 clinical psychology in europe 2020, vol.2(2), article e2701 https://doi.org/10.32872/cpe.v2i2.2701 https://doi.org/10.1097/psy.0000000000000195 https://doi.org/10.1016/j.neuropsychologia.2013.08.014 https://doi.org/10.1016/s1740-1445(03)00002-0 https://doi.org/10.1111/cp.12010 https://doi.org/10.1348/0144665031752925 https://doi.org/10.1037/0012-1649.37.2.243 https://doi.org/10.1177/0361684311420250 https://doi.org/10.1098/rspb.2010.2547 https://doi.org/10.1080/17470218.2016.1181768 https://www.psychopen.eu/ interoceptive accuracy and body image dissatisfaction (introduction) material and method participants measures procedure statistical analysis results discussion (additional information) funding competing interests acknowledgments references a response to marvin goldfried's article on the immaturity of the psy-professions letter to the editor, commentary a response to marvin goldfried's article on the immaturity of the psy-professions vik nair a [a] nhs greater glasgow and clyde, glasgow, united kingdom. clinical psychology in europe, 2020, vol. 2(2), article e3105, https://doi.org/10.32872/cpe.v2i2.3105 published (vor): 2020-06-30 corresponding author: vik nair, glasgow psychological trauma centre, the anchor, festival business centre, 150 brand street, glasgow, g51 1dh, united kingdom. e-mail: vikas.nair@nhs.net marvin goldfried’s article (goldfried, 2020) critiqued the lack of consensus within the psy-professions, articulating reasons for this, but without mentioning power or interest. i believe the preoccupation with new theories described by goldfried arises from our inability to discard unworkable ideas, despite ample empirical or conceptual grounds for doing so, because of the workings of power. if technology is the ability to understand and manipulate the non-human material world, social power is the ability to influence the behaviour of other humans. social pow‐ er varies according to the identities of the parties involved, while technology does not. disciplines concerned with humans affect and are affected by social power, immediately creating uncertainty. people do not passively accept the effects of new knowledge, but seek to achieve outcomes favourable to their interests by taking control over that knowl‐ edge (“history is written by the victors”). research findings are not determined solely by empirical data, but also through the exercise of ideological power. social dynamics affect what is asked, what answers are acceptable, how data is interpreted and how much attention is paid to conclusions. our profession's immaturity is not for want of empirical data. questions that may have been answerable decades ago persist because the answers have been unacceptable to powerful interests. would we really expect the psychometric industry (enmeshed with clinical psychology because of the power it affords the profession) to accept that there is no evidence to support the existence of g or temporally and contextually stable personality? would the legal systems in our societies suddenly shift from punishment to pragmatism, as proposed by skinner (1973) almost half a century ago, simply because of empirical data refuting free will? is the persistence of psychiatric diagnosis due to its utility or to the power of the psychiatric profession? how many expert witnesses in legal this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i2.3105&domain=pdf&date_stamp=2020-06-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ cases point out to judges that data obtained through self-report psychometrics is in no way objective? this is not to suggest that change cannot happen, but that social power is as least as important as “truth” in determining how knowledge develops. attempts to increase the maturity of our discipline have to take account of power and interest. funding: the author has no funding to report. competing interests: the author has declared that no competing interests exist. acknowledgments: the author has no support to report. references goldfried, m. r. (2020). the field of psychotherapy: over 100 years old and still an infant science. clinical psychology in europe, 2(1), article e2753. https://doi.org/10.32872/cpe.v2i1.2753 skinner, b. f. (1973). beyond freedom and dignity. new york, ny, usa: bantam books, vintage books. (original work published 1971) clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. letter to the editor 2 clinical psychology in europe 2020, vol.2(2), article e3105 https://doi.org/10.32872/cpe.v2i2.3105 https://doi.org/10.32872/cpe.v2i1.2753 https://www.psychopen.eu/ development and initial validation of a brief questionnaire on the patients’ view of the in-session realization of the six core components of acceptance and commitment therapy research articles development and initial validation of a brief questionnaire on the patients’ view of the in-session realization of the six core components of acceptance and commitment therapy thomas probst a, andreas mühlberger b, johannes kühner c, georg h. eifert d, christoph pieh a, timo hackbarth b, johannes mander e [a] department for psychotherapy and biopsychosocial health, danube university krems, krems, austria. [b] department of psychology, regensburg university, regensburg, germany. [c] practice for psychotherapy, würzburg, germany. [d] department of psychology, chapman university, orange, ca, usa. [e] center for psychological psychotherapy, heidelberg university, heidelberg, germany. clinical psychology in europe, 2020, vol. 2(3), article e3115, https://doi.org/10.32872/cpe.v2i3.3115 received: 2019-01-21 • accepted: 2020-03-25 • published (vor): 2020-09-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: thomas probst, danube university krems, dr.-karl-dorrek-str. 30, 3500 krems, austria. email: thomas.probst@donau-uni.ac.at supplementary materials: materials [see index of supplementary materials] abstract background: assessing in-session processes is important in psychotherapy research. the aim of the present study was to create and evaluate a short questionnaire capturing the patients’ view of the in-session realization of the six core components of acceptance and commitment therapy (act). method: in two studies, psychotherapy patients receiving act (study 1: n = 87) or cognitivebehavioral therapy (cbt) (study 2, sample 1: n = 115; sample 2: n = 156) completed the act session questionnaire (act-sq). therapists were n = 9 act therapists (study 1) and n = 77 cbt trainee therapists (study 2). results: factor structure: exploratory factor analyses suggested a one-factor solution for the actsq. reliability: cronbach’s alpha of the act-sq was good (study 1: α = .81; study 2, sample 1: α = .84; sample 2: α = .88). convergent validity: the act-sq was positively correlated with validated psychotherapeutic change mechanisms (p < .05). criterion validity: higher act-sq scores were associated with better treatment outcomes (p < .05). conclusion: the study provides preliminary evidence for the reliability and validity of the actsq to assess the in-session realization of the six core components of act in the patients’ view. further validation studies and act-sq versions for therapists and observers are necessary. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i3.3115&domain=pdf&date_stamp=2020-09-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords acceptance and commitment therapy, session report, reliability, validity highlights • the act-sq is a patient self-report on the in-session realization of the six core components of act. • data of two studies (act, cbt therapies) support the reliability and validity of the act-sq. • further validation studies and act-sq versions for therapists and observers are necessary. acceptance and commitment therapy (act; hayes, 2004) is one of the third-wave cognitive-behavioral therapies (cbt). several reviews and meta-analyses summarized the effectiveness of act for various clinically relevant problems (a-tjak et al., 2015; graham, gouick, krahé, & gillanders, 2016; öst, 2014; powers, zum vörde sive vörding, & emmelkamp, 2009; swain, hancock, hainsworth, & bowman, 2013). a central treat‐ ment strategy in act is reducing the patients’ psychological inflexibility and thereby increasing psychological flexibility. the act model of psychological flexibility consists of the following of six core components (see table 1): acceptance, cognitive defusion, contact with the present moment, self-as-context, values, and committed action. these six core components of psychological flexibility can be described as mindfulness and acceptance processes (acceptance, cognitive defusion, contact with the present moment, self-as-context) as well as commitment and behavior change processes (contact with the present moment, self-as-context, values, and committed action). the counterparts of these six components of psychological flexibility are formulated in the act model of psychological inflexibility (see table 1): experiential avoidance (vs. acceptance), cognitive fusion (vs. cognitive defusion), dominance of the conceptualized past and feared future (vs. contact with the present moment), attachment to the conceptualized self (vs. self-ascontext), lack of values (vs. values), and inaction, impulsivity, or avoidant persistence (vs. committed action). a meta-analysis on laboratory-based component studies revealed positive effects for treatment strategies on the six act core components (levin, hildebrandt, lillis, & hayes, 2012). moreover, psychotherapy research has shown that patients who improve their skills in acceptance, cognitive defusion, contact with the present moment, and values-based actions during therapy show better treatment outcomes (e. g., åkerblom, perrin, rivano fischer, & mccracken, 2015; arch, wolitzky-taylor, eifert, & craske, 2012b; baranoff, hanrahan, kapur, & connor, 2013; forman, herbert, moitra, yeomans, & geller, 2007; forman et al., 2012; hesser, westin, & andersson, 2014; niles et al., 2014; vowles & mccracken, 2008; zettle, rains, & hayes, 2011). interestingly, some of these development and validation of the act-sq 2 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ studies found improvements in act processes to be beneficial for the outcome not only in act but also in cbt as well as multidisciplinary treatments. act processes might therefore be change mechanisms in other psychotherapies than act as well, i. e. general change mechanisms. some act processes were even more strongly associated with the outcome in cbt than in act, for example in the study by arch et al. (2012b) in which cognitive defusion predicted worry reductions more in cbt than in act. table 1 act model of psychological flexibility and act model of psychological inflexibility act model of psychological flexibility act model of psychological inflexibility component description component description acceptance being open towards all experiences experiential avoidance avoiding unwanted experiences cognitive defusion observing thoughts and inner experiences come and go cognitive fusion being entangled in one’s thoughts and inner experiences contact with the present moment non-judgmental awareness of current experiences dominance of the conceptualized past and feared future ruminating on the past or worrying about the future self-as-context being aware of one’s experiences without attachment to them attachment to the conceptualized self inflexible identification with a self-image values having identified valued directions lack of values having no orientation in life committed action effective behavior related to one’s values inaction, impulsivity, or avoidant persistence problems to keep either commitments or to set goals several questionnaires have been published to measure a patient’s skill in the act components: e. g., acceptance and action questionnaire ii (bond et al., 2011); acceptance and action questionnaire for university students (levin, krafft, pistorello, & seeley, 2019); comprehensive assessment of acceptance and commitment therapy processes (francis, dawson, & golijani-moghaddam, 2016); chronic pain acceptance questionnaire (mccracken, vowles, & eccleston, 2004), cognitive fusion questionnaire (gillanders et al., 2014), multidimensional experiential avoidance questionnaire (gámez, chmielewski, kotov, ruggero, suzuki, & watson, 2014), tinnitus acceptance question‐ naire (weise, kleinstäuber, hesser, westin, & andersson, 2013), the valued living ques‐ tionnaire (wilson, sandoz, kitchens, & roberts, 2010). how strong patients improve their skills in act components might depend on the in-session realization of the act probst, mühlberger, kühner et al. 3 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ components. as far as we know, no study has yet explored this research question. this might be because only the observer-based drexel university act/cbt therapist adherence rating scale (dutars; mcgrath, 2012) is available to measure the degree the act components are realized in a psychotherapy session. the dutars was applied in previous clinical trials on act to assess treatment adherence (arch et al., 2012a; gloster et al., 2015). although such observer-based measures provide valuable data, there are several barriers to apply observer-based ratings in psychotherapy, especially under the conditions of routine practice. for example, observers must be trained to provide reliable and valid data, financial or other compensations are necessary since observing sessions or session segments consumes a serious amount of time (weck, grikscheit, höfling, & stangier, 2014), and only certain consent to being observed in-session limiting the generalizability of the results. besides observer ratings, ratings given by patients are complementary data sources. patient ratings on in-session processes are easier to obtain than observer ratings. patients can fill out session questionnaires directly after the psychotherapy session to measure the degree therapeutic factors were realized in this given psychotherapy session. patient ratings of in-session processes are especially relevant as they correlate most consistently with psychotherapy outcome (e. g, horvath & symonds, 1991; mander et al., 2013, 2015; ogrodniczuk, piper, joyce, & mccallum, 2000). several session questionnaires were published on the in-session realization of the therapeutic alliance (horvath & greenberg, 1989) and the psychotherapeutic change processes according to grawe (1997): problem actuation (activation of problems and related emotions), clarification of meaning (acquir‐ ing new insights and a deeper understanding of the problems), resource activation (rec‐ ognizing potential, strengths, and positive facets), and mastery (the ability to cope with problems) (see mander et al., 2013, 2015). yet, no session report exists, to our knowledge, which captures the in-session realization of the six core components of act. a brief, time-economic and psychometrically sound act session report would have the potential to enrich psychotherapy research as well as clinical practice. clinical implications would be that this measure could be applied in more settings than the observer-based dutars and that therapists could use this measure to obtain feedback on the patients’ perspective of the in-session realization of the act components. in the present study, we developed and evaluated a brief act session questionnaire (act-sq; see supplementary materials). the act-sq was created to obtain patient ratings on the in-session realization of the act components of psychological flexibility. in this manuscript, we present two studies. study 1 investigated the factor structure, the reliability, and the convergent validity. study 2 analyzed the factor structure, the reliability, the convergent validity, and also criterion validity. the following research questions were evaluated: 1. what is the factor structure of the act-sq? 2. how is the reliability (internal consistency) of the act-sq? development and validation of the act-sq 4 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ 3. with regard to convergent validity: how are the associations between the act-sq and general change mechanisms? the general change mechanisms proposed by grawe (1997) – problem actuation, clarification of meaning, resource activation, mastery – were used to evaluate convergent validity. the general change mechanisms of grawe were used to test convergent validity due to two reasons. first, these general change mechanisms are considered to be relevant in all psychotherapies, therefore also in act. second, act processes might also be general psychotherapeutic change mechanisms, since – as mentioned above – improvements in act processes have been found to beneficial for the outcome not only in act but also in cbt and multidisciplinary treatments. 4. are the factor structure, reliability, and convergent validity of the act-sq comparable between a sample of patients treated with act (study 1) and a sample of patients treated with cbt (study 2)? act and cbt have similarities and differences (arch & craske, 2008; harley, 2015) so that the factor structure, reliability, and convergent validity of the act-sq might resemble more the similarities or the differences. 5. regarding criterion validity: is the act-sq associated with treatment outcomes? 6. are the factor structure, reliability, convergent validity, and criterion validity of the act-sq comparable in different treatment phases? it has been discussed that the earlier and later phases of psychotherapy differ for example in common factors (ilardi & craighead, 1994; lambert, 2005) so that the factor structure, reliability, convergent validity, and criterion validity of the act-sq might depend on the treatment phase. study 1 method the study was performed according to the resolution of helsinki and the professional obligations for therapists. no ethics committee was involved in study 1 because no harmful procedures were applied and questionnaire-data were collected anonymously. the responsible psychotherapists asked their patients to take part in the study. the informed consent of the participants was implied through questionnaire completion. the anonymized questionnaires were sent by the therapists to the first author. measures the following two questionnaires were administered simultaneously to the patients during psychotherapy: the newly developed act-sq and the psychometrically sound patient version of the “scale for the multiperspective assessment of general change mechanisms in psychotherapy” (sacip; mander et al., 2013). probst, mühlberger, kühner et al. 5 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ the sacip evaluates the degree the therapeutic alliance and other change mecha‐ nisms according to grawe (1997) were realized in the given psychotherapy session. the sacip consists of adapted items from the german shortened version of the working alliance inventory (wai-s; munder, wilmers, leonhart, linster, & barth, 2010) as well as from the bernese post session report (bpsr; flückiger et al., 2010). factor analyses revealed the following six sacip scales: emotional bond, agreement on collaboration, problem actuation, clarification of meaning, mastery, and resource activation (mander et al., 2013). the emotional bond scale and the agreement on collaboration scale measure aspects of the therapeutic alliance, the problem actuation scale assesses how strong problems as well as related emotions were activated in the session, the clarification of meaning scale measures the new insights the patient gained into his/her behavior during the session, the mastery scale assesses the degree the session helped the patients to cope with his/her problems, and the resource activation scale measures how strong the patients’ strengths were used in-session. the measure demonstrated an excellent factor structure with factor loadings of .51 ≤ λ ≤ .85. confirmatory factor analyses supported the exploratory model. the instrument revealed good to excellent internal consistencies with .71 ≤ α ≤ .90. studies also demonstrated criterion validity since treatment outcome was significantly predicted by all change mechanisms except for problem actuation (e.g. mander et al., 2013, 2015). example items of the sacip patient version are the following: “today, i felt comfortable in the relationship with the therapist” (emotional bond), “in today’s session, i was highly emotionally involved” (problem actuation), “today, the therapist intentionally used my abilities for therapy” (resource activation), “today, i became more aware of the motives for my behavior” (clarification of meaning), “today, the therapist and i worked toward mutually agreed upon goals” (agreement on collabora‐ tion), “today, we really made progress in therapy in overcoming my problems (mastery). in the act-sq, patients rate how strong the act components of psychological flexibility were realized in psychotherapy sessions on a five point likert scale. each item of the act-sq represents one act component. six pilot items of the act-sq were formulated by t.p. on the basis of the act literature. t.p. then discussed the items with cbt psychotherapists with act expertise (j.k., g.h.e., and a.m.). the experts gave feedback regarding the fit of the items to the act model and provided concrete suggestions how the items could be optimized. the six pilot items were changed and refined accordingly. the resulting six items represent the items of the final act-sq and were used in the present study (the act-sq is available license free, the german and english version are included in the appendix, see supplementary materials). participants therapists: the n = 69 act therapists listed in the german section of the association for contextual behavioral science (deutschsprachige gesellschaft für kontextuelle ver‐ haltenswissenschaften e.v.; dgkv) were invited to participate in october 2015 and the development and validation of the act-sq 6 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ n = 68 act therapists listed in the e-mail list of the german act network were invited to partake in december 2014. therefore, therapists listed in both the german section of the association for contextual behavioral science and the e-mail list of the german act network were contacted twice. nine act therapists (see acknowledgements) took part and encouraged their patients to fill in the act-sq and the sacip after one psychothera‐ py session. the nine act therapists were certified in cognitive-behavioral therapy (cbt) and their average work experience with act amounted to m = 4.56 years (sd = 2.46). patients: eighty-seven patients treated by the n = 9 act therapists completed the act-sq after the m = 21.25th psychotherapy session (sd = 19.84). the description of the participating n = 87 patients is given in table 2. the diagnoses were made by the responsible therapist. table 2 description of the patients of study 1 gender n % male 33 37.9 female 53 60.9 no data 1 1.2 diagnoses according to chapter v of the icd-10 (all diagnoses, not only primary diagnosis) n % f4 53 40.2 f3 46 34.8 f1 15 11.4 f6 8 6.1 others 10 7.6 outpatients / inpatients n % outpatient 78 89.7 inpatient 9 10.3 comorbidity: amount of diagnoses according to chapter v of the icd-10 m sd 1.54 0.71 age at time of assessment m sd 42.48 14.79 note. f4 = neurotic, stress-related and somatoform disorders; f3 = mood (affective) disorders; f1 = mental and behavioural disorders due to psychoactive substance use; f6 = disorders of adult personality and behavior. number of diagnoses higher than number of patients since multiple diagnoses per patients are possible. analyses spss 25 was used to perform the statistical analyses. means (m), standard deviations (sd), frequencies (n), and percentages (%) were calculated for the sample description. to explore the factor structure of the act-sq, an exploratory factor analysis (efa) with maximum likelihood estimation and with oblique rotation (oblimin direct) was performed. the kaiser criterion (factors with eigenvalues larger than 1 were retained), the kaiser-meyer-olkin measure of sampling adequacy (kmo), and the bartlett’s test probst, mühlberger, kühner et al. 7 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ of sphericity were applied. cronbach’s alpha (α) was computed to measure reliability. furthermore, pearson correlation coefficients (r) were calculated to measure correlations between the act-sq and general change mechanisms (convergent validity). all statisti‐ cal tests were performed two-tailed and the significance value was set to p < .05. results will be presented with and without bonferroni-correction for multiple comparisons. results factor structure and reliability: the efa produced a kmo value of .79 and the bartlett’s test reached significance, χ2(15) = 150.04; p < .01. the eigenvalues amounted to 3.06, 0.85, 0.73, 0.58, 0.44, 0.34. therefore, only one factor was retained when kaiser’s criterion was applied. the loadings of the six items are presented in table 3. there were no cross-loadings. cronbach’s alpha (α) across all six items amounted to α = .81. table 3 loadings of the act-sq in study 1 the last (xy) psychotherapy session(s) helped me… loading λ item 1 acceptance “…to accept unpleasant feelings, thoughts or body sensations rather than fight them” .58 item 2 cognitive defusion “…to gain more inner distance from unpleasant feelings, thoughts or body sensations and to observe them rather than getting caught up in them” .65 item 3 contact with the present moment “…to stay in the here and now (in the present moment) rather than concerning myself with my future and my past” .60 item 4 self-as-context “…to realize that my feelings, thoughts and body sensations are part of me, but that i am more than my feelings, thoughts and body sensations” .72 item 5 values “…to recognize what is important to me in my life and what gives orientation to my life” .61 item 6 committed action “…to act in daily life according to what is important to me in my life and what gives orientation to my life” .70 note. sample of study 1: n = 87 patients treated by n = 9 act therapists. correlations with general change mechanisms: the associations between the act-sq mean score and the mean scores of the sacip scales are presented in table 4. before applying bonferroni correction (p < .05), the act-sq was significantly correlated with all general change mechanisms except for problem actuation. the association between the development and validation of the act-sq 8 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ act-sq and the emotional bond, however, was not significant anymore after (p < .008) applying bonferroni correction (p = .05 / 6 comparisons). table 4 correlations between the act-sq and the sacip scales in study 1 variable sacip emotional bond problem actuation resource activation clarification of meaning agreement on collaboration mastery act-sq .23* .10 .55** .43** .40** .64** note. sample of study 1: n = 87 patients treated by n = 9 act therapists. act-sq = act session questionnaire; sacip = scale for the multiperspective assessment of general change mechanisms in psychotherapy. *p < .05. **p < .001. discussion the results provide preliminary evidence for the factor structure, the reliability, and the convergent validity of the act-sq. regarding research question 1, we found a one-factor solution. results for research question 2 indicate a good reliability. conver‐ gent validity (research question 3) was supported by significant correlations between the act-sq and general change mechanisms except for problem actuation. a limitation of the study is the relatively small sample size of participating act therapists. future research could use recently published recommendations on how to motivate therapists for psychotherapy research (taubner, klasen, & munder, 2016) to obtain larger samples. moreover, no associations between the act-sq and treatment outcomes (criterion validi‐ ty) were evaluated. therefore, study 2 was planned to investigate the criterion validity of the act-sq. another aim was to investigate whether the factor structure, the reliability, and the convergent validity as shown in study 1 can be replicated in study 2. study 2 method the methods of study 2 were approved by the local ethics committee (ethikkommission der fakultät für verhaltensund empirische kulturwissenschaften der universität hei‐ delberg) and written informed consent was obtained from the patients. measures the act-sq and the sacip (see measures in study 1) were administered to patients after the 15th therapy session and at the end of psychotherapy. furthermore, the german versions of the brief symptom inventory (bsi; franke, 2000) and the beck depression probst, mühlberger, kühner et al. 9 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ inventory (bdi-ii; hautzinger, keller, & kühner, 2009) were administered as outcome measures at pre-treatment and post-treatment as well as after the 15th psychotherapy session. the global severity index (gsi) of the bsi and the total score of the bdi-ii were used in the study at hand. these measures are reliable and valid (see for example, franke, 2000 for the german version of bsi; derogatis & melisaratos, 1983 for the english version of bsi; kühner et al., 2007 for the german version of bdi-ii; beck & steer, 1998 for the english version of bdi-ii). references. cronbach’s alpha (α) values have been reported to be high: between .92 and .96 for the gsi of the german bsi and ≥ .84 for the german bdi-ii. participants therapists and patients were different from the therapists and patients included in study 1. between november 2016 and november 2017, n = 77 cbt trainee therapists working at a large outpatient training center took part. these therapists treated the n = 254 patients who completed the act-sq: n = 115 outpatients completed the act-sq after the 15th cbt session and n = 156 outpatients completing the act-sq at the end of cbt (post-treatment). as the act-sq was implemented for ongoing and new therapies, these two patient sample were independent from each other except for n = 17 patients who completed the act-sq at both assessment points. a subset of patients filling in the act-sq also provided data for the outcome measures (see flow-chart in figure 1) and their data was used to evaluate associations between the act-sq and pre-post outcome as well as early and late patient progress (research questions 5 and 6). figure 1 flow-chart development and validation of the act-sq 10 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ the patients answering the act-sq at the end of cbt had on average m = 39.68 (sd = 14.98) individual therapy sessions. the description of the participating patients is given in table 5. structured clinical interviews (scid) were used to make the diagnoses. table 5 description of the patients of study 2 variable 15th session sample post-treatment sample n % n % gender male 51 44.3 68 43.6 female 64 55.7 88 56.4 diagnoses according to chapter v of the icd-10 (all diagnoses, not only primary diagnosis) f4 68 36.0 87 34.3 f3 72 38.1 102 40.2 f1 10 5.3 16 6.3 f6 22 11.6 23 9.1 others 17 9.0 26 10.2 m sd m sd comorbidity: amount of diagnoses according to chapter v of the icd-10 1.64 .84 1.63 .87 age at time of assessment 36.50 13.03 35.73 13.60 note. f4 = neurotic, stress-related and somatoform disorders; f3 = mood (affective) disorders; f1 = mental and behavioural disorders due to psychoactive substance use; f6 = disorders of adult personality and behavior. number of diagnoses higher than number of patients since multiple diagnoses per patients are possible. analyses spss 25 was used to perform the statistical analyses. means (m), standard deviations (sd), frequencies (n), and percentages (%) were calculated for the sample description. an efa with maximum likelihood estimation and oblique rotation (oblimin direct) was performed to investigate the factor structure of the act-sq. the kaiser criterion (factors with eigenvalues larger than 1 were retained), the kaiser-meyer-olkin measure of sampling adequacy (kmo), and the bartlett’s test of sphericity were applied. cronbach’s alpha (α) was computed to measure reliability. furthermore, pearson correlation coefficients (r) were calculated to measure associations between the act-sq and general change mecha‐ nisms (convergent validity). moreover, associations between the act-sq and treatment outcome were explored with linear regression analyses. to measure the pre-post out‐ come, the outcome measure (gsi, bdi-ii) at post-treatment was the dependent variable and the act-sq at post-treatment as well as the outcome measure (gsi, bdi-ii) at pre-treatment were independent variables. we also investigated associations between the act-sq and early as well as late patient progress. for early patient progress, the patient reported outcome measure (gsi, bdi-ii) at the 15th cbt session was the dependent probst, mühlberger, kühner et al. 11 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ variable and the act-sq at the 15th cbt session as well as the outcome measure (gsi, bdi-ii) at pre-treatment were independent variables. for late patient progress, the patient reported outcome measure (gsi, bdi-ii) at post-treatment was the dependent variable and the act-sq at post-treatment as well as the outcome measure (gsi, bdi-ii) at the 15th cbt session were independent variables. we also performed these analyses without the act-sq as independent variable to evaluate how the r2-squared values change when including the act-sq as independent variable. all statistical tests were performed two-tailed and the significance value was set to p < .05. results will be given with and without bonferroni-correction for multiple comparisons. results factor structure and reliability for the 15th cbt session sample: the efa produced a kmo value of .86 and the bartlett’s test was significant, χ2(15) = 235.14; p < .01. the eigenvalues were 3.33, 0.81, 0.54, 0.50, 0.46, 0.36. only one factor was retained when kaiser’s criterion was applied. the loadings of the six items are given in table 6. there were no cross-loadings. cronbach’s alpha (α) across all six items was α = .84 for the 15th cbt session sample. table 6 loadings of the act-sq in study 2 the last (xy) psychotherapy session(s) helped me… loading λ 15th session sample post-treatment sample item 1 acceptance “…to accept unpleasant feelings, thoughts or body sensations rather than fight them” .53 .66 item 2 cognitive defusion “…to gain more inner distance from unpleasant feelings, thoughts or body sensations and to observe them rather than getting caught up in them” .78 .73 item 3 contact with the present moment “…to stay in the here and now (in the present moment) rather than concerning myself with my future and my past” .65 .78 item 4 self-as-context “…to realize that my feelings, thoughts and body sensations are part of me, but that i am more than my feelings, thoughts and body sensations” .67 .69 development and validation of the act-sq 12 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ the last (xy) psychotherapy session(s) helped me… loading λ 15th session sample post-treatment sample item 5 values “…to recognize what is important to me in my life and what gives orientation to my life” .67 .84 item 6 committed action “…to act in daily life according to what is important to me in my life and what gives orientation to my life” .78 .79 note. 15th session sample of study 2: n = 115 patients; post-treatment sample of study 2: n = 156 patients; both samples treated by n = 77 cbt trainee therapists. factor structure and reliability for the post-treatment sample: for the efa, the kmo value was .87 and the bartlett’s test reached significance, χ2(15) = 450.37; p < .01. the eigenvalues were 3.79, 0.58, 0.54, 0.44, 0.40, 0.25. only one factor was retained when kaiser’s criterion was applied. the loadings of the six items are shown in table 6. there were no cross-loadings. cronbach’s alpha (α) across all six items amounted to α = .88 for the cbt post-treatment sample. correlations with general change mechanisms: the associations between the actsq mean score and the mean scores of the sacip scales at cbt session 15th and at post-treatment are shown in table 7. the correlations were all positive and statistically significant before (p < .05) and after (p < .004) correcting for multiple testing (p = .05 / 12 comparisons). table 7 correlations between the act-sq and the sacip scales in study 2 act-sq sacip emotional bond problem actuation resource activation clarification of meaning agreement on collaboration mastery 15th session sample .40** .42** .75** .73** .54** .78** post-treatment sample .49** .59** .78** .74** .66** .83** note. 15th session sample of study 2: n = 115 patients; post-treatment sample of study 2: n = 156 patients; both samples treated by n = 77 cbt trainee therapists. act-sq = act session questionnaire; sacip = scale for the multiperspective assessment of general change mechanisms in psychotherapy. **p < .001. associations with treatment outcome: the results of the linear regression models are summarized in table 8. the results indicate that higher act-sq scores were associated with more beneficial pre-post outcome as well as with early and late patient progress before (p < .05) and after (p < .008) bonferroni correction (p = .05 / 6 comparisons). probst, mühlberger, kühner et al. 13 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ table 8 associations between the act-sq and treatment outcomes dependent variable / parameter unstandardized coefficient b standardized coefficient β t pβ se outcome gsi at post-treatment (n = 38) constant 1.19 0.23 5.13 < .001 gsi at pre-treatment 0.40 0.10 0.47 3.97 < .001 act-sq at post-treatment -0.36 0.07 -0.59 -5.00 < .001 bdi-ii at post-treatment (n = 38) constant 25.56 3.91 6.55 < .001 bdi-ii at pre-treatment 0.33 0.09 0.34 3.85 < .001 act-sq at post-treatment -7.91 0.99 -0.71 -8.03 < .001 early patient progress gsi at 15th therapy session (n = 112) constant 0.66 0.17 3.83 < .001 gsi at pre-treatment 0.70 0.06 0.72 11.78 < .001 act-sq at 15th therapy session -0.20 0.06 -0.21 -3.36 .001 bdi-ii at 15th therapy session (n = 111) constant 13.86 3.05 4.54 < .001 bdi-ii at pre-treatment 0.62 0.06 0.65 9.96 < .001 act-sq at 15th therapy session -4.42 1.02 -0.28 -4.31 < .001 late patient progress gsi at post-treatment therapy session (n = 61) constant 0.79 0.22 3.54 .001 gsi at 15th therapy session 0.63 0.11 0.53 5.72 < .001 act-sq at post-treatment -0.25 0.06 -0.38 -4.09 < .001 bdi-ii at post-treatment session (n = 61) constant 18.65 4.06 4.59 < .001 bdi-ii at 15th therapy session 0.51 0.10 0.45 5.04 < .001 act-sq at post-treatment -5.77 1.06 -0.49 -5.45 < .001 note. se = standard error; act-sq = act session questionnaire; gsi = global severity index of the brief symptom inventory; bdi-ii = beck depression inventory. for the pre-post outcome, the r-squared values were .17 (gsi) and .28 (bdi-ii) when predicting the outcome measure at post-treatment by the outcome measure at pre-treat‐ ment and the r-squared values changed to .52 (gsi) and .75 (bdi-ii) when predicting the outcome measure at post-treatment by the outcome measure at pre-treatment as well as by the act-sq. for the early patient progress, the r-squared values were .56 (gsi) and .46 (bdi-ii) when predicting the outcome measure at the 15th session by the outcome measure at pretreatment and the r-squared values changed to .60 (gsi) and .54 (bdi-ii) when predicting development and validation of the act-sq 14 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ the outcome measure at the 15th session by the outcome measure at pre-treatment as well as by the act-sq. for late patient progress, the r-squared values were .44 (gsi) and .49 (bdi-ii) when predicting the outcome measure at post-treatment by the outcome measure at the 15th session and the r-squared values changed to .57 (gsi) and .67 (bdi-ii) when predicting the outcome measure at post-treatment by the outcome measure at the 15th session as well as by the act-sq. discussion study 2 supported the one-factor solution (research question 1), a good reliability (re‐ search question 2), as well as associations between the act-sq and general change mechanisms (convergent validity, research question 3). the results were comparable to the results obtained in study 1 with the exception that the general change mechanism problem actuation was correlated with the act-sq only in study 2 (research question 4). the results indicate that the act-sq has many similarities in act and cbt but that there are also differences (research question 5): the overlap between the in-session real‐ ization of problem actuation and the act components was specific for cbt. criterion validity was not evaluated in study 1 (act) but the significant associations between the act-sq and pre-post outcome in study 2 (cbt) indicate criterion validity (research question 5). despite possible differences between earlier and later treatment phases (ilardi & craighead, 1994; lambert, 2005), the factor structure, reliability, convergent validity, and criterion validity of the act-sq were comparable in the earlier and later treatment phases (research question 6). a limitation of study 2 is that the sample size on associations between the act-sq and pre-post outcome was relatively small. moreover, the results on criterion validity rely on a cross-sectional basis (outcome at x+1 was associated with the act-sq at x+1) and future studies including session-to-session act-sq and outcome assessments should investigate whether the act-sq at session x-1 predicts the outcome at session x (rubel, rosenbaum, & lutz, 2017). general discussion a brief session questionnaire act-sq was designed to obtain patient ratings on the in-session realization of the act components of psychological flexibility. the act-sq was evaluated in act as well as cbt. results showed a one-factor solution (research question 1) and a good reliability (research question 2). all kmo values were good (.7 .8) or great (.8 .9) according to hutcheson and sofroniou (1999) or field (2009). moreover, all bartlett’s tests were significant indicating that factor analysis was appropriate (field, 2009). the loadings of all items were well above .45 as recommended in the literature (see for example, probst, mühlberger, kühner et al. 15 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ bühner, 2010) and there were no cross-loadings. the one extracted factor could stand for the degree the in-session processes helped to increase the patient’s psychological flexibility. to further evaluate this hypothesis, a study is necessary investigating whether higher act-sq session scores result in more improvements on established instruments measuring skills of psychologically flexibility (e. g., acceptance and action questionnaire ii; bond et al., 2011). besides factor structure and reliability, we tested the convergent validity. convergent validity was evaluated by correlating the act-sq with the general change mechanisms proposed by grawe (1997) since these mechanisms are considered to be relevant in all psychotherapies and because act processes might also be general change mechanisms as they mediated the outcome not only in act but also in cbt and multidisciplinary treatments (e. g., åkerblom et al., 2015; arch et al., 2012b). these analyses related to research question 3 revealed that the act-sq is significantly associated with general change mechanisms (except for problem actuation in study 1) according to grawe (1997), most strongly with resource activation and mastery. a cautious clinical interpretation of these findings could be as follows: the content of the act-sq items are associated with coping and self-efficacy as is the content of the items of the sacip resource activation and mastery scales (mander et al., 2013). furthermore, the sacip emotional bond and agreement on collaboration scales reflect the interaction processes between patient and therapist. the act-sq items do not directly target this therapeutic relationship aspect. hence, stronger associations of act-sq and resource activation and mastery than with the alliance scales seem plausible. in summary, it is important to note that the act-sq items are most strongly related to proximal items (resources and mastery) but also to items with more distanced but clinically relevant content (therapeutic alliance). this further underlines the validity of the measure. with regard to similarities and differences between act and cbt (arch & craske, 2008; harley, 2015), most psychometric values were comparable between act and cbt, only a few differences emerged in the context of convergent validity (research question 4): associations between the act-sq and problem actuation reached significance only in cbt. this could indicate more overlap be‐ tween problem actuation and the act components in cbt than in act but it could also be related to the fact that the sample size of study 1 (act) was not as large as the sample size of study 2 (cbt). the same reasons might explain why the association between the act-sq and the emotional bond was not significant anymore after controlling for multiple testing in study 1 (act) but not in study 2 (cbt). in another step, we tested the criterion validity. this was related to research ques‐ tion 5 and the results showed significant associations between the act-sq and outcome measures. it should be kept in mind, however, that relations with treatment outcomes were investigated only in cbt. future research is necessary to evaluate whether the associations between the act-sq and treatment outcomes are comparable or different between cbt and act. finally, the factor structure, reliability, convergent validity, and development and validation of the act-sq 16 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ criterion validity were comparable between earlier and later treatment phases (research question 6). although differences in treatment phases have been highlighted (ilardi & craighead, 1994; lambert, 2005), these differences did apparently no affect the psycho‐ metric values of the act-sq. a limitation of the current work is that only a patient version of the act-sq was created and evaluated. a therapist version of the act-sq would be an important tool that could be developed by future studies to get a more comprehensive picture of the therapeutic process. other shortcomings of the studies at hand are that criterion validity was tested only in cbt but not in act. moreover, contrasting the psychometric values in earlier vs. later treatment phases was possible only in cbt but not in act. future studies on act are important to investigate criterion validity and similarities/differences between earlier and later act phases. a further limitation is that the mean of sessions attended was relatively high so that it remains unclear how well the results can be generalized to shorter psychotherapies. moreover, we did not include other measures of act processes to correlate them with the act-sq. further validation studies should, therefore, compare act-sq patient ratings with observer-based dutars ratings, since patient ratings are only one data source to rate in-session processes. related to the factor analysis, setting the kaiser criterion for determining the amount of factors at 1 is rather an arbitrary rule of thumb and an empirically founded way of determining the factors (i.e. horn’s parallel analysis or velicer’s map test) would have been a better method. in replication studies with larger samples, the factor structure needs to be tested with confirmatory factor analysis whether the instrument shows adequate model fit (bühner, 2010). it is per se more probable for such a short questionnaire like the act-sq to have a one-factor solution. another suggestion for future research would be to enter additional predictors to the regression analyses to test interactions between patient characteristics (e. g., amount of diagnoses) and the impact the act-sq has on the outcome. it would also be very interesting for future research to examine whether the factor structure of the act-sq remains stable when patients are treated by specific act modules (open vs. engaged, see villatte et al., 2016). the act-sq might also be useful to measure adherence to act and to continuously track the act processes during psychotherapy. parallel session-to-session assessments of the act processes and outcomes would allow investigating how the act processes are associated with patient progress on a betweenand within-person level (rubel et al., 2017). such a systematic monitoring would also enable evaluating the act processes before and after sudden losses or sudden gains (wucherpfennig, rubel, hofmann, & lutz, 2017). future research on group psychothera‐ py could also explore associations between group factors (see for example, tasca et al., 2016, and vogel, blanck, bents, & mander, 2016) and act components. in summary, the act-sq has a clear factor structure, good reliability, shows strong associations to other validated psychotherapeutic change processes and is associated with treatment outcomes. implications of this study are that the license-free act-sq is probst, mühlberger, kühner et al. 17 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ a reliable and valid measure that can be used to measure how patients experience the in-session realization of act components. funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. author contributions: t.p. developed the questionnaire, wrote the manuscript and performed the statistical analyses; a.m. developed the questionnaire and revised the manuscript; j.k. developed the questionnaire and revised the manuscript; ge revised the questionnaire and the manuscript; c.p. revised the manuscript; t.h. collected data for study 1 and revised the manuscript; j.m. collected data for study 2 and revised the manuscript. supplementary materials the supplementary materials contain the english and german version of the act-sq (for unre‐ stricted access see index of supplementary materials below). index of supplementary materials probst, t., mühlberger, a., kühner, j., eifert, g. h., pieh, c., hackbarth, t., & mander, j. (2020). supplementary materials to "development and initial validation of a brief questionnaire on the patients’ view of the in-session realization of the six core components of acceptance and commitment therapy" [questionnaire; english and german version]. psychopen. https://doi.org/10.23668/psycharchives.3462 references åkerblom, s., perrin, s., rivano fischer, m., & mccracken, l. m. (2015). the mediating role of acceptance in multidisciplinary cognitive-behavioral therapy for chronic pain. the journal of pain, 16, 606-615. https://doi.org/10.1016/j.jpain.2015.03.007 arch, j. j., & craske, m. (2008). acceptance and commitment therapy and cognitive behavioral therapy for anxiety disorders: different treatments, similar mechanisms? clinical psychology: science and practice, 15, 263-279. https://doi.org/10.1111/j.1468-2850.2008.00137.x arch, j. j., eifert, g. h., davies, c., plumb vilardaga, j. c., rose, r. d., & craske, m. g. 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(2011). processes of change in acceptance and commitment therapy and cognitive therapy for depression: a mediation reanalysis of zettle and rains. behavior modification, 35, 265-283. https://doi.org/10.1177/0145445511398344 development and validation of the act-sq 22 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://doi.org/10.1016/j.brat.2016.12.007 https://doi.org/10.1016/j.cpr.2013.07.002 https://doi.org/10.1080/10503307.2014.963729 https://doi.org/10.1080/10503307.2014.938256 https://doi.org/10.1016/j.brat.2015.12.001 https://doi.org/10.1055/s-0042-104495 https://doi.org/10.1037/0022-006x.76.3.397 https://doi.org/10.1016/j.beth.2014.03.003 https://doi.org/10.1080/16506073.2013.781670 https://doi.org/10.1007/bf03395706 https://doi.org/10.1037/ccp0000263 https://doi.org/10.1177/0145445511398344 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. probst, mühlberger, kühner et al. 23 clinical psychology in europe 2020, vol.2(3), article e3115 https://doi.org/10.32872/cpe.v2i3.3115 https://www.psychopen.eu/ development and validation of the act-sq (introduction) study 1 method results discussion study 2 method results discussion general discussion (additional information) funding competing interests acknowledgments author contributions supplementary materials references the effect of television and print news stories on the nocebo responding following a generic medication switch research articles the effect of television and print news stories on the nocebo responding following a generic medication switch kate mackrill a, greg d. gamble b, keith j. petrie a [a] department of psychological medicine, university of auckland, auckland, new zealand. [b] department of medicine, university of auckland, auckland, new zealand. clinical psychology in europe, 2020, vol. 2(2), article e2623, https://doi.org/10.32872/cpe.v2i2.2623 received: 2019-12-31 • accepted: 2020-02-16 • published (vor): 2020-06-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: keith j. petrie, psychological medicine, faculty of medical and health sciences, university of auckland, private bag 92019, auckland, new zealand. e-mail: kj.petrie@auckland.ac.nz abstract background: following a nationwide switch to a generic antidepressant, a series of negative media stories publicised the experiences of some patients having side effects following the switch. this occurred first in print media and five months later it occurred again in television news. in this study we examined the effect of television news stories compared to print stories on adverse drug reaction reporting. we also examined the change in reporting rate of specific side effects mentioned in the tv news bulletins. method: using an interrupted time series analysis of data from a national adverse reactions database, we compared the number of adverse reaction reports after the print and television coverage and the changes in reporting rate of side effects mentioned and not mentioned in tv news stories. results: we found a significant increase in adverse reaction reports following tv news items that discussed patients’ reports of side effects following the medication switch (interruption effect = 73.25, p = .046). the reporting rate of symptoms mentioned in the tv news bulletins also increased, in particular suicidal thoughts (interruption effect = 23.60, p = .031). the effect of tv stories on adverse reaction reports was 211% greater than the print articles. conclusions: television stories have a much stronger effect than print media on nocebo responding and specific symptoms mentioned in the bulletins have a direct influence on the type of side effects subsequently reported. media guidelines should be developed to reduce the negative public health effects of media coverage following medication switches. keywords nocebo effect, television media, print media, side effects, medication switch, generic medicine this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i2.2623&domain=pdf&date_stamp=2020-06-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • this study shows that television news items have a considerably greater effect on the rate of adverse reaction reporting than print media. • the specific side effects mentioned in the television coverage, especially suicidal thoughts, showed an increase in reporting. • this study provides further evidence that media coverage of side effects can induce a nocebo effect and have negative effects on public health. negative media stories about medication can increase public anxiety and lead to a reduc‐ tion in the use of the drug highlighted in the news story. studies have shown that media coverage of the negative effects of statin medication is linked to the early discontinuation of the drug by patients in the united kingdom (matthews et al., 2016), australia (schaffer, buckley, dobbins, banks, & pearson, 2015) and france (saib et al., 2013) and led to a subsequent increase in the rates of heart attacks and cardiac deaths in denmark (nielsen & nordestgaard, 2016). while drops in rates of antidepressant dispensing have also been reported in the united states after widespread media coverage linking antidepressant medication to a possible increase in the risk of suicidal behaviour in young people (yu et al., 2014). negative news coverage can also lead to an increase in the rate of adverse reactions reported to medication due to the nocebo effect (petrie & rief, 2019). this typically occurs following publicity about a particular drug’s side effects, which increases the reporting of the specific side effects mentioned in the story, due to common symptoms being misattributed to the effect of the medicine (tan et al., 2014). an increase in the rate of adverse drug reaction reports was shown in new zealand following television news stories reporting that patients were experiencing problems after the appearance of a common thyroid replacement medication had changed due to a shift in manufacturing plant (faasse et al., 2009; faasse et al., 2012). a large increase in the adverse drug reac‐ tions reports to statins was also documented following a dutch television programme on the benefits and risks of statins (van hunsel et al., 2009). it seems likely that television may have a stronger effect on the nocebo response than print media, although this has not been formally investigated. despite the increased role of the internet and a drop in the number of young people watching, television still reaches a larger audience than other forms of news media (gollust et al., 2019). television news is also seen as having an important role in surveillance, by informing the public what health risks to be vigilant of and concerned about (brosius & kepplinger, 1990). television news stories about health risks also typically make more use of individual case studies and individual narratives as a key part of the story, which can play an important role in social modelling of side effects (faasse & petrie, 2016), as well as causing an overestimation of the likelihood of a health problem occurring (gollust et al., 2019). effect of television news stories 2 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://www.psychopen.eu/ a recent nationwide switch from a branded to generic antidepressant medicine in new zealand in 2017 provided us with the opportunity to investigate the impact of newspaper stories on the nocebo effect. in this previous study we examined how news‐ paper stories published in february and april 2018 influenced side effect reporting up to july 2018 (mackrill et al., 2019). we found the number of side effects, particularly those mentioned in the stories, and complaints of reduced dug efficacy increased immediately after the newspaper stories before returning to baseline levels. however, later in the year after our paper was submitted, the medicine switch received more media attention, this time from television news. four tv news stories were broadcast from september 2 to no‐ vember 30 and discussed patients’ negative reactions following the generic venlafaxine switch. the television news coverage of the same generic switch allowed us to quantify the relative impact of newspaper and television media on the nocebo response. based on previous research we hypothesised that television news would have a larger impact. we also investigated the hypothesis that the specific side effects mentioned in the television news reports would increase adverse reaction reports to the national centre for adverse reactions monitoring (carm), compared to previously equivalently reported side effects not mentioned in the television bulletins. method media coverage newspaper articles in february and april 2018, two of new zealand’s largest print media outlets published three newspaper and online articles discussing a small group of patients’ adverse reac‐ tions to the new generic version of the antidepressant venlafaxine (see table 1). the pre‐ vious year, 45,000 patients prescribed either the branded originator or a generic version of venlafaxine were switched to another generic, enlafax. this compulsory nationwide switch had been initiated by pharmac – the new zealand government’s pharmaceutical agency. the articles described patients’ concerns that enlafax was less effective and was causing side effects such as suicidal thoughts, nausea and headaches (see mackrill et al., 2019 for further details of the newspaper reports). mackrill, gamble, & petrie 3 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://www.psychopen.eu/ ta bl e 1 n ew z ea la nd p ri nt a nd t el ev is io n m ed ia c ov er ag e of th e ve nl af ax in e b ra nd c ha ng e d at e n ew s ou tl et it em ti tl e u r l pr in t m ed ia fe br ua ry 2 8 20 18 n ew z ea la nd h er al d pa tie nt s s ay g en er ic p ha rm ac -fu nd ed v er sio n of an tid ep re ss an t v en la fa xi ne le ft th em d ep re ss ed , an xi ou s ht tp s:/ /w w w. nz he ra ld .co .n z/ nz /n ew s/ ar tic le .cf m ?c _i d= 1& ob je ct id =1 20 02 91 8 fe br ua ry 2 8 20 18 st uf f.c o. nz a nt i-d ep re ss an t s w ap : s uf fe re rs cl ai m g en er ic d ru g is ha rm in g th ei r c on di tio n ht tp s:/ /w w w. st uf f.c o. nz /n at io na l/h ea lth /1 01 62 83 17 /a nt id ep re ss an t-s w ap -s uf fe re rs -c la im ge ne ric -d ru gisha rm in gth ei rco nd iti on a pr il 27 2 01 8 st uf f.c o. nz fi gh t o ve r p ha rm ac 's sw itc h to g en er ic a nt i-d ep re ss an t br an d co nt in ue s ht tp s:/ /w w w. st uf f.c o. nz /n at io na l/h ea lth /9 93 88 64 5/ fig ht -o ve rph ar m ac ssw itc hto ge ne ric -a nt id ep re ss an t-b ra nd -c on tin ue s te le vi si on m ed ia se pt em be r 2 2 01 8 o ne n ew s gr ow in g nu m be r o f p at ie nt s q ue st io ni ng p ha rm ac 's de ci sio n to fu nd a d iff er en t b ra nd o f a nt i-d ep re ss an t ht tp s:/ /w w w. tv nz .co .n z/ on ene w s/ ne w -z ea la nd /g ro w in gnu m be rpa tie nt squ es tio ni ng ph ar m ac sde ci sio nfu nd -d iff er en t-b ra nd -a nt i-d ep re ss an t se pt em be r 2 6 20 18 o ne n ew s pa tie nt s r ep or tin g lif eth re at en in g sid e ef fe ct s f ro m ne w a nt id ep re ss an t ht tp s:/ /w w w. tv nz .co .n z/ on ene w s/ ne w -z ea la nd /p at ie nt sre po rti ng -li fe -th re at en in gsid eef fe ct sne w -a nt id ep re ss an t o ct ob er 2 0 20 18 o ne n ew s m en ta l h ea lth sp ec ia lis ts q ue st io n ne w an tid ep re ss an t's e ffe ct iv en es s ht tp s:/ /w w w. tv nz .co .n z/ on ene w s/ ne w -z ea la nd /m en ta l-h ea lth -s pe ci al ist squ es tio nne w an tid ep re ss an ts -e ffe ct iv en es s? au to =5 85 11 84 16 90 01 n ov em be r 3 0 20 18 o ne n ew s pa tie nt s c la im d isc rim in at io n af te r m ed sa fe w ar ns ab ou t j oi nt su pp le m en t b ut n ot a nt id ep re ss an t ht tp s:/ /w w w. tv nz .co .n z/ on ene w s/ ne w -z ea la nd /p at ie nt scl ai m -d isc rim in at io naf te rm ed sa fe -w ar ns -jo in t-s up pl em en t-b ut -n ot -a nt id ep re ss an t? au to =5 97 34 39 90 10 01 effect of television news stories 4 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12002918 https://www.stuff.co.nz/national/health/101628317/antidepressant-swap-sufferers-claim-generic-drug-is-harming-their-condition https://www.stuff.co.nz/national/health/101628317/antidepressant-swap-sufferers-claim-generic-drug-is-harming-their-condition https://www.stuff.co.nz/national/health/99388645/fight-over-pharmacs-switch-to-generic-antidepressant-brand-continues https://www.stuff.co.nz/national/health/99388645/fight-over-pharmacs-switch-to-generic-antidepressant-brand-continues https://www.tvnz.co.nz/one-news/new-zealand/growing-number-patients-questioning-pharmacs-decision-fund-different-brand-anti-depressant https://www.tvnz.co.nz/one-news/new-zealand/growing-number-patients-questioning-pharmacs-decision-fund-different-brand-anti-depressant https://www.tvnz.co.nz/one-news/new-zealand/patients-reporting-life-threatening-side-effects-new-antidepressant https://www.tvnz.co.nz/one-news/new-zealand/patients-reporting-life-threatening-side-effects-new-antidepressant https://www.tvnz.co.nz/one-news/new-zealand/mental-health-specialists-question-new-antidepressants-effectiveness?auto=5851184169001 https://www.tvnz.co.nz/one-news/new-zealand/mental-health-specialists-question-new-antidepressants-effectiveness?auto=5851184169001 https://www.tvnz.co.nz/one-news/new-zealand/patients-claim-discrimination-after-medsafe-warns-joint-supplement-but-not-antidepressant?auto=5973439901001 https://www.tvnz.co.nz/one-news/new-zealand/patients-claim-discrimination-after-medsafe-warns-joint-supplement-but-not-antidepressant?auto=5973439901001 https://www.psychopen.eu/ television news items five months after the print coverage, the venlafaxine brand change featured in a series of primetime news items on one news, new zealand’s largest television news broadcaster. the first item aired on september 2 and discussed the increasing number of patients questioning pharmac’s decision to fund a generic version of venlafaxine. three patients were interviewed and stated that enlafax had serious side effects, including increased suicidal ideation. while it is estimated that 2.4 of 4.8 million new zealanders watch television each day (thinktv, 2018), ratingpoint, a television viewership database by analytics company nielsen, shows that one news had an estimated audience of 679,500 viewers on september 2. later that month on september 26, another news item stated that more than 200 peo‐ ple had reported adverse reactions from the new generic some of which were considered life threatening. the side effects specifically mentioned were thoughts of self-harm and suicide, nightmares and feeling depressed. a general practitioner was interviewed for the item and stated that the side effects were linked to enlafax and called for patients’ previous medication to remain available as an alternative to the generic. this news bulletin received slightly fewer views at 577,100. on october 20, one news broadcast a third item on the venlafaxine brand change. this media report included interviews with patients as well as two mental health special‐ ists who questioned the effectiveness of the generic enlafax. patients reported feeling disorientated, having a foggy brain and experiencing brain zaps. in a statement, pharmac and medsafe (new zealand’s medicine’s safety authority) stood by the decision to change the funded brand of venlafaxine, emphasising that the medications are pharmaceutically identical. this item received 395,000 views, the lowest of the four items. the last media report on november 30 discussed patients’ claims of discrimination, as the new zealand government’s ministry of health had released two public health warnings about an over-the-counter supplement but had not issued a warning about ven‐ lafaxine, despite patient complaints. this item received 540,600 views and no side effects were mentioned. all four one news items were aired early in the nightly news bulletin between 6pm to 6:15pm. in 2018, one news had the highest ratings of all programmes in new zealand and was the most watched news programme (nielsen, 2018). outcome measures number of adverse reaction reports the primary variable of interest to this study was the number of adverse reaction reports submitted to carm each month. both healthcare professionals and patients can submit a report describing a suspected adverse reaction from a medicine or vaccine directly to carm. adverse reaction data was collected from october 2017 to march 2019 which mackrill, gamble, & petrie 5 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://www.psychopen.eu/ covered a four-month period before the print articles (february 28 – april 27) to four months after the tv bulletins (september 2 – november 30). total side effects and decreased therapeutic response the total number of side effects reported each month was calculated by summing each patient’s side effect reports excluding decreased therapeutic response, which was calcula‐ ted separately. specific side effects we calculated the reporting rate for suicidal thoughts, foggy brain and brain zaps that were mentioned in the television news items. the carm side effects categories of suici‐ dal ideation, suicidal tendency, suicidal attempt, thoughts of self-harm, and intentional self-injury were summed and recoded as suicidal thoughts. both foggy brain and brain zaps mentioned in the television items do not have specific terms in the carm database. we used reports of fuzzy head and electrical shock sensations as the closest coded categories. we compared the side effects that were mentioned in the television coverage with three control side effects that were not mentioned in television bulletins but were reported at similar rates prior to the media coverage. these control side effects were dizziness, drug withdrawal syndrome and irritability. statistical analyses three analyses were conducted to investigate the study hypotheses. an interrupted time series analysis was conducted to determine whether the television news items were associated with an increase in carm reports, total side effects, reports of decreased therapeutic response, and the specific side effects of suicidal thoughts, foggy brain, brain zaps, dizziness, drug withdrawal syndrome and irritability. an automated integrated moving average model (arima [1,0,1]) was used. to indicate the presence of the televi‐ sion media in the model, an independent binary variable was created with the months september to december 2018 coded 1 and the five baseline pre-media months coded 0. this analysis produces an estimated interruption effect (the change in rate between the months coded 0 and 1) and indicates whether this is a significant change. in addition to this analysis, the number of adverse reaction reports was modelled using general linear modelling (glimmix) assuming a poisson distribution to test for differences in the total number of reports in discrete time periods: 5 pre-media baseline months, 3 months during the print media stories, the next 3 months (a pre-tv, no media period), 4 months during which television media reports appeared, and an additional post-tv 3 months. these time periods were pragmatically determined: initiated by the start of each type of media report and ending when reports had returned to the pre-me‐ dia reporting baseline. tukey’s hsd test was used to protect the overall 5% significance level after pairwise post hoc comparison of time periods. effect of television news stories 6 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://www.psychopen.eu/ to examine the effect of print versus television media on adverse reporting, a poisson events test was conducted comparing total number of reports between pairs of months, specifically the peak month of reporting during the print media period and the peak during the tv media period. percentage change was used to describe the effect of the print and television media on number of carm reports. analyses were conducted in sas (v9.4 sas institute inc., cary, nc) and alpha level of .05 was considered significant for all analyses. results number of adverse reaction reports from august 2018 to march 2019 there were 341 adverse reaction reports to carm, with 317 of these occurring during the four-month period when the television items aired. the average age of reporters was 44.3 years old and 79.1% were female. these demographic proportions are similar to the total population of people taking venlafaxine in new zealand, the median age range being 40-49 years and 64.5% identifying as female (mackrill & petrie, 2018). the first aim of this study was to examine the impact of the television coverage on adverse event reporting and compare this with what was observed following the print media. there were significant differences between time periods in the number of adverse reaction reports (glimmix p < .001). in the five months before any print or television media (october 2017 to february 2018), there was an average of 6.00 (sd = 1.23) adverse reaction reports to carm per month. however, in the four months where the television coverage occurred, carm reports significantly increased to an average of 79.25 (sd = 60.26) reports per month (interruption effect [ie] = 73.25, p = .046). comparing the average effect of print versus television media, carm reports following the television coverage were 210.8% greater than those that followed the print (mean number of reports = 25.50, sd = 12.02), which was a significant difference (glimmix p = .004) as shown in figure 1. a poisson events test showed that the peak month of adverse reaction reporting during the television coverage was 408.8% greater than the peak during the print media period (p < .001). mackrill, gamble, & petrie 7 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://www.psychopen.eu/ figure 1 the effect of television compared to print media stories on total number of adverse reaction reports to the centre for adverse reactions monitoring following a switch to generic venlafaxine note. the number of adverse reaction reports during pre-media baseline was not significantly different to the reporting rate pre (glimmix p = .220) or post (glimmix p = .120) the television coverage. total number of side effects and decreased therapeutic response reports individual carm reports submitted from august 2018 to march 2019 listed an average of 2.88 side effects attributed to enlafax. the rate of side effect reporting significantly changed from baseline to post-television. the total number of side effects reported to carm significantly increased from an average of 7.00 reports (sd = 4.18) per month before any media coverage to 235.75 (sd = 184.77) following the television items (ie = 228.75, p = .042). reports of ‘decreased therapeutic response’ increased from 4.00 (sd = 2.12) before the media to 52.25 (sd = 39.35) after the television, however this was not a statistically significant change (p = .064). specific side effects reports we investigated the change in reporting of rate of three side effects that were mentioned in the television coverage (figure 2). the generalised mixed model and interrupted time series analyses both showed a significant increase in reports of suicidal thoughts from an average of 0.40 (sd = 0.55) in the five months before any media coverage to 24.00 (sd = 16.66) following the television (glimmix p = .029; ie = 23.60, p = .031). the reporting rate of foggy brain did not show a statistically significant increase in the number of effect of television news stories 8 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://www.psychopen.eu/ reports in each time period (glimmix p = .160; ie = 8.13, p = .160), however there was an increasing trend with reports going from 0.20 (sd = 0.40) before the media coverage to 8.33 (sd = 9.74) after the television item aired in october. while there were no reports of brain zaps during the pre-media period, the rate increased to an average of 7.00 (sd = 8.52) but this was not significantly different to baseline (glimmix p = .150; ie = 7.00, p = .098). figure 2 number of reports of side effects mentioned in the television news reports on the venlafaxine switch compared to side effects that were not mentioned finally, we examined whether there was a change in the reporting rate of three side effects that were not mentioned in the media (figure 2). reports of dizziness increased from an average of 0.20 (sd = 0.40) over the five baseline months to 7.00 (sd = 6.40) following the television coverage, which has a statistically significant interruption effect (ie = 6.80, p = .024), however, the general linear model was not statistically significant (glimmix p = .110). the reporting rate of drug withdrawal syndrome did not significant‐ ly change from 0.40 (sd = 0.49) to 4.25 (sd = 2.86) after the television media (glimmix mackrill, gamble, & petrie 9 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://www.psychopen.eu/ p = .470; ie = 3.85, p = .180). similarly, reports of irritability did not significantly change from 0.20 (sd = 0.40) to 4.75 (sd = 3.27) (glimmix p = .011; ie = 4.55, p = .240). discussion main findings this study found a significant increase in the number of adverse reaction reports fol‐ lowing a switch to a generic formulation of venlafaxine, which corresponded to the broadcast of four television news items that discussed this medication change. in line with our hypothesis, we found the effect of tv stories on adverse reaction reports to carm was significantly higher than print media, causing an approximately 200% greater rise in adverse reaction reports than the publication of the print articles earlier that year. television news also had a 400% greater peak in reported adverse reports compared to print media, indicating a much stronger nocebo response. there was also partial support for the hypothesis that the specific symptoms mentioned in the tv coverage would be reflected in subsequent side effect reporting. there was an increase in the reporting of side effects mentioned in the television items, especially suicidal thoughts, and although this was generally larger than the symptoms that were not mentioned, it could be that tv coverage causes a greater awareness of side effects in general, rather than being restricted to those specifically mentioned in the bulletins. looking at the reasons why tv has a much stronger effect than print media, it seems unlikely that this is due to the use of expert opinion or difference in the amount of cover‐ age (3 print versus 4 tv stories). a more likely explanation is that television contains a stronger and more impactful modelling element by including real patient stories and experiences that can be easily identified with by viewers (faasse, grey, jordan, garland, & petrie, 2015; faasse & petrie, 2016). comparison with other studies the results are consistent with data in the medical area showing intense negative media coverage on statins was followed by an increase in patients stopping the drug (matthews et al., 2016; schaffer et al., 2015). the results also align with previous work on tv news stories. for example, the thyroxine drug scare produced an increase in both symptom reporting and the specific symptoms mentioned in bulletins, increasing adverse reaction reports by 1,866% following the first television news story (faasse et al., 2012). the current study showed an even larger increase in adverse reaction reports after the first television news bulletin of 4,283%. more widely, the data are consistent with the powerful social modelling effects of tv in the context of suicidal behaviour (hawton & williams, 2002), mass shootings (meindl & ivy, 2017) and the transmission of acute stress following terrorist attacks (holman et al., 2014). the unique contribution of this paper is effect of television news stories 10 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://www.psychopen.eu/ to quantify the relative impact of television compared to print media and to demonstrate how much more impact tv has in the context of a health scare. it may be that the nature of the population taking venlafaxine could have influenced the strength of the nocebo response. the indications for the drug are for depressive and anxiety disorders and the nocebo effect has been shown to occur more frequently in patients being treated for psychological conditions (weissenfeld et al., 2010). individuals taking venlafaxine may have been more reactive to negative stories, increasing their overall concerns about the medication. it is likely that the increased nocebo response apparent following media coverage arose from an overall increase in anxiety, increased expectations of side effects and greater personal monitoring of the side effects specifical‐ ly mentioned in these bulletins (crichton et al., 2014; faasse & petrie, 2016; petrie, mossmorris, grey, & shaw, 2004; petrie & rief, 2019). of particular concern in such situations is the media transmission of suicidal thoughts, which seem to be easily converted into increased rates of suicidal ideation following both print and television media stories and possibly greater rates of suicidal behaviour, although this has yet to be determined in this situation. strengths and limitations the study is limited by reliance on reporting to the national centre and is likely to be a low estimate of the true rate of nocebo response following the media stories as many patients would not have reported symptoms to carm or to a health professional. it is also likely that many doctors may not have taken the time to file a report. previous studies estimate that reports to a national database are less than 10% of adverse drug reactions (mcgettigan et al., 1997). as the reports to carm are de-identified we are unable to examine other personal characteristics that may be associated with increased or decreased nocebo responding. however, people who are older, female and with lower medicine efficacy beliefs have been shown to report more side effects following a generic medicine switch (mackrill & petrie, 2018). it should be also noted that the current study only had access to adverse reaction reports per month. this makes it more difficult to separate out media effects from background noise compared to a finer grain of measure‐ ment such as weekly reports. in conclusion, we believe this is the first study to compare the effect of both print and television media on medication adverse event reporting. we found television news stories have around a 200% stronger effect on nocebo responding than print media and cause an immediate increase in overall adverse reaction responding as well as influenc‐ ing the type of symptoms reported following the coverage. television news coverage can easily increase overall anxiety about a medication and cause individuals to focus on their symptoms as possible side effects. the transmission of symptoms of suicidal ideation is of special concern as there is good evidence of a strong modelling effect on suicidal behaviour from media stories (hawton & williams, 2002). we believe the data indicate mackrill, gamble, & petrie 11 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://www.psychopen.eu/ that media guidelines should be developed to reduce the possible harm from stories that focus on dramatic negative effects reported by individual patients to include information from a wider range of professionals and agencies as well as including information about the nocebo response. funding: the authors have no funding to report. competing interests: km & gg declare no conflicts of interest. kp has received research grants in the past from pharmac, the new zealand government’s pharmaceutical management agency. acknowledgments: the authors have no support to report. references brosius, h.-b., & kepplinger, h. m. 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(2010). the nocebo effect: a reason for patients’ non-adherence to generic substitution? die pharmazie, 65, 451-456. https://doi.org/10.1691/ph.2010.9749 yu, c. y., lakoma, m. d., madden, j. m., rusinak, d., penfold, r. b., simon, g., . . . soumerai, s. b. (2014). changes in antidepressant use by young people and suicidal behaviour after fda warnings and media coverage: quasi experimental study. bmj, 348, article g3596. https://doi.org/10.1136/bmj.g3596 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. effect of television news stories 14 clinical psychology in europe 2020, vol.2(2), article e2623 https://doi.org/10.32872/cpe.v2i2.2623 https://doi.org/10.1691/ph.2010.9749 https://doi.org/10.1136/bmj.g3596 https://www.psychopen.eu/ effect of television news stories (introduction) method media coverage outcome measures statistical analyses results number of adverse reaction reports total number of side effects and decreased therapeutic response reports specific side effects reports discussion main findings comparison with other studies strengths and limitations (additional information) competing interests funding acknowledgments references cultural adaptation of scalable psychological interventions: a new conceptual framework latest developments cultural adaptation of scalable psychological interventions: a new conceptual framework eva heim a, brandon a. kohrt b [a] department of psychology, university of zurich, zurich, switzerland. [b] department of psychiatry, george washington university, washington, dc, usa. clinical psychology in europe, 2019, vol. 1(4), article e37679, https://doi.org/10.32872/cpe.v1i4.37679 received: 2019-06-25 • accepted: 2019-11-01 • published (vor): 2019-12-17 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: eva heim, university of zurich, department of psychology, binzmuehlestrasse 14/17, 8050 zurich, switzerland. e-mail: e.heim@psychologie.uzh.ch abstract background: the worldwide mental health treatment gap calls for scaling-up psychological interventions, which requires effective implementation in diverse cultural settings. evidence from the field of global mental health and cultural clinical psychology indicates cultural variation in how symptoms of common mental disorders are expressed, and how culturally diverse groups explain the emergence of such symptoms. an increasing number of studies have examined to what extent cultural adaptation enhances the acceptability and effectiveness of psychological interventions among culturally diverse groups. to date, this evidence is inconclusive, and there is a lack of studies that dismantle the multiple types of modifications involved in cultural adaptation. method: based on empirical evidence from ethnopsychological studies, cultural adaptation research, and psychotherapy research, the present paper offers a new conceptual framework for cultural adaptation that lays the groundwork for future empirical research. results: the cultural adaptation framework encompasses three elements: i) cultural concepts of distress; ii) treatment components; and iii) treatment delivery. these three elements have been discussed in literature but rarely tested in methodologically rigorous studies. innovative research designs are needed to empirically test the relevance of these adaptation elements, to better understand the substantial modifications that enhance acceptability and effectiveness of psychological interventions. conclusion: using a theory-driven approach and innovative experimental designs, research on cultural adaptation has the potential not only to make psychological treatments more accessible for culturally adverse groups, but also to further advance empirical research on the basic question about the “key ingredients” of psychotherapy. keywords cultural adaptation, psychological interventions, culturally diverse groups, migrant populations this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i4.37679&domain=pdf&date_stamp=2019-12-17 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • the phenomenology of common mental disorders, as well as mind-body concepts, vary across cultures. • cultural adaptation may enhance the acceptability and effectiveness of psychological interventions. • there is a lack of empirical evidence on the substantial modifications in cultural adaptation. • theory-driven, experimental approaches are needed in cultural adaptation research. on 10 october 2017, mental health europe celebrated world mental health day in the european parliament. participants in this conference discussed the urgent need to sup‐ port the mental health of refugees, migrants and asylum seekers (mental health europe, 2017). according to united nations, 180’000 migrants arrived in europe in 2017, and 134’000 in 2018 (un dispatch, 2018). prevalence rates of common mental disorders such as depression, anxiety, and post-traumatic stress disorder (ptsd) are high among immi‐ grants in europe, and particularly among survivors of armed conflicts (bogic, njoku, & priebe, 2015; priebe, giacco, & el-nagib, 2016). worldwide, there is a large mental health treatment gap, i.e. a high number of people in need of treatment who have not received adequate treatment. the treatment gap for common mental disorders is around 60% in high-income countries, 65% in upper-middle income countries, and over 80% in lower-middle income countries (alonso et al., 2018; thornicroft et al., 2017). although the treatment gap is lower in high-income countries, there are specific barriers to mental health care for culturally diverse groups, which in‐ clude poor command of the host country language, cultural beliefs about mental health, lack of trust in mental health services, and mental health related stigma (priebe et al., 2016). the lancet commission on global mental health and sustainable development (patel et al., 2018) calls for action to scale up mental health services as an essential com‐ ponent of universal health coverage. in response to the worldwide treatment gap, who and other research groups have invested in developing a series of potentially scalable psychological interventions (who, 2017). scalability is defined as “the ability of a health intervention shown to be effica‐ cious on a small scale and or under controlled conditions to be expanded under real world conditions to reach a greater proportion of the eligible population, while retaining effectiveness” (milat, king, bauman, & redman, 2013, p. 289). one particular question for scaling-up concerns the extent to which results from one cultural group can be transferred to another. ethnic minorities are generally underrepre‐ sented in clinical trials in high-income countries (hussain-gambles, atkin, & leese, 2004; la roche & christopher, 2008; wendler et al., 2005). there is an ongoing debate in litera‐ cultural adaptation of psychological interventions 2 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ ture on the extent to which psychological interventions developed in western, educated, industrialized, rich, and democratic (weird) societies (henrich, heine, & norenzayan, 2010) require cultural adaptation to be effective for the treatment of common mental dis‐ orders among culturally diverse groups. literature indicates cultural variety in how symptoms of common mental disorders are expressed (haroz et al., 2017; kohrt et al., 2014), and how different cultural groups explain the emergence of such symptoms, there‐ by revealing their (implicit) assumptions about mind-body relationships, and religious or spiritual beliefs (e.g., kohrt & hruschka, 2010). despite such cultural variance in symptoms and assumed causes, meta-analytic evi‐ dence suggests that evidence-based psychological interventions are effective for the treatment of common mental disorders among culturally diverse groups (cuijpers, karyotaki, reijnders, purgato, & barbui, 2018; singla et al., 2017). but to what extent cul‐ tural adaptation can further enhance the acceptability and effectiveness of such interven‐ tions is subject to current debate in literature. cultural adaptation of psychological interventions bernal, jiménez-chafey, and domenech rodríguez (2009) define cultural adaptation as “the systematic modification of an evidence-based treatment (ebt) or intervention proto‐ col to consider language, culture, and context in such a way, that it is compatible with the client’s cultural patterns, meanings, and values” (p. 362). cultural adaptation can range from relatively low investment of resources (e.g., adaptation of illustrations or case exam‐ ples) to adaptations which require a large amount of time and human resources, e.g. adaptation to cultural concepts of distress (kohrt et al., 2014). bernal and colleagues (bernal, bonilla, & bellido, 1995; bernal & sáez-santiago, 2006) developed a framework for cultural adaptation of psychological interventions which en‐ compasses eight elements: (a) language, (b) therapeutic relationship, (c) metaphors, (d) content of intervention, (e) concept of illness, (f) treatment goals, (g) delivering methods, and (h) context. meta-analytic evidence suggests that culturally adapted psychological in‐ terventions are effective when compared to a variety of control conditions (d = 0.45) (griner & smith, 2006), and more effective than unadapted versions of the same interven‐ tion in direct comparison (g = .52) (hall, ibaraki, huang, marti, & stice, 2016). moreover, two meta-analyses showed that effect sizes increased with the number of implemented adaptation elements according to the bernal framework (harper shehadeh, heim, chowdhary, maercker, & albanese, 2016; smith, domenech rodríguez, & bernal, 2011). however, a series of difficulties have been reported in cultural adaptation literature. first, the framework developed by bernal and colleagues (bernal et al., 1995; bernal & sáez-santiago, 2006) has been criticised, particularly because of its list-like format and re‐ ported difficulties with implementing the elements in real-world settings (chu & leino, heim & kohrt 3 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ 2017). the eight elements are not distinct but overlap, e.g. it is hard to differentiate be‐ tween adaptations made in language or metaphors, which are closely intertwined. in ad‐ dition, the framework was developed for face-to-face treatments, and its use for other treatment formats such as self-help interventions is limited (harper shehadeh et al., 2016). second, when looking into the original studies included in the above cited metaanalyses, it becomes evident that such studies tested a large variety of interventions such as psychoeducation, parenting programs, cognitive-behavioural therapy, interpersonal therapy, skills training, systemic therapy, problem solving, etc. the assumed mechanisms of action behind these approaches vary greatly, thus most likely not all of these interven‐ tions require the same level of cultural adaptation. what is more, most original studies and meta-analyses do not provide detailed descriptions of the cultural adaptations that were done in the original studies, with some exceptions (e.g., abi ramia et al., 2018). third, there is very little evidence to determine which cultural adaptation elements are particularly relevant for enhancing treatment acceptability and effectiveness. benish, quintana, and wampold (2011) showed that cultural adaptation of the illness myth, i.e. the explanatory model provided to patients for their symptoms (bhui, rudell, & priebe, 2006), was the sole moderator of larger effect sizes of culturally adapted psychotherapy when compared to other active treatments (d = 0.21). but this finding was based on weak empirical evidence. aside from the bernal framework, a series of other frameworks have been published in the past decade (domenech rodríguez & bernal, 2012). in an attempt to organize the variety of elements suggested in these frameworks, chu and leino (2017) conducted a systematic review and developed a new, data-driven cultural adaptation framework, in which they basically make a distinction between the adaptation of core vs. peripheral as‐ pects in psychotherapy. core components are the therapeutic ingredients that are as‐ sumed to cause symptom change, based on psychological theories, whereas peripheral components include the treatment aspects that are related to the feasibility and accepta‐ bility of the intervention (e.g., language or case examples). in their review, chu and leino (2017) found that all included studies had implemented peripheral adaptations, whereas 11% had modified and 60% had added core components. the new adaptation framework by chu and leino (2017) is an improvement when compared to other frameworks, particularly due to the fact that it was based on original studies rather than expert opinions. moreover, the division of treatment aspects into pe‐ ripheral (i.e., engagement and methods of delivery) and core aspects provides an intrigu‐ ing simplicity in comparison with other frameworks. on the other hand, this framework is based on what has been done so far and therefore cannot capture aspects that have potentially been neglected in literature. moreover, due to its heuristic nature, it does not provide the necessary theoretical assumptions of how and why cultural adaptation might cultural adaptation of psychological interventions 4 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ increase the acceptance and effectiveness of psychological interventions. a more theorybased framework can set the ground for empirical research to examine these questions. when adopting such a theory-driven rather than heuristic perspective, the division between core and peripheral aspects of psychological interventions might not be as straightforward as suggested by chu and leino (2017). two recent prominent systematic reviews conclude that current evidence is insufficient to explain change mechanisms in psychotherapy (cuijpers, cristea, et al., 2019; lemmens, muller, arntz, & huibers, 2016). it might well be that psychotherapy works through common factors, such as the thera‐ peutic alliance, positive expectations, and a convincing treatment rationale rather than the specific techniques that are assumed to cause changes in symptoms (cuijpers, reijnders, & huibers, 2019). thus, factors classified as peripheral by chu and leino (2017), e.g. psychoeducation, might actually be the core ingredients of psychotherapy, as is explained more in detail below. in a more general manner, resnicow, baranowski, ahluwalia, and braithwaite (1999) differentiate between surface and deep structure adaptations to health interventions. sur‐ face adaptations refer to matching materials (e.g., illustrations, language), as well as channels and settings for treatment delivery to observable characteristics of the target population. by contrast, deep structure adaptations take into account how cultural, so‐ cial, environmental or historical factors influence health behaviours. such adaptations are based on assumptions of how members of a particular cultural group perceive the cause, course, and treatment of a particular illness. in other words, and as highlighted by the authors, deep structure conveys salience. resnicow et al. (1999) developed their framework for health interventions in general. when applying this logic to the cultural adaptation of psychological interventions for the treatment of common mental disorders, deep structure adaptations may take into account results from ethnopsychological stud‐ ies. theoretical and empirical foundations for cultural adaptation ethnopsychology uses ethnological research to examine different populations’ notions of psychological concepts such as the self, emotions, and human nature (white, 1992). eth‐ nopsychological studies have brought forward a large body of evidence on cultural con‐ cepts of distress (ccd), a term that was introduced in dsm-5 to describe local mental health-related phenomena (american psychiatric association, 2013). ccd encompass other terms used in literature, such as culture-bound syndromes (american psychiatric association, 1994), idioms of distress (nichter, 1981, 2010), explanatory models (bhui & bhugra, 2002), or illness narratives (groleau, young, & kirmayer, 2006). kohrt et al. (2014) summarised evidence on ccd from different parts of the world in a systematic review. they found that more rigorous studies revealed ccd that clearly dif‐ heim & kohrt 5 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ fered from western diagnoses of common mental disorders. such studies examine peo‐ ple’s ways of expressing suffering, their assumptions about causes of distress and possi‐ ble ways to overcome it, physiological and spiritual meanings attributed to suffering, and the distinction between universal human suffering and mental illness (e.g., keys, kaiser, kohrt, khoury, & brewster, 2012; kohrt & hruschka, 2010; shala, morina, salis gross, maercker, & heim, 2019). one example of adapting psychological interventions to such ccd was delivered by hinton, rivera, hofmann, barlow, and otto (2012), who developed culturally adapted cognitive behavioural therapy (ca-cbt) for ptsd. ca-cbt was first developed for cambodian survivors of the khmer rouge. it targets the ccd of khyâl attacks that is based on cambodians’ assumptions about a wind-like substance that circulates in the body (hinton, pich, marques, nickerson, & pollack, 2010). according to this assumption, an imbalance in the khyâl flow causes symptoms such as dizziness and anxiety, which are accompanied by catastrophic beliefs and trauma memories. ca-cbt is based on this particular mind-body concept, and the main treatment components are emotion exposure and emotion regulation techniques (i.e., meditation and yoga-like stretching). thus, cacbt uses techniques that are not unique for cambodians, but the treatment rationale pro‐ vided to patients is rooted in their own explanatory model that is based on khyâl. this example illustrates one of the basic debates in psychotherapy research, namely the question whether the effect of the treatment is rooted in the techniques themselves, or rather the rationale provided for their use (wampold & imel, 2015). as brought to the point by wampold (2007) “[p]sychotherapy is not simply the vehicle for the delivery of psychological ingredients but is, rather, a highly entwined system that uses language to construct, or better said, reconstruct the client’s interpretations of the world” (p. 8). in psychotherapy research, older and more recent meta-analyses come to the consistent conclusion that after decades of randomised controlled trials (rcts), we do not know what the “key ingredients” of psychotherapy are (ahn & wampold, 2001; cuijpers, cristea, et al., 2019; lemmens et al., 2016). “key ingredients” are the treatment compo‐ nents that (are assumed to) cause the symptom change. the current state of the evidence does not allow to conclude whether symptom improvement is caused by specific interven‐ tions (e.g., behavioural activation or stress management techniques) or by unspecific fac‐ tors such as the therapeutic alliance, positive outcome expectations, or providing a con‐ vincing treatment rationale (cuijpers, cristea, et al., 2019). this conclusion is highly relevant for research on cultural adaptation of psychological interventions. chu and leino (2017) considered “psychoeducation” to be a peripheral as‐ pect of cultural adaptation. however, explaining the purpose of a specific therapeutic technique in a particular way to make it more congruent with the patient’s worldview might be much more than just a peripheral adaptation to make the intervention more ac‐ ceptable. such adaptations in language might touch on patients’ implicit explanatory models, which in turn might change the underlying mechanisms of action, even if the cultural adaptation of psychological interventions 6 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ intervention itself (e.g., a stress management technique) remains the same. thus, one and the same adaptation might be considered as core or peripheral. in summary, theory-driven, experimental studies are needed to better understand whether and how cultural adaptation contributes to the acceptability and effectiveness of psychological interventions. such studies may in the longer run also contribute to better understand the active ingredients of psychotherapy itself. we aim to lay the groundwork for such studies by suggesting a new conceptual framework. the elements of our frame‐ work are based on empirical evidence from ethnopsychological studies, research on the cultural adaptation of psychological interventions, and psychotherapy research outlined above. a new framework for cultural adaptation our framework is based on the elements of psychological interventions that could poten‐ tially be adapted – regardless of whether this has been done in previous research or not. before conducting empirical studies, it seems important to take a conceptual approach in order to include all aspects of an intervention that might contribute to symptom change. our cultural adaptation framework (figure 1) consists of three main elements which are further described below. we do not formulate pre-assumptions about the components that cause symptom change. because evidence on substantial modifications is lacking, all elements are considered to be equally relevant for empirical testing. the elements gener‐ ally reflect the two dimensions suggested by resnicow et al. (1999), i.e., surface and deep structure adaptations (see above). while resnicow et al.’s framework was developed more generally for health interventions, we further specified potential deep structure adaptations in psychological interventions for the treatment of common mental disor‐ ders. the elements are presented in what we consider to be a plausible sequence, starting with what may lie at the heart of cultural adaptations, namely the ccd. from ccd – i.e. explanatory models and idioms of distress – relevant treatment components can be de‐ rived, and hypotheses can be generated about treatment delivery. in the following, we describe the three main elements and the corresponding sub-elements of the new frame‐ work and provide examples from literature to underpin our assumptions. at the same time, we make suggestions on how to implement these adaptations. our primary aim is to provide a framework as a basis for empirical testing, but the elements outlined below can also be used for adaptations in clinical practice. heim & kohrt 7 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ figure 1. new framework for cultural adaptation. cultural concepts of distress the first element of the framework focuses on core beliefs about human suffering, and the cultural resonance of hypothesized psychological mechanisms of action with ethno‐ theories of healing. this includes two aspects: explanatory models (i.e., aetiological as‐ sumptions) and idioms of distress (i.e., the expression of symptoms). several semi-struc‐ tured interview guidelines have been developed to examine ccd, e.g., the cultural for‐ mulation interview in dsm-5 (american psychiatric association, 2013), the short explana‐ tory model interview (semi, lloyd et al., 1998), the barts explanatory model inventory (be‐ mi, rüdell, bhui, & priebe, 2009) or the mcgill illness narrative interview (mini, groleau et al., 2006). these interviews cover both aspects – idioms of distress and explanatory models – and can help to better understand patients’ realities. a. explanatory models. people who suffer from psychological distress develop explanations for their symptoms (wampold, 2007). these explanations are based on intuitive and culturally shaped notions of how mind and body interact (kirmayer, 2001; kirmayer & bhugra, 2009). above, we outlined the example of khyâl attacks among cambodian survivors of the khmer rouge (hinton et al., 2010). other examples the concept of the heart-mind described in nepal (kohrt & hruschka, 2010), or the heart narratives related to psychological distress in haiti (keys et al., 2012). another example are findings related to fatalism. an ethnopsychological study showed that albanian-speaking immigrants in switzerland understood their suffering as part of normal life, given by god or fate (fati), and something that cannot be cured but has to be borne with endurance (durim) (shala et al., 2019). fatalism was also found among turkish immigrants in germany (franz et al., 2007; reich, cultural adaptation of psychological interventions 8 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ bockel, & mewes, 2015). when compared to german patients, turkish immigrants showed more fatalistic-external control attributions for mental distress, which resulted in lower motivation for psychotherapy. the concept of fate is also described in islamic understandings of suffering: “the notion of qadar ( رَدَقلا , ‘fate’) is central to this context. this acceptance of fate should not be equated with fatalism, but can be better understood within a framework of self-abandonment, which is reflected in the value of patience in the face of helplessness and adversity, such as illness and loss. life may be viewed as a transient phase of existence, a testing place for the eternal life that comes after death” (hassan et al., 2015, p. 27). psychological interventions ideally provide explanations that differ from the patient’s own views, but that are not sufficiently discrepant from the patient’s intuitive assumptions as to be rejected (wampold, 2007). for treatment adherence and compliance, it is vital that patients understand and to some point share the rationale behind the treatment. on the other hand, it is also important to provide a new explanation and treatment rationale, in order to motivate patients to try and practice the therapeutic techniques. as an example, reich, zürn, and mewes (2019) developed a web-based intervention to address fatalism and to enhance motivation for psychotherapy among turkish immigrants in germany. in a pilot study, they found that this intervention enhanced treatment motivation and reduced fatalistic beliefs. b. idioms of distress. this element scrutinises the cultural salience of symptoms that are targeted with an intervention. common mental disorders are latent (i.e., nonvisible) concepts measured through the expression of symptoms (i.e., their phenomenology). there is a vast body of literature on the difference in symptom expression across cultures, e.g. with regard to emotional vs. somatic complaints (e.g., kirmayer, 2001; ma-kellams, 2014; ryder et al., 2008). moreover, ethnopsychological studies from different parts of the world have delivered a broad range of labels used for expressing mental distress in a socially and culturally acceptable manner (e.g., haroz et al., 2017). as an example, thinking too much is an expression that has been found in many parts of the world and can be used in health communication as a nonstigmatizing way to describe symptoms of psychological distress (kaiser et al., 2015). however, it would be erroneous to assume that such labels are simply varying expressions of the same, latent construct (e.g., depression or anxiety). such local expressions often reflect implicit assumptions about mind-body interactions as described above. therefore, it is relevant to carefully assess culturally salient symptoms, and to select or target treatment components accordingly. treatment components to describe treatment components, we draw on an existing taxonomy developed by singla et al. (2017), who conducted a systematic review and meta-analysis of psychologi‐ heim & kohrt 9 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ cal interventions in lowand middle-income countries. they applied a multistep analysis of existing taxonomies of common psychological treatment elements and behavioural change techniques used for common mental disorders. based on this analysis, they pro‐ posed a taxonomy of treatment components, which includes the following elements: spe‐ cific therapeutic elements (i.e., behavioural, cognitive, interpersonal, and emotional inter‐ ventions); nonspecific elements to enhance engagement (e.g., empathy, empathic listen‐ ing, or discussing advantages of and barriers to treatment); and in-session techniques (e.g., goal-setting, role playing, or praising). in their meta-analysis, they found that two specific techniques (i.e., interpersonal and emotional), and nonspecific elements showed the strongest association with trial effectiveness. in the following, we describe how these components may be culturally adapted. a. specific elements. studies testing psychological interventions in lowand middleincome countries have often provided reasons for choosing one technique over another, e.g. arguing that behavioural activation is easier to explain than cognitive techniques, particularly when provided by lay helpers (dawson et al., 2015). the selection of therapeutic techniques is ideally based on core assumptions about human suffering and healing in the target population, and culturally salient symptoms of psychological distress. as an example, behavioural activation is based on the theoretical assumption that inertia and avoidance are key mechanisms of action in depression (ferster, 1973; lewinsohn, 1974; veale, 2008). however, a qualitative study conducted in lebanon for the cultural adaptation of an internetbased intervention (abi ramia et al., 2018), showed that inertia and inactivity were not key symptoms of depression. depressed people in lebanon rather maintain their necessary activities, yet, they were described as becoming irritable, tired, sad, frustrated or angry while continuing to function. this appears to be a global phenomenon: a qualitative systematic review of depression around the world demonstrated similar findings with irritability, anger, and pain figuring prominently but, “[t]he majority of study populations did not raise problems with daily functioning as part of their subjective experiences of depression” (haroz et al., 2017, p. 160). in resource-scarce settings where people can simply not afford to become inactive, and where cultural values impede social withdrawal, behavioural activation might not be the first-choice psychological intervention for the treatment of depression. in addition, the focus on improving one’s mood through engaging in pleasant activities might not necessarily be a convincing treatment rationale in societies where pursuing affectively positive experiences for oneself is not a key cultural value (schwartz, 2006). as another example, tol et al. (2018) argued that for people in humanitarian settings who suffer from a broad range of symptoms related to psychological distress that cannot be easily categorized as a mental disorder (e.g., nonpathological anxiety, cultural adaptation of psychological interventions 10 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ grief reactions, and demoralization), general stress management techniques might be more relevant than disorder-specific treatments. stress management techniques that focus on dealing with negative emotions such as anger, sadness, or nervousness, might be more relevant in such contexts (hinton et al., 2012; tol et al., 2018). b. nonspecific elements (common factors). singla et al. (2017) describe these as the elements that are either universal to all treatments, or the ones that are used for enhancing treatment engagement, such as active listening or discussing advantages and disadvantages of the treatment. with regard to elements that are universal to all treatments (e.g., active listening), the cultural adaptation may be limited to surface aspects (see below), such as how active listening is expressed verbally or nonverbally. when it comes to treatment engagement, providing a convincing and culturally congruent explanatory model may be relevant (see above). for discussing advantages and disadvantages of treatment, it may be relevant to consider culturally-specific notions of stigma, and the way how mental health-related stigma threatens the life domains that “matter most” (yang, thornicroft, alvarado, vega, & link, 2014) to members of a specific cultural group (e.g., marriage, employment, social networks). advantages and disadvantages of treatment may relate to such culture-specific notions of stigma. people affected by mental disorders could fear stigmatisation if they accept a treatment. on the other hand, patients may realise that treatment and symptom reduction can help in reducing mental health-related stigma, particularly when they are re-integrated into employment or other societal domains. c. in-session techniques. singla et al. (2017) subsume a broad range of techniques under this element, such as role-playing, goal setting, homework, or behavioural experiments. formative research (e.g., key informant interviews or focus groups) can be used to better understand whether such techniques are acceptable in a particular target group, or how these techniques can be adapted to be accessible for members of this target group (ramaiya, fiorillo, regmi, robins, & kohrt, 2017). treatment delivery once the treatment components are defined, the delivery format can be selected, or dif‐ ferent formats can be used for different target groups (e.g., face-to-face interventions for older participants and mobile applications for youths). for cultural adaptation of these el‐ ements, factors such as literacy level, socio-economic status, gender, or assumptions about the patient-therapist relationship may be taken into account. a. delivery format. this element describes cultural preferences and acceptability for different treatment modalities. as an example, several trials have tested the groupbased delivery of potentially scalable interventions as opposed to individual treatment sessions (epping-jordan et al., 2016; sangraula et al., 2018; verdeli et al., heim & kohrt 11 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ 2003). furthermore, internet-based interventions are currently propagated as one potential measure to address the worldwide mental health treatment gap, as they can widely be disseminated among difficult-to-reach populations (schröder, berger, westermann, klein, & moritz, 2016). there is an ongoing debate about the necessity of guidance in internet-based or other self-help interventions (baumeister, reichler, munzinger, & lin, 2014). it is theoretically possible that the answer to that question is culturally relative – i.e. that for some cultural groups, guidance is more relevant than for others. empirical evidence is needed to answer this question. b. surface. this element comes closest to what chu and leino (2017) considered to be peripheral aspects of psychological interventions, and what resnicow et al. (1999) described as surface adaptations. a large variety of descriptions of such adaptations has been delivered in literature, such as using culturally adapted language and metaphors (ramaiya et al., 2017), providing culturally relevant illustrations and case examples (verdeli et al., 2003), or using easy-to-understand texts (carswell et al., 2018). evidence on such adaptations has been summarised in systematic reviews (chowdhary et al., 2014; harper shehadeh et al., 2016). however, so far there is no evidence to show to what extent such adaptations are necessary to enhance acceptance and effectiveness of psychological interventions. of course, there is a moral obligation not to use treatment materials that are potentially offensive or that may hurt religious feelings. and of course, an intervention is more likely to be accepted when patients feel that the contents are congruent with their own living situations, experiences, and cultural values. but so far, there is insufficient empirical evidence to support this assumption. outlook: how to enhance empirical evidence on cultural adaptation with this new framework, we aim to inspire a theory-driven, empirical approach to cul‐ tural adaptation of psychological interventions. a systematic review (hall et al., 2016) provided indications that culturally adapted psychological interventions are indeed more effective than the unadapted versions of the same interventions. however, there is a lack of evidence on the substantial modifications that cause the higher effectiveness of adapted interventions. in most studies, several aspects were adapted at the same time, and cultur‐ al adaptation methods are rarely documented in a replicable manner. in order to advance cultural adaptation research, it would be important to formulate theory-driven hypothe‐ ses about the components that are assumed to cause the higher acceptance and effective‐ ness of adapted interventions, and to test these components using experimental designs. when developing this framework, we mainly had potentially scalable interventions in mind, i.e., modified, low-intensity and highly standardised evidence-based treatments, which are applied in self-help or guided self-help format, or delivered by lay helpers cultural adaptation of psychological interventions 12 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ (who, 2017). such interventions are condensed versions of what is done in face-to-face treatments. for such interventions, it is of vital importance to discover which compo‐ nents are most relevant for symptom change, and which aspects are nice-to-have. this also applies to cultural adaptation. for future research and implementation, it is crucial to better understand the treatment elements that have to be culturally adapted to make sure the intervention is acceptable and effective. the main difference between lowand high-intensity interventions lies – as the names suggest – in the intensity of therapist involvement. in high-intensity interven‐ tions, trained therapists can (and most probably do) make “on-the-fly” adaptations when‐ ever working individually with patients from culturally diverse groups. in low-intensity and potentially scalable interventions, most of the treatment aspects are standardised, and in unguided self-help, no contact with a therapist or lay helper is provided at all. in view of transparency and economy of treatments and trainings, it seems helpful to iden‐ tify the potential cultural adaptations that can and should be made in a standardised manner to ensure that a treatment is acceptable and effective. in contrast to previous frameworks for cultural adaptation (bernal et al., 1995; chu & leino, 2017), we used cultural concepts of distress (ccd) as the pivotal point for deep structure adaptation (resnicow et al., 1999). we suggest starting with an assessment of ccd using semi-structured interviews such as the cultural formulation interview in dsm-5 (american psychiatric association, 2013) or the barts explanatory model inventory (bemi, rüdell et al., 2009), and to derive all relevant adaptations from results of such for‐ mative research. a desk literature review can help to identify studies that have already assessed ccd in the target population, to avoid duplication of work. however, we inten‐ tionally formulated our framework in a way that it does not make pre-assumptions about which adaptations are substantial. it might well be that experimental research (see below) will show that adapting psychological interventions to ccd does not make any differ‐ ence with regard to their acceptability and/or effectiveness. in our view, it is essential to take this step back and to start with a conceptual framework that includes what seems to be most plausible according to current evidence. from such a conceptual framework, hy‐ potheses can be formulated and tested in empirical studies. aside from a new framework, novel research approaches are needed to advance the empirical evidence on the cultural adaptation of psychological interventions. direct com‐ parison of adapted and unadapted versions of the same interventions are still rather the exception (hall et al., 2016). this is understandable, as such direct comparisons require very large sample sizes, since small effects are to be expected when comparing two simi‐ lar treatments with small deviations (cuijpers, cristea, et al., 2019). moreover, training therapists to provide two different versions of the same intervention – adapted and unad‐ apted – is a difficult task. other treatment formats such as internet or mobile-based inter‐ ventions, self-help books or audio recordings, are promising for such research. such highly standardised materials, where input from therapists or lay helpers is minimal, can heim & kohrt 13 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ be used to show users two different versions of the same intervention, without large in‐ vestments in training. innovative research approaches, e.g. factorial experiments (collins, 2018) can be used, in which several components are manipulated at the same time. such research designs can contribute to better understand the substantial modifications in cul‐ tural adaptation. results from cultural adaptation may also potentially contribute to basic psychothera‐ py research. for a long time, there has been a debate about the specific and nonspecific components of psychotherapy, and a recent meta-analysis came to the following conclu‐ sion: “based on this set of studies, the only conclusion that can be drawn is that we sim‐ ply don’t know if specific components of specific therapies are effective ingredients of these therapies, or whether all effects are caused by universal, nonspecific factors that are common to all therapies” (cuijpers, cristea, et al., 2019, p. 12). cultural adaptation research provides a promising new approach to this question. as an example, if one and the same intervention (e.g., a stress management technique) shows the same effect, re‐ gardless of the explanatory model provided to patients, this is an indicator that the spe‐ cific intervention caused the symptom change. by contrast, if the same intervention shows a higher effect if it is framed in a culturally-shaped manner, this is an indicator that providing a convincing rationale is indeed a “key ingredient” of psychotherapy, as postulated by ahn and wampold (2001). thus, aside from enhancing access to treatments for culturally diverse groups, cultural adaptation research can make an important contri‐ bution to psychotherapy research as a whole. one important challenge refers to the selection of the target population for cultural adaptation. how do we define a “cultural group”? as an example, bernal et al. (1995) de‐ veloped their framework in the context of their work with “latinos/as” in the united states, and hinton et al. (2010) worked with “cambodian refugees”. a cultural group can be defined in terms of language, country or region, religion, or other socio-demographic characteristics. migration is another important aspect, as with time, immigrants start adopting cultural values and norms of the host country, which may be relevant for cul‐ tural adaptation of psychological interventions. for research purposes, it is most relevant to carefully define the target population and to be transparent about the criteria accord‐ ing to which this population is defined, to make sure results of studies can be interpreted accordingly. in individual therapy, semi-structured interviews can be used to tailor the interventions to the specific characteristics of the patient. conclusion considering the millions of people in need of psychological treatments worldwide (the who world mental health survey consortium, 2004; turrini et al., 2017), the limited re‐ sources available for mental health (patel et al., 2018), the cultural diversity in common mental disorders (kohrt et al., 2014), and the variety of treatment components that are potentially relevant for adaptation (bernal et al., 1995; bernal & sáez-santiago, 2006; chu cultural adaptation of psychological interventions 14 clinical psychology in europe 2019, vol.1(4), article e37679 https://doi.org/10.32872/cpe.v1i4.37679 https://www.psychopen.eu/ & leino, 2017), it is vital to expand the empirical evidence as a basis for decision-making on how much and where to invest in cultural adaptation of psychological interventions. the present paper offers a conceptual framework that lays the groundwork for such empirical research. the three elements suggested in this framework are based on empiri‐ cal evidence from ethnopsychological studies, cultural adaptation research, and psycho‐ therapy research. innovative research designs are needed to evaluate the relevance of these elements. using a theory-driven approach and innovative experimental designs, re‐ search on cultural adaptation has the potential not only to make psychological treat‐ ments more accessible for culturally adverse groups, but also to further advance empiri‐ cal research on the basic question of the key ingredients and mechanisms of action in psychotherapy. funding: eh is supported by the swiss national science foundation (grant 10001c_169780) and the swiss foundation for psychiatry and psychotherapy. bak is supported by the us national institute of mental health (grants k01mh104310, r21mh111280). in addition, both authors are part of indigo. the indigo partnership research programme is a part of the indigo network; a collaboration of research colleagues in over 30 countries worldwide committed to developing knowledge about mental-illness-related stigma and discrimination, both in terms of their origins and their eradication. it is coordinated by the centre for global mental health, institute of psychiatry, psychology and neuroscience at king’s college london. this work was supported in part by the medical research council (grant number mr/r023697/1). competing interests: the authors declare no conflicts of interest. acknowledgments: the authors have no support to report. references abi ramia, j., harper shehadeh, m., kheir, w., zoghbi, e., watts, s., heim, e., & el chammay, r. 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[b] division of psychotherapy and gero-psychology, department of psychology, university of salzburg, salzburg, austria. [c] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2019, vol. 1(3), article e39435, https://doi.org/10.32872/cpe.v1i3.39435 published (vor): 2019-09-20 corresponding author: anton-rupert laireiter, faculty of psychology, university of vienna, liebiggasse 5, 1010 vienna, austria. e-mail: anton-rupert.laireiter@univie.ac.at as pointed out in the editorial paper by laireiter and weise (2019)1, manuscripts submit‐ ted to this section should address the following two topics: (1) legal regulations on educa‐ tion, training, and practice in clinical psychology and psychological treatment in the cor‐ responding country, (2) specific aspects related to politics and education, e.g. prerequi‐ sites for, and contents of, training in various psychological treatments, or the relationship between clinical psychology and psychological treatment in the respective country. in addition, commentaries on university studies (e.g. master's or doctorate level), european harmonization, or pan-european regulations (e.g. by the european federation of psycho‐ logists' associations or other organizations) are also welcome. to facilitate writing of papers but also to make presentations from different countries equivalent and comparable, the editors decided to refine the general criteria by offering more specific guidelines for reporting national regulations in clinical psychology. these guidelines are not a must, but can be seen as a reference and support for structuring pa‐ pers in this section of cpe. additionally, authors are not bound to report about all points; they may select parts of it or even focus on only a few of them. • legal or state regulations for psychology: do legal regulations for psychology exist in your country? are they for psychology in general or for clinical psychology (or any other field of psychology) in specific? please describe. 1) https://doi.org/10.32872/cpe.v1i1.34406 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i3.39435&domain=pdf&date_stamp=2019-09-20 https://doi.org/10.32872/cpe.v1i1.34406 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ • legal or state regulations for psychological treatment: are there (different/ further) legal regulations for psychotherapy? what is the relation between clinical psychology and psychotherapy, e.g. are they independent from each other (i.e. two independent professions), or is one part of the other? which one is superior? are other professions also subject to state regulations in your country (e.g., social workers)? • details of legal regulations: what are the details of national regulations for (clinical) psychologists? is there, for example, a state law or act on psychology? does this refer to clinical psychology? what other fields of psychology are also part of this act? please describe the main structure of the regulations in clinical psychology. do other state laws, e.g. insurance acts, national health system acts, regulate clinical psychology and their professional activities? • professional status of clinical psychologists: what is the professional status of clinical psychologists in your country? is it a “free” profession in which clinical psychologists are allowed to take up residence and work autonomously and without instruction and supervision by any other profession (e.g. psychiatrists, physicians) in the national health system (nhs) of your country? is its professional activity limited to specific sectors of the nhs, e.g. to inpatient medical settings, psychiatry or psychosomatics? do patients have direct and independent access to psychological treatment, or is access to it dependent on the referral by physicians? • core professional activities: what are the core professional activities of clinical psychologists provided by legal regulations in your country (e.g. assessment/ diagnostics, psychological treatment/psychotherapy, emergency interventions, preventive interventions, health promotion, counseling/coaching, supervision, teaching, research)? • training in (clinical) psychology: what kind of university training and postgraduate training is required to provide clinical psychological diagnostics and treatment? give an overview on the criteria (e.g. master in (clinical) psychology, additional requirements) and elements of training (theory, supervision, practice etc.) including hours/training units. please comment on the curricula: are there specific regulations for certain treatment traditions or approaches or limitations to specific traditions, e.g. psychodynamic, cbt, humanistic? are internships in outpatient and inpatient treatment centers required and to what extent? are there specific trainings and regulations for clinical psychologists for adults versus for children and adolescents? • licensing/public register: is there any kind of licensing for clinical psychologists? what are the main criteria for receiving a license (or any other kind of public approval) as a clinical psychologist? how many clinical psychologists in your country are licensed or have another kind of public approval (e.g. being listed in a public register for clinical psychologists), for example compared to psychiatrists or (other) psychotherapists? guidelines for papers in the section “politics and education” 2 clinical psychology in europe 2019, vol.1(3), article e39435 https://doi.org/10.32872/cpe.v1i3.39435 https://www.psychopen.eu/ • financial situation: are clinical psychological activities (e.g. assessment, treatment, psychotherapy) part of the national health insurance system? if yes, which activities specifically, e.g. assessment, treatment, psychotherapy, any other? what are the similarities and differences between psychological and medical psychotherapists related to payment and rights? do clinical psychologists receive a regular salary during postgraduate training/internships? • clinical psychological research: what are the implications of the legal or state regulations for research, especially at university departments of clinical psychology and psychological treatments? do outpatient clinics at university departments exist? can patients easily access those treatment centers at psychological university institutes? what kind of obstacles do exist for research in clinical psychology and psychotherapy in your country? • conclusion: final and concluding evaluation of the situation of clinical psychology in your country. necessary changes, current discussions or concerns, goals for the future, etc. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. laireiter, rief, & weise 3 clinical psychology in europe 2019, vol.1(3), article e39435 https://doi.org/10.32872/cpe.v1i3.39435 https://www.psychopen.eu/ embracing computational approaches can stimulate clinical psychology research editorial embracing computational approaches can stimulate clinical psychology research omer van den bergh a, nadine lehnen b [a] health psychology, university of leuven, leuven, belgium. [b] department of psychosomatic medicine and psychotherapy, technical university of munich, munich, germany. clinical psychology in europe, 2019, vol. 1(3), article e39237, https://doi.org/10.32872/cpe.v1i3.39237 published (vor): 2019-09-20 corresponding author: omer van den bergh, university of leuven, health psychology, tiensestraat 102, 3000 leuven, belgium. e-mail: omer.vandenbergh@kuleuven.be clinical psychology is predominantly a “verbal” science: we derive most clinically useful information from what people say and talking is a critical means in the preferred unit of intervention: person-to-person interaction. psychologists often tend to believe that num‐ bers are a poor means of capturing and representing what goes on in the individual’s mind and sometimes consider attempts to do so as naïve, if not offensive, to the essence of human nature and existence. one of the arguments advanced cites “complexity”: the human mind is simply too rich and complex to reduce it to numbers. interestingly, com‐ plexity in other sciences and clinical specialties is often cited as one of the main reasons to use computing and to develop mathematical models and apply simulations. should clinical psychology consider going down this path? as a scientific endeavor, clinical psychology is (and should be) rooted in empirical da‐ ta and validated theoretical models that allow prediction. indeed, in a broad sense, both diagnostic and therapeutic steps (implicitly) involve a probabilistic prediction about fu‐ ture behavior. one way to validate models is to carry out experiments. however, reality in experiments is artificially reduced and controlled in order to test the effect of one or only a small set of independent (manipulated) variables on some variable of interest. the benefit is that they allow us to detect causal relationships and develop heuristics to un‐ derstand behavior. this is why experiments should be simple: our human mind can hard‐ ly grasp a 2-way interaction, let alone a 3or 4-way interaction1. however, since multiple higher order interactions and recursive effects (effects feed back on causes) are the rule in life, experiments do not allow us to predict actual behavior in a real context. 1) courtesy for this statement to my old professor of statistics, ovdb this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i3.39237&domain=pdf&date_stamp=2019-09-20 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ this is no different to natural sciences: just like experimentally investigating the rela‐ tionship between pressure, temperature and volume of a gas is important to eventually understand weather systems, the equations generated in experiments will not enable us to predict the weather across the next few days. the latter implies more complicated computational models with deterministic and stochastic variables in which lab-based equations act as building blocks that are fed with initial data and that are continuously updated as new information unfolds. eventually, our human mind may not be able to fully grasp all the higher-order interactions, but nevertheless we may become quite good at predicting the weather. computational science as an interdisciplinary field develops concepts, methods and tools to mathematically model and analyze complex problems and systems. it is, by itself, rather content-free. computational approaches have been successfully used in neuro‐ sciences for a long time (sejnowski, koch, & churchland, 1988; huys, maia, & frank, 2016) and have been promoted in psychiatry (friston, stephan, montague, & dolan, 2014; petzschner, 2017) and psychosomatics (petzschner, weber, gard, & stephan, 2017). com‐ putational approaches are advocated, for example, to bridge the gap between neural pat‐ tern activity and behavioral data (stephan & mathys, 2014), to improve (data-driven) phe‐ notyping of patients (patzelt, hartley, & gershman, 2018), and to develop, test and im‐ prove theoretical explanatory models through simulation (lehnen et al., submitted). a re‐ cent first attempt at the latter approach, combining mathematical formulization of an ex‐ isting explanatory model with experiments, has proven useful to deepen our understand‐ ing of the complex mechanisms underlying persistent physical symptoms (lehnen, schröder, henningsen, glasauer, & ramaioli, 2019). how relevant is this for clinical psychology in practice? several important new devel‐ opments will probably force us to go in this direction. first, ecological momentary assess‐ ments will undoubtedly become increasingly standard to measure self-reported variables of cognitive and affective processes and social interactions while they are occurring. sec‐ ond, it will increasingly become standard to concurrently collect psychophysiological and behavioral data through unobtrusive body sensors. both sources of information in real life will generate large multilevel sets of data per person in multiple conditions. since clinical psychology is primarily concerned with care for an individual patient in a partic‐ ular context, this is exactly the kind of data that is relevant for personalized care. individ‐ ualized functions comprising deterministic and stochastic variables that model observa‐ tions registered across multiple occasions in multiple relevant contexts actually represent a theory of an individual that may act as an empirically based tool to expect/predict (and understand) behavior. in addition, such functions can be used to assess step by step change over time in a therapeutic process. aggregation of single-case data may enable us to generalize and develop data-driven models and theories and/or to test and refine exist‐ ing theoretical models. such an approach, which has already been successfully applied in other clinical specialties (for a recent example see glasauer, dieterich, & brandt, 2018), editorial 2 clinical psychology in europe 2019, vol.1(3), article e39237 https://doi.org/10.32872/cpe.v1i3.39237 https://www.psychopen.eu/ turns the current situation upside down: rather than using heuristics that are based on experiments to intuitively predict/understand behavior of an individual patients in a par‐ ticular context, the reverse sequence might result in quite different models that, for ex‐ ample, attribute much more weight to contextual variables. obviously, this may require clinical psychologists to be trained in a completely different way, as well as may require much more interdisciplinary collaboration. references friston, k. j., stephan, k. e., montague, r., & dolan, r. j. 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(2014). computational approaches to psychiatry. current opinion in neurobiology, 25, 85-92. https://doi.org/10.1016/j.conb.2013.12.007 van den bergh & lehnen 3 clinical psychology in europe 2019, vol.1(3), article e39237 https://doi.org/10.32872/cpe.v1i3.39237 https://doi.org/10.1016/s2215-0366(14)70275-5 https://doi.org/10.1007/s00415-018-8909-5 https://doi.org/10.1038/nn.4238 https://doi.org/10.1016/bs.pbr.2019.02.006 https://doi.org/10.1017/pen.2018.14 https://doi.org/10.1016/j.bpsc.2017.03.003 https://doi.org/10.1016/j.biopsych.2017.05.012 https://doi.org/10.1126/science.3045969 https://doi.org/10.1016/j.conb.2013.12.007 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. editorial 4 clinical psychology in europe 2019, vol.1(3), article e39237 https://doi.org/10.32872/cpe.v1i3.39237 https://www.psychopen.eu/ post-event processing after embarrassing situations: comparing experience sampling data of depressed and socially anxious individuals research articles post-event processing after embarrassing situations: comparing experience sampling data of depressed and socially anxious individuals jasmin čolić a , anna latysheva a, tyler r. bassett a, christian imboden b, klaus bader c, martin hatzinger d, thorsten mikoteit de, andrea hans meyer f, roselind lieb f, andrew t. gloster g §, jürgen hoyer a § [a] institute of clinical psychology and psychotherapy, technische universität dresden, dresden, germany. [b] private clinic wyss, muenchenbuchsee, switzerland. [c] centre for psychosomatics and psychotherapy, psychiatric hospital, university of basel, basel, switzerland. [d] psychiatric services solothurn, solothurn, switzerland. [e] centre for affective, stress and sleep disorders, psychiatric hospital, university of basel, basel, switzerland. [f] division of clinical psychology and epidemiology, department of psychology, university of basel, basel, switzerland. [g] division of clinical psychology and intervention science, department of psychology, university of basel, basel, switzerland. §these authors contributed equally to this work. clinical psychology in europe, 2020, vol. 2(4), article e2867, https://doi.org/10.32872/cpe.v2i4.2867 received: 2020-02-25 • accepted: 2020-11-01 • published (vor): 2020-12-23 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: jasmin čolić, technische universität dresden, institute of clinical psychology and psychotherapy, hohe str. 53, d-01187 dresden (germany). phone: +49 176 80834539. e-mail: jasmin.colic@tudresden.de supplementary materials: materials [see index of supplementary materials] abstract background: post-event processing (pep) after social interactions (sis) contributes to the persistence of social phobia (sp). this study investigated whether pep as a transdiagnostic process also occurs in major depressive disorder (mdd) and controls. we also tested to what extent pep was explained by trait levels of social anxiety (sa) or depression. method: for seven days, a total of n = 165 patients (n = 47 sp, n = 118 mdd) and n = 119 controls completed five surveys per day on their smartphones. event-based experience sampling was used. pep was assessed following subjective embarrassment in sis with two reliable items from the postevent processing questionnaire. data were analysed via multilevel regression analyses. results: individuals with sp or mdd experienced more embarrassing sis than controls and, accordingly, more pep. the relative frequency of pep after embarrassing sis was equally high in all groups (86-96%). the groups did not differ regarding the amount of time pep was experienced. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i4.2867&domain=pdf&date_stamp=2020-12-23 https://orcid.org/0000-0001-8504-9898 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ after controlling trait depression, embarrassment occurred more frequently only in sp compared to controls. when controlling trait sa, between-group differences in indications of embarrassment, and consequently in pep, dissipated. conclusions: pep could be interpreted as a common coping strategy among all individuals, while more frequent embarrassment might be specific for clinical groups. embarrassment was primarily driven by sa. the alleviation of sa could lead to the reduction of embarrassment and, further, of pep. on this basis, a model describing pep in mdd is proposed, while current models of pep in sp are complemented. keywords post-event processing, social anxiety, depression, transdiagnostic processes, embarrassment, experience sampling highlights • individuals with social phobia or major depression experienced more embarrassing social interactions than healthy controls and, accordingly, more post-event processing. • the frequency of post-event rumination within embarrassing interactions was high in all groups (86-96%). • after controlling trait levels of social anxiety, between-group differences in the number of embarrassing situations, and consequently in post-event processing, dissipated. • when controlling trait levels of depression, post-event rumination was higher in social phobia compared to healthy controls and major depression. background social phobia (sp, or social anxiety disorder) is characterised by fear of acting in a way that could cause embarrassment or rejection from others in one or more social situations (apa, 2013). sp is highly persistent and usually has a chronic and stable course (beesdo‐baum et al., 2012; fehm, beesdo, et al., 2008). one of the key processes that contributes to its persistence is post-event processing (pep; brozovich & heimberg, 2008; clark & wells, 1995; hofmann, 2007; rapee & heimberg, 1997). pep refers to ruminative thinking that centres on one’s self-perception and anxious feelings following a social event (abbott & rapee, 2004; clark & wells, 1995). it is highly associated with in-situation anxiety and with avoidance of future social situations (dannahy & stopa, 2007; hofmann, 2007; mellings & alden, 2000; rachman et al., 2000). during pep, the affected individual mentally reviews a previous event in detail, while pondering over thoughts indicative of the belief that he or she was evaluated negatively (abbott & rapee, 2004). this leads to the event being recalled as more negative than it actually was (hofmann, 2007). accordingly, pep serves as a chain link in a vicious cycle in which recollections of past “failures” lead to anticipatory anxiety and to predictions post-event processing in social phobia, major depressive disorder and controls 2 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ of negative evaluation in subsequent social events (mellings & alden, 2000), thus increas‐ ing the probability to avoid such events completely (rachman et al., 2000). therefore, interventions designed to minimise pep were included in prominent treatment protocols for sp (e.g. rapee & heimberg, 1997). because individuals with sp predominantly fear scrutiny by others, social situations in which said persons felt embarrassed or humiliated could bear particular risk for heightened social anxiety (sa) and pep. in social interactions (si), embarrassment usually results from unwanted exposure of a topic or motive that a person would rather keep hidden or concealed from others (crozier, 2001). to avoid such exposure, individuals with sp maintain high self-focused attention, while scanning their environment for impending negative evaluation. they usually detect such signs rapidly, deeming their behaviour as embarrassing (bögels & mansell, 2004; rapee & heimberg, 1997). both negative evalua‐ tion by others (makkar & grisham, 2011) and negative self-evaluation (chen et al., 2013; perini et al., 2006) have been shown to significantly predict pep. thus, embarrassment, as a catalyst for perceived negative evaluation, might significantly contribute to pep. patterns of ruminative thinking such as pep, are however symptomatic for many mental disorders (mcevoy et al., 2010). this is due to shared cognitive and behaviou‐ ral processes underlying a wide range of clinical conditions (ehring & watkins, 2008; harvey et al., 2004). hence, it remains unclear whether pep is specific to only sp. another disorder to which ruminative thinking has a robust and consistent relation‐ ship is major depressive disorder (mdd; mor & winquist, 2002; nolen-hoeksema et al., 2008). in mdd, rumination is defined as a response style that consists of repetitive and negative thinking about causes and implications of depressive symptoms (nolenhoeksema, 1991; nolen-hoeksema et al., 2008). rumination is associated with dysphoric mood in mdd (nolen-hoeksema, 2000; nolen-hoeksema & morrow, 1993), and is predic‐ tive of the onset and duration of future depressive episodes (nolen-hoeksema, 2000; nolen-hoeksema et al., 1993). rumination exacerbates and maintains depression by in‐ terfering with effective problem solving and with instrumental behaviour (lyubomirsky & nolen-hoeksema, 1993, 1995; nolen-hoeksema et al., 2008; pyszczynski & greenberg, 1987). unlike pep in sp though, rumination in mdd is not bound to specific social events, but rather presents a more general, trans-situational style of thinking (mcevoy et al., 2010). also, it revolves around depressive symptoms and themes of loss (nolenhoeksema et al., 2008), while pep in sp is related to social anxiety and thoughts of negative evaluation (kocovski & rector, 2007). however, as patients with mdd exhibit pronounced interpersonal problems as well (e.g. garrison et al., 2012; pemberton & fuller tyszkiewicz, 2016), this opens the possibility that they, just like socially anxious individuals, would also engage in pep after social events. in interpersonal encounters, depressed individuals were shown to be inhibited, reas‐ surance seeking, and less socially skillful (allen & badcock, 2003; l. h. brown et al., 2011; hames et al., 2013; joiner et al., 1999). this leads others to behave towards them in a čolić, latysheva, bassett et al. 3 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ more detached manner during the interaction or to avoid them completely (gotlib et al., 2004; segrin, 2000). rejection by others can lead to feelings of loneliness and heightened dysphoric mood, which ultimately can lead to rumination (hames et al., 2013; heinrich & gullone, 2006). individuals with mdd also have the propensity to process interpersonal reactions in a negative manner, even if they were not inherently harmful (bistricky et al., 2016; joiner et al., 1999). as embarrassing sis are often accompanied by a certain reaction from others, like an evaluative gaze (robbins & parlavecchio, 2006), they could as well be potentially detrimental for individuals with mdd. behaviours like that could be highly ambiguous and be appraised as negative evaluation (gotlib et al., 2004; joiner et al., 1999; trew & alden, 2009). perceived negative evaluation can trigger depressive feelings and successive rumination in individuals with mdd, especially when it is linked to people close to the individual (like family members or partners; anderson et al., 1999; garrison et al., 2012). hence, it can be assumed that feelings of embarrassment in sis, once they are triggered, can produce ruminative thinking in depressed individuals. one major methodological problem of the studies cited is recall bias, which refers to systematic errors during the retrieval of autobiographical episodes (shiffman et al., 2008). recall bias is especially accentuated in individuals prone to ruminative thinking (williams et al., 2007), like individuals diagnosed with sp or mdd. these individuals tend to resort to overgeneral memory (conway & pleydell-pearce, 2000) and tend to have difficulties recalling specific episodes. as a result, research methodologies that limit recall bias are needed. experience sampling method (esm) as a data collection strategy that is anchored in daily life has proven to bypass these limitations (fahrenberg et al., 2007). while pep in sp has successfully been investigated in everyday life (badra et al., 2017; helbig-lang et al., 2016), no study to date has used esm to explore whether pep is a transdiagnostic phenomenon occurring in mdd as well. the findings could advance the understanding of the genesis, the predecessors and the clinical specificity of pep, and shine light on its natural occurrence in everyday life. it would provide insights into social behaviour of individuals with mdd and the transdiagnostic character of pep as well, which could contribute to the development and enhancement of appropriate treatment strategies. on this basis, we explored the frequency and duration of pep after embarrassing sis in patients with sp and mdd, as well as controls without sp or mdd. we derived two main hypotheses. the first hypothesis (h1) concerned between-group differences in fre‐ quency and duration of pep. because pep is primarily linked to sa and social situations (fehm et al., 2007), and because of the higher importance of embarrassment in sp, we hypothesized that the frequency and duration of pep would be significantly higher in sp compared to mdd. due to symptoms of sa or depression being elevated in both mdd and sp, however, we also hypothesized that the frequency and duration of pep would be significantly higher in both clinical groups (sp and mdd) compared to controls. the post-event processing in social phobia, major depressive disorder and controls 4 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ second hypothesis (h2) concerned the contribution of trait sa and trait depression to indications of embarrassment and to pep. due to the previously exemplified relation of dysphoric feelings to interpersonal rejection (e.g. gotlib et al., 2004) we expected that pep in mdd would be primarily driven by trait levels of depression, while pep in sp would be facilitated by trait sa. to test this hypothesis, we analysed between-group differences while partialling out trait sa or trait depression. we expected that after controlling trait depression, pep would remain elevated in sp compared to controls. on the other hand, when controlling trait sa, we expected that pep would remain significantly higher in mdd compared to controls. lastly, in our third hypothesis (h3) we explored if there are differences in embarrassment and pep between the comorbid sp/mdd group and the sp group without mdd as comorbidity, and the mdd group without sp as a comorbid diagnosis. because of elevated levels of both depression and sa, we predicted that pep would be significantly higher in the comorbid group compared to the non-comorbid groups. we tested all our hypotheses in an esm framework to minimise recall bias and to enhance ecological validity. method study design the study was part of a larger project about daily symptom fluctuations in mdd and sp (gloster et al., 2017). data collection was conducted at two research centers, one in switzerland and one in germany. financing was provided by the swiss national science foundation. the study protocol was approved by the ethics committee of the university of basel (approval # ekbb 236/12). participants recruitment and selection criteria participant recruitment and data collection occurred between may 2014 and august 2016 (gloster et al., 2017). patients with sp and mdd were recruited through the outpatient clinics of the research centres, through local practitioners and through internet advertise‐ ments. if the recruited individuals were 18-65 years old, met diagnostic criteria for sp or mdd according to the diagnostic and statistical manual of mental disorders (4th ed., text rev., dsm-iv-tr; apa, 2000), and did not meet any of the exclusion criteria, they were invited to participate in the study. the diagnostic assessments were conducted with the structured clinical interview for dsm-iv axis i disorders (scid-i; first et al., 1997). the exclusion criteria were: current suicidal tendencies, current substance abuse and physical disabilities that prohibited proper use of a smartphone (e.g. an inability to see text on the screen or hear the smartphone’s signal; gloster et al., 2017). the inability to understand german was exclusionary. the controls were recruited through internet advertisements. čolić, latysheva, bassett et al. 5 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ if, according to the scid-i, they did not meet criteria for sp or mdd and were 18-65 years old, while not meeting any exclusion criteria, they were eligible for inclusion. sample size calculation the outpatient clinics, from which the patients were recruited, see an estimated 110 sp and 520 mdd patients per year. thus, the sample size calculation of the overall project (gloster et al., 2017), in which the present study was embedded, was grounded on the assumption that the maximum number of patients with sp that could feasibly be recruited within the study time period would be n = 48. assuming a dropout rate of 5%, this led to an expected number of 45 sp patients to complete the study. this number was used for the power analysis which assumed alpha = .05, power = .8, and a two-sided test for group comparisons on the between-subjects level. based on a medium effect size (d = 0.5), and 45 subjects in the sp group, the sample size necessary to achieve .8 power is 111 subjects in each of the other groups (mdd & controls). assuming a 5% dropout rate, 117 subjects would need to be recruited in each of these two groups. given that we conducted multilevel analyses on the within-subjects level, which usually requires a smaller number of subjects to reach a certain degree of statistical power than the between-subjects level (bellemare et al., 2016; charness et al., 2012), we considered this sample size sufficient for the test of our hypothesis. final sample a total of n = 290 participants were initially included, but n = 6 of them did not complete at least 50% of the esm time points. as an a priori decision (gloster et al., 2017), these participants were removed from the dataset. the final sample size consisted of n = 284 (n = 119 controls; n = 118 with mdd; n = 47 with sp). in the sp group, n = 15 (31.9%) had co-morbid mdd, while n = 29 (24.6%) patients with mdd had co-morbid sp. in controls, n = 9 subjects fulfilled criteria for a clinical diagnosis. the sociodemographic and clinical characteristics of the sample, as well as prevalent diagnoses among controls are presented in table 1. post-event processing in social phobia, major depressive disorder and controls 6 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ table 1 sociodemographic and clinical characteristics of the sample (n = 284) characteristics controls (n = 119) mdd (n = 118) sp (n = 47) age (m, sd) 32.2 (12) 32.7 (12) 28.3 (7.8) female (%) 67.2 66.1 66.0 education (years) (%) 8-10 12.0 21.1 9.3 11-13 53.0 51.4 67.4 14+ 35.0 27.5 23.3 living arrangement (%) alone 30.3 22.9 21.3 family/partner 49.6 60.2 55.3 other 20.2 16.9 23.4 employed (%) 57.1 52.5 38.3 number of diagnoses (%) 0 90.8a 0.0 0.0 1 6.7 45.8 44.7 2 1.7 29.7 27.7 3+ 0.8 24.6 27.7 in therapy (%) 14.3 58.5 46.8 note. controls = control group; mdd = major depressive disorder; sp = social phobia. afollowing diagnoses were prevalent in controls: specific phobia (n = 3), panic disorder (n = 2), anxiety disorder, unspecified (n = 1), obsessive-compulsive disorder (n = 2), agoraphobia with panic disorder (n = 1). measures post-event processing pep was measured with two items from the post-event processing questionnaire (pepq; rachman et al., 2000; german version: fehm, hoyer, et al., 2008): 1. “do you still think about the embarrassing moment from the interaction?”; and 2. “do you have difficulties to forget the embarrassing moment?”. the items were rated on a scale from 0 = not at all to 100 = 100% of the time since the interaction (50 = 50% of the time). the anchors of the scale were changed to percentages because the “percentage of time” approach is preferable to asking for durations, when symptoms lack a clear beginning or end (schimmack et al., 2000). these items were chosen because of their high factor loadings on the first factor (fehm, hoyer, et al., 2008). the german version of the pep-q had an internal consistency of α =.72 in the original translation of the pep-q and α = .90 in the extended version (see fehm, hoyer, et al., 2008). čolić, latysheva, bassett et al. 7 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ sis participants were asked about the number of sis (“since the last inquiry, how many social interactions did you have?”) and the number of meaningful sis (“since the last inquiry, how many of your social interactions were meaningful for you?”) since the last inquiry. they could indicate their answers on a scale from 0 = none to 6 = more than five (1 = one si, 2 = two sis, etc.). if they indicated having at least one meaningful si, they were asked to report about one si that was the most meaningful for them (from then on questions began with “regarding the most meaningful si…”). they were then asked whether they behaved in an embarrassing manner during that si (“regarding the most meaningful si, did you, in your own opinion, in some way behave in an embarrassing manner?”). only if they indicated doing something embarrassing, were they asked about the degree of pep (for survey structure see figure 1). figure 1 survey structure social interaction anxiety scale (sias) the sias is an inventory developed to assess anxiety in sis (mattick & clarke, 1998). it consists of 20 items that depict multiple socially anxious behaviours. the items are rated on a five-point scale. the german version of the sias (stangier et al., 1999) showed high internal consistency (α = .89-.94) across sp and mdd, as well as high test-retest reliability (r = .92) across various samples. post-event processing in social phobia, major depressive disorder and controls 8 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ beck depression inventory ii (bdi-ii) the bdi-ii (beck et al., 1996) is the most widely used measure of depression. it consists of 21 items depicting various dimensions of depression. the german version (hautzinger et al., 2006) that was used in the present study showed sound psychometric properties, exhibiting a high internal consistency (cronbach’s α = .92-.93) and a high test-retest reliability (r = .93). procedure in the overall study project, data were collected over two weeks with observations in seven-day intervals (gloster et al., 2017). time 1 occurred on the first day, time 2 on the eight day and time 3 on the 15th day of the study. the esm took place between time 2 and time 3. both the sias and bdi-ii were assessed as traits at time point 2 before giving out the smartphones (for the complete study design see gloster et al., 2017). participants received a smartphone and were instructed in its use. they were shown how to operate the smartphone, how to recognize the signal tone and how to initiate a survey after a signal. the esm took place for seven days. every day participants completed five surveys on the smartphone screen at fixed times, every three hours, meaning that participants could have completed a maximum of 35 (i.e. 7 x 5) surveys (gloster et al., 2017). prior to receiving the smartphone, participants could decide whether the first survey of the day would be at 10 a.m. or at 11 a.m. the survey would then start on all of the following days at that chosen time. statistical analysis data were analysed with stata statistical software version 14.2. (statacorp, 2015). for the analysis of between-group differences in sis, in indications of embarrassment and in the relative frequency of pep (h1, frequency; exploratory analysis), random effects logistic regression analyses were conducted (rabe-hesketh & skrondal, 2012). for these purposes, both pep variables were recoded. if participants indicated having pep in both items, the answer was coded with 1, and in the opposite case with 0. also, the items assessing the number of overall and meaningful sis were dichotomized (0 = 0, ≥ 1 = 1). to analyse the contributions of trait-social anxiety (sa) and trait-depression to pep (h2), the sias and bdi-ii scores were mean-centred and added as level-2 variables in the previous regression analysis. additionally, we estimated via multilevel mixed effects linear regression analysis (h1, duration) whether groups differed regarding time spent thinking about the event (pep, item 1) and regarding time spent having difficulties to forget the event (pep, item 2). in all estimations, the variable indicating group-affiliation was dummy coded (controls = 0, mdd = 1, sp = 2) and used in the regression analysis as predictor. for comparisons of two groups, the group coded with the lower number was čolić, latysheva, bassett et al. 9 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ used as the reference group (controls in the case of controls vs. mdd and controls vs. sp; mdd in the case of mdd vs. sp). the mentioned analyses were conducted also for comparisons between the “pure” sp (without mdd, coded as 0) and mdd group (without sp, coded as 1) and the comorbid group (mixed sp/mdd; h3). the intercept was specified as random. except for the linear regression analysis, odds ratios with corresponding 95% confidence intervals were calculated as the resulting measures. in all analyses, the p-value was set to .05. results overall, the participants completed 91.8% of the ema-assessments. there were no be‐ tween-group differences in the response rate (see supplemental materials). sis and embarrassment the controls differed from mdd and sp regarding the number of overall sis, while there was no difference between mdd and sp. there were no between-group differences in the number of meaningful sis (see table 2). for a more detailed overview of results see villanueva et al. (2020). the relative frequencies of embarrassing situations within the re‐ ported meaningful interactions were significantly higher in mdd and sp in comparison to controls, while there were no differences between mdd and sp. also, we explored between-group differences in instances of repeated embarrassment on the same day. these were higher in mdd and in sp compared to controls, while mdd and sp did not differ (see table 2). pep after embarrassing sis (h1) frequency when considering only the interactions in which participants felt embarrassed, partici‐ pants indicated thinking repetitively about the interaction (pep item 1) in 95.68% of embarrassing sis (controls: 96.67%; mdd: 96.07%; sp: 94.62%). difficulties to forget the event (pep item 2) were reported in 94.02% of embarrassing sis (controls: 86.67%; mdd: 93.82%; sp: 96.77%). there were neither differences between the groups in the relative frequency of repetitive thoughts (pep, item 1: controls vs. mdd, or = 0.85, p = .888, 95% ci [0.09, 7.70]; controls vs. sp, or = 0.58, p = .646, 95% ci [0.06, 5.69]; mdd vs. sp, or = 0.69, p = .567, 95% ci [0.19, 2.47]), nor in the relative frequency of difficulties to forget the event (pep, item 2: controls vs. mdd, or = 4.57, p = .170, 95% ci [0.52, 40.16], controls vs. sp, or = 7.45, p = .123, 95% ci [0.58, 96.11], mdd vs. sp, or = 1.62, p = .651, 95% ci [0.20, 13.50]). due to elevated indications of embarrassment in sp and mdd compared to controls, it follows that pep would also be higher in the clinical groups. post-event processing in social phobia, major depressive disorder and controls 10 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ to account for imprecisions during the answer selection on the visual analogue scale (e.g. mistakenly marking a low number instead of a 0), we repeated the analyses while recoding the pep variables as 0 when pep ≤ 5% and when pep ≤ 10%. however, no between-group differences were found. results are available upon request. duration the reported duration of pep is presented in table 3. there were no between-group differences. controlling for social anxiety and depression (h2) embarrassment in sis when trait sa was controlled, no differences between mdd and controls were found in indications of embarrassment. when trait depression was controlled, sis were interpreted as embarrassing significantly more in sp compared to controls. the results are shown in table 2. pep after embarrassing sis the between-group differences in the frequency and duration of pep remained non-sig‐ nificant even after controlling for levels of sa and depression of the individual. the results are presented in the supplemental materials. day-level embarrassment and pep we calculated day level embarrassment and pep in the groups and we explored be‐ tween-group differences. controls differed significantly from mdd and from sp in each embarrassment and pep (both variables), while there were no differences between mdd and sp (see table 4). čolić, latysheva, bassett et al. 11 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ ta bl e 2 b et w ee ng ro up d if fe re nc es in r el at iv e fr eq ue nc ie s of in di ca tio ns o f o ve ra ll si s, o f m ea ni ng fu l s is a nd o f e m ba rr as sm en t w ith in r ep or te d in qu ir ie s (n = 2 84 ) va ri ab le c on tr ol s m d d sp c on tr ol s vs . m d d c on tr ol s vs . s p m d d v s. sp rf (% ) rf (% ) rf (% ) o r p* 95 % c i o r p 95 % c i o r p 95 % c i a ny s ia 80 .4 74 .0 72 .6 0. 63 .0 06 [0 .4 5, 0 .8 7] 0. 57 .0 10 [0 .3 7, 0 .8 7] 0.9 0 .62 5 [0 .58 , 1 .38 ] a ny m ea ni ng fu l s ib 84 .9 85 .3 85 .2 1.0 1 .68 2 [0 .73 , 1 .38 ] 1.0 9 .68 2 [0 .72 , 1 .67 ] 1.0 9 .70 2 [0 .71 , 1 .66 ] in di ca tio ns o f e m ba rr as sm en tc 2.1 4 8.9 6 11 .73 4. 78 < .0 01 [2 .5 5, 8 .9 6] 6. 93 < .0 01 [3 .3 5, 1 4. 35 ] 1.4 5 .21 3 [0 .81 , 2 .60 ] re pe at ed e m ba rr as sm en td 3.3 3 14 .04 12 .90 2. 80 .0 05 [1 .0 4, 5 .9 1] 2. 76 .0 06 [1 .0 5, 6 .2 0] 0.2 1 .83 6 [-1 .25 , 1 .54 ] d iff er en ce s i n in di ca tio ns o f e m ba rr as sm en t w hi le co nt ro lli ng fo r tr ai t s oc ia l a nx ie ty 1.8 6 .08 5 [0 .92 , 3 .76 ] – – tr ai t d ep re ss io n – 3. 76 .0 01 [1 .7 7, 7 .9 8] – n ot e. co nt ro ls = co nt ro l s ub je ct s; m d d = m aj or d ep re ss iv e di so rd er ; s p = so ci al p ho bi a; rf (% ) = re la tiv e pe rc en ta ge s. a fr eq ue nc ie s a re re la tiv e to th e to ta l s um o f s oc ia l i nt er ac tio ns : 9 10 5 (d en om in at or s: co nt ro ls = 38 68 , m d d = 3 74 7, sp = 1 49 0) . b fr eq ue nc ie s a re re la tiv e to th e to ta l s um o f m ea ni ng fu l s oc ia l i nt er ac tio ns : 6 96 5 (d en om in at or s: co nt ro ls = 31 11 , m d d = 2 77 2, sp = 1 08 2) . c fr eq ue nc ie s a re re la tiv e to th e to ta l s um o f r ep or ts a bo ut th e m os t m ea ni ng fu l s oc ia l i nt er ac tio n: 4 18 3 (d en om in at or s: co nt ro ls = 79 3, m d d = 1 98 6, sp = 1 40 4) . d fr eq ue nc ie s a re re la tiv e to th e to ta l s um o f i nd ic at io ns o f e m ba rr as sm en t: 30 1 (d en om in at or s: co nt ro ls = 30 , m d d = 1 78 , s p = 93 ). *s ig ni fic an t d iff er en ce s a re b ol d. ta bl e 3 b et w ee ng ro up d if fe re nc es in th e d ur at io n of t im e sp en t e ng ag in g in p os tev en t p ro ce ss in g (n = 2 84 ) va ri ab le c on tr ol s m d d sp c on tr ol s vs . m d d c on tr ol s vs . s p m d d v s. sp m (s e) m (s e) m (s e) z p 95 % c i z p 95 % c i z p 95 % c i pe p, it em 1 35 .50 (5 .47 ) 43 .57 (2 .60 ) 40 .05 (3 .75 ) 1.3 3 .18 2 [-3 .79 , 1 9.9 4] 0.6 9 .49 3 [-8 .45 , 1 7.5 6] -0 .77 .44 0 [-1 2.4 8, 5.4 3] pe p, it em 2 32 .10 (5 .72 ) 43 .68 (2 .78 ) 40 .72 (4 .05 ) 1.8 2 .06 9 [-0 .88 , 2 4.0 6] 1.2 3 .21 9 [-5 .12 , 2 2.3 7] -0 .60 .54 6 [-1 2.5 9, 6.6 7] n ot e. pe p, it em 1 = t im e sp en t t hi nk in g re pe tit iv el y ab ou t t he e m ba rr as sin g ev en t; pe p, it em 2 = t im e sp en t h av in g di ffi cu lti es to fo rg et th e em ba rr as sin g ev en t; co nt ro ls = co nt ro l g ro up ; m d d = m aj or d ep re ss iv e di so rd er ; s p = so ci al p ho bi a. post-event processing in social phobia, major depressive disorder and controls 12 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ ta bl e 4 b et w ee ng ro up d if fe re nc es in d ay l ev el s of e m ba rr as sm en t a nd p os tev en t p ro ce ss in g (n = 2 84 ) va ri ab le c on tr ol s m d d sp c on tr ol s vs . m d d c on tr ol s vs . s p m d d v s. sp m (s d ) m (s d ) m (s d ) z p 95 % c i z p 95 % c i z p 95 % c i em ba rr as sm en t 0.0 3 (0 .20 ) 0.2 1 (0 .55 ) 0.2 9 (0 .60 ) 5. 16 < .0 01 [0 .1 1, 0 .2 5] 5. 30 < .0 01 [0 .1 6, 0 .3 4] 1.4 1 .16 [-0 .03 , 0 .15 ] pe p1 0.0 3 (0 .19 ) 0.2 0 (0 .54 ) 0.2 7 (0 .59 ) 5. 09 < .0 01 [0 .1 1, 0 .2 4] 5. 06 < .0 01 [0 .1 4, 0 .3 2] 1.2 1 .22 [-0 .03 , 0 .14 ] pe p2 0.0 3 (0 .18 ) 0.2 0 (0 .54 ) 0.2 8 (0 .58 ) 5. 10 < .0 01 [0 .1 1, 0 .2 4] 5. 29 < .0 01 [0 .1 5, 0 .3 3] 1.4 4 .15 [-0 .02 , 0 .15 ] n ot e. pe p, it em 1 = t im e sp en t t hi nk in g re pe tit iv el y ab ou t t he e m ba rr as sin g ev en t; pe p, it em 2 = t im e sp en t h av in g di ffi cu lti es to fo rg et th e em ba rr as sin g ev en t; co nt ro ls = co nt ro l g ro up ; m d d = m aj or d ep re ss iv e di so rd er ; s p = so ci al p ho bi a. čolić, latysheva, bassett et al. 13 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ we also explored associations between embarrassment and both pep variables on the day level. both variables significantly predicted embarrassment: repetitive thoughts, β = 0.58, p < .001, 95% ci [0.56, 0.60]; difficulties to forget the event, β = 0.43, p < .001, 95% ci [0.42, 0.45]. controlling for co-morbidities between mdd and sp (h3) to investigate the contribution of co-morbidity, we divided the groups into patients with mdd and no sp as a co-morbid diagnosis (= mdd/nosp), patients with sp and no mdd as a co-morbid diagnosis (= sp/nomdd) and patients with mixed mdd and sp (= mixed/mdd/sp). we then analysed differences between these groups in indications of embarrassment as well as in the duration and frequency of both pep items. no between-group differences were found regarding any of these variables. results are presented in the supplemental materials. discussion the findings highlight the high incidence of pep in individuals with sp and mdd, as well as controls, whenever a situation is perceived as embarrassing. the comprehensive nature of pep and its close ties to embarrassment are best reflected in its consistently high rates across all groups. at least 86% of all participants, irrespective of their diagnos‐ tic status, reported pep following an embarrassing si. the groups differed regarding neither its relative frequency nor its duration. these findings must be interpreted with caution, as we do not know the specific content of those repetitive thoughts in clinical groups and controls. while the clinical groups may have reinforced their dysfunctional cognitions, the controls might have focused more on coping with the embarrassing moment. however, while repetitive thinking about a recent embarrassing event seems to be common to all individuals, the more frequent indications of the event as being embarrassing in the first place might be specific for sp and mdd. thus, we can argue that the repetitive thoughts or difficulties to forget the embarrassing moment are not unusual, but rather the contextual processes preceding and laying foundation for their emergence, like the higher occurrence of subjective embarrassment. this was evident in the repeated embarrassment and the day-levels of embarrassment as well. one explanation may be that individuals with sp and mdd engage in misappraisals of the situation. such misappraisals are driven by high sa, characteristic not just for socially anxious but depressed individuals as well (e.g. t. a. brown et al., 2001), as between-group differences in indications of embarrassment dissipated after holding sa constant. this is in line with existing research of self-perception and cognitive biases related to sa. individuals with elevated levels of sa scrutinise their behaviour and un‐ derestimate how well they appear to others (mansell & clark, 1999). they are especially post-event processing in social phobia, major depressive disorder and controls 14 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ sensitive to threat cues and are more likely to interpret ambiguous reactions as evidence of negative social evaluation (heinrichs & hofmann, 2001; stopa & clark, 2000). an alternate explanation is that individuals with sp or mdd actually behave in more embarrassing ways due to a potential lack of social competence or due to the use of open or covert safety behaviours and concerns about their appearance (e.g. moscovitch et al., 2013). empirical data make this explanation, however, less probable as individuals with high social anxiety tend to be more biased in their evaluation of their own performance than in their social competence per se (alden & wallace, 1995; stopa & clark, 2000). accordingly, we can assume that heightened sa contributes to an event more likely to be perceived as embarrassing by the individual. however, once feelings of embar‐ rassment are activated, they can produce subsequent ruminative patterns irrespective of the diagnostic status. when trait sa is low, the indications of embarrassment, and consequently pep, are reduced to non-clinical levels. nonetheless, because of the high‐ er occurrence of repeated embarrassment and day-level embarrassment in the clinical groups, day-level pep was also significantly increased compared to controls. we can draw on these findings to propose a model of pep in mdd and to complement previous research on the formation of pep in sp. considering our analyses, in mdd both depressive and socially anxious states func‐ tion as catalysts for pep, but only symptoms of sa are a prerequisite to experience pep. hence, the following cycle can be proposed: heightened levels of sa in mdd might lead to more social events being interpreted as embarrassing. once embarrassment is experienced, the ongoing ruminations in depressed individuals, which are more general and encompass various areas of life (mcevoy et al., 2010; nolen-hoeksema et al., 2008), might include social encounters as a subject matter too, so that pep arises. on the other hand, if sa is low in mdd, it can be argued that social events might drop out as a possible content of ruminations, thus reducing the frequency of pep. however, it is not clear from our data what the content of these ruminations was, because only the frequency and duration of pep was assessed. while the quantity of pep might have been the same, just as with sis in previous research (baddeley et al., 2013; nezlek et al., 2000), the “quality” (i.e. content, affectivity) might have differed. according to previous research, it is reasonable to assume that in mdd the content consists of interpersonal rejection and accompanying beliefs of being less valuable (dill & anderson, 1999; gotlib et al., 2004; segrin, 2000). to explore this possibility, additional research investigating the cognitive content of pep in mdd is needed. in relation to sp, our results imply that sa and the heightened probability of pep are mediated through feelings of embarrassment. this is consistent with previous findings that negative self-perception mediates the relationship between sa and pep (perini et al., 2006). the present study expands those findings to other diagnoses, as well as to healthy individuals. on this basis, we can argue that sa is a marker that facilitates negative self-perception, which then enhances feelings of embarrassment and ultimately pep. čolić, latysheva, bassett et al. 15 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ a treatment approach for pep could comprise interventions correcting for maladap‐ tive interpretations that act as its precursor. thus, by minimising the (mis-) perceptions of embarrassment during sis, it can be argued that the probability of subsequent pep might significantly be reduced. another strategy would be meta-cognitive therapeutic interventions correcting for the subsequent ruminations (wells, 2009). also, we found that patients with mdd or sp indicated less frequently having had any si since the last inquiry than controls. this might reflect the social difficulties of the clinical groups (e.g. l. h. brown et al., 2011; chen et al., 2013). however, the groups did not differ in indications of meaningful sis. this could reflect the importance of social values compared to other values for patients with mdd and sp. patients tend to exhibit value-consistent behavior in social life areas, which could lead them into sis that are meaningful to them (wersebe et al., 2017). limitations and outlook the question remains whether the contents of those ruminations were maladaptive as well, since we only inquired if repetitive thinking occurred and if individuals had difficul‐ ties forgetting the events. it is possible that the controls focused on coping with the event and reframing the embarrassing moment in a positive way, while the clinical groups focused on negative evaluation or self-worthlessness. to discriminate between controls and clinical groups, as well as between specific cognitive biases in sp and mdd, future research should include additional items exploring the content of ruminative thoughts. an additional limitation is the use of only two items to measure pep, which makes our assessment highly specific. future studies should include a questionnaire that encom‐ passes multiple dimensions of pep and ideally a cut-off score for clinically significant severity of pep. that would allow us to explore whether the incidence rates of pep remain equally high in controls as in the clinical groups. it could as well be possible that the current pep measure is not sensible enough to detect differences between clinical groups and controls. even though we assessed the duration of pep as well and did not find differences between groups, an option in future research could be the inclusion of multiple pep measures. also, the nested structure of the survey allowed for explorations of pep only within the most meaningful si in which also feelings of embarrassment were experienced. this is due to the study being embedded within a large research project that explores a variety of transdiagnostic phenomena with multiple measures and across multiple disor‐ ders (gloster et al., 2017). while this strategy provides an abundance of insights across multiple domains, some questions regarding pep remain open. most notably, it remains unclear how often pep occurs across other sis (vs. the most meaningful) during the day. future esm studies constructed specifically for the investigation of pep should explore these research questions. post-event processing in social phobia, major depressive disorder and controls 16 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://www.psychopen.eu/ lastly, as the present study put the importance of embarrassment forward, it would be intriguing to explore further emotion and thought patterns following embarrassing sis. since this goes beyond the scope of the present article, it should be also a matter of future esm studies. conclusions the main conclusions of the study were that patients with sp and mdd had equal dura‐ tions and frequencies of pep as controls, but more frequent indications of embarrassment in meaningful sis than controls. the indications of embarrassment were primarily driven by trait social anxiety. the limitations notwithstanding, the investigation clearly demonstrated that sa and embarrassment (as a potential mediator) can be considered important psychological mechanisms behind pep in sp and in mdd. by implementing esm, responses are ecolog‐ ically valid and less biased than in questionnaire or laboratory research. funding: this work was supported by the swiss national science foundation [grant/award number: 100014_149524/1 and pp00p1_163716/1], awarded to andrew t. gloster. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. author note: prof. dr. a. gloster and prof. dr. j. hoyer planned and conducted this study in close collaboration and function as shared senior authors. supplementary materials the supplementary materials contain the following sections (for access see index of supplementa‐ ry materials below): • section x1 = between-group differences in the occurrence of post-event processing after embarrassing social interactions after controlling for social anxiety and depression • section x2 = differences in embarrassment, and the frequency and duration of post-event processing between the exclusive sp and mdd groups and the comorbid sp/mdd group • section x3 = differences in completed ema-assessments index of supplementary materials čolić, j., latysheva, a., bassett, t. r., imboden, c., bader, k., hatzinger, m., . . . hoyer, j. (2020). supplementary materials to "post-event processing after embarrassing situations: comparing experience sampling data of depressed and socially anxious individuals" [additional information]. psychopen. https://doi.org/10.23668/psycharchives.4429 čolić, latysheva, bassett et al. 17 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://doi.org/10.23668/psycharchives.4429 https://www.psychopen.eu/ references abbott, m. j., & rapee, r. m. (2004). post-event rumination and negative self-appraisal in social phobia before and after treatment. journal of abnormal psychology, 113(1), 136-144. https://doi.org/10.1037/0021-843x.113.1.136 alden, l. e., & wallace, s. t. (1995). social phobia and social appraisal in successful and unsuccessful social interactions. behaviour research and therapy, 33(5), 497-505. https://doi.org/10.1016/0005-7967(94)00088-2 allen, n. b., & badcock, p. b. t. 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(2007). autobiographical memory specificity and emotional disorder. psychological bulletin, 133(1), 122-148. https://doi.org/10.1037/0033-2909.133.1.122 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. čolić, latysheva, bassett et al. 23 clinical psychology in europe 2020, vol.2(4), article e2867 https://doi.org/10.32872/cpe.v2i4.2867 https://doi.org/10.1007/s41347-019-00121-x https://doi.org/10.1016/j.jcbs.2016.11.005 https://doi.org/10.1037/0033-2909.133.1.122 https://www.psychopen.eu/ post-event processing in social phobia, major depressive disorder and controls (introduction) background method study design participants measures procedure statistical analysis results sis and embarrassment pep after embarrassing sis (h1) controlling for social anxiety and depression (h2) controlling for co-morbidities between mdd and sp (h3) discussion limitations and outlook conclusions (additional information) funding competing interests acknowledgments author note supplementary materials references coping in the emergency medical services: associations with the personnel’s stress, self-efficacy, job satisfaction, and health research articles coping in the emergency medical services: associations with the personnel’s stress, self-efficacy, job satisfaction, and health roberto rojas 1 , maxi hickmann 1 , svenja wolf 1, iris-tatjana kolassa 2 , alexander behnke 2 [1] university psychotherapeutic outpatient clinic, institute of psychology and education, ulm university, ulm, germany. [2] clinical and biological psychology, institute of psychology and education, ulm university, ulm, germany. clinical psychology in europe, 2022, vol. 4(1), article e6133, https://doi.org/10.32872/cpe.6133 received: 2021-02-12 • accepted: 2022-01-16 • published (vor): 2022-03-31 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: roberto rojas, university psychotherapeutic outpatient clinic, institute of psychology and education, ulm university, schaffnerstraße 3, 89073 ulm, germany. phone: +49/731-50 31601, fax: +49/731-50 1231601. e-mail: roberto.rojas@uni-ulm.de supplementary materials: materials [see index of supplementary materials] abstract background: emergency medical services personnel (emsp) are recurrently exposed to chronic and traumatic stressors in their occupation. effective coping with occupational stressors plays a key role in enabling their health and overall well-being. in this study, we examined the habitual use of coping strategies in emsp and analyzed associations of coping with the personnel’s health and well-being. method: a total of n = 106 german red cross emsp participated in a cross-sectional survey involving standardized questionnaires to report habitual use of different coping strategies (using the brief-cope), their work-related stress, work-related self-efficacy, job satisfaction, as well as mental and physical stress symptoms. results: a confirmatory factor analysis corroborated seven coping factors which have been identified in a previous study among italian emergency workers. correlation analyses indicated the coping factor “self-criticism” is associated with more work-related stress, lower job satisfaction, and higher depressive, posttraumatic, and physical stress symptoms. although commonly viewed as adaptive coping, the coping factors “support/venting”, “active coping/planning”, “humor”, “religion”, and “positive reappraisal” were not related to health and well-being in emsp. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6133&domain=pdf&date_stamp=2022-03-31 https://orcid.org/0000-0003-2144-7832 https://orcid.org/0000-0002-8414-3812 https://orcid.org/0000-0001-7847-1847 https://orcid.org/0000-0002-4128-9627 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ exploratory correlation analyses suggested that only “acceptance” was linked to better well-being and self-efficacy in emsp. conclusion: our results emphasize the need for in-depth investigation of adaptive coping in emsp to advance occupation-specific prevention measures. keywords emergency medical services, coping strategies, stress, job satisfaction, work-related self-efficacy highlights • previously reported seven factor structure of briefcope was confirmed in german ems personnel. • adaptive coping factors (e.g., support/venting) are not linked to better health and well-being. • self-criticism correlates with lower job satisfaction, higher stress, and more stress symptoms. • acceptance is associated with less stress symptoms and higher self-efficacy. emergency medical services personnel (emsp) are recurrently confronted with traumat­ ic events during medical rescue missions and undergo adverse working conditions such as shiftwork, time pressure, insufficient sleep, and social conflicts (donnelly & siebert, 2009; karutz et al., 2013; sterud et al., 2006). these factors pose a high emotional stress on emsp (johnson et al., 2005; karrasch et al., 2020; schmid et al., 2008), which can compromise their job satisfaction (boudreaux et al., 1997; portero de la cruz et al., 2020; sterud et al., 2011) and may trigger mental health problems, including depression, posttraumatic stress disorder (ptsd), and alcohol abuse (berger et al., 2012; kleim & westphal, 2011; petrie et al., 2018; sterud et al., 2006; s. l. wagner et al., 2020) as well as physical health problems (aasa et al., 2005; bentley & levine, 2016; friedenberg et al., 2022; hegg-deloye et al., 2014). to maintain their health and work capacity, emsp are required to employ effective strategies to cope with chronic stress and recurrent exposure to traumatic events on duty (arble & arnetz, 2017; karrasch et al., 2020). coping is defined as a person’s effort to deal with external or internal demands that are perceived as stressful or possibly exceed the individual’s resources (lazarus & folkman, 1984). research has described various strategies to cope with stress. some of them such as social support seeking, acceptance, and positive reappraisal are viewed as adaptive in reducing stress and benefiting health and well-being (holton et al., 2016; moritz et al., 2016). conversely, strategies involving self-criticism, denial, dissociation, and avoidance are viewed as maladaptive for stress management and can lead to impaired health and well-being (holton et al., 2016; prati & pietrantoni, 2009). coping strategies in emergency medical services 2 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ in the context of their work, emsp and other frontline workers are confronted with high emotional demands and physical stressors due to shift work, time pressure, high responsibility, and recurrent traumatic event exposure. as a result, emsp may find certain coping strategies not helpful in handling their work-related demands, although in other contexts, the same strategies may be highly adaptive, and vice versa. in this line, growing evidence shows that coping strategies may differ in their actual adaptiveness depending on the context of their application (cheng et al., 2014; folkman & moskowitz, 2004; levy-gigi et al., 2016). “maladaptive” coping in emsp there is consistent evidence that “maladaptive” coping strategies are linked to poorer well-being and health in emsp. self-criticism is linked to more burnout, compassion fatigue, depression, and ptsd symptoms, and lower compassion satisfaction (boland et al., 2019; boudreaux et al., 1997; cicognani et al., 2009; kirby et al., 2011; prati et al., 2011). furthermore, avoidant coping such as substance (ab)use and denial was linked to poorer mental health outcomes in the long-term such as elevated ptsd symptoms (arble & arnetz, 2017; cicognani et al., 2009; kerai et al., 2017; kirby et al., 2011; leblanc et al., 2011; portero de la cruz et al., 2020; regehr et al., 2002). despite negative consequences, emsp engage in avoidant coping because these strategies allow to instantly alleviate emotional strain (levy-gigi et al., 2016; regehr et al., 2002). for example, it was shown that emsp use emotional avoidance after critical mission incidents (figley, 2008). “adaptive” coping in emsp previous studies reported that coping strategies, which are assumed adaptive in the gen­ eral population, show inconsistent or even negative associations with the well-being and health of emsp (cicognani et al., 2009; prati et al., 2011; raynor & hicks, 2019). upon exposure to stressful events, emsp may profit from social support to receive emotional support and relief (alexander & klein, 2001; almutairi & el mahalli, 2020; boland et al., 2019; donnelly & siebert, 2009). in emsp, social support has been associated with lower risk of depressive, burnout, and trauma-related symptoms (boland et al., 2019; essex & scott, 2008; feldman et al., 2021; fjeldheim et al., 2014; guilaran et al., 2018; prati & pietrantoni, 2010; wild et al., 2016). however, other studies found that social support did not moderate the negative influence of stressful mission experiences on ptsd symptoms (c.-m. chang et al., 2008). higher social support was also linked to burnout and compassion fatigue among emsp (cicognani et al., 2009; prati et al., 2011). moreover, emsp may cope actively with stress through focusing on the next step in planning and actively solving problems (boland et al., 2019; regehr et al., 2002). active coping/planning was associated with lower stress levels (brown et al., 2002; jamal et al., 2017) and stronger posttraumatic growth (kirby et al., 2011) in emsp. however, folkman rojas, hickmann, wolf et al. 3 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ and moskowitz (2004) theorized that the effectivity of active coping depends on the controllability of stressors. emsp are regularly confronted with critical mission events and adverse working conditions they cannot fully control. therefore, active coping may be ineffective or possibly counterproductive in certain situations. indeed, previous studies linked active coping to higher levels of stress and burnout in emergency workers (cicognani et al., 2009; prati et al., 2011). it is proposed that humor enables emsp to experience critical situations as less serious and threatening (moran, 2002). healthcare workers who used humor perceived work-related situations less stressful (canestrari et al., 2021), and the use of humor was linked to less ptsd symptoms among firefighters (sliter et al., 2014). however, humor is a very complex construct with various subtypes which may have opposite effects in handling stress (leist & müller, 2013; martin et al., 2003). indeed, humor was also associated with higher burnout levels in emsp (cicognani et al., 2009; prati et al., 2011). as an emotion-focused coping strategy, religion has been linked to less burnout symptoms (boland et al., 2019) and higher levels of posttraumatic growth (ogińska-bulik & zadworna-cieślak, 2018), but also with more burnout symptoms and compassion fatigue in emsp (cicognani et al., 2009; prati et al., 2011). in their concept of posttrau­ matic growth, tedeschi and calhoun (1996) assume increasing spirituality as an adaptive consequence of traumatic experiences. accordingly, positive associations between stress symptoms and religious coping in emsp could indicate emerging posttraumatic growth. moreover, emsp reported to manage their work-related stress through acceptance of negative emotions as well as positive reappraisal (boland et al., 2019; kirby et al., 2011). acceptance was consistently linked to increased posttraumatic growth (kirby et al., 2011; prati & pietrantoni, 2009) and milder posttraumatic stress symptoms in emsp (zhao et al., 2020). positive reappraisal was associated with more burnout and compassion fatigue symptoms (almutairi & el mahalli, 2020; cicognani et al., 2009) but was also related with stronger posttraumatic growth (kirby et al., 2011). adaptive coping and self-efficacy self-efficacy refers to the deep conviction that one has sufficient resources and abilities to cope successfully with adversity (bandura, 1997). self-efficacy determines the individ­ ual’s approach and self-perception when coping with stressors. thereby, it influences ex­ ecution of coping strategies as well as the persistency of coping efforts (bandura, 1997). as a result, self-efficacious individuals experience job stress less threatening, working conditions more positively, and focus more on available resources (e.g., social support) (consiglio, borgogni, alessandri, & schaufeli, 2013). studies in the ems found that personnel with longer work experience report higher self-efficacy, which contributed to less burnout and compassion fatigue as well as more compassion satisfaction (cicognani et al., 2009; groß et al., 2004; prati et al., 2010). in nurses, the beneficial effect of coping strategies in emergency medical services 4 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ self-efficacy on health and well-being was partially mediated through problem-focused coping (chang & edwards, 2015). present study coping behavior of emsp may change with increasing professional experience and/or as a function of the recurrent exposure to stress and traumatic events (essex & scott, 2008). through habituating with their work, emsp will increasingly engage in coping strategies they experience as helpful in alleviating stress in the short-term (figley, 2008). resulting coping habits will conceivably differ from those of the general population as well as of occupations with other demands. therefore, cicognani et al. (2009) explored specific factors of coping strategies in 764 italian emergency workers, including emsp, firefight­ ers, and civil-protection personnel. from the 14 coping strategies assessed with the brief­ cope, an exploratory factor analysis extracted seven coping factors, i.e., support/venting, active coping, positive reappraisal, humor, religion, self-distraction, and self-criticism, which showed complex associations with the personnel’s quality of life and mental health. the coping factor model identified by cicognani et al. (2009) is yet to be confirmed. with this study, we tested whether cicognani et al.’s factor model fits the coping behav­ ior of german emsp. moreover, we hypothesized “maladaptive” coping (e.g., self-distrac­ tion, self-criticism) is linked to higher perceived stress, lower job satisfaction, and more mental and physical stress symptoms. conversely, we expected “adaptive” coping (e.g., support/venting, active coping, positive reappraisal, humor, religion) to be linked to better health and well-being. additionally, we hypothesized that emsp with longer work experience show higher work-related self-efficacy. higher self-efficacy was expected to correlate with higher job satisfaction, lower work-related stress, and fewer mental and physical symptoms. method procedure the authors conducted an in-house training module offered seven times within three months at two ambulance stations of the local german red cross (grc) division. of the division’s 318 employees, 241 attended the training and were invited to participate in this study. interested emsp left their email address, and via email they received the link to the study survey. at the beginning of the survey, participants were informed about the study aims and procedures. a total of 115 employees declared their written informed consent and participated in the survey (46.6% response rate) that assessed sociodemographic characteristics (e.g., age, gender) and exposure to traumatic events, personality traits, mental and physical health conditions as well as coping strategies using standardized questionnaires. the survey also assessed other health-relevant factors rojas, hickmann, wolf et al. 5 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ such as emotion regulation and sense of coherence that were reported in previous studies (behnke, conrad, et al., 2019; gärtner et al., 2019). the survey took approximately one hour for completion. participants received no remuneration. the study protocol was approved by the ulm university ethics committee. participants regarding the variables investigated in this study, complete data were available from n = 106 emsp (63.2% men), presenting 33.3% of the local grc divisions’ total workforce. participating emsp were 18 to 61 years of age, mdn (iqr) = 26 (15.8), and their work experience ranged from one month to 35 years, mdn (iqr) = 3.3 (10.3) years. additional sociodemographic characteristics are detailed in table 1. study participants corresponded well to the entirety of local ems employees in terms of sex, stationing, and ems work experience. small differences occurred regarding employment type and age. measures coping strategies were measured with the 28-item german brief-cope (knoll et al., 2005). the brief-cope subscales’ internal consistency ranged from cronbach’s α = .43–.89. as an exception, the subscale behavioral disengagement showed an inaccepta­ ble internal consistency of α = -.04 (see supplementary materials, table x1, for details). perceived work-related stress was recorded with an ems-specific questionnaire (gärtner et al., 2019). on eight items, participants reported their perceived stress due to alarms, shift work, etc. on a 5-point likert scale anchored at 0 (never experienced) and 4 (very bothering). reponses were aggregated to a sum score (range: 0–32; cronbach’s α = .77). depressive symptoms were measured with the 9-item german patient health ques­ tionnaire scale for depression (phq-9; löwe et al., 2002). responses are recorded on a four-point likert scale ranging from 0 (not at all) to 3 (almost every day) and were aggregated to a sum score (range: 0–27; cronbach’s α = .83). posttraumatic symptoms were assessed with the german ptsd checklist for dsm-5 (pcl-5; krüger-gottschalk et al., 2017). participants were requested to recall their most stressful life event. as previously reported, 53% of the emsp participating in this study encountered their most stressful life events in the line of their duty (behnke, rojas, et al., 2019). with eight qualitative items, the pcl-5 evaluates whether the most stressful life event fulfils the dsm-5 criteria of a traumatic event. on 20 items, participants rated the severity of their posttraumatic stress symptoms on a 5-point likert scale ranging from 0 (not at all) to 4 (very strong). severity ratings were aggregated to a sum score (range: 0–80, cronbach’s α = .91). physical ailments were assessed using the 15-item german patient health question­ naire scale for physical symptoms (phq-15; löwe et al., 2002). the item asking for coping strategies in emergency medical services 6 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ menstrual pain was excluded for reasons of gender comparability. responses are recor­ ded on a 3-point likert scale ranging from 0 (not at all) to 2 (very strong). the sum score of all items represents the severity of physical ailments (range: 0–30, cronbach’s α = .84). table 1 demographic sample characteristics compared to the local ems personnel demographic variable study cohort local ems employees statistical test n % n % test statistic p effect size total 106 33.3# 318 sex – .229 -.061 male 67 63.2 222 69.8 female 39 36.8 96 30.2 ambulance station – 1 -.003 ulm 74 69.8 223 70.1 heidenheim 32 30.2 95 29.9 employment form χ2(2) = 11.51 .003 .165 salaried 80 75.5 198 62.3 voluntary 16 15.1 101 31.8 in apprentice 10 9.4 19 6.0 professional qualification emt–paramedic (“notfallsanitäter”) 64 60.4 – – emt–basic (“rettungssanitäter”) 32 30.2 – – emt–paramedic trainee 10 9.4 – – family status single 50 47.2 – – divorced 8 7.5 – – partnership/married 48 45.3 – – m (sd) mdn m (sd) mdn age [years] 29.8 (10.9) 26.0 32.1 (11.1) 27.5 u = 13906 .007 -.131 ems working experience [years] 7.5 (8.7) 3.3 5.7 (5.5) 3.8 u = 16172.5 .629 -.023 note. #proportion of total staff. population and sample frequency distributions were compared using fisher’s exact tests and χ2 tests, where applicable, and φ as effect-size measure. continuous variables were compared using mann-whitney u-tests using cohen’s r as effect-size measure. rojas, hickmann, wolf et al. 7 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ job satisfaction was evaluated using a subscale of the german michigan organiza­ tional assessment questionnaire (cammann et al., 1979). on three items, participants rated their job satisfaction on a 4-point likert-scale ranging from 1 (strongly disagree) to 4 (strongly agree). responses were combined as sum score (range: 3–12, cronbach’s α = .69). work-related self-efficacy was assessed using the two items of the professional self-ef­ ficacy expectation scale with the highest item-total correlation (schyns & collani, 2014). responses were recorded on a 4-point likert scale ranging from 0 (not at all) to 4 (very strong) and combined to a sum score (range: 0–8, cronbach’s α = .67). statistical analyses statistical analyses were performed in r 3.6.2 (r core team, 2019). to examine whether the factor structure reported in cicognani et al. (2009) fits the present data, a confirmato­ ry factor analysis (cfa) was performed using the lavaan package (rosseel, 2012). as a majority of the brief-cope items did not follow unior multivariate normal distribution (energy test: e = 2.44, p < .001), we used pairwise maximum likelihood (pml) estimators as a computationally less intense alternative to full information maximum likelihood (fiml) (katsikatsou et al., 2012). the absolute χ2 statistic and its p-value (p > .05), the root mean square error of approximation (rmsea ≤ .06) and its 90% confidence interval (ci), and robust versions of the standardized root mean square residual (srmr ≤ .08), the comparative fit index (cfi ≥ .95), and the tucker-lewis index (tli ≥ .95) were used as model fit criteria (hu & bentler, 1999). convergent and discriminant factor validity was examined applying the criteria by fornell and larcker (1981), and bollen’s ω (raykov, 2001) quantified the internal factor consistency. bivariate correlations were analyzed using nonparametric spearman correlations because several variables were not normally distributed. p-values were corrected for multiple testing using the false discovery rate (fdr) (benjamini & yekutieli, 2001). results confirmatory factor analyses all brief-cope subscales were non-normal distributed, and some subscales were strong­ ly right-skewed, that is, these strategies were almost never used by our study cohort (table x1, supplementary materials). this was also observed by cicognani et al. (2009), and in accordance with their procedure, we disregarded the items 3/8 (denial: skew = 2.32), 6/16 (behavioral disengagement: skew = 1.45), and 4/11 (substance use: skew = 2.10) in the cfa. additionally, the scales self-blame (skew = 1.27) and religion (skew = 1.87) displayed a strong right skew in our sample. we nevertheless retained these items to allow testing the adequacy of cicognani et al.’s factor model in our data. coping strategies in emergency medical services 8 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ the cfa revealed the model by cicognani et al. (2009) fits our data relatively well: robust-χ2(5.54) = 9.47, p = .120; cfirob = .926; tlirob = .911; srmrrob = .069; rmsea < .001, 90% ci [.001, .041], prmsea = .988. the first factor (figure 1) comprised the six items of the subscales emotional support, instrumental support, and venting (standardized factor loadings: β = .58–.89, p’s < .001) with an internal factor consistency of ω = .89. figure 1 results of the confirmatory factor analysis examining the fit of cicognani et al.’s (2009) seven-factor model of coping to the data of this study .60 .37 f2 “active coping/planning” item 7 item 2 item 25 item 14 .59 .62 .55 .70 .35 .38 .31 .49 ε ε ε ε f3 “humor” item 18 item 28 .73 .97.93 ε ε .54 f4 “religion” item 22 item 27 .87 .72.52 ε ε .75 f5 “self -distraction” item 1 item 19 .56 .70.50 ε ε .32 f6 “self -criticism” item 13 item 26 .86 .81.66 ε ε .74 f7 “positive reappraisal” item 12 item 17 .36 .76.58 ε ε .13 f1 “support/venting” item 15 item 5 item 23 item 10 .75 .89 .80 .84 .56 .79 .65 .71 ε ε ε ε item 21 item 9 .33 .35 ε ε .59 .58 .40 .28 .54 .85 .48 .65 .51 .42 note. n = 106. values on paths indicate standardized regression coefficients (β) and values on covariance paths indicate significant factor correlations (r). italic values above the items display the explained variance per item (r2). rojas, hickmann, wolf et al. 9 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ the second factor comprised the items of active coping and planning (β = .55–.70, p’s < .001; ω = .71). the third factor presented the humor subscale (β = .73–.97, p’s < .001; ω = .83), the fourth religion (β = .72–.87, p’s < .001; ω = .78), the fifth self-distraction (β = .56–.70, p’s < .001; ω = .58), the sixth self-criticism (β = .81–.86, p’s < .001; ω = .83), and the seventh positive reappraisal (β = .36–.76, p’s < .005; ω = .49). examining the factors’ convergent and discriminant validity (table 2) revealed that support/venting, humor, religion, and self-criticism are clearly distinguishable albeit correlated factors. conversely, the items of active coping/planning share considerable variance with the items of self-distraction and positive reappraisal, indicating that their factors are not clearly separable. as a result, these factors had a low internal factor consistency (see table 2). table 2 indicators of internal factor consistency ω (at diagonal), convergent and discriminant validity along with factor correlations coping factor f1 f2† f3 f4 f5† f6 f7† f1 support/venting .89 .60*** -.17 .37*** .40* .28* .54*** f2 active coping/planning .71 -.04 .19 .85*** .48*** .65*** f3 humor .83 -.16 .22 -.11 .19 f4 religion .78 .02 .06 .28 f5 self-distraction .58 .42** .51** f6 self-criticism .83 .16 f7 positive reappraisal .49 average variance extracted (ave) .576 .380 .709 .650 .420 .705 .354 maximum shared variance (msv) .356 .724 .047 .139 .724 .226 .422 note. an average variance extracted of ave > .50 indicates sufficient convergent factor validity (i.e., more than 50% of the items’ variances converged on their common factor). satisfactory discriminant factor validity is assumed when the maximum shared variance msv < ave. factors indicated with † violate aforementioned criteria. *p < .05. **p < .01. ***p < .001, two-tailed, corrected for multiple testing with fdr. correlation of coping factors with well-being and health correlation analyses (table 3) indicated that support/venting was less used by older emsp, whereas no associations emerged with other studies variables. active coping/plan­ ning, religion, self-distraction, and positive reappraisal were not related to any study variable. in trend, emsp with more work experience also reported more self-criticism (pfdr = .102), and frequent use of self-criticism was positively associated with higher perceived stress, more mental and physical symptoms, and lower job satisfaction. coping strategies in emergency medical services 10 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ ta bl e 3 sp ea rm an r an k c or re la tio ns (n = 1 06 ) c op in g fa ct or a ge se xa em s w or k ex pe ri en ce pc l5 ph q -1 5 ph q -9 pe rc ei ve d st re ss jo b sa ti sf ac ti on b w or kre la te d se lf -e ff ic ac y f1 s up po rt /v en tin g -.2 8* -.0 7 -.0 8 .0 9 -.0 7 -.1 5 .0 7 .1 7 .1 4 f2 a ct iv e co pi ng /p la nn in g .0 5 .0 5 .0 5 .2 3 .0 5 .0 2 .1 6 -.0 7 .1 1 f3 h um or .1 5 .2 4 .1 1 -.0 1 .0 8 .0 9 -.0 3 .0 0 .3 4* f4 r el ig io n -.1 0 -.1 0 .0 0 .2 6 .0 4 .0 0 .1 3 .1 0 -.0 8 f5 s el fdi st ra ct io n .1 1 .1 3 .1 0 .1 6 .0 1 .0 1 .1 0 -.0 5 .2 6 f6 s el fcr iti ci sm .0 9 -.0 2 .2 2 .4 9* ** .3 2* .3 4* .2 7* -.2 7* -.2 2 f7 p os iti ve r ea pp ra is al -.1 0 -.0 2 -.1 0 .1 7 -.0 2 -.0 5 .0 9 .1 2 .1 3 w or kre la te d se lfef fi ca cy .2 1 .2 9* .1 8 -.2 2 -.2 3 -.2 6 -.0 4 .2 4 a po si tiv e co ef fi ci en t i nd ic at e hi gh er v al ue s in m en th an w om en . b tw o m is si ng v al ue s. *p < .0 50 . * ** p < .0 01 , t w ota ile d, c or re ct ed fo r m ul tip le te st in g w ith f d r. rojas, hickmann, wolf et al. 11 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ these associations were also supported by the zero-order correlations between the brief­ cope subscales and the study variables (table x2, supplementary materials). additional­ ly, we observed relevant correlations of the brief-cope’s acceptance subscale, which has been neglected in the cfa in order to test the factor solution reported by cicognani et al. (2009). in detail, emsp in our sample who reported higher acceptance showed less stress-related symptoms (pcl-5: rs = -.21, pfdr = .138; phq-15: rs = -.31, pfdr = .020; phq-9: rs = -.32, pfdr = .018). work-related self-efficacy and coping male (pfdr = .037) and older emsp (pfdr = .102) reported higher work-related self-ef­ ficacy, which was associated in trend with higher job satisfaction (pfdr = .081) and less posttraumatic (pfdr = .101), depressive (pfdr = .053), and physical stress symptoms (pfdr = .090, cf. table 3). moreover, self-efficacy correlated with a conceivably more adaptive coping behavior, in a way that emsp with higher self-efficacy were prone to use less self-criticism in trend (pfdr = .102) as well as more humor (see table 3) and acceptance (rs = .38, pfdr = .002; table x2, supplementary materials). discussion we investigated habitual coping behavior in a cohort of german emsp and its relevance for the personnel’s health and well-being. thereby, we replicated the seven-factor struc­ ture of brief-cope items which has been previously identified by cicognani et al. (2009) in italian emergency workers. among these coping factors, self-criticism showed significant associations with stress, job satisfaction, and stress symptoms of emsp. similar to the italian emergency workers (cicognani et al., 2009), our cohort of german emsp rarely engaged in denial, behavioral disengagement, and substance (ab)use when coping with stress. unlike the italian sample, however, our cohort of emsp almost never coped through religion. cross-cultural studies indicate that reliance on religion in coping with adversity and stress varies across countries (chai et al., 2012; shirazi et al., 2011). therefore, differences in the use of coping strategies between our study cohort and that of cicognani et al. (2009) may result from cultural differences between italian and german rescue personnel. future cross-cultural research should compare coping in frontline workers with different cultural and social background. consistent with cicognani et al. (2009), our cfa corroborated a factor unifying items of support seeking and venting, indicating that emsp seek the support of others to share their unpleasant emotions and find comfort. unexpectedly, this factor was not associated with better health or well-being, adding to previous inconsistent findings on the adap­ tiveness of social support for the well-being of emsp (boland et al., 2019; essex & scott, 2008; feldman et al., 2021; fjeldheim et al., 2014; kleim & westphal, 2011; kshtriya et al., coping strategies in emergency medical services 12 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ 2020; wild et al., 2016). one reason for these heterogeneous findings could be the timing of social support: in their review, wagner at al. (2016) conclude that pre-trauma social support can enhance resilience against ptsd, while post-trauma social support appears to promote posttraumatic growth. conceivably, emsp actively seek social support when feeling particularly stressed, and this adaptive behavior could enable personal growth. moreover, previous research has differently defined and operationalized social support: while we included support and venting into one factor (cf. cicognani et al., 2009), other studies focused on received and/or perceived social support by different groups, e.g., family, colleagues (fjeldheim et al., 2014; wild et al., 2016). as previously reported (essex & scott, 2008), we found that older emsp reported less support seeking and a lower tendency to communicate their feelings. senior emsp with many years of work experience are likely to have encountered more traumatic mission events, and studies showed that after highly aversive missions, a relevant proportion of emsp refrains from talking to their colleagues to avoid showing personal weakness, pos­ sible consequences of perceived mistakes, and “unnecessarily” raising their colleagues’ emotional burden (häller et al., 2009; richter, 2014). this behavior could lead to social distancing and isolation in the long-term. however, in western societies, there is a general trend toward decreasing social support networks across the lifespan (nicolaisen & thorsen, 2017), and social isolation particularly affects men (e.g., gurung, taylor, & seeman, 2003; walen & lachman, 2000). in our cohort, the correlation of higher age and work experience with decreased social support/venting could be specifically pronounced, as the ems has been primarily a “male profession”, and our study participants with longer work experience were almost exclusively men. preventive measures to maintain emsps’ health could aim to impart social and emotional competencies among colleagues and supervisors, establish an institutional support culture, and develop structured profes­ sional counselling interventions for personnel (wild et al., 2020). in this sample, using humor as a coping strategy was not associated with well-being and health. previous evidence on humor in helping profession is mixed. some studies showed, humor allowed perceiving work less stressful (canestrari et al., 2021) and was linked to fewer ptsd symptoms (sliter et al., 2014). other studies linked humor to higher burnout symptoms (cicognani et al., 2009; prati et al., 2011). this inconsistency may originate from different styles of humor which may exert opposite effects in stress coping (leist & müller, 2013). black or “gallows” humor presents a form of emotional avoidance that can help emsp to quickly distance from adverse experiences (moran, 2002). however, in the long-term, black humor may establish cynicism towards their patients in emsp, and this attitude might compromise the emotional support they receive from their family and friends (rowe & regehr, 2010). in this study and previous studies (cicognani et al., 2009; prati et al., 2011), humor was assessed with two items, thus not allowing to differentiate humor styles. future studies are required to investigate the rojas, hickmann, wolf et al. 13 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ role of humor styles more comprehensively to understand its effect on the health and well-being of emsp. in our study, the factors active coping/planning and positive reappraisal were unrela­ ted to emsps’ well-being and health, whereas previous studies linked active coping to reduced stress (brown et al., 2002; jamal et al., 2017; prati et al., 2011) and fewer stress symptoms (kirby et al., 2011). moreover, the inclination to find positive reinterpretations of adverse experiences has been linked to stronger posttraumatic growth (kirby et al., 2011). in our study, however, the factors overlapped with the emsps’ engagement in self­ distraction. this suggests that emsp tend to actively engage in compensatory activities and denying stress through positive reinterpretations in order to distract themselves from work-related stress. unlike the classical view of active coping and positive reappraisal as adaptive stress coping, in emsp, such attempts rather reflect a distraction tendency to achieve short­ term stress relief. in par with this, levy-gigi et al. (2016) reported firefighters engage in distractive strategies to achieve immediate stress relief, although such distractive coping attempts exert counterproductive effects on the regulation of stress in the long-run (cicognani et al., 2009; kirby et al., 2011; leblanc et al., 2011). however, in our study, using these strategies seemed to have no implications for the emsps’ health status and well-being. additional research is required to better distinguish the shortor long-term motives of frontline workers to engage in distractive coping strategies. in addition, active coping aims to overcome a stressful situation through planning and problem solving. thus, the actual effectiveness of this strategy depends on whether stressors are actually controllable and changeable (folkman & moskowitz, 2004). as emsp regularly face adverse situations which they may not be able to control or change, it could be that attempting to actively change uncontrollable problems has no (gärtner et al., 2019) or even opposite implications for the well-being of emsp (cicognani et al., 2009; prati et al., 2011). persistent attempts to find solutions for uncontrollable adversity might even initiate rumination (ayduk & kross, 2010), which is a major risk factor for developing ptsd, depression, and burnout in emsp and firefighters (e.g., bryant & guthrie, 2007; gärtner et al., 2019; wild et al., 2016). correspondingly, our results indicate that engaging in self-critical reflections about one’s actions and feelings is associated with poorer health and well-being in emsp. this result corroborates previous studies implicating self-criticism as a maladaptive coping strategy (boland et al., 2019; boudreaux et al., 1997; cicognani et al., 2009; kirby et al., 2011; prati et al., 2011). self-criticism involves repetitive negative evaluations of one’s own abilities and decisions. in this sense, it is closely related to rumination as the tendency to repeatedly focus mentally on negative emotional experiences as well as their causes and consequences (james et al., 2015). longitudinal studies are warranted to assess self-criticism and rumination in the prospect of health and well-being in emsp. coping strategies in emergency medical services 14 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ beyond the coping factors reported by cicognani et al. (2009), the briefcope subscale acceptance was linked to higher self-efficacy and better well-being in emsp. this result suits previous findings and meta-analyses which established acceptance as highly adap­ tive in retaining health upon adverse experiences (aldao et al., 2010; kirby et al., 2011; schäfer et al., 2017; zhao et al., 2020). acceptance-related elements are featured in several evidence-based therapeutic approaches (e.g., mentalization-based therapy, bateman & fonagy, 2012; acceptance and commitment therapy, hayes, 2016), and initial research on stress-preventive trainings in emsp indicates that imparting strategies to differentiate, name, and accept unpleasant feelings can decrease symptoms of burnout and emotional exhaustion (buruck & dörfel, 2018). bandura (1997) theorized self-efficacy enhances stress resilience through influencing which and how persistently coping strategies are executed upon stress. accordingly, self-efficacy was positively linked to problem-focused and active coping and negatively linked to emotion-focused coping in nurses (chang & edwards, 2015). our findings partially corroborate this perspective, as we found emsp with higher self-efficacy to use less self-criticism when coping with stress. however, self-efficacy was not linked to strategies such as coping/planning or support/venting. instead, it was linked to acceptance and humor presenting rather emotion-focused coping strategies. moreover, in line with previous studies in the ems (behnke, conrad, et al., 2019; cicognani et al., 2009; groß et al., 2004; prati et al., 2010, 2011), personnel with longer work experience reported higher self-efficacy, and higher self-efficacy was associated with higher job satisfaction and fewer physical and depressive symptoms in trend. future research could aim to comprehensively examine the nature and relationship of self-efficacy, acceptance, humor, and self-criticism/rumination with health and well-being in frontline workers. limitations and future directions studies did not conclude on a unique hierarchical structure of the coping strategies assessed with the brief-cope (hanfstingl et al., 2021; solberg et al., 2021). therefore, we decided to test the adequacy of the factor solution explored by cicognani et al. (2009) and were able to replicate the factor structure. however, additional reliability analyses showed that some of the extracted factors overlap, which compromises their factor reliability. our sample size is rather small for conducting cfa, and future studies should aim to recruit larger samples. moreover, simulation studies demonstrated that drawing reliable conclusions about model-to-data fit in cfa is not trivial, as hu and bentler’s (1999) criteria may lead to unreliable results (beierl et al., 2018; heene et al., 2011). compared to previous studies in the ems, the response rate in our study (46.6%) is in the upper range (brown et al., 2002; fritz & sonnentag, 2005). nevertheless, general­ izability of our findings is limited by convenience sampling. results may be biased by differences between study participants and non-participants; i.e., emsp with more stress symptoms and/or socially inappropriate coping behaviors (e.g., substance abuse) were rojas, hickmann, wolf et al. 15 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ perhaps unmotivated or avoided participation (non-response bias; bortz & döring, 2004). emsp who were unable to work or had changed their profession due to severe stress-re­ lated health problems could not be included in the study. this may lead to biased results, as highly stressed personnel might use less effective coping strategies (healthy-worker effect; costa, 2003). future studies should compare coping habits of emsp capable to work and those with work-related health problems. limitations in validity could result from retrospective recall errors (jonkisz et al., 2012). that is, emsp remembered stressful events but did not associate them with specific cop­ ing strategies, or they are completely unaware of using certain strategies. moreover, the study’s cross-sectional correlative design does not allow causal or predictive conclusions. longitudinal research is required to better characterize the interplay of coping, stress exposure, and well-being through high-frequency measurements, for example, on a daily basis using mobile phone applications. such “ecological momentary assessments” enable identifying coping behaviors with prospective relevance in handling daily occupational stressors and traumatic mission events in the ems. conclusions effective coping with occupational stressors is pivotal for retaining health and well-being in emergency workers. with this cross-sectional study in german emsp, we confirmed seven coping factors that were previously identified by cicognani et al. (2009) in italian emergency workers. among these coping factors, only self-criticism was significantly as­ sociated with the emsps’ work-related stress, job satisfaction, and well-being. addition­ ally, exploratory correlations indicated that using acceptance was potentially beneficial for the self-efficacy and well-being of emsp. our findings implicate investigating the use and relevance of self-criticism and acceptance in prospective longitudinal designs. determining the relevance of certain coping strategies regarding health and well-being is key to developing occupation-tailored preventive interventions. coping strategies in emergency medical services 16 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://www.psychopen.eu/ funding: this study was supported by the german red cross (deutsches rotes kreuz), rescue service heidenheimulm ggmbh. acknowledgments: we thank suchithra varadarajan for proof reading. competing interests: the authors have declared that no competing interests exist. author contributions: rr, ab, and itk developed the study concept. rr and ab conducted the study setup and data collection. ab and mh performed the statistical analysis. rr, mh, sw, and ab drafted the paper under supervision of itk. all authors contributed to the interpretation of data, critically revised the manuscript, and approved the final version of the paper for submission. data availability: the datasets for this manuscript are not publicly available because we do not have the consent of the ethics committee or our participants to grant any form of access to or insight in all or parts of the collected data. supplementary materials supplementary tables presenting: descriptive statistics, internal consistencies, and univariate nor­ mality assessment of brief-cope subscales (table x1), and spearman correlations between brief­ cope subscales and the other study variables (table x2) (for access see index of supplementary materials below). index of supplementary materials rojas, r., hickmann, m., wolf, s., kolassa, i.-t., & behnke, a. 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(2020). self-acceptance, post-traumatic stress disorder, posttraumatic growth, and the role of social support in chinese rescue workers. journal of loss and trauma, 25(3), 264–277. https://doi.org/10.1080/15325024.2019.1672935 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. rojas, hickmann, wolf et al. 25 clinical psychology in europe 2022, vol. 4(1), article e6133 https://doi.org/10.32872/cpe.6133 https://doi.org/10.1002/jts.2490090305 https://doi.org/10.1080/10926771.2016.1152341 https://doi.org/10.1037/trm0000251 https://doi.org/10.1177/0265407500171001 https://doi.org/10.1080/00332747.2020.1750215 https://doi.org/10.1017/s0033291716000532 https://doi.org/10.1080/15325024.2019.1672935 https://www.psychopen.eu/ coping strategies in emergency medical services (introduction) “maladaptive” coping in emsp “adaptive” coping in emsp adaptive coping and self-efficacy present study method procedure participants measures statistical analyses results confirmatory factor analyses correlation of coping factors with well-being and health work-related self-efficacy and coping discussion limitations and future directions conclusions (additional information) funding acknowledgments competing interests author contributions data availability supplementary materials references the field of psychotherapy: over 100 years old and still an infant science editorial the field of psychotherapy: over 100 years old and still an infant science marvin r. goldfried a [a] stony brook university, stony brook, ny, usa. clinical psychology in europe, 2020, vol. 2(1), article e2753, https://doi.org/10.32872/cpe.v2i1.2753 published (vor): 2020-03-31 corresponding author: marvin r. goldfried, department of psychology, stony brook university, psychology b building, stony brook, ny 11794-2500, usa. twitter: @goldfriedmarvin. e-mail: marvin.goldfried@stonybrook.edu keywords clinical trials, therapy alliance, clinical training, practice-research gap, psychotherapy integration, rdoc although the field of psychotherapy has been in existence for well over 100 years, we have not yet reached the point of becoming what sociologists of science have called a “mature” science. sociologists who study the evolution of different scientific enterprises have defined a mature field as one where there is not only the cutting edge–where new contributions are being made–but also an agreed-upon core or consensus. although there is often disagreement among those contributing to the cutting edge of a mature science, there nonetheless remains the agreed-upon core. in the field of psychotherapy, although there are clinicians and researchers who have been working at the cutting edge, what we lack is an agreed-upon core or consensus. in essence, even after more than 100 years, psychotherapy is still considered an infant science. one of my first experiences in recognizing the disjointed nature of psychotherapy occurred when i was in graduate school way back in the 1950s when i was traumatized by paul meehl over diner. as i have described elsewhere: meehl paid a visit to our program, delivered a colloquium, and spent some time with us graduate students. i was fortunate enough to be among a small group of students that went out to dinner with him. this was a rare treat, especially since i had read virtually everything meehl had written, and had enormous respect for his insights on research, practice, and the philosophy of science. indeed, he was my role model. at one point during the evening, someone asked him the question about the extent to which his clinical work was informed by research. without any hesitation, he replied, “not at all.” as someone who was this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i1.2753&domain=pdf&date_stamp=2020-03-31 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ struggling to adopt the identity of scientist–practitioner, i left this memorable dinner disheartened. i don’t think i ever fully recovered. the challenge of how we could close the gap between research and practice has stayed with me all these years, and because i am attracted to challenges–my experiential colleagues would probably call it “unfinished business”–i have continued to be intrigued with the integration of research and practice. (goldfried, 2015, pp. 1086-1087). one can most assuredly forgive meehl for not making use of research in his clinical work; there was relatively little research on psychotherapy in the 1950s. however, the gap between research and practice continues to exist, even though there is now an extraordinary amount of research on psychotherapy. however, the researchers complain that the clinicians are not making use of their findings, and the clinicians are complain‐ ing that the researchers are not studying issues that are relevant to their therapeutic practices. and although there are many professionals in the field who are trying to close this gap, it nonetheless continues to exist. another most significant factor that prevents the field of psychotherapy from forming a core is that we think in terms of schools of therapy rather than basic processes or principles. that the field of psychotherapy is made up of so many different schools of therapy also means that these views compete with each other. although some therapists maintain that diversity is good, sociologists of science have characterized a field with competing schools of thought as being “immature.” there are several factors that motivate the development of competing schools. rela‐ tively little professional credit goes to those who simply repeat what has already been said in the past. after all, careers are made by making history, not knowing it. in the field of psychotherapy, there are also social, personal, and economic factors that operate as well. however, developing still another new school of therapy is working at the cutting edge, and does nothing to contribute to an agreed-upon core. in essence, the field of psychotherapy has been spinning its wheels by proliferating different approaches to therapy. we seem to be more interested in what is “new” than what is “old.” here again, what is new is at the cutting edge and therefore is more likely to be rewarded. when a new school of therapy is proposed, it often comes with its own set of theoretical jargon (e.g., “observing ego,” “metacognition,” “decentering,” “reflective functioning”). one of the unintended consequences of developing new terms for old phenomenon is that clinical and research contributions on a given topic may disappear by virtue of the fact that the keywords used to search the literature change. thus, to talk about “values” as an important phenomenon in therapeutic intervention can mask earlier work on encourag‐ ing patients to identify and express their needs. thus, a “new wave” of therapy that comes up with new terms for old phenomena may wash away relevant keywords, such as “assertiveness.” editorial 2 clinical psychology in europe 2020, vol.2(1), article e2753 https://doi.org/10.32872/cpe.v2i1.2753 https://www.psychopen.eu/ although i most certainly do not propose that i have the answer to how the field of psychotherapy might move forward, there nonetheless are directions i believe might be pursued (for further details please refer to goldfried, 2019). i have no doubt that one day the field of psychotherapy will develop an agreed-upon core or consensus, using a common language that facilitates communication to all. funding: the author has no funding to report. competing interests: the author has declared that no competing interests exist. acknowledgments: the author has no support to report. references goldfried, m. r. (2015). a professional journey through life. journal of clinical psychology/in session, 71, 1083-1092. https://doi.org/10.1002/jclp.22218 goldfried, m. r. (2019). obtaining consensus in psychotherapy: what holds us back? the american psychologist, 74(4), 484-496. https://doi.org/10.1037/amp0000365 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. goldfried 3 clinical psychology in europe 2020, vol.2(1), article e2753 https://doi.org/10.32872/cpe.v2i1.2753 https://doi.org/10.1002/jclp.22218 https://doi.org/10.1037/amp0000365 https://www.psychopen.eu/ the heterogeneity of national regulations in clinical psychology and psychological treatment in europe politics and education the heterogeneity of national regulations in clinical psychology and psychological treatment in europe where are we coming from, where are we now, and where are we going? anton-rupert laireiter ab, cornelia weise c [a] institute of applied psychology: health, development, enhancement and intervention, faculty of psychology, university of vienna, vienna, austria. [b] division of psychotherapy and clinical gerontopsychology, department of psychology, university of salzburg, salzburg, austria. [c] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2019, vol. 1(1), article e34406, https://doi.org/10.32872/cpe.v1i1.34406 received: 2019-02-17 • accepted: 2019-03-09 • published (vor): 2019-03-29 handling editor: winfried rief, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany corresponding author: anton-rupert laireiter, faculty of psychology, liebiggasse 5, 1010 vienna, austria. tel.: +43 (0)1 4277-47233; mobil: +43 (0)664 432 3018. e-mail: anton-rupert.laireiter@univie.ac.at abstract background: the bologna process was initiated to harmonize study processes and contents throughout europe in order to facilitate communication and cross-border study exchange. however, when it comes to postgraduate education and practical work in clinical psychology, no such harmonization exists there is still significant heterogeneity between european countries. method: to initiate the section politics and education, we analysed the current situation in europe with regard to national regulations on education, training and practice in clinical psychology and psychological treatment and give a brief summary on the status quo. results: there are extensive differences across europe regarding governmental and national regulations for psychologists in general, and clinical psychologists in particular. whereas some countries have very detailed regulations including a description of reserved activities for clinical psychologists, others leave the profession widely unregulated. when it comes to psychological treatment, some countries define it as an independent activity allowed to be applied by different professions, others clearly restrict access to the profession of psychotherapists. conclusion: a great diversity in national regulations and practical issues related to clinical psychology and psychological treatment exists across europe. our results underline the importance of the politics and education section in the journal clinical psychology in europe in order to strengthen the development of an international perspective on clinical psychology. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i1.34406&domain=pdf&date_stamp=2019-03-29 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords clinical psychology, psychological treatment, education, national regulations, europe highlights • national regulations for clinical psychologists differ significantly between european countries. • structure and contents of postgraduate training in clinical psychology vary widely across europe. • in some countries, treatment is reserved to psychologists, in others it's open for further professions. • the politics and education section shall foster understanding, communication and cooperation. the section "politics and education" has been included in clinical psychology in europe (cpe) to inform our readers about national regulations for training and practice in clini‐ cal psychology and psychological treatment. to describe the current political and educa‐ tional situation of clinical psychology in europe, the bologna process is an important starting point: as an intergovernmental cooperation of 48 european countries, the bolo‐ gna process aims to improve the internationalization of higher education throughout eu‐ rope. its aim is to not only harmonize study processes and, in part, study contents across europe, but also to facilitate an easier comparison of qualifications in order to facilitate exchange and cross-cultural communication. however, postgraduate education and prac‐ tical work in various health professions have been unaffected by the bologna process (baeten, 2017). this is of particular importance for clinical psychology, which is still a rather young and emerging profession. currently, legal regulations for clinical psycholo‐ gists (e.g. requirements for the admission to postgraduate training, structure and con‐ tents of postgraduate training, or prerequisites for work permission as a health care pro‐ vider in a clinical practice) vary substantially throughout europe (european commission [ec], 2016; hokkanen et al., 2019). accordingly, clinical psychology in europe is charac‐ terized by diversification rather than by convergence and agreement. even neighboring countries, such as the nordic countries or german-speaking ones, which in some cases cooperate very closely at university level, differ significantly in postgraduate education and their respective professional status (ec, 2016; karayianni, 2018; kryspin-exner, kothgassner, & felnhofer, 2017). further substantial differences can be found in the rela‐ tionship and differentiation between clinical psychology and psychological treatment (van broeck & lietaer, 2008). although the pan-european heterogeneity in clinical psychology is obvious, details about conditions in various countries are not well known. this applies both to countries and their bilateral communication, but also for multinational initiatives or the superordi‐ national regulations in clinical psychology 2 clinical psychology in europe 2019, vol.1(1), article e34406 https://doi.org/10.32872/cpe.v1i1.34406 https://www.psychopen.eu/ nate administration (e.g. the european union, eu) (ec, 2016). even professionals are of‐ ten unaware of the regulations in their respective countries, not to mention the differen‐ ces between countries. as a european journal of clinical psychology, it is an essential goal of cpe to shed light on this important issue. the following article introduces this section of the journal and starts with an over‐ view of different structures of governmental regulations for clinical psychology in eu‐ rope. in addition, we specify the tasks and objectives of this section and goals for possible contributions. we aim not only to provide information on differences between countries, but also to present strengths and limitations of various national regulations, and to pro‐ vide examples that could be helpful for countries who are currently in the process of es‐ tablishing national regulations for clinical psychology. finally, knowledge about the het‐ erogeneity of national regulations in clinical psychology is also essential for investigators of european projects including psychological treatments. starting points: clinical psychology in academia and clinical practice clinical psychology has different roots and traditions in europe (routh, 2014). whereas more psychodynamically oriented approaches have been developed in central europe and influenced the german-speaking and romano-phone countries, the empirically ori‐ ented anglo-american tradition has had a substantial impact on the current state of clin‐ ical psychology in europe (routh, 2014). although the understanding of clinical psychol‐ ogy as an empirical science with a strong neuro-scientific component has prevailed in academia in almost all european countries, the transfer of this conception into clinical practice varies widely (cheshire & pilgrim, 2004; plante, 2011). however, basic psycho‐ logical and neuroscientific theories and empirical findings should be applied with the goal of improving the understanding as well as the classification, prevention and treat‐ ment of mental disorders and relevant psychological aspects of medical conditions. in‐ stead, applied clinical psychology has been strongly influenced by the strong identifica‐ tion of psychologists, associations, and sometimes even societies with a specific approach to psychotherapy (e.g. psychodynamic, cognitive-behavioral, humanistic, or systemic ap‐ proaches; plante, 2011). it should be noted that this runs contrary to the primary goal of an academic profession: practical work should not be based on selected belief systems, but on scientific evidence relevant to its field, along with clinical expertise. governmental regulations for psychologists according to the eu, more than 6,000 professions are subject to state or supranational (eu) regulations, 42% of which are in the health and social care sector (baeten, 2017). the laireiter & weise 3 clinical psychology in europe 2019, vol.1(1), article e34406 https://doi.org/10.32872/cpe.v1i1.34406 https://www.psychopen.eu/ professions of psychology and clinical psychology are, in most european countries, regu‐ lated by the relevant member state, but are not subject to supranational eu regulations (ec, 2016). this adds to the understanding of the diversity of clinical psychology throughout europe. europe-wide analyses of the professional state of psychology and clinical psychology in the 28 euand four of the non-eu states (i.e. iceland, liechten‐ stein, norway and switzerland) revealed the following picture (ec, 2016; hokkanen et al., 2019): only five states (15.6%) had no legal or state regulation of any kind for psychol‐ ogy in general or health care in particular (ec, 2016, pp. 8ff.). hokkanen et al. (2019) ana‐ lyzed a slightly different sample and found state regulations in 25 out of 29 examined countries (86%). countries without any general psychology regulations are bulgaria, ger‐ many, and the three baltic states, with germany having regulations for psychological psychotherapists and child/adolescent psychotherapists, and bulgaria stipulating mini‐ mal educational requirements for working as a psychologist in health care facilities. in 17 of the above mentioned 32 countries, there are regulations for the profession "psycholo‐ gists" in general, some of which also include clinical-psychological activities. twelve states have specific regulations for "clinical psychologists" and nine for "psychologists in health care" (health psychology). in 11 of these countries, there are separate regulations for other specialized psychologists and activities in various fields, for example forensic, counseling, school, traffic, occupational, or neuropsychologists (for further details see ec, 2016). in addition, some states have specific regulations for the treatment of children and adolescents (e.g. czech republic, hungary, lithuania and the united kingdom [uk]). this brief overview clearly demonstrates how diversely the profession is regulated throughout europe. specific regulations for clinical psychologists as reported above, 12 european countries have specific regulations for clinical psycholo‐ gists, including austria, cyprus, the czech republic, hungary, iceland, ireland, malta, the netherlands, slovakia, slovenia, spain, and the uk (ec, 2016). still, clinical psychologists are trained very differently; they have a differing range of reserved activities and work in diverse areas (e.g. public health care services vs. private sector). in some countries, clini‐ cal psychology is narrowly defined as a singular profession (e.g. austria, hungary and czech republic) whereas in others it is conceptualized as a clinically focused specializa‐ tion of health psychology (e.g. malta, netherlands, spain and the uk). in general, there is no consistent distinction between health psychology and clinical psychology: in some states, both professions are separated by their range of activities (e.g. prevention and health promotion vs. treatment and rehabilitation in cyprus or the uk), in others by the severity of the mental disorder (e.g. health psychology for mild cases, and clinical psy‐ chology for severe cases in the czech republic or the netherlands). similarly, there are differing understandings of clinical psychology, clinical psychological treatment, and national regulations in clinical psychology 4 clinical psychology in europe 2019, vol.1(1), article e34406 https://doi.org/10.32872/cpe.v1i1.34406 https://www.psychopen.eu/ psychotherapy: in some countries, psychotherapy is a sub-specialization of clinical-psy‐ chology and thereby reserved for clinical psychologists (e.g. slovakia, hungary), in oth‐ ers, psychotherapy is a distinct profession with separate regulations and may also be open to holders of qualifications from related fields (e.g. medicine or pedagogy). as men‐ tioned above, in some states clinical psychology is affiliated to other specialties, e.g. for‐ ensic psychology (malta, cyprus and the uk), neuropsychology (netherlands and hun‐ gary), or counseling psychology (ireland, malta, slovakia, czech republic, uk and cy‐ prus) (see ec, 2016) which implies a specific appearance of clinical psychological work in these countries. differences across europe are also evidenced by whether the title "clinical psycholo‐ gist" is protected by a specific (psychology) law, or if the profession and its activities are only generally mentioned in another law, e.g. a health law. the former is the case in about 50% of european countries (hokkanen et al., 2019), the latter in about one third (e.g. denmark, ireland and spain). in some countries, both a title protection and a refer‐ ence in specific health acts can be found (e.g. iceland and lithuania). further differences pertain to the reservation of activities for clinical psychologists: according to the ec overview (ec, 2016, p. 19 ff.), two states have pure title protection without any reserved activities (netherlands and the uk), three others have reserved activities without title protection (ireland, slovakia and cyprus), and seven have both (iceland, malta, austria, slovenia, spain, czech republic and hungary). and finally, the core competencies of clinical psychologists in europe are defined to a differing degree. competencies include in most european countries clinical-psychological diagnostics and assessment and psychological treatment. additionally, clinical psycholo‐ gists in various countries are enabled to carry out activities such as counseling, crisis in‐ tervention, education and training, as well as research and evaluation. in some countries these competencies are very clearly defined (e.g. austria), in many others they are vague‐ ly specified and are difficult to separate from activities of other professions in the health care system (ec, 2016). education and training in clinical psychology the situation of education and training for clinical psychologists is an important topic for the profession, and also for this journal. and again, there are tremendous differences between various european states regarding the structure, extent, and contents of train‐ ing. in the majority of european countries, training in clinical psychology requires uni‐ versity studies (bachelor and master) followed by postgraduate training. only in a few countries is training in clinical psychology already included during graduate studies (e.g. norway). postgraduate training varies between two to 12 years (ec, 2016) and contains a broad range of subjects, e.g. training in diagnostics and (clinical) psychological testing, training in counseling, specific treatment methods and crisis intervention as well as laireiter & weise 5 clinical psychology in europe 2019, vol.1(1), article e34406 https://doi.org/10.32872/cpe.v1i1.34406 https://www.psychopen.eu/ training in research methods and evaluation. in most curricula, specific obligatory cour‐ ses are integrated into internships or trainee programs and are accompanied by continu‐ ous supervision. moreover, in some countries the training is accompanied by personal and professional self-reflection (e.g. austria), and is completed by a state examination (e.g. austria or spain) (ec, 2016). the most comprehensive training in clinical psycholo‐ gy can be found in the czech republic, hungary, the netherlands, slovenia, and spain (ec, 2016), where it is usually based on training in health psychology. austria has the shortest training of between 1.5 and 2 years. differentiation between clinical psychology and psychological treatment significant differences between the european countries can also be found in the relation‐ ship between clinical psychology and psychological treatment (bptk, 2011; ec, 2016; van broeck & lietaer, 2008). of the 28 eu states, 13 separately regulate the profession of psy‐ chotherapists via governmental law (austria, belgium, finland, france, germany, hun‐ gary, italy, lithuania, luxembourg, the netherlands, romania, slovakia and sweden), a further three states regulate psychotherapists in a health-related law (croatia, latvia and malta), and bulgaria regulates the educational requirements for psychotherapists (mas‐ ter's degree in psychology). ireland and cyprus are planning to issue laws for psychologi‐ cal treatment and two non-eu countries (liechtenstein and switzerland) already have them. however, the regulations of the different countries are very heterogeneous and dif‐ fer significantly regarding their understanding of psychological treatment in general, cri‐ teria for theoretical and practical training, as well as the number of approved methods (van broeck & lietaer, 2008). in austria, finland and sweden, psychotherapy is defined as an independent occupa‐ tion that can be learnt and practiced by different professions (almost 40 in austria, eight to ten in finland and sweden). in most other countries, access to the profession of psy‐ chotherapists is restricted, mostly to psychologists and physicians/psychiatrists (e.g. france, italy, liechtenstein, switzerland, slovakia and hungary). in belgium, germany and the netherlands, pedagogues (general, clinical, or social pedagogues for children and adolescents) are additionally admitted to practice psychological treatment. accordingly, in most european countries, non-medical psychological treatment is reserved to psychol‐ ogists; in hungary, psychotherapy is a reserved activity for clinical psychologists, an ap‐ proach which is also planned in ireland (ec, 2016). in most countries, only the titles "psychotherapy" and "psychotherapist" are protec‐ ted, but not the activity itself. hence psychological treatment can also be carried out by other professions (e.g. physicians, clinical psychologists, and clinical pedagogues) in the context of their respective professional activities, although it is not permitted to be called national regulations in clinical psychology 6 clinical psychology in europe 2019, vol.1(1), article e34406 https://doi.org/10.32872/cpe.v1i1.34406 https://www.psychopen.eu/ "psychotherapy". in some countries, further specific activities (e.g. family therapy) are re‐ served for psychotherapists, (e.g. germany, hungary, italy, slovakia, and switzerland). there is also a great difference in the number of psychotherapeutic methods ap‐ proved for training and practice. the numbers vary between four (finland) and 23 (aus‐ tria), with five to seven approved methods in the majority of countries. the generally ac‐ cepted methods are cognitive behavioral therapy (incl. 3rd wave methods), psychoanaly‐ sis, psychodynamically-oriented approaches (e.g. analytic psychotherapy following c.g. jung, or individual psychology according to a. adler), client centered psychotherapy ac‐ cording to rogers, systemic (family) therapy, gestalt therapy following perls, existential psychotherapies (e.g. according to frankl). occasionally, hypnosis, integrative, or femi‐ nist therapies are also accepted (bptk, 2011). conclusion and consequences in conclusion, we find a great diversity in regulations of clinical and health-related psy‐ chology and psychological treatment as well as in the relation of clinical psychology and psychological treatment on all levels of analysis. psychological treatment is, in a few countries, reserved exclusively for clinical psychologists, whereas in others it can also be applied by other psychologists and/or other professions. in most cases, however, clinical psychology and psychological treatment are two independent professional fields. in ger‐ many, for example, clinical psychology represents an academic-scientific subject and (psychological) psychotherapy is its application in practice (kryspin-exner et al., 2017). the great diversity and heterogeneity demonstrated in this overview underlines the im‐ portance of the goal of cpe's section "politics and education": accomplishing transparen‐ cy and clarity about the political and educational situation regarding clinical psychology and psychological treatment in europe. this will be a necessary precondition for improv‐ ing communication between different countries and different professions, for improving the field of clinical psychology as a whole, as well as for being able to coordinate europe‐ an or multinational initiatives regarding research, structural changes, and psychological treatment. tasks and objectives of the "politics and education" section it is the aim of the journal clinical psychology in europe and its various sections to devel‐ op and strengthen an international perspective on clinical psychology and psychological treatment (https://cpe.psychopen.eu/about#aimsandscope). accordingly, for the section "politics and education", the main purpose is to publish articles dealing with various as‐ pects of the political and legal situation and recent developments in europe regarding training in clinical psychology and clinical psychological practice. the primary goal is to increase knowledge about different regulations and training modalities in europe in or‐ laireiter & weise 7 clinical psychology in europe 2019, vol.1(1), article e34406 https://doi.org/10.32872/cpe.v1i1.34406 https://cpe.psychopen.eu/about#aimsandscope https://www.psychopen.eu/ der to foster understanding, communication and cooperation between professionals in the field of clinical psychology. a central topic of european integration is promoting mobility and exchange of pro‐ fessions, which also applies for clinical psychology. on the one hand, clinical psycholo‐ gists planning to move to another eu country or a country outside the eu should be kept fully informed about regulations as well as opportunities to perform their job in the re‐ spective country. on the other hand, comprehensive information is important for crossnational initiatives (e.g. on education and training in clinical psychology and psychologi‐ cal treatment), scientific projects, and the promotion of evidence-based practical applica‐ tions of clinical psychology. it is, however, not planned to compile a legal encyclopedia in this section. rather, papers should deal with the topics of interest in an introductory manner, provide an overview, and refer to further readings. papers to be submitted to this section manuscripts submitted to this section should address one of the following topics: (1) legal regulations on education, training, and practice in clinical psychology and psychological treatment in health care; (2) specific aspects related to politics and education, e.g. prereq‐ uisites for, and contents of, training in various psychological treatments, or the relation‐ ship between clinical psychology and psychological treatment in a certain country; (3) commentaries on university studies (e.g. master's or doctorate level), european harmoni‐ zation, or pan-european regulations (e.g. by the european federation of psychologists' associations or other organizations) are also welcome. the focus of the papers should be on clinical psychology, or on psychological treatment as an area of the application of clinical psychology. all contributions will be reviewed by the editors and must meet the requirements of the journal (for details please see https://cpe.psychopen.eu/about#author-guidelines). manuscripts should not exceed a maximum of 2,500 words (excluding references, author description and cover page). papers can be submitted to the journal at any time. howev‐ er, one of the editors should be contacted beforehand to agree upon the planned topic. in addition, the editors will actively invite experts to submit manuscripts on various topics of interest. funding: the authors have no funding to report. competing interests: arl is section editor of the politics and education section but played no editorial role for this particular paper. cw is managing editor of clinical psychology in europe (cpe) but played no editorial role for this particular paper. the current paper was peer-reviewed by winfried rief, who is editor-in-chief of cpe. acknowledgments: the authors have no support to report. national regulations in clinical psychology 8 clinical psychology in europe 2019, vol.1(1), article e34406 https://doi.org/10.32872/cpe.v1i1.34406 https://cpe.psychopen.eu/about#author-guidelines https://www.psychopen.eu/ references baeten, r. (2017). was the exclusion of health care from the services directive a pyrrhic victory? a proportionality test on regulation of health professions (ose paper series, opinion paper no. 18, european social observatory). retrieved from http://www.ose.be/files/publication/osepaperseries/baeten_2017_opinionpaper18.pdf bundespsychotherapeutenkammer (bptk). (2011). psychotherapy in europe – disease management strategies for depression: national concepts of psychotherapeutic care. retrieved from https://www.bptk.de/fileadmin/user_upload/themen/pt_in_europa/ 20110223_nationalconcepts-of-psychoth-care.pdf cheshire, k., & pilgrim, d. (2004). a short introduction to clinical psychology. london, united kingdom: sage. european commission (ec). (2016). mutual evaluation of regulated professions – overview of the regulatory framework in the health services sector – psychologists and related professions (report grow/e5). retrieved from https://ec.europa.eu/docsroom/documents/16683?locale=en hokkanen, l., lettner, s., barbosa, f., constantinou, m., harper, l., kasten, e., . . . hessen, e. (2019). training models and status of clinical neuropsychologists in europe: results of a survey on 30 countries. the clinical neuropsychologist, 33(1), 32-56. https://doi.org/10.1080/13854046.2018.1484169 karayianni, e. (2018). a european perspective on regulating psychology: a review of the european commission’s mutual evaluation of regulated professions. psichologija, 58, 125-134. https://doi.org/10.15388/psichol.2018.7 kryspin-exner, i., kothgassner, o. d., & felnhofer, a. (2017). central europe. in s. g. hofmann (ed.), international perspectives on psychotherapy (pp. 87–106). cham, switzerland: springer. https://doi.org/https://doi.org/10.1007/978-3-319-56194-3 plante, t. (2011). contemporary clinical psychology (3rd ed.). hoboken, nj, usa: john wiley & sons. routh, d. k. (2014). a history of clinical psychology. in d. barlow (ed.), the oxford handbook of clinical psychology (2nd ed., pp. 23–33). new york, ny, usa: oxford university press. https://doi.org/https://doi.org/10.1093/oxfordhb/9780195366884.001.0001 van broeck, n., & lietaer, g. (2008). psychology and psychotherapy in health care: a review of legal regulations in 17 european countries. european psychologist, 13(1), 53-63. https://doi.org/10.1027/1016-9040.13.1.53 laireiter & weise 9 psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. www.leibniz-psychology.org http://www.ose.be/files/publication/osepaperseries/baeten_2017_opinionpaper18.pdf https://www.bptk.de/fileadmin/user_upload/themen/pt_in_europa/20110223_nationalconcepts-of-psychoth-care.pdf https://www.bptk.de/fileadmin/user_upload/themen/pt_in_europa/20110223_nationalconcepts-of-psychoth-care.pdf https://ec.europa.eu/docsroom/documents/16683?locale=en https://doi.org/10.1080/13854046.2018.1484169 https://doi.org/10.15388/psichol.2018.7 https://doi.org/https://doi.org/10.1007/978-3-319-56194-3 https://doi.org/https://doi.org/10.1093/oxfordhb/9780195366884.001.0001 https://doi.org/10.1027/1016-9040.13.1.53 https://www.leibniz-psychology.org/ https://www.psychopen.eu/ national regulations in clinical psychology (introduction) starting points: clinical psychology in academia and clinical practice governmental regulations for psychologists specific regulations for clinical psychologists education and training in clinical psychology differentiation between clinical psychology and psychological treatment conclusion and consequences tasks and objectives of the "politics and education" section papers to be submitted to this section (additional information) funding competing interests acknowledgments references cognitive-behavioral and emotion-focused couple therapy: similarities and differences scientific update and overview cognitive-behavioral and emotion-focused couple therapy: similarities and differences guy bodenmann a, mirjam kessler a, rebekka kuhn a, lauren hocker b, ashley k. randall b [a] clinical psychology for children/adolescents and couples/families, university of zurich, zurich, switzerland. [b] counseling and counseling psychology, arizona state university, tempe, az, usa. clinical psychology in europe, 2020, vol. 2(3), article e2741, https://doi.org/10.32872/cpe.v2i3.2741 received: 2019-07-03 • accepted: 2020-06-21 • published (vor): 2020-09-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: guy bodenmann, university of zurich, department of psychology, binzmuehlestrasse 14, box 1, 8050 zurich/switzerland, phone +41 (0)44 635 71 51. e-mail: guy.bodenmann@psychologie.uzh.ch abstract background: couples and families often seek therapy to deal with relational distress, which is a result of external or internal factors of the relationship. two approaches are acknowledged to be most effective in dealing with relationship distress or psychological disorders in couples: (a) cognitive behavioral couple therapy with new directions (cbct) and (b) emotion-focused couple therapy (efct). in this article we investigate how much cbct and efct really differ with regard to working with emotions, which is claimed to be a major focus of efct, and whether there exist significant differences in efficacy between these two approaches. method: this article critically reviews the theoretical background, process, techniques and outcomes associated with cbct and efct in an effort to challenge the assumptions noted above. results: there is no evidence that efct is more emotion-focused than cbct. both approaches were repeatedly examined with rct studies with follow-ups. in sum, no significant differences in effect size were found between cbct and efct. conclusion: cbct and efct are both effective in reducing couples’ distress. keywords couple therapy, cognitive behavioral couple therapy, emotion-focused couple therapy, efficacy this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i3.2741&domain=pdf&date_stamp=2020-09-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • cbct and efct are both effective in helping couples deal with relationship distress. • both are similarly effective in helping couples to better understand and cope with their presenting concerns. • both approaches address the importance of personal schema, triggering relevant cognitions and emotions. • both approaches help couples wherein one partner has been diagnosed with a clinical disorder. for couples seeking couple therapy, there is broad international empirical evidence advocating that couple therapy is advantageous in reducing relationship distress and improving relationship quality. overall, couple therapy exhibits excellent efficacy with an internationally established mean effect size of d = 0.95, ranging from d = 0.59 to 1.03 (e.g., shadish & baldwin, 2003, 2005). among a large range of different therapeutic approaches, cognitive-behavioral couple therapy (cbct) and emotion-focused couple therapy (efct) are amongst the most wide‐ ly applied couples’ interventions. cbct as well as efct have repeatedly been examined regarding their efficacy. some claim that efct outperforms cbct and represents the most effective approach for treating relationship problems (e.g., roesler, 2018). howev‐ er, an ancient meta-analysis revealed only marginal differences between the various approaches (shadish & baldwin, 2005). the purpose of this review is to analyze recent studies on efficacy of both approaches and to test the assumption that efct (attachment based) is more emotion-focused than cbct (learning based). brief review of the theoretical underpinnings of cbct and efct in this section, we will provide a brief overview of the theoretical underpinnings and common methods used in cbct and efct. denominations of emotion-focused versus cognition-focused are tested regarding their meaning for clinical work. cognitive-behavioral couple therapy background cognitive-behavioral couple therapy (cbct) relies on principles from social learning theories and focuses on the interplay between partners’ cognitions, behaviors, and emotional responses to help them improve their communication and problem-solving (epstein & zheng, 2017). cbct draws on concepts stemming from behavioral couple cognitive-behavioral and emotion-focused couple therapy 2 clinical psychology in europe 2020, vol.2(3), article e2741 https://doi.org/10.32872/cpe.v2i3.2741 https://www.psychopen.eu/ therapy, cognitive therapy, as well as empirical findings in basic research (baucom et al., 2008). therapists working from a cbct lens aim to improve partners’ skills (e.g., com‐ munication and problem-solving skills), modify dysfunctional cognitions and attitudes, in an attempt to improve relationship quality and decrease emotional distress such as anger, sadness or disgust (epstein & baucom, 2002; epstein & zheng, 2017). process the goal of cbct is to help partners restructure cognitions that may yield relational distress, which include unrealistic expectations, dysfunctional attributions and irrational assumptions (epstein & zheng, 2017). cbct operates under the premise that cognitions cause emotions and subsequent behaviors (e.g., the cognition “you do not care about me” may lead to emotions such as anger and sadness that motivates coercive behavior to get more attention). thus, the assumption of cbct is that negative mood (dissatisfaction) and emotions (anger, disappointment, frustration, resignation), reflected in deleterious behaviors (i.e., generalized criticism, defensiveness, belligerence, contempt, aggression or violence), are a major motive why couples seek for interventions (bradbury & bodenmann, 2020). techniques one of the common techniques used in cbct is cognitive restructuring, wherein the clinician guides partners to “identify and evaluate cognitions as they occur” (epstein & zheng, 2017, p. 143). dysfunctional cognitions, either regarding irrational beliefs, dysfunctional expectancies or negative attribution styles are viewed as the causes of negative emotions (bradbury & fincham, 1990). cbct aims to strengthen partners’ communication skills in order to allow partners to safely disclose their needs and emo‐ tions, without risk of their partner’s negative reactions. therefore, instead of blaming the partner, partners learn to express their sentiments and needs using speaker-listener rules and techniques. cbct also applies cognitive-emotional techniques such as cognitive restructuring (i.e., identifying and disputing irrational thoughts leading to negative emo‐ tions) (e.g., baucom et al., 2019). more recent approaches such as the integrative behavioral couple therapy (ibct; jacobson & christensen, 1996) and coping-oriented couple therapy (coct; bodenmann, 2010) also refer to cbct principles. however, ibct focuses on acceptance in addition to the above-mentioned techniques and tries to improve couples’ mutual tolerance. coct focuses on stress and its impact on couples’ functioning. this approach addresses mutual emotional understanding facing stress-related negative behaviors towards the partner. by means of the 3-phase-method, partners learn to engage in deepened emotional self-dis‐ closure, empathic listening and providing emotion-focused support (i.e., dyadic coping) that matches the partners’ needs. by doing this, emotional bonding, mutual intimacy and closeness as well as mutual trust between partners are enhanced (bodenmann & randall, bodenmann, kessler, kuhn et al. 3 clinical psychology in europe 2020, vol.2(3), article e2741 https://doi.org/10.32872/cpe.v2i3.2741 https://www.psychopen.eu/ 2020). in sum, techniques used in cbct aim at improving partners’ skills in an attempt to modify dysfunctional cognitions, emotions and behaviors or to accept them under specific circumstances. outcomes cbct has shown to be effective in improving couples’ function. in addition, positive effects are reported regarding partner’s psychological (e.g., ptsd and ocd) and physical health (e.g. cancer), as well as other severe stressors that may yield relational concerns (for a review see epstein & zheng, 2017). emotion-focused couple therapy background emotionally focused couple therapy (efct) is an experiential, humanistic and systemic therapy grounded in attachment theory and social neuroscience (greenman, johnson, & wiebe, 2019). efct does not directly focus on skill training, rather, the focus is to build new emotional experiences between partners that foster attachment security (wiebe & johnson, 2016). the original framework of efct proposed that distress in the relation‐ ship could be repaired though regulation of emotions by the other partner (greenberg & johnson, 1988). this was later adapted to include foundations of attachment theory as well as working to increase both partner’s emotional self-regulation and other regulation (greenberg & goldman, 2008; johnson, 2004). efct primarily aims to facilitate the expression of primary emotions (such as feelings of hurt, feelings of inadequacy and deprivation of love, respect and appreciation) and to understand these feelings behind secondary emotions such as anger or contempt (greenberg & johnson, 1988). process the overarching goals of efct is to have partners access and reprocess their emotional experiences to restructure partners’ interaction patterns. the outcome of this approach is to help partners learn new aspects about themselves and develop a more functional pattern of interaction with their partner that is matching with their specific attachment needs (johnson, 2019). within efct, the therapist tries to strengthen the attachment bond between partners by addressing the intrapsychic (attachment-related experiences) and interpersonal perspective regarding dysfunctional interaction patterns of distressed partners. emotion-focused couple therapy understands these patterns as the result of an insecure attachment bond where both partners signal attachment distress in a way that inadvertently keeps their partner at a distance (greenman et al., 2019). typically, efct is differentiated in three stages (greenman et al., 2019). in the first stage (cycle de-escalation), the therapist tracks and reflects the pattern of interaction with the couple and tries to identify negative patterns wherein the partners may “criticize/at‐ cognitive-behavioral and emotion-focused couple therapy 4 clinical psychology in europe 2020, vol.2(3), article e2741 https://doi.org/10.32872/cpe.v2i3.2741 https://www.psychopen.eu/ tack” one another, which is often followed by “defensiveness/distance”. these interaction patterns are viewed as hindering constructive emotional exchange. the goal of the first stage is to gain a meta-perspective of the couples’ interaction by realizing that the partners’ dysfunctional interaction maintains both partners’ attachment insecurity and causes emotional distress. in the second stage (restructuring interactions), the therapist tries to give insight into new emotional experiences by facilitating new interactions, which will help lead to secure bonding. the therapist helps to explore attachment vul‐ nerabilities that partners share with each other. in this method, partners learn how to respond to the other in an emotionally attuned and supportive way. instead of blaming or withdrawing from the partner, partners learn to become more responsive to the other; increasing their awareness of their partner’s attachment needs. instead of negativity, primary emotions such as sadness, fear or shame are expressed. the therapist helps the speaker to find adequate wording for their emotional state. in the third stage (consolida‐ tion), partners learn new ways of solving problems that become possible based on their secure attachment experience. techniques a primary focus in efct is helping couples learn how to communicate their emotions more effectively with one another (gladding, 2015). couples are instructed to better perceive their emotions and to engage more in mutual responsiveness and dyadic en‐ gagement (burgess moser & johnson, 2008). hence, in efct, couples are encouraged to explore here-and-now emotional experiencing (greenman et al., 2019). instead of sharing primary emotions, distressed couples often communicate secondary emotions expressed in attacking, nagging, and withdrawing. as such, the efct therapists help guide each partner to uncover primary emotions (sadness, fear, shame, etc.). the therapist guides both partners, working out primary emotions for one, and showing the other partner how to listen emotionally engaged and how to respond in an emotionally attuned way. the “new emotional music then elicits new responses and, gradually, changes the dance between partners” which means that new behavioral interaction patterns can be estab‐ lished (wiebe & johnson, 2016, p. 390). common techniques within efct include bonding and enactments. therapists guide couples through the conversations about emotion and encourage each partner to engage in a release of that emotion, to increase self-awareness (gladding, 2015). this process leads to the therapeutic technique of bonding, which is when the partner who is hearing the emotional response can become more aware of their partner’s perception, thus in‐ creasing empathy. enactments, reminiscent of gestalt therapy, help each partner explore and express deeper emotions by engaging in role-play or two-chair techniques (gladding, 2015). bodenmann, kessler, kuhn et al. 5 clinical psychology in europe 2020, vol.2(3), article e2741 https://doi.org/10.32872/cpe.v2i3.2741 https://www.psychopen.eu/ outcomes various studies have shown efct’s effectiveness with couples in distress, couples coping with post-traumatic stress disorder (ptsd), and couples coping with chronic illness (bailey, 2002; beckerman, 2004; bradley & johnson, 2005). additionally, efct has been effective in increasing intimacy between partners (soltani et al., 2013). similarities and differences between both approaches cbct and efct approaches are grounded in different theories and, as such have a different conceptualization of the development and maintenance of relationship distress. traditional cbct is skill-oriented and aimed at teaching couples’ new ways of communi‐ cation and conflict resolution. methods are a highly structured and often manualized, such as the communication training. new directions in cbct, like the acceptance ap‐ proach (jacobson & christensen, 1996) or 3-phase-method (bodenmann, 2010) further expand these methods by focusing on insight-oriented empathic understanding and deepened emotional experiences in the case of the latter approach. all techniques in cbct, however, focus on the interplay between cognitions and emotions as the major outcome of interest. however, instead of working directly with emotions, therapists address dysfunctional thinking and information processing, negative and unrealistic or exaggerated attitudes towards the partner and their impact on couple’s emotional experi‐ ences and behaviors. thus, techniques utilized in cbct focus on modifying cognitive distortions with the goal to tap into the emotional exchange between partners. coct and ibct further offer techniques directly allowing shared emotional experiences like this is the case in the 3-phase-method or the empathic joining technique. efct is considered an experiential approach that enables partners to develop new feelings and interaction patterns. it primarily focuses on attachment schemas or personal needs of belonging, being respected and validated. partners learn to understand that negative emotions and dysfunctional interaction patterns result from the non-fulfilment of these attachment needs. instead of a structured training like in cbct, the efct-thera‐ pists work with emotional experiences during partners’ interactions by making them visible and tangible. creating emotional and cognitive awareness of the partner’s insecure attachment is a key component of this approach. efct-therapists explain emotional reactions and search together with the partners for an attachment-based understanding. thus, the goals are somewhat similar in efct and cbct (compare 3-phase-method), however, the methods vary. efct-therapists are not teaching skills, their approach is less structured and thera‐ pists are more active in uncovering processes. cbct-therapists are similarly allowing emotional experiences and emotional understanding, but by using techniques such as socratic questioning or the method of prompting (therapists explore and reinforce rele‐ vant cognitions and deeper emotions, ask open-ended questions and guide smoothly to cognitive-behavioral and emotion-focused couple therapy 6 clinical psychology in europe 2020, vol.2(3), article e2741 https://doi.org/10.32872/cpe.v2i3.2741 https://www.psychopen.eu/ the personally relevant construct that may be an attachment scheme, but can also be any other type of schema). in sum, both cbct and efct approaches aim to address relationship distress, with the goal of helping couples deal more effectively with negative emotions. both approaches work with partners’ emotional experience, however, the ways in which each method addresses them is different. efficacy of cbct and efct in psychotherapy research, minimal differences in outcomes of the various approaches are reported (wampold et al., 2002). while some psychotherapies show higher effective‐ ness in treating specific disorders (e.g., cbct for anxiety disorders), in general, common factors such as the therapeutic alliance account for more variance than specific treatment modality. correspondingly, wampold et al. (2002) report that only 1% of the variability of treatment outcome can be explained by a specific treatment. findings are similar in couple therapy and again, differences between various ap‐ proaches are minimal (christensen & heavey, 1999). efficacy of cbct cbct is considered one of the most widely evaluated therapeutic approaches for work‐ ing with couples. since the 1980ies, several dozens of rct-studies have supported the effectiveness and efficacy of cbct (bradbury & bodenmann, 2020). 70% of the couples improved after cbct (baucom et al., 1998), and 50% show stable effects over a period of five years (christensen et al., 2010). christensen et al. (2004) reported 71% of clinical recovery in integrated cbct compared to 54% in classical cbct. according to this study, cbct proves to be efficient in the long term, with an effect size of d = 0.92 at the 5-year follow-up, slightly outperformed by icbt (d = 1.03) (christensen & glynn, 2019). bodenmann et al. (2008) reported effect sizes of d = 1.46 at the 6-months follow-up and d = 1.74 at the one-year follow-up of coping-oriented cbct in treating depression. in the various meta-analysis, effect sizes for cbct ranged from d = 0.53 (rathgeber et al., 2019) up to d = 0.95 (byrne et al., 2004). efficacy of efct the efficacy of efct has been examined in 10 rct-studies, all which support its efficacy. however, these studies do not always present classical effect sizes. in the meta-analysis by johnson et al. (1999), including four randomized trials, an effect size of d = 1.31 is reported. more recently, beasley and ager (2019) published a new meta-analysis that included studies that were conducted and published since the last meta-analysis, covering a period of 19 years. in this meta-analysis, nine rct studies were included. however, authors did not calculate cohen’s d, but hedges’s g. thus, results are not bodenmann, kessler, kuhn et al. 7 clinical psychology in europe 2020, vol.2(3), article e2741 https://doi.org/10.32872/cpe.v2i3.2741 https://www.psychopen.eu/ directly comparable with previous research or studies related to cbct. hedges’s g was 2.09 (beasley & ager, 2019). in earlier research on efct, johnson and talitman (1997) report an improvement in relationship quality in 50% of couples (no rct-study) at post-test, while 70% showed recovery at 3-month follow-up. in a recent study (wiebe et al., 2017), 61% fully recovered, 11% improved (but no recovery), 25% remained unchanged and 4% showed a deteriora‐ tion. comparison of intervention studies and meta-analyses statements on the efficacy of cbct are based on a great number of studies (n = 86 studies in the different meta-analyses), usually relatively large samples, and randomized controlled trials (which represent the golden standard in treatment evaluation studies). the evaluation of efct is based on fewer studies (n = 32 studies in the different metaanalyses), not always rct designs and usually smaller samples. the above-cited most recent meta-analysis by beasley and ager (2019) on the effectiveness of efct included only four methodologically sound rct studies, and the first meta-analysis (johnson et al., 1999) had also included only four trials. only 0.01% of all conducted evaluation studies in efct could be included in this latest meta-analysis because of insufficient methods or sample sizes or other statistical shortfalls. thus, only four follow-up studies out of nine met inclusion criteria within the last 19 years (beasley & ager, 2019). the mean sample size in these studies was considerably small with nmean = 14 in the interven‐ tion group versus nmean = 13 in the intervention group. three out of nine studies were rated to not meet criteria for treatment integrity and the others were at least acceptable (beasley & ager, 2019). often studies were not in the context of relationship distress but related to other problems such as medical issues (e.g., infertility, end-stage cancer or psychological disorders such social anxiety, depression). they represented no “pure” studies on effects of efct on relationship distress. more interesting than reviews and meta-analyses on one single approach are studies directly comparing both approaches. the meta-analysis with 33 suitable primary studies by rathgeber et al. (2019) is such an example (n = 21 studies on cbct, n = 12 studies on efct). in this study, a total of 2,730 participants were included. results reveal a medium overall effect size at post-test g = 0.60 (behavioral cognitive therapy (bct): g = 0.53; efct: g = 0.73). after 6 months smaller effects were reported (overall: g = 0.44; bct: g = 0.35; efct: g = 0.66). most important, no significant differences in effect sizes were found between the two couple therapy approaches. this finding echoes results of the study by byrne et al. (2004), where large effect sizes for both treatments (dbct = 0.95, defct = 1.27) on quality of couples’ relationships compared to waiting-list controls are reported. “taken together, meta-analyses of existing efficacy studies continue to support an approximate d of at least 0.80 for bct and efct, with 60–72% of couples experiencing reliable pre–post improvements in satisfaction” (bradbury & bodenmann, 2020, p. 102). cognitive-behavioral and emotion-focused couple therapy 8 clinical psychology in europe 2020, vol.2(3), article e2741 https://doi.org/10.32872/cpe.v2i3.2741 https://www.psychopen.eu/ conclusion in sum, cbct and efct are both effective in helping couples deal with relationship distress (bradbury & bodenmann, 2020). based on our review of the literature, it is im‐ portant to acknowledge that while both approaches have their strengths and weaknesses, both are similarly effective in helping couples to better understand and cope with their presenting concerns. additionally, both approaches address the importance of personal schema, triggering relevant cognitions and emotions. the assumption that cbct is purely behavioral, focusing on cognitions and neglecting emotions is often wrongly derived from the designation, but lacks any theoretical and practical basis. cbct and efct both address similarly the emotional experiences between partners; however, each approach does so differently. both approaches have been found to be beneficial in improving relationship distress and helping couples overcome their relational difficul‐ ties, in addition to helping couples wherein one partner has been diagnosed with a clinical disorder. it is important that clinicians and policy makers are aware of these two evidence-based approaches, and expand their application to other areas wherein couples may be experiencing distress (e.g., health psychology). therefore, publications building public awareness for the use of couple therapy in treating psychological disorders are important (fischer et al., 2016; leuchtmann & bodenmann, 2017). funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. references bailey, g. 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(2017). two‐year follow‐up outcomes in emotionally focused couple therapy: an investigation of relationship satisfaction and attachment trajectories. journal of marital and family therapy, 43(2), 227-244. https://doi.org/10.1111/jmft.12206 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. cognitive-behavioral and emotion-focused couple therapy 12 clinical psychology in europe 2020, vol.2(3), article e2741 https://doi.org/10.32872/cpe.v2i3.2741 https://doi.org/10.1111/j.1752-0606.2003.tb01694.x https://doi.org/10.1037/0022-006x.73.1.6 https://doi.org/10.1016/j.sbspro.2013.06.293 https://doi.org/10.1016/s0165-0327(00)00287-1 https://doi.org/10.1111/famp.12229 https://doi.org/10.1111/jmft.12206 https://www.psychopen.eu/ cognitive-behavioral and emotion-focused couple therapy (introduction) brief review of the theoretical underpinnings of cbct and efct cognitive-behavioral couple therapy emotion-focused couple therapy similarities and differences between both approaches efficacy of cbct and efct conclusion (additional information) funding competing interests acknowledgments references reflecting on psychotherapy practice for psychologists: towards guidelines for competencies and practices politics and education reflecting on psychotherapy practice for psychologists: towards guidelines for competencies and practices anne plantade-gipch a, nady van broeck b, koen lowet c, eleni karayianni d, maria karekla d [a] school of practitioners psychologists, paris, france. [b] university of leuven, leuven, belgium. [c] flemish association of clinical psychologists, beringen, belgium. [d] university of cyprus, nicosia, cyprus. clinical psychology in europe, 2020, vol. 2(4), article e2601, https://doi.org/10.32872/cpe.v2i4.2601 received: 2019-12-20 • accepted: 2020-10-19 • published (vor): 2020-12-23 handling editor: anton-rupert laireiter, university of vienna, vienna, austria corresponding author: anne plantade-gipch, 23 rue du montparnasse, 75006 paris, france. tel: +33 6 37 11 30 14. e-mail: aplantade@psycho-prat.fr abstract in 2017, the european federation of psychologists associations made a statement on psychotherapy. it recognizes that psychotherapy is a “special competence” practiced by psychologists, and that psychologists practicing psychotherapy receive specific education, including supervision. the statement also stresses that they have demonstrated competencies in scientifically validated or established theories on human emotions, cognitions, and behavior, and on processes of development, as well as the application of these methods to achieve change. moreover, the declaration recognizes that they are trained in the scientific application of the methods of change based upon these theories. within the standing committee of psychology and health in collaboration with the s-eac, the group on psychotherapy is presently working on a conceptual framework and on guidelines for psychotherapy practiced by psychologists. this document is starting to define the necessary skills and competencies for european psychologists practicing psychotherapy. it also makes recommendations for basic training, for the development of practical skills and competencies, for continuing professional development, and for ethical decision making. it especially puts forward psychologists’ scientific approach to psychotherapy. keywords psychotherapy, competencies, specificities of psychotherapy practiced by psychologists, psychologists’ scientific approach to psychotherapy in europe, the practice of psychotherapy among psychologists is diverse. as such, it is important to identify the common ground for the work of european psychologists practicing psychotherapy. the european federation of psychologists associations (efpa) this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i4.2601&domain=pdf&date_stamp=2020-12-23 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ offers the possibility of obtaining a europsy specialist certificate in psychotherapy1 for psychologists who meet specified requirements. this certificate can be awarded to psychologists individuals who already possess a basic europsy certificate and who meet the specified training and supervised practice criteria laid out by the specialist certificate. also, in 2016, a reflection on the skills and competencies of psychologists practicing psychotherapy was launched in france, under the auspices of the french federation of psychologists and psychology. a first working document was developed, which served as a basis to build upon the proposed guidelines. in 2017, during its general assembly, the european federation of psychologists associations (efpa) created the psychotherapy group within the standing committee of psychology and health, which started an exploration around the practices of european psychologists practicing psychotherapy. at the time, the group included representatives from portugal, belgium, cyprus, and france. one of the core principles specified is that the practice of psychotherapy by psychologists is based on scientific evidence. in its two year’s work plan, the group focused on several topics relating to practice, such as skills and competencies, basic training, continuing professional development, and ethical decision making. the current paper presents the work on skills and competencies of this group so far. it is formulated in terms of expectations concerning european psychologists’ practice of psychotherapy. this work will continue to be developed in the years to come. psychotherapy definition: a difficult consensus to reach working on guidelines for psychologists practicing psychotherapy is not simple. indeed, such a reflection requires a clear definition of psychotherapy. despite various descrip‐ tions of what constitutes psychotherapy provided by both researchers and professional psychologist associations, there is no consensus regarding its definition, especially as uniquely practiced by psychologists. existing descriptions present a tendency to polarize psychotherapy, either highlighting the active psychological treatment components or emphasizing the therapeutic relationship and encounter. this split is often related to schools of thoughts, whose epistemological foundations diverge, especially from the point of view of human nature and development, which results in different underlying intervention objectives. also, a chasm often seems to separate research and practice, which is problematic as it hinders achieving one complete and comprehensive definition of psychotherapy (goldfried et al., 2014). traditionally, the practice of psychotherapy by psychologists was part of a continuum of care, with, on the one hand, interventions promoting self-exploration, and on the other, therapeutic actions based on counseling 1) the s-eac-psypt is an efpa body functioning under the eac (europsy awarding committtee) who is responsible for the granting of the europsy specialist certificate for psychologists specialized in psychotherapy. reflecting on psychotherapy practice for psychologists 2 clinical psychology in europe 2020, vol.2(4), article e2601 https://doi.org/10.32872/cpe.v2i4.2601 https://www.psychopen.eu/ principles. for efpa, the following definition of psychotherapy suggested by norcross (1990) attained consensus in 2017 between member associations: “psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable” (efpa, 2017; norcross, 1990). this definition served as a basis for drawing up the initial recommendations made in this paper, concerning the skills expected of psychologists practicing psychotherapy. the practice of psychotherapy in our profession is based on the acquisition and use of established evidence-based psychotherapeutic methods and techniques and scientific knowledge. psychologists practicing psychotherapy stay informed about the most recent scientific developments concerning methods and techniques, as well as the effectiveness of the therapeutic approaches. the scientific approach to psychotherapy, as practiced by psychologists, is grounded in sound explanatory models of human behavior, emotion, personality, and development. this scientific approach includes the importance of deriv‐ ing interventions on evidence-based data, as well as adjusting the intervention to the particular situation of the patient, taking into account life contexts, personal characteris‐ tics, culture, preferences and values (american psychological association [apa], 2006). in this group we believe that scientific investigation of our therapeutic approaches and techniques should be an aim, to ensure that individuals in need receive the best care possible for their problem and circumstances. the practice of psychotherapy by psychologists is overall characterized by a concern for the mental health and overall functioning of the patient, as well as by the rigor of its methods, resulting from scientific data and practical reasoning, as well as based on sound theoretical grounds (efpa, 2005). the advanced skills and competencies outlined in this paper for psychologists practicing psychotherapy are at their infancy and the work is yet to be finished. in the coming years, this work will be expanded through a project group especially formed by efpa, and competencies and skills of psychologists practicing psychotherapy will be further developed. psychological assessment, diagnosis, and case conceptualization prior to intervention psychologists’ basic training places great importance to the thorough assessment of the mental state, psychopathological symptoms and problems, and the life situation of the patient(s). the practice of psychotherapy by psychologists always includes assessment of functioning and of the patient’s context, for the case conceptualization and the formula‐ tion of hypotheses. assessment can be carried out throughout the psychotherapy process according to patient’s problems and demand (ggz standaarden, 2020). assessment is a specific work methodology of the profession that is supported by the scientific literature plantade-gipch, van broeck, lowet et al. 3 clinical psychology in europe 2020, vol.2(4), article e2601 https://doi.org/10.32872/cpe.v2i4.2601 https://www.psychopen.eu/ (apa, 2006). more specifically, psychologists practicing psychotherapy have extensive knowledge in the field of psychopathology, diagnosis, and its assessment using a variety of methods and tools. included in their assessment are means to establish a historical account of difficulties and any previous therapeutic attempts (including medical and pharmacological interventions), contributing and maintaining factors, contextual factors, psychopathological symptoms and variables, and comorbid medical and psychological conditions. for these purposes, it is important that psychologists practicing psychothera‐ py possess a basic knowledge of psychopharmacology as well as the effects of medical problems and treatment on psychopathology. based on their assessment, they first estab‐ lish a case conceptualization where they evaluate the psychological and mental state of the patient, the symptoms and level of functioning within context and in relation to social influences and the person's environment. they establish a diagnosis when relevant (e.g., based on the dsm or icd). they also assess the patients motives and needs for the therapy, their personal and external resources, as well as the subjective and environ‐ mental factors that could hinder the intervention. as a prerequisite to the treatment, psychologists practicing psychotherapy build an intervention plan in collaboration with the patient, which then allows both patient and therapist to be able to appraise the ther‐ apeutic progress. the case formulation constitutes a working hypothesis, in that based on new knowledge and a continuous assessment process during therapy, changes may be made to it and treatment goals modified accordingly. progress is also continuously assessed and utilized to further guide the case conceptualization and therapy (duncan et al., 2010). an expertise in interviewing and psychotherapeutic prevention and intervention techniques psychologists practicing psychotherapy have an expertise in interviewing techniques, utilizing basic clinical skills, which help to be able to mobilize a patient to talk about their problem. the aim is also to collect valuable information during their assessment. psychologists practicing psychotherapy consider the patient's right to self-determination, respecting the rules linked to the therapeutic framework, such as, for examples, neutral‐ ity and abstinence (efpa, 2005). psychologists practicing psychotherapy have a thorough knowledge of intervention techniques belonging to at least one psychological theoretical approach. they utilize a variety of techniques based on the needs of the patient and the context at hand. they work within the limits of a therapeutic framework and a contract, which can be negotiated with the patient. based on their theoretical approach, psychologists practicing psychotherapy possess an amalgam of psychotherapeutic prevention and intervention techniques and tools that can be used to achieve the aims and goals for each specific patient. in addition, reflecting on psychotherapy practice for psychologists 4 clinical psychology in europe 2020, vol.2(4), article e2601 https://doi.org/10.32872/cpe.v2i4.2601 https://www.psychopen.eu/ they possess skills to evaluate the effectiveness of the therapeutic process in a dynamic manner. they make changes in the direction of the intervention as needed, to be able to result in effective behavior change and alleviation of suffering in the patient(s) they serve. a comprehensive understanding of the patient's difficulties during their basic training, psychologists deepen their knowledge of the major psycho‐ logical theories of human behavior, development, and psychopathology. subsequently, they continue to deepen their knowledge in at least one psychotherapeutic theory, grounded in a substantial body of scientific knowledge, and recognized in its applications by the profession of psychologist. psychologists practicing psychotherapy can justify and explain the interventions they suggest to the patient, based on their case conceptual‐ ization and theoretical grounding models. when the situation of the patient requires it and based on their psychotherapy training and their expertise, they may utilize psycho‐ logical intervention techniques arising from other models than their preferred one, in accordance with the patient’s needs and the empirical literature. they consider the limits of their competence and upon agreement of the patient refer to other professionals or theoretical models when needed (efpa, 2005). they perceive the difference between the objectives of their own approach, knowledge and expertise, and the needs and demands of the patient. they are aware of the competences of other health care professionals and are trained to collaborate with other health care disciplines when indicated and agreed upon by the client. maintaining a therapeutic relationship and an alliance scientific research on evidence-based therapeutic relationships has significantly devel‐ oped over the last 30 years. emphasis on the therapeutic relationship heavily influenced the training of practicing psychologists. psychologists practicing psychotherapy are aware of the factors affecting the therapeutic relationship and their effectiveness as therapists, that allow the patients to reach their therapeutic goals (barkham et al., 2017). research demonstrates that certain intrapersonal therapist characteristics (e.g., self-relat‐ edness) may interact with patient characteristics and pathology (baldwin & imel, 2013; heinonen & nissen-lie, 2020). these can aid or alternatively hinder the therapeutic process. psychologists practicing psychotherapy acknowledge these factors and attempt to capitalize on their strengths while aiming to improve on any of their identified weaknesses. they work on taking a step back from the interpersonal difficulties arising plantade-gipch, van broeck, lowet et al. 5 clinical psychology in europe 2020, vol.2(4), article e2601 https://doi.org/10.32872/cpe.v2i4.2601 https://www.psychopen.eu/ in psychotherapy. they give themselves means to analyze these, such as being involved in supervision or peer consultations, or conduct research relating to factors affecting effectiveness (milne, 2009; wampold, 2017). they recognize their own contribution to the therapeutic relationship and consider variations in the alliance (ackerman et al., 2001; castonguay et al., 2006; muran & barber, 2010). specific assessment techniques can be recommended to assess parameters of the therapeutic relationship and to monitor the patients experience of the therapeutic sessions and process (gondek et al., 2016). self-assessment and professional help in difficult situations psychologists practicing psychotherapy evaluate the effects of their interventions as well as the satisfaction of the patient. they recognize their own limits and engage in psychotherapeutic work for which they have demonstrated in depth knowledge and competency. when necessary, they refer to other professionals or approaches having the patients’ needs and well-being as guides. in case of referring out a patient, they ensure a favorable transition to the continuation of treatment (efpa, 2005). continuously learning and updating skills, knowledge, and tools, is an integral part of being a professional. psychologists practicing psychotherapy are required to demonstrate this with continuing education practices. one area that has entered into the practice of assessment and therapy for which previous generations of therapists had not received training is the digitalization of health and mental health and the availability of new opportunities to utilize technology in therapists’ repertoire of practices (van daele et al., 2020). psychologists practicing psychotherapy should demonstrate flexibility and a drive for new learning and updating. maintaining patients’ mental health and wellbeing at the center of the psychotherapy psychologists practicing psychotherapy remain aware of the evolving needs of the pa‐ tient. their intervention is always carried by their professional ethics. they know their code of ethics and how to apply it. they constantly give themselves the means of improving and analyzing situations. the therapeutic process concludes for the benefit of the patients and the consolidation of their therapeutic achievements whilst ensuring that plans are made and resources are known for dealing with difficulties in the future (efpa, 2005). reflecting on psychotherapy practice for psychologists 6 clinical psychology in europe 2020, vol.2(4), article e2601 https://doi.org/10.32872/cpe.v2i4.2601 https://www.psychopen.eu/ conclusion this paper presented an overview of skills and competencies drafted by the efpa group on psychotherapy. there seems to be a relative consensus between member associations of efpa that the practice of psychotherapy by psychologists is based on scientific evi‐ dence and on practitioners’ expertise. psychotherapy, its scientific approach, and practice are at the heart of the identity of the profession of psychologists. in the next few years, the psychotherapy project group of the efpa standing committee on psychology and health will enlist experts from all around europe to tackle issues related to psychothera‐ py as practiced by psychologists. in collaboration with the europsy specialist certificate awarding committee, the work of the group will expand particularly from the point of development of competencies, training new professionals, professional parameters, and ethics. funding: the authors have no funding to report. competing interests: the authors have declared that no 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clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. plantade-gipch, van broeck, lowet et al. 9 clinical psychology in europe 2020, vol.2(4), article e2601 https://doi.org/10.32872/cpe.v2i4.2601 https://www.psychopen.eu/ reflecting on psychotherapy practice for psychologists (introduction) psychotherapy definition: a difficult consensus to reach psychological assessment, diagnosis, and case conceptualization prior to intervention an expertise in interviewing and psychotherapeutic prevention and intervention techniques a comprehensive understanding of the patient's difficulties maintaining a therapeutic relationship and an alliance self-assessment and professional help in difficult situations maintaining patients’ mental health and well-being at the center of the psychotherapy conclusion (additional information) funding competing interests acknowledgments references widespread recommendations can change our habits of hand-washing and physical distance during the covid-19 pandemic research articles widespread recommendations can change our habits of hand-washing and physical distance during the covid-19 pandemic stefanie c. biehl a , melissa schmidmeier a, theresa f. wechsler a, leon o. h. kroczek a, andreas mühlberger a [a] department of clinical psychology and psychotherapy, university of regensburg, regensburg, germany. clinical psychology in europe, 2021, vol. 3(1), article e3061, https://doi.org/10.32872/cpe.3061 received: 2020-04-07 • accepted: 2020-10-28 • published (vor): 2021-03-10 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: stefanie c. biehl, department of clinical psychology and psychotherapy, university of regensburg, universitaetsstraße 31, 93053 regensburg, germany. phone: +49 (0)941 943 6043. e-mail: stefanie.biehl@psychologie.uni-regensburg.de supplementary materials: materials [see index of supplementary materials] abstract background: habits and behaviors in everyday life currently need to be modified as quickly as possible due to the covid-19 pandemic. two of the most effective tools to prevent infection seem to be regular and thorough hand-washing and physical distancing during interpersonal interactions. method: two hundred and eighty-four participants completed a short survey to investigate how previous habits regarding hand-washing and physical distancing have changed in the general population as a function of the current pandemic and the thereby increased information and constant recommendations regarding these behaviors. results: participants aged 51 and older reported a greater change in everyday hand-washing behavior than younger participants. in addition, participants aged 31 and older selected significantly greater distances to have a conversation than younger participants. however, that was not the case if participants had to actively stop their conversational partner from approaching. conclusion: participants aged 51 years and older seem to be well aware of their at-risk status during the current pandemic and might therefore be willing to change their behavior more strongly than younger survey participants. nevertheless, they seem to struggle with enforcing the current rules towards others. the group aged between 31 and 50 years, however, reports a this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3061&domain=pdf&date_stamp=2021-03-10 https://orcid.org/0000-0002-1232-4200 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ comparable level of fear, but no corresponding change in hand-washing behavior. future surveys should try to provide more insight into why this might be the case. keywords covid-19 pandemic, everyday habits, hand-washing, physical distancing highlights • habits and behaviors need to be modified quickly during the current covid-19 pandemic. • participants aged 51 years and older seem to be willing to change their behavior more strongly. • however, they seem to struggle with enforcing some of the current rules towards others. the current covid-19 pandemic forces us to change our everyday lives and associ­ ated habits as quickly as possible. regular thorough hand-washing and physical distanc­ ing have been recommended as two of the most effective tools to prevent infection (bundeszentrale für gesundheitliche aufklärung, 2020). habits regulating these behav­ iors, however, are triggered by similar contextual circumstances, can be implemented using minimal resources, and can be used to predict future behavior in a similar situation (for a review see ouellette & wood, 1998). habitual behavior thus needs to be modified by consciously inhibiting previously established habitual behavior and implementing alternative responses (for a review see gardner, 2015). social psychological models fur­ thermore suggest that social behavior is not only driven by a reflective system based on consequences and probabilities, but also by an impulsive system based on spreading acti­ vation (strack & deutsch, 2004), which can cause fear to at least co-determine behavior. regular thorough hand-washing is already recommended during periods of increased probability of infections to prevent the spreading of infectious diseases like influenza (bundeszentrale für gesundheitliche aufklärung, 2018). previous population-based re­ search, however, does not show a clear reduction in influenza transmission (simmerman et al., 2011) or acute respiratory tract infections (merk, kühlmann-berenzon, linde, & nyrén, 2014) as a function of self-reported hand-washing. of note, the latter inves­ tigation suggested a protective effect for health-care workers, leading the authors to conclude that the knowledge regarding adequate hand-washing might be insufficient in the general population. we implemented a short survey to investigate how previous habits regarding hand­ washing were changed in the general population as a function of the current pandemic and the thereby increased information and constant recommendations regarding ade­ quate hand-washing. we also assessed whether the general public is aware of and able change of habits during the covid-19 pandemic 2 clinical psychology in europe 2021, vol.3(1), article e3061 https://doi.org/10.32872/cpe.3061 https://www.psychopen.eu/ to follow further recommendations, particularly with regard to physical distancing in interpersonal situations. method assessment data were collected for the duration of twelve days, starting on the day of the imple­ mentation of movement restrictions in bavaria (march 21st, 2020) and ending on april 1st. the questionnaire was implemented via evasys (electric paper evaluationssysteme gmbh, lueneburg, germany), an online questionnaire tool operated by the university of regensburg. it consisted of seven questions assessing the frequency of hand-washing in different situations as well as possible changes since the outbreak of the corona virus sars-cov-2. situations were chosen to cover a range of everyday situations, in which hand-washing is recommended (before eating, after entering your flat/house, after blowing your nose, after coughing/sneezing in your hand, after touching another person not living in the same household, after touching an object that is also touched by other people) as well as a baseline item (after using the bathroom). participants were asked to report both the frequency of and the change in hand-washing in these situations on a five-point scale (“0 = never” to “4 = always” and “0 = unchanged” to “4 = very much more”, respectively). data were aggregated to form mean scores across situations with self-reference (before eating, after entering your flat/house, after blowing one’s nose, after coughing/sneezing in your hand) and with other-reference (after touching another person/an object touched by other people), both for frequency and change since the outbreak of the virus. in addition, the questionnaire assessed the use of soap/disinfectant, the adherence to further recommendations to avoid infection (not touching one’s face and physical dis­ tancing), the subjective importance of following the recommendations regarding hand­ washing, and the attention to observing adequate physical distance during interactions. participants were also asked to select interpersonal distances where they a) were current­ ly most comfortable with (passive distancing) and b) would stop someone else from approaching (active distancing) from one of three standardized virtual reality pictures showing an agent at the distances of 1m, 1.5m, and 2m (see figure 1), which were taken as still frames from a virtual reality scenario (vtplus gmbh, würzburg, germany). furthermore, participants’ fear of covid-19 for themselves and for relatives as well as the incidence of pathological hand-washing as occurring in obsessive compulsive disorder (ocd; i.e. washing one’s hands more frequently and longer than necessary) were assessed. biehl, schmidmeier, wechsler et al. 3 clinical psychology in europe 2021, vol.3(1), article e3061 https://doi.org/10.32872/cpe.3061 https://www.psychopen.eu/ figure 1 virtual reality pictures used in the assessment of physical distancing note. standardized pictures from virtual reality with an agent at the distances of 1.5m (1), 1m (2), and 2m (3) taken from an experimental vr-paradigm, joint project optapeb. ©vtplus. participants were informed beforehand that participation in the survey was entirely voluntary and that they could end the survey at any time, in which case no data were transmitted. to comply with current regulations of data protection and to ensure de facto anonymity, age was only collected in the form of age ranges (5 years per range except for 18 to 21 years). care was furthermore taken to keep the survey as short as possible and to not include questionnaires that might cause distress in survey participants (e.g. assess­ ing mental health problems). all participants gave their informed consent to participate in the survey. a link to access the questionnaire was distributed via personal contacts, social media, university mailing lists, and a press release on the university’s home page. participants a total of 284 adults (205 women) between 18 and 75 years of age participated in the survey. while participants’ place of residence was not obtained to ensure anonymity, 93.7% of the sample (266 participants) reported movement restrictions at their place of residence when taking the survey. as this was not the case for 62.5% of the german federal states at the time of data collection (steinmetz, batzdorfer, & bosnjak, 2020), it is likely that most participants lived in bavaria at the time of the survey. overall, 72.2% of participants were aged 40 years or younger, with the largest percentage of participants (30.6%) in the 21 to 25 years age group. to facilitate analyses, participants were assigned to one of the age groups: “young age” (ya, 18-30 years of age; 150 participants); “middle age” (ma, 31-50 years of age; 86 participants), and “best/older age” (oa, >50 years of age; 48 participants). the category “best/older age” was chosen to include all participants with a theoretically increased risk for severe or critical course of covid-19, as the robert koch-institute lists older people as having a steadily increased risk for a severe course of the disease, starting at age 50 to 60. (robert koch-institut, 2021). there was a trend for a greater proportion of women in the ya group, χ2(2) = 5.2, p = .074; see table change of habits during the covid-19 pandemic 4 clinical psychology in europe 2021, vol.3(1), article e3061 https://doi.org/10.32872/cpe.3061 https://www.psychopen.eu/ 1 for descriptive data. most participants (78.9%) reported high-school level education (abitur), with 39.4% of the sample currently attending university. results descriptive data showed a mean frequency of hand-washing across all age groups and situations slightly below the “3 = often” scale point (m = 2.7, sd = 0.8) on a five-point scale (“0 = never” to “4 = always”), and a mean change in hand-washing frequency slightly above the “2 = somewhat changed” scale point (m = 2.3, sd = 1.0), also on a five-point scale (“0 = unchanged” to “4 = very much more”). a repeated measures analysis of variance (anova) for frequency of hand-washing with the factors age group (ya, ma, oa) and situation (self-reference, other-reference) showed a main effect for situation, with participants reporting more frequent hand­ washing in situations with self-reference as compared to situations with other-reference, f(1, 281) = 18.50, p < .001, ηp2 = .062. there was no significant main effect of age group (p = .474) and no significant interaction (p = .879; see figure 2, panel a). figure 2 mean hand-washing frequency and change note. mean hand-washing frequency (a.) and mean change in hand-washing frequency (b.) in situations with self-reference and other-reference for the three age groups (young age, middle age, and best/older age). mean hand-washing frequency on a scale from “0 = never” to “4 = always” (a.) and mean change in hand-washing frequency on a scale from “0 = unchanged” to “4 = very much more” (b.). error bars denote standard error of the mean. **p < .01. ***p < .001. biehl, schmidmeier, wechsler et al. 5 clinical psychology in europe 2021, vol.3(1), article e3061 https://doi.org/10.32872/cpe.3061 https://www.psychopen.eu/ a repeated measures anova for change in hand-washing with the factors age group (ya, ma, oa) and situation (self-reference, other-reference) also showed a main effect for situation. participants reported a greater change of hand-washing in situations with other-reference as compared to situations with self-reference, f(1, 281) = 67.37, p < .001, ηp2 = .193. in addition, there was a significant main effect of age group, f(2, 281) = 6.24, p = .002, ηp2 = .043. post-hoc t-tests for independent samples revealed a greater change in the oa group as compared to the ya group (p = .001) and the ma group (p = .003). the ya and the ma groups were not significantly different (p = .788). there was no significant interaction of age group and situation (p = .756; see figure 2, panel b). importantly, the univariate anova for the baseline item (after using the bathroom) showed no significant effect of age group for either frequency of (p = .130) or change in (p = .834) hand-washing. the repeated measures anova for everyday physical distancing with the factors age group (ya, ma, oa) and distancing (passive, active) showed a main effect for distancing, f(1, 281) = 337.75, p < .001, ηp2 = .546, with participants selecting greater physical distan­ ces in passive than in active distancing. there was no main effect of age group (p = .222). there was, however, a significant interaction of age group and distancing, f(2, 281) = 7.28, p = .001, ηp2 = .049. post-hoc t-tests for independent samples showed significantly higher passive distancing in the oa group compared to the ya group (p = .001) but not to the ma group (p = .200), which also showed higher passive distancing than the ya group (p = .022). in contrast, there were no significant differences between the three groups for active everyday distancing (all ps > .2; see figure 3, panel a). a repeated measures anova for fear of covid-19 with the factors age group (ya, ma, oa) and fear target (self, relatives) showed a main effect for fear target, with participants reporting more fear of covid-19 for relatives than for themselves, f(1, 281) = 404.54, p < .001, ηp2 = .590, and a main effect of age group, f(2, 281) = 4.61, p = .011, ηp2 = .032, with the ya reporting less overall fear than the ma group (p = .007) and the oa group (p = .039). in addition, there was a significant interaction of age group and fear target, f(2, 281) = 3.32, p = .037, ηp2 = .023. post-hoc t-tests for independent samples showed significantly lower fear for themselves in the ya group compared to the ma group (p = .001) and the oa group (p = .005), which were not significantly different (p = .882). in contrast, there were no significant differences between the three groups for fear for relatives (all ps > .1; see figure 3, panel b). change of habits during the covid-19 pandemic 6 clinical psychology in europe 2021, vol.3(1), article e3061 https://doi.org/10.32872/cpe.3061 https://www.psychopen.eu/ figure 3 mean passive and active physical distancing and mean fear of covid-19 note. mean passive and active physical distancing (a.) and mean fear of covid-19 for self and for relatives (b.) for the three age groups (young age, middle age, and best/older age). mean fear of covid-19 on a scale from “0 = not at all” to “4 = very much”. error bars denote standard error of the mean. *p < .05. **p < .01. ***p < .001. general fear of covid-19 was further investigated by calculating bivariate correlations with change in hand-washing frequency, physical distancing, and pathological hand­ washing across all participants. of note, there were significant associations of change in hand-washing frequency and passive physical distancing with both participants’ fear for themselves, r(282) = .19, p = .002 and r(282) = .19, p = .002, respectively, and for relatives, r(282) = .26, p < .001 and r(282) = .17, p = .005, respectively. participants reporting higher fear levels also reported greater changes in hand-washing frequency and more passive physical distancing. in contrast, active physical distancing was not associated with gen­ eral fear of covid-19 (both ps > .08). in addition, general fear of covid-19 for both themselves as well as for relatives was correlated with pathological hand-washing, r(282) = .22, p < .001 and r(282) = .20, p = .001, respectively. participants reporting higher fear levels also reported washing their hands more frequently and longer than necessary (see supplementary materials for group-specific correlations). univariate anovas with the factor age group (ya, ma, oa) yielded no age group differences with regard to the use of soap (p = .103) or disinfectant (p = .448), trying not to touch one’s face (p = .699), the average amount of people not belonging to one’s household met per day (p = .633), or pathological hand-washing (p = .248; see table 1 for all means and standard deviations). biehl, schmidmeier, wechsler et al. 7 clinical psychology in europe 2021, vol.3(1), article e3061 https://doi.org/10.32872/cpe.3061 https://www.psychopen.eu/ table 1 descriptive data for the younger age (ya), middle age (ma), and best/older age (oa) groups behavior ya ma oa m sd m sd m sd use of soap 3.8 0.4 3.7 0.6 3.9 0.5 use of disinfectant 1.4 1.1 1.2 1.0 1.3 1.1 trying not to touch one’s face 2.6 1.0 2.6 1.0 2.7 1.1 average number of people met per daya 3.2 10.6 2.1 5.9 2.5 3.8 pathological hand-washing 1.4 1.1 1.1 1.1 1.4 1.3 importance of observing hand-washing 3.6 0.7 3.6 0.6 3.9 0.4 attention to physical distance 3.4 0.7 3.6 0.6 3.8 0.5 n n female n n female n n female 150 116 86 59 48 30 note. means and standard deviations for use of soap and disinfectant, trying not to touch one’s face, average amount of people met per day, pathological hand-washing, subjective importance of hand-washing, and atten­ tion to physical distancing (on 5-point scales starting at 0) for the three groups. anot belonging to one’s household. there was, however, a marginally significant main effect of age group for the subjective importance of observing the recommendations regarding hand-washing, f(2, 281) = 2.88, p = .058, ηp2 = .020, with the oa group perceiving the observation of these recommenda­ tions as significantly more important than the ya group (p = .025) and the ma group (p = .032). in addition, there was a significant main effect of age group for attention to observing adequate physical distancing during interactions, f(2, 281) = 5.09, p = .007, ηp2 = .035, with the oa group reporting significantly more attention than the ya group (p = .002) and also marginally more attention than the ma group (p = .076). discussion this survey provides some insight into how health behavior habits in different age groups recently changed based on the actual pandemic situation and current recommen­ dations for the prevention of infections. importantly, the survey shows an increase in hand-washing after situations carrying a direct risk of infection by others (touching another person or an object touched by other people). however, conditions might still not allow for consistent hand-washing in these situations as the overall hand-washing is still lower than after situations that do not involve direct contact with others. this should urgently be investigated in further surveys. importantly, overall change in hand-washing frequency was highest in the best/older age group, compared to both the young and the middle age group. it could thus be change of habits during the covid-19 pandemic 8 clinical psychology in europe 2021, vol.3(1), article e3061 https://doi.org/10.32872/cpe.3061 https://www.psychopen.eu/ hypothesized that the best/older age group is well aware of their at-risk status and is therefore willing to change their behavior more strongly than the younger survey participants. indeed, general fear of covid-19 correlated positively with changes in hand-washing frequency and with passive physical distancing. in addition, the best/older age group reports a significantly higher fear of contracting covid-19 than the younger age group. in contrast, the middle age group reports a comparable level of fear, but no corresponding change in behavior. however, when fear of contracting covid-19 was included as a covariate, effect sizes decreased but the reported results still retained significance. previous research showed increased health behavior when the framing of the health message matched participants’ emotional states (gerend & maner, 2011). given the uncertain situation and the emphasis on age as the main risk factor at the beginning of the pandemic, it is understandable that older participants were generally more scared than younger participants. the initial “loss-framed” campaigns focusing on the risk of insufficient hand-washing and physical distancing thus might have led to stronger behavior changes in this age group. should the pandemic worsen again in the future, it might therefore be worthwhile to also focus on “gain-framed” campaigns for the younger age groups stressing the (societal) benefits of hand-washing and physical distancing. in addition, health behavior can be promoted by correcting misperceptions of injunctive norms (reid & aiken, 2013). it might therefore be helpful to provide self-tests of hand­ washing frequency and physical distancing that allow people to compare their own perceptions of acceptable behavior to the parameters actually considered acceptable by a representative sample. with regard to age group differences, the young age group is somewhat less consis­ tent implementing physical distancing in real life. when confronted with a selection of varying physical distances in an interpersonal situation, 12% of survey participants aged 30 or younger chose a distance of only 1 meter to have a conversation. this percentage was significantly lower in both older age groups. however, all participants seem to strug­ gle with enforcing an appropriate physical distance when their conversational partner is not following recommendations. about half of the younger participants (53%) would actively stop their conversational partner from approaching any further at a distance of only 1 meter, with this percentage rising in the middle age group (57%) to almost two thirds (65%) of the best/older age group. as this group is most at-risk for complications from covid-19, clinical psychologists might be called upon to provide assistance by instructing the general public on socially acceptable assertive behavior (e.g. based on hinsch & pfingsten, 2007). clinical psychological research should also monitor the incidence of compulsive washing as seen in obsessive compulsive disorder (ocd). it seems worrisome that fear of contracting covid-19 was associated with self-reported more frequent and longer hand-washing than necessary across all age groups in our sample. according to the biehl, schmidmeier, wechsler et al. 9 clinical psychology in europe 2021, vol.3(1), article e3061 https://doi.org/10.32872/cpe.3061 https://www.psychopen.eu/ classic model of ocd by salkovskis (1985), the reduction of anxiety through neutralizing behavior (i.e. hand-washing) provides powerful negative reinforcement, thereby increas­ ing the likelihood of its occurrence in the future. as the knowledge about ocd in the general public is still rather low (coles, heimberg, & weiss, 2013), clinical psychologists should try to offer expert opinions on the chance of increasing rates of ocd in the wake of the pandemic whenever possible. on a related note, recommendations regarding physical and social distancing could be detrimental for people suffering from depressive disorders or social phobia. this should also be closely monitored in the future. there are also several limitations: the sample in this survey is rather small, self-se­ lected, and probably highly educated, with many participants reporting a high degree of formal schooling and almost 40% attending university at the time of data collection. it would therefore be worthwhile to investigate a larger and more representative sample. as our current sample was too small for meaningful analyses with regard to gender, it would be especially informative for future surveys to examine how the general recom­ mendations are perceived and implemented in men as compared to women and if this changes with increasing age. unfortunately, we did not inquire whether participants were experiencing covid-19 symptoms at the time of taking the survey. future surveys should include this question to allow for more in-depth analyses. in addition, the ob­ served findings were quite likely heavily influenced by the time period of data collection as infections were rising quickly and it was uncertain if and how the epidemic could be controlled in germany at the time. while it is important to have assessed the data for this period in the pandemic, it would be worthwhile to revisit the survey questions at present (after many of the restrictions have been lifted) and examine if the behavioral changes reported earlier are still being maintained. in addition, results might be specific for germany, as government reactions to the pandemic differed in different countries. it would therefore be informative to gather and compare similar data from other countries. overall, it has to be noted that all age groups rate their observance of recommenda­ tions regarding hand-washing and physical distancing as very important and that the use of soap during hand-washing was very high in this sample, suggesting a good knowledge and acceptance of the current recommendations (bundeszentrale für gesundheitliche aufklärung, 2020). a sharp decrease on this year’s influenza rates also testify to the effectivity of the current overall measures with regard to physical distancing (buchholz, buda, & prahm, 2020). our results furthermore show that recommendations given in a pandemic situation can in fact break through relevant habits. whether this effect is mainly based on reflective decision-making (e.g. salient recommendation) or on impul­ sive processes (e.g. actual fear) should be further investigated. an additional challenge is now the long-term maintenance of these new adaptive behaviors as well as the manage­ ment of potential negative effects of physical distancing and increased hand-washing on mental health. change of habits during the covid-19 pandemic 10 clinical psychology in europe 2021, vol.3(1), article e3061 https://doi.org/10.32872/cpe.3061 https://www.psychopen.eu/ funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. supplementary materials the supplementary materials contain the english translation of the items analyzed in the manu­ script (the original items are available from the authors upon request) and group-specific correla­ tions and p-values for fear and age group (for access see index of supplementary materials below). index of supplementary materials biehl, s. c., schmidmeier, m., wechsler, t. f., kroczek, l. o. h., & mühlberger, a. 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(2004). reflective and impulsive determinants of social behavior. personality and social psychology review, 8(3), 220-247. https://doi.org/10.1207/s15327957pspr0803_1 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. change of habits during the covid-19 pandemic 12 clinical psychology in europe 2021, vol.3(1), article e3061 https://doi.org/10.32872/cpe.3061 https://doi.org/10.1186/1471-2334-14-509 https://doi.org/10.1037/0033-2909.124.1.54 https://doi.org/10.1037/a0028140 https://www.rki.de/de/content/infaz/n/neuartiges_coronavirus/steckbrief.html https://doi.org/10.1016/0005-7967(85)90105-6 https://doi.org/10.1111/j.1750-2659.2011.00205.x https://doi.org/10.23668/psycharchives.3019 https://doi.org/10.1207/s15327957pspr0803_1 https://www.psychopen.eu/ change of habits during the covid-19 pandemic (introduction) method assessment participants results discussion (additional information) funding competing interests acknowledgments supplementary materials references clinical psychology in spain: history, regulation and future challenges politics and education clinical psychology in spain: history, regulation and future challenges javier prado-abril a, sergio sánchez-reales b, alberto gimeno-peón c, josé antonio aldaz-armendáriz a [a] department of mental health, aragón healthcare service (spanish national health system), zaragoza, spain. [b] department of mental health, murcia healthcare service (spanish national health system), murcia, spain. [c] department of mental health, principality of asturias healthcare service (spanish national health system), gijón, spain. clinical psychology in europe, 2019, vol. 1(4), article e38158, https://doi.org/10.32872/cpe.v1i4.38158 received: 2019-07-10 • accepted: 2019-09-25 • published (vor): 2019-12-17 handling editor: anton-rupert laireiter, university of vienna, vienna, austria corresponding author: javier prado-abril, aragón healthcare service, plaza de la convivencia, 2, 50017 zaragoza, spain. e-mail: jpradoabril@gmail.com abstract the heterogeneity of national regulations in clinical psychology and psychological treatment across europe requires a detailed description of every regulation to start a shared discussion. in the current paper, we describe the history, legal regulations, a specialized training program, the current status and some future challenges for clinical psychology in spain. the evolution of clinical psychology in the spanish national health system (nhs) towards a health specialty regulated by law, exemplifies a balanced process of expansion, social recognition and professional settlement. overall, the growth of clinical psychology in spain may depend on access to leadership and management positions in the nhs that would allow a better organization of care resources to improve citizens’ access to psychological treatment. keywords clinical psychology, psychological treatment, training, education, national regulation, spain this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i4.38158&domain=pdf&date_stamp=2019-12-17 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • spanish regulation of clinical psychology is mediated by socio-cultural and political changes that occurred in the late 70's and 80’s in the country. • recognition as a licensed clinical psychologist is obtained through a 4-year training system as an intern resident psychologist (pir). • pir is a training system of supervised internships, with increasing autonomy in various healthcare departments in the national health system (nhs). • achieving independent clinical psychology services within the nhs in order to organize, implement and deliver evidence-based practices is currently one of our biggest challenges in the near future. spanish clinical psychology welcomes the creation of the european association of clinical psychology and psychological treatment (eaclipt) and its journal clinical psychology in europe (cpe). in its first issue, laireiter and weise (2019) reviewed and updated the het‐ erogeneity of national regulations in clinical psychology and psychological treatment in europe and invited european clinicians to start a discussion on the matter. as suggested by van broeck and lietaer (2008), this heterogeneity is influenced at least by political is‐ sues, the organization of health care and educational aspects. this paper tries to contrib‐ ute to the discussion with a description of the history, development and current status of clinical psychology in spain. a brief history of clinical psychology in spain spain endured a dictatorship from the end of our civil war (1936-1939) until 1975. the subsequent democratization process ushered in a series of key events, the appreciation of which is necessary in order to understand the development of clinical psychology as a health specialty in our country. in 1978, the new democratic constitution stated in article 43 that spaniards should be entitled to health protection. more specifically, the constitu‐ tion emphasized that public authorities should provide appropriate measures to assist people with mental health problems. in 1986, the general health law (law 14/1986) de‐ veloped the constitutional mandate and established the basis of a public national health system (nhs). from the very beginning, governmental policies tried to develop the high‐ est healthcare standards and welfare benefits for our citizens. likewise, the key element of quality of care became the responsibility of health specialists who had to meet strict and demanding training programs (sánchez-reales, prado-abril, & aldaz-armendáriz, 2013). simultaneously, so-called psychiatric reform in 1985 brought about a significant change in psychiatric care policies in spain: (i) the development of new mental health management structures with an extensive community network of outpatient mental clinical psychology in spain 2 clinical psychology in europe 2019, vol.1(4), article e38158 https://doi.org/10.32872/cpe.v1i4.38158 https://www.psychopen.eu/ health centers, (ii) the integration of care for psychiatric patients into the general health care system, and (iii) the adoption of an interdisciplinary clinical approach (vázquezbarquero & garcía, 1999). interdisciplinary mental health teams allowed psychologists to gradually become part of mental health units in the newly created nhs. at the same time, new faculties of psychology opened in several spanish universities (olabarría & garcía, 2011). prior to this, psychologists did not receive a specific education or bache‐ lor’s degree in psychological science. they used to graduate with a philosophy and let‐ ters degree and obtained a mention in psychology after following a certain academic tra‐ jectory. the institutionalization of psychology was then at its infancy. in the meantime, the nhs created its own training system in the early 80’s mainly for medical specialties (royal decree [rd] 127/1984). the training of health specialists was now entrusted to the nhs rather than universities or other educational institutions. specialized training now fell under the auspices of the nhs and regulated and exclusively controlled by central government (olabarría & garcía, 2011; sánchez-reales et al., 2013). specialties were to be approved by rd at the proposal of the ministries of health and education (rd 639/2014), and competence in non-specialized education was left to universities alone (prado-abril, sánchez-reales, & aldaz-armendáriz, 2014). from 1986 until late into the first decade of the 21st century, spain experienced a po‐ litical process of decentralization. nowadays, health care is provided by autonomous re‐ gional governments (arg). they manage health care plans and are the main public health care providers. nonetheless, certain national controls are preserved to guarantee equal access to nhs services and healthcare assistance (law 16/2003). some arg as‐ sumed health competences before others. these regions pioneered training programs in clinical psychology. these training programs followed the training model that was al‐ ready established for medical specialties based on internship and placements. the princi‐ pality of asturias was the first arg to promote a clinical psychology training program in 1983 (garcía solar et al., 1986). andalusia and castile-leon in 1986 and navarre in 1988 followed (aparicio, 1990). training was based on several supervised internships on dif‐ ferent mental health placements in hospitals and other public health services. this was professionalizing and remunerated employment. trainees were allowed increasing clini‐ cal autonomy and responsibilities during the three-year training. in 1993, the first national call took place once regional trial programs were considered successful (olabarría, 1998). access to training was based on a national psychology test. since then, the pir test call (for its acronym in spanish, test of access to specialized health training as intern resident psychologist) has taken place every year. access is based on principles of equality, merit and ability (e.g., ministerial order scb/947/2018). later, in 1998, the title of psychologist specialized in clinical psychology (rd 2490/1998) was created and regulated after a complex process of political and professional negotia‐ tions (anpir, 2018). this rd regulates the health specialty in clinical psychology and es‐ prado-abril, sánchez-reales, gimeno-peón, & aldaz-armendáriz 3 clinical psychology in europe 2019, vol.1(4), article e38158 https://doi.org/10.32872/cpe.v1i4.38158 https://www.psychopen.eu/ tablishes the pir system as the only way to obtain this title. however, a transitory homolo‐ gation process was established for practicing psychologists. currently, it is estimated that there could be up to 9,000 clinical psychologists in our country although there is no official register in spain as yet (duro, 2019). as for other health professionals, there are probably three psychiatrists for each clinical psychologist if we take into account that there are twice as many training posts per year for psychia‐ trists and their specialized education began some years before ours. psychotherapy is not a regulated health profession. however, the ministry of health has launched a national register of health professionals1. this will enable us to know, in the near future, the exact number of professionals in each of the regulated health specialties. the process by which clinical psychology became a health specialty regulated by law (rd 2490/1998), with similar administrative, organizational and competence status as medical specialties (law 44/2003), shows how a balanced approach of growth, social rec‐ ognition and professional settlement took place in spain over the past three decades. this was a process that also suffered socio-political, economic, and organizational constraints some of which came from professional psychology corporations (olabarría, 1998; olabarría & garcía, 2011; sánchez-reales et al., 2013). therefore, the presence of clinical psychology in the nhs is intimately related to the process of democratization in spain. legally regulated tasks such as (clinical) assessment, diagnosis, (psychological) treatment, management and team leadership were now recognized as part of the scope of roles of clinical psychologists within the nhs. clinical psychologists now hold full professional autonomy and clinical responsibility without interference from any other health profes‐ sionals and enjoy a similar legal status to any other health specialty (law 44/2003) such as, for example, psychiatrists or neurologists. pir test access, pir training system and psychologist specialized in clinical psychology nowadays, clinical psychology is structured in three different stages: bachelor’s degree in psychology (4 years and 240 ects), non-academic postgraduate specialized training (pir), and continuing education (ce) for specialists or independent practice as psycholo‐ gists specialized in clinical psychology (law 44/2003). however, other educational trajec‐ tories which can improve basic health training are currently under discussion (gonzálezblanch, 2015; prado-abril et al., 2014; sánchez-reales et al., 2013). specifically, the socalled degree-master-pir itinerary is being proposed as the standard access to the pir ex‐ am call from a master’s degree level of university education. this sequential education could be useful to support the progressive acquisition of skills and competences from lower to higher level of expertise. similarly, it would foster a needed mutual understand‐ 1) https://www.mscbs.gob.es/profesionales/registroestatal/home.htm clinical psychology in spain 4 clinical psychology in europe 2019, vol.1(4), article e38158 https://doi.org/10.32872/cpe.v1i4.38158 https://www.mscbs.gob.es/profesionales/registroestatal/home.htm https://www.psychopen.eu/ ing and collaboration between academics and clinicians. it may also promote a reduction in the gap between research and practice. pir posts are annually announced by the ministry of health (141 vacancies this 2019; ministerial order scb/947/2018) and psychologists, who have finished their undergradu‐ ate education, can apply. the exam usually takes place around february every year. those who obtain the best scores can opt for different training placements throughout the nhs and begin their pir specialized training (tables 1, 2) in may. table 1 pir specialized training: distribution and duration of supervised internships periods training program duration (in months) (p1) community care, outpatient mental health and primary care support 12 (p2) primary care 3 (p3) addictions 4 (p4) psychosocial rehabilitation and recovery 6 (p5) acute psychiatric ward, hospitalization and emergencies 4 (p6) clinical health psychology and liaison 6 (p7) child and adolescent clinical psychology 6 (p8) specific training areas 4 (p9) free disposal 3 note. source: order sas/1620/2009, https://www.boe.es/boe/dias/2009/06/17/pdfs/boe-a-2009-10107.pdf table 2 organization and annual planning m1 m2 m3 m4 m5 m6 m7 m8 m9 m10 m11 m12 r1 (p1) community care, outpatient mental health and primary care support m13 m14 m15 m16 m17 m18 m19 m20 m21 m22 m23 m24 r2 (p2) primary care (p3) addictions (p4) psychosocial rehabilitation and recovery m25 m26 m27 m28 m29 m30 m31 m32 m33 m34 m35 m36 r3 (p4 cont.) (p5) ward, hospitalization, emergencies (p6) clinical health psychology and liaison (p7) m37 m38 m39 m40 m41 m42 m43 m44 m45 m46 m47 m48 r4 (p7 cont.: child and adolescent clinical psychology) (p8) specific training areas (p9) free disposal note. m1, m2, etc. = month 1, month 2, etc.; r1, r2, etc. = 1st year intern resident psychologist (pir), 2nd year pir, etc.; p1, p2, etc. = training program 1, training program 2, etc. (see table 1); cont. = continued. source: order sas/1620/2009, https://www.boe.es/boe/dias/2009/06/17/pdfs/boe-a-2009-10107.pdf training lasts 4 years. the exam consists of a psychology general knowledge test with 225 items (plus 10 reserve items) with a 4-option multiple-choice system. testers have 5 hours to complete the exam. the test is composed of an open list of topics including all the contents of the psychology degree. however, a higher percentage of questions are prado-abril, sánchez-reales, gimeno-peón, & aldaz-armendáriz 5 clinical psychology in europe 2019, vol.1(4), article e38158 https://doi.org/10.32872/cpe.v1i4.38158 https://www.boe.es/boe/dias/2009/06/17/pdfs/boe-a-2009-10107.pdf https://www.boe.es/boe/dias/2009/06/17/pdfs/boe-a-2009-10107.pdf https://www.psychopen.eu/ taken from psychopathology, clinical and health psychology, psychological treatment, psychotherapy, psychological assessment and personality and individual differences. the final score is calculated from a formula whereby 90% of the score is obtained from the exam and 10% from the academic record. it is a very demanding access test since there are thousands of applicants and only 189 estimated vacancies for 2020 (source: ministry of health). only one study has evalu‐ ated the characteristics of the applicants that obtain a placement (carreras & morilla, 2010). using a survey completed by 61 out of the 131 intern resident psychologists that began their training in 2010, authors found that the test preparation phase involved an average of 16.11 months of full-time study, with an average 7 study hours a day and a total amount of 2,881 hours before the exam. this scenario contrasts with the number of vacancies offered at degree level by academic institutions that draws an excessive and ir‐ responsible formative bubble that leaves a structural unemployment of 20,000 non-spe‐ cialist psychologists (sánchez-reales et al., 2017). the need to restrict access at degree level and the development of a sustainable profession as a whole is a national controver‐ sy that exceeds the purposes of this paper, but is outlined in sánchez-reales et al. (2017). regarding the pir specialized training, article 21 (law 44/2003) establishes the proce‐ dure to approve the training programs of the health specialties. the national commis‐ sion of the specialty in clinical psychology (ncscp) elaborated and proposed the cur‐ rent training program in 2009 (tables 1, 2). since the ncscp is an advisory committee, the training program was then ratified by the national council of specialties in health sciences of the ministries of health and education (order sas/1620/2009). consequently, after passing the pir test and choosing one of the nhs vacancies, trainees are enrolled at a hospital teaching unit of psychiatry and clinical psychology. this teaching unit will ensure compliance with the program for 4 years. in addition, trainees sign a full-time contract of 37.5 hours a week. they become full members of staff at the health area to which they are attached. their income is around 15,400-22,400 € be‐ fore tax per year depending on different incentives (rd 1146/2006). their clinical practice is supervised by staff clinical psychologists assuming increasing clinical responsibility and professional autonomy over the 4 years of training. this training system fundamentally provides skills and competences to future clinical psychologists for a performance in clinical and healthcare settings. it basically provides skills and legal competence for clinical assessment, diagnosis and psychological treat‐ ment (order sas/1620/2009). however, as a theoretical-technical program, and in coher‐ ence with the eaclipt task force proposal (2019), the training program goes further and establishes four main thematic areas: (i) co-education and training, with other spe‐ cialists in health sciences (doctors, pharmacists, biologists, chemists), in bioethics and professional deontology, healthcare organization and management, health legislation, and research methods; (ii) general theoretical education in clinical psychology (e.g., clini‐ cal sessions, seminars, specific training in psychotherapy schools); (iii) clinical and clinical psychology in spain 6 clinical psychology in europe 2019, vol.1(4), article e38158 https://doi.org/10.32872/cpe.v1i4.38158 https://www.psychopen.eu/ healthcare contents or different internships (table 1); and (iv) continuing care. therefore, as part of future professional challenges, clinical psychologists are enabled for healthcare policy management and leadership of mental healthcare services. nonetheless, most management posts are occupied nowadays by physicians and psychiatrists. the training program also promotes teaching and research and many residents complete their aca‐ demic phd during their training or shortly after finishing it. as in other european countries, there is a close relationship between training in clini‐ cal psychology and psychotherapy, which requires a more detailed explanation. first, clinical psychology holds a broader scope than psychotherapy. despite the progressive expansion of the integrative approach, psychotherapy continues to be a set of schools and name brands (or acronym-defined treatments) with epistemological, theoretical and technical differences sometimes irreconcilable (paris, 2013). instead, clinical psychology in spain was designed from the very beginning, taking inspiration from the boulder mod‐ el (1949; cited in frank, 1984) in order to promote an atheoretical training that combined scientific knowledge with the delivery of professional service mainly from a public health care stance (ávila espada, 1990). right now, we can perhaps say that pir training is a pluralistic and free-school education system, although subject to the requirements of evidence-based practice (american psychological association [apa], 2006). likewise, in licensed clinical psychologists, although they should follow clinical guidelines, integra‐ tive attitudes prevail as shown in a recent national survey (prado-abril et al., under review). it is important to emphasize that training in clinical psychology lays the groundwork for a clinical psychologist to face clinical practice in spain with a broad view (eaclipt task force on “competences of clinical psychologists”, 2019). future sub-specialization may be required in certain mental health settings. we are aware that our pir training system may seem long and excessive in certain european countries. however, it has been emphasized that excellence is a goal in the nhs (law 14/1986) and this is based on hav‐ ing well trained health specialists. from that viewpoint, some contents that appear in table 1 may be better understood. the specific training areas that clinical psychologists pursue could be sub-specialized into psycho-oncology and palliative care, neuropsycholo‐ gy, psychogeriatrics, sexual and reproductive health, eating disorders, personality disor‐ ders or extend 4 more months in child and adolescent clinical psychology, among other options. the free disposal internship placement reinforces this strategy and it allows for a placement in an international mental health institution or in accredited excellence healthcare settings, while keeping their salary. the most common destinations are the united states, argentina and the united kingdom (uk). anpir society offers scholar‐ ships to the best candidates and a list of some of the centers chosen in recent years can be seen in https://www.anpir.org/becas-anpir/. finally, continuing care is a very impor‐ tant part of the program since it allows a supervised continued clinical activity through‐ out the 4 years of training allowing a broader view of clinical practice that sometimes can prado-abril, sánchez-reales, gimeno-peón, & aldaz-armendáriz 7 clinical psychology in europe 2019, vol.1(4), article e38158 https://doi.org/10.32872/cpe.v1i4.38158 https://www.anpir.org/becas-anpir/ https://www.psychopen.eu/ be limited by short-term specific internships. continuing care is carried out in different ways such as the performance of low and high-intensity psychological treatments in in‐ dividual and/or group formats, both in outpatient mental health centers or primary care, liaison programs (in oncology, neurology…) or even, taking part in emergency guards with their psychiatry co-residents. conclusions and future challenges in the last 26 years, clinical psychology in spain has progressively acquired its own iden‐ tity based on a solid specialized health training that also has a clear interest in contribu‐ ting to the development of high-quality public health services. however, spanish clinical psychology faces some important future challenges. the two main future challenges are improving training and citizens’ access to psy‐ chological treatments within the nhs. concerning training, there are suggestive evi‐ dence-based proposals on how to improve supervision and a more individual-focused training (callahan & watkins, 2018; prado-abril, gimeno-peón, inchausti, & sánchezreales, 2019). once training in evidence-based treatments is established, it is crucial to promote those personal and interpersonal attitudes and skills that have proven to influ‐ ence the outcome of psychological treatments (bennett-levy, 2019; heinonen & nissenlie, 2019). the goal is to get our specialists to be flexible while remaining faithful to wellestablished procedures (norcross & wampold, 2018; truijens, zühlke-van hulzen, & vanheule, 2019) and involved in ce throughout their professional life. the second goal is perhaps somewhat more complicated but inspired by the uk expe‐ rience (clark, 2018). primary care-mental health interface programs and stepped care models should be implemented and developed so as to improve access to well-established psychological treatments. this would allow a better management of common mental health disorders that otherwise do not receive adequate treatment and reducing the men‐ tal disorders burden charge (ruiz-rodríguez et al., 2018). catalonia has pioneered this strategy since 2006, so by 2017 all mental health programs in primary care were available for the entire catalonian territory. the rest of the country is still far behind, but the psi‐ cap project (psicología en atención primaria [psychology in primary care]; e.g., gonzález-blanch et al., 2018; ruiz-rodríguez et al., 2018) is gradually helping to change the mindset of health and policy managers. psicap is a national multicentric randomized controlled trial that pursues testing the effectiveness, cost-effectiveness and cost-utility of a transdiagnostic cognitive-behavioral group therapy versus treatment as usual with common mental health disorders in the primary care settings (cano-vindel et al., 2016). other specific challenges that derive from these two major issues listed above are now going to be summarized. in order to carry out a solid and professional mental health care project, we will not only need better trained professionals, but also a greater number of them and, consequently, more than 141 or 189 pir vacancies per year. similarly, devel‐ clinical psychology in spain 8 clinical psychology in europe 2019, vol.1(4), article e38158 https://doi.org/10.32872/cpe.v1i4.38158 https://www.psychopen.eu/ oping child prevention and care requires a greater sub-specialization. the creation and regulation of a child and adolescent clinical psychology specialty is being considered at this moment (source: ministry of health). it will enable clinicians to offer more effective care to children and adolescents. likewise, there is increasing interest in strengthening training in specific areas such as neuropsychology. nevertheless, there is still a lot of re‐ luctance in certain healthcare contexts of the nhs regarding the development and con‐ solidation of clinical psychology, particularly in management or leadership positions. at this point, it should be outlined that the psychiatric reform was an incomplete process due to a counter-reform led by some psychiatrists that gave way, at times to authoritari‐ an, pharmaco-centric biomedical approaches. under these limitations, our attachment to psychiatry services does not make sense anymore. there is now an increasing demand amongst clinical psychologists to create clinical psychology services. it would allow clini‐ cal psychologists to improve service delivery, management and clinical programs based on evidence-based practices without the limitations of a biomedical model that now con‐ trols care policies in mental health in spain, limiting access to proper psychological treat‐ ment. funding: the authors received no financial support for the research, authorship, and/or publication of this article. competing interests: jpa, ssr and agp are members of the board of directors of the spanish national association of clinical psychologists and intern resident psychologists (asociación nacional de psicólogos clínicos y residentes, anpir). acknowledgments: the authors have no support to report. references anpir. 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(1999). deinstitutionalization and psychiatric reform in spain. european archives of psychiatry and clinical neuroscience, 249, 128-135. https://doi.org/10.1007/s004060050077 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. clinical psychology in spain 12 clinical psychology in europe 2019, vol.1(4), article e38158 https://doi.org/10.32872/cpe.v1i4.38158 https://doi.org/10.1002/jclp.22712 https://doi.org/10.1027/1016-9040.13.1.53 https://doi.org/10.1007/s004060050077 https://www.psychopen.eu/ clinical psychology in spain (introduction) a brief history of clinical psychology in spain pir test access, pir training system and psychologist specialized in clinical psychology conclusions and future challenges (additional information) funding competing interests acknowledgments references ok computer? a time analysis of google searches about symptoms research article ok computer? a time analysis of google searches about symptoms keith j. petrie a, kate mackrill a, connor silvester a, greg d. gamble b, nicola dalbeth b, james w. pennebaker c [a] department of psychological medicine, university of auckland, auckland, new zealand. [b] department of medicine, university of auckland, auckland, new zealand. [c] department of psychology, university of texas, austin, tx, usa. clinical psychology in europe, 2019, vol. 1(2), article 32774, https://doi.org/10.32872/cpe.v1i2.32774 received: 2019-01-01 • accepted: 2019-04-02 • published (vor): 2019-06-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: keith j. petrie, psychological medicine, faculty of medical and health sciences, university of auckland, private bag 92019, auckland, new zealand. e-mail: kj.petrie@auckland.ac.nz abstract background: google searches are now a popular way for individuals to seek information about the significance of common symptoms and whether they should seek medical assistance. as analysis of search patterns may help understand the demand for medical care, we examined what times over a 24-hour period and on what days of the week people searched google for information about common symptoms. method: we analysed google searches for symptoms in the united kingdom during the week from july 30 to august 5, 2018 using google trends. we recorded the time points with the highest search volume for 50 common symptoms relative to other searches, and the day of the week with the highest search peak for each particular symptom. results: all of the peak searches for the symptoms we examined occurred during the night between 10pm and 8am. the majority 32/50 (64%) occurred between 3am to 6am with 12/50 (24%) between midnight and 3am. most symptom searches were more common during the week and lowest during the weekend. typically, searches for a particular symptom peaked at a similar time each night over the week. conclusions: searches for symptoms are significantly more common during night-time hours, and particularly between 3 and 6am. symptom searches show relatively stable diurnal and weekly patterns. keywords google searches, symptoms, health anxiety, internet, time of day this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i2.32774&domain=pdf&date_stamp=2019-06-28 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • google searches for health information are common and individuals regularly search for their specific symptoms before deciding whether to seek medical care. • searches for common symptoms are significantly more likely to occur, relative to other searches, during the night-time hours and are highest during the working week and lowest at weekends. • the majority of symptom searches show relatively stable diurnal and weekly patterns. experiencing physical symptoms is very common but it is often difficult for individuals to determine whether the symptom is serious and needs medical attention (pennebaker, 1982; petrie & broadbent, 2019). a recent general population survey showed that individ‐ uals experience an average of five symptoms in a week, while 23% of the sample reported experiencing 10 or more symptoms (petrie, faasse, crichton, & grey, 2014). the meaning of symptoms can often be uncertain and individuals have in the past sought advice from family and friends about whether a symptom is a sign of a serious illness (hartzband & groopman, 2010). however, google is now being used as an alternative resource for un‐ derstanding symptoms, with google searches frequently used by the public to determine the significance and threat posed by particular symptoms and whether medical assistance should be sought (jacobs, amuta, & jeon, 2017). perhaps it is google’s anonymity, accessibility and information availability that has seen health-related searches become the second most searched thematic area amongst all searches (sullivan, 2016), with searches for symptoms now accounting for approximately 1% of the three billion searches each day (pinchin, 2016). in patients specifically, a recent survey of those attending an emergency department found that 49% regularly use the in‐ ternet for health information and 35% had searched for information on their specific symptoms before presenting (cocco et al., 2018). patients can also check their symptoms using online symptom checking algorithms that can provide advice about whether to seek medical care (semigran, linder, gidengil, & mehrotra, 2015). there has been concern raised that such searches may lead to a baseless increase in health anxiety or “cyberchondria” due to the fact that searches for common symptoms are often linked to rare, serious or fatal illnesses (filipkowski et al., 2010; north, ward, varkey, & tulledge-scheitel, 2012; white & horvitz, 2009). given the impact that health anxiety has shown in areas such as healthcare utilisation (barsky, ettner, horsky, & bates, 2001), there is surprisingly little information available on when individuals search for symptoms and how this may relate to utilisation of health care and the demand for out of hours care. time-analysis of google searches 2 clinical psychology in europe 2019, vol.1(2), article 32774 https://doi.org/10.32872/cpe.v1i2.32774 https://www.psychopen.eu/ the access to google search data through google trends has enabled research on how often particular search terms are entered relative to the total volume of searches. this data can also be aggregated for different parts of the world or different time periods. analyses of search terms by google trends has been used to estimate the level of influ‐ enza illness in a population (lampos, miller, crossan, & stefansen, 2015), stock market trends (preis, moat, & stanley, 2013), and to investigate sensitive topics like sexual behav‐ iour, where surveys are likely to lead to misleading data (stephens-davidowitz, 2017). analysis of google trends for symptom searches can provide aggregated data on precise‐ ly when during the day or the week people are more likely to be looking for informa‐ tion about their symptoms and thus offer information about the likely demand for nonurgent care. in this study we examined when individuals searched for common symp‐ toms across a 24-hour period and on what days of the week. based on previous work on the non-urgent demand for emergency department visits in the united kingdom, which showed that the majority of non-urgent attendance occurs late at night or in the early hours of the morning (o’keeffe, mason, jacques, & nicholl, 2018), we hypothesized that google searches about symptoms would follow a similar pattern. method symptoms we used a list of 50 common symptoms to investigate the peak search period for each symptom. forty-seven symptoms were drawn from a previous study investigating the frequency of symptom complaints in a general population sample (petrie et al., 2014). these included common symptoms such as back pain, fatigue, headache, insomnia and joint pain. we also added three other terms to the list. this included “hangover”, due to the frequency of this condition reported in general population studies (gjerde et al., 2010; tolstrup, stephens, & grønbaek, 2014) and its association with emergency room and pri‐ mary care visits (cherpitel & ye, 2015). as it has often been acknowledged that searching benign symptoms in google can produce results suggesting cancer or imminent death (north et al., 2012; white & horvitz, 2009), we included both “cancer” and “death” in the list. google search data google trends (trends.google.com) is a publicly available online tool that allows people to analyse how often a specific term or phrase has been searched in google over a speci‐ fied time period or in a particular geographic region, relative to other searches (nuti et al., 2014). google trends adjusts the data by taking a random sample of searches for a term and computing its popularity relative to the total number of google searches over petrie, mackrill, silvester et al. 3 clinical psychology in europe 2019, vol.1(2), article 32774 https://doi.org/10.32872/cpe.v1i2.32774 https://www.psychopen.eu/ the same period of time. the time point with highest search volume for a term has the value of 100, while a score of 50 indicates half the popularity. a google trends search for the 50 symptoms or conditions of interest in the united kingdom was conducted. if a symptom phrase contained ‘or’, as in fever or increased temperature, this was changed to + in the google trend search. symptoms such as back or neck pain became back pain + neck pain. prior to searching, computer clocks were changed to london time to ensure that the google trend results corresponded to the cor‐ rect time zone. the time period of the search was the week from july 30 to august 5, 2018. we chose this week during the summer period so the data was less likely to be af‐ fected by winter colds and flu viruses. as minutes are only available for time periods of 24-hours or less, wednesday august 1 was taken as the representative day of the week and the time (hours and minutes) that each symptom was searched the most on this day was recorded. the day of the week that had the greatest number of searches for each symptom was also examined. collecting data over short periods, such as the week used in the present study, has demonstrated strong predictive power and representation of fu‐ ture data. for example, collecting data from one saturday-sunday period can forecast economic trends for subsequent months (choi & varian, 2012). the rate of google searches during the day (6am to midnight) and night were calcula‐ ted using www.openepi.com and compared using a mid-p exact method. the median number of symptoms searched for on google during the hours 6am to midnight was compared to the number at night (midnight to 6am) using the wilcoxon non-parametric method and a poisson regression model was to determine whether the number of google searches performed per hour differed. analyses were performed in sas (v 9.4, sas insti‐ tute inc, cary, nc). the significance level was set at p < .05. results we examined the peak time for searches for each of the 50 symptoms and these are illus‐ trated in figure 1. all of the peak searches for symptoms occur between 10pm and 8am. only 3 searches for symptoms (cancer, increased appetite and sexual problems) peak be‐ fore midnight and only 2 (muscle pain and difficulty concentrating) are after 6am. of the remaining symptom searches, the majority 32/50 (64%) occur between 3am to 6am, while 12/50 (24%) are between midnight and 3pm; these include death at 1.48am. the hour with the most symptom searches is 4-5am with 16 (32%) conducted during this period. time-analysis of google searches 4 clinical psychology in europe 2019, vol.1(2), article 32774 https://doi.org/10.32872/cpe.v1i2.32774 http://www.openepi.com https://www.psychopen.eu/ figure 1. peak of searches for common symptoms in united kingdom during the week of july 30 to august 5, 2018. in total there were 45 symptoms reported in the 6 hours from midnight to 6 am (nighttime) (7.5 searched per hour, 95% ci [5.5, 9.9]). during the day (6am to midnight) there were 5 searches in 18 hours (0.28 searches per hour, 95% ci [.01, 0.62]). there were there‐ fore about 7 searches fewer per hour in the day than at night (rate difference -7.2 (-9.4, -5.0) (mid-p exact comparison of rates (p < .0001). significantly fewer symptoms were re‐ ported during the day than at night (median (min, max) 0 (0,2) v 5.5 (0,17) respectively, p = .001). there was a significant difference in the number of counts observed between hour blocks (poisson regression, p < .0001). we next examined the distribution of symptom search peaks over the days of the week we sampled. we found that monday, tuesday and friday had the greatest numbers of peaks of searches for symptoms, each with 10. saturday was lowest with 3 symptoms, while wednesday had 7, thursday 4 and sunday 6. most symptoms (76%) did not differ in the peak pattern of searching across the week. this is illustrated in the top two panels of figure 2, which shows the pattern of searches for cough and vomiting. death also shows a similar daily pattern. an exception is searches for hangover, which show a strong weekly pattern with higher levels over the weekend and lower numbers of searches for hangover symptoms during the week (bottom of figure 2). petrie, mackrill, silvester et al. 5 clinical psychology in europe 2019, vol.1(2), article 32774 https://doi.org/10.32872/cpe.v1i2.32774 https://www.psychopen.eu/ figure 2. weekly pattern of symptom searching for cough, vomiting, death and hangover symptoms. the other symptoms that did not show a strong weekly pattern were increased appetite, sexual problems, low blood pressure, difficulty urinating, muscle weakness, dizziness, bruising easily, agitation, depressed mood, ear or hearing problems and difficulty concen‐ trating. discussion we found searches for symptoms are much more likely to occur relative to other searches during the night-time hours, and particularly between 3 and 6am. most symptom search‐ es show a consistent pattern over the week, with peaks at similar times of night. symp‐ tom searches are more common during the week and lowest during the weekend. the results suggest that individuals with high levels of health anxiety may be advised to re‐ strict google symptom searches during the night-time in order to avoid unnecessary worry and healthcare use brought on by anxiety-provoking search results. another im‐ plication may be for clinicians to ask about, and treat, sleeping problems in patients with high levels of somatic complaints. the pattern of searches for symptoms during the night-time hours is consistent with previous research showing that people are most likely to notice symptoms when they are alone, not distracted by other activity and have time to focus on sensations that they time-analysis of google searches 6 clinical psychology in europe 2019, vol.1(2), article 32774 https://doi.org/10.32872/cpe.v1i2.32774 https://www.psychopen.eu/ rarely notice when immersed in daily life (pennebaker, 1982). the night-time period is also a time when it is difficult to consult medical services about symptom concerns. pre‐ vious analysis of google trends has also noted that searches for the “big” questions such as “what is the meaning of life?” and “is there life on other planets?” also peak between 2 and 4 am (stephens-davidowitz, 2017). the study also highlights the use that can be made of google trends for understanding patient search behaviour around health issues. analysis of google searches has been used recently for understanding how patients man‐ age their gout and arthritis (jordan, pennebaker, petrie, & dalbeth, 2018), whether using google is associated with statin intolerance (khan, holbrook, & shah, 2018) and for see‐ ing if particular internet searches were associated with a subsequent diagnosis of pancre‐ atic cancer (paparrizos, white, & horvitz, 2016). some limitations of the study should be acknowledged. the data is limited to those with internet access and who use google as opposed to other search engines. the data is from only one country and needs replication in other locations and in non-english speaking populations. as we used symptoms as specific search terms, we do not know what exactly the search was about or its context. it is also not possible to get absolute rather than relative numbers of searches. it should also be noted that there is a lack of information on how data from google trends is derived, including the proportion of total searches sampled and the algorithms involved (nuti et al., 2014). bearing these limita‐ tions in mind, it is likely that google trends may in the future provide more insights into how patients use the internet to seek information on health topics and as a driver for seeking health care. it is also important to consider that google searches may have positive effects for pa‐ tients and healthcare professionals alike. for example, a recent survey of adult patients presenting to an emergency department demonstrated that searching for symptoms on google and seeking information online resulted in a more positive doctor-patient interac‐ tion and did not reduce adherence to treatment (cocco et al., 2018). for these patients, it may be that the internet serves as a supplementary resource that provides information that supports the doctor’s opinions and enhances this relationship (wald, dube, & anthony, 2007). however, this is dependent on the information being searched for re‐ flecting the opinion of the health professional; in cases where the two information sour‐ ces are incongruent, the relationship can be negatively affected and patients may become more likely to ignore healthcare professional advice (russ, giveon, catarivas, & yaphe, 2011). as such, while searching for symptoms may have some beneficial outcomes, the extent of this is limited by the accuracy the information searches provide. this research has various implications for health professionals. firstly, a greater un‐ derstanding of patterns of high internet symptom searching may help health professio‐ nals better understand and determine the health anxiety levels of a patient, and how that may contribute to the experience of symptoms. given that patients with higher anxiety levels may be more likely to misattribute general symptoms to an illness (severeijns, petrie, mackrill, silvester et al. 7 clinical psychology in europe 2019, vol.1(2), article 32774 https://doi.org/10.32872/cpe.v1i2.32774 https://www.psychopen.eu/ vlaeyen, van den hout, & picavet, 2004) and are more likely to seek out information about symptoms online (eastin & guinsler, 2006), asking about online search activity may be valuable clinical information. secondly, this research may have significant applications at a population level such as better management of healthcare services. recent research has demonstrated that visits to health websites the preceding night can be used to predict emergency department traf‐ fic on the following day (ekström, kurland, farrokhnia, castrén, & nordberg, 2015). this logic may also be applied to searches for symptoms, where the number of symptoms goo‐ gled may predict emergency department traffic. further research should investigate the predictive validity of google symptom searches, and whether deviations of such from the times and days outlined in the current study have differential implications for healthcare service traffic. funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. references barsky, a. j., ettner, s. l., horsky, j., & bates, d. w. 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(2009). experiences with web search on medical concerns and self diagnosis. amia ... annual symposium proceedings amia symposium, 2009, 696-700. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. time-analysis of google searches 10 clinical psychology in europe 2019, vol.1(2), article 32774 https://doi.org/10.32872/cpe.v1i2.32774 https://blog.google/products/search/im-feeling-yucky-searching-for-symptoms https://doi.org/10.1038/srep01684 https://doi.org/10.1136/bmj.h3480 https://doi.org/10.1037/0278-6133.23.1.49 http://searchengineland.com/google-nowhandles-2-999-trillion-searches-per-year-250247 https://doi.org/10.1111/acer.12238 https://doi.org/10.1016/j.pec.2007.05.016 https://www.psychopen.eu/ time-analysis of google searches (introduction) method symptoms google search data results discussion (additional information) funding competing interests acknowledgments references standardised research methods and documentation in cultural adaptation: the need, the potential and future steps latest developments standardised research methods and documentation in cultural adaptation: the need, the potential and future steps eva heim 1,2 , christine knaevelsrud 3 [1] institute of psychology, university of lausanne, lausanne, switzerland. [2] department of psychology, university of zürich, zürich, switzerland. [3] department of education and psychology, freie universität berlin, berlin, germany. clinical psychology in europe, 2021, vol. 3(special issue), article e5513, https://doi.org/10.32872/cpe.5513 received: 2020-12-27 • accepted: 2021-06-08 • published (vor): 2021-11-23 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: eva heim, university of lausanne, institute of psychology, géopolis, bureau 4114, 1015 lausanne, switzerland. e-mail: eva.heim@unil.ch related: this article is part of the cpe special issue “cultural adaptation of psychological interventions”, guest editors: eva heim & cornelia weise, clinical psychology in europe, 3(special issue), https://doi.org/ 10.32872/10.32872/cpe.v3.si supplementary materials: materials [see index of supplementary materials] abstract background: refugees and asylum seekers in europe are affected by high prevalence of common mental disorders. under the call ‘mental health of refugee populations’, the german federal ministry of education and research (fmer) funded a series of research projects to test evidencebased psychological interventions among refugee populations in germany. in addition, the “task force for cultural adaptation of mental health interventions for refugees” was established to develop a structured procedure for harmonising and documenting cultural adaptations across the fmer-funded research projects. method: a template for documenting cultural adaptations in a standardised manner was developed and completed by researchers in their respective projects. documentation contained original data from formative research, as well as references and other sources that had been used during the adaptation process. all submitted templates and additional materials were analysed using qualitative content analysis. results: research projects under the fmer call include minors, adults, and families from different origins with common mental disorders. two studies used and adapted existing manuals for the treatment of ptsd. four studies adapted existing transdiagnostic manuals, three of which had already been developed with a culture-sensitive focus. four other studies developed new this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5513&domain=pdf&date_stamp=2021-11-23 https://orcid.org/0000-0001-7434-7451 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ intervention manuals using evidence-based treatment components. the levels of cultural adaptation varied across studies, ranging from surface adaptations of existing manuals to the development of new, culture-sensitive interventions for refugees. conclusions: cultural adaptation is often an iterative process of piloting, feedback, and further adaptation. having a documentation system in place from start helps structuring this process and increases transparency. keywords cultural adaptation, refugees, randomised controlled trials, documentation, monitoring, formative research highlights • a series of evidence-based psychological interventions are tested among refugees in germany. • a structured procedure for harmonising and documenting cultural adaptations was developed. • cultural adaptation is often an iterative process of piloting, feedback, and further adaptation. • documenting the decision-making process, based on evidence from formative research, is key. in view of the increasing numbers of refugee populations worldwide (unhcr, 2020) and the high prevalence of common mental disorders among them (turrini et al., 2017), there is an urgent need for evidence-based mental health interventions to target these populations. according to the world health organization (who, 2017), common mental disorders include depression, anxiety, and posttraumatic stress disorder (ptsd). substantial empirical evidence reveals cultural variation in how symptoms of com­ mon mental disorders are expressed (haroz et al., 2017; kohrt et al., 2014). in addition, culture-specific assumptions about mental health and mental disorders (e.g., grupp et al., 2018; kohrt & hruschka, 2010) and beliefs about treatment and recovery (e.g., reich et al., 2015; shala et al., 2020) have been documented. based on this evidence, the term cultural concepts of distress (ccd) was introduced in the diagnostic and statistical manual of mental disorders, fifth edition (dsm-5, american psychiatric association, 2013). ccd include i) idioms of distress, ii) cultural explanations, and iii) cultural syndromes (lewis­ fernández & kirmayer, 2019). evidence shows that ccd differ from diagnostic categories in the dsm (kohrt et al., 2014). there is an ongoing debate on the extent to which psychological interventions de­ veloped in western, educated, industrialised, rich, and democratic (weird) societies (henrich et al., 2010) require cultural adaptation to be effective for the treatment of common mental disorders among ethnic and cultural minorities. ethnic minorities are generally underrepresented in clinical trials in high-income countries (hussain-gambles standardised research methods and documentation in cultural adaptation 2 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://www.psychopen.eu/ et al., 2004; la roche & christopher, 2008; wendler et al., 2005), which means that the term ‘evidence-based interventions’ has to be used with caution in this context. for this reason, the who and other groups of researchers increasingly invest in cultural adaptation of psychological interventions prior to testing them in randomised controlled trials (rcts) (e.g., abi ramia et al., 2018; heim et al., 2019; tol et al., 2018). resnicow et al. (1999) differentiate between surface and deep structure adaptations. surface structure adaptations refer to matching materials (e.g., illustrations, language), as well as channels and settings for treatment delivery to observable characteristics of the target population. by contrast, deep structure adaptations convey salience of an intervention by considering how members of a particular cultural group perceive the cause, course, and treatment of a particular illness. several meta-analyses showed that culturally adapted psychological interventions are effective when compared to a variety of control conditions (e.g., chowdhary et al., 2014; griner & smith, 2006). one meta-analysis (hall et al., 2016) found that culturally adapted versions were more effective than the unadapted versions of the same intervention in direct comparison (g = 0.52). and one meta-analysis showed that the adaptation of the ‘illness myth’ (i.e., the explanatory model and the treatment rationale) was the most important factor contributing to higher efficacy of adapted interventions (benish et al., 2011). although the meta-analytic evidence seems promising, it is important to mention that it is based on rather low quality of evidence, caused by the following three specific flaws in prior studies: first, there is a lack of theoretical underpinnings in cultural adaptation literature. most of the literature is based on heuristic frameworks that were developed based on expert opinions and previous studies. a theory-based approach that takes into account literature from the field of cultural clinical psychology and transcul­ tural psychiatry could potentially contribute to a better understanding of what to adapt and why. second, previous frameworks for cultural adaptation have focused on clinical practice (e.g., bernal et al., 2009; castro et al., 2010; chu & leino, 2017; hwang, 2006), but there are no frameworks or guidelines for implementing and documenting cultural adaptations in psychological trials. this is a particularly relevant gap in the literature, as it hinders the replicability and transparency of trials, both of which are increasingly demanded in the scientific realm. in most published studies, adaptation methods are not well documented (harper shehadeh et al., 2016), which leads to a ‘black box’ with regard to how the cultural adaptation was implemented. this lack of documentation also adds to blurring sources of bias when assessing and analysing factors of intervention efficacy. third, and as a consequence of the first two flaws, there is a lack of empirical evidence on the kinds of adaptations that lead to higher acceptability or efficacy of treatments (heim & kohrt, 2019). in order to foster empirical research and replicability, transparent criteria on how to implement and document the process of cultural adaption are needed (heim et al., 2021, this issue). heim & knaevelsrud 3 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://www.psychopen.eu/ to address the first problem — the lack of theory — heim and kohrt (2019) developed a new conceptual framework for the cultural adaptation of psychological interventions as a basis for empirical research. the authors suggest using ccd as the pivotal element for cultural adaptation and to adapt treatment elements to ccd. treatment elements are defined in accordance with a taxonomy developed by singla et al. (2017). this taxonomy differentiates among specific treatment elements (i.e., interventions based on theoretical assumptions such as behavioural or cognitive treatment elements), unspecific treatment elements (i.e., common factors such as the therapeutic relationship or provid­ ing a meaningful treatment rationale), and therapeutic techniques (i.e., exercises and other interventions that are done to transmit the therapeutic components, such as role plays or homework). in accordance with resnicow et al. (1999), adaptations of specific and unspecific treatment elements are deep structure adaptations. with regard to surface adaptations, heim and kohrt (2019) suggest considering different modes of treatment delivery (e.g., internet-based, face-to-face, and group interventions). in addition, surface cultural adaptations include, for example, modifications to texts, illustrations, or case examples. the present paper addresses the second problem, the lack of documentation. it outlines the work and outcomes achieved by the task force for cultural adaptation of mental health interventions for refugees. this task force was established by a group of researchers from germany and switzerland. in 2016, the german federal ministry of ed­ ucation and research (fmer) launched a call for research proposals covering the ‘mental health of refugee populations’. seven research projects were funded. one exclusively focuses on diagnostics, and the other six projects will test evidence-based psychological interventions. each of those six projects consists of three or more sub-projects, in which different interventions with different target groups are tested, implementation methods are compared, and other aspects such as cost-effectiveness are addressed. a total of 11 rcts (rcts) will be conducted within these six larger projects. these research projects are currently ongoing. a total of 11 rcts will be conducted within these six larger projects. the task force for cultural adaptation of mental health interventions for refugees was launched as a cross-cutting project to harmonise and document cultural adaptation across the 11 sub-projects. the parallel implementation of 11 rcts that include diverse target populations and a variety of interventions offered a unique opportunity to develop and test such a standardised procedure and to consolidate the experiences in a shared learning process. regarding the third problem — the lack of empirical evidence — more consistent doc­ umentation of cultural adaptation procedures will contribute to enhancing transparency and replicability in clinical trials. consistent documentation will also foster meta-analytic evidence, as it will be possible to compare studies with regard to the level (and quality) of cultural adaptation applied in such trials. standardised research methods and documentation in cultural adaptation 4 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://www.psychopen.eu/ aim the task force for cultural adaptation of mental health interventions for refugees aimed to develop a structured procedure for harmonising and documenting cultural adaptations of psychological interventions in clinical trials. the present paper describes the proce­ dures and outcomes of this joint initiative. method procedures the task force started its work in july 2019. it consisted of the coordinator (first author, eh) and representatives of the 11 rcts. representatives were principal investigators and post-doctoral researchers in charge of the cultural adaptation process in each study. in a first step, the coordinator revised the project descriptions and gathered additional information in telephone interviews with representatives of each project. after these initial contacts, a first workshop was held in september 2019 in which the members of the task force agreed on a common procedure to guide and monitor the cultural adaptation process across the 11 projects. thereafter, a series of webinars and conference calls was held between october and december 2019 to discuss upcoming topics in the cultural adaptation process. in a second workshop, which was held in february 2020, all members of the task force presented their results of the cultural adaptation process. experiences were shared and consolidated in small group discussions about specific topics. documentation a template for documenting cultural adaptations in a standardised manner was devel­ oped based on the theoretical framework by heim and kohrt (2019). it consisted of the following sections: i) target group; ii) formative research methods; iii) ccd (i.e., idioms of distress, explanatory models); iv) target intervention; v) deep structure adaptations (i.e., specific and unspecific elements, in-session techniques); and vi) surface adaptations (i.e., mode of delivery, materials). researchers in their respective projects used the tem­ plate to document the cultural adaptation process. this documentation contained origi­ nal data (e.g., gathered through key informant interviews of focus group discussions), as well as references and other sources that had been used during the adaptation process (e.g., published papers on ccd in the target population, pilot studies, or formative work). a revised version of the template can be found in heim et al. (2021), this issue. heim & knaevelsrud 5 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://www.psychopen.eu/ data analysis all submitted templates and additional materials were entered into an nvivo database and analysed using qualitative content analysis. codes corresponded to the sections of the template (i.e., target group, ccd, elements of the target intervention, etc.). a few sub-codes were developed inductively from the data, where researchers had provided information that did not correspond to one of the sections of the template (e.g., cultural concepts of attachment). data were analysed by the first author (eh). since researchers themselves had allocated information on their projects to the corresponding sections and sub-sections of the template, no second coder was involved in the data analysis. dis­ agreements were clarified between the first author and researchers who had completed the template. results overview of studies an overview of the 11 projects is provided in table 1 in the appendix, supplementary materials). eight of the 11 sub-projects returned the completed templates and additional material. the other three had already completed the cultural adaptation, with limited possibilities to document this process. in four studies, the process of cultural adaptation was documented retrospectively by analysing qualitative data collected during the adap­ tation process that had not been analysed nor published. and four studies adapted their interventions during the course of the present project and documented this process continuously. target populations and disorders the first section of the template contained the target population and the ‘western’ diag­ nostic categories addressed in the respective trials. three studies focused on minors, five on adults, and two on families (i.e., parents and their children). the majority (seven stud­ ies) included refugees from different countries of origin, three studies included afghan and syrian refugees, and one study included arabic-speaking refugees. studies including refugees from different countries of origin developed a ‘culture-sensitive’ rather than a ‘culture-specific’ treatment approach (e.g., lotzin et al., 2021, this issue). across the 11 projects, the targeted disorders were post-traumatic symptoms (five studies), common mental disorders (three studies as primary outcome, and one study as secondary out­ come), and substance use disorder (one study). in addition, one study aimed at increasing knowledge about common mental disorders, psychological resources, and services of care (mewes et al., 2021, this issue). standardised research methods and documentation in cultural adaptation 6 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://www.psychopen.eu/ formative research methods researchers in the respective projects gathered relevant information for cultural adap­ tation from published literature and through qualitative research. formative research revealed information related to ccd, as well as information regarding the target inter­ ventions themselves (e.g., acceptance, suggestions for adaptations). a literature review was conducted in all but one project. in three studies, information on ccd (i.e., idioms of distress and explanatory models) was gathered through focus group discussions or individual interviews ahead of starting the process of cultural adaptation. cultural concepts of distress results of literature reviews and qualitative research revealed mind–body concepts, idioms of distress, and explanatory models, which are described more in detail in the respective papers in this special issue. in addition to ccd, other related concepts were taken into account: two studies considered assumptions about help-seeking, and one study reported on cultural concepts of attachment. in addition, four studies reported that fatalistic beliefs were relevant in their target populations. and one study also included cultural resources alongside ccd. target interventions the studies varied with regard to their therapeutic approaches. two studies used and adapted existing manuals for the treatment of ptsd. four studies adapted existing trans­ diagnostic manuals, three of which had already been developed with a culture-sensitive focus. four other studies developed new intervention manuals using evidence-based treatment components. cultural adaptations: surface and deep structure the levels of cultural adaptation varied across studies, ranging from surface adaptations of existing manuals to the development of new, culture-sensitive interventions for refu­ gees. other studies conducted deep structure adaptations of existing interventions, such as by adding, changing, or modifying specific treatment components. in addition, several studies considered the mode of delivery of the intervention, such as online vs. face-to­ face, or group vs. individual. most studies described surface adaptations (resnicow et al., 1999), such as the use of a culture-specific or culture-sensitive language, the inclusion of specific idioms of distress, the use of illustrations and non-verbal material for non-ger­ man speaking participants, or the consideration of gender-related aspects and religious concerns (e.g., not offering food in a closing ritual during ramadan). psychoeducation materials were culturally adapted in most studies, and psychoeduca­ tion was extensively discussed during the second workshop of the task force. some of the considerations around psychoeducation involved metaphors and analogies to describe heim & knaevelsrud 7 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://www.psychopen.eu/ the therapeutic process, such as the wound metaphor (trauma as a wound), the process of healing (e.g., of a broken leg), psychotherapy as training (e.g., muscle training), or the metaphor of the messy cupboard that must be cleaned up. another relevant issue in psychoeducation concerned mental health-related stigma, which was addressed in some studies through normalising, the use of non-stigmatising terms, or using an encouraging rather than a problematising language. regarding specific therapeutic elements, all studies conducted a careful analysis of interventions to address the most common symptoms of psychological distress in their respective target populations. as an example, three studies discussed the inclusion or exclusion of problem solving in their respective interventions (böttche et al., 2021, this issue; kananian et al., 2021, this issue; unterhitzenberger et al., 2021, this issue). this discussion showed that, on the one hand, problem solving seemed to be a helpful inter­ vention to address the refugees’ most pressing concerns, such as asylum status or family reunification. on the other hand, problem solving seemed to be overly cognitive for some participants, and it bears the risk that such practical problems become more important than the psychotherapeutic work in the sessions. the discussion across the three projects contributed to finding ways to use problem solving while keeping these downsides to a minimum. documentation process the level of detail of information provided in the adaptation template varied across stud­ ies. researchers in two studies used the template to guide and document their process of cultural adaptation, whereas two other studies (and four sub-studies) used it to structure the documentation process retrospectively. this was mainly because in these projects, an iterative process of intervention development, cultural adaptation, and piloting had been implemented before acquiring the funding for the rcts, and hence before the task force had started its work. during the project, it became clear that the template required more detailed instruc­ tions on the information required in the sub-sections. in addition, researchers expressed difficulties in making decisions about cultural adaptations based on the evidence they had gathered on their target population. two studies specifically focused on this deci­ sion-making process from formative research to adaptation (i.e., böttche et al., 2021, this issue; lotzin et al., 2021, this issue). only one study documented the decision-making process itself, that is, the opinions expressed by the different researchers on the team. discussion despite the growing body of literature on cultural adaptation of psychological interven­ tions, there is still a lack of evidence on adaptations that will contribute to increase standardised research methods and documentation in cultural adaptation 8 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://www.psychopen.eu/ the feasibility, acceptance, and efficacy of such interventions. we have argued that this is mainly due to a lack of theory-based approaches to cultural adaptation (heim & kohrt, 2019), of systematic documentation (harper shehadeh et al., 2016), and of rigorous empirical studies. in this project, a standardised documentation procedure was developed and applied across 11 studies that will evaluate psychological interventions in clinical trials with refugee populations in germany. the parallel implementation of 11 rcts with refugee populations provided a unique opportunity to develop and test such a standardised procedure and to better understand the process, challenges, and specific requirements of cultural adaptation in psychological trials. experiences in this project revealed important lessons learned concerning the content (i.e., what) and the process (i.e., how) of cultural adaptation. regarding content, researchers in this task force described both surface and deep structure adaptations (resnicow et al., 1999). surface adaptations are increasingly descri­ bed in the literature (e.g., chowdhary et al., 2014). deep structure adaptations, such as the selection or development of treatment elements in accordance with ccd and other relevant aspects, is less prominent in the literature (hall et al., 2016). based on the theoretical framework by heim and kohrt (2019), several studies included here used ccd (i.e., idioms of distress, explanatory models, and culturally salient symptoms) as a starting point for cultural adaptation. aside from ccd, other aspects that are relevant for cultural adaptation were mentioned, such as cultural resources (mewes et al., 2021, this issue), gender and religious aspects (kananian et al., 2021, this issue), or cultural concepts other than ccd (e.g., attachment). researchers considered the use of specific treatment elements in function of participants’ needs and conditions, such as problem solving (böttche et al., 2021, this issue; kananian et al., 2021, this issue). regarding process, our experiences showed that the documentation system must be in place from the beginning of the adaptation process. in three studies, the adaptation was done in parallel with the work of the task force. in other studies, the adaptation process was documented retrospectively based on unpublished data, and some projects had already completed their adaptation process, with limited possibilities for retrospec­ tive documentation. it became clear that retrospective documentation is very difficult, even if unpublished data are available (e.g., transcripts from focus groups), particularly due to the difficulty to replicate the decision-making process. in addition, our experien­ ces showed that the template for documentation should be simple and contain clear instructions to avoid additional workload for the research staff. decision making is a major challenge in cultural adaptation. only one study docu­ mented the different views of the team members as a basis for decisions (lotzin et al., 2021, this issue). another study mentioned the risk of excluding other groups if adaptations are too specific for one particular group (böttche et al., 2021, this issue). our experiences show that the decision of what to adapt, and why, remains a subjective heim & knaevelsrud 9 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://www.psychopen.eu/ process to some extent. in view of transparency, it is therefore essential to document the considerations behind this process, the different views of team members, and the strength of evidence that supported decisions. that said, a further process-related lesson learned is that cultural adaptation takes time. several studies went through an iterative process of piloting, feedback, and further adaptation. some of the projects used culture-sensitive interventions and further adapted them to their target population (böttche et al., 2021, this issue; kananian et al., 2021, this issue; lotzin et al., 2021, this issue). keeping track of this process and documenting the different stages of adaptation is a labour-intensive and time-consuming process. one study concluded that the balance between investment (i.e., time and financial expen­ diture) and outcome was not yet determined (böttche et al., 2021, this issue). indeed, experimental studies are needed to determine the effects of cultural adaptation on the feasibility and effectiveness of interventions (heim et al., 2020). the present paper has several limitations. first, due to administrative reasons, not all project included in the task force were in the same adaptation phase when the task force started its activities. some projects had concluded their cultural adaptation process, while other studies conducted the cultural adaptation as part of the task force activities. how­ ever, this allowed for considering challenges occurring at different moments throughout the cultural adaptation process, which enhanced the richness of our lessons learned. second, all studies included in this task force were conducted in germany, which limits the generalisability to other contexts. and third, this task force focused on the process of documentation only. examining the effect of cultural adaptation on trial efficacy was beyond the scope of this task force. the main focus of this task force was on establishing a standardised documentation system, which will hopefully be an important step in guiding and improving the quality of cultural adaptation research in the future. based on our experiences, a sub-group of the task force elaborated a set of reporting criteria for cultural adaptation in psychological trials (recapt), which are presen­ ted in this special issue (heim et al., 2021, this issue). as a next step, experimental research is needed to determine the impact of surface and deep structure adaptations on the acceptability and effectiveness of psychological interventions. such experimental research may include rcts comparing different levels of cultural adaptation (heim et al., 2020) or other research designs like factorial experiments. in addition, standardised documentation of cultural adaptation can contribute to meta-analytic evidence, in which the association between levels of cultural adaptation and trial effectiveness is analysed in meta-regression (e.g., harper shehadeh et al., 2016). in view of the increasing need to develop and test psychological interventions for di­ verse cultural and ethnic groups, cultural adaptation can no longer remain the unwanted stepchild in psychological science. over the past decades, high-quality standards have been increasingly applied in clinical trials in general, which are defined in the consort statement (moher et al., 2001). transparency and replicability are increasingly demanded standardised research methods and documentation in cultural adaptation 10 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://www.psychopen.eu/ for clinical trials with psychological interventions, not least as a consequence of the open science movement. it is essential that we request the same level of quality, transparency, and replicability for cultural adaptation in clinical trials with culturally diverse groups and ethnic minorities. by using such high-quality standards, the interventions we devel­ op will hopefully be used, have a positive effect, and help people manage their lives. funding: german federal ministry of education and research (01ef1806h). acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: eva heim is one of the guest editors of this special issue of clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • appendix appendix a provides an overview table of the research projects described in this paper, i.e., target populations, target symptoms and disorders, interventions, and information on the cultural adaptation process. • recapt template a template for documenting the cultural adaptation process that was developed by the “task force for cultural adaptation of mental health interventions for refugees”. a documented version for better understanding is provided, along with an empty template in word format that can be used for future studies. index of supplementary materials heim, e., & knaevelsrud, c. (2021a). supplementary materials to "standardised research methods and documentation in cultural adaptation: the need, the potential and future steps" [appendix]. psychopen gold. https://doi.org/10.23668/psycharchives.5200 heim, e., mewes, r., abi ramia, j., glaesmer, h., hall, b., harper shehadeh, m., ünlü, b., kananian, s., kohrt, b. a., lechner-meichsner, f., lotzin, a., moro, m. r., radjack, r., salamanca-sanabria, a., singla, d. r., starck, a., sturm, g., tol, w., weise, c., & knaevelsrud, c. (2021b). supplementary materials to "reporting cultural adaptation in psychological trials – the recapt criteria" [recapt template]. psychopen gold. https://doi.org/10.23668/psycharchives.5192 heim & knaevelsrud 11 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://doi.org/10.23668/psycharchives.5200 https://doi.org/10.23668/psycharchives.5192 https://www.psychopen.eu/ references abi ramia, j., harper shehadeh, m., kheir, w., zoghbi, e., watts, s., heim, e., & el chammay, r. (2018). community cognitive interviewing to inform local adaptations of an e-mental health intervention in lebanon. global mental health, 5, article e39. https://doi.org/10.1017/gmh.2018.29 american psychiatric association. (2013). diagnostic and statistical manual of mental disorders (5th ed.). american psychiatric publishing. benish, s. g., quintana, s., & wampold, b. e. 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(2017). depression and other common mental disorders: global health estimates. world health organization (licence: cc by-nc-sa 3.0 igo). https://apps.who.int/iris/handle/10665/254610 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. heim & knaevelsrud 15 clinical psychology in europe 2021, vol. 3(special issue), article e5513 https://doi.org/10.32872/cpe.5513 https://doi.org/10.1371/journal.pmed.0030019 https://apps.who.int/iris/handle/10665/254610 https://www.psychopen.eu/ standardised research methods and documentation in cultural adaptation (introduction) aim method procedures documentation data analysis results overview of studies target populations and disorders formative research methods cultural concepts of distress target interventions cultural adaptations: surface and deep structure documentation process discussion (additional information) funding acknowledgments competing interests supplementary materials references the list of competences of clinical psychologists as a professional asset editorial the list of competences of clinical psychologists as a professional asset martin grosse holtforth a [a] university of bern & inselspital bern, bern, switzerland. clinical psychology in europe, 2019, vol. 1(2), article e37420, https://doi.org/10.32872/cpe.v1i2.37420 published (vor): 2019-06-28 corresponding author: martin grosse holtforth, university of bern, clinical psychology and psychotherapy, fabrikstr. 8, ch-3012 bern and psychosomatic competence center, inselspital, haus c.l.lory, u1 59, ch-3010 bern. e-mail: martin.grosse@psy.unibe.ch the eaclipt task force on “competences of clinical psychologists” (this issue; eaclipt, 2019) has proposed a list of core competences of european clinical psycholo‐ gists. the document is a discussion paper that outlines a competence profile that covers both, professional knowledge as well as clinical skills. the list of criteria is not consid‐ ered final, is open to discussion, and shall be updated regularly in interaction with chang‐ ing environments, new scientific evidence as well as national and/or cultural specificities. the list extends existing lists of competences (e.g., by the university college of london, n.d.) by not only defining the competences of psychotherapists as a major sub‐ group of clinical psychologists, but also listing e.g. diagnostic and methodological compe‐ tences. thereby, the list covers a wider and more comprehensive range of knowledge and skills of clinical psychologists. importantly, the task force refrained from defining compe‐ tences of clinical psychologists in reference to overarching theoretical models or schools. by that, clinical psychologists’ competences as well as the quality of their services are defined and may be evaluated regardless of potentially underlying theoretical orienta‐ tion. with the presented list, the task force provides an important service to patients and families, to the profession of clinical psychologists as a whole, to society, to educational institutions and students/trainees, as well as to research. for patients and their families, the list of competencies transparently defines what pa‐ tients can expect to receive from professionals justifiably calling themselves “clinical psy‐ chologist.” thereby, the list may assist potential “customers” and/or patients to navigate through the “psycho-jungle” in search of help for psychological problems and may enable patients to better distinguish between good and not-so-good services. relatedly, the list this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i2.37420&domain=pdf&date_stamp=2019-06-28 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ may also help pinpointing potential malpractice by incompetent, wrong, or fraudulent practice of clinical psychologists. for clinical psychologists as a profession, the list may help to define themselves as a psychology profession, to support the development of a professional identity, as well as to unite clinical psychologists as a group in political and/or professional struggles within respective health care systems. the list may also facilitate communication and coopera‐ tion with health care providers of other professions as well as their societies. depending on the respective national health care system, the list of competences may also help clini‐ cal psychologists to receive reimbursement by health insurances. an internationally agreed-upon list of competences of clinical psychologists will foster clinicians’ mobility across europe by defining standard criteria of clinical psychologists’ expertise and there‐ by facilitate accreditation of professional titles by foreign health care systems. a europe‐ an definition of competences will also facilitate international professional exchange and collaboration within europe and beyond. as strauß and kohl (2009) have shown for the subgroup of psychotherapists, the con‐ ditions of training and practice of clinical psychologists in europe greatly vary depend‐ ing on the respective national health care system and can be expected to vary even more if not only psychotherapists are considered. having an agreed-upon list of competences of clinical psychologists in europe will surely make professional life easier for practising clinical psychologists as well as health administrators. in case the title of “clinical psy‐ chologist” is not yet legally protected and regulated in a particular european country, the list of competences will help to develop legislation related to mental health services in general and clinical psychology in specific. as part of this, the list may also help to devel‐ op and refine quality criteria as well as ethical standards and thereby strengthen the trust in clinical psychologists as a profession. for educational institutions offering teaching and training of future clinical psycholo‐ gists, the list of competences helps to specify the knowledge and skills that students and trainees should attain to receive an academic degree and/or professional title. however, the question which knowledge and which skills should be taught/trained at which level (bachelor, master, postgraduate training) and by which institution(s) will have to be an‐ swered by specialists within a respective national educational and health care system in coordination with respective authorities. future development of potential hierarchies of competences to be sequentially at‐ tained may help to develop curricula at different levels of expertise and thereby poten‐ tially “streamline” teaching and training in clinical psychology. an according optimiza‐ tion by levels of training may reduce the time and money spent by clinical psychologists in training as well as by the society. furthermore, the list of competences may not only help to structure curricula, but in turn, practical experiences with implementing the cri‐ teria within curricula will inform the continuous refinement, extension and revision of the criteria and the curricula. the list of competences of clinical psychologists as a professional asset 2 clinical psychology in europe 2019, vol.1(2), article e37420 https://doi.org/10.32872/cpe.v1i2.37420 https://www.psychopen.eu/ research may also profit from the explication of competence criteria by the eaclipt list. for example, the teaching and training of single skills, such as interpersonal skills, may be evaluated and may lead to scientifically founded recommendations for eventual modifications of training contents and/or procedures. also, the explication of clinical skills will facilitate research including diverse therapists and will help to identify poten‐ tial moderators of skill acquisition. identification of moderators of skill acquisition may aid the individualization of trainings. furthermore, the explication of clinical skills nicely parallels the systematic differentiation and research of moderators, mechanisms, and pro‐ cesses of change in psychotherapy (crits-christoph, connolly gibbons, & mukherjee, 2013; doss, 2004), which may to be applied for examining the wider range of clinical psy‐ chology and may be brought together to advance our theoretical and clinical knowledge. like the list of competences itself, the list of beneficiaries and benefits of the eaclipt list of competences has to be incomplete and can be extended. overall, clinical psychologists having acquired competences as defined by the eaclipt list will have an excellent foundation for their professional practice of clinical psychology in service of fostering the best possible mental health of their patients. references crits-christoph, p., connolly gibbons, m. b., & mukherjee, d. (2013). psychotherapy processoutcome research. in m. j. lambert (ed.), bergin and garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 298–340). new york, ny, usa: wiley. doss, b. d. (2004). changing the way we study change in psychotherapy. clinical psychology: science and practice, 11(4), 368-386. https://doi.org/10.1093/clipsy.bph094 eaclipt task force on “competences of clinical psychologists”. (2019). competences of clinical psychologists. clinical psychology in europe, 1(2), article e35551. https://doi.org/10.32872/cpe.v1i2.35551 strauß, b., & kohl, s. (2009). entwicklung der psychotherapie und der psychotherapieausbildung in europäischen ländern [development of psychotherapy and psychotherapy training in european countries]. psychotherapeut, 54(6), 457-463. https://doi.org/10.1007/s00278-009-0703-5 university college of london. (n.d.). competence frameworks. retrieved from https://www.ucl.ac.uk/pals/research/clinical-educational-and-health-psychology/researchgroups/core/competence-frameworks grosse holtforth 3 clinical psychology in europe 2019, vol.1(2), article e37420 https://doi.org/10.32872/cpe.v1i2.37420 https://doi.org/10.1093/clipsy.bph094 https://doi.org/10.32872/cpe.v1i2.35551 https://doi.org/10.1007/s00278-009-0703-5 https://www.ucl.ac.uk/pals/research/clinical-educational-and-health-psychology/research-groups/core/competence-frameworks https://www.ucl.ac.uk/pals/research/clinical-educational-and-health-psychology/research-groups/core/competence-frameworks https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. the list of competences of clinical psychologists as a professional asset 4 clinical psychology in europe 2019, vol.1(2), article e37420 https://doi.org/10.32872/cpe.v1i2.37420 https://www.psychopen.eu/ evaluation of the factor structure and psychometric properties of the german version of the clinical perfectionism questionnaire: the cpq-d research articles evaluation of the factor structure and psychometric properties of the german version of the clinical perfectionism questionnaire: the cpq-d isabel roth 1, barbara cludius 1 , sarah j. egan 2 , karina limburg 1 [1] department of psychology, lmu munich, munich, germany. [2] school of psychology and speech pathology, curtin university, perth, australia. clinical psychology in europe, 2021, vol. 3(2), article e3623, https://doi.org/10.32872/cpe.3623 received: 2020-04-27 • accepted: 2021-03-30 • published (vor): 2021-06-18 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: barbara cludius, department of clinical psychology and psychotherapy, lmu munich, leopoldstr. 13, 80802, munich, germany. +49 (0)89 2180 5590. e-mail: barbara.cludius@psy.lmu.de abstract background: the aim was to create a german version of the clinical perfectionism questionnaire (cpq-d) and to test its factor structure, reliability, and validity in a non-clinical population. method: we recruited n = 432 participants via an online panel. the factor structure of cpq-d was examined. the convergent, discriminative, and incremental validity was assessed in relation to the frost multidimensional perfectionism scale (fmps) and the positive and negative affect schedule (panas). results: exploratory factor analysis resulted in two factors. factor 1 represented the over evaluation of striving and factor 2 was associated to concern over mistakes. internal consistency was acceptable with ω = .81 for the total score, ω = .77 for factor 1, and ω = .73 for factor 2. convergent, discriminative, and incremental validity was demonstrated. important to note, item 12 should be used with caution since it showed low communality and a low item-total correlation and should therefore be further evaluated in future research. conclusion: the results indicate that the german translated version of the cpq has acceptable internal consistency, convergent, discriminative and incremental validity. future research should test the cpq-d scale further in clinical and non-clinical populations and assess a broader variety of scales to determine validity of the scale. keywords perfectionism, clinical perfectionism questionnaire, german version, validity, factor analysis this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3623&domain=pdf&date_stamp=2021-06-18 https://orcid.org/0000-0003-4814-1497 https://orcid.org/0000-0002-3715-4009 https://orcid.org/0000-0002-4061-8679 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • a german translation of the cpq was tested and validated in a large community sample. • the factor structure equals the english version, revealing two factors of clinical perfectionism. • the cpq-d proved to be a reliable and valid measure in a non-clinical sample. perfectionism is the tendency to set very high standards and to critically evaluate one’s own behaviour (frost, marten, lahart, & rosenblate, 1990). the construct of perfection­ ism is usually defined as multidimensional and mostly assessed with two multidimen­ sional perfectionism scales (fmps; frost et al., 1990; hmps; hewitt & flett, 1991). factor analyses of the two scales have consistently resulted in two factors: perfectionistic striv­ ings and perfectionistic concerns (stöber & otto, 2006). perfectionistic strivings refer to striving for high standards and perfectionistic concerns refer to concerns over mistakes and the belief others hold high standards of the individual. recent meta-analytic evi­ dence has demonstrated that both dimensions of perfectionism are linked to psychopa­ thology, particularly eating disorders, but also depression, anxiety and obsessive-compul­ sive disorder (limburg, watson, hagger, & egan, 2017). in order to focus on the clinically relevant aspects of perfectionism, shafran, cooper, and fairburn (2002) proposed a model of clinical perfectionism, defined as an overdependence of self-evaluation on meeting personally demanding, self-imposed standards, despite adverse consequences (shafran et al., 2002). thus, the multidimensional construct of perfectionism (including perfectionis­ tic strivings and concerns) differs from clinical perfectionism as the definition of clinical perfectionism puts a central emphasis on self-worth being dependent on meeting high standards. this emphasis is not present in the definition of perfectionistic strivings and concerns. shafran and colleagues (2002) developed a model which outlines a range of cognitive and behavioural processes which maintain clinical perfectionism. based on the clinical perfectionism model (shafran et al., 2002) cognitive behaviour therapy (cbt) interventions were developed to target clinical perfectionism as a transdiagnostic process which is a predisposing and maintaining process in a range of psychological disorders (egan, wade, & shafran, 2011). cbt for perfectionism has been demonstrated to result in transdiagnostic reductions in anxiety, depression and eating disorders (suh, sohn, kim, & lee, 2019). this approach to treat clinical perfectionism across disorders is in line with the current approach of process-based treatment (hofmann & hayes, 2019). in order to evaluate treatment efficacy, it is crucial to have a psychometrically sound scale assessing clinical perfectionism. therefore, fairburn, cooper, and shafran (2003) developed the clinical perfectionism questionnaire (cpq), consisting of 12 items that assess clinical perfectionism in the previous month. several studies have examined the validity and reliability of the cpq. the german version of the cpq 2 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://www.psychopen.eu/ chang and sanna (2012) found the cpq was positively correlated with depression and anxiety, indicating convergent validity. the cpq further accounted for additional variance in depression and anxiety beyond the hmps (hewitt & flett, 1991), which demonstrated incremental validity (chang & sanna, 2012). dickie, surgenor, wilson, and mcdowall (2012) tested the cpq in a non-clinical sample. they excluded items 7 (“have you judged yourself on the basis of your ability to achieve high standards?”) and 8 (“have you done just enough to get by?”) due to low or negative correlations with all other items and low item-total correlations. a factor analysis of the remaining ten items resulted in two factors representing personal standards and concerns about failure with acceptable reliability (α = .71 for both factors; dickie et al., 2012). similar conclusions were drawn by stöber and damian (2014) who also excluded items 7 and 8 because of low correlations and crossloadings on the two factors they found. convergent validity was demonstrated by positive correlations with other perfectionism measures (stöber & damian, 2014). egan and colleagues (2016) tested the psychometric properties of the cpq including all 12 items in both a clinical eating disorder and community sample. their factor analysis also resulted in two factors representing similar constructs as previous studies. factor 1 comprised the overevaluation of striving, and convergent validity was indicated by a significant positive correlation (r = .64) with the fmps subscale personal standards. factor 2 was related to reacting to perceived failure, and convergent validity was demonstrated with self-criticism indicated by substantial and significant positive correlations with the fmps subscales concern over mistakes (r = .61) and doubts about actions (r = .56). further indicating convergent validity, the second factor of the cpq was correlated with the negative affect subscale of the positive and negative affect schedule (panas; watson, clark, & tellegen, 1988). discriminant validity of the cpq was shown because it could reliably discriminate between both participants with high and low negative affect as well as between the eating disorder sample and healthy controls. in terms of incremental validity, the fmps accounted for 23% of variance while the cpq accounted for an additional 11% of variance in the panas-na scores (egan et al., 2016). prior and colleagues (2018) also found in a clinical eating disorder sample a two factor structure using a bifactor approach, comprising of overevaluation of striving and concern over mistakes, in a 10 item version of the cpq excluding the two items found in previous research to be problematic. due to the focus of the cpq on clinical aspects of perfectionism relevant to treatment, the aim of this study was to develop a german version of the scale in order to extend access to and distribution of the cpq. this is important in further evaluating the efficacy of cbt for perfectionism in german speaking areas in clinical practice and research. in the present study a german translation of the cpq was developed and tested within a community sample in order to explore the factor structure and psychometric properties of the scale. since this is the first study on a german version, we used all 12 items instead of the reduced set of 10 items. we hypothesized that the german version (cpq-d) would consist of two factors roth, cludius, egan, & limburg 3 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://www.psychopen.eu/ with a similar structure to the english version found in previous research (egan et al., 2016; prior et al., 2018) and that convergent, discriminant, and incremental validity would be demonstrated. materials and methods sample we used a community sample and recruited participants via the online panel psyweb (https://psyweb.uni-muenster.de). inclusion criteria were age above 18 years and self-re­ ported good german language abilities. since sample sizes of n = 200-300 are regarded suitable for a factor analysis even with lower communalities of the items, we aimed to recruit a minimum sample of n = 250 (bühner, 2011). measures to create the german version of the cpq (cpq-d), the original version of the cpq was first translated into german by the first author, then translated back to english and compared to the original version by the senior author. finally, a few linguistic changes were made by the first and the senior author. the original cpq (fairburn et al., 2003) is a self-report measure that assesses the core elements of clinical perfectionism (see table 2). the 12 items, of which items 2 and 8 are reverse-scored, are rated based on participants’ past 28 days on a 4-point likert scale from 1 (not at all) to 4 (all the time). total scores therefore range from 12 to 48 and a higher score indicates a higher level of clinical perfectionism. the german version of the frost multidimensional perfectionism scale (fmps; frost et al., 1990; stöber, 1995) was used to assess multidimensional perfectionism with six sub­ scales: personal standards (ps), concern over mistakes (cm), doubts about actions (da), parental expectations (pe), parental criticism (pc), and organisation (o) and a sum score. the fmps-d was chosen because its subscales personal standards and concern over mistakes are close to the definition of clinical perfectionism (egan et al., 2016; shafran et al., 2002). it consists of 35 items rated on 5-point likert scales from 1 (strongly disagree) to 5 (strongly agree). following recommendations of dunn, baguley, and brunsden (2014), mcdonald’s ω (mcdonald, 1999) was used instead of cronbach’s α to examine internal consistency. for the fmps it was acceptable with ω = .92 for concern over mistakes, ω = .84 for personal standards and ω = .76 for doubts about actions. the fmps score in our study comprised the subscales personal standards, doubts about actions, and concern over mistakes, following previous research examining the validity of the cpq (egan et al., 2016). we used the german version of the positive and negative affect schedule (panas; krohne, egloff, kohlmann, & tausch, 1996; watson et al., 1988) to measure positive and the german version of the cpq 4 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://psyweb.uni-muenster.de https://www.psychopen.eu/ negative affect over the past 28 days. the scale contains ten words describing pleasant and ten words describing unpleasant emotions, representing the subscales positive affect (pa) and negative affect (na), respectively. participants rate to what extent they had experienced each of the 20 emotions during the past weeks on a 5-point scale. the panas is valid (krohne et al., 1996) and in the present sample the internal consistency for the positive affect scale (panas-pa) was ω = .90 and for the negative affect scale (panas-na) was ω = .89. procedure the study was approved by the ethics committee of the faculty for psychology and educational science at the ludwig-maximilians university munich. participants provided informed consent and there was no identifying data. the online survey started with a short introduction after which participants were asked to complete the cpq-d, the fmps-d and the panas. finally, personal feedback regarding individual results on the fmps-d was provided. statistical analyses the free software r, version 3.5.1 (r core team, 2019), was used for all statistical anal­ yses. the following additional packages were necessary for the analyses: gparotation (bernaards & jennrich, 2005), boot (canty & ripley, 2017), semplot (epskamp, 2019), quantpsych (fletcher, 2012), polycor (fox, 2016), car (fox & weisberg, 2019), hmisc (harrell, 2019), mbess (kelley, 2019), ggm (marchetti et al., 2015), foreign (r core team, 2018), psych (revelle, 2018), corpcor (schafer et al., 2017), effsize (torchiano, 2018), ggplot2 (wickham, 2016). significance level for all tests was α=.05. after calculating de­ scriptive statistics, bartlett’s test was used to test for sphericity and kaiser-meyer-olkin test was applied to examine sampling adequacy. further, inter-item-correlations were calculated to investigate whether all 12 items could be included in the exploratory factor analysis (efa). afterwards and based on the results of the preceding tests, an efa was conducted for the cpq-d. the number of factors was determined with a scree plot and a parallel analysis. in the parallel analysis the eigenvalues of the empirical data were compared against the 95th percentile of eigenvalues generated from 1000 simulated analyses, corresponding in size and number of items. to not risk keeping too many or irrelevant factors, the conservative approach of using only the 95th percentile of the simulated eigenvalues was applied. factors with actual eigenvalues greater than those simulated eigenvalues were maintained (hayton, allen, & scarpello, 2004). again, mcdonald’s ω was used instead of cronbach’s α to examine internal con­ sistency of the factors (dunn et al., 2014; mcdonald, 1999). to test convergent and discriminative validity, correlations between the measures were calculated. substantial and significant positive correlations between the cpq-d, the fmps-d, and panas-na roth, cludius, egan, & limburg 5 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://www.psychopen.eu/ were considered evidence for convergent validity. in terms of discriminant validity, small positive and/or negative correlations were expected between the cpq-d and panas-pa. correlation coefficients were interpreted according to the rule of thumb by cohen (1988), with 0.1≤|r|< 0.3 indicating small, 0.3≤|r|< 0.5 indicating moderate, and |r|> 0.5 indicating high correlations. to further test discriminant validity, we conducted t-tests to examine if participants with low negative affect differed from those with high negative affect in their cpq-d scores. effect sizes were assessed with cohen’s d and interpreted as small if 0.2≤|d|< 0.5, medium if 0.5≤|d|< 0.8, and high if |d|> 0.8 (cohen, 1988). finally, a hierarchical linear regression analysis predicting the panas-na score with the fmps-d and cpq-d scores as independent variables was conducted to check for incremental validity. results participants we collected data from 439 participants. data screening resulted in the exclusion of three datasets due to missing consent, two were excluded due to invalid age information, one due to voluntary withdrawal, and one due to insufficient knowledge of the german language. the final sample consisted of n = 432 participants. descriptive data of the sample along with means and standard deviations for the cpq-d, fmps-d, and panas are presented in table 1. the mean cpq-d total was m = 26.50 (sd = 5.70). factor structure and internal consistency inter-item correlations were mostly moderate, only items 8 and 12 had small correlations to other items (r < .30). the same items had small item-total correlations of r = .19 for item 8 and r = .20 for item 12. due to results of bartlett’s test, χ2(66) = 1253.53, p < .001, and kmo test (msa = .85) and since inter-item correlations were significant for all items, we decided to run the factor analysis for the complete set of items instead of excluding items 8 and 12. an exploratory factor analysis using maximum likelihood estimation with promax rotation resulted in two factors with simple structure. two factors were assumed based on the scree plot and parallel analysis. of note, the eigenvalue rule was not fulfilled with only one factor having an eigenvalue greater than one, but the eigenvalue criterion has been marked as too strict (jolliffe, 1972). eight items loaded on factor 1 and four items on factor 2. factor 1 explained 20% and factor 2 accounted for 15% of variance, factors were moderately correlated with r = .49. the factor structure along with communalities of the items is depicted in table 2. internal consistency was ω = .81 for the total score, ω = .77 for factor 1, and ω = .73 for factor 2. the german version of the cpq 6 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://www.psychopen.eu/ table 1 sample characteristics, n = 432 variable m (sd) or n (%) age (years), m (sd) 49.53 (15.00) female, n (%) 251 (58.10) education, n (%) 9th grade or less 19 (4.40) 10th grade 62 (14.35) high school graduate 102 (23.61) university graduate 243 (56.25) other degree 6 (1.39) psychological diagnosis, n (%) 137 (31.71) psychotherapeutic and/or psychiatric treatment, n (%) yes, currently, n (%) 61 (14.12) yes, formerly, n (%) 162 (37.50) never, n (%) 233 (53.94) cpq-d total, m (sd) 26.50 (5.70) factor 1, m (sd) 18.21 (4.17) factor 2, m (sd) 8.29 (2.41) fmps-d total, m (sd) 98.84 (21.24) personal standards, m (sd) 21.64 (5.50) doubts about actions, m (sd) 9.99 (3.82) concern over mistakes, m (sd) 22.11 (8.43) parental expectations, m (sd) 11.98 (5.11) parental criticism, m (sd) 10.11 (4.61) organisation, m (sd) 23.02 (4.48) panas-na, m (sd) 20.61 (7.74) panas-pa, m (sd) 31.91 (7.39) note. cpq-d = clinical perfectionism questionnaire, german version; fmps-d = frost multidimensional perfectionism scale; panas-na = positive and negative affect schedule, negative affect subscale; panas-pa = positive and negative affect schedule, positive affect subscale. roth, cludius, egan, & limburg 7 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://www.psychopen.eu/ ta bl e 2 pr om ax -r ot at ed f ac to r st ru ct ur e of th e c pq -d it em n o. it em c pq it em c pq -d f1 f2 h2 1 h av e yo u pu sh ed y ou rs el f r ea lly h ar d to m ee t y ou r go al s? h ab en s ie s ic h se hr a ng es tr en gt , u m ih re z ie le z u er re ic he n? .4 8 .0 8 .2 7 3 h av e yo u be en to ld th at y ou r st an da rd s ar e to o hi gh ? w ur de ih ne n ge sa gt , d as s ih re a ns pr üc he z u ho ch s in d? .5 3 .1 2 .3 6 6 h av e yo u ra is ed y ou r st an da rd s be ca us e yo u th ou gh t t he y w er e to o ea sy ? h ab en s ie ih re a ns pr üc he e rh öh t, w ei l s ie d ac ht en s ie s ei en z u le ic ht z u er re ic he n? .4 6 .0 0 .2 1 7 h av e yo u ju dg ed y ou rs el f o n th e ba si s of y ou r ab ili ty to a ch ie ve hi gh s ta nd ar ds ? h ab en s ie s ic h se lb st a nh an d de ss en b eu rt ei lt, o b si e ho he a ns pr üc he e rr ei ch en k ön ne n? .5 8 .2 3 .5 1 8 h av e yo u do ne ju st e no ug h to g et b y? (r ) h ab en s ie g er ad es o ge nu g ge ta n, u m ü be r di e ru nd en z u ko m m en ? (r ) .4 2 -.2 3 .1 4 9 h av e yo u re pe at ed ly c he ck ed h ow w el l y ou a re d oi ng a t m ee tin g yo ur s ta nd ar ds (f or e xa m pl e, b y co m pa ri ng y ou r pe rf or m an ce w ith th at o f o th er s) ? h ab en s ie w ie de rh ol t ü be rp rü ft , w ie g ut s ie s ic h da ri n sc hl ag en , ho he a ns pr üc he z u er re ic he n (z um b ei sp ie l, in de m s ie ih re le is tu ng m it de r an de re r ve rg lic he n) ? .5 1 .2 0 .3 9 10 d o yo u th in k th at o th er p eo pl e w ou ld h av e th ou gh t o f y ou a s a “p er fe ct io ni st ”? g la ub en s ie , d as s an de re l eu te s ie a ls „p er fe kt io ni st /i n“ b ez ei ch ne n w ür de n? .6 2 -.1 4 .3 2 11 h av e yo u ke pt tr yi ng to m ee t y ou r st an da rd s, e ve n if th is h as m ea nt th at y ou h av e m is se d ou t o n th in gs ? h ab en s ie a uc h da nn v er su ch t, ih re a ns pr üc he z u er re ic he n, w en n si e da du rc h an de re d in ge v er sä um t h ab en ? .5 6 .0 5 .3 4 2 h av e yo u te nd ed to fo cu s on w ha t y ou h av e ac hi ev ed , ra th er th an o n w ha t y ou h av e no t a ch ie ve d? (r ) h ab en s ie s ic h eh er d ar au f f ok us si er t w as s ie e rr ei ch t h ab en , a ls da ra uf , w as s ie n ic ht e rr ei ch t h ab en ? (r ) -.0 3 .4 5 .1 9 4 h av e yo u fe lt a fa ilu re a s a pe rs on b ec au se y ou h av e no t su cc ee de d at m ee tin g yo ur g oa ls ? h ab en s ie s ic h w ie e in /e v er sa ge r/ in g ef üh lt, w en n es ih ne n ni ch t g el an g, ih re z ie le z u er re ic he n? .1 4 .7 6 .7 0 3 h av e yo u be en a fr ai d th at y ou m ig ht n ot r ea ch y ou r st an da rd s? h at te n si e a ng st , d as s si e ih re z ie le m ög lic he rw ei se n ic ht er re ic he n kö nn te n? .1 4 .7 1 .6 1 12 h av e yo u av oi de d an y te st s of y ou r pe rf or m an ce (a t m ee tin g yo ur g oa ls ) i n ca se y ou fa ile d? h ab en s ie je de a rt d er ü be rp rü fu ng ih re r le is tu ng v er m ie de n, w ei l s ie b ei d er e rr ei ch un g ih re r z ie le v er sa gt h ab en k ön nt en ? -.0 3 .3 5 .1 1 n ot e. f 1 = lo ad in gs o n fa ct or 1 ; f 2 = lo ad in gs o n fa ct or 2 ; h 2 = c om m un al ity ; ( r) = r ev er se -c od ed , l oa di ng s > 0. 3 ar e pr in te d in b ol d. re pr in t o f o ri gi na l i te m s w ith c ou rt es y of r oz s ha fr an . the german version of the cpq 8 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://www.psychopen.eu/ construct validity pearson’s correlations between the measures are seen in table 3. table 3 pearson correlations and partial correlations of the scales scale cpq-d total factor 1 f1.f2 factor 2 f2.f1 fmps-d total .68*** [.63, .73] personal standards .60*** [.54, .66] .66*** [.60, .71] .62*** .29*** [.20, .38] -.02 concern over mistakes .67*** [.62, .72] .55*** [.48, .61] .37*** .61*** [.59, .70] .53*** doubts about actions .51*** [.44, .58] .35*** [.27, .43] .09 .65*** [.55, .67] .54*** panas-na .55*** [.48, .61] .40*** [.32, .48] .17*** .61*** [.55, .66] .52*** panas-pa -.11* [-.21, -.02] .07 [-.03, .16] -.39*** [-.46, -.30] note. cpq-d = clinical perfectionism questionnaire, german version; fmps = frost multidimensional perfec­ tionism scale; panas-na = positive and negative affect schedule, negative affect subscale; panas-pa = positive and negative affect schedule, positive affect subscale. values in brackets depict the 95% ci for the respective pearson correlation coefficient. f1.f2 = partial correlation of factor 1 controlled for factor 2, f2.f1 = partial correlation of factor 2 controlled for factor 1. *p < .05. **p < .01. ***p < .001. convergent validity the cpq-d total was highly correlated with the fmps-d total and the relevant subscales personal standards, concern over mistakes, and doubts about actions, and with panas­ na. factor 1 correlated with personal standards, but also concern over mistakes. when controlling for overlap with factor 2, the relationship was only moderate. factor 2 corre­ lated highly with concern over mistakes, doubts about actions, and panas-na and the relationship remained when controlling for factor 1. hence, the cpq-d demonstrated convergent validity. roth, cludius, egan, & limburg 9 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://www.psychopen.eu/ discriminative validity as expected, correlations between cpq-d and both factors and panas-pa were small to negative. following egan and colleagues (2016), we classified participants with panas­ na scores of > 25 (75th percentile) as “high” (n = 114) and those with scores < 15 (25th percentile) as “low” (n = 133). an independent samples t-test revealed that those with higher panas-na scores had significantly higher scores on cpq-d total than those with low panas-na scores (“high” panas-na group: m = 31.18, sd = 5.42; “low” panas-na group: m = 23.14, sd = 4.44; t(218.51) = 12.61, p < .001). cohen’s d was large with d = 1.63 (95% ci [1.34, 1.92]). similar findings were evident for factor 1 and factor 2 (factor 1: “high” panas-na group: m = 20.75, sd = 4.01; “low” panas-na group: m = 16.38, sd = 3.60; t(226.94) = 8.84, p < .001, d = 1.14, 95% ci for d [.87, 1.41]; factor 2: “high” group: m = 10.43, sd = 2.26; “low” group: m = 6.77, sd = 1.62; t(201.23) = 14.40, p < .001, d = 1.88, 95% ci for d [1.58, 2.19]). incremental validity a multiple hierarchical linear regression model showed that the fmps-d accounted for 23.6% of variance in panas-na (p < .001) and that the cpq-d accounted for an additional 11% of variance (p < .001). upon inclusion of the cpq-d total in the regression model, the predictive value of the fmps-d reduced from β = .49 to β = .21, which could be due to the strong correlation of both variables (r = .68). the variance inflation factor of 1.86 confirmed that there was no multicollinearity between the predictors. hence, in the final model including fmps-d and cpq-d, the latter was a stronger predictor for negative affect than the fmps-d. discussion consistent with previous studies on the original version of the cpq, the cpq-d consists of two factors, with the same eight items loading on factor 1 as the respective items in the english version and the same four items loading on factor 2 (dickie et al., 2012; egan et al., 2016; stöber & damian, 2014). the values of the loadings of the single items differ slightly between all sighted analyses, but never by more than 0.15 between the german and the english version (egan et al., 2016). similar to previous studies factor 1 represents primarily the over evaluation of striving whereas factor 2 assesses concern over mistakes (egan et al., 2016; prior et al., 2018). unlike the english version, the german version contains no cross loadings greater than 0.3 on both factors, which suggests that the german translation might discriminate more precisely between the two factors. internal consistency of the factors and the total score were acceptable. the amount of variance explained by both factors was 35%, a very low proportion considering recommendations that at least 60% of variance should be explained (hair et al., 2013). previous studies found diverging amounts of variance explained, with 47.9% (dickie et al., 2012), 45.9% the german version of the cpq 10 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://www.psychopen.eu/ (stöber & damian, 2014), and 79% (egan et al., 2016). the low proportion we found could indicate that there is a third latent variable behind the construct of clinical perfectionism that could not be covered by the items. alternatively, formulation of the translated items may not be adequate so that they cannot sufficiently assess the two latent variables. prior and colleagues (2018) argued that a single, latent construct of clinical perfectionism could also explain the structure of the cpq in a clinical eating disorder sample, and it is possible that a unidimensional structure may be worth further investigating in future research. a noteworthy finding was that items 8 and 12 had both low communalities, indi­ cating small associations with both factors, and low item-total correlations, indicating that these items insufficiently represent the total scale. findings for item 8 (“have you done just enough to get by?”) can be interpreted in accordance with previous research finding this reverse scored item problematic (dickie et al., 2012; prior et al., 2018). this is supported by item 8 having relatively high loadings with opposite items on both factors, which means that participants with a high score on factor 1 (over evaluation of striving) seem to interpret item 8 in an opposite way to participants with high scores on factor 2 (concern over mistakes). this is likely due to the item being reverse scored and participants were reading the item incorrectly assuming it was similar to other items. future research on the german cpq should examine the 12-item version and a 10-item version of the scale with the reverse scored items removed. item 12 (“have you avoided any test of your performance (at meeting your goals) in case you failed?”) was not problematic in studies on the english version. they found that item 12 loaded on factor 2 between .37 and .71 and had corrected item total correlations (citc) of .24 or higher. in the german version the loading on factor 2 was slightly smaller, but more problematic were the low citc of .20 and the low communality of .11. this indicates that item 12 does not represent factor 2 well and does not contribute much to assessing the construct of clinical perfectionism. one reason could be that the german translation of item 12 may have been too complicated to be easily understood by participants. furthermore, avoidance of performance tests could be associated with other factors than perfectionism, for example test anxiety, a lack of motivation to be tested, or simply having no test situations available in everyday life. future research on the cpq-d should address this issue because the original content of item 12 (testing and evaluating one’s performance) is an important part of the definition of clinical perfectionism. in terms of validity, our results provided evidence for convergent validity, discrimina­ tive validity, and incremental validity. convergent validity was demonstrated by high correlations with the fmps-d and the negative affect subscale of the panas. factor 1 correlated highly with fmps-d subscales assessing the setting and evaluation of strivings while factor 2 correlated with scales measuring concerns about mistakes, concerns re­ garding meeting personal standards, and negative emotions. this supports the interpre­ tation of factor 1 representing perfectionistic strivings and factor 2 assessing emotional roth, cludius, egan, & limburg 11 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://www.psychopen.eu/ consequences of failure. discriminative validity was shown by low correlations with the positive affect subscale of the panas and by the finding that the cpq-d could discriminate well between participants with high vs. low negative affect. finally, the cpq-d explained variance in negative affect beyond the proportion explained by the fmps-d, demonstrating incremental validity. strengths and limitations considering that we had similar findings compared to previous studies on the english version of the cpq in terms of factor structure and construct validity, it seems like trans­ lation of the measure was successful. also, it shows a simple structure which ensures interpretability. another strength is that we tested the cpq-d not only in a student sample, but in a community sample, of which nearly a third of the participants had a self­ reported diagnosed psychological disorder and 14% reported to be in psychotherapeutic and/or psychiatric treatment, indicating some generalisability towards clinical samples. however, there were some limitations. first, the community sample was recruited using an online panel. this method only reaches certain target groups. participants in our sample were on average 49.53 years old and highly educated, which decreases gener­ alisability of our results (e.g., our results may not apply to younger or people with lower education). future research should consider using test theory to explore item-person fit. second, we did not assess the number of specific psychological disorders, although it would be interesting to know whether there are diverging results for different disorders. third, we used a limited number of measures to assess construct and incremental validi­ ty. other measures assessing perfectionism and further constructs (e.g., depression, anxi­ ety, eating disorder symptoms, general well-being, personality traits) would have been valuable to examine validity more comprehensively. fourth, regarding translation of the measure, it would have been worthwhile to have the german version translated back to english by several people and to have the german scale evaluated by several clinicians. moreover, it should be considered in future research to use a cognitive interview to validate the german translation. finally, there are no “clinical” cut-offs or severity ranges for the cpq. instead, clinicians and researchers currently interpret the score on the basis of higher scores indicating greater clinical perfectionism. it would be useful for future research to determine severity ranges (e.g., mild, moderate, severe) to further enhance the clinical and research application of the scale. conclusion overall, we found evidence for the reliability and validity of the cpq-d, the factor structure is the same as in the english version (dickie et al., 2012; egan et al., 2016; prior et al., 2018; stöber & damian, 2014). therefore, the cpq-d can be used in a similar way to the english version. it would be useful for future research to examine if there the german version of the cpq 12 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://www.psychopen.eu/ are differences between clinical perfectionism across countries, for example, between the united kingdom (uk) where the cpq was developed, and germany. to date, cultural differences in the definition and perception of perfectionism have been found when comparing individualistic and collectivistic cultures, for example, caucasian and asian samples (nilsson, paul, lupini, & tatem, 1999; pietrabissa et al., 2020). as both germany and the uk are individualistic cultures which share common values (juslin, barradas, ovsiannikow, limmo, & thompson, 2016) we do not assume great cultural differences. however, future research should test this possible effect on the results. future studies should also examine the cpq-d in non-clinical and clinical populations in order to evalu­ ate whether the factor structure can be replicated and whether it is possible to explain more variance of the underlying construct than in the current study. additionally, they should use a wider variety of additional measures to test its validity. further, future research may wish to compare the cpq-d in its current version with a version that excludes items 8 and 12 due to their difficult properties. in summary, the cpq-d appears to be a valid and reliable measure to assess clinical perfectionism in a german speaking population. hence, it has the potential to be used as an efficient measure to assess the process of clinical perfectionism within the framework of process-based cbt (hofmann & hayes, 2019). funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references bernaards, c. a., & jennrich, r. i. 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(2016). ggplot2: elegant graphics for data analysis. new york, ny, usa: springer. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. the german version of the cpq 16 clinical psychology in europe 2021, vol. 3(2), article e3623 https://doi.org/10.32872/cpe.3623 https://cran.r-project.org/package=corpcor https://doi.org/10.1016/s0005-7967(01)00059-6 https://doi.org/10.1037/cou0000355 https://doi.org/10.1016/j.paid.2014.01.003 https://doi.org/10.1207/s15327957pspr1004_2 https://doi.org/10.5281/zenodo.1480624 https://doi.org/10.1037/0022-3514.54.6.1063 https://www.psychopen.eu/ the german version of the cpq (introduction) materials and methods sample measures procedure statistical analyses results participants factor structure and internal consistency construct validity discussion strengths and limitations conclusion (additional information) funding acknowledgments competing interests references only the lonely: a study of loneliness among university students in norway research articles only the lonely: a study of loneliness among university students in norway mari hysing a, keith j. petrie b, tormod bøe a, kari jussie lønning cd, børge sivertsen efg [a] department of psychosocial science, faculty of psychology, university of bergen, bergen, norway. [b] department of psychological medicine, university of auckland, auckland, new zealand. [c] the norwegian medical association, oslo, norway. [d] the student welfare organization of oslo and akershus (sio), oslo, norway. [e] department of health promotion, norwegian institute of public health, bergen, norway. [f] department of research & innovation, helse-fonna hf, haugesund, norway. [g] department of mental health, norwegian university of science and technology, trondheim, norway. clinical psychology in europe, 2020, vol. 2(1), article e2781, https://doi.org/10.32872/cpe.v2i1.2781 received: 2019-06-10 • accepted: 2020-01-13 • published (vor): 2020-03-31 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: mari hysing, department of psychosocial science, faculty of psychology, university of bergen, post box 7807, 5020 bergen, norway; +47 55 58 86 98. e-mail: mari.hysing@uib.no abstract background: loneliness is a major public health concern among college and university students, the evidence is inconsistent regarding whether there is an increasing trend or not. furthermore, knowledge of the demographic determinants for loneliness are limited. the present study assesses recent trends of loneliness from 2014 to 2018, and explores demographic risk indicators of loneliness among students. method: data was drawn from two waves of a national student health survey from 2014 and 2018 for higher education in norway (the shot-study). in 2018, all 162,512 fulltime students in norway were invited to participate and 50,054 students (69.1% women) aged 18-35 years were included (response rate = 30.8%). loneliness was measured by “the three-item loneliness scale” (t-ils) and one item from the hopkins symptom checklist-25 (hscl-25). results: age showed a curvilinear association with loneliness, with the youngest and oldest students reporting the highest level of loneliness across all measures. other significant demographic determinants of loneliness were being female, single and living alone. there was a considerable increase in loneliness from 2014 (16.5%) to 2018 (23.6%, p < .001), and the increase was particularly strong for males, for whom the proportion of feeling “extremely” lonely had more than doubled. conclusion: the high rate of loneliness and the increasing trends indicate the need for preventive interventions in the student population. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i1.2781&domain=pdf&date_stamp=2020-03-31 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords loneliness, students, young adults, partnership status, student accomodation highlights • loneliness among norwegian university students increased from 2014 to 2018, particularly for males. • students in transitional periods, both the youngest and oldest reported the most loneliness. • being single and living alone were risk factors for loneliness. loneliness reflects the subjective feeling of disconnectedness and not belonging, and is often characterized as “a perceived discrepancy between desired and actual social rela‐ tionships” (portnoy, 1983). loneliness is associated with more health problems (hayley et al., 2017), and has been linked to an increased mortality risk (holt-lunstad, smith, baker, harris, & stephenson, 2015). loneliness has often been thought of as a concern that peaks in older age. however, recent evidence has shown that the developmental trajectory is more u-shaped, with young adults having the highest levels of loneliness (luhmann & hawkley, 2016), followed by a second peak in older age groups. the transition from adolescence to young adulthood makes college and universi‐ ty students a particularly vulnerable group for feelings of loneliness (diehl, jansen, ishchanova, & hilger-kolb, 2018). this may be related to developmental-specific risk factors, such as moving away from home and their local community, and re-establishing new social networks. surprisingly, the epidemiology of loneliness in young people has received scant attention. knowledge of risk indicators and vulnerable subgroups are important in order to promote preventive actions. if loneliness is limited to, or peaks at the actual transition from moving away from home, a decline in loneliness over time should be expected among more senior students, which has been demonstrated in a german university sample (diehl et al., 2018). a recent uk study of 18-year-old twins found that loneliness was equally common across sexes and socioeconomic status (ses) (matthews et al., 2019), whereas others have found both higher (mounts, 2004) and lower (mcwhirter, 1997) levels of loneliness among men. this inconsistency was also confirmed in a recent meta-analysis (mahon, yarcheski, yarcheski, cannella, & hanks, 2006). in the general population, loneliness is more prevalent among adults without partners (beutel et al., 2017), and also students living alone report more loneliness compared to those living in dorms or with a partner/ friend (diehl et al., 2018). still, the literature remains sparse on the issue of identifying risk indicators of loneliness among young adults. it has been suggested that the prevalence of loneliness is increasing, but very few studies have examined this over time (cacioppo, grippo, london, goossens, & cacioppo, loneliness among university students 2 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ 2015). a study of older dutch people showed no change in loneliness from 2005 to 2010, with the exception of a subgroup of individuals with activity limitations, where the trend was increasing (honigh-de vlaming, haveman-nies, groeniger, de groot, & van ’t veer, 2014). a similar stable pattern was observed in a swedish study of an elderly population (dahlberg, agahi, & lennartsson, 2018). in contrast, there was a rising rate of loneliness among danish adolescents from 1991 to 2014, with the largest increase being observed among adolescents from families with high ses (madsen et al., 2019). this study addressed three main questions in a large nationally representative sample of young people: (1) what demographic factors are associated with loneliness in young adult college and university students? (2) how does partnership status offer protection from feelings of loneliness? and (3) has the rate of loneliness changed from 2014 to 2018 in this population? method procedure the shot study (students’ health and wellbeing study) is a national student survey for higher education in norway. the main aim of the survey is to monitor students’ health, wellbeing and psychosocial environment. the survey has been carried out three times (2010, 2014 and 2018), and the two most recent waves (2014 and 2018) were used in the present study. the shot2014 study was conducted by the three largest student welfare organizations (sammen [bergen], sit [trondheim] and sio [oslo and akershus]) in collaboration with, and with participation from, the 10 largest student welfare organizations in norway, also targeting full-time norwegian students < 35 years of age. data for the shot2014 study were collected electronically using a web-based platform in the period from 24 february 2014 to 27 march 2014. an invitation email containing a link to an anonymous online questionnaire was sent to 47,514 randomly selected students and stratified by study institutions, faculties, and departments. the overall response rate was 28.5% and included 13,525 students. the shot2018 was initiated by the three largest student welfare organizations (sam‐ men [bergen and surrounding area], sit [trondheim and surrounding area] and sio [oslo and akershus]), representing all student welfare organizations in norway and done as a joint effort between these student welfare organisations and the norwegian institute of public health (niph). data were collected between february 6 and april 5, 2018 and all fulltime norwegian students aged between 18 and 35 years taking higher education (both in norway and abroad) were invited to take part. the survey data were collected electronically through a web-based platform and some institutions allocated time during classes for the students to complete the set of questionnaires. for the shot2018 study, hysing, petrie, bøe et al. 3 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ 162,512 students fulfilled the inclusion criteria, of whom 50,054 (30.8%) students comple‐ ted the online questionnaires (sivertsen, råkil, munkvik, & lønning, 2019). ethics the authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimenta‐ tion and with the helsinki declaration of 1975, as revised in 2008. all procedures in‐ volving human subjects/patients were approved by the regional committee for medical and health research ethics in western norway (no. 2017/1176 [shot2018]). informed consent was obtained electronically after the participants had received a detailed intro‐ duction to the study. approvals for conducting the shot2014 studies were granted by the data protection officer for research at the norwegian centre for research data. instruments demographic information all participants indicated their sex and age. in the current study, age was used both as a continuous and categorical variable, the latter employing the following age categories (18-20 years, 21-22 years, 23-25 years and 26-35 years). participants were also asked about their relationship status (response options: “single”, “girl-/boyfriend”, “cohabitant”, and “married/ registered partner”), as well as their accommodation status (response options: “living alone”, “living with partner”, “living with friends/others in a collective”, and “living with parents”). participants were categorized as an immigrant if either the student or his/her parents were born outside norway. finally, all students indicated if they were living or studying abroad. loneliness loneliness was measured by one item of the depression subscale of the hscl-25 (derogatis, lipman, rickels, uhlenhuth, & covi, 1974) in 2014 and 2018. in the past two weeks, including today, how much have you been bothered by feeling lonely? the response alternatives were “not at all”, “a little”, “quite a bit”, and “extremely”. in shot2018 loneliness was assess using an abbreviated version of the widely used ucla loneliness scale, “the three-item loneliness scale (t-ils)” (hughes, waite, hawkley, & cacioppo, 2004). the t-ils include the following three items, each rate along a 5-point likert scale (“never”, “seldom”, “sometimes”, “often”, and “very often”). for each question below, please indicate how often you have felt that way during the last year: 1) how often do you feel that you lack companionship? 2) how often do you feel left out, and 3) how often do you feel isolated from others? the t-ils has displayed satisfactory reliability and both concurrent and discriminant validity. (hughes et al., 2004) in addition loneliness among university students 4 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ to analysing each of the three t-ils items separately, we also calculated a total score, adding the three items together. the cronbach’s alpha of the t-ils total score was .88. statistics ibm spss version 25 (spss inc., chicago, il, usa) for mac was used for all analyses. chi-square tests and logistic regression analysis were used to examine differences in the three loneliness items across demographical characteristics. analysis of variance (anova) were conducted to examine potential polynomial/curvilinear associations be‐ tween loneliness and age group by entering quadratic terms. we also used the curve estimation command in spss to test both the linear and curvilinear association between age as a continuous variable and overall loneliness. anovas were also used to examine the t-ils total score against the demographic variables. effect sizes (pooled sd) were calculated using the cohen’s d formula (cohen, 1988). pearson’s chi-squared tests were used to test for significant changes in loneliness over time. missing values were handled using listwise deletion. results descriptive characteristics compared to all invited students – 58.1% women (n = 93,267) and 41.9% men (n = 67,558) – the current sample included a larger proportion of women (69.1%) than men (30.9%). the mean age was 23.2 (sd = 3.3). loneliness in shot2018 the response patterns of the three loneliness items are detailed in figure 1. almost one in four students (21% in males and 24% in females) felt that they lacked companionship “often” or “very often”. the corresponding estimates for the items “feeling left out” and “feeling isolated” were slightly lower, with 14%-15% in women and 17-18% in men (see figure 2 for details). one in ten students (10.1%) reporting “often/very often” on all three items (females: 10.6% and males: 8.8%). all sex differences were statistically significant (p < .001). hysing, petrie, bøe et al. 5 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ figure 1 response pattern of the three loneliness items in the t-ils among college/university students in the shot2018 study note. error bars represent 95% confidence intervals. loneliness and age figure 2 shows the prevalence of the three loneliness items across the different age groups. as indicated by the dotted trend lines, there was a significant curvilinear rela‐ tionship (all ps < .001) on all forms of loneliness for both men and women; both the youngest and oldest age-groups reported higher levels of both lacking companionships, feeling left out and feeling isolated (see figure 2 for details). table 1 shows the results from the logistic regression analyses. for example, compared to being 23-25 years old, female students aged between 18 and 20 years had 1.38 higher or, 95% ci [1.29, 1.48], of reporting that they lacked companionship. there were significant sex × age interactions for all three loneliness items (see table 1 for more details). as detailed in table 2, analysing the t-ils total score continuously showed a similar pattern u-shaped, with small cohen’s d effect-sizes. loneliness among university students 6 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ ta bl e 1 o dd sr at io s (o r s) o f d em og ra ph ic f ac to rs a ss oc ia te d w ith l on el in es s (“ o ft en ” or “ ve ry o ft en ”) a m on g n or w eg ia n u ni ve rs ity s tu de nt s d em og ra ph ic fa ct or la ck c om pa ni on sh ip le ft o ut is ol at ed w om en m en w om en m en w om en m en o r 95 % c i o r 95 % c i o r 95 % c i o r 95 % c i o r 95 % c i o r 95 % c i a ge g ro up se x in te ra ct io n: w al d (d f) = 11 .41 (3 ), p = .01 0 se x in te ra ct io n: w al d (d f) = 29 .70 (3 ), p < .00 1 se x in te ra ct io n: w al d (d f) = 25 .28 (3 ), p < .00 1 18 -2 0 ye ar s 1.3 8* ** 1.2 9, 1.4 8 1.3 2* ** 1.1 7, 1.4 8 1.2 2* ** 1.1 3, 1.3 2 1.0 5 0.9 1, 1.2 1 1.2 7* ** 1.1 8, 1.3 8 1.1 5* 1.0 1, 1.3 2 21 -2 2 ye ar s 1.0 5 0.9 8, 1.1 2 0.9 7 0.8 7, 1.0 7 1.0 2 0.9 5, 1.1 0 0.8 2* * 0.7 3, 0.9 3 1.0 4 0.9 7, 1.1 2 0.8 1* ** 0.7 2, 0.9 1 23 -2 5 ye ar s 1.0 0 1.0 0 1.0 0 1.0 0 1.0 0 1.0 0 26 -3 5 ye ar s 1.0 7* 1.0 0, 1.1 6 1.2 4* ** 1.1 1, 1.3 8 1.2 2* ** 1.1 2, 1.3 2 1.4 7* ** 1.3 0, 1.6 5 1.2 1* ** 1.1 1, 1.3 2 1.3 7* ** 1.2 2, 1.5 4 r el at io ns hi p st at us se x in te ra ct io n: w al d (d f) =1 59 .58 (3 ), p < .00 1 se x in te ra ct io n: w al d (d f) = 88 .48 (3 ), p < .00 1 se x in te ra ct io n: w al d (d f) = 82 .32 (3 ), p < .00 1 si ng le 1.6 1* ** 1.3 9, 1.8 6 2.8 5* ** 2.1 4, 3.8 1 1.0 1 0.7 4, 1.1 8 1.5 9* * 1.1 8, 2.1 4 1.1 8* 1.0 1, 1.3 9 1.6 5* ** 1.2 3, 2.2 1 bo y/g irl fri en d 1.2 7* * 1.0 9, 1.4 8 1.2 4 0.9 2, 1.6 8 1.0 2 0.7 4, 1.1 9 0.9 0 0.6 6, 1.2 2 1.0 5 0.9 0, 1.2 4 0.8 5 0.6 2, 1.1 6 co ha bi ta nt 1.0 5 0.9 0, 1.2 2 0.9 1 0.6 7, 1.2 5 1.1 0 0.9 4, 1.2 9 1.0 8 0.7 9, 1.4 8 1.1 0 0.9 3, 1.2 9 0.9 4 0.6 9, 1.2 8 m ar rie d / r eg ist er ed p ar tn er 1.0 0 1.0 0 1.0 0 1.0 0 1.0 0 1.0 0 a cc om m od at io n st at us se x in te ra ct io n: w al d (d f) = 86 .75 (3 ), p < .00 1 se x in te ra ct io n: w al d (d f) = 32 .32 (3 ), p < .00 1 se x in te ra ct io n: w al d (d f) = 36 .86 (3 ), p < .00 1 a lo ne 1.9 6* ** 1.8 2, 2.1 1 3.8 5* ** 3.3 7, 4.3 9 1.2 6* ** 1.1 7, 1.3 7 1.9 9* ** 1.7 4, 2.2 8 1.5 0* ** 1.3 9, 1.6 2 2.4 4* ** 2.1 3, 2.8 0 w ith p ar tn er 1.0 0 1.0 0 1.0 0 1.0 0 1.0 0 1.0 0 w ith fr ie nd s / o th er s i n a co lle ct iv e 1.2 4* ** 1.1 6, 1.3 2 2.0 8* ** 1.8 5, 2.3 5 0.7 9* ** 0.7 4, 0.8 4 1.0 2 0.9 0, 1.1 5 0.8 5 0.8 0, 0.9 2 1.1 5* 1.0 2, 1.3 1 w ith p ar en ts 1.4 5* ** 1.3 1, 1.5 9 2.7 4* ** 2.3 3, 3.3 4 1.1 8* * 1.0 7, 1.3 1 1.5 7* ** 1.3 2, 1.8 8 1.3 5* ** 1.2 1, 1.4 9 1.7 5* ** 1.4 6, 2.0 9 im m ig ra ti on s ta tu s se x in te ra ct io n: w al d (d f) = 3.7 7( 1) , p = .0 52 se x in te ra ct io n: w al d (d f) = 0.1 6( 1) , p = .6 88 se x in te ra ct io n: w al d (d f) = 1.6 5( 1) , p = .4 22 n or w eg ia n 1.0 0 1.0 0 1.0 0 1.0 0 1.0 0 1.0 0 im m ig ra nt 1.4 8* ** 1.3 5, 1.6 1 1.7 2* ** 1.5 1, 1.9 5 1.4 5* ** 1.3 2, 1.5 9 1.4 0* ** 1.2 0, 1.6 2 1.4 4* ** 1.3 1, 1.5 9 1.5 5* ** 1.3 4, 1.7 9 st ud yi ng a br oa d se x in te ra ct io n: w al d (d f) = 1.2 6( 1) , p = .2 62 se x in te ra ct io n: w al d (d f) = 6.1 4( 1) , p = .0 13 se x in te ra ct io n: w al d (d f) = 2.5 2( 1) , p = .1 12 n o 1.0 0 1.0 0 1.0 0 1.0 0 1.0 0 1.0 0 ye s 1.1 9* * 1.0 6, 1.3 5 1.0 4 0.8 4, 1.2 8 1.1 6* 1.0 2, 1.3 3 0.8 0 0.6 1, 1.0 4 1.1 6* 1.0 1, 1.3 3 0.9 2 0.7 1, 1.1 8 hysing, petrie, bøe et al. 7 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ figure 2 loneliness prevalence (“often”/”very often”) stratified by age-group in male and female students note. the curves show the polynomial/curvilinear trendline (order 2). table 2 demographic factors associated with loneliness (t-ils sum score) among norwegian university students demographic factor women men m sd cohen's da m sd cohen's d age group 18-20 years 7.90 3.11 0.12 7.32 3.10 0.15 21-22 years 7.60 3.00 0.02 6.87 2.93 reference 23-25 years 7.55 2.98 reference 7.07 3.02 0.07 26-35 years 7.66 3.19 0.04 7.50 3.26 0.20 relationship status single 7.78 3.05 0.17 7.62 3.15 0.36 boy-/girlfriend 7.58 3.00 0.10 6.53 2.78 0.01 cohabitant 7.52 3.08 0.08 6.52 2.88 0.01 married / registered partner 7.27 3.07 reference 6.49 3.04 reference accommodation status alone 8.25 3.16 0.25 8.09 3.26 0.52 with partner 7.49 3.07 0.01 6.48 (2.91) reference with friends / others in a collective 7.47 2.92 reference 7.02 2.92 0.18 with parents 7.86 3.22 0.13 7.36 3.30 0.28 immigration status norwegian 7.61 3.03 reference 7.08 3.05 reference immigrant 8.17 3.19 0.14 7.73 3.24 0.05 studying abroad no 7.63 3.05 reference 7.13 3.07 reference yes 8.03 2.99 0.13 7.24 2.84 0.04 acohen’s d effect sizes (pooled sd) were calculated for each demographic variable using the category with the lowest t-ils score (sex specific) as the reference group. loneliness among university students 8 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ when analyzing the association between age as a continuous variable and overall lone‐ liness, similar findings were observed. there was a statistically significant quadratic (curvilinear) association between continuous age and overall loneliness, f(2, 48685) = 12.91, p < .001, but there was no evidence of a significant linear association, f(1, 48686) = 1.48, p = .224). loneliness and relationship status single students reported more often that they lacked companionship compared to stu‐ dents with another relationship status, a tendency that was especially pronounced for single male students, or = 2.85; 95% ci [2.14, 3.81], see table 1 for details. and whereas feeling left out was also more prevalent in single male students, relationship status was not significantly associated with feeling left out in female students. in terms of feeling isolated, single male students reported higher levels of isolation, whereas relationship status was less clearly associated with feeling isolated in female students (see figure 3 for details). there were significant sex × relationship interactions for all three loneliness items (all ps < .001). analyses of the t-ils total score showed a similar pattern (see table 1 for details). figure 3 loneliness prevalence (“often”/”very often”) by relationship status in male and female students note. error bars represent 95% confidence intervals. hysing, petrie, bøe et al. 9 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ loneliness and accommodation status similar to the findings for relationship status, also accommodation status was signifi‐ cantly associated with loneliness. both female and male, but especially male students living alone had the highest loneliness scores across all three items. students living with their parents more often reported lacking companionship, feeling left out and isolated compared with students living with a partner/friends (see figure 4 for details). there were significant sex × accommodation interactions for all three loneliness items (all ps < .001). analyses of the t-ils total score showed a similar pattern (see table 1 for details). figure 4 loneliness prevalence (“often”/”very often”) by accommodation status in male and female students note. error bars represent 95% confidence intervals. loneliness and studying abroad as detailed in table 1, females students living/studing abroad had significantly higher odds of reporting loneliness across all three t-ils items, whereas a similar pattern was not observed for male students. however, a significant sex × studying abroad interaction was only observed for “feeling left out” (see table 1 for details). trend of loneliness from 2014 to 2018 figure 5 shows the prevalence of loneliness across from 2014 to 2018. there was a signif‐ icant overall increase in students reporting feeling lonely (“quite a bit”, or “extremely”) loneliness among university students 10 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ from 2014 (16.5%) to 2018 (23.6%; p < .001). the increase was evident in both men and women, and across both response categories (see figure 5 for details). figure 5 prevalence of loneliness (from the hscl-25) from 2014 to 2018 by sex note. error bars represent 95% confidence intervals. discussion this large national survey from 2018 of norwegian fulltime students found that feelings of loneliness were common. age showed a curvilinear association with loneliness, with the youngest and oldest students reporting the highest level of loneliness across all indicators of loneliness. other significant demographic determinants of loneliness were being female, single, living alone and studying abroad. there was a considerable increase in loneliness reported by the 2018 cohort compared to the 2014 cohort, and this effect was particular strong for males, for whom the proportion of feeling “extremely” lonely had more than doubled. the findings confirm that loneliness is frequently experienced among college and university students, as indicated by 14-24% of the students responding that they “often” or “very often” lacked companionship, felt left out, or felt isolated. in line with a previous german study (diehl et al., 2018), we found that loneliness peaked among the youngest students (aged between 18-20 years), possibly as a result of the transition to university hysing, petrie, bøe et al. 11 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ life. however, a second peak in loneliness was found among the oldest age group (26-35 years). this may be related to a second transitional period towards the end of the studies, in preparation for moving into full-time work. it may also be that these individuals are establishing new relationships after a transition into work and they identify less with student life and are spending less time in student social activities at this stage. being in a close relationships was associated with less loneliness among the students, comparable to the protective effect of close relationships in the general population (beutel et al., 2017). for students, their living situation is a period-specific buffer against loneliness, with students sharing accommodation reporting less loneliness than those that live alone, a finding which also is in line with a previous german university study (diehl et al., 2018). the complex associations between sex and loneliness may be understood in light of the inconsistencies in sex differences in previous studies (mahon et al., 2006). the general pattern is that female students report more loneliness than men across most categories, especially in the younger age groups, while the difference is attenuated in the oldest student group. some risk factors had differential effects across sexes, including a stronger association between relationship status and loneliness among men, with single men being a noteworthy high-risk group. similarly, living alone was also a stronger risk factor for men than women. overall, it seems that men are more sensitive to the structural factors and relationship status for loneliness than females. this may also indi‐ cate that interventions should be attentive toward sex-specific risks, and it might be that differential interventions are needed. future interventions studies could explore if men show a more beneficial more effect of structural interventions such as organised activites and housing, while women might respond better to strengthening social relationships. women reporting more loneliness than men may also be a result of woman may more easily acknowledging feelings of loneliness, due to less social consequences of lonliness for woman (borys & perlman, 1985). we found a substantial increase in reported loneliness from 2014 to 2018. while there is limited studies reporting on trends, a danish study found a similar pattern from 1991 to 2014 among adolescents (madsen et al., 2019). the effect in that study was strongest for the high ses groups. although we have no information on family ses in the current study, all the included participants are pursuing higher education. two studies of elderly have reported an opposite pattern, with loneliness decreasing over time (honigh-de vlaming et al., 2014; lempinen, junttila, & sourander, 2018), but it might very well be that the trends are different across age groups, and this limits the comparison. the recency of the present study also precludes comparison to others in the same time period. it is uncertain if this is an ongoing trends, but the next planned wave of the shot study in 2022 will give new and valuable information on the longer trajectories of loneliness over time. what the drivers of this increase may be is also uncertain. it may reflect a general increase in mental distress, with recent evidence from the same dataset loneliness among university students 12 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ as the current study showing that both sleep problems and self-harm have increased across the same time period (sivertsen, hysing, et al., 2019; sivertsen, vedaa, et al., 2019). the generalizabilty of the findings to the whole student population should be done with care given the relatively modest response rate for the shot2014 (29%) and shot2018 (31%). in relation to this, the issue of sample comparability is important. as the surveys in 2014 and 2018 included somewhat different welfare organizations and institutions, a recent report using the same datasets, performed detailed sensitivity analyses of the hscl-25, comprising only institutions that were included in both surveys (knapstad et al., 2019). the results from these analyses showed near-identical effect-sizes of the trend data, suggesting that the two samples from 2014 and 2018 are comparable. regarding the representativeness of the sample in comparison to the total student population in norway, the shot2018 study consisted of 69% females, compared to 58% of all those who were invited. as such, this may represent a bias for the overall estimates, which is why we mainly present gender-specific results. in contrast, the age distribution was almost identical between the invited and the participating student, thus supporting the representativeness of the sample (sivertsen, vedaa, et al., 2019). rather, it may be more appropriate to emphasize the relative differences between men and women, as well as different age cohorts and sociodemographic factors found in the current study, as these estimates are less prone to selection bias. the cross-sectional nature of the shot2018-study precludes conclusions on temporal order and causality. for instance, being lonely might reduce the chances for cohabiting, and thus loneliness might be a predictor of accomodation status and not its consequence. the loneliness measure is a three item, psychometrically sound measure, but a more nuanced understanding could have been gained by a more thorough assessment. future studies should investigate risk and protective factors for loneliness over and beyond demographic characteristics. both individual characteristics of the students as well as systemic characteristics of the teaching situation should be investigated to in‐ crease our understanding of what constitutes risks for loneliness in this group to inform preventive interventions. the digital society may be one aspect that could account for the increase in loneliness and should be investigated further (odacı & kalkan, 2010) further, if the trend of increasing loneliness will further strengthen in the coming years or will attenuate should be investigated in the present study as well as other epidemio‐ logical studies of students the findings also have notable implications. the rise in loneliness over a four year period warrants concern, and should be met with preventive actions. the demographic determinants identified in this study could give indications of high risk groups to target, including the transitional periods and those living alone. there might be a need for interventions to target male and female students diffentially. hysing, petrie, bøe et al. 13 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://www.psychopen.eu/ funding: shot 2018 has received funding from the norwegian ministry of education and research (2017) and the norwegian ministry of health and care services (2016). competing interests: the authors have declared that no competing interests exist. acknowledgments: we wish to thank all students participating in the study, as well as the three largest student welfare organizations in norway (sio, sammen, and sit), who initiated and designed the shot study. references beutel, m. e., klein, e. m., brähler, e., reiner, i., jünger, c., michal, m., . . . tibubos, a. n. 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(2019). suicide attempts and non-suicidal self-harm among university students: prevalence study. bjpsych open, 5(2), article e26. https://doi.org/10.1192/bjo.2019.4 hysing, petrie, bøe et al. 15 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://doi.org/10.1177/0898264313518066 https://doi.org/10.1177/0164027504268574 https://doi.org/10.1017/s0033291719003350 https://doi.org/10.1111/jcpp.12807 https://doi.org/10.1037/dev0000117 https://doi.org/10.1093/pubmed/fdy133 https://doi.org/10.1097/00006199-200611000-00009 https://doi.org/10.1017/s0033291718000788 https://doi.org/10.1002/j.1556-6676.1997.tb02362.x https://doi.org/10.1177/0743558403258862 https://doi.org/10.1016/j.compedu.2010.05.006 https://doi.org/10.1192/bjo.2019.4 https://www.psychopen.eu/ sivertsen, b., råkil, h., munkvik, e., & lønning, k. j. (2019). cohort profile: the shot-study, a national health and well-being survey of norwegian university students. bmj open, 9(1), article e025200. https://doi.org/10.1136/bmjopen-2018-025200 sivertsen, b., vedaa, ø., harvey, a. g., glozier, n., pallesen, s., aarø, l. e., . . . hysing, m. (2019). sleep patterns and insomnia in young adults: a national survey of norwegian university students. journal of sleep research, 28(2), article e12790. https://doi.org/10.1111/jsr.12790 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. loneliness among university students 16 clinical psychology in europe 2020, vol.2(1), article e2781 https://doi.org/10.32872/cpe.v2i1.2781 https://doi.org/10.1136/bmjopen-2018-025200 https://doi.org/10.1111/jsr.12790 https://www.psychopen.eu/ loneliness among university students (introduction) method procedure ethics instruments statistics results descriptive characteristics loneliness in shot2018 loneliness and age loneliness and relationship status loneliness and accommodation status loneliness and studying abroad trend of loneliness from 2014 to 2018 discussion (additional information) funding competing interests acknowledgments references the 12-month course of icd-11 adjustment disorder in the context of involuntary job loss research articles the 12-month course of icd-11 adjustment disorder in the context of involuntary job loss louisa lorenz a , andreas maercker a , rahel bachem a [a] department of psychology, university of zurich, zurich, switzerland. clinical psychology in europe, 2020, vol. 2(3), article e3027, https://doi.org/10.32872/cpe.v2i3.3027 received: 2019-05-10 • accepted: 2020-07-18 • published (vor): 2020-09-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: louisa lorenz, department of psychology, university of zurich, binzmuehlestrasse 14/17, ch-8050 zurich, switzerland. tel.: +41 44 635 74 57. e-mail: l.lorenz@psychologie.uzh.ch supplementary materials: materials [see index of supplementary materials] abstract background: after its redefinition in icd-11, adjustment disorder (ajd) comprises two core symptom clusters of preoccupations and failure to adapt to the stressor. only a few studies investigate the course of ajd over time and the definition of six months until the remission of the disorder is based on little to no empirical evidence. the aim of the present study was to investigate the course of ajd symptoms and symptom clusters over time and to longitudinally evaluate predictors of ajd symptom severity. method: a selective sample of the zurich adjustment disorder study, n = 105 individuals who experienced involuntary job loss and reported either high or low symptom severity at first assessment (t1), were assessed m = 3.4 (sd = 2.1) months after the last day at work, and followed up six (t2) and twelve months (t3) later. they completed a fully structured diagnostic interview for ajd and self-report questionnaires. results: the prevalence of ajd was 21.9% at t1, 6.7% at t2, and dropped to 2.9% at t3. all individual symptoms and symptom clusters showed declines in prevalence rates across the three assessments. a hierarchical regression analysis of symptoms at t3 revealed that more symptoms at the first assessment (β = 0.32, p = .002) and the number of new life events between the first assessment and t3 (β = 0.29, p = .004) significantly predicted the number of ajd symptoms at t3. conclusion: although prevalence rates of ajd declined over time, a significant proportion of individuals still experienced ajd symptoms after six months. future research should focus on the specific mechanisms underlying the course of ajd. keywords adjustment disorder, icd-11, job loss, prevalence, disorders specifically associated with stress this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i3.3027&domain=pdf&date_stamp=2020-09-30 https://orcid.org/0000-0001-8639-5661 https://orcid.org/0000-0001-6925-3266 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • symptoms of icd-11 adjustment disorder were highly prevalent among individuals who experienced involuntary job loss up to nine months previously. • in 30% of the adjustment disorder cases the symptoms persisted beyond the 6month remission threshold defined in the diagnostic manuals. • subsequent life events might complicate recovery from adjustment disorder. • mechanisms underlying symptom improvement or exacerbation need to be further studied. the new description of adjustment disorder (ajd) in the international classification of diseases, 11th version (icd-11) includes the presence of (a) one or a series of psychoso‐ cial stressor(s); of (b) preoccupation with the stressor(s); of (c) failure to adapt to the stressor(s); and of (d) significant impairment in personal, family, social, educational, oc‐ cupational or other important areas in functioning (world health organisation [who], 2018). in contrast, the diagnostic and statistical manual of mental disorders, 5th version (dsm-5) does not define specific symptoms and the diagnosis of ajd is not applicable in the presence of any other mental disorder (american psychiatric association [apa], 2013). the usage of ajd based primarily on an exclusion criterion in dsm-5 and earlier icd-versions has resulted in its usage as a diagnostic rest category with subsyndromal character (bachem & casey, 2018; baumeister & kufner, 2009). another difference be‐ tween the current manuals is that the dsm-5 distinguishes subtypes of ajd, such as depressed mood, anxiety, disturbance of conduct and mixed subtypes (apa, 2013), where‐ as the icd-11 does not. the diagnostic manuals state that the symptoms usually emerge within one (icd-11) and three (dsm-5) months after the onset of the stressor and that they typically resolve within 6 months, unless the stressor persists for a longer duration (who, 2018). this makes ajd a disorder with an essential benign outcome and spontaneous remission by definition. a few studies that investigated readmission rates for ajd cases in clinical settings support this concept (jäger, burger, becker, & frasch, 2012; jones, yates, & zhou, 2002). however, ajd is also associated with an elevated risk for concurrent or subsequent mental disorders and for suicidality (casey & doherty, 2012; gradus et al., 2010; o’donnell et al., 2016) and the definition of the 6-months’ period is still based on little to no empirical evidence. in injury survivors, 16% of the participants still met the diagnostic criteria of dsm-5 ajd after twelve months post-injury (o’donnell et al., 2016). in a representative sample from germany, a significant proportion of individuals who reported ajd symptoms (72%) indicated that the symptoms were present for six to twen‐ ty-four months (maercker et al., 2012). finally, a study assessing ajd symptoms several years after organ transplantations found that the time since the medical procedure was 12-month course of icd-11 adjustment disorder 2 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ unrelated to ajd symptom severity (bachem, baumann, & köllner, 2019). to the best of our knowledge, these are the only studies that specifically focused on the course of ajd over time based on a recent definition of the disorder, all of them putting the six months’ period in question. the zurich adjustment disorder study (zads) investigates the validity of the new icd-11 definition of ajd in a sample of individuals who involuntarily lost their job and explores predictors of ajd development over time. previous analyses revealed that the prevalence of ajd in this high-risk sample was 15.5% when applying the full icd-11 diagnostic criteria to a structured diagnostic interview schedule (perkonigg, lorenz, & maercker, 2018). based on questionnaire results, the prevalence of a tentative ajd diagnosis was 25.6% at approximately three months after the last day at work (lorenz, perkonigg, & maercker, 2018b), and 18.2% six months later (lorenz, makowski, & maercker, 2019). demographic factors such as higher age, female gender or low household budget as well as characteristics of the stress experience such as first job loss, a job that required “brainwork”, a job with high responsibility, and a larger number of job applications written to get a new position correlated with higher symptom severity and/or higher odds for a diagnosis of ajd (perkonigg et al., 2018). established intrapersonal resources that support coping with adversity such as high self-efficacy and sense of coherence were similarly related to fewer symptoms of ajd (perkonigg et al., 2018). finally, the socio-in‐ terpersonal framework model for stress-response syndromes (maercker & horn, 2013) suggests that different levels of social contexts play a crucial role in the recovery after stress experiences. these contexts include social affects (e.g., shame, anger, loneliness), interactions in close relationships (e.g., social support, empathy) or societal and cultural factors (e.g. social acknowledgement). in accordance with the model, lower self-efficacy, stronger feelings of loneliness, higher dysfunctional disclosure, less perceived social support, and more negative social interactions were identified as correlates of higher symptom severity (lorenz, perkonigg, & maercker, 2018b). the aim of the present paper is to expand upon previous findings of the zads and other longitudinal investigations. first, we aimed to report on the development of ajd symptoms and icd-11 core symptom clusters in the context of involuntary job loss across three assessments. based on the current disorder model and previous research, we expected that the prevalence rates of symptoms and symptom clusters would be high ini‐ tially and that they would decline after six and twelve months. second, several potential predictors of ajd development were explored. we hypothesized that ajd-related features (initial ajd symptoms, life events experienced), socio-demographic factors (gender, age, household income), and psychosocial factors relevant for stress-response syndromes (e.g., personal beliefs, interpersonal resources) would be associated with long-term outcome. lorenz, maercker, & bachem 3 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ method participants and procedure the data for the present analysis stem from the zads investigating the new proposal for adjustment disorder in icd-11 in a sample of individuals who experienced involuntary job loss (perkonigg et al., 2018). the ethics committee of the university of zurich approved the study in june 2015 and all participants gave written informed consent. the study included all participants who were assessed at three time points with a fully structured clinical diagnostic interview for ajd. the first assessment took place up to nine months after the last day at work (t1), followed by a six-months (t2) and a twelve-months (t3) follow-up assessment. the participants were recruited through local employment offices, newspaper articles, and mailing lists in the greater zurich area. participants were excluded if they did not speak german fluently, were unable to give written informed consent, or suffered from a severe mental illness. the latter criterion led to the exclusion of one individual who was assumed to experience a psychotic episode. all participants were invited to participate in the first and second assessment of the study. since a comparison of extreme groups was planned for the original study, only a sub-sample was invited to the third assessment. inclusion in the sub-sample was determined after completion of t2. in the symptomatic group, we invited individuals who (a) met the criteria for an ajd at t1 or a subclinical ajd (either only preoccupation or only failure to adapt) at t1 and who (b) identified the same worst event at t1 and t2. in the non-symptomatic group, we invited individuals who reported a maximum of one symptom of ajd at t1 and at t2. of the 330 individuals that participated in the first assessment, 294 took part in the second assessment. of these individuals, 78 met the criteria for the symptomatic group and could be assessed a third time; 27 individuals met the criteria for the non-symptomatic group and could be assessed a third time. this led to a total sample size of n = 105 for the present analysis. the participant flow is shown in figure 1. table 1 displays a summary of the demographic characteristics of the sample. t1 was conducted m = 3.4 (sd = 2.1) months after the last day at work (mdn = 3.2). the interval between t1 and t3 was m = 12.3 (sd = 0.8) months. at t3, 17.1% (n = 18) of the participants had started a new job since t2, 48.6% (n = 51) of the sample continued the new job they had started between t1 and t2, 30.5% (n = 32) were still unemployed, and 1.9% (n = 2) experienced a new job loss. 12-month course of icd-11 adjustment disorder 4 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ figure 1 participant flow of the zurich adjustment disorder study note. t1 = first assessment; t2 = second assessment; t3 = third assessment. lorenz, maercker, & bachem 5 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ table 1 demographic characteristics of the sample (n = 105) variable m sd n % age at t1 46.3 10.0 gender male 56 53.3 female 49 46.7 marital status at t1 married 38 36.2 separated / divorced 21 20.0 never married 45 42.9 registered partnership 1 1.0 children at t1 0.9 1.1 vocational qualification on-the-job-training 3 2.9 formal apprenticeship 39 37.1 university / university of applied sciences 56 53.3 phd 3 2.9 no qualification 2 1.9 missing 2 1.9 measures adjustment disorder module for composite international diagnostic interview (ajd-cidi) adjustment disorder was assessed with a new module of the composite international diagnostic interview (cidi) that specifically focuses on ajd after icd-11 and dsm-5 (ajd-cidi) (perkonigg, strehle, et al., in press). in the beginning, the ajd-cidi assesses stressors (e.g. family conflict, financial problems, illness of a loved one) that occurred during the 12 months prior to the interview and event-specific characteristics (e.g. time of onset, duration). at the end of this first part, the participants were asked which of the events they experienced as the most distressing. the second part of the interview asks for a range of symptoms occurring in response to this event following the icd-11 and the dsm-5 definition. the 25 symptoms represent the areas of preoccupation with the stressor and failure to adapt to the stressor, as well as accessory symptoms of avoidance, depression, anxiety and impulsivity. the third part of the module assesses information about onset, recency of symptoms and functional impairment (perkonigg, strehle, et al., in press). we used a modified follow-up version of the ajd module for t2. in this version, the first part asks for new life events and the most distressing event from the previous 12-month course of icd-11 adjustment disorder 6 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ interview is coded. the participant then indicated the currently most distressing event out of the new and the old events. then, the second and third part of the ajd-cidi were applied with regard to the event coded at t1. at t3, the symptomatic group was interviewed with a version that asked specifically for symptoms in response to the event they talked about at t1 and t2. the diagnosis of ajd according to icd-11 (who, 2018) was made if the following criteria were met: a) occurrence of a significant life event; b) presence of at least one symptom of preoccupation (recurrent involuntary thoughts about the event, and constant worries related to the event); c) presence of at least two failure to adapt symptoms (con‐ centration problems, difficulties at work/daily activities, loss of interest in work, social network or leisure activities, sleep problems, and loss of self-confidence); d) frequency of symptoms at least 10-15 times per month or clinical relevance of symptoms (impair‐ ment at least “moderate” or contact with a health professional about the symptoms); e) exclusion of cases who presented with a current depressive episode and of cases who presented with a current generalized anxiety disorder as defined by the cidi. scales for predictor variables the general self-efficacy scale (gse; schwarzer & jerusalem, 1999) was used for the assessment of self-efficacy. the 10-item scale has a 4-point likert scale response-format (1, not correct – 4, absolutely correct). the total score is obtained by summing up all indi‐ vidual items and higher scores indicate higher self-efficacy. the psychometric properties of the gse were satisfactory in earlier validation studies with internal consistencies of .80 – .90 (hinz, schumacher, albani, schmid, & brähler, 2006; schwarzer & jerusalem, 1999). the internal consistency in the present study was α = .88. we measured sense of coherence using the sense of coherence scale – revised (soc-r; bachem & maercker, 2018). the scale, consisting of 13 items, measures manageability, reflection, and balance. the response-format is a 5-point likert scale (1, not at all, 5, completely). all items are summed up to build a total score of the soc-r, with one reco‐ ded item. higher scores indicate a higher sense of coherence. earlier validation studies reported satisfactory psychometric properties for the soc-r with internal consistencies of α = .75 – .81 (bachem & maercker, 2018; mc gee, höltge, maercker, & thoma, 2018). the internal consistency in the present study was α = .71. a composite score of two single items from other scales was used to measure feelings of loneliness (lorenz, perkonigg, & maercker, 2018b). we used one item from the brief symptom inventory – 18 (spitzer et al., 2011) and one item of the social functioning questionnaire (tyrer et al., 2005). the item formulations were ‘how strong did you experience feelings of loneliness during the past 7 days?’ and ‘i feel lonely and isolated from other people’. the response-format was a 5-point likert scale (0, not at all – 4, very strong) and a 4-point likert scale (0, almost all the time – 3, not at all), respectively. the lorenz, maercker, & bachem 7 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ latter item was recoded before building a sum score with the first item of the scale. the correlation between the two items in the present study was α = .70. the disclosure of trauma questionnaire (dtq) was used in an abbreviated form (pielmaier & maercker, 2011) to measure dysfunctional disclosure. the scale, consisting of 12 items with a 6-point likert scale (0, not at all – 5, absolutely) response-format, measures the urge to talk, the reluctance to talk, and emotional reactions while disclos‐ ing. the individual items are summed up to build a total score; higher scores indicate higher dysfunctional disclosure. previous studies found satisfying psychometric proper‐ ties for the dtq (müller, beauducel, raschka, & maercker, 2000; müller & maercker, 2006). the internal consistency of the abbreviated form was α = .75 in previous studies (pielmaier & maercker, 2011) and α = .81 in the present study. we used the social support questionnaire, short form (fsozu-k; fydrich, sommer, tydecks, & brähler, 2009) to measure perceived social support. the 14 items are an‐ swered on a 5-point likert scale (1, don’t agree, 5, agree). the mean of all answered items is used to build the total score and higher scores indicate higher perceived social support. the psychometric properties in the validation of the fsozu-k were satisfactory with an internal consistency of α = .94 (fydrich et al., 2009). the internal consistency in the present study was α = .93. a subset of items of the daily hassles scale (perkonigg & wittchen, 1998) was used to measure negative social interactions (lorenz, perkonigg, & maercker, 2018b). six items measured negative interactions with the partner, children, parents, siblings, friends, or neighbours during the last two weeks. the original 4-point likert scale response-format of the items (1, often – 4, never) was reverse coded, so that a higher mean score indicates more negative social interactions. the internal consistency was α = .68 in a previous study (lorenz, perkonigg, & maercker, 2018b) and α = .73 in the present study. the social acknowledgement questionnaire (saq; maercker & müller, 2004) measured perceived acknowledgement of the difficult situation of the individual by the social environment. the 16 items, answered on a 4-point likert scale (0, not at all – 3, complete‐ ly), measure general disapproval, disapproval by family or friends, and recognition as a victim. following the authors of the scale, the total score was built by summing up items 3, 9, and 11 through 16, and subtracting items 1, 2, 4 through 8, and 10. a higher score indicates more social acknowledgement. the validation study of the questionnaire reported satisfactory psychometric properties with an internal consistency of α = .86 (maercker & müller, 2004). the internal consistency in the present study was α = .73. statistical analysis data were analysed using spss version 23. the highest number of missing values was found for social acknowledgement (13%), all other variables had less than 3% missing val‐ ues and data were missing completely at random. pairwise case deletion was used in the analyses. the prevalence of icd-11 ajd was computed with and without consideration 12-month course of icd-11 adjustment disorder 8 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ of the exclusion criterion. to investigate predictive factors, we performed a hierarchical regression analysis with the number of symptoms at t3 as outcome. we decided to include all symptoms that were measured by the ajd-cidi to increase the variance of the outcome variable and because there is still uncertainty about the best conceptualisation of ajd (lorenz, hyland, perkonigg, & maercker, 2018). the analysis included three steps. in the first step, we included the number of symptoms at t1, the total number of life events reported at t1, and the total number of new life events reported between t1 and t3 as predictors. the second step included socio-demographic characteristics (gender, age, household income < 4000 swiss francs) and the third step included psychosocial variables (general self-efficacy, loneliness, dysfunctional disclosure, perceived social support, nega‐ tive social interactions, social acknowledgement). in the second and third step, we inclu‐ ded predictor variables that were found to be associated with initial symptom severity and 6-months outcomes in previous publications from this sample (lorenz, hyland, et al., 2018; lorenz, perkonigg, & maercker, 2018a, 2018b; perkonigg et al., 2018). the final model was selected based on the significance of the f-statistics. no multicollinearity was found based on the vif measure (ranged between 1.030 and 1.078). results descriptives the total amount of symptoms as measured by the ajd-cidi was m = 7.1 (sd = 5.5; mdn = 7.0, range = 0-19) at t1, m = 4.3 (sd = 5.0; mdn = 2.0, range = 0-20) at t2, and m = 2.1 (sd = 2.8; mdn = 1.0, range = 0-13) at t3. the total number of life events reported at t1 was m = 2.3 (sd = 1.2, range = 1-7) and the total number of new life events experienced between t1 and t3 was m = 1.0 (sd = 1.3, range = 0-7). the majority of participants (74.3%) indicated the job loss, financial problems or problems with authorities as their worst event at t1, followed by family matters (22.9%; family conflicts/separation/illness or death of family member). the descriptive statistics for the predictor variables and the correlation coefficients between the main predictor variables can be found in the supplementary material. prevalence of ajd symptoms the prevalence rates of the individual symptoms as measured by the ajd-cidi are displayed in figure 2. for the majority of symptoms, the prevalence was highest at t1 and lowest at t3. the symptoms measuring preoccupation with the stressor, sleep disturbances (as part of failure to adapt), and feeling low and sad (as part of depressive symptoms) were the most prevalent at t1 with over 40% of the individuals reporting each of them. at t2, repetitive thoughts, feeling low and sad, and feeling discouraged and hopeless for the future (depressive symptom) were the most prevalent symptoms lorenz, maercker, & bachem 9 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ (each over 30%). the most prevalent symptoms at t3 were repetitive thoughts, rumination about the event, and avoiding situations or individuals that could remind of the event (avoidance symptom) with roughly a 20% prevalence each. figure 2 prevalence (%) of individual symptoms that may occur in icd-11 adjustment disorder across the three assessments note. pre = preoccupation; fta = failure to adapt; avo = avoidance; dep = depression; anx = anxiety; imp = impulsivity. *items used for diagnostic algorithm for adjustment disorder. prevalence of ajd symptom groups table 2 displays the prevalence of the diagnostic criteria across the three assessments. criterion a was met by every participant since the presence of a stressor was an inclu‐ sion criterion of the study. the prevalence rates of preoccupation (criterion b), failure to adapt (criterion c), and impairment in social functioning (criterion d) were highest for the first assessment and declined over time. the prevalence rate of exclusive disorders (criterion e) remained stable across the three assessments. approximately every fifth individual met the full diagnostic criteria at t1 (21.9%). this prevalence declined to 6.7% at t2, and to 2.9% at t3. the majority of individuals reported no ajd across all assessments (n = 80; 76.2%). most of the other participants met the diagnostic guidelines only at t1 (n = 16, 15.2%) or only at t1 and t2 (n = 5, 4.8%). one individual (1.0%) received an ajd diagnosis at all three assessments. 12-month course of icd-11 adjustment disorder 10 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ table 2 prevalence of adjustment disorder criteria across the three assessments adjustment disorder criterion t1 t2 t3 n % n % n % criterion a: event 105 100.0 105 100.0 105 100.0 criterion b: preoccupation 63 60.0 32 30.5 15 14.3 criterion c: failure to adapt 44 41.9 18 17.1 10 9.5 criterion d: impairment 82 78.1 67 63.8 40 38.1 criterion e: exclusive disorders 10 9.5 10 9.5 9 8.6 icd-11 adjustment disorder without exclusion criterion 29 27.6 12 11.4 4 3.8 icd-11 adjustment disorder with exclusion criterion 23 21.9 7 6.7 3 2.9 note. t1 = first assessment; t2 = second assessment; t3 = third assessment. prediction of ajd symptoms at t3 table 3 displays the results of the hierarchical regression analysis for the total number of ajd-cidi symptoms at t3. the first step included the number of ajd-cidi symptoms at t1, the number of life events reported at t1, and the number of new live events experienced between t1 and t3 as predictors. this model was significant, f(3, 86) = 7.648, p < .001. the second model, which included socio-demographic characteristics, and the third model, which included psycho-social variables, did not significantly increase the fit of the model. thus, the model only including adjustment disorder related characteristics (model 1) was interpreted. a higher number of ajd-cidi symptoms at t1 and a higher number of life events experienced between t1 and t3 were associated with a higher number of ajd-cidi symptoms at t3. the model explained 18% of the variance in the outcome (adjusted r 2 = .183). table 3 hierarchical regression results (standardized β coefficients) for the total number of ajd-cidi symptoms at the third assessment (n = 105) predictor model 1 2 3 number of ajd-cidi symptoms at t1 0.316** 0.365*** 0.278* number of life events at t1 0.060 0.083 0.088 number of new life events between t1 and t3 0.291** 0.286** 0.292** gender -0.235* -0.205 age (t1) 0.046 0.007 household income < 4000 sfr (t1) 0.000 -0.001 general self-efficacy (t1) -0.079 lorenz, maercker, & bachem 11 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ predictor model 1 2 3 sense of coherence (t1) -0.029 loneliness (t1) 0.164 dysfunctional disclosure (t1) -0.032 perceived social support (t1) 0.078 negative social interactions (t1) 0.069 social acknowledgement (t2) -0.035 f 7.648*** 2.130 0.518 r 2 .211 .267 .300 adjusted r 2 .183 .214 .181 δr 2 .056 .033 note. gender: 1 = male; 2 = female; household income < 4000 sfr (0 = no; 1 = yes). *p < .05. **p < .01. ***p < .001. discussion the aim of the present analysis was to investigate the course of adjustment disorder in the context of involuntary job loss over the course of twelve months. it was the first investigation of prevalence rates according to icd-11 with a new structured diagnostic interview in a high-risk sample. we found an ajd prevalence rate of 21.9% at the first assessment. previous studies using icd-10 or dsm-iv criteria found prevalence rates ranging between 6.9% and 38% in high risk populations (e.g., mitchell et al., 2017; rundell, 2006), between 3% and 12% in medical settings (e.g., fernández et al., 2012; yaseen, 2017), and between 11% and 17% in psychiatric settings (bruffaerts, sabbe, & demyttenaere, 2004; shear et al., 2000). based on a self-report questionnaire, studies investigating the new icd-11 approach reported varying prevalence rates between 21% and 61% in high-risk populations (e.g., dannemann et al., 2010; dobricki, komproe, de jong, & maercker, 2010). however, they refer to a tentative diagnosis and did not apply the icd-11 exclusion criterion. the prevalence rate in this sample, consisting of extreme groups with high or low ajd symptoms at previous assessments, dropped to 3% at the third assessment, which is only slightly higher than prevalence rates found in general population-based samples (e.g., ayuso-mateos et al., 2001; glaesmer, romppel, braehler, hinz, & maercker, 2015). at the same time, the prevalence rate was lower than the twelve-months prevalence rate found in the o’donnell et al. (2016) study investigating the dsm-5 model in a post-injury sample. this could be either an effect of the different diagnostic guidelines applied (icd-11 or dsm-5) or an effect of the stressor (job loss vs. injuries). future studies should aim at a direct comparison between icd-11 and dsm-5 diagnostic guidelines. 12-month course of icd-11 adjustment disorder 12 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ as expected, there was a decline in ajd symptoms over time. this generally supports the assumption of a favourable outcome of ajd. however, a substantial proportion (seven of the twenty-three cases) with an ajd at the first assessment still met the diagnostic criteria for an ajd six months later. this represents 30% of the ajd cases that show a longer duration of the disorder than the conditional six-month threshold in icd-11 and dsm-5. it could be argued that the life event ‘job loss’, which was rated to be the worst event by the majority of the sample, or its consequences is often not resolved within the time period of six months the icd-11 mentions as “typical” for a resolution. this argument is supported by the high number of new or subsequent life events in the present sample, which might complicate recovery. it emphasizes the difficulty of apply‐ ing time period features like six months in stress-related disorders and implies to use this feature only after a thorough substantive examination and a flexible interpretation of the abovementioned period. the second aim of this study was to investigate factors that predict ajd symptoms after twelve months. the hierarchical approach allowed us to examine whether only ajd-related characteristics explain long-term outcome or whether socio-demographic factors and psychosocial processes add explanatory power over the course of twelve months. the results indicate that higher initial symptomatology and more life stressors following the event significantly predicted higher symptomatology twelve months later and that ajd-related characteristics might be a sufficient explanation for symptom se‐ verity over the course of twelve months, supporting the concept of a stress-response syndrome. however, the selection of potential risk and protective factors was limited, and future studies should include other relevant predictors since the model was only able to explain 18% of the variation in symptom severity after twelve months. we included socio-demographic and psychosocial predictors that were associated with initial symptom severity in earlier studies (e.g., lorenz, perkonigg, & maercker, 2018b; perkonigg et al., 2018). although these predictors were not longitudinally asso‐ ciated with ajd symptoms, they were associated with initial symptom severity. since initial symptom severity was one of the strongest predictors of long-term outcome, the effect of the socio-demographic and psychosocial predictors on t3 ajd symptoms could be indirect, via symptoms at t1. hence, future studies could focus on a possible mediation effect of initial symptom severity on the association between socio-demographic and psychosocial predictors and long-term outcome. if this mediation was true, it could be reasonable to target these factors to achieve a better long-term outcome. this assumption finds support in two recent self-help intervention studies for ajd. these interventions aimed at enhancing resilience for example by improving problem-solving skills or mo‐ bilizing social support and showed medium to large effect sizes for the reduction of ajd related symptomatology over time (bachem & maercker, 2016; eimontas, rimsaite, gegieckaite, zelviene, & kazlauskas, 2018). alternative explanations for the result that especially the number of life events predicted symptom severity at t3 could be memory lorenz, maercker, & bachem 13 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ effects or attention deficits. the ajd-cidi stressor list also covers psychosocial stress of minor intensity, such as troubles with neighbours or giving up a hobby. individuals who are worse off could be particularly sensitive to these minor stressors while better adjusted individuals may find it unnecessary to report these events. the analyses for ajd symptoms were based on all symptoms that may occur in ajd rather than only the icd-11 core symptom cluster of preoccupation and failure to adapt because of the differences between the major diagnostic classification systems. while the icd-11 defines specific core symptoms (who, 2018), the dsm-5 kept the previous defini‐ tion that is not based on specific criteria but on the exclusion of other mental disorders (apa, 2013). these dissimilarities are a result of the lack of research around ajd and of a lack of agreement on the main characteristics of the disorder, and they might result in differences in access to treatment. across the three assessments, different symptoms of preoccupation with the stressor were among the most prevalent symptoms, supporting the inclusion of this symptom group in the diagnostic guidelines in icd-11. symptoms that reflect depressive reactions were also commonly present, suggesting that it might be reasonable to include mood alterations in the ajd definition as it is the case in dsm-5. these results could be a first evidence for the validity of both approaches and further revisions of the guidelines might include features of both definitions. future research should not only focus on the most prevalent symptoms but also try to identify symptoms that are associated with high functional impairment or that show high discriminatory power. the use of the new icd-11 diagnostic guidelines and a fully structured clinical diagnostic interview make this study unique. still, it has several limitations. first, the data stems from a particular high-risk sample, which limits the generalizability to all ajd cases. second, the sample for this study was based on specific selection criteria. we specifically defined a symptomatic and a non-symptomatic group to increase variance in the data. moreover, we lifted inclusion criterion b) for the non-symptomatic group in order to be able to investigate incidence rates for adjustment disorder. this specific methodology complicated interpretation of prevalence findings at t3. furthermore, the recruitment was based on self-selection since we did not apply a systematic or stratified recruitment strategy. these methodological concerns restrict the generalizability of the results to the whole population of unemployed individuals. third, we did only control for the presence of a depressive episode and/or generalised anxiety disorder and not the full list of exclusive disorders as recommended by icd-11. future studies should consider the full range of clinically meaningful exclusions. fourth, the interval between assessments was chosen at six months to investigate the proposal of the diagnostic guidelines for ajd. research that includes shorter intervals between assessments could shed further light into the dynamics of the disorder. last, the number of predictors in the hierarchical regression could have limited the power of the analysis considering the sample size. this could have masked some predictive effects and future studies should increase the sample 12-month course of icd-11 adjustment disorder 14 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ size. in addition, loneliness was assessed with two items from different scales rather than with an established questionnaire. adjustment disorder has been a diagnostic category that received little attention in research despite a frequent use in clinical practice (evans et al., 2013; reed, correia, esparza, saxena, & maj, 2011). the relatively high prevalence of ajd in this study, the methodological concerns raised by our findings, and the aforementioned issues of disor‐ der definition again stress the importance of a systematic inclusion of ajd in research in order to understand maladaptive responses to life stress better, especially since ajd is associated with a higher risk for the development of severe psychopathology and suicidality (e.g., casey & doherty, 2012; o’donnell et al., 2016). this study furthermore showed that even though ajd symptomatology shows a favourable course over time, it can also persist beyond the six-month threshold as proposed by icd-11 and dsm-5. further research is needed to understand the mechanisms underlying the disorder and determining the long-term outcome of ajd. moreover, future studies comparing preva‐ lence rates between icd-11 and dsm-5 may deepen our understanding of maladjustment to stressful life events. funding: this research was funded by a grant of the swiss national science foundation (#100019_159436) and financial support by the jacobs foundation. competing interests: the authors have declared that no competing interests exist. acknowledgments: this work is part of the zurich adjustment disorder study (2014-2018). we thank co-pi dr. axel perkonigg, all respondents of the study for their participation and lisa makowski, bsc., for her work regarding data collection and data processing. we acknowledge the office of economy and labour zurich for cooperation on respondents’ recruitment and dr. beesdo-baum, dr. wittchen and dipl. math. jens strehle (tu dresden) for collaboration on the ajd-cidi module. ethics approval: the authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the helsinki declaration of 1964 and its later amendments. all persons gave their written informed consent prior to their inclusion in the study. data availability: data from this study are not publicly available as informed consent and ethical approval for public data sharing were not obtained from participants. the data are readily available upon request by qualified scientists. any enquiries regarding data accessibility can be addressed to the first author. supplementary materials the supplementary materials contain the descriptive statistics of the main measures of the study and the correlations between study variables (for access see index of supplementary materials below). lorenz, maercker, & bachem 15 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ index of supplementary materials lorenz, l., maercker, a., & bachem, r. 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(2017). adjustment disorder: prevalence, sociodemographic risk factors, and its subtypes in outpatient psychiatry clinic. asian journal of psychiatry, 28, 82-85. https://doi.org/10.1016/j.ajp.2017.03.012 lorenz, maercker, & bachem 19 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://doi.org/10.3402/ejpt.v2i0.8749 https://doi.org/10.1002/j.2051-5545.2011.tb00034.x https://doi.org/10.1016/j.genhosppsych.2006.04.006 https://doi.org/10.1176/appi.ajp.157.4.581 https://doi.org/10.1055/s-0031-1281602 https://doi.org/10.1177/0020764005057391 https://icd.who.int/browse11/l-m/en https://doi.org/10.1016/j.ajp.2017.03.012 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. 12-month course of icd-11 adjustment disorder 20 clinical psychology in europe 2020, vol.2(3), article e3027 https://doi.org/10.32872/cpe.v2i3.3027 https://www.psychopen.eu/ 12-month course of icd-11 adjustment disorder (introduction) method participants and procedure measures statistical analysis results descriptives prevalence of ajd symptoms prevalence of ajd symptom groups prediction of ajd symptoms at t3 discussion (additional information) funding competing interests acknowledgments ethics approval data availability supplementary materials references pre-sleep arousal and fear of sleep in trauma-related sleep disturbances: a cluster-analytic approach research articles pre-sleep arousal and fear of sleep in trauma-related sleep disturbances: a cluster-analytic approach gabriela g. werner a, sarah k. danböck ab, stanislav metodiev a, anna e. kunze a [a] department of psychology, lmu munich [study institution], munich, germany. [b] department of psychology, university of salzburg, salzburg, austria. clinical psychology in europe, 2020, vol. 2(2), article e2699, https://doi.org/10.32872/cpe.v2i2.2699 received: 2019-09-27 • accepted: 2019-12-05 • published (vor): 2020-06-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: gabriela g. werner, department of psychology, lmu munich, leopoldstraße 13, 80802 munich, germany. phone +49 89 2180 5297. fax: +49 89 2180 5288. e-mail: gabriela.werner@psy.lmu.de abstract background: trauma-related sleep disturbances constitute critical symptoms of posttraumatic stress disorder (ptsd), but sleep symptoms often reside even after successful trauma-focused psychotherapy. therefore, currently unattended factors – like fear of sleep (fos) – might play a crucial role in the development and maintenance of residual sleep disturbances. however, it is unclear whether trauma-exposed individuals exhibit different symptomatic profiles of sleep disturbances that could inform individualized therapeutic approaches and eventually enhance treatment efficacy. method: in a large online study, a two-step cluster analysis and a hierarchical cluster analysis using ward’s method were performed to explore subgroups among trauma-exposed individuals (n = 471) in terms of fos, different aspects of trauma-related sleep disturbances (e.g., insomnia symptoms, nightmares, arousal), and ptsd symptoms. these variables were compared between resulting clusters using anovas and scheffé’s post-hoc tests. results: the hierarchical cluster analysis supported 3and 4-cluster solutions. the 3-cluster solution consisted of one “healthy” (n = 199), one “subclinical” (n = 223), and one “clinical” (n = 49) cluster, with overall low, medium, and high symptomatology on all used variables. in the 4-cluster solution, the clinical cluster was further divided into two subgroups (n = 38, n = 11), where one cluster was specifically characterized by elevated somatic pre-sleep arousal and high levels of fos. conclusions: a subgroup of trauma-exposed individuals with ptsd and sleep disturbances suffers from increased pre-sleep arousal and fos, which has been suggested as one possible explanation for residual sleep disturbances. in these patients, fos might be a relevant treatment target. keywords trauma-related sleep disturbances, pre-sleep arousal, insomnia, nightmares, fear of sleep, posttraumatic stress disorder, cluster analysis this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i2.2699&domain=pdf&date_stamp=2020-06-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • fear of sleep is one additional, important aspect of trauma-related sleep disturbances. • trauma-exposed individuals can be clustered based on their sleepand ptsdrelated symptomatology. • one subgroup was specifically characterized by increased fear of sleep and somatic pre-sleep arousal. • fear of sleep might be a relevant treatment target and might provide more specialized treatments with greater response rates. • somatic pre-sleep arousal might reflect the physiological component of fear of sleep. during the last decade, the body of research on sleep disturbances in traumaand stressor-related disorders, particularly posttraumatic stress disorder (ptsd), has rapidly grown. sleep disturbances following traumatic experiences are mostly conceptualized as symptoms of insomnia (e.g., difficulties falling or staying asleep) and recurrent night‐ mares (pace-schott & bottary, 2018), which were previously seen as secondary symptoms of ptsd (spoormaker & montgomery, 2008). this might be due to the fact that these types of sleep disturbances are represented in the formal diagnosis of ptsd (american psychiatric association, 2013). however, recent research has consistently shown that sleep disturbances are more than a mere epiphenomenon, as they appear to constitute a crucial factor in the development and maintenance of ptsd (cox, tuck, & olatunji, 2017; germain, mckeon, & campbell, 2017; sinha, 2016; spoormaker & montgomery, 2008). furthermore, although evidence-based treatment for ptsd (lee et al., 2016; schnurr, 2017) often leads to significant reductions in symptoms of insomnia as well as night‐ mares, in contrast to other ptsd symptoms, sleep disturbances do not usually fully remit (belleville, guay, & marchand, 2011; galovski, monson, bruce, & resick, 2009; gutner, casement, stavitsky gilbert, & resick, 2013; lommen et al., 2016; woodward et al., 2017). sleep-focused treatments, like cognitive behavioral therapy for insomnia (cbt-i) or forms of trauma-related nightmare treatments (e.g., imagery rehearsal therapy, irt; or exposure, relaxation, and rescripting therapy, errt), lead to stronger reductions in sleep disturbances and nightmares respectively (casement & swanson, 2012; ho, chan, & tang, 2016), and additionally moderately reduce ptsd symptoms (davis et al., 2011; davis & wright, 2007; pruiksma, cranston, rhudy, micol, & davis, 2018). however, most studies show that even after sleep-focused treatments, sleep disturbances remain in the clinical range, especially in more severe ptsd samples (nappi, drummond, thorp, & mcquaid, 2010; swanson, favorite, horin, & arnedt, 2009; ulmer, edinger, & calhoun, 2011). this leads to the assumption that other factors, which are currently unattended, seem to play a role in the development and maintenance of trauma-related sleep distur‐ bances. fear of sleep in trauma-related sleep disturbances 2 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ one such factor is fear of sleep (fos), which includes dysfunctional beliefs about one’s perceived safety during sleep, fear of nightmares, and maladaptive behaviors. fos seems to develop due to two main reasons: first, traumatic experiences together with daytime ptsd-symptoms (e.g., intrusive re-experiencing) induce a feeling of loss of control, which can trigger strong feelings of helplessness and reduced trust in other people and in the world (ehlers, hackmann, & michael, 2004). yet sleep is a state where a reduced ability to monitor the environment and giving up control is inevitable (dahl, 1996). therefore, it is plausible that trauma survivors with ptsd might be particularly fearful of this state because they feel extremely vulnerable during sleep. second, due to a fear of re-experiencing the traumatic event during sleep, nightmares might additionally enhance fos (davis, 2009; krakow, tandberg, scriggins, & barey, 1995; neylan et al., 1998). also, related sleep-interfering maladaptive behaviors, such as sleeping with lights on, the use of heavy blankets, exaggerated safety checking before sleeping, or delaying bedtime in order to deal with nightmares or being vulnerable during sleep, can be considered part of fos (pruiksma et al., 2014). as fos is not targeted during traumaor sleep-focused psychotherapy (pigeon & gallegos, 2015), it has recently been suggested as an underlying mechanism of residual sleep disturbances (pruiksma et al., 2014). several empirical findings support correlational links between fos and increased symptoms of insomnia and nightmares, as well as overall ptsd symptomatology (huntley, hall brown, kobayashi, & mellman, 2014; kanady et al., 2018; neylan et al., 1998; pruiksma, cranston, jaffe, & davis, 2011). however, other factors can also influence the maintenance of trauma-related sleep disturbances. for example, traumatic experien‐ ces generally lead to a state of heightened cognitive and somatic arousal – particularly during the pre-sleep period – that might consequently induce sleep disturbances (sinha, 2016). furthermore, the severity of trauma-related insomnia symptoms and nightmares per se might be one important factor for the persistence of sleep disturbances. finally, both difficulty maintaining sleep and nightmares have also been associated with more interrupted, and therefore fragmented, rapid eye movement (rem) sleep, which can in‐ terfere with treatment response via impaired extinction learning (pace-schott, germain, & milad, 2015; riemann et al., 2012). overall, there is a need to investigate these various aspects of trauma-related sleep disturbances in order to provide additional promising treatment targets. fos might be a particularly relevant factor influencing the maintenance of trauma-related sleep distur‐ bances because other factors (e.g., feeling of safety during the day, sleep disturbances, and nightmares in general) are already targeted during traumaor sleep-focused therapy (pigeon & gallegos, 2015). however, the role of fos in individuals with trauma-related sleep disturbances is currently unknown. therefore, we have investigated fos together with symptoms of insomnia, nightmares, pre-sleep arousal, and rem sleep fragmentation in the context of traumatic experiences in a general population sample that included both healthy individuals and individuals with clinically relevant ptsd symptoms. through werner, danböck, metodiev, & kunze 3 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ the use of a cluster-analytic approach, this study aims to explore symptomatic profiles of trauma-exposed individuals on fos, insomnia symptoms, nightmares, pre-sleep arousal, and rem sleep fragmentation, as well as ptsd symptomatology. classifying this hetero‐ geneous group of individuals with traumatic experiences into better-defined subgroups could help to provide more specialized treatments with greater response rates, especially with regard to trauma-related sleep disturbances. method sample and procedures overall, 754 individuals (62% female, mean age = 48.69 years; sd = 14.00; range 18– 92) from the german nationwide online panel psyweb (n = 12.317 in 2017; https:// www.uni-muenster.de/psyweb) participated in the study. psyweb is a panel that provides information about psychological topics of common interest and offers possibilities to take part in anonymous psychological tests and studies for registered members from the general population (i.e., panel members). panel members were contacted via e-mail by the panel organization and were invited to take part in an online survey study investigating influencing factors on sleep and sleep problems. we specifically invited all panel members, independent of existing sleep problems or previous traumatic experi‐ ences. study participants did not receive any monetary compensation but were offered automated feedback regarding their sleep quality and depression scores after completion of the survey. participants were included if they were 18 years or older and proficient in the german language, but were excluded from all analysis if they did not give written informed consent. it is worth noting that the data collected in this study was also used to validate the german version of the fear of sleep inventory-short form (fosi-sf; drexl, kunze, & werner, 2019). both projects were preregistered specifying their different research foci and analytic approaches (kunze, drexl, metodiev, & werner, 2017; werner, metodiev, drexl, & kunze, 2017). measures the survey included several measures assessing fos, insomnia symptoms, nightmares, traumatic experiences, ptsd symptoms, and other aspects of trauma-related sleep distur‐ bances, like arousal and a proxy for fragmented rem sleep, with higher scores indicating increased symptomatology. traumatic experiences and ptsd symptoms were measured by the german version of the life events checklist (lec-5, including the extended crite‐ rion a assessment), followed by the ptsd checklist for dsm-5 (pcl; range 0-80; krügergottschalk et al., 2017) if any traumatic experience was indicated by the participant. in the present sample, internal consistency for the pcl was excellent (cronbach’s α = .95). fear of sleep in trauma-related sleep disturbances 4 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.uni-muenster.de/psyweb https://www.uni-muenster.de/psyweb https://www.psychopen.eu/ insomnia severity was measured via the german version of the insomnia severity index (isi; range 0-28; gerber et al., 2016). it assesses difficulties with initiating or maintaining sleep as well as early morning awakenings and related worries, and there is good internal consistency in our sample (α = .84) and a clinical cut-off at 15 for moderate insomnia. furthermore, nightmares were assessed using the german version of the nightmare distress questionnaire (ndq; range 13-65; böckermann, gieselmann, & pietrowsky, 2014) with excellent internal consistency in the present sample (α = .91). additionally, fos was measured via the german version of the fosi-sf (drexl et al., 2019). the fosi-sf contains 13 items (range 0–52) on the fear of being particularly vulnerable during sleep, fear of experiencing nightmares, fear of darkness, and related behaviors, such as sleeping with lights on. the fosi-sf showed good internal consistency in this sample (α = .86). further measures linked to trauma-related sleep disturbances included the german ver‐ sions of the pre-sleep arousal scale (psas; range 15-75; gieselmann, de jong-meyer, & pietrowsky, 2012; somatic arousal [8 items]: α = .80; cognitive arousal [7 items]: α = .92) as well as nocturnal mentations as a proxy for rem sleep fragmentation (nms; range 3-27; wassing et al., 2016); however internal consistency was questionable for this 3-item scale (α = .63). depression and anxiety were assessed for exploratory purposes using the german versions of the depression module of the patient health questionnaire (phq-9; range 0-27; löwe, spitzer, zipfel, & herzog, 2002) and the general anxiety disorder screener (gad-7; range 0–21; löwe et al., 2008). statistical analyses only participants with at least one potentially traumatic experience (according to dsm-5) – and therefore valid values for ptsd symptom severity (pcl) – were further included in the analyses. potentially traumatic experiences were defined on the basis of the lec-5 and the extended criterion a assessment if one of the traumatic events was personally experienced or witnessed (weathers et al., 2013). however, if the indicated index traumatic event for the pcl did not include any of the following criterion a characteristics, the participant was assigned to the no-trauma group and excluded from further analyses. the criterion a characteristics were: danger of life, serious injury, sexu‐ al violence, or – in the case of the death of a close family member – accident or violence. after exclusion, the remaining sample consisted of 471 trauma-exposed individuals (see table 1 for demographic variables of the sample). all analyses were carried out using the statistical package for the social sciences (ibm spss statistics, version 24). cluster analysis is a data-driven approach seeking to identify specific subgroups of individuals within a larger sample on the basis of shared charac‐ teristics. specifically, cluster analyses aim to group individuals that are similar to each other on specified variables into distinct groups. in the present study, cluster analyses were used to explore different symptomatic profiles of trauma-exposed individuals. in order to identify subgroups within our sample, we first performed a non-hierarchical werner, danböck, metodiev, & kunze 5 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ two-step cluster analysis. this type of cluster analysis is advantageous, as it automati‐ cally uses standardized variables and chooses the optimal number of clusters based on schwarz’s bayesian criterion (bic) and the ratio of distance measures (schendera, 2010); in this case the euclidian distance measure was used. the resulting cluster quality was automatically rated based on the silhouette measure for cohesion and separation. for ptsd symptomatology we used the pcl score without items referring to sleep (“pcl-”, i.e., pcl without items 2 and 20) to decrease overlap with other measures assessing sleep-relevant variables. table 1 demographic variables of the trauma-exposed subsample (n = 471) variable age m sd 49.02 13.25 female n % 306 64.97 marital status n % single 101 21.44 in relationship 95 20.17 married 201 42.68 divorced or widowed 74 15.71 education n % middle school degree 55 11.68 high school degree 98 20.81 university degree 268 56.90 vocational education 45 9.55 other 5 1.06 occupation n % student 33 7.00 employed 319 67.73 unemployed 13 2.76 retired 86 18.26 other 20 4.25 past psychotherapeutic treatment n % 225 47.77 as non-hierarchical cluster analyses only detect main clusters, we also conducted a hierarchical cluster analysis, using ward’s method (ward, 1963). this method, which has been broadly used in the social sciences (clatworthy, buick, hankins, weinman, fear of sleep in trauma-related sleep disturbances 6 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ & horne, 2005), seeks to minimize the total within-cluster variance (leading to more homogeneous subgroups) and tends to create approximately equally sized, non-overlap‐ ping clusters (schendera, 2010). using this agglomerative approach, each individual initially represents its own cluster and clusters then progressively merge with others (as a function of their relative distance, i.e., the squared euclidian distance) until one cluster including all cases is formed. the ideal number of clusters was determined by inspection of the resulting dendrogram and agglomeration coefficients, where a large increase between two consecutive cluster solutions indicates an unfavorable combination of two heterogeneous clusters and should therefore be abandoned. if the dendrogram and agglomeration coefficients supported more than one cluster solution, they were all trea‐ ted as final solutions and further examined. differences in clustering variables between the resulting clusters of the final cluster solution were then explored via subsequent analyses of variance (anovas) followed by post-hoc analyses. differences in secondary and demographic variables were investigated for exploratory purposes. results psychometric variables the psychometric characteristics of the sample with regard to variables used in the cluster analyses are given in table 2. ptsd symptomatology is reported both overall (pcl) and without items referring to sleep disturbances (pcl-), as the latter was used for cluster analyses. table 2 psychometric characteristics of the trauma-exposed subsample variable m sd range ptsd symptoms (pcl) 14.60 14.71 0–71 ptsd symptoms without sleep disturbances (pcl-) 13.23 13.57 0–63 insomnia symptoms (isi) 8.63 5.39 0–26 nightmare distress (ndq) 23.10 8.99 13–54 fear of sleep (fosi-sf) 2.07 4.39 0–35 pre-sleep arousal (psas) 27.56 9.70 15–62 somatic pre-sleep arousal (psas, somatic subscale) 12.56 4.51 8–32 cognitive pre-sleep arousal (psas, cognitive subscale) 15.01 6.30 7–33 rem sleep fragmentation (nocturnal mentations) 10.86 5.91 3–27 note. pcl = posttraumatic checklist; pcl= pcl score without items 2 and 20; isi = insomnia severity index; ndq = nightmare distress questionnaire; fosi-sf = fear of sleep inventory-short form; psas = pre-sleep arousal scale. werner, danböck, metodiev, & kunze 7 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ two-step cluster analysis the lowest bic (2067.80) and the largest ratio of distance (1.39) both supported a 2cluster solution, which was automatically chosen. cluster quality was rated as good, based on the silhouette measure for cohesion and separation. cluster 1 was characterized by low values of all variables (“healthy cluster”; n = 418), and cluster 2 was characterized by high values of all variables (“clinical cluster”; n = 53) (see table 3). subsequent t-tests revealed significant differences between the two clusters on all grouping variables, ps ≤ .001. table 3 mean scores of clustering variables in clusters obtained by two-step cluster analysis variable healthy cluster n = 418 clinical cluster n = 53 m sd m sd pcl 11.35 11.01 40.25 15.09 pcl10.28 10.28 36.45 14.07 isi 7.69 4.78 15.98 4.09 ndq 21.18 6.92 38.28 9.10 fosi 1.06 2.00 10.09 8.27 psas-s 11.70 3.53 19.32 5.65 psas-c 13.70 5.16 25.28 4.95 nms 10.22 5.72 15.85 4.93 note. pcl is reported for descriptive purposes, pclwas used as clustering variable. pcl = posttraumatic checklist; pcl= pcl score without items 2 and 20; isi = insomnia severity index; ndq = nightmare distress questionnaire; fosi-sf = fear of sleep inventory-short form; psas-s = pre-sleep arousal scale somatic subscale; psas-c = pre-sleep arousal scale cognitive subscale; nms = nocturnal mentations. hierarchical cluster analysis the dendrogram of the hierarchical cluster analysis using ward’s method and squared euclidian distances showed possible solutions of two, three, and four clusters (see figure s1, supplementary material). there was a smaller increase in agglomeration coefficients between the 4and 3-cluster solutions (155.73) and a larger increase between the 3and 2-cluster solutions (525.09), indicating a stronger increase in the heterogeneity within clusters between the latter solutions (see table s1, supplementary material). therefore, the 2-cluster solution was abandoned and the 3and 4-cluster solutions were further described. the 3-cluster solution revealed two bigger clusters and one smaller cluster (cluster 1: n = 199; cluster 2: n = 223; cluster 3: n = 49). one-way anovas and scheffé’s post-hoc comparisons indicated that all clusters differed significantly from each other regarding all fear of sleep in trauma-related sleep disturbances 8 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ variables (see table 4 for descriptive values and inferential statistics). specifically, cluster 1 was characterized by low levels, cluster 2 by medium levels, and cluster 3 by high levels of all variables. based on these results, and taking the clinical cut-offs for insomnia (isi ≥ 15) and ptsd symptoms (pcl ≥ 33) into consideration, these clusters were named “healthy cluster”, “subclinical cluster”, and “clinical cluster” (see table 4). in line with the two-step cluster analysis, the clinical clusters of both analytic approaches are comparable with respect to cluster size (n = 53 vs. n = 49) and mean scores of all variables. table 4 descriptive values and inferential statistics of the 3-cluster solution variable healthy cluster n = 199 subclinical cluster n = 223 clinical cluster n = 49 statistics m sd m sd m sd f(2, 468) η2 pcl 5.36a 5.15 16.98b 12.31 41.29c 14.16 256.36*** .52 pcl4.84a 4.81 15.39b 11.58 37.45c 13.27 239.18*** .51 isi 4.78a 2.92 10.39b 4.63 16.22c 3.92 210.29*** .47 ndq 16.92a 3.32 25.27b 7.30 38.35c 9.09 260.68*** .53 fosi 0.20a 0.57 2.24b 3.01 8.92c 9.11 115.86*** .33 psas-s 10.06a 2.14 13.09b 3.87 20.27c 4.84 183.94*** .44 psas-c 10.61a 2.71 16.45b 5.25 26.29c 3.42 303.46*** .56 nms 7.23a 4.00 12.90b 5.62 16.29c 5.07 102.60*** .31 note. pcl is reported for descriptive purposes, pclwas used as clustering variable. omnibus tests and η2 of one-way anovas are reported (independent variable: cluster, dependent variables: clustering variables). differ‐ ent subscripts indicate significant differences in scheffé's post-hoc comparisons (p < .001). pcl = posttraumatic checklist; pcl= pcl score without items 2 and 20; isi = insomnia severity index; ndq = nightmare distress questionnaire; fosi-sf = fear of sleep inventory-short form; psas-s = pre-sleep arousal scale somatic subscale; psas-c = pre-sleep arousal scale cognitive subscale; nms = nocturnal mentations. ***p < .001. regarding the 4-cluster solution, the clinical cluster was further divided into two clusters (cluster 3: n = 38; cluster 4: n = 11). one-way anovas and scheffé’s post-hoc compari‐ sons were again used to explore differences between the identified clusters regarding all clustering variables as well as some additional exploratory and demographic variables (see table 5 for descriptive values and inferential statistics). in line with the 3-cluster solution, scheffé’s post-hoc comparisons demonstrated that both clinical clusters were characterized by significantly higher levels of all variables compared to the subclinical cluster and the healthy cluster; only nocturnal mentations did not differ significantly between one of the clinical clusters (cluster 4) and the healthy cluster (cluster 1), mdiff = 0.92, p = .948 (see table 5). however, comparing both clinical clusters, cluster 4 werner, danböck, metodiev, & kunze 9 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ additionally showed significantly increased levels of somatic pre-sleep arousal, mdiff = 3.41, p = .033, as well as much higher levels of fos than cluster 3, mdiff = 18.16, p ≤ .001 (see also figure 1 for cluster group mean z-scores). moreover, the amount of variance in fos that can be explained by clustergroup membership (η2) was much higher in the 4-cluster solution (η2 = .64) than in the 3-cluster solution (η2 = .33), while the amount of explained variance of all other variables did not differ between solutions. therefore, cluster 4 was named “clinical cluster with fos”, while the third cluster remained a more general “clinical cluster”. table 5 descriptive values and inferential statistics of the 4-cluster solution variable healthy cluster n = 199 subclinical cluster n = 223 clinical cluster n = 38 clinical cluster with fos n = 11 statistics m sd m sd m sd m sd f(3, 467) η2 pcl 5.36a 5.15 16.98b 12.31 41.11c 13.84 41.91c 15.90 170.58*** .52 pcl4.84a 4.81 15.39b 11.58 37.21c 13.06 38.27c 14.60 159.19*** .51 isi 4.78a 2.92 10.39b 4.63 16.82c 3.94 14.18c 3.25 142.35*** .48 ndq 16.92a 3.32 25.27b 7.30 38.37c 7.26 38.27c 14.20 173.42*** .53 fosi 0.20a 0.57 2.24b 3.01 4.84c 4.37 23.00d 6.81 278.75*** .64 psas-s 10.06a 2.14 13.09b 3.87 19.5c 4.29 22.91d 5.89 127.60*** .45 psas-c 10.61a 2.71 16.45b 5.24 26.58c 2.97 25.27c 4.67 202.52*** .57 nms 7.23a 4.00 12.90b 5.62 17.00c 5.04 13.82a, c 4.58 69.96*** .31 phq-9 12.66a 2.82 18.05b 4.83 25.11c 4.79 27.45c 5.05 150.43*** .49 gad-7 10.08a 2.27 13.93b 3.82 20.61c 3.51 20.09c 3.78 148.64*** .49 age 51.27a 13.42 48.09a,b 12.82 44.08b 12.55 44.18a,b 14.52 4.64* .03 note. pcl scores are reported for descriptive purposes, pclwas used as clustering variable. omnibus tests and η2 of one-way anovas are reported (independent variable: cluster, dependent variables: clustering variables and secondary variables). different subscripts indicate significant differences in scheffé's post-hoc comparisons (p < .05). pcl = posttraumatic checklist; pcl= pcl score without items 2 and 20; isi = insomnia severity index; ndq = nightmare distress questionnaire; fosi-sf = fear of sleep inventory-short form; psas-s = pre-sleep arousal scale somatic subscale; psas-c = pre-sleep arousal scale cognitive subscale; nms = nocturnal mentations; phq-9 = patient health questionnaire, depression module; gad-7 = general anxiety disorder screener. *p < .05. **p < .01 ***p < .001. fear of sleep in trauma-related sleep disturbances 10 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ figure 1 profile of z-scores (with standard error bars) for clustering variables by cluster group note. pcl scores are reported for descriptive purposes only and were not included in the analysis. pcl = posttraumatic checklist; pcl= pcl score without items 2 and 20; isi = insomnia severity index; ndq = nightmare distress questionnaire; fosi-sf = fear of sleep inventory-short form; psas-s = pre-sleep arousal scale somatic subscale; psas-c = psas cognitive subscale; nms = nocturnal mentations. additionally, one-way anovas and scheffé’s post-hoc comparisons were used to explore differences between the final four clusters regarding secondary and demographic varia‐ bles that were not used as clustering variables (see table 5 for descriptive values and inferential statistics). both clinical clusters were characterized by significantly higher levels of depression and anxiety compared to the subclinical cluster and the healthy clus‐ ter. however, comparing both clinical clusters, no differences in the levels of depression and anxiety were found. considering age, only a difference between the healthy and the clinical cluster was found indicating higher age in the healthy cluster. furthermore, there was a significant association between cluster group membership and gender, χ2(3) = 23.67, p < .001. overall, clusters with higher symptom severity were associated with female gender (healthy cluster: 53.8% women; subclinical cluster: 70.7% women; clinical cluster: 84.2% women; clinical cluster with fos: 90.9% women). werner, danböck, metodiev, & kunze 11 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ discussion the present study investigated fos together with other factors that might be important for the maintenance of trauma-related sleep disturbances in trauma-exposed individuals (i.e., symptoms of insomnia, nightmares, pre-sleep arousal, rem fragmentation, and ptsd symptoms) by using a data-driven, cluster-analytic approach. identifying different symptomatic profiles in individuals with trauma-related sleep disturbances might help to provide more individualized treatment targets. the main analyses supported a 3-cluster as well as a 4-cluster solution: the 3-cluster solution revealed one healthy, subclinical, and clinical cluster with respective low, medium, and high scores for all variables. in the 4-cluster solution, the clinical cluster was further split into two smaller clusters. both clusters again demonstrated significantly higher levels of all variables compared to the healthy and subclinical clusters. additionally, one of the two clinical clusters was characterized by elevated levels of somatic pre-sleep arousal and considerably higher levels of fos compared to the other clinical cluster. the results suggest that a subgroup of individuals suffering from ptsd is characterized by increased somatic pre-sleep arousal and fos, which might be relevant treatment targets, particularly for these individuals. in general, trauma-exposed individuals differ dramatically with regard to their levels of psychopathology. empirical findings indicate that, on average, around 10% of trau‐ ma-exposed individuals demonstrate residual stress-related symptoms and subsequently develop ptsd (hidalgo & davidson, 2000). in line with these observations, both cluster methods in this study revealed clinical clusters whose size accounted for around 10% of the trauma-exposed sample. in the two-step cluster analysis, the clinical sample consisted of 53 (11.25%) individuals who showed ptsd and insomnia symptoms above the pro‐ posed clinical cut-offs (bovin et al., 2016; gerber et al., 2016). in the hierarchical cluster analysis using ward´s method, the clinical sample consisted of 49 (10.40%) individuals, again with ptsd and insomnia symptoms above the clinical cut-off (3-cluster solution). these findings support the representativeness of our online sample with regard to ptsd symptomatology. furthermore, 47% of the trauma-exposed sample formed a subclinical cluster with significantly higher levels on all variables (i.e., fos, insomnia symptoms, nightmares, pre-sleep arousal, rem sleep fragmentation, and ptsd symptoms) compared to the healthy cluster. in further support of the dimensionality of the constructs meas‐ ured in the present study, this cluster indicated levels of subthreshold insomnia symp‐ toms (gerber et al., 2016) as well as medium levels on all other variables. in the 4-cluster solution, the clinical cluster of the 3-cluster solution was further split into two clusters. while one of these two clusters was very similar to the clinical cluster in the 3-cluster solution (i.e., clinical cluster), the fourth cluster additionally showed significantly higher levels of somatic pre-sleep arousal as well as absolute levels of fos that were nearly 5 times higher than in the clinical cluster (i.e., clinical cluster with fos). this cluster accounted for 22% of the clinical sample and 2% of the overall sample. however, the average scores of fos in this cluster are slightly higher than those fear of sleep in trauma-related sleep disturbances 12 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ observed in other studies with diagnosed ptsd patients, whereas the average fos score in the other clinical cluster is significantly lower (see figure 1). this might indicate that, although the percentage of individuals with clinically-relevant ptsd symptoms is in line with the prevalence of ptsd in the general population, the overall symptom severity, and especially fos, is less pronounced in this online sample, with only a subgroup demonstrating fos values that are rather comparable to those observed in diagnosed clinical samples (kanady et al., 2018; pruiksma et al., 2014; short, allan, stentz, portero, & schmidt, 2018). although a clinical cut-off for the fosi-sf is currently lacking, a detailed assessment of various aspects of sleep disturbances, like fos (including whether the traumatic event took place in a sleep-related context and maladaptive sleep-interfering behaviors), could inform practitioners whether or not sleep and/or fos should also be targeted in treatment. furthermore, preliminary findings on the temporal links between fos and sleep disturbances have shown that increased fos during a baseline period predicted worse daily sleep quality during the following week in ptsd patients (short et al., 2018). in our sample, individuals in the clinical cluster with fos indicated that they experience fos once or twice per week (mean fosi-sf = 1.77), whereas individuals in the clinical cluster indicated that they never experience fos (mean fosi-sf = 0.37; scale 0 = not at all, 1 = a few times per month, 2 = once or twice per week, 3 = several times per week, 4 = every night). it is worth noting that in the fos subgroup, participants overwhelmingly indicated that they experienced the fear of loss of control and being vulnerable during sleep as often as several times per week or nearly every night. al‐ though losing control and feeling vulnerable are cognitive dysfunctional beliefs, they are also a form of anticipatory anxiety that goes along with enhanced arousal (davis, 2009). accordingly, our results show that pre-sleep somatic arousal, conceptualized as various physical sensations during the pre-sleep period (e.g., palpitations, breathlessness, sweating, or muscle tension), was also significantly enhanced in the fos subgroup (see figure 1). somatic pre-sleep arousal might reflect the physiological component that accompanies cognitive dysfunctional beliefs about safety during sleep. in contrast, cog‐ nitive arousal was conceptualized as more general rumination behaviors and worries about sleep disturbances as well as non-sleep-related problems and a feeling of mental activation in this study. cognitive arousal might therefore be more characteristic of individuals suffering only from insomnia, but not in the context of ptsd, where the feeling of safety is more important than the effect of non-restorative sleep (pigeon & gallegos, 2015). overall, enhanced fos might increase sleep disturbances due to increased somatic pre-sleep arousal on the one hand, and, on the other hand, through increased engagement in sleep-interfering maladaptive behaviors. completing this vicious cycle, there is considerable evidence supporting a perpetuating role of sleep disturbances for daytime ptsd symptomatology (short, allan, & schmidt, 2017). werner, danböck, metodiev, & kunze 13 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ trauma-focused treatments aim to differentiate between past experiences and the present situation in order to restructure dysfunctional posttraumatic cognitions with regard to safety and control (könig, resik, karl, & rosner, 2012). however, dysfunctional beliefs about safety during sleep are not part of standardized treatments. consequently, anticipatory anxiety together with somatic pre-sleep arousal and subsequent maladaptive behaviors might contribute to prolonged trauma-related sleep disturbances, even after remission of other ptsd symptoms (belleville et al., 2011). these are only theoretical considerations and research investigating the sensitivity of fos across trauma-focused treatment is yet to be conducted. though current sleep-focused treatments do not explic‐ itly target fos, promising findings have been reported recently. for example, studies using trauma-related nightmare treatments (e.g., errt) have reported reductions in fos from preto post-treatment as well as during the follow-up assessments, together with reductions in overall sleep disturbances and ptsd symptom severity (davis et al., 2011; davis & wright, 2007; pruiksma et al., 2018). it is assumed that these treatments target mastery (“i can deal with/manage the nightmares”), which might increase a more general sense of control (germain et al., 2004). thus, it seems plausible that trauma-related nightmare treatments, such as errt, might also affect fos. other approaches, like cbt-i, have also shown moderate reductions in fos after 8 weekly sessions with 29 individuals with ptsd and clinical insomnia (vs. 16 waitlist controls), although beliefs about the safety of the bed or bedroom were intentionally not targeted (kanady et al., 2018). given that reduced dysfunctional beliefs about sleep have been linked to better sleep in insomnia (morin, blais, & savard, 2002), specifically changing dysfunctional beliefs about one’s safety during sleep and the corresponding maladaptive behaviors (i.e., fos) might reduce trauma-related sleep disturbances. therefore, directly targeting fos in addition to trauma-focused and/ or sleep-focused treatment in individuals with high levels of fos might increase treatment response, especially with regard to trauma-related sleep disturbances. limitations some limitations must be considered when interpreting the current findings. first, al‐ though the lec-5 and specific items regarding the index traumatic experience were used to identify trauma-exposed individuals according to ptsd criterion a as defined in the dsm-5 (weathers et al., 2013), traumatic experiences and ptsd symptomatology were based solely on online self-report measures. second, this is the first study to classify individuals on the basis of fos, insomnia symptoms, nightmares, arousal, a self-report proxy for rem sleep fragmentation, and ptsd symptoms. although meaningful cluster solutions were found, we were not able to validate cluster stability and meaningfulness of cluster membership with an external criterion. therefore, it is essential to replicate and extend the present findings in diagnosed ptsd samples. for this purpose, we are currently collecting data in ptsd patients before trauma-focused treatment with fear of sleep in trauma-related sleep disturbances 14 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ a twofold aim: 1) to investigate whether the results of the current study also hold for clinically diagnosed ptsd samples and 2) to validate the meaningfulness of the identified subgroups by using treatment outcome as an external criterion. third, somatic pre-sleep arousal and sleep difficulties were only measured via self-report. especially in sleep research the use of self-reported versus objectively measured sleep is an often discussed topic. however, the subjective “sleep quality” experience seems to cover aspects that cannot be exhaustively captured via objective indices yet (see krystal & edinger, 2008, for a discussion on this topic). the diagnosis of insomnia disorder is currently only based on subjective complaints (e.g., harvey & spielman, 2011), therefore focusing on subjective indices in clinical studies is a common approach. fourth, the 3-item measure of nocturnal mentations, which was used as a self-report proxy for rem sleep fragmentation, showed low internal consistency and was the only variable that did not consistently differentiate between the healthy, subclinical, and clinical clusters. to increase the validity of this self-report proxy, future research should include physiological measures of arousal and rem sleep fragmentation. finally, medication and substance use as well as other sleep disturbances that might occur in ptsd (e.g., sleep apnea, parasomnias, and disruptive nocturnal behaviors) were not assessed. conclusion in sum, the data-driven, cluster-analytic approach used in this study clearly supports fos as an important characteristic and possible additional treatment target of trauma-re‐ lated sleep disturbances in individuals with ptsd. current standard trauma-focused and/ or sleep-focused treatments seem to only moderately reduce trauma-related sleep disturbances, and residual sleep symptoms often remain. the present data support the proposition that fos might offer an important construct involved in the development and maintenance of sleep disturbances after exposure to a traumatic event, at least in a subgroup of individuals suffering from ptsd. however, research about fos is still in its infancy and additional studies are needed to investigate whether directly targeting fos during treatment – particularly in ptsd subgroups with high fos scores – might enhance treatment efficacy. funding: the second author is supported by the doctoral college “imaging the mind” (fwf; w1233-b). competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors would like to thank margaret tyson and jona meyer for translating the english version of the fosi-sf questionnaire forward and backward, as well as keisuke takano for his statistical support. werner, danböck, metodiev, & kunze 15 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://www.psychopen.eu/ supplementary materials the supplementary materials include the dendrogram of the hierarchical cluster analysis as well as the corresponding agglomeration schedule (for access see index of supplementary materials below): index of supplementary materials werner, g. g., danböck, s. k., metodiev, s., & kunze, a. e. 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(2017). effects of psychotherapies for posttraumatic stress disorder on sleep disturbances: results from a randomized clinical trial. behaviour research and therapy, 97, 75-85. https://doi.org/10.1016/j.brat.2017.07.001 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. fear of sleep in trauma-related sleep disturbances 20 clinical psychology in europe 2020, vol.2(2), article e2699 https://doi.org/10.32872/cpe.v2i2.2699 https://doi.org/10.1016/j.smrv.2015.01.008 https://doi.org/10.1016/j.smrv.2007.08.008 https://doi.org/10.1002/jts.20468 https://doi.org/10.5664/jcsm.28042 https://doi.org/10.1080/01621459.1963.10500845 https://doi.org/10.1073/pnas.1522520113 http://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp https://osf.io/vumh6/ https://doi.org/10.1016/j.brat.2017.07.001 https://www.psychopen.eu/ fear of sleep in trauma-related sleep disturbances (introduction) method sample and procedures measures statistical analyses results psychometric variables two-step cluster analysis hierarchical cluster analysis discussion limitations conclusion (additional information) funding competing interests acknowledgments supplementary materials references the impact of an insecure asylum status on mental health of adult refugees in germany research articles the impact of an insecure asylum status on mental health of adult refugees in germany victoria sophie boettcher 1 , frank neuner 1 [1] department of clinical psychology and psychotherapy, bielefeld university, bielefeld, germany. clinical psychology in europe, 2022, vol. 4(1), article e6587, https://doi.org/10.32872/cpe.6587 received: 2021-04-18 • accepted: 2021-10-20 • published (vor): 2022-03-31 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: victoria sophie boettcher, department of clinical psychology and psychotherapy, bielefeld university, postbox 100131, 33501 bielefeld, germany. phone: +49 521 106-3890. e-mail: victoria.boettcher@unibielefeld.de supplementary materials: materials [see index of supplementary materials] abstract background: forcibly displaced people have a higher chance of developing post-traumatic stress disorder (ptsd) compared to people who have not experienced displacement. in addition to potentially traumatic events due to war, persecution, and flight, post-migration living stressors are an important influencing factor. among these, an insecure asylum status is one of the main stressors with which forcibly displaced people must cope. the aim of this study was to investigate the additive effect of an insecure asylum status on ptsd symptomatology in refugees, over and above the influence of other preand peri-migration factors, in particular potentially traumatic event types reported and duration of stay in germany. method: two overlapping convenience samples of 177 and 65 adult refugees that were assessed at different timepoints were interviewed by means of face-to-face interviews. interviews were conducted in either arabic, farsi, kurmancî, english, or german with the assistance of interpreters where necessary. besides residence status and potentially traumatic events experienced, mental distress was assessed via the refugee health screener-15 (rhs-15; study a) and the ptsd checklist for dsm-5 (pcl-5; study b). results: in both samples, an insecure asylum status explained a significant additional amount of variance of ptsd symptomatology, on top of traumatic events experienced and time since arrival in germany. conclusion: results suggest that refugees with an insecure asylum status are at higher risk for experiencing increased ptsd symptomatology. policy changes of asylum procedure in receiving countries could have a positive impact on refugees’ mental health. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6587&domain=pdf&date_stamp=2022-03-31 https://orcid.org/0000-0002-1524-8012 https://orcid.org/0000-0001-5427-3432 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords refugees, forcibly displaced people, mental health, post-traumatic stress disorder, insecure asylum status, postmigration living stressors highlights • prevalence rates of mental disorders are high among forcibly displaced people. • the impact of post-migration stressors on refugees’ mental health should not be disregarded. • as one of the possible post-migration stressors, asylum status is substantially associated with mental health. • changes to reception policies may be taken into account. background at the end of 2019, 79.5 million people were forcibly displaced worldwide. over the course of the previous decades this number has increased consistently (unhcr, 2020). the high numbers pose serious challenges to the receiving countries, straining their capacity to provide housing, food, healthcare services, and education. as a result, during the last years, several potential receiving countries have adapted their reception policies regarding people seeking refuge (fazel, karunakara, & newnham, 2014; jakubowicz, 2016; li, liddell, & nickerson, 2016). as a consequence, in 2019 less than 40% of asylum seekers were formally recognized as refugees (unhcr, 2020). compared to non-refugees, those who have been forcibly displaced have a higher risk of mental disorders, most prominently post-traumatic stress disorder (ptsd) and depression (bozorgmehr et al., 2016; gäbel, ruf, schauer, odenwald, & neuner, 2006). studies demonstrated that mental disorders among refugees come along with a high burden. due to the symptoms, such as difficulty concentrating or sleeping problems, learning a new language, staying engaged in classes, or going to work on a regular basis can be much harder (elbert, wilker, schauer, & neuner, 2017). several studies have pointed out that post-migration stressors in the receiving coun­ tries have an impact on the onset and maintenance of psychological disorders (chu, keller, & rasmussen, 2013; li et al., 2016). asylum application procedure in germany one of the most salient post-migration stressors is an insecure residence permit that may leave refugees living in uncertainty and with restricted rights for months and even years (li et al., 2016). in germany, there are several different types of residence status for refugees (federal office for migration and refugees, 2019). the entitlement to asylum, according to article 16a para. 1 of the constitution (grundgesetz), and the refugee protection, according to section 3 subs. of the asylum act (asylg), involve similar insecure asylum status and mental health 2 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ implications for affected people’s lives. both comprise a residence permit for three years. access to the labor market is not restricted and the refugees are entitled to family reunification. moreover, in case people meet preconditions like german language skills, a permanent settlement permit after three or five years is possible. according to section 4 subs. 1 of the asylum act (asylg), subsidiary protection comprises a residence permit for one year, which can be repeatedly extended by two years. similar to the two other forms of protection stated above, receiving a settlement permit is possible but only after five years. access to the labor market is unrestricted as well. in contrast to the entitlement to asylum and the refugee protection, people with a subsidiary protection are not entitled to privileged family reunification. individuals holding one of these three types of permits have a right to move to their own homes with some regional restrictions and a comparable health care protection as the general population in germany. individuals who receive a national ban on deportation have a residence permit for at least one year, with possibility of extension. again, receiving a settlement permit is possible after five years. in contrast to the other forms of protection stated above, there are restrictions regarding the access to the labor market. the same holds for asylum seekers with pending applications. when an asylum application is turned down, the person has to leave germany in the near future. consequences of an insecure residence status for mental health in refugees during recent years, the potential influence of an insecure residence status on mental health in forcibly displaced people became increasingly apparent. research findings tend to show that insecure status is correlated with mental health symptoms (heeren et al., 2016; müller, zink, & koch, 2018; newnham, pearman, olinga-shannon, & nickerson, 2019). in a study by momartin et al. (2006), residing under a temporary permit to stay was found to be the greatest predictor of ptsd symptomatology even when having accounted for trauma experiences in the analyses. however, some studies have provided mixed results (schick et al., 2016; winkler, brandl, bretz, heinz, & schouler-ocak, 2019). schick et al. (2016) found that, while ptsd symptomatology was correlated with a sum-score of other post-migration stressors, there was no isolated influence of visa status. similarly, winkler et al. (2019) did not find a significant association between visa status and ptsd symptoms. however, among participants who fulfilled ptsd criteria, symptom intensity was increased with an insecure asylum status. as reported above, visa insecurity often comes with restrictions in daily life like limited access to health care services or limited rights (müller et al., 2018). these factors seem to increase the risk of mental disorders (chu et al., 2013) and complicate the proc­ ess of integrating into a new society because opportunities to do so are limited (müller et al., 2018). these findings are supported by previous research that found that mental boettcher & neuner 3 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ health improved following the granting of a residence permit (lamkaddem, essink-bot, deville, gerritsen, & stronks, 2015). next to visa status, the duration of stay in the host country (nickerson et al., 2019) that is highly associated with the duration of the asylum procedure (laban, gernaat, komproe, van der tweel, & de jong, 2005) may have an influence on mental health of refugees and people seeking asylum. in a study with refugees in australia, duration of stay was correlated with suicidal intent (nickerson et al., 2019). an association of duration of asylum procedure and anxiety disorders was found by laban et al. (2005). however, findings in the literature have been unable to confirm a consistent association, since other studies have found no effect (heeren et al., 2016; winkler et al., 2019). it may be conceivable that duration of stay assumes central importance only when it exceeds a threshold value. differentiating between different aspects of post-migration stressors, laban, komproe, gernaat, and de jong (2008) concluded that asylum seekers who had been in the netherlands for more than two years had several post-migration stressors to cope with, which might explain the association they made in earlier research (laban et al., 2005) regarding the length of stay in the receiving country with mental health. although the nature of the association between asylum seekers’ mental health and their length of stay in their host context remains uncertain, it is clear that forcibly displaced people often encounter significant stressors and have limited access to coping resources because of their preand peri-migration experiences, new living situation, and post-migration stressors. research has shown that the stressors experienced by people seeking asylum and recognized refugees can be divided in two categories (womersley, kloetzer, & goguikian ratcliff, 2017). the first category is associated with difficulties with housing and labor, which are reported by both groups. the second category is experienced more acutely by asylum seekers, who have reported uncertainty, lack of control, and insecurity. asylum seekers live under constant threat of being expelled from their relatively safe living environment (müller et al., 2018). uncertainty is one of the factors increasing the probability of continuing mental disorders (bogic et al., 2012; ryan, benson, & dooley, 2008) and personal control is lost (ryan, benson, & dooley, 2008). therefore, no complete security can be felt, which seems to be closely related with the development and maintenance of mental distress/ptsd. aim of the study this study seeks to investigate the effects of asylum status on ptsd symptomatology over and above the influence of potentially traumatic event types reported and length of stay in country of arrival in refugees living in germany. insecure asylum status and mental health 4 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ method in this paper, two studies and the respective results are presented. study a and study b, including procedures and measures used, will be presented successively. the samples are overlapping and sample b is a detailed and more comprehensive re-assessment of a subset of sample a. all participants of study a who consented to a second interview were tried to be reached via telephone, email, or in person. participants in sample b participated in additional clinical face-to-face interviews by an expert interviewer that allowed to apply more detailed clinical scales some months after the first interview. sample study a. between february and august 2018 face-to-face interviews were conducted with 198 refugees (23.2% female, n = 46). the unselected convenience sample ranged from 18 to 75 years of age (m = 33.03, sd = 11.02). refugees were eligible to participate if they were at or above the age of majority, were living in north rhine-westphalia, had sufficient language skills to be able to conduct the interview in arabic, farsi, kurmancî (as these three languages were the most common ones on site at the time of the study), english or german, and their time since arrival in germany did not exceed six years. study b. between august 2018 and march 2019, refugees form study a were recon­ tacted and approached for interviews. out of these, 65 refugees (20.0% female, n = 13) participated, the remaining could not be contacted or were not available for a re-inter­ view. the participation rate of 32.8% may be explained by the fact that a substantial proportion of the participants of study a had no secure residence status and had possibly been forced to leave germany in the meantime. in general, most participants could be contacted successfully via telephone, email, or in person were consenting to take part in study b. participants ranged from 19 to 75 years of age (m = 34.50, sd = 12.13). procedures data collection was conducted within the framework of the research consortium “flüge– opportunities and challenges that global refugee migration presents for health care in germany” and was part of a larger study. the program was funded by the ministry of culture and science of the state of north rhine-westphalia, germany. thirteen para­ professional interviewers (12 male, 1 female) were trained as both interviewers and inter­ preters (9 arabic native speakers, 3 farsi native speakers, 4 kurmancî native speakers). data was collected in a region in the north-east of north rhine-westphalia, germany. interviews took place in shared accommodation facilities, private apartments, and on the bielefeld university campus. potential literacy problems were avoided by reading out all questions to participants. the respondents were free not to answer single questions without giving reasons. the ethical review board of bielefeld university granted appro­ boettcher & neuner 5 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ val for the study. to ensure the voluntariness of participation in an interview that may provoke distress in some individuals no compensation was provided for participation. study a. all material (informed consent forms, information letters, questionnaire) was translated by a professional translation agency and native speakers. blind back­ translations ensured correct translation. participants were identified through contact with social workers who have been working in the region and made contact with the shared accommodations. during informational events, initial interview appointments were arranged. further appointments were agreed on by asking people present in the accommodations and via snowball sampling. field teams consisted of two supervising re­ searchers and the necessary interviewers. the face-to-face interviews lasted on average 90 minutes (sd = 31.9). study b. informed consent forms and information letters were again translated and blind back translated. in the event that participants had previously provided their written consent and contact information, they were contacted via telephone, email, or home visits. face-to-face interviews were conducted by german speaking researchers with the assistance of interpreters where necessary. interviews lasted 116 minutes on average (sd = 48.2). participants were interviewed an average of six months after they had been interviewed for study a. measures study a. information regarding age, gender, citizenship, education, marital status, length of time since arrival in germany, and potentially traumatic event types was collected (see appendix a in the supplementary materials). in addition, mental distress and residence status were assessed (see detailed description below). study b. in addition to the questions assessed in the first interview, participants were asked to answer further questions regarding potentially traumatic event types and ptsd symptomatology. residence status was assessed again (see detailed description below). mental distress study a. the 15 item refugee health screener-15 (rhs-15; hollifield et al., 2013) assesses mental distress in refugees. the first 13 questions assess the presence of differ­ ent symptoms of depression, anxiety, and ptsd during the last month. question 14 measures the general coping capacities. answers are given on a 5-point likert scale (not at all – extremely). question 15 assesses how much suffering the participant experienced last week. responses to this item were reported on a scale of 0–10 on a “distress ther­ mometer”. effectiveness, validity, and reliability of the screening instrument have been demonstrated in various studies (hollifield et al., 2016; hollifield et al., 2013; kaltenbach, härdtner, hermenau, schauer, & elbert, 2017). in study a a cronbach's α of .87 was found. the cutoff value recommended by hollifield et al. (2013) is a sum-score of ≥ 12 regarding questions 1–14 and/or a score of ≥ 5 regarding the distress thermometer. insecure asylum status and mental health 6 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ the former cutoff is used in this study. regarding this cutoff, a sensitivity of = .81 and specificity of = .87 for ptsd was reported (hollifield et al., 2013). study b. the german version of the posttraumatic stress disorder checklist for dsm-5 (pcl-5; krüger-gottschalk et al., 2017) was used to assess ptsd symptomatology within the past month. the pcl-5 consists of 20 questions. answers were rated 0 (not at all) – 4 (extremely), which results in the highest possible score of 80. in the current sample, cronbach’s α was .86. good psychometric properties have been demonstrated in previous studies (krüger-gottschalk et al., 2017; wortmann et al., 2016). ibrahim, ertl, catani, ismail, and neuner (2018) used the translated checklist in displaced arab and kurdish populations and came up with a cut-off score of 23 to be the best balance between specificity and sensitivity in these populations. residence status the answers regarding the question assessing residence status were grouped in six categories (recognized as refugee, entitled to asylum, subsidiary protection, asylum appli­ cant with pending procedure, temporary suspension of deportation, demand to leave germany). the first three of the categories were classified as “secure residence status”. the latter three were classified as “insecure residence status”. data analysis statistical analyses were performed with ibm spss statistics version 27 for macos. due to ≥ 10% missing data in the rhs-15, 21 participants were excluded from study a. regarding cases with < 10% missing values on the rhs-15, values were set equal to 0. multiple linear regression analyses with two levels were carried out for both samples. in study a, the rhs sum-score to assess mental distress and in study b, the pcl-5 sum-score to assess ptsd symptomatology were used as dependent variables. both analyses accounted for age, gender (females coded as 0, males coded as 1), number of traumatic event types reported, and time (in month) since arrival in germany. the variables accounted for were entered in step one. the dummy coded residence status (secure residence status coded as 0, insecure residence status coded as 1) was added in the second step. for the analyses the alpha level was set at 0.05. results study a. the 177 participants (20.3%; n = 36 female) were, on average, 33 years old (sd = 11.21). with 42.4% (n = 75) the largest proportion of participants had a syrian citizenship, followed by 26.6% (n = 47) with an iraqi citizenship, and 9.0% (n = 16) with an afghan citizenship. the average time since arrival in germany was 28.5 months (sd = 9.96). an insecure residence status was reported by 30.5% (n = 61) of participants. rhs boettcher & neuner 7 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ mean sum-score (items 1–14 of the rhs-15) was 15.61 (sd = 10.92). a score above the cutoff (score ≥ 12) was reached by 54.8% (n = 97) of the participants. study b. the 65 participants (20.0%, n = 13 female) were, on average, 35 years old (sd = 12.13). the majority stated holding a syrian citizenship (58.5%, n = 38), followed by 23.1% (n = 15) with an iraqi citizenship. average time since arrival in germany was almost three years (m = 34.66 month; sd = 10.68). an insecure residence status was indicated by 15 participants (16.5%; see appendix a in the supplementary materials for all descriptive data). the mean score on the pcl-5 was 19.68 (sd = 14.58). using a suggested cut-off score of 23 for arabic and kurdish displaced populations (ibrahim et al., 2018), 25 participants (38.5%) met dsm-5 criteria for probable ptsd diagnosis. mental distress study a. participants who indicated having an insecure residence status had a higher rhs-15 sum-score (m = 20.52; sd = 11.53) compared to participants holding a secure residence status, m = 13.00; sd = 9.76; t(171) = −4.54, p < .001. study b. participants holding an insecure residence status reported an average score of 30.67 (sd = 15.98) on the pcl-5, whereas participants with a secure residence status scored 16.38 (sd = 12.52) on average, t(63) = −3.63, p = .001 (see appendix a in the supplementary materials for all descriptive data). residence status of the 177 participants in study a, four participants did not indicate their residence status, 61 indicated having a relatively secure residence status (34.5%). in study b, 23.0% of participants reported an insecure residence status (see table 1 for a detailed overview). table 1 descriptive statistics of participants’ residence status type residence status study a (n = 177) study b (n = 65) n % n % secure residence status recognized as refugee 42 23.7 6 9.2 entitled to asylum 35 19.8 24 36.9 subsidiary protection 35 19.8 20 30.8 insecure residence status; n (%) asylum applicant with pending procedure 38 21.5 6 9.2 temporary suspension of deportation 19 10.8 8 12.3 demand to leave germany 4 2.3 1 1.5 missing 4 2.3 0 0.0 note. % figures rounded to one decimal place. insecure asylum status and mental health 8 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ the impact of residence status on mental health–multiple regression analyses study a. variables added in the first step (age, gender, number of event types repor­ ted, time (in month) since arrival in germany) resulted in an r 2 of .12 (p < .001). the variables accounted for a significant amount of variance of mental distress variability. adding residence status in the second step explained an additional 7.7% of variance (∆r 2 = .08, p < .001). in the first step, age, gender, and number of traumatic event types experienced were significantly associated with the rhs sum-score. in the second step, gender, number of reported event types, and residence status were significantly associated with the rhs sum-score. an insecure residence status was associated with a higher rhs sum-score. overall, a significant regression equation was found, f(5, 161) = 7.82, p < .001. the final model accounted for 19.5% of the total variance in mental distress captured by the rhs-15 (see table 2 for exact values). table 2 hierarchical regression analysis of ptsd symptoms variable study a (rhs-15 sum-score as dependent variable)a study b (pcl-5 sum-score as dependent variable)b b [95% ci] p b [95% ci] p step 1 age 0.15 [0.00, 0.30] .046* 0.12 [-0.14, 0.39] .351 gender -5.47 [-9.61, -1.33] .010* -15.29 [-23.70, -6.88] .001* number traumatic event types reported 0.92 [0.45, 1.30] < .001* 1.02 [0.37, 1.68] .003* time since arrival in germanyc -.04 [-0.22, 0.14] .657 0.49 [0.17, 0.82] .004* step 2 age 0.14 [-0.01, 0.28] .059 0.16 [-0.08, 0.40] .187 gender -5.35 [-9.32, -1.38] .009* -16.33 [-24.09, -8.56] < .001* number traumatic event types reported 0.67 [0.20, 1.14] .005* 0.71 [0.09, 1.34] .026* time since arrival in germanya -0.04 [-0.21, 0.14] .640 0.45 [0.14, 0.75] .004* insecure residence status 6.65 [3.30, 10.00] < .001* 12.38 [5.13, 19.63] .001* ar 2 = .12 for step 1 (p < .001); ∆r2 = .08 for step 2 (p < .001). listwise deletion. n = 167. br 2 = .34 for step 1 (p < .001); ∆r 2 = .11 for step 2 (p = .001). listwise deletion. n = 64. cin month. *p ≤ .05. study b. variables added in the first step accounted for 34.4% of variance of ptsd symp­ tomatology (r 2 = .34, p < .001). by adding residence status in the second step additional 11.0% of variance of the pcl-5 sum-score was explained (∆r 2 = .11, p = .001). apart from age, all variables were significantly associated with the ptsd symptom variability in both steps of the regression analysis. a significant regression equation was found, boettcher & neuner 9 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ f(5, 58) = 9.64, p < .001. the final model accounted for approximately 45.4% of the total variance of ptsd symptomatology (see table 2 for exact values). discussion impact of residence status on refugees’ mental health our study of forcibly displaced people found that people with an insecure asylum status are at higher risk for an increased ptsd symptomatology. these findings are in line with earlier research (heeren et al., 2016; müller et al., 2018; newnham et al., 2019). potential explanations for our results must include a consideration of the kind and amount of post-migration stressors experienced by the refugees. as described by womersley et al. (2017), people with an insecure asylum status often have a larger number of stressors than those with a more secure asylum status. female gender was accompanied with increased symptomatology scores (5.35 on the rhs-15 and 16.33 on the pcl-5). this finding is in line with earlier research reporting female gender as a predictor of ptsd symptomatology (mahmood, ibrahim, goessmann, ismail, & neuner, 2019; nickerson et al., 2019). as females did not report a significantly higher number of potentially traumatic event types, we assume that it may be the type of trauma rather than simply the number that is associated with an increased mental stress/ ptsd symptomatology score. moreover, other factors like perceived social support may play a role here. the fact that participants in our studies holding an insecure asylum sta­ tus reported having experienced a higher number of traumatic event types, on average, is in line with earlier studies as well (e.g., nickerson et al., 2019). for every additional event type reported, the rhs-15 and pcl-5 sum-scores increased by 0.67 in study a and 0.71 points in study b. participants with an insecure asylum status reached an rhs-15 sum-score 6.65 points higher than participants with a secure asylum status. the pcl-15 sum-score was 12.38 points higher for participants with an insecure status. duration of stay was only significant in study b. a possible explanation is that participants who took part in study b had spent on average six months longer in germany and thus had a longer exposure to post-migration stressors. furthermore, the different finding may be explained by the different questionnaires used in the studies. strength and limitations an advantage of having two different studies is the potential for participants to develop an increased level of trust with research staff by taking part in study b. this aspect was emphasized by statements of some of the participants describing a joy to meet again. by collecting all information through face-to-face interviews instead of (online) questionnaires, possible difficulties in comprehension could be resolved. insecure asylum status and mental health 10 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ our study is based on convenience samples that, although unselected, are far from representative of refugee populations in germany, which limits the generalizability of the findings. however, the fact that the same associations were found consistently across two measurements with different instruments supports validity of findings. data collection was cross-sectional in both studies. to be able to increase explanato­ ry power and investigate causation longitudinal studies are needed. even though the rhs-15 is a well-known screening tool with good reliability and validity scores, it is a screening tool with 15 items and does not allow a more detailed insight in a person’s mental health status or the diagnosis of potential mental health disorders. recommendations in line with previous research (chu et al., 2013), we found that asylum status as a post­ migration factor explains a significant amount of variance in ptsd symptomatology. it seems evident that post-migration conditions can interfere with recovery from traumatic experiences (heeren et al., 2014). people are best positioned to thrive when they experi­ ence a safe environment to be able to profit from available resources (ryan et al., 2008). further research on post-migration stressors could provide more insight in the potential influence of these stressors on ptsd symptomatology. moreover, including additional measures apart from rhs-15 and pcl-5 to investigate mental health status could offer an even more comprehensive insight in refugees’ mental health. lastly, investigating the possible confounding associations of citizenship with asylum status and mental distress may be insightful. however, to make reliable statements and draw conclusions, a larger sample size with a more balanced distribution of citizenships as well as residence status types will be needed. refugees need the opportunity to participate in everyday life. with a working per­ mit for integration, learning a new language, making socially supportive contacts, the ptsd rate decreases (hocking, kennedy, & sundram, 2015). policy changes regarding the asylum procedure in receiving countries could therefore have a positive impact on refugees’ mental health (porter & haslam, 2005). as long as asylum procedures cannot be substantially shortened, freedom of movement and access to the labor market should be provisionally granted. these changes may relieve at least some post-migration stressors. furthermore, the possible influence of an insecure asylum status on psychotherapy needs to be considered (chu et al., 2013). the additional stress might impede the thera­ peutic process. the increased risk of symptoms becoming chronic and the accompanying higher costs for the health care system could be bypassed by granting unconditional access to the health care system regardless of asylum procedure. knowing about the negative aspects of post-migration living stressors it might be also interesting to consider the opposite side, namely whether easing post-migration living conditions can promote recovery and growth. boettcher & neuner 11 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ conclusions it is not only the potentially traumatic events experienced before or during flight that have an impact on refugees’ mental health. in fact, conditions in the receiving countries contribute to psychological well-being. to be able to expect successful integration, op­ portunities for inclusion in everyday life need to be offered. changes in residence status policies may be one step in the right direction. apart from the people going through the established asylum procedure, forcibly displaced people who immigrated illegally should be kept in mind as well. healthcare services should not be hold back for people suffering from physical or mental illness regardless of asylum status. by providing refugees opportunities to be independent and active members of their communities, both they and society at large stand to benefit as refugees have a clearer path to realizing their potential. funding: the research reported was supported by the ministry of culture and science of the state of north rhinewestphalia; under grant 321-8.03.07-127600. the funding body had no influence on designing the study, collecting, analyzing interpreting the data, or writing the manuscript. acknowledgments: we sincerely thank all participants who made this research possible. we acknowledge support regarding data collection by the “flüge” research consortium and all of our interviewers. we sincerely thank justin preston for proofreading the manuscript. competing interests: there are no potential conflicts of interest in the professional or financial affiliations of any of the authors which may have biased the presentation of material in the paper. supplementary materials in the supplementary materials, a table with descriptive statistics of all relevant variables is displayed (for access see index of supplementary materials below). index of supplementary materials boettcher, v. s., & neuner, f. 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(2016). psychometric analysis of the ptsd checklist-5 (pcl-5) among treatmentseeking military service members. psychological assessment, 28(11), 1392–1403. https://doi.org/10.1037/pas0000260 boettcher & neuner 15 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://doi.org/10.5694/j.1326-5377.2006.tb00610.x https://doi.org/10.1007/s10903-017-0555-y https://doi.org/10.1007/s00038-019-01249-6 https://doi.org/10.1080/20008198.2019.1688129 https://doi.org/10.1001/jama.294.5.602 https://doi.org/10.1097/nmd.0b013e31815fa51c https://doi.org/10.3402/ejpt.v7.28057 https://www.unhcr.org/5ee200e37.pdf https://doi.org/10.1055/a-0806-3568 https://doi.org/10.1037/pas0000260 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. insecure asylum status and mental health 16 clinical psychology in europe 2022, vol. 4(1), article e6587 https://doi.org/10.32872/cpe.6587 https://www.psychopen.eu/ insecure asylum status and mental health background asylum application procedure in germany consequences of an insecure residence status for mental health in refugees aim of the study method sample procedures measures data analysis results mental distress residence status the impact of residence status on mental health–multiple regression analyses discussion impact of residence status on refugees’ mental health strength and limitations recommendations conclusions (additional information) funding acknowledgments competing interests supplementary materials references efficacy of psychological treatments for patients with schizophrenia and relevant negative symptoms: a meta-analysis systematic reviews and meta-analyses efficacy of psychological treatments for patients with schizophrenia and relevant negative symptoms: a meta-analysis marcel riehle a , mara cristine böhl a, matthias pillny a , tania marie lincoln a [a] clinical psychology and psychotherapy, universität hamburg, hamburg, germany. clinical psychology in europe, 2020, vol. 2(3), article e2899, https://doi.org/10.32872/cpe.v2i3.2899 received: 2020-03-03 • accepted: 2020-09-10 • published (vor): 2020-09-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: marcel riehle, clinical psychology and psychotherapy, institute for psychology, universität hamburg, von-melle-park 5, 20146 hamburg, germany. twitter: @drriehle, @pb_unihh (faculty account). tel.: (+49) (0)40 42838 6072; fax: (+49) (0)40 42838 6170. e-mail: marcel.riehle@uni-hamburg.de supplementary materials: materials [see index of supplementary materials] abstract background: recent meta-analyses on the efficacy of psychological treatments for the negative symptoms of schizophrenia included mostly trials that had not specifically targeted negative symptoms. to gauge the efficacy of such treatments in the target patient population – namely people with schizophrenia who experience negative symptoms – we conducted a meta-analysis of controlled trials that had established an inclusion criterion for relevant negative symptom severity. method: we conducted a systematic literature search and calculated random-effects meta-analyses for controlled post-treatment effects and for pre-post changes within treatment arms. separate analyses were conducted for different therapeutic approaches. our primary outcome was reduction in negative symptoms; secondary outcomes were amotivation, reduced expression, and functioning. results: twelve studies matched our inclusion criteria, testing cognitive behavioral therapy (cbt) vs. treatment-as-usual (k = 6), cognitive remediation (cr) vs. treatment-as-usual (k = 2), cbt vs. cr (k = 2), and body-oriented psychotherapy (bpt) vs. supportive group counseling and vs. pilates (k = 1 each). accordingly, meta-analyses were performed for cbt vs. treatment-as-usual, cr vs. treatment-as-usual, and cbt vs. cr. cbt and cr both outperformed treatment-as-usual in reducing negative symptoms (cbt: hedges’ g = -0.46; cr: g = -0.59). there was no difference between cbt and cr (g = 0.12). significant pre-post changes were found for cbt, cr, and to a lesser extent for treatment-as-usual, but not for bpt. conclusion: although effects for some approaches are promising, more high-quality trials testing psychological treatments for negative symptoms in their target population are needed to place treatment recommendations on a sufficiently firm foundation. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i3.2899&domain=pdf&date_stamp=2020-09-30 https://orcid.org/0000-0002-7839-077x https://orcid.org/0000-0003-2395-8433 https://orcid.org/0000-0002-6674-2440 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords schizophrenia and psychosis, negative symptoms, psychotherapy, nonpharmacological treatment, meta-analysis highlights • this meta-analysis assesses the efficacy of psychological treatments for relevant negative symptoms. • cognitive behavioral therapy and cognitive remediation show promising effects reducing symptoms. • interventions show differential effects for the subcomponents amotivation and reduced expression. • the evidence-base is not in line with recommendations made in treatment guidelines. the negative symptoms of schizophrenia, i.e. blunted affect, alogia, anhedonia, asociality, and avolition (marder & galderisi, 2017), are among the best predictors of patients’ social functioning levels (fervaha, foussias, agid, & remington, 2014; galderisi et al., 2014) and accordingly an important treatment target. with respect to psychological treat‐ ments, meta-analyses have reported moderate treatment effects for negative symptoms in response to cognitive behavioral therapy for psychosis (cbtp) (wykes, steel, everitt, & tarrier, 2008), cognitive remediation (cr) (cella, preti, edwards, dow, & wykes, 2017; roder, mueller, & schmidt, 2011), social skills training (sst) (kurtz & mueser, 2008; turner et al., 2018), and mindfulness-based interventions (khoury, lecomte, gaudiano, & paquin, 2013). in the case of cbt, the effect was not significant in a more recent metaanalysis (velthorst et al., 2015). among studies comparing different active psychological interventions to one another, sst seems to be superior to other treatments (turner, van der gaag, karyotaki, & cuijpers, 2014) and is recommended for negative symptoms in two german treatment guidelines (dgppn e.v., 2019; lincoln, pedersen, hahlweg, wiedl, & frantz, 2019). according to the british nice guidelines (nice, 2014), offering arts therapy (including music and body-oriented therapy) should be considered both in acute phases and “to assist in promoting recovery, particularly in people with negative symp‐ toms” (p. 220). nice does not recommend any other approach for negative symptoms. why yet another meta-analysis? besides the mixed conclusions from previous meta-analyses, all of the meta-analyses mentioned share the limitation that almost all included original trials reported on nega‐ tive symptoms as a secondary, not a primary outcome. for example for cbtp, only 3 out of 30 studies (velthorst et al., 2015; wykes et al., 2008) specifically targeted negative symptoms. in the case of cr, cella et al. (2017), p. 43, noted that “negative symptoms have not been considered a primary target for cr”. instead, due to the focus on positive psychological treatments for negative symptoms 2 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ symptoms in most included trials, participants in the trials often had passed some min‐ imum criterion for the presence of positive symptoms. therefore, we cannot rule out that the moderate meta-analytic effects for negative symptoms mentioned above result from primary studies that did not include any patients with relevant1 negative symptoms. this makes it extremely difficult to select appropriate treatments for the patients with schizophrenia, who present with relative negative symptoms, which have been estimated to constitute one (buchanan, 2007) or even two (bobes, arango, garcia-garcia, & rejas, 2010) thirds of the total patient population. to emphasize this point; this is as if we wanted to judge the efficacy of an intervention for auditory hallucinations on the basis of studies that did not make sure that their participants actually had auditory hallucinations before the intervention. more specifically, because previous meta-analyses did not limit their eligibility crite‐ ria to studies that required that their patients present with at least some relevant level of negative symptoms, there are several possible ways by which these meta-analyses may have either overor underestimated the effect size of psychological negative symptom treatments. for instance, floor effects need to be expected if patients without relevant negative symptoms and thus little room for improvement in this domain are included in the studies. this would lead to an underestimation of the effect size. on the other hand, we need to consider the possibility that patients with more severe negative symptoms benefit less from therapy or that the interventions’ effects primarily reflect changes in the so-called “secondary” (carpenter, heinrichs, & wagman, 1988) negative symptoms (e.g., social withdrawal due to paranoia). each of these would lead to an overestimation of the effect size. in fact, at least the latter possibility is likely, given that–much more often than not–positive symptoms were the focus of the primary research that fed into the meta-analyses mentioned above. another problem with this focus of most considered trials is that the interventions analyzed usually targeted positive psychotic symptoms and for this reason were derived from psychological models of those symptoms. given that positive and negative symptoms are usually uncorrelated (e.g., engel, fritzsche, & lincoln, 2014; strauss et al., 2012), it is not scientifically plausible that these interventions should work well for negative symptoms. to overcome these uncertainties, we conducted a meta-analysis of only those con‐ trolled treatment studies that focused specifically on psychological interventions for negative symptoms and that made sure that enrolled patients presented with relevant negative symptoms. as the primary outcome, we estimated the controlled meta-analytic effect size for negative symptoms post treatment. as secondary outcomes, we estimated the controlled meta-analytic effect size for each of the two negative symptom dimen‐ 1) because there are no unified criteria to demarcate the presence from the absence of negative symptoms, we use the concept of „relevant negative symptoms“ throughout this paper as an umbrella term for the different ways that have been put forward to describe negative symptoms that can be considered in need of treatment (see for instance table 1 in this paper or the differing criteria used in buchanan, 2007 and bobes et al., 2010). riehle, böhl, pillny, & lincoln 3 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ sions, motivational and expressive negative symptoms (blanchard & cohen, 2006), as well as for level of functioning. as a secondary analysis, we estimated the meta-analytic pre-post changes within treatment arms for each outcome. method eligibility criteria we defined six eligibility criteria in accordance with the picos criteria. first, we inclu‐ ded only studies that exclusively enrolled adult patients with a diagnosis of schizophre‐ nia spectrum disorder according to dsm or equivalent icd diagnoses. second, studies were eligible only when they had established any minimum inclusion criterion of neg‐ ative symptom severity (i.e. relevant negative symptoms). third, studies were eligible when they tested a psychological intervention, defined as manual-based non-invasive non-pharmacological talkor exercise-based intervention and when this intervention specifically targeted negative symptoms. fourth, all eligible studies had to include either a wait-list condition (e.g., treatment-as-usual, tau) or an alternative active intervention as a comparator. fifth, eligible studies needed to report outcomes on at least one of the following validated negative symptom assessments: brief negative symptom scale (bnss; kirkpatrick et al., 2011), clinical assessment interview for negative symptoms (cains; horan, kring, gur, reise, & blanchard, 2011), negative symptom assessment (nsa; alphs, summerfelt, lann, & muller, 1989), positive and negative syndrome scale (panss; kay, fiszbein, & opler, 1987), scale for the assessment of negative symptoms (sans; andreasen, 1989). sixth, eligible studies had to be designed as controlled trials (ct) or randomized controlled trials (rct). finally, studies were only eligible if they reported on original data (i.e. no secondary analyses) and were published in a peer-re‐ viewed journal in english or german language. literature search we searched the databases of medline(r) and psycinfo on august 24, 2020, using the following search term: (negative symptoms) and (schizophrenia or psychosis) and (treatment or intervention or therapy or psychotherapy or training or remediation). we also consulted reference lists of several systematic reviews and meta-analyses (cella et al., 2017; devoe, peterson, & addington, 2018; khoury et al., 2013; kurtz & mueser, 2008; lutgens, gariepy, & malla, 2017; roder et al., 2011; turner et al., 2014; velthorst et al., 2015; wykes et al., 2008). m.c.b. screened titles and abstracts of all studies in the search pool for non-eligibility and read full texts of all potentially eligible studies. m.c.b. made final decisions on eligible studies and resolved any uncertainties with m.r. a hierarchical decision structure was used to code the reason for exclusion of a study after reading the full-text: a) not retrievable, b) not a treatment study, c) secondary analysis, d) psychological treatments for negative symptoms 4 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ no ct or rct, e) included patients outside the diagnostic spectrum, f) did not report on a validated negative symptom assessment, g) no inclusion criterion for relevant negative symptoms, h) data reported insufficiently for meta-analysis. in the case of insufficient data, we contacted the study’s corresponding author up to four times to request data. data extraction we developed a coding protocol based on the cochrane handbook (higgins & deeks, 2008). the full item list can be requested from the first author. for our primary outcome, negative symptoms, we extracted per availability the post treatment negative symptom scores (m and sd) for the experimental and control group, respectively, or the between-group effect size estimate reported post treatment. post-treatment scores were defined as the first assessment after the termination of the in‐ tervention. if studies reported on more than one validated negative symptom assessment, we used the data from the one assessment labelled as primary outcome in the study. for all outcomes post treatment, results from intent-to-treat analyses (e.g., last observation carried forward) were prioritized over completer analyses. for the secondary outcomes, motivational negative symptoms, expressive negative symptoms, and level of functioning, we extracted per availability post treatment scores (m and sd) or the between-group effect size estimate reported post treatment. we defined the following as potential measures of motivational negative symptoms: bnss scales anhedonia, asociality, and avolition, cains scale motivation and anticipation of pleasure, sans scales avolition-apathy and anhedonia-asociality, and panss items n2 and n4 (fervaha et al., 2014; jang et al., 2016). we defined the following as potential measures of expressive negative symptoms: bnss scales blunted affect and alogia, cains scale expressive reduction, sans scales affective flattening and alogia, and panss items n1, n3, n6, and g7 (fervaha et al., 2014; jang et al., 2016). we defined measures of level of functioning as assessments of patients’ functionality in one or more of the following areas: family, friendship and partnership, vocation, or recreation. for our secondary analysis on pre-post changes, we also extracted pre-treatment scores (m and sd) on negative symptoms, motivational negative symptoms, expressive negative symptoms, and level of functioning or pre-post within-group effect size esti‐ mates. pre-treatment scores were defined as the last assessment before the start of the intervention. effect size computation at the levels of the individual studies we computed hedges’ g as the mean difference between groups (experimental minus control group) divided by the pooled standard deviation (cohen’s d) multiplied with a correction term (borenstein, 2009; hedges & olkin, 1985). the variance of g was calcu‐ riehle, böhl, pillny, & lincoln 5 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ lated according to borenstein, hedges, higgins, and rothstein (2009) (for the complete formulae see the supplementary materials). for pre-post within group comparisons we calculated g and its variance using the formulae for pre-post changes provided in borenstein et al. (2009) (see supplementary materials for complete formulae). these formulae account for the pre-post correlation of the repeated measure (cf. mcgaw & glass, 1980) that we estimated at r = .50 based on the pre-post correlations of studies included in this meta-analysis (see supplementary mate‐ rials) and in line with recommendations in the literature (lincoln, suttner, & nestoriuc, 2008; smith, glass, & miller, 1980). in cases in which several subscales needed to be integrated into one measure, we estimated d for each subscale, and computed a study-wise mean d, and subsequently g, and estimated its variance based on an integration of the variances of the subscales and their inter-correlations (borenstein et al., 2009). if such correlations could not be obtained from the studies themselves, they were estimated from relevant literature (for details see supplementary materials). we interpreted g ≥ 0.2 as a small effect, g ≥ 0.5 as a moderate effect, and g ≥ 0.8 as a large effect (cohen, 1992). effect size integration we integrated the effect sizes using random-effects models accounting for potential heterogeneity between studies. the effect sizes of single studies were weighted by their inverse variance (shadish & haddock, 2009). variance among studies was estimated according to dersimonian and laird (1986). we assessed heterogeneity between studies with the qand i 2-statistics (higgins, thompson, deeks, & altman, 2003; shadish & haddock, 2009). in accordance with higgins et al. (2003), we defined heterogeneity as‐ sessed with i 2 as low (25%), moderate (50%), and high (75%). all analyses were conducted with the package metafor (viechtbauer, 2010) in rstudio version 1.1.453. all significance tests were performed on an α-level of .05. because we were interested in comparing the efficacy of different psychological treatments for negative symptoms, we calculated separate meta-analyses for each psy‐ chological treatment approach identified in our search. based on a recent literature review (riehle, pillny, & lincoln, 2017), we expected to find studies for the following approaches: cbt, sst, cr, and body-oriented psychotherapy (bpt). we also planned to analyze studies comparing an intervention to tau separately from studies comparing an intervention to an active control condition or an alternative treatment. we integrated effect sizes, when two or more studies were found that could be integrated. psychological treatments for negative symptoms 6 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ risk of bias analyses risk of bias for individual studies was assessed with seven criteria that were based on the cochrane risk of bias tool (higgins, altman, & sterne, 2008). the seven criteria were evaluated on a dichotomous true (high quality)/false (low quality) scale and were: a) use of randomization for group allocation, b) use of an intent-to-treat analysis to account for dropouts, c) assessment of treatment fidelity, d) assessors blinded to group allocation, e) non-selective reporting of outcomes, f) matching of experimental and control group, g) exclusion of patients with high levels of positive psychotic symptoms (cf. savill, banks, khanom, & priebe, 2015). to account for potential publication bias influencing the meta-analysis, we inspected funnel plots (effect sizes plotted against their standard errors) for asymmetry (borenstein et al., 2009; sterne, egger, & moher, 2008) and conducted trim-and-fill analyses (duval & tweedie, 2000). results study selection the flow-chart in figure 1 illustrates the study selection process. we identified k = 12 studies fulfilling our inclusion criteria. of the twelve studies, k = 6 tested cbt vs. tau (bailer, takats, & westermeier, 2001; choi, jaekal, & lee, 2016; favrod et al., 2019; grant, 2012; pos et al., 2019; velligan et al., 2015), k = 2 tested cbt vs. cr (klingberg et al., 2011; penadés et al., 2006), k = 2 tested cr vs. tau (li et al., 2019; mueller, khalesi, benzing, castiglione, & roder, 2017), k = 1 tested bpt vs. group supportive counselling (röhricht & priebe, 2006), k = 1 tested bpt vs. pilates (priebe, savill, wykes, bentall, lauber, et al., 2016a; priebe, savill, wykes, bentall, reininghaus, et al., 2016b). accordingly, we calculated meta-analyses for the comparisons of cbt vs. tau, cr vs. tau, and cbt vs. cr. for the meta-analysis of pre-post changes in negative symptoms within the study groups, we integrated data from all samples included in the twelve studies that received comparable forms of treatment: cbt (k = 8), cr (k = 4), bpt (k = 2), tau (k = 8). data was not available for all outcomes in all studies and tables s3 and s4 in the supplementary materials show in detail which studies were included in which analyses. the study characteristics are shown in table 1. as can be seen, every study used a unique criterion to establish a minimum level of negative symptom severity. riehle, böhl, pillny, & lincoln 7 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ figure 1 flow chart of the literature selection process psychological treatments for negative symptoms 8 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ ta bl e 1 c ha ra ct er is tic s of s tu di es in cl ud ed in th e m et aa na ly si s, s or te d by c om pa ri so n c om pa ri so n/ r ef er en ce c ou nt ry o f or ig in n a eg b / c g c d ro pou ts eg b /c g c m al e se x eg b /c g c tr ea tm en t du ra ti on in w ee ks pr im ar y ou tc om e m ea su re m ot ./e xp . n es m ea su re le ve l o f fu nc ti on in g n es in cl us io n cr it er io n c bt v s. ta u ba ile r e t a l., 2 00 1 ge r 20 / 19 13 % / 2 1% 54 % / 5 8% 12 sa n s sa n s da sm ≥ 2 on a ny s a n s sc al e or d a sm g lo ba l ch oi e t a l., 2 01 6 ko r 22 / 19 4% / 21 % 52 % / 5 0% 10 pa n ss -n bn ss > 3 on a t l ea st 2 p a n ss n it em s fa vr od e t a l., 2 01 9 ch e 40 / 40 8% / 0% 53 % / 7 0% 8 sa n s sa n s ≥ 2 on s a n s ap at hy / an he do ni a gr an t e t a l., 2 01 2 us a 31 / 29 10 % / 1 0% 68 % / 6 6% 72 sa n s sa n s ga f ≥ 4 on a t l ea st 1 o r ≥ 3 on 2 s a n s sc al es po s e t a l., 2 01 9 n ed 49 / 50 18 % / 2 0% 76 % / 8 6% 10 bn ss bn ss ga f pa n ss n 2 or n 4 ≥ 3 or bn ss a so ci al ity it em s ≥ 2 ve lli ga n et a l., 2 01 5 us a 17 / 22 35 % / 1 2% 65 % / 6 8% 36 n sa ca in s > 3 on a t l ea st 2 n sa sy m pt om d om ai ns c r v s. ta u li e t a l., 2 01 9 ch i 16 / 15 6% / 27 % 53 % / 7 2% 4 pa n ss -n sa n s pa n ss -n a t l ea st 6 po in ts > p a n ss -p m ue lle r e t a l., 2 01 7 ch e 28 / 33 14 % / 6 % 76 % / 7 9% 15 pa n ss -n pa n ss it em s n 1, n 4, n 6 ga f > 3 on p a n ss n 1, n 4, an d/ or n 6 riehle, böhl, pillny, & lincoln 9 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ c om pa ri so n/ r ef er en ce c ou nt ry o f or ig in n a eg b / c g c d ro pou ts eg b /c g c m al e se x eg b /c g c tr ea tm en t du ra ti on in w ee ks pr im ar y ou tc om e m ea su re m ot ./e xp . n es m ea su re le ve l o f fu nc ti on in g n es in cl us io n cr it er io n c bt v s. c r kl in gb er g et a l., 2 01 1 ge r 99 / 99 9% / 20 % 59 % / 5 3% 36 pa n ss -m n s sa n s ga f > 10 o n pa n ss -m n s su m sc or e pe na dé s e t a l., 2 00 6 es p 20 / 20 15 % / 2 0% 55 % / 6 0% 16 pa n ss -n ls p pa n ss -n > p a n ss po sit iv e sc al e bp t vs . p ila te s pr ie be e t a l., 2 01 6b gb r 13 1 / 1 23 2% / 4% 50 % / 4 8% 10 pa n ss -n ca in s m a n sa ≥ 18 o n pa n ss -n bp t vs . g sc rö hr ic ht & p rie be , 2 00 6 gb r 24 / 19 4% / 9% 74 % / 7 4% 10 pa n ss -n pa n ss it em s n 1, n 6 m a n sa ≥ 20 o n pa n ss -n a nd /o r ≥ 6 on p a n ss n 1, n 2, or n 6 n ot e. eg = ex pe rim en ta l g ro up ; c g = co nt ro l g ro up ; n es = n eg at iv e sy m pt om s; cb t = co gn iti ve b eh av io ra l t he ra py ; t a u = tr ea tm en t-a sus ua l; cr = c og ni tiv e re m ed ia tio n; b pt = b od yor ie nt ed p sy ch ot he ra py ; g sc = g ro up s up po rti ve c ou ns el lin g; s a n s = sc al e fo r t he a ss es sm en t o f n eg at iv e sy m pt om s; da sm = d isa bi lit y as se ss m en t s ch ed ul e; pa n ss -n /m n s = po sit iv e an d n eg at iv e sy nd ro m e sc al e n eg at iv e sc al e/ m od ifi ed n eg at iv e fa ct or (n 1, n 2, n 3, n 4, n 6, g7 , g 16 ); bn ss = b rie f n eg at iv e sy m pt om s ca le ; n sa = n eg at iv e sy m pt om a ss es sm en t; ca in s = cl in ic al a ss es sm en t i nt er vi ew fo r n eg at iv e sy m pt om s; ga f = gl ob al as se ss m en t o f f un ct io ni ng ; l sp = l ife s ki lls p ro fil e; m a n sa = m an ch es te r s ho rt as se ss m en t o f q ua lit y of l ife . a n co rr es po nd s t o nu m be r o f p ar tic ip an ts a va ila bl e fo r a m et aan al ys is on th e pr im ar y ou tc om e m ea su re . b cb t fo r c bt v s. cr . c cr fo r c bt v s. cr . psychological treatments for negative symptoms 10 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ controlled post-treatment effects figure 2 contains the forest plots for the comparisons of cbt vs. tau, cr vs. tau and cbt vs. cr on controlled effect sizes for a global measure of negative symptoms. cbt vs. tau as can be seen in figure 2, there was a moderate and significant treatment effect favoring cbt over tau for our primary outcome, negative symptoms post treatment. heterogeneity across the four studies was moderate. regarding secondary outcomes, for motivational negative symptoms, there was a moderate significant post treatment effect favoring cbt over tau k = 6, n = 347, g = -0.50, 95% ci [-0.77, -0.22] (heterogeneity: q = 8.04, p = .154, i 2 = 37.8%). for expressive negative symptoms, there was no difference between cbt and tau, k = 5, n = 248, g = -0.05, 95% ci [-0.30, 0.20] (heterogeneity: q = 4.29, p = .369, i 2 = 6.70%). for level of functioning, there was a moderate but non-significant and highly heterogeneous effect favoring cbt over tau, k = 3, n = 198, g = 0.56, 95% ci [-0.11, 1.23] (heterogeneity: q = 9.95, p = .007, i 2 = 79.9%). cr vs. tau as also can be seen in figure 2, there was a moderate and significant treatment effect favoring cr over tau for our primary outcome, negative symptoms post treatment. no heterogeneity was noted across the two studies. regarding secondary outcomes, for motivational negative symptoms, there was a small but non-significant post treatment effect favoring cr over tau k = 2, n = 87, g = -0.23, 95% ci [-0.64, 0.19] (heterogeneity: q = 0.80, p = .371, i 2 = 0.0%). for expressive negative symptoms, there was a moderate and significant effect favoring cr over tau, k = 2, n = 87, g = -0.53, 95% ci [-0.93, -0.12] (heterogeneity: q = 0.30, p = .584, i 2 = 0.0%). for level of functioning, only one study reported sufficient data (mueller et al., 2017), so that no effect size integration was performed. cbt vs. cr as shown in figure 2, there was no significant difference between cbt and cr for negative symptoms post treatment and the heterogeneity measure indicated uniformity of the two studies’ effects. regarding the secondary outcomes, for level of functioning, there was a small but non-significant post treatment effect favoring cr over cbt, k = 2, n = 238, g = 0.31, 95% ci [-0.71, 1.34] with high heterogeneity, q = 8.47, p = .004, i 2 = 88.2%. for motivational and expressive negative symptoms, only one of the two studies reported sufficient data (klingberg et al., 2011), so that no effect size integration was performed. riehle, böhl, pillny, & lincoln 11 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ figure 2 forest plot of the random effects meta-analyses for the controlled treatment effects of cbt vs. tau, cr vs. tau, and cbt vs. cr in reducing relevant negative symptoms pre-post within group changes the meta-analytic results for the pre-post within group changes are detailed in table 2. for our primary outcome, global negative symptoms, significant moderate effects were noted for cbt and cr. the moderate effect of bpt was non-significant and highly heterogeneous. a small significant effect emerged for tau. for our secondary outcome motivational negative symptoms, cbt and cr showed moderate significant effects accompanied by high heterogeneity. tau showed a small significant effect. for bpt there was insufficient data. for expressive negative symptoms, cr showed a significant moderate effect. a small significant effect emerged for cbt. there was also a moderate effect of bpt on expres‐ sive negative symptoms, which was, however, non-significant due to high heterogeneity. we did not find an effect of tau. for level of functioning, small to moderate significant effects emerged for cbt, cr, and tau, all with moderate heterogeneity, whereas there was no effect of bpt. psychological treatments for negative symptoms 12 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ table 2 results of the random-effects meta-analyses on pre-post changes within treatment arms for primary and secondary outcomes, sorted by type of intervention intervention k n g 95% ci q i2 global negative symptoms cbt 7 286 -0.50*** -0.66, -0.35 8.54 29.7% cr 4 162 -0.60*** -0.86, -0.35 5.33 43.7% bpt 2 154 -0.62† -1.36, 0.11 7.93** 87.4% tau 7 194 -0.20* -0.38, -0.03 8.74 31.3% motivational negative symptoms cbt 7 289 -0.58*** -0.90, -0.26 36.92*** 83.8% cr 3 142 -0.59* -1.11, -0.07 11.69** 82.9% bpt tau 8 220 -0.26** -0.45, -0.06 14.09* 50.3% expressive negative symptoms cbt 5 209 -0.24** -0.41, -0.08 5.43 26.4% cr 3 142 -0.48*** -0.64, -0.32 0.86 0.0% bpt 2 154 -0.57 -1.41, 0.23 10.38** 90.4% tau 6 144 -0.10 -0.26, 0.06 4.59 0.0% level of functioning cbt 5 238 0.61*** 0.30, 0.92 17.37** 77.0% cr 3 147 0.40*** 0.10, 0.70 4.63† 56.8% bpt 2 152 0.10 -0.07, 0.25 0.23 0.0% tau 3 112 0.41* 0.08, 0.74 5.61† 64.3% note. cbt = cognitive behavioral therapy; cr = cognitive remediation; bpt = body-oriented psychotherapy; tau = treatment-as-usual. †p < .10. *p < .05. **p < .01. ***p < .001. risk of bias analyses publication bias inspection of the funnel plots (cf. supplementary materials) for the three comparisons of cbt vs. tau, cr vs. tau, and cbt vs. cr and trim-and-fill analyses suggested the following: no studies were estimated to be missing for cbt vs. tau and cr vs. tau. for cbt vs. cr, one study was estimated to be missing; the corrected effect, k = 3, g = 0.12, 95% ci [-0.12, 0.36], did not change the interpretation that there was no difference between the two interventions. risk of bias in individual studies and sensitivity analyses the results of the quality assessment of individual studies are shown in table 3. riehle, böhl, pillny, & lincoln 13 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ table 3 results of the quality assessment of included studies, sorted by comparison comparison/ reference random‐ ization intent-totreat analysis assessment of treatment fidelity blinded assessors nonselective outcome report matching groups high levels of positive symptoms excluded cbt vs. tau bailer et al., 2001 + + -/+ choi et al., 2016 + + + + favrod et al., 2019 + + -/+ + + + grant et al., 2012 + + + + + + pos et al., 2019 + + + + + + -/+ velligan et al., 2015 + + + + + + cr vs. tau li et al., 2019 + + +/+ mueller et al., 2017 + + + + + cbt vs. cr klingberg et al., 2011 + + + + + + + penadés et al., 2006 + + + + + -/+ bpt vs. pilates priebe et al., 2016b + + + + + + bpt vs. gsc röhricht & priebe, 2006 + + + + + + note. cbt = cognitive behavioral therapy; tau = treatment-as-usual; cr = cognitive remediation; bpt = body-oriented psychotherapy; gsc = group supportive counselling; + = criterion fulfilled; = criterion not fulfilled; -/+ = unclear; criterion probably fulfilled. as can be seen there, the overall study quality was high. non-selective reporting of results was implemented in all studies included in the meta-analysis and all investigated at least largely matching experimental and control groups. about half of the studies included a criterion to confine positive symptom severity in addition to their negative symptom inclusion criterion. three studies did not randomize their participants to the treatment arms (i.e., bailer et al., 2001; choi et al., 2016; li et al., 2019). as can be seen in figure 2, these three studies contributed the three largest controlled effect sizes. this could be due to patient prefer‐ ences playing a role in group allocation (e.g., in li et al., 2019). also, these three studies on average fulfilled two quality criteria less than the rcts. for this reason, we performed sensitivity analyses for all effects including only rcts. because for cr vs. tau there was only a single rct and because both cbt vs. cr and both bpt studies were rcts, sensitivity analyses of controlled post treatment effects were performed exclusively for cbt vs. tau. for the primary outcome, global negative symptoms, there remained a small marginally significant effect favoring cbt over tau k = 4, n = 278, g = -0.24, psychological treatments for negative symptoms 14 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ 95% ci [-0.47, 0.004] (heterogeneity: q = 0.56, p = .905, i 2 = 0.0%). regarding secondary outcomes, for motivational negative symptoms, there remained a small significant effect favoring cbt over tau k = 4, n = 278, g = -0.35, 95% ci [-0.58, -0.11] (heterogeneity: q = 1.93, p = .586, i 2 = 0.0%). for expressive negative symptoms, there was no difference between cbt and tau, k = 3, n = 179, g = 0.10, 95% ci [-0.18, 0.38] (heterogeneity: q = 0.65, p = .723, i 2 = 0.00%). finally, for level of functioning, there remained a small but non-significant effect favoring cbt over tau, k = 2, n = 159, g = 0.26, 95% ci [-0.27, 0.78] (heterogeneity: q = 2.61, p = .106, i 2 = 61.7%). results of the sensitivity analyses for the pre-post effects for cbt, cr, and tau can be found in table s5 in the supplementary materials. discussion different national treatment guidelines have recommended different psychological thera‐ pies to treat the negative symptoms of schizophrenia (e.g., dgppn e.v., 2019; lincoln et al., 2019; nice, 2014). the purpose of such recommendations is to inform clinicians about which treatments to offer to their patients who experience these symptoms (i.e. the target population of the treatment). for this reason, it is important to base the recommendations on research that can answer the question whether a given treatment reduces negative symptoms in the target patient population. here, we conducted the first systematic literature search and meta-analysis of controlled trials of psychological treatments that had employed an inclusion criterion for negative symptom severity. our search identified twelve controlled studies matching our inclusion criteria. these twelve studies targeted cognitive behavioral therapy (cbt), cognitive remediation (cr), and body-oriented psychotherapy (bpt). by integrating findings of studies that investi‐ gated comparable forms of treatments (e.g., all trials testing cbt vs. treatment-as-usual, tau), we were able to calculate meta-analyses on the controlled treatment effects for the comparisons of cbt vs. tau, cr vs. tau, and cbt vs. cr, respectively. we found that cbt reduced negative symptoms more than tau with a small to mod‐ erate effect size (g = -0.46). this effect was larger than in other recent meta-analyses on the efficacy of cbt on negative symptoms (i.e. -0.09 to -0.16, velthorst et al., 2015; -0.34, lutgens et al., 2017). however, our sensitivity analysis including only rcts suggested that the effect size could be only half as big (g = -0.24) in more rigorous trials. this confirms what has already been observed for cbt in psychosis more generally, namely that effect sizes tend to be smaller in more rigorous trials (jauhar et al., 2014; wykes et al., 2008). having this caveat in mind, further high-quality rcts on the efficacy of cbt for negative symptoms in the target patient population are needed to confirm (or disconfirm) the effect found in this meta-analysis. we also found cr to reduce negative symptoms more than tau with a moderate effect size (g = -0.59). again, this effect size is considerably larger than the ones found in riehle, böhl, pillny, & lincoln 15 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ previous meta-analyses (i.e., cella et al., 2017; es = -0.30 to -0.40). however, this effect is based on only two studies, of which one (li et al., 2019) did not randomize patients to the treatment arms and even based their treatment allocation on patients’ preferences. the only rct that compared cr to tau in patients with relevant negative symptoms found a moderate effect favoring cr (mueller et al., 2017). the similar effect sizes for cbt vs. tau (-0.46) and cr vs. tau (-0.59) along with the finding of no significant difference between cbt and cr suggest that cbt and cr may be similarly efficacious. as no alternative psychological treatments have been investigated for this target population compared to cbt and cr, at present we can only conclude that adding a specific psychological treatment for negative symptoms (in this case cbt or cr) to standard care reduces relevant negative symptoms more than standard care alone. nevertheless, the findings from our secondary outcome analyses suggest at least some degree of specificity of treatment effects for cbt and cr. for example, cbt but not cr was efficacious in reducing amotivation. in contrast, cr but not cbt had an effect on reduced expression. moreover, as will be discussed below, bpt could be specifically efficacious to improve reduced expression but might not have an effect on amotivation. even though these findings are certainly tentative, they highlight that there may be treatments that are specifically efficacious for the different subcomponents of negative symptoms. therefore, future research should account for the distinction of the negative symptom subcomponents more explicitly and make these subcomponents the primary outcomes. two of the more recent studies in our meta-analysis already adopted this approach (favrod et al., 2019; pos et al., 2019). an important question then is, whether our findings accord with published treatment guidelines. for example, based on previous rcts and meta-analyses in schizophrenia samples (e.g., granholm, holden, link, & mcquaid, 2014; kurtz & mueser, 2008; turner et al., 2018, 2014), the german treatment guidelines (dgppn e.v., 2019; lincoln et al., 2019) recommend social skills training (sst) for negative symptoms. as we did not identify any study that tested sst in the target group, we argue that there is little evi‐ dence to support this recommendation. therefore, methodologically rigorous tests of sst in patients with relevant negative symptoms are needed. in this regard, it is promising that we found one registered rct testing cognitive behavioral social skills training in people with relevant negative symptoms (twamley, granholm, & clinicaltrials.gov, 2014). the case of bpt, as for example recommended in the british nice guidelines (nice, 2014) is more complex. in our synthesis, we did not find clear evidence that bpt re‐ duces negative symptoms. one important reason is that the large and methodologically rigorous bpt trial that we included and which was published after the last update of the nice guidelines (priebe et al., 2016b) mostly did not show significant results. nevertheless, in line with other trials on bpt (martin, koch, hirjak, & fuchs, 2016; psychological treatments for negative symptoms 16 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ röhricht & priebe, 2006), the priebe et al. (2016b) study found a significant effect for the reduction of expressive negative symptoms that did not show up in our meta-analysis for methodological reasons (i.e. the effect in priebe et al. (2016b) only showed up as a time by group interaction). in the light of very limited treatment options for the expressive subcomponents of negative symptoms, bpt should be further explored as one potentially specific approach for this aspect of negative symptoms. another result of our meta-analysis is that we found a small albeit significant effect for tau on global negative symptoms from pre to post treatment (k = 7, g = -0.20). this somewhat confirms a recent meta-analysis by savill et al. (2015), who showed that negative symptoms decline over time in tau conditions with a less than small, yet significant, effect (k = 15, es = -0.15). together, these findings suggest that current routine care has a negligible impact on relevant negative symptoms. several strengths and limitations need mentioning. due to space restrictions, we have provided a detailed discussion of these issues in the supplementary materials. the limitations discussed include the heterogeneity across primary studies regarding negative symptom assessments and the negative symptom inclusion criteria. we also address the potential lack of fit between interventions and current etiological models of negative symptoms. finally, we address strengths and limitations that arise from our strict inclusion criterion that primary studies needed to have employed an entry criterion for negative symptom severity. this includes a discussion of power issues due to the small number of primary studies. we also address how our study relates to the issue of “pseudo-specificity” in research on negative symptom treatments (cf., fusar-poli et al., 2015). having these caveats in mind, this meta-analysis indicates that routine care has a negligible effect on negative symptoms, whereas there is some evidence for the efficacy of cbt and cr. however, the effects were instable (especially for cbt) and the effect sizes leave room for improvement. additionally, some approaches may be more promis‐ ing to reduce motivational negative symptoms (cbt) and some more promising to reduce expressive negative symptoms (cr, bpt). therefore, research efforts should be held up for the targeted and symptom-specific psychological approaches to reduce negative symptoms in order to place treatment recommendations on a firmer foundation. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors. competing interests: tml is first author of german treatment manuals for cbtp. all other authors declare that they have no conflict of interest. acknowledgments: we thank paul grant, dawn i. velligan, and rafael penadés for providing additional data and information necessary for the analyses. riehle, böhl, pillny, & lincoln 17 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://www.psychopen.eu/ supplementary materials the supplementary material contains formulae used for the calculation of effect sizes, additional results, and an in-depth discussion of strengths and limitations (for access see index of supplemen‐ tary materials below). index of supplementary materials riehle, m., böhl, m. c., pillny, m., & lincoln, t. m. 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(2008). cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. schizophrenia bulletin, 34(3), 523-537. https://doi.org/10.1093/schbul/sbm114 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. riehle, böhl, pillny, & lincoln 23 clinical psychology in europe 2020, vol.2(3), article e2899 https://doi.org/10.32872/cpe.v2i3.2899 https://doi.org/10.1017/s0033291714001147 https://doi.org/10.18637/jss.v036.i03 https://doi.org/10.1093/schbul/sbm114 https://www.psychopen.eu/ psychological treatments for negative symptoms (introduction) why yet another meta-analysis? method eligibility criteria literature search data extraction effect size computation at the levels of the individual studies effect size integration risk of bias analyses results study selection controlled post-treatment effects pre-post within group changes risk of bias analyses discussion (additional information) funding competing interests acknowledgments supplementary materials references change processes in cognitive therapy for social anxiety disorder delivered in routine clinical practice research articles change processes in cognitive therapy for social anxiety disorder delivered in routine clinical practice graham r. thew abc, anke ehlers acde, nick grey def, jennifer wild ac, emma warnock-parkes acde, rachelle l. dawson a, david m. clark acde [a] department of experimental psychology, university of oxford, oxford, united kingdom. [b] oxford university hospitals nhs foundation trust, oxford, united kingdom. [c] oxford health nhs foundation trust, oxford, united kingdom. [d] institute of psychiatry, psychology and neuroscience, king’s college london, london, united kingdom. [e] national institute for health research mental health biomedical research centre, south london and maudsley nhs foundation trust, london, united kingdom. [f] sussex partnership nhs foundation trust, worthing, united kingdom. clinical psychology in europe, 2020, vol. 2(2), article e2947, https://doi.org/10.32872/cpe.v2i2.2947 received: 2020-03-15 • accepted: 2020-05-05 • published (vor): 2020-06-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: graham r. thew, oxford centre for anxiety disorders and trauma, department of experimental psychology, university of oxford, the old rectory, paradise square, oxford ox1 1tw, uk. e-mail: graham.thew@psy.ox.ac.uk abstract background: most studies examining processes of change in psychological therapy for social anxiety disorder (sad) have analysed data from randomised controlled trials in research settings. method: to assess whether these findings are representative of routine clinical practice, we analysed audit data from two samples of patients who received cognitive therapy for sad (total n = 271). three process variables (self-focused attention, negative social cognitions, and depressed mood) were examined using multilevel structural equation models. results: significant indirect effects were observed for all three variables in both samples, with negative social cognitions showing the strongest percent mediation effect. ‘reversed’ relationships, where social anxiety predicted subsequent process variable scores, were also supported. conclusion: the findings suggest the processes of change in this treatment may be similar between research trials and routine care. keywords social anxiety, cognitive therapy, change processes, structural equation model, mediation this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i2.2947&domain=pdf&date_stamp=2020-06-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • the three process variables examined showed significant indirect effects on subsequent social anxiety. • there was evidence of a bidirectional relationship between process and outcome. • results are consistent with the theoretical model underpinning the treatment. • the change processes of this treatment in routine practice may be similar to those found in research trials. there is good evidence for the efficacy of psychological therapies in the treatment of mental health problems. however, there is a less clear understanding of the exact pro‐ cesses through which they operate. further research on mechanisms of clinical improve‐ ment has been highlighted as a significant need in clinical psychology (emmelkamp et al., 2014; holmes et al., 2018; kazdin, 2007). if we can determine which process variables are involved in producing clinical improvement, it may be possible to adapt therapies to place more emphasis on these, and to implement techniques that target them earlier in therapy, so as to increase the efficacy and efficiency of treatment. in social anxiety disorder (sad), there is a small but growing body of literature exploring process-outcome relationships in psychological therapy. the choice of process variables to be assessed is generally derived from theoretical accounts of sad, such as the cognitive model of clark and wells (1995), and the cognitive-behavioural model of rapee and heimberg (see hope, heimberg, & turk, 2006; rapee & heimberg, 1997). the clark and wells model specifies several anxiety-maintaining factors that are potential predictors of clinical change. these include negative social anxiety-related cognitions, avoidance and safety behaviours, and self-focused, evaluative attention. the rapee and heimberg model also highlights hypervigilance, avoidance and attentional bias towards perceived threat as potential mechanisms of anxiety maintenance. besides anxiety-main‐ taining factors, other variables such as working alliance, or measures of the degree of compliance with clinical techniques, could be examined. five studies, mostly focusing on cognitive-behavioural interventions (boden et al., 2012; calamaras, tully, tone, price, & anderson, 2015; goldin et al., 2014; gregory, wong, marker, & peters, 2018; hoffart, borge, sexton, clark, & wampold, 2012), have shown evidence that changes in negative cognitions and threat appraisals were as‐ sociated with improvements in social anxiety, while two studies (mörtberg, hoffart, boecking, & clark, 2015; niles et al., 2014) did not find evidence of an association be‐ tween changing negative cognitions and outcome. evidence of changes in self-focused at‐ tention being associated with clinical improvement was found in the study by mörtberg et al. (2015), and in both individual and group cognitive therapy (ct) in a study by hedman et al. (2013). two studies showed support for avoidance of social situations as change processes in ct for social anxiety 2 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ a predictor of outcome (aderka, mclean, huppert, davidson, & foa, 2013; hedman et al., 2013), and the study of participants’ use of exposure and thought records (hawley, rector, & laposa, 2016) also supported a predictive relationship for these factors. in contrast, the two studies analysing working alliance either did not find a mediation relationship (calamaras et al., 2015) or found that the alliance-outcome relationship was itself mediated by cognitive factors (hoffart et al., 2012). the one study investigating physiological anxiety symptoms did not find evidence of a predictive association with outcome (aderka et al., 2013), while the one study examining depression found a weak effect (moscovitch, hofmann, suvak, & in-albon, 2005). although it is promising that mediation and other predictive effects in treatments for sad are starting to emerge, there is a lack of consistency across the studies to date regarding which process variables, and which treatments, are examined. it is rare for two studies to examine the same process variables within the same treatment. in addition, the participant samples analysed in the studies are almost all drawn from randomised controlled trials (rcts), meaning there is a lack of research using data from routine clinical practice. datasets from such settings typically include a larger number of thera‐ pists, some therapists who are less experienced, and fewer participant selection criteria relative to rcts. in the same way that effectiveness studies in routine clinical settings complement efficacy studies, in that they can test whether findings from controlled research settings apply in routine practice (gunter & whittal, 2010; kettlewell, 2004; weisz, ng, & bearman, 2014), it can be argued that for a predictor to be considered reliable, it should operate similarly regardless of setting. it is therefore important to examine process-outcome effects within data from routine clinical practice. the present study therefore aimed to explore change processes during cognitive therapy for social anxiety disorder (ct-sad) based on the clark and wells (1995) model delivered in routine clinical practice, using data from an audit of clinical outcomes from a specialist national health service (nhs) anxiety clinic in london. to be consis‐ tent with previous literature, negative social cognitions and self-focused attention were examined as process variables, and were measured in the same way as in previous studies (e.g. hedman et al., 2013; mörtberg et al., 2015). these variables have a strong theoretical basis given their key roles within the clark and wells (1995) model. in addition, depressed mood, which is not a component of the cognitive model of sad, was investigated as an additional process variable to examine the specificity of any effects found using the other two theoretically-derived factors (see preacher, 2015). there is, however, a plausible rationale for changes in depressed mood being associated with improvements in social anxiety, in that a reduction in depressed mood over time may be accompanied by greater hopefulness and optimism about treatment and the future, leading to subsequent improvement in social anxiety outcomes. thew, ehlers, grey et al. 3 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ method participants data were drawn from an audit of clinical outcomes of psychological therapy for sad, which examined consecutive referrals to the centre for anxiety disorders and trauma, a uk nhs specialist clinic in london. the service receives referrals from general prac‐ titioners and community mental health teams. assessments were completed between may 2001 and august 2010. all assessments were conducted by a trained clinician and included the structured clinical interview for dsm-iv (scid-iv; first, spitzer, gibbon, & williams, 2002) to determine primary and comorbid diagnoses. the personality disorder screener questions of the scid-ii (first, gibbon, spitzer, williams, & benjamin, 1997) were also given, with further assessment undertaken as clinically indicated. all partici‐ pants met dsm-iv criteria for sad, with sad being judged to be the main problem by the assessing clinician. exclusion criteria were current psychosis, or dependence on alcohol or substances. across the audit period, 317 people were treated with ct-sad. three of these people were re-referred during the audit period and received a second course of treatment; only their first course of treatment was included in the analysis. files of seven people who received treatment were not available for data entry. to be included in the present studies, participants were required to have attended at least five treatment sessions and completed the weekly questionnaires on at least five occasions. this ensured a sufficient number of measurement points per participant to permit analysis of process variables over time. as 23 participants attended fewer than five sessions, and 13 completed insuffi‐ cient questionnaire data for analysis, the final sample size for the analysis of standard ct-sad was 271. these participants completed an average of 12.3 sessions (sd = 2.9). six participants (2%) had more than 18 sessions and the greatest number of sessions attended was 26. treatment extended over an average of 204.3 days (sd = 103.7). there were 69 partici‐ pants who received their treatment as part of research trials running at the time. some of the outcome measures used by the clinic were changed in september 2008 when the clinic joined the improving access to psychological therapies (iapt) programme (see clark, 2018). participants treated before (sample 1; n = 185) and after (sample 2; n = 86) this change in outcome measures were analysed separately. demo‐ graphic and clinical characteristics of both samples are shown in table 1. the audit was approved by the local ethics committee. change processes in ct for social anxiety 4 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ table 1 demographic and clinical characteristics participant variable sample 1 (n = 185) sample 2 (n = 86) total (n = 271) % female 48 52 49 mean age (sd) 32.2 (8.6) 33.2 (9.5) 32.5 (8.9) marital status n (%) married 19 (10.3) 22 (25.6) 41 (15.1) cohabiting 28 (15.1) 8 (9.3) 36 (13.3) widowed 1 (0.5) 0 1 (0.4) divorced 3 (1.6) 0 3 (1.1) separated 5 (2.7) 3 (3.5) 8 (3.0) single/never married 120 (64.9) 45 (52.3) 165 (60.9) not given 9 (4.9) 8 (9.3) 17 (6.3) ethnicity n (%) black 11 (5.9) 8 (9.3) 19 (7.0) caucasian 140 (75.7) 37 (43.0) 177 (65.3) indian 2 (1.1) 2 (2.3) 4 (1.5) pacific asian 1 (0.5) 0 1 (0.4) other 6 (3.2) 0 6 (2.2) not given 25 (13.5) 39 (45.3) 64 (23.6) highest qualification n (%) doctoral degree 7 (3.8) 2 (2.3) 9 (3.3) masters degree 18 (9.7) 11 (12.8) 29 (10.7) professional qualification 15 (8.1) 5 (5.8) 20 (7.4) bachelors degree 71 (38.4) 27 (31.4) 98 (36.2) a levels 31 (16.8) 12 (14.0) 43 (15.9) gcses 23 (12.4) 9 (10.5) 32 (11.8) none 12 (6.5) 3 (3.5) 15 (5.5) other 7 (3.8) 3 (3.5) 10 (3.7) not given 1 (0.5) 14 (16.3) 15 (5.5) employment status n (%) unemployed 33 (17.8) 11 (12.8) 44 (16.2) full time 103 (55.7) 52 (60.5) 155 (57.2) part time 20 (10.8) 6 (7.0) 26 (9.6) self-employed 4 (2.2) 5 (5.8) 9 (3.3) sick leave 3 (1.6) 1 (1.2) 4 (1.5) retired 0 2 (2.3) 2 (0.7) student 17 (9.2) 2 (2.3) 19 (7.0) homemaker 2 (1.1) 1 (1.2) 3 (1.1) freelance 0 1 (1.2) 1 (0.4) thew, ehlers, grey et al. 5 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ participant variable sample 1 (n = 185) sample 2 (n = 86) total (n = 271) compassionate leave 0 1 (1.2) 1(0.4) not given 3 (1.6) 4 (4.7) 7 (2.6) mean age of sad onset in years (sd) 19.3 (8.4) 19.1 (7.1) 19.3 (8.0) mean duration of sad in years at assessment (sd) 12.9 (9.5) 13.9 (10.8) 13.2 (9.9) % prescribed psychotropic medication 30 25 29 treatment all participants received individual ct-sad as described in clark et al. (2006). manuals, videos of workshops, and other therapist support materials are available at https://oxca‐ datresources.com (oxford centre for anxiety disorders and trauma, 2019). the standard structure of treatment used in rcts comprises 14 weekly sessions, followed by up to three booster sessions at monthly intervals. for the present participants treated in rou‐ tine clinical practice, this structure was followed in most cases, but for some, adjustments in the number and spacing of sessions were made due to clinical need. end of treatment outcomes were taken from the last attended session. therapists therapists were mental health professionals with a range of professional backgrounds including clinical psychology, counselling psychology, nursing and/or specialist cbt training. some of the therapists were on training placements within the service (trainee clinical psychologists, trainee high intensity therapists, and specialist psychiatry regis‐ trars). a total of 22 therapists treated the participants in sample 1, and 36 therapists for the participants in sample 2. the number of participants seen by each therapist ranged from 1 to 24. session-by-session measures self-focused attention this was measured using the mean score of the two self-focused attention items in the social phobia weekly summary scale (spwss; clark, 1995, available at https://oxcadatre‐ sources.com) where people provide a rating of their self-focused attention in general, and in situations they found difficult, over the past week. the full six-item scale also elicits ratings of avoidance, anticipatory worry, and post-event rumination over the previous week, along with an overall rating of social anxiety. all items are rated on 0-8 likert scales, with total scores ranging between 0 and 48. the spwss has been shown to be sensitive to treatment effects and has good internal consistency (clark et al., 2006; clark et al., 2003). cronbach’s alpha in the present sample for the two self-focused attention items was .75 at baseline and .89 at end of treatment. change processes in ct for social anxiety 6 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://oxcadatresources.com https://oxcadatresources.com https://oxcadatresources.com https://oxcadatresources.com https://www.psychopen.eu/ negative social cognitions the social cognitions questionnaire (scq; oxford centre for anxiety disorders and trauma, 2019; wells, stopa, & clark, 1993) was used, which presents 22 negative social cognitions, each of which is rated for both the frequency with which it occurred in the last week when the respondent was anxious (rated from 1 = “thought never occurs” to 5 = “thought always occurs when i am nervous”), and the degree to which they believe the thought to be true when it occurs (rated from 0 = “i do not believe this thought”, to 100 = “i am completely convinced this thought is true”). mean scores are calculated for frequency (range 1-5) and belief (range 0-100) with higher scores indicating more negative social cognition. cronbach’s alpha in the present sample was .90 (baseline) and .96 (end of treatment) for the frequency subscale and .91 (baseline) and .97 (end of treatment) for the belief subscale. for the present studies the frequency and belief subscales were standardised and averaged to produce a single composite z score. depressed mood for sample 1, depressed mood was measured using the beck depression inventory (bdi; beck & steer, 1993). cronbach’s alpha in the present sample was .91 at baseline and .94 at end of treatment. for sample 2, depressed mood was measured using the patient health questionnaire – 9-item version (phq; kroenke, spitzer, & williams, 2001). cronbach’s alpha in the present sample was .88 at baseline and .92 at end of treatment. social anxiety for sample 1, social anxiety was measured using the social phobia weekly summary scale (clark et al., 2003; oxford centre for anxiety disorders and trauma, 2019), minus the two attention items. a total social anxiety severity score was computed from the items: overall rating of social anxiety, avoidance, anticipatory worry, and post-event rumination. cronbach’s alpha for the baseline and end of treatment scores were .74 and .91 respectively. for sample 2, social anxiety was measured using the social phobia inventory (spin; connor et al., 2000), a 17-item scale listing a range of sad-related problems, incorporating fear, avoidance, and physical symptoms. cronbach’s alpha for the baseline and end of treatment scores were .90 and .93 respectively. analysis a series of multilevel structural equation models (msem) were computed (see preacher, zhang, & zyphur, 2011; preacher, zyphur, & zhang, 2010) based on the analytic strategy of mörtberg et al. (2015), with total scores at each session (level 1) nested within participants (level 2). therapist was not included as a third level given the limited number of therapists1, and the variability in the number of participants seen by each therapist. for two-level models, data simulations have shown that sample sizes of 50 and thew, ehlers, grey et al. 7 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ above produce unbiased parameter estimates under a range of conditions (hox, maas, & brinkhuis, 2010). the number of elapsed days in treatment was used as the independent variable, and severity of social anxiety as the dependent variable (see figure 1). three process variables were assessed: 1) self-focused attention, 2) negative social cognitions; and 3) depressed mood. all variables were measured at level 1 following the mediation procedure described by bauer et al. (2006). to incorporate temporal precedence of the process variable (media‐ tor), lagged scores were used, where social anxiety scores at any given assessment point (time j) were regressed on the scores on the process variable at the previous assessment point (time j-1). social anxiety scores from the first week of therapy were therefore not included in the analysis due to the absence of prior scores on the process variable. social 1) maas and hox (2005) suggest group sizes over 50 at the higher level of multilevel models are most appropriate to avoid biased estimates. figure 1 simplified path diagram of multilevel structural equation model (msem) to test the indirect effect of time on scores on the social phobia inventory (spin) via one of three process variables note. filled circles indicate paths specified as random, and raised arrows indicate residuals. change processes in ct for social anxiety 8 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ anxiety data from all other available sessions were included, as the model incorporated time gaps between assessment points. models used robust maximum likelihood estima‐ tion (mlr). path a (regression of the process variable on the independent variable) and path c’ (regression of the dependent variable on the independent variable, in the presence of the process variable) were allowed to vary across participants and were therefore estimated as random, while path b (regression of the dependent variable on the process variable) was modelled as a fixed effect. this was done both to limit model complexity, and because the extent of between-subject variability in this relationship was not of primary interest in this study. to prevent the conflation of withinand between-sub‐ jects variance, independent and process variables were disaggregated into withinand between-level components via group mean centering. the participant (group) mean-cen‐ tered scores, and the participant mean scores across all timepoints therefore represented the within and between components of these variables, respectively, and were entered into the model separately (see hoffart, borge, & clark, 2016; preacher et al., 2010). this approach therefore permits the examination of within-subjects effects, controlling for between-subjects effects. to further examine the direction of the mediated effect, a series of models were computed which were identical to the models described above apart from the process and outcome variables, which were swapped. these therefore examined the ‘reversed’ relationship, using social anxiety at time j-1 as the potential mediator, and self-focused attention, negative social cognitions, or depressed mood at time j as the dependent variable. percent mediation (pm) of outcome by the process variable was calculated as an indicator of the strength of any indirect effects following the procedures described in kenny et al. (2003) and moscovitch et al. (2005); pm = 100 × [((ab + c’ + σab) c’) / (ab + c’ + σab)], where a, b, and c’ represent the respective path coefficients, and σab is the covariance between a and b. however, as path b was specified as fixed, and the covariance between a random and fixed path equals zero, the formula simplifies to pm = 100 × (ab / ab + c’), and the indirect effect to a × b (see mörtberg et al., 2015). analyses were performed using mplus version 7.0 (muthén & muthén, 1998-2015) and r version 3.4.3 (r core team, 2017) using the r package ‘mplusautomation’ (hallquist & wiley, 2018). inspection of the intraclass correlation coefficients for each model indicated sufficient between-subject variance to justify multilevel analysis (icc = .43 – .68). alongside p-values, confidence intervals of parameter estimates were reviewed to assess statistical significance. thew, ehlers, grey et al. 9 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ results baseline and end of treatment means and standard deviations for samples 1 and 2 are shown in table 2. significant decreases were observed across treatment on all of the measures assessed. table 2 baseline and end of treatment mean scores for samples 1 and 2 measure baseline m (sd) end of treatment m (sd) test statistic pre-post dcohen [95% ci] sample 1 (n = 185) spwss (4-item) 21.07 (5.04) 9.41 (7.18) t(183) = 22.23, p < .001 1.88 [1.63, 2.12] sfa 5.30 (1.48) 2.52 (1.75) t(176) = 18.59, p < .001 1.72 [1.47, 1.96] scq-c 1.38 (1.22) -0.91 (1.36) t(182) = 22.77, p < .001 1.77 [1.53, 2.01] bdi 18.32 (11.03) 7.94 (10.07) t(184) = 14.68, p < .001 0.98 [0.77, 1.20] sample 2 (n = 86) spin 41.52 (12.72) 21.71 (15.67) t(70) = 12.35, p < .001 1.39 [1.04, 1.74] sfa 4.82 (1.80) 2.92 (1.83) t(82) = 9.21, p < .001 1.05 [0.73, 1.37] scq-c 1.42 (1.29) -0.74 (1.34) t(77) = 15.34, p < .001 1.64 [1.29, 2.00] phq 11.17 (6.85) 5.21 (6.17) t(83) = 9.59, p < .001 0.91 [0.60, 1.23] note. baseline (pre) scores are taken from the initial assessment, or the session 1 score in cases where no assessment score was available. end of treatment (post) scores used the last available score. t statistics represent paired t-tests comparing baseline and end of treatment scores. spwss = social phobia weekly summary scale; sfa = self-focused attention; scq-c = social cognitions questionnaire – composite z score; bdi = beck depression inventory. spin = social phobia inventory; phq = patient health questionnaire. dcohen calculated using the pooled standard deviation as the denominator, calculated as sqrt((sd 2 initial + sd 2 post) / 2) (van etten & taylor, 1998). confidence intervals for dcohen were calculated using the hedges and olkin formula (see lee, 2016). cohen (1988) suggested that broadly, effect sizes of 0.2, 0.5, and 0.8 indicated small, medium, and large effects, respectively. sample 1 results of the msem models are shown in table 3. significant indirect effect estimates were observed for all three of the process variables assessed, indicating that self-focused attention, negative social cognitions, and depressed mood all mediated the effect of time on social anxiety. the significant and negative path a coefficients highlighted that as time in therapy increased, scores on the process variables decreased, with the significant, positive path b coefficients indicating that these lower scores predicted lower social anxiety at the following assessment. inspection of the percent mediation values indicated that negative social cognitions showed the strongest indirect effect. the reversed models, which swapped the social anxiety and process variables but re‐ tained the time-lag component, were also significant for the three process variables change processes in ct for social anxiety 10 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ assessed. these findings suggest that lower social anxiety scores were associated with subsequent reduced self-focused attention, reduced negative social cognitions, and im‐ proved mood at the following assessment. the percent mediation values for these models were similar across the three variables examined. table 3 model results for sample 1: unstandardised path coefficients, random slope variances, and indirect effect estimates parameter self-focused attention negative social cognitions depressed mood estimate se p pm estimate se p pm estimate se p pm a -0.013 0.001 < .001 -0.011 0.001 < .001 -0.035 0.003 < .001 b 0.821 0.100 < .001 1.922 0.162 < .001 0.162 0.034 < .001 c’ -0.039 0.002 < .001 -0.029 0.002 < .001 -0.044 0.003 < .001 vara < 0.001 < 0.001 < .001 < 0.001 < 0.001 < .001 0.001 < 0.001 < .001 varc’ 0.001 < 0.001 < .001 < 0.001 < 0.001 < .001 0.001 < 0.001 < .001 indirect effect ab -0.010 0.001 < .001 21 -0.021 0.002 < .001 42 -0.006 0.001 < .001 11 models reversing process variable and outcome a -0.053 0.003 < .001 -0.053 0.03 < .001 -0.053 0.003 < .001 b 0.096 0.008 < .001 0.073 0.005 < .001 0.159 0.030 < .001 c’ -0.006 0.001 < .001 -0.005 < 0.001 < .001 -0.022 0.003 < .001 vara 0.001 < 0.001 < .001 0.001 < 0.001 < .001 0.001 < 0.001 < .001 varc’ (see notes) (see notes) 0.001 < 0.001 < .001 indirect effect ab -0.005 0.001 < .001 46 -0.004 < 0.001 < .001 43 -0.008 0.002 < .001 28 note. n = 185. path a represents the effect of time on the process variable. path b represents the effect of the process variable on social anxiety score at the subsequent assessment (with time held constant). path c’ represents the effect of time on social anxiety score controlling for the effect of the process variable. path ab represents the indirect, or mediated, effect. the ‘reversed’ models swap the process and outcome variables. se = standard error, pm = percent mediation (i.e. the percentage of the total effect of time on outcome score that is accounted for by the mediated path ab), var = variance. due to lack of model convergence when the c’ path was specified as random, the reversed models for self-focused attention and negative social cognitions were run using a fixed c’ path therefore no variance is given. sample 2 results of the msem models for sample 2 are shown in table 4. these models also showed significant indirect effect estimates for all three of the process variables assessed (self-focused attention, negative social cognitions, and depressed mood), indicating that these variables mediated the effect of time on social anxiety as measured by the spin. the percent mediation values again indicated that negative social cognitions showed the strongest effect, though the strength of the indirect effect for self-focused attention was weaker in sample 2 compared to sample 1. the reversed models were significant for the three process variables assessed, with similar percent mediation values across the three thew, ehlers, grey et al. 11 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ variables, as was observed in sample 1. overall, the consistency of model results between the two samples was high, suggesting the sample 1 findings were replicated in sample 2. table 4 model results for sample 2: unstandardised path coefficients, random slope variances, and indirect effect estimates parameter self-focused attention negative social cognitions depressed mood estimate se p pm estimate se p pm estimate se p pm a -0.016 0.001 < .001 -0.016 0.001 < .001 -0.036 0.005 < .001 b 0.796 0.250 .001 3.199 0.448 < .001 0.428 0.123 < .001 c’ -0.128 0.011 < .001 -0.092 0.010 < .001 -0.127 0.011 < .001 vara < 0.001 < 0.001 < .001 < 0.001 < 0.001 < .001 0.001 < 0.001 < .001 varc’ 0.007 0.001 < .001 0.005 0.001 < .001 0.007 0.001 < .001 indirect effect ab -0.013 0.004 .003 9 -0.050 0.008 < .001 35 -0.015 0.005 .002 11 models reversing process variable and outcome a -0.158 0.012 < .001 -0.158 0.012 < .001 -0.159 0.012 < .001 b 0.030 0.007 < .001 0.040 0.005 < .001 0.078 0.021 < .001 c’ -0.010 0.002 < .001 -0.007 0.001 < .001 -0.021 0.005 < .001 vara 0.010 0.002 < .001 0.010 0.002 < .001 0.010 0.002 < .001 varc’ < 0.001 < 0.001 < .001 (see notes) 0.001 < 0.001 .001 indirect effect ab -0.005 0.001 < .001 32 -0.006 0.001 < .001 47 -0.012 0.004 .001 37 note. n = 86. path a represents the effect of time on the process variable. path b represents the effect of the process variable on social anxiety score at the subsequent assessment (with time held constant). path c’ represents the effect of time on social anxiety score controlling for the effect of the process variable. path ab represents the indirect, or mediated, effect. the ‘reversed’ models swap the process and outcome variables. se = standard error, pm = percent mediation (i.e. the percentage of the total effect of time on outcome score that is accounted for by the mediated path ab), var = variance. due to lack of model convergence when the c’ path was specified as random, the reversed model for negative social cognitions was run using a fixed c’ path therefore no variance is given. discussion this study aimed to examine whether self-focused attention, negative social cognitions, and depressed mood were associated with clinical improvement in ct-sad delivered in a routine clinic setting. negative social cognitions were supported as a mediator of clinical improvement in samples 1 and 2, showing the strongest percent mediation values of the three process variables assessed. the results therefore support the clark and wells (1995) model that underpins the treatment, and suggest that one of the reasons why people experience less social anxiety as they progress through treatment is that they are experiencing fewer and less-convincing negative thoughts about social situations. these findings are in line with a number of other studies investigating cognitions as a possible change processes in ct for social anxiety 12 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ process variable driving improvements in social anxiety (boden et al., 2012; calamaras et al., 2015; goldin et al., 2014; gregory et al., 2018; hoffart et al., 2012). self-focused attention was supported as a mediator of clinical improvement in both samples 1 and 2, suggesting that successfully shifting towards a more external focus of attention is one reason for the reduction in social anxiety as time in therapy increases. these findings are consistent with the three existing studies of self-focused attention (hedman et al., 2013; hoffart et al., 2016; mörtberg et al., 2015), all of which used the same treatment protocol and found process-outcome effects within rct datasets using analytic approaches similar to the present study. however, the results from both of the present samples indicated a weaker effect for self-focused attention compared to cogni‐ tions. this may indicate a distinction between the rct context and routine practice, for example in how the self-focus aspects of treatment were implemented. the clinical methods to address self-focused attention were further refined during the audit period, so it is likely that not all participants completed an ‘attention training’ session or had this consistently emphasised during treatment. in contrast, participants in the hoffart et al. (2016), hedman et al. (2013), and mörtberg et al. (2015) studies all completed a specific attention training session, and were supported to practise externally focused attention throughout therapy. it is possible that the lesser emphasis on targeting self-focused attention in the present samples, especially in comparison to targeting cognitions, may help to explain the differences observed in the strength of these effects. depressed mood showed significant mediation across samples 1 and 2, though the percent mediation values indicated a weaker relationship compared to negative social cognitions. the weaker and less consistent effects observed for this variable, which is not part of the theoretical model underpinning ct-sad, therefore lend some support to the specificity of the effects found for the theoretically-derived process variables. it is notable that for both samples 1 and 2, significant ‘reversed’ effects were observed across the three process variables, with similar or greater percent mediation values than in the forward models. this may indicate a cyclical relationship between process and outcome, where changes in negative cognitions and self-focused attention lead to subsequent reductions in social anxiety, and in addition, reductions in social anxiety have a beneficial effect in reducing negative social beliefs and perhaps reducing the perceived need to monitor and focus on yourself in social situations. strengths and limitations from a methodological perspective, the use of an additional process variable that is not part of the theoretical model being tested, and statistical methods such as msem to account for repeated-measures data and the betweenand within-person variance were strengths of the present work and should be considered for future studies in this area. reversed models are also not implemented consistently and are therefore recommended. while the division of the data into two samples was necessary given the different thew, ehlers, grey et al. 13 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ outcome measures used, it provided a helpful opportunity to assess whether the sample 1 results would replicate, and the similarity of the results between samples affords increased confidence in the findings. the self-focused attention models may be limited by the use of a two-item mean score to measure this construct. while this measure has been used previously (hoffart et al., 2016; mörtberg et al., 2015) future research could usefully develop more nuanced tools to monitor change in this variable over time. it remains possible that other process variables not assessed in the present studies could show strong associations with outcome; for example the use of safety behaviours would be hypothesised as a mediator based on the clark and wells (1995) model, but could not be examined here given this was not measured weekly. it is noted also that the present models only examine consecutive timepoints (usually weekly measures), so do not assess process-outcome effects on broader levels, for example delayed or cumulative effects of changes in process variables. conclusion overall, the present study found that in routine clinical practice, three process variables (negative social cognitions, self-focused attention, and depressed mood) were associated with subsequent social anxiety outcomes in ct-sad, with negative social cognitions showing the strongest and most consistent effect. the findings are therefore in line with the clark and wells (1995) model that underpins the treatment, and are consistent with rct-based research findings examining cognitive-behavioural therapies for sad. further work examining associations between process variables and clinical outcomes within datasets from routine clinical practice is recommended. change processes in ct for social anxiety 14 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ funding: the study was supported by the wellcome trust [102176 (grt); 069777 and 200796 (ae & dmc)], the nihr oxford biomedical research centre (grt), the oxford health nihr biomedical research centre (grt, ae), nihr senior investigator awards (ae, dmc), and the nihr mental health biomedical research centre at south london and maudsley nhs foundation trust and king’s college london. the views expressed are those of the authors and not necessarily those of the nhs, the nihr or the department of health. the funding sources had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors wish to thank the clients and therapists of the centre for anxiety disorders and trauma. we would like to thank kelly archer, georgina bremner, lauren canvin, siobhan commins, laura franklin, ruth morgan, hannah murray, jennifer readings, anna sandall, elizabeth woodward and yvette yeboah for their help with data collection and entry, margaret dakin, sue helen, and julie twomey for administrative support, magdalena janecka for statistical advice, and milan wiedemann for comments on an earlier version of the manuscript. author contributions: grt and dmc developed the data analysis concept. dmc and ae designed the data collection protocol and with ng, jw, and ewp supervised treatment and data collection. rd collated, entered, and cleaned the data. grt performed the analyses and drafted the paper, under supervision from ae and dmc who provided critical revisions. all authors reviewed and approved the final version of the paper for submission. references aderka, i. m., mclean, c. p., huppert, j. d., davidson, j. r., & foa, e. b. 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(1993). the social cognitions questionnaire. unpublished manuscript, university of oxford, oxford, united kingdom. change processes in ct for social anxiety 18 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://doi.org/10.1017/s1352465813000738 https://doi.org/10.1037/0022-006x.73.5.945 https://doi.org/10.1016/j.beth.2014.04.006 https://oxcadatresources.com http://www.webcitation.org/76nrqtxmt https://doi.org/10.1146/annurev-psych-010814-015258 https://doi.org/10.1080/10705511.2011.557329 https://doi.org/10.1037/a0020141 https://doi.org/10.1016/s0005-7967(97)00022-3 https://www.r-project.org/ https://doi.org/10.1002/(sici)1099-0879(199809)5:3<126::aid-cpp153>3.0.co;2-h https://doi.org/10.1177/2167702613501307 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. thew, ehlers, grey et al. 19 clinical psychology in europe 2020, vol.2(2), article e2947 https://doi.org/10.32872/cpe.v2i2.2947 https://www.psychopen.eu/ change processes in ct for social anxiety (introduction) method participants treatment therapists session-by-session measures analysis results sample 1 sample 2 discussion strengths and limitations conclusion (additional information) funding competing interests acknowledgments author contributions references evaluating a programme for intercultural competence in psychotherapist training: a pilot study research article evaluating a programme for intercultural competence in psychotherapist training: a pilot study ulrike von lersner a, kirsten baschin a, nora hauptmann a [a] department of psychology, humboldt university of berlin, berlin, germany. clinical psychology in europe, 2019, vol. 1(3), article e29159, https://doi.org/10.32872/cpe.v1i3.29159 received: 2018-08-21 • accepted: 2019-06-07 • published (vor): 2019-09-20 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: ulrike von lersner, department of psychology, humboldt-universität zu berlin, rudower chaussee 18, 12489 berlin, germany. e-mail: ulrike.von.lersner@hu-berlin.de abstract background: great cultural diversity among clients poses considerable challenges to mental health service providers. therefore, staff in the mental health sector needs to be adequately trained. to date, however, there is little empirical evidence regarding such training. the present pilot study evaluates the effect of a standardised training programme to improve the intercultural competence of therapists. method: intercultural competence and therapeutic relationship were measured three times (pre, post and follow-up) in n = 29 psychotherapists. a control group of n = 48 therapists was included at pre-test to control for covariables. results: the data show a significant increase in intercultural competence as well as an improvement in the therapeutic relationship. interestingly, this positive outcome extends to nonimmigrant clients. conclusion: the results confirm the assumption that culture is not limited to ethnic or national background but includes other dimensions such as age, gender and socioeconomic status which shape illness beliefs and expectations in the psychotherapeutic context. therefore, intercultural competence can be considered a general therapeutic skill that can be taught in short interventions like the one developed in this study. keywords evaluation, intercultural competence, diversity, psychotherapy, migration, awareness this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i3.29159&domain=pdf&date_stamp=2019-09-20 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • mental health services and practitioners need to be able to respond appropriately to increasing cultural diversity. • intercultural competence in psychotherapy can be enhanced by special training programmes. • these training programmes should focus on three components: intercultural knowledge, cultural awareness and culture-specific therapeutic skills. as a consequence of continuously increasing global mobility, as well as war and environ‐ mental migration, cultural diversity in western societies is growing rapidly. these pro‐ cesses are generating a degree of cultural diversity that requires mental health service administrators and practitioners to be able to respond appropriately. yet, in mental health services a considerably smaller percentage of immigrants is be‐ ing treated now than would be expected considering their overall population share. this has been explained by some as a product of lower service use by clients with a migration background (chen & rizzo, 2010; claassen, ascoli, berhe, & priebe, 2005; koch, hartkamp, siefen, & schouler-ocak, 2008; lindert et al., 2008; machleidt, behrens, ziegenbein, & calliess, 2007; ta et al., 2015). previous studies have also shown that insti‐ tutional barriers can hamper service uptake, including problems of language and other means of communication (claassen et al., 2005; kirmayer et al., 2011; yeo, 2004), per‐ ceived or expected discrimination, and structural and financial barriers (chen & rizzo, 2010; kirmayer et al., 2011). moreover, surveys of psychotherapists have shown a high degree of insecurity and helplessness in intercultural contexts, which can lead to a great‐ er likelihood of rejecting them as patients or to higher dropout rates (de haan, boon, de jong, & vermeiren, 2018; von lersner, 2015; wohlfart, hodzic, & özbek, 2006). the status quo, outlined above, suggests that an intercultural opening up of the men‐ tal health sector is urgently needed (kirmayer et al., 2011; machleidt et al., 2007), imply‐ ing an adaptation of institutional and organisational structures to the needs of immigrant clients. meanwhile, benish, quintana, and wampold (2011) in their meta-analysis have suggested that intercultural therapies have better outcomes when therapists include pa‐ tients’ culturally shaped explanatory models in treatment. furthermore, therapists should be better prepared for this group of clients through their professional training, in order to reduce insecurities and improve treatment outcomes in the long run (aggarwal, cedeño, guarnaccia, kleinman, & lewis-fernández, 2016; kirmayer, 2012; von lersner, baschin, wormeck, & mösko, 2016). evaluation of a program for intercultural competence 2 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ intercultural competence training even though intercultural competence appears to be of high relevance in clinical settings, evaluations of intercultural training in the psychotherapeutic context are unfortunately still very rare (kulik & roberson, 2008; mösko, baschin, längst, & von lersner, 2012). to our knowledge, there has been no such training evaluation in german-speaking areas. in the present study, we evaluated an intercultural training programme for therapists aimed at improving intercultural competence and therapeutic relationship. thus, we evaluated cognitive, skill-based and affective learning, as well as possible improvements in the therapeutic relationship, as components of behavioural change that should emerge after training. since the training programme was being conducted for the first time, our evaluation has the character of a pilot study. before discussing the intercultural training, the concept of culture as it is used in the present study needs to be defined. according to geertz (1973, p. 83), culture describes ‘a system of inherited conceptions expressed in symbolic forms by means of which men communicate, perpetuate, and develop their knowledge about, and attitudes toward, life’. thus, it can be said to refer to a set of values and norms shared by a group of people independently of their national or ethnic backgrounds. meanwhile, in its current usage, the term intercultural competence stands for a wide range of definitions associated with numerous practical implications (steinhäuser, martin, von lersner, & auckenthaler, 2014). however, a widely used concept in clinical settings is the one formulated by sue and sue (1990), which includes the following three dimensions: • awareness: exploration of and reflection on one’s own cultural embeddedness as well as its influence on perceptions of clients and the formation of the therapeutic relationship. • knowledge: knowledge of the cultural background of the client and possible implications for his or her worldview. • skills: the development of culturally sensitive intervention strategies and techniques. these three components, which can be said to constitute the basis of effective treatment in intercultural settings, represent a goal that is unlikely to be achieved in a one-off train‐ ing session; rather, it requires an active, ongoing process that practitioners have to go through over a longer period of time (guzder & rousseau, 2013). the model developed by sue and sue (1990) has also become the basis of national guidelines on intercultural competence in various countries and organisations, such as the multicultural guidelines of the american psychological association (2003, 2008) and the guidelines for training in cultural psychiatry (kirmayer et al., 2012). they have also been applied in a european strategy paper on intercultural competence in the mental health sector (bennegadi, 2009) and in the german guidelines for the training of intercul‐ tural competence of psychotherapists (von lersner et al., 2016). von lersner, baschin, & hauptmann 3 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ intercultural competence training can be carried out in multiple ways and can be quite heterogeneous with regard to target groups, duration, methods used and content, to name only a few dimensions. the majority of intercultural training evaluation studies in the health sector have been conducted with nursing staff and doctors as well as universi‐ ty students as subjects (delgado et al., 2013; khanna, cheyney, & engle, 2009). four systematic reviews, covering 69 studies from 1980 through to 2010, have ana‐ lysed the effectiveness of intercultural training for nursing staff and medical doctors mainly in the us (beach et al., 2005; chipps, simpson, & brysiewicz, 2008; lie, lee-rey, gomez, bereknyei, & braddock, 2011; price et al., 2005). beach et al. (2005) reported very good evidence of increased cultural knowledge among doctors and nursing staff as a re‐ sult of such training, a result that was replicated by chipps et al.’s (2008) study focusing on staff in rehabilitation centres. there is also good evidence from these studies that awareness and skills (see sue & sue, 1990) can change and improve through such train‐ ing. an evaluation of training programmes by kulik and roberson (2008) also reported large benefits in intercultural awareness and knowledge across target groups and train‐ ing settings, but little improvements on the skills dimension. regarding the quality of training schemes, both lie et al. (2011) and price and colleagues (2005) suggest that the quality of the evaluation studies examined was only low to moderate: most of them failed to control for confounding variables and effect sizes varied between zero and moderate. thus, in contrast to the large number of training schemes available, there is a conspicu‐ ous lack of transparently documented and published studies on their effectiveness. one concept that is widely used in intercultural competence training—and in the training programme evaluated in our study too—is the diversity approach. according to this perspective, there are six diversity dimensions that can influence perceptions of commonality and difference and are likely to lead to forms of discrimination: age; gender; sociocultural background, including migration history and skin colour; handicaps and skills; sexual orientation; and religion (van keuk, ghaderi, joksimovic, & david, 2011). diversity training can focus on one or more of these dimensions, implying that cultural background is only one possible dimension. participants should learn to be aware of the different types of diversity among their clients and how to deal with them in a positive way. a meta-analysis of the effectiveness of diversity training by kalinoski et al. (2013) found significant effects on knowledge and skills but none on attitudes and awareness. their analysis of training methods and structural factors suggested that training sessions lasting 12−16 hours and applying active training methods such as role play, discussion or critical incident technique had the greatest effectiveness, with training spread over multi‐ ple sessions being more effective than one-session programmes. effective training should have a positive impact on the cultural competence of the therapist as well as improving the therapeutic process, wherein the therapeutic relation‐ ship is of special interest. norcross (2010, p. 113) defines the client–therapist relationship as ‘the feelings and attitudes that therapist and client have toward one another and how evaluation of a program for intercultural competence 4 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ these are expressed’. meanwhile, khanna and colleagues (2009) describe the therapeutic relationship within the intercultural therapeutic process as an important predictor of compliance and outcomes. therefore, the present pilot study focuses on this aspect as well. with regard to efficiency, it is also relevant to evaluate whether rather short inter‐ ventions, such as the one developed for the present study, can initiate such positive change. from the start, we assumed that our programme would have a positive impact on the intercultural competence of participants, and that these effects would be quantifiable across our three points of measurement—before, immediately after and three months af‐ ter participation—of the programme. we further hypothesised that having to consider in‐ tercultural issues during the programme would affect the therapeutic relationship in a beneficial way. as such an impact would probably only unfold with time (guzder & rousseau, 2013; kulik & roberson, 2008), we assumed that the effects would be most ob‐ servable during the follow-up analysis. further, as another goal of the pilot study was to assess whether the training programme could serve groups of therapists with different levels of experience, we included therapists in training as well as experienced therapists and analysed the effects of the training on them separately. we assumed that participants would benefit from the training regardless of their level of therapeutic experience; that is, that therapists in training would benefit from the programme in a comparable manner to that of experienced therapists. method study design data were collected in berlin as part of a project conducted in the department of psycho‐ therapy and somatopsychology at humboldt university of berlin, in collaboration with the department of medical psychology of university medical centre hamburg-eppen‐ dorf, from october 2013 until march 2014. the project was funded by the european inte‐ gration fund (eif) and ethical approval for the study was given by the ethical review board of the department of psychology at humboldt. the conceptual underpinnings of the training programme evaluated in this study were based on the guidelines for inter-/transcultural competence training of psychothera‐ pists, which were developed during a previous project by our workgroup (von lersner et al., 2016). data were acquired before (pre-), immediately after (post-) and three months after (follow-up) the training programme. participants were recruited through mailing lists of educational institutions for clini‐ cal psychologists and psychological associations in berlin. we included five institutes for cognitive behavioural therapy as well as five for psychoanalysis and depth psychology. von lersner, baschin, & hauptmann 5 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ the main inclusion criterion for participation in the training programme was having had professional training in psychotherapy for adult clients. therapists who were still in training had to have passed on to the practical stage and be treating clients under super‐ vision. a control group that did not participate in the programme was polled online dur‐ ing the pre-measurement phase. participation in both groups was voluntary, based on in‐ formed consent and without any incentives or remuneration. unfortunately, as we re‐ cruited participants through mailing lists, we were not able to track a reliable response rate. figure 1 illustrates the flow of participants in the course of the study. figure 1. flow of participants. evaluation of a program for intercultural competence 6 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ implementation of the training programme before implementation of the training programme, a pilot training session was carried out with psychology students. subsequent adjustments were made for the final training manual which would guide the training programme analysed here. the intervention took place in berlin and consisted of two consecutive days of train‐ ing—16.5 hours in total. three weeks later, an additional, one-day refresher session was carried out consisting of six units of 45 minutes each (4.5 hours total). experienced thera‐ pists and therapists in training received separate training circuits, which were run by ex‐ perienced intercultural trainers from the project team. programme content the learning objectives defined in the aforementioned guidelines for intercultural compe‐ tence (von lersner et al., 2016) formed the basis of the content of the training programme. as recommended by hager, patry, and brezing (2000), an outline of the training pro‐ gramme was discussed by an expert panel (consisting of the project team and four expe‐ rienced intercultural trainers from the university medical centre hamburg-eppendorf and the transcultural centre in stockholm), and subsequent adaptations incorporated in‐ to the final version by the project team. table 1 provides a brief overview of the different aspects of intercultural competence covered by individual modules of the programme. in terms of the didactic methods employed, input lectures, self-reflective exercises, critical incident technique, plenary discussions and role play were included. table 1 overview of the training modules module content culture e.g. definition of culture in the personal and therapeutic context, transcultural competence, ethnocentrism, diversity migration e.g. information on facts and figures on migration pathways, stressors & resources, political framework experiencing cultural foreignness in everyday life e.g. personal experiences of cultural foreignness, stereotypes & prejudices, individual norms and values, discrimination working with cultural brokers and interpreters e.g. the meaning of language in the therapeutic process, language barriers, rules for the inclusion of interpreters in the therapeutic setting von lersner, baschin, & hauptmann 7 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ module content psychometric testing & classification of mental disorders e.g. opportunities and limitations of culture-sensitive testing, epidemiology of mental disorders in different cultural settings, culture-specific symptom presentation, cultural concepts of distress in dsm-5 exploration and anamnesis e.g. cultural formulation interview, culture-specific explanatory models of mental illness experiencing cultural foreignness in the clinical setting e.g. critical incidents booster session (three weeks later) e.g. supervision, clarification of outstanding questions, identification of ‘cultural pitfalls’ (auernheimer, 2002) on the basis of own examples measures sociodemographic data basic variables regarding the sociodemographic background of participants—gender, age, migration background, therapeutic approach and first language—were recorded. further, information regarding prior experience of intercultural competence training as well as level of personal interest in the topic was collected. personality traits in order to assess the influence of the personality trait of openness, the survey also inclu‐ ded the short version of the big five inventory (bfi-10; rammstedt & john, 2005), which measures the big five personality dimensions using just two items for each of them. rammstedt (2007) reports satisfactory values for the test’s quality criteria, and the items on openness exhibit moderate values for retest reliability (rtt = .62). intercultural competence the intercultural competence of participants was measured via the widely used four-di‐ mension multicultural counseling inventory (mci; sodowsky, taffe, gutkin, & wise, 1994). the mci is based on the three dimensions of intercultural competence formulated by sue and sue (2012)—knowledge, awareness and skills—but also seeks to capture an ad‐ ditional, fourth dimension: the multicultural therapeutic relationship. this four-factor structure allows single scores to be calculated for each of the dimensions as well as an overall sum score for intercultural competence. the 40 items of the mci comprise state‐ ments about counselling and therapy in intercultural settings. participants are asked to respond on a five-point likert scale, ranging from 1 = ‘very inaccurate’ to 5 = ‘very accu‐ rate’. for the present study, the mci was translated into german via the back-translation evaluation of a program for intercultural competence 8 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ method (brislin, 1970) and adapted linguistically from counselling to therapeutic settings. the mci meets the requirements for questionnaires in terms of reliability (.71 ≤ α ≤ .90) as well as validity. in our sample, it had a cronbach’s alpha α = .88 at t1, α = .88 at t3 and α = .89 at t4, which represent good values. cronbach’s alphas for the subscales were as follows: αrelationship = .68, αawareness = .78, αknowledge = .85 and αskills = .79 at t1; αrelationship = .63, αawareness = .80, αknowledge = .80 and αskills = .76 at t3; and, αrelationship = .67, αawareness = .82, αknowledge = .79 and αskills = .84 at t4. therapeutic relationship in addition to the multicultural therapeutic relationship dimension of the mci, a closer examination of the therapeutic relationship was achieved using the german version of the scale to assess the therapeutic relationship in community mental health care, clinician version (star-c; mcguire-snieckus, mccabe, catty, hansson, & priebe, 2007). the self-report star-c questionnaire consists of 12 items that seek to evaluate the quali‐ ty of the therapeutic relationship from the perspective of the therapist. it consists of three factors: 1) positive collaboration, 2) positive clinician input and 3) emotional diffi‐ culties. participants rated the therapeutic relationship separately for their clients with and without a migration background. retest reliability of the german version is r = .54, which is satisfactory (gairing, jäger, ketteler, rössler, & theodoridou, 2011). in our sam‐ ple, cronbach´s alphas were as follows: αstar_german clients = .67 and αstar_immigrant clients = .42 at t1; αstar_german clients = .64 and αstar_immigrant clients = .45 at t3; and, αstar_german clients = .64 and αstar_immigrant clients = .62 at t4 which reflect moderate to poor values. figure 2 gives an overview of the research design and the measures used at different sections of the study. evaluation at t1 and t4 was carried out online, whereas at t2 and t3 data was collected in a paper and pencil format. figure 2. overview of the research design. note. ig = intervention group. cg = control group. von lersner, baschin, & hauptmann 9 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ statistical analysis data analysis was carried out using spss (version 22.0). in order to compare characteris‐ tics of the intervention and the control group, between-subject descriptive variables were compared using independent-sample t-tests or wilcoxon rank-sum tests for continuous data and chi-square analysis for categorical data. within-subject descriptive variables were compared using either paired-sample t-tests or wilcoxon signed-rank tests, depend‐ ing on data level. internal consistency of the star-c, bfi and mci variables and therefore the reliabili‐ ty of the measures used in this study was examined by calculating cronbach’s alpha for the pre-, postand follow-up total scores. in order to control for possible selection bias for the variables of prior intercultural competence (mci pre) and prior knowledge, as well as proportion of immigrant clients, personal interest and openness, univariate anovas were carried out. post-hoc tests us‐ ing bonferroni correction allowed us to localise the effects. further, to calculate the influence of the training programme on intercultural compe‐ tence the friedman test was used. for localisation of the effects over time, wilcoxon signed-rank tests were applied to non-parametric data and t-tests to parametric data. meanwhile, interaction between time and status of participants (trainee vs. experienced therapist) was examined in a manova with repeated measures. throughout the whole study, effect size is reported as cohen’s d, r and ω. an alpha of .05 was used to define statistical significance in all analyses, and power analysis was carried out using g*power (faul, erdfelder, lang, & buchner, 2007). results sample characteristics at t1 the intervention group consisted of 35 participants. table 2 shows demographic characteristics of this group in comparison to the control group. statistical analysis showed significant differences between the groups in terms of age and therapy method with the control group being younger and containing a larger percentage of cbt thera‐ pists. evaluation of a program for intercultural competence 10 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ table 2 demographic variables of training group and control group at t1 intervention group (n = 35) control group (n = 48) demographic variables n % n % p gender .55 female 31 88.6 42 88.0 male 4 11.4 6 12.0 age .01 21 – 30 years 8 22.9 18 37.5 31 – 40 years 10 28.6 23 47.9 41 – 50 years 9 25.7 5 10.4 51 – 60 years 5 14.3 2 4.2 > 61 years 3 8.6 0 0.0 therapy method < .001 cbt 18 51.4 45 93.8 psychoanalysis 14 40.0 3 6.3 no information 3 8.6 previous intercultural training .34 yes 3 8.6 8 16.7 no 32 91.4 40 83.3 proportion of immigrant clients in daily practice .70 < 10% 14 40.0 19 39.6 10 – 30% 13 37.1 19 39.6 30 – 60% 4 11.4 7 14.6 60 – 90% 2 5.7 2 4.2 > 90% 2 5.7 1 2.1 immigrant background .35 yes 14 40.0 14 29.2 no 21 60.0 34 70.8 note. cbt = cognitive behavioural therapy. *p ≤ .05. **p ≤ .01. the whole training programme and evaluation was completed by n = 24 participants, 33% of whom were between 31 and 40 years old and 82% female; 58% were trained (or still in training) in cbt; and 13% had previously participated in intercultural training programmes lasting on average six hours. regarding prior experience of immigrant cli‐ ents, a quarter of participants reported that immigrants made up about 30% of their clien‐ tele, whereas the remaining participants treated significantly fewer. furthermore, 38% of von lersner, baschin, & hauptmann 11 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ participants had a migration background themselves, meaning that either they them‐ selves or one of their parents had immigrated to germany (federal statistics office, 2016). prerequisites and verification of selection bias the verification of differences between the intervention and control groups before train‐ ing revealed no significant differences in terms of intercultural competence before train‐ ing (mci-pre), t(68.53) = -1.35, p = .183, proportion of immigrant clients, h = 2.739, p = .434, χ2(4) =3.01, p = .556, or openness (w = 726.5, p = .361). however, there were significant differences between the intervention group and control group regarding inter‐ est (w = 1509.5, p < .001) and prior intercultural knowledge (w = 261, p < .001). within groups, i.e. between trainees and therapists, no significant differences in mean values were detected. intercultural competence table 3 shows the development of intercultural competence over time by presenting the results of the four subscales as well as the total score for the mci. table 3 intercultural competence on the mci over the course of the training sub-scale of the mci pre post follow-up prepost prepostt1 t3 t4 follow-up follow-up m sd m sd m sd d d d skills 3.80 0.51 3.75 0.51 3.93 0.40 -.10 .28** .39* awareness 3.09 0.86 3.32 0.67 3.33 0.74 .35* .30* .01 therapeutic relationship 3.39 0.46 3.38 0.47 3.54 0.31 -.02 .38 .40** knowledge 3.22 0.58 3.51 0.50 3.64 0.48 .54* .79** .27 total score 3.41 0.46 3.52 0.30 3.62 0.33 .28* .53** .32* *p ≤ .05. **p ≤ .01. the data indicate a significant effect of time as a variable across both groups (experi‐ enced therapists and therapists in training, χ2(2, n = 24) = 17.70, p < .01, ω = .86). the wilcoxon signed-rank test revealed significant changes between all three measurement times (pre to post: z = -3.29, p < .01, φ =.67, 1 β = .43; postto follow-up: z = -2.29, p < .001, φ =.47, 1 β =.44; pre to follow-up: z = -4.00, p < .01, φ =.82, 1 β =.79). significant changes on the dimensions of awareness and knowledge occurred immediately after training, whereas values for skills and therapeutic relationship increased significantly at follow-up. the status of trainees had no influence on training outcomes, meaning that evaluation of a program for intercultural competence 12 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ experienced therapists and therapists in training benefitted from the training programme to the same degree, f(2, 44) = 2.23, p = .12, η2 = .09. the therapeutic relationship, as seen from the perspective of the therapist, was inves‐ tigated in further detail using star-c. thus, participants were asked at t1, t3 and t4 to rate their therapeutic relationships with their non-immigrant and immigrant clients, sep‐ arately. statistical analysis revealed significant improvement in the therapeutic relationship with non-immigrant clients from t1 to t3, t(28) = -1.73, p = .047, and a clear trend toward significant change from t1 to t4, t(24) = -1.47, p = .076, and t3 to t4, t(22) = -0.43, p = .334. yet, in contrast, no significant changes were observed with immigrant clients, t1 to t3: t(28) = -0.58, p = .284, t1 to t4: t(24)= -1.40, p = .086, and t3 to t4 t(22) = -0.82, p = .210 (see table 4). table 4 therapeutic relationship over the course of the training measured with star-c therapeutic relationship pre post follow-up prepost prepostt1 t3 t4 follow up follow up m sd m sd m sd d d d non-immigrant clients 3.40 .39 3.47 .26 3.52 .25 .21 .37 .20 immigrant clients 3.35 .30 3.37 .25 3.46 .30 .07 .37 .33 discussion in this pilot study we evaluated an intercultural training programme for psychothera‐ pists, focusing particularly on changes over time in the intercultural competence of par‐ ticipants as well as the therapeutic relationship from the perspective of the therapist. in order to control for a possible selection bias among participants a control group was in‐ cluded at t1 and we measured variables such as interest in intercultural issues prior to training and prior knowledge and experience of immigrant clients, as well as work expe‐ rience. international evaluation studies point to a general effectiveness of intercultural com‐ petency training (benish et al., 2011; betancourt & green, 2010; kalinoski et al., 2013; kulik & roberson, 2008), and our first evaluation of one such training programme in ger‐ many follows these studies in its overall assessment. even though intercultural compe‐ tence training programmes for therapists existed prior to our study, no systematic evalu‐ ation had been carried out with this target group. applying our approach, intercultural competence as measured with the mci in‐ creased significantly. this was the case for the total score as well as the separate scores for each of the four dimensions of the inventory. von lersner, baschin, & hauptmann 13 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ our training programme also had an immediate effect on the dimensions of aware‐ ness and knowledge, as described by beach et al. (2005). in the domain of awareness, this implies, for example, reflecting on one’s own prejudices and examining stereotypes so as to develop better awareness of and openness to cultural diversity, and learning about the interplay between one’s own attitudes towards immigrant clients and the therapeutic process. meanwhile, increases in the domain of knowledge imply being better informed about the diversity of cultural groups, differences in cultural concepts of distress and styles of communication, and the use of cultural brokers in therapy. it may also include greater understanding of the socio-political contexts in which intercultural therapy takes place. these are areas of improved intercultural competence that can be absorbed rather quickly and immediately. in contrast, effects on the dimensions of skills and the therapeutic relationship, again as measured by the mci, only became evident at the three-month follow-up. as already presumed by kulik and roberson (2008), it seems that such changes only become preva‐ lent with direct interaction with clients; thus, these aspects can only be reliably evaluated after participants have returned to work rather than immediately after participation in the programme. campinha-bacote (2002) and guzder and rousseau (2013) describe the development of intercultural competence as an ongoing process in which trainees are constantly chal‐ lenged to be aware of and question their own cultural imprints, thereby becoming able to take their clients’ different cultural backgrounds into account in therapy. but critical analysis of one’s own values and norms, and the acquiring of new skills, are comprehen‐ sive and long-term developmental processes that do not happen overnight. interestingly, though, the results of the present study indicate that this process can be successfully ini‐ tiated through training programmes like the one presented here. our comparison of the study group and the control group revealed that groups did not differ in terms of intercultural competence before training, proportion of immigrant clients or openness but did differ in terms of interest and prior intercultural knowledge. we cautiously take this to assume that selection bias can thus be excluded, and that by and large training outcomes can be attributed solely to the training programme. at the same time, we have to consider that the sample of this pilot study was too small to carry out reliable regression analyses and to safely rule out a selection bias. this shortcoming could be addressed in future research by larger samples and the inclusion of a control group across all times of measurement. one reason for the positive outcome of the programme could be the teaching meth‐ ods used. according to kalinoski et al. (2013), emotion-focused techniques such as critical incident technique, self-reflective units or active sessions can be more effective in inter‐ cultural training than simply imparting theoretical knowledge. the training programme that we developed, implemented and evaluated here includes a high proportion of emo‐ tion-activating methods throughout. in each module, a brief introduction is followed by evaluation of a program for intercultural competence 14 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ exercises in which participants can try out a new approach, discuss case vignettes or re‐ flect upon their own perspective. kalinoski et al. (2013) also demonstrated that training sessions distributed over two or more points in time tend to be more effective compared with longer, one-off interventions. as our training programme consisted of core or pri‐ mary training sessions spread over two days and an additional refresher session three weeks later, this could also account for the positive outcomes observed. besides effective training methods and structure, an additional success factor could be the greater specific‐ ity of the target group we selected compared with those participating in previous train‐ ing programmes, given that the programme was specifically both developed for and eval‐ uated by psychotherapists. as we have mentioned, there was no significant difference in programme outcomes between experienced therapists and therapists in training, suggesting that the pro‐ gramme is appropriate for all therapists regardless of level of experience. this is impor‐ tant for the practical applicability of the programme, as one can either use one pro‐ gramme for all therapists or develop separate curricula for participants of different expe‐ rience levels. the data suggest that the level of therapeutic experience is not important and thus that the training programme could be applied in postgraduate training as well as in trainings at a later point in therapists’ careers. this finding is in line with the guidelines for intercultural training (kirmayer et al., 2012, von lersner et al., 2016), which are based on the same assumption and define quality criteria for intercultural training across all groups of therapists. therapeutic relationship to assess the impact of the programme on the therapeutic process, we examined the per‐ ceived therapeutic relationship from the perspective of the participants over the course of the training. however, our study generated unexpected findings. overall, from the per‐ spective of the therapist, it seems that the therapeutic relationship benefits significantly from additional training. this was evident from the star-c post measurement as well as the relevant sub-domain of the mci at follow-up. yet, when participants were asked to rate the therapeutic relationship for non-immigrant and immigrant clients separately, significant improvement was observable for non-immigrant clients only. at first sight this would appear to be an unexpected outcome, given that the training programme fo‐ cused on intercultural issues with the intention that immigrants should particularly ben‐ efit from it. two possible reasons for this counter-intuitive effect are considered here. first, if we recall the definition of culture on which our training programme is based, this effect should not be so surprising. according to geertz (1973), culture consists of a set of values and norms shared by a group of people independently of their regional origin, a perspec‐ tive that is also linked to the concept of diversity introduced earlier in this paper. thus, during the training sessions regional origin and migration status were only two of nu‐ von lersner, baschin, & hauptmann 15 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ merous dimensions associated with culture and diversity. the results found here would seem to confirm this perspective: the quality of the therapeutic relationship improved for the majority of clients irrespective of their immigrant status, suggesting that factors such as openness, greater sensitivity towards clients’ socio-cultural background and better awareness of one’s own cultural norms and expectations can be beneficial to all clients. secondly, our sample size was rather small at t1 and had decreased further by the time of the follow-up, with the remaining therapists treating a rather small number of immigrants—at or below 30% of their clients—in their daily practice. thus, it may be due to the small size of this reference group that improvements in the therapeutic relation‐ ship between these immigrant clients and their therapists were simply not readily appa‐ rent. at the same time, our statistical results clearly point to a positive trend regarding the effect of the training on the therapeutic relationship. this appears to have been con‐ firmed when we used the mci—on which only the therapeutic relationship with immi‐ grant clients was rated—which reported significant improvement. nonetheless, we feel that, as a consequence of this pilot study, the evaluation should be repeated with a larger sample and more reliable measures in the future. internal consistencies of star-c scales were unsatisfactory and might have had a negative effect on the outcome values. consid‐ eration should also be given to modifying the training programme’s units on migrationrelated issues, so as to increase the likelihood that the therapeutic relationship with im‐ migrant clients benefits in the same way as that with non-immigrant clients did. further‐ more, in order to achieve robust positive training outcomes, guzder and rousseau (2013) recommended ongoing supervision following training. this could support participants in terms of strengthening their newly acquired skills and dealing with any uncertainties arising in the process, both of which may have a long-term, positive impact on the thera‐ peutic relationship. limitations and implications in addition to its positive outcomes, the study also has a number of limitations. because of the small sample size, some statistical trends may have been imperceptible that may have been significant with a larger dataset. also, effect sizes were relatively small. an‐ other result of the small sample size is that our findings cannot be confidently general‐ ised to all therapists. thus, further studies with larger sample sizes are urgently needed to underpin the effects found in this study. in the meantime, in view of the lack of studies in this field internationally, as well as in germany, our pilot data provide important infor‐ mation and empirical insights. the statistical values of the star-c were also unsatisfactory, potentially reducing the explanatory power of our findings on the therapeutic relationship. this limitation should be addressed in future research. nevertheless, significant effects of the programme were established in spite of the poor statistical values of the star-c and the small sample size. evaluation of a program for intercultural competence 16 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ hence, necessary further studies with larger samples are currently being carried out by our team. in line with kulik and roberson (2008), we believe that in future research it would be interesting to evaluate the impact of single training units or specific interventions. in ad‐ dition, shorter versions of the programme could be evaluated to increase the applicability of the approach in time-strapped clinical settings. turning to methodological issues, we feel that in the intercultural therapy context it is difficult using questionnaires to meas‐ ure awareness or attitudes as they may manifest instead at the behavioural level. hence, it might be useful to examine video recordings of therapy sessions—with real or simula‐ ted clients, before and after training intervention—to examine the behavioural level more directly. other indicators of behavioural change resulting from the training might be cli‐ ent satisfaction with treatment, duration of treatment, percentage of immigrant clients and immigrant-client drop-out rates. it would also appear to be necessary to evaluate cli‐ ent perspectives on the therapeutic relationship, especially those of immigrants. conclusions we conclude from this first evaluation of our intercultural training programme that it of‐ fers an effective intervention in terms of enabling psychotherapists to be more culturally sensitive towards clients from migration backgrounds. such effects were demonstrable to our satisfaction, even with our small sample. we suggest that this training programme— which is actually a rather brief intervention—could lead to significant improvements in therapeutic practice in crucial ways. funding: the authors received no financial support for the research, authorship, and/or publication of this article. competing interests: the authors declare no conflicts of interest. acknowledgments: the authors have no support to report. references aggarwal, n. k., cedeño, k., guarnaccia, p., kleinman, a., & lewis-fernández, r. 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(2011). transkulturelle kompetenz in klinischen und sozialen arbeitsfeldern. stuttgart, germany: kohlhammer. von lersner, u. (2015, january). kultursensibel aber wie? leitlinien für trainings transkultureller kompetenzen von psychotherapeuten und implikationen für die praxis. paper presented at the berliner psychiatrietage, berlin, germany. von lersner, u., baschin, k., wormeck, i., & mösko, m. (2016). kultursensibel, aber wie? leitlinien für trainings inter-/ transkulturelle kompetenzen in der aus-, fortund weiterbildung von psychotherapeut_innen. abschlusspublikation des projektes. retrieved from https://www.psychologie.hu-berlin.de/prof/the/leitlinien/view wohlfart, e., hodzic, s., & özbek, t. (2006). transkulturelles denken und transkulturelle praxis in der psychiatrie und psychotherapie. in e. wohlfart & m. zaumseil (eds.), transkulturelle psychiatrie & interkulturelle psychotherapie. interdisziplinäre theorie und praxis (pp. 142−168). heidelberg, germany: springer. yeo, s. (2004). language barriers and access to care. annual review nursery research, 22(1), 59-73. https://doi.org/10.1891/0739-6686.22.1.59 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. von lersner, baschin, & hauptmann 21 clinical psychology in europe 2019, vol.1(3), article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychologie.hu-berlin.de/prof/the/leitlinien/view https://doi.org/10.1891/0739-6686.22.1.59 https://www.psychopen.eu/ evaluation of a program for intercultural competence (introduction) intercultural competence training method study design implementation of the training programme programme content measures statistical analysis results sample characteristics prerequisites and verification of selection bias intercultural competence discussion therapeutic relationship limitations and implications conclusions (additional information) funding competing interests acknowledgments references how strongly connected are positive affect and physical exercise? results from a large general population study of young adults research articles how strongly connected are positive affect and physical exercise? results from a large general population study of young adults sarah d. pressman a, keith j. petrie b, børge sivertsen cde [a] department of psychological science, university of california irvine, irvine, ca, usa. [b] department of psychological medicine, university of auckland, auckland, new zealand. [c] department of health promotion, norwegian institute of public health, bergen, norway. [d] department of research & innovation, helse-fonna hf, haugesund, norway. [e] department of mental health, norwegian university of science and technology, trondheim, norway. clinical psychology in europe, 2020, vol. 2(4), article e3103, https://doi.org/10.32872/cpe.v2i4.3103 received: 2020-04-16 • accepted: 2020-11-13 • published (vor): 2020-12-23 handling editor: omer van den bergh, university of leuven, leuven, belgium corresponding author: sarah d. pressman, department of psychological science, university of california, irvine, ca 92697, usa. e-mail: pressman@uci.edu abstract background: previous research has shown a link between low positive affect (pa) and numerous physical and psychological well-being outcomes but, recent research has raised the possibility that this relationship may be driven by physical activity. thus, we were interested in exploring the paexercise connection by examining this relationship across differing levels of body mass and athleticism. we also looked at whether the item “active” that is used in many pa assessments was responsible for this effect. method: participants were part of the norwegian shot2018 national survey of 50,054 young adults (mean age = 23.2, 68.9% women), who completed electronic surveys about their exercise levels (duration, frequency and intensity) and affect. results: there was a clear and strong dose-response association between current state pa and the duration, frequency and intensity of exercise. for example, duration, magnitude, and slope effects were strongly driven by regular exercisers who had more than a 20-fold greater likelihood of being in the highest pa deciles compared to the least frequent exercisers. these dose-response connections replicated across both healthy and overweight bmis, as well as in elite athletes. removing the word “active” from the pa measure substantially reduced the size of this association, although the dose-response relationship remained. conclusion: the observed strong connections have critical implications for health researchers and clinicians, and point to a need to carefully consider what types of activities are most strongly tied to well-being. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i4.3103&domain=pdf&date_stamp=2020-12-23 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords positive affect, exercise, physical exercise, vigor, well-being highlights • there is a strong dose-response connection between exercise and positive emotion. • this pattern persists across a range of body types and athlete characteristics. • overlap between adjectives in affect and self-reported activity scales partially but not fully explains the connection. • past work showing benefits of happiness on health may be partially or primarily driven by activity, not emotion. it has long been established in both research and in common public knowledge that exercise can lead to greater positive affect (pa; arent, landers, & etnier, 2000; elavsky et al., 2005) as well as a reduction in negative affect (na; e.g., depression) (berger & owen, 1983; ströhle, 2009). while perhaps less recognised, it is also true that people high in pa engage in more physical exercise, as well as other positive health behaviors (boehm et al., 2018; cohen & pressman, 2006) indicating potentially bidirectional and strongly interconnected associations between these two variables (pasco et al., 2011). recent work even indicates the value of positive psychology interventions for increasing physical exercise in the context of illness and stress (huffman, millstein, et al., 2020). with the common goal of improving well-being in patient samples, it is critical that we more fully explore this question so as to better inform the value of positive psychology interventions in clinical populations. understanding the nature of this association becomes even more critical given the burgeoning literature connecting pa to better physical health across a wide range of domains (chida & steptoe, 2008; diener & chan, 2011; pressman, jenkins, & moskowitz, 2019). this includes longitudinal studies showing that pa predicts later health outcomes such as longevity (danner, snowdon, & friesen, 2001; pressman & cohen, 2012; willroth, ong, graham, & mroczek, 2020), infectious illness (cohen, alper, doyle, treanor, & turner, 2006; cohen, doyle, turner, alper, & skoner, 2003), heart disease (boehm & kubzansky, 2012), hiv severity (moskowitz, 2003) and other morbidities, even after accounting for critical covariates such as baseline health, medication use, negative affect, and other relevant factors. these types of studies, as well as recent positive psychology interventions showing improvements in later self-reported health (kushlev et al., 2020) and mental health outcomes in diseased samples (see review by pressman, jenkins, & moskowitz, 2019) point to the interesting possibility that pa can cause better health. this work has helped foster a new field of “positive health” research (seligman, 2008) as well as a burgeoning area of research trying to improve health via positive psychology positive affect and physical exercise 2 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ interventions (e.g., huffman et al., 2011; moskowitz et al., 2017, 2012). however, as discussed recently (pressman & cross, 2018), this literature becomes potentially less compelling and the focus on positive psychology interventions for health promotion less useful, if the reason that the pa-health association is largely due to the overlap between positive affect and physical exercise or fitness. that is, is pa correlated with better health primarily because happy people are also more physically active, and therefore healthier people? recent evidence confirming the causal effects of positive psychological interventions on increased exercise and general activity points to this possibility (e.g., huffman, feig, et al., 2019). this problem is compounded by the fact that when utilizing self-report scales, there can be a large overlap between physical health self-reports and pa self-reports. for example, many popular affect measures rely on adjectives like “active” and “energetic” to tap positive affect (mcnair, lorr, & droppleman, 1971; watson, clark, & tellegen, 1988). while these items do tap feelings of vitality important to the conceptualization of pa, critically, they also tap physical fitness and perceived health, as evidenced by frequently used self-reported health scales that use these types of items (kind, brooks, & rabin, 2005; mcnair et al., 1971). that is, if we take the word “active” (an item from the posi‐ tive and negative affect schedule [panas]; watson, clark, & tellegen, 1988) literally, then someone feeling active may also be more (physically) active. assessments do not distinguish between psychological versus physical forms of these vigorous feelings. this is problematic because to the extent that these measures represent the same underlying construct, it may be that feelings of happiness and joy are not predicting future health, but rather that it is health predicting health. we examined this issue recently in a large sample of over 5000 older adults (petrie et al., 2018). consistent with past pa-mortality research (chida, hamer, wardle, & steptoe, 2008), lower pa was associated with nearly double the mortality risk over a 16-year follow-up as compared to those with the highest pa. however, when unpacking the subtypes of pa responsible for this effect, we found that the association was primarily driven by the active item of the panas. this effect remained after accounting for the effects of the remaining panas items, demographics, and other important covariates. thus, it was not the more emotionally laden and less activity/arousal based items driving longevity but the panas activity item. while we did control for exercise in analyses as well, a limitation was that physical activity was assessed by only a single 3-point item asking about weekly level of exercise which did not allow us to look more closely at the nature of the pa (or felt activity) and exercise connection. this minimalist approach to assessing physical activity is echoed across the pa-health literature, including in studies showing that it is the high and not low energy compo‐ nents of pa most tied to reduced mortality (no activity control) (pressman & cohen, 2012) and decreased susceptibility to catching the common cold (included a simple measure of days exercised multiplied by effort) (cohen et al., 2003). this practice is also pressman, petrie, & sivertsen 3 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ common in studies on the connections between general pa and longevity where studies use single yes/no item regarding vigorous activity (steptoe & wardle, 2011) or no activity assessment (danner, snowdon, & friesen, 2001). unfortunately, it is also the case that many studies focused on physical activity do minimal assessments of pa, relying, for example on assessments of only one type of pa (e.g., vigor) or instead infer pa and wellbeing because of a drop in mental health problems like depression or anxiety symptoms (berger & motl, 2000; penedo & dahn, 2005; schinke, stambulova, si, & moore, 2017). thus, clearly there is a need to examine the association between these related varia‐ bles in more detail where pa can be compared to a range of activity markers across a large number of individuals. furthermore, given the concern about high pa simply being a marker of healthy fitness, this should be tested in those both high and low in fitness. this will enable a deeper understanding of the degree of connection association between fitness and high arousal pa, and more clarity about past research linking pa to health and mortality. to examine the extent to which pa and physical activity are overlapping constructs, we used data from the shot2018 study, a sample of over 50,000 norwegian young adults. we hypothesized that pa would be strongly associated with all measures of self-reported physical exercise including exercise frequency, intensity and duration. in addition, we consider several previously unexplored avenues. we capitalized on the survey questions that distinguished young people who self-identified as elite athletes. this allowed us to examine whether top athletes had significantly greater odds of also having higher pa, as well as whether the opposite would be true in individuals with high body mass index. the large size of the sample also enabled an examination of whether the pa-physical exercise connections holds between men and women and within each of the frequency, intensity and duration of exercise dimensions. finally, based on its importance in our past work, we explored to what extent the associations found in the above analyses changed when the word “active” was removed from the panas pa measure and the size of the association of feeling “active” with these exercise measures. method participants the shot study (an acronym for the norwegian name: studentenes helseog triv‐ selsundersøkelse [students’ health and wellbeing study]) is a national student survey for higher education in norway. details of the study have been published elsewhere (sivertsen, råkil, munkvik, & lønning, 2019). so far, three health surveys of the student population in norway have been completed (2010, 2014, and 2018). both the size and scope of the shot studies have expanded over time, and now include detailed informa‐ tion on both mental and physical health, quality of life, and health-related behaviours. positive affect and physical exercise 4 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ the shot2018 study was a joint effort between the three largest student welfare organizations in norway and the norwegian institute of public health (niph). the study was conducted between february 6th and april 5th, 2018, on all full-time norwegian stu‐ dents taking higher education (both in norway and abroad). the collection of the health survey was in close collaboration with all the student welfare organizations in norway. students were told that participation was completely voluntary, and that there were no penalties for not filling out the survey. eight percent of the sample were immigrants, defined as either the student or his/her parents being born outside of norway. the study protocol was approved by the regional committee for medical and health research ethics of western norway (no. 2017/1176/rek vest), whose directives are based on the declaration of helsinki. written electronic consent was obtained from all subjects included in this study. measures the positive and negative affect schedule (panas) the panas (watson et al., 1988) is a 20-item questionnaire which comprises two sub‐ scales, one that measures positive affect (pa) and the other which measures negative affect (na). the pa scale of interest here includes the terms interested, alert, enthusias‐ tic, excited, proud, inspired, strong, active, and attentive. participants are instructed to rate to what extent they experience each emotion right now, rated on a 5-point scale from “very slightly or not at all” (coded as 1) to “extremely” (coded as 5). a sum score is calculated with higher scores representing greater pa. for the purpose of the present study, the sum scores were divided into both tertiles and deciles separately for men and women. the cronbach’s alpha for the pa subscale in the current study was 0.91. the na subscale was not included in the shot study1. physical exercise the students were first presented with the following brief definition of physical exercise: “with physical exercise, we mean that you, for example, go for a walk, go skiing, swim or take part in a sport.” physical exercise was assessed using three sets of questions, assessing the average number of times exercising each week, and the average intensity and average hours each time: 1) “how frequently do you exercise?” (never, less than once a week, once a week, 2–3 times per week, almost every day); 2) “if you do such exercise as frequently as once or more times a week: how hard do you push yourself? (i 1) na was not the focus of the paper given our past work showing that it does not alter pa-health associations (petrie et al., 2018), extensive work on the independence of pa and na in the panas (watson et al., 1988), existing work on this sample examining na and mental health (grasdalsmoen, eriksen, lønning, & sivertsen, 2020), and the fact that the questions here target the potential overlap specific to panas pa (not na) and physical activity measurements. pressman, petrie, & sivertsen 5 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ take it easy without breaking into a sweat or losing my breath, i push myself so hard that i lose my breath and break into a sweat, i push myself to near-exhaustion); and 3) “how long does each session last?” (less than 15 minutes, 15–29 minutes, 30 minutes to 1 hour, more than 1 hour”. detailed results of college students’ exercise in the shot studies have been published elsewhere (grasdalsmoen, eriksen, lønning, & sivertsen, 2019). this 3-item questionnaire has previously been used in the large population-based nord-trøndelag health study (the hunt studies). previous validation studies (kurtze, rangul, hustvedt, & flanders, 2008) have demonstrated moderate-to-strong correlations between the questionnaire responses, and direct measurement of vo2max (r = 0.48), (an objective indicator of cardiorespiratory fitness) during maximal work on a treadmill, with actireg (r = 0.39), an instrument that measures pa and energy expenditure (ee), and with the international physical activity questionnaire (ipaq; r = 0.55). respondents were also asked if they considered themselves to be a “top athlete” (yes/no), and if so, how many hours per week they trained (drop-down menu: 0 to 40 hours). statistical analyses ibm spss statistics 25 for mac (spss inc., chicago, il) was used for all analyses. multino‐ mial logistic regression models were computed to assess the association between levels of physical exercise (independent variable; lowest level of the three physical exercise variables being the reference category) and deciles of pa (dependent variable; first decile being the reference category). being similar to binary logistic regression, multinomial regression is used when the dependent variable is nominal with more than two levels. results are presented as odds-ratios (ors) with 95% confidence intervals (95% cis). there was very little missing data on the pa items, with missing responses ranging from n = 167 (1.1%) to n = 1092 (2.6%), and hence techniques involving multiple imputations were not considered, and missing values were handled using listwise deletion. results descriptive statistics in terms of frequency of physical exercise, 24% of the sample reported being physically active “every day”, while 47% responded exercising “2-3 times per week”. moreover, 16%, 12% and 4% reported training “once a week”, “less than once a week”, or “never”, respectively. regarding the students’ reports of their average physical exercise intensity, 11% of the sample responded “i push myself to near-exhaustion”, while 71% reported “i push myself so hard that i lose my breath and break into a sweat” and 18% responded “i take it easy without breaking into a sweat or losing my breath”. on the item assessing the duration of each episode of physical exercise, 37% reported an average duration of positive affect and physical exercise 6 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ “more than 1 hour”, compared to 52%, 10% and 2% reporting “30 minutes to 1 hour”, “15–29 minutes”, and “less than 15 minutes”, respectively. the response distribution of the 10 pa items for both men and women are presented in figure 1. as shown, the proportion of students responding feeling “attentive” either quite a bit or extremely was 51%, followed by “determined” (48%) and “interested” (47%). in contrast, only 17% of the sample responded feeling “excited” quite a bit or extremely. there were only marginal sex differences in terms of the response distribution of pa items. figure 1 distribution of positive affect items in men and women in the shot2018 study women men women men women men women men women men women men women men women men women men women men ex ci te d a le rt pr ou d in sp ir ed en th us ia st ic a ct iv e st ro ng in te re st ed d et er m in ed a tt en ti ve very slightly or not at all a little moderately quite a bit extremely 21 % 19 % 12 % 6 % 15 % 12 % 13 % 9 % 12 % 10 % 14 % 10 % 12 % 9 % 6 % 5 % 8 % 7 % 6 % 4 % 25 % 26 % 23 % 17 % 22 % 20 % 22 % 19 % 19 % 18 % 21 % 19 % 19 % 17 % 16 % 12 % 16 % 16 % 14 % 13 % 38 % 38 % 39 % 38 % 32 % 32 % 32 % 32 % 34 % 34 % 27 % 27 % 28 % 29 % 32 % 29 % 28 % 30 % 29 % 30 % 15 % 15 % 23 % 34 % 27 % 30 % 28 % 33 % 30 % 32 % 29 % 32 % 33 % 35 % 39 % 45 % 36 % 36 % 40 % 41 % 2 % 2 % 2 % 5 % 4 % 6 % 5 % 7 % 5 % 7 % 8 % 12 % 9 % 10 % 6 % 9 % 12 % 12 % 11 % 12 % 0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 % note. sorted by proportion of students reporting each item “quite a bit” or “extremely”. is positive affect associated with physical exercise? the physical exercise characteristics according to sex-specific tertiles on the pa-scale are presented in table 1. low pa scores were more prevalent among those with lower exercise levels. these trends were present in a dose-response manner, and evident across all four physical exercise items (see table 1 for details). pressman, petrie, & sivertsen 7 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ ta bl e 1 a ge g ro up a nd p hy si ca l e xe rc is e c ha ra ct er is tic s by p os iti ve a ff ec t ( pa ) t er til e st ra tif ie d by s ex in th e sh ot 20 18 s tu dy , n or w ay , 2 01 8 g ro up c ha ra ct er is ti cs w om en m en pa l ow er te rt ile pa m id dl e te rt ile pa u pp er te rt ile pa l ow er te rt ile pa m id dl e te rt ile pa u pp er te rt ile a ge g ro up 18 -2 0 ye ar s 36 .0% 34 .8% 29 .2% 36 .5% 32 .8% 30 .7% 21 -2 2 ye ar s 33 .5% 34 .7% 31 .8% 31 .7% 34 .0% 34 .3% 23 -2 5 ye ar s 33 .7% 34 .0% 32 .3% 33 .8% 31 .8% 34 .3% 26 -2 8 ye ar s 35 .6% 32 .2% 32 .2% 39 .0% 30 .4% 30 .6% 29 -3 5 ye ar s 30 .3% 32 .7% 37 .0% 38 .8% 31 .9% 29 .3% ph ys ic al e xe rc is e (f re qu en cy ) n ev er 59 .5% 27 .2% 13 .3% 62 .5% 24 .4% 13 .1% le ss th an o nc e a w ee k 47 .1% 34 .2% 18 .8% 51 .6% 28 .2% 20 .1% o nc e a w ee k 39 .9% 35 .3% 24 .8% 40 .2% 35 .7% 24 .0% 2– 3 tim es p er w ee k 31 .1% 35 .5% 33 .5% 31 .6% 34 .5% 34 .0% a lm os t e ve ry d ay 24 .6% 31 .4% 44 .1% 22 .0% 31 .3% 46 .8% ph ys ic al e xe rc is e (in te ns it y) i t ak e it ea sy w ith ou t b re ak in g in to a sw ea t o r l os in g m y br ea th 43 .5% 34 .6% 21 .9% 48 .0% 29 .7% 22 .3% i p us h m ys el f s o ha rd th at i lo se m y br ea th a nd b re ak in to a sw ea t 31 .0% 34 .7% 34 .3% 31 .4% 34 .1% 34 .5% i p us h m ys el f t o ne ar -e xh au st io n 27 .0% 31 .0% 42 .1% 27 .4% 30 .4% 42 .2% ph ys ic al e xe rc is e (d ur at io n) le ss th an 1 5 m in ut es 55 .0% 29 .0% 16 .0% 58 .5% 25 .4% 16 .2% 15 –2 9 m in ut es 43 .5% 34 .8% 21 .7% 42 .8% 31 .7% 25 .5% 30 m in ut es to 1 h ou r 33 .4% 34 .3% 32 .3% 35 .5% 33 .5% 30 .9% m or e th an 1 h ou r 27 .9% 34 .5% 37 .6% 28 .2% 32 .8% 39 .0% to p at hl et e ye s 18 .8% 26 .9% 54 .3% 15 .6% 23 .0% 61 .3% n o 24 .9% 31 .6% 43 .5% 22 .2% 31 .8% 46 .0% n ot e. a ll p < .00 1. p va lu es re fe r t o th e re su lts fr om th e ch i-s qu ar ed te st s. positive affect and physical exercise 8 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ figure 2 displays the results from the multinomial regression analysis examining the predictive effect of each physical exercise item on the level of pa, operationalized by deciles on the pa-subscale. as shown, there was a strong dose-response relationship between frequency of physical exercise and pa level. although the associations were significant across all response categories of physical exercise (compared to “never”), the odds-ratios were especially strong among students reporting to train multiple times per week. similarly, the effect sizes gradually increased parallel to elevating pa deciles. for example, students training every day had more than 20-fold increased odds of having a pa-score above the 90th percentile (compared to the lowest decile). the correlations between the total pa score and exercise frequency for men and women were r = 0.28 and r = 0.23, respectively (both ps < .001). a similar pattern was observed for the item assessing the intensity and duration of physical exercise and pa level. as displayed in figure 3, the harder the exercise, the higher the odds-ratio between physical exercise and pa. similar to the frequency item, there was a clear dose-response association for both men and women. the duration of the physical exercise (figure 4) was also associated with pa level in a similar manner: the longer the exercise, the stronger the association with high levels of pa. for example, both men and women reporting an average duration of exercise of more than one hour had between six to eight times increased odds of scoring in the top decile of the pa-subscale. figure 2 odd-ratios of frequency of physical exercise associated with deciles of the positive affect (pa) subscale of panas stratified by sex in the shot2018 study 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 almost every day 2-3 x/wk 1 x/wk < 1 x/wk almost every day 2-3 x/wk 1 x/wk < 1 x/wk nemnemow o dd sra ti o outcome: positive affect deciles: how frequently do you exercise? 1st (ref) 2nd 3rd 4th 5th 6th 7th 8th 9th 10th note. reference category: never. error bars represent 95% confidence intervals. pressman, petrie, & sivertsen 9 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ figure 3 odd-ratios of intensity of physical exercise associated with deciles of the positive affect subscale of panas stratified by sex 0 1 2 3 4 5 6 7 8 9 i push myself to near-exhaustion i push myself so hard that i lose my breath and break into a sweat i push myself to near-exhaustion i push myself so hard that i lose my breath and break into a sweat nemnemow o dd sra ti o outcome: positive affect deciles: how hard do you push yourself? 1st (ref) 2nd 3rd 4th 5th 6th 7th 8th 9th 10th note. reference category: i take it easy without breaking into a sweat or losing my breath. error bars represent 95% confidence intervals. figure 4 odd-ratios of duration of physical exercise associated with deciles of the positive affect subscale of panas stratified by sex 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 more than 1 hour 30 minutes to 1 hour 15–29 minutes more than 1 hour 30 minutes to 1 hour 15–29 minutes nemnemow o dd sra ti o outcome: positive affect deciles: how long does each session last? 1st (ref) 2nd 3rd 4th 5th 6th 7th 8th 9th 10th note. reference category: “less than 15 minutes”. error bars represent 95% confidence intervals. positive affect and physical exercise 10 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ what is the relationship between exercise and positive affect in top athletes? finally, students considering themselves to be a top athlete had significantly higher odds of also having a high level of pa. as shown in figure 5, the associations were also here in a dose-response manner, although the associations were particularly strong for the top two deciles of the pa-subscale (above the 80th percentile). these patterns were similar for both men and women, and there were no significant sex interactions for any of the analysis. figure 5 odd-ratios of being a top athlete associated with deciles of the positive affect subscale of panas stratified by sex 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 etelhtapotetelhtapot nemnemow o dd sra ti o outcome: positive affect deciles: do you consider yourself to be a top athlete? 1st (ref) 2nd 3rd 4th 5th 6th 7th 8th 9th 10th note. reference group: those not indicating that they are a top athlete. error bars represent 95% confidence intervals. is this graded association true in both lean and overweight/ obese participants? as shown in figure 6, across healthy weight and obese/overweight categories, the associ‐ ation persists and is seen to be nearly identical across the two bmi groups at different levels of exercise. pressman, petrie, & sivertsen 11 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ figure 6 the association between exercise frequency and decile of panas positive affect for normal and overweight/ obese participants 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 almost every day 2-3 x/wk 1 x/wk < 1 x/wk almost every day 2-3 x/wk 1 x/wk < 1 x/wk overweight/obesenormal weight o dd sra ti o outcome: positive affect deciles: normal weight versus overweight/obese: exercise frequency 1st (ref) 2nd 3rd 4th 5th 6th 7th 8th 9th 10th what happens when the word active is separated from the panas? removing the adjective “active” from the panas cut the association between pa and ex‐ ercise frequency a great deal. as shown in figure 7, when considering exercise frequency, while the graded association remained robust and in the same pattern, some associations dropped by 50%. for example, the odds for daily exercisers of being in the highest pa decile went from approximately 18x to 9x (figure 7, panel 1). the degree of change in odds was less severe at lower levels of exercise. while not as dramatic a change, but in the same direction, the odds of being in the top decile for those who push themselves the hardest during exercise dropped from a 4.8 to a 3.8 (figure 7, panel 2). on the flip side this pattern was present in other activity outcomes, although not to the same degree. for example, in the duration of exercise outcome, there was no observable change from removing “active” from the 15-29 minute of exercise at a time subset (figure 7, panel 3). positive affect and physical exercise 12 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ figure 7 panel 1 0 2 4 6 8 10 12 14 16 18 20 22 24 26 almost every day 2-3 x/wk 1 x/wk < 1 x/wk (ref) almost every day 2-3 x/wk 1 x/wk < 1 x/wk (ref) )evitcatuohtiw(ap)evitcahtiw(ap o dd sra ti o outcome: positive affect deciles how frequently do you exercise? 1st (ref) 2nd 3rd 4th 5th 6th 7th 8th 9th 10th figure 7 panel 2 0 1 2 3 4 5 6 i push myself to near-exhaustion i push myself so hard that i lose my breath and break into a sweat i push myself to near-exhaustion i push myself so hard that i lose my breath and break into a sweat )evitcatuohtiw(ap)evitcahtiw(ap o dd sra ti o outcome: positive affect deciles: how hard do you push yourself? 1st (ref) 2nd 3rd 4th 5th 6th 7th 8th 9th 10th pressman, petrie, & sivertsen 13 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ figure 7 panel 3 0 1 2 3 4 5 6 7 8 9 10 11 more than 1 hour 30 minutes to 1 hour 15–29 minutes more than 1 hour 30 minutes to 1 hour 15–29 minutes )evitcatuohtiw(ap)evitcahtiw(ap o dd sra ti o outcome: positive affect deciles: how long does each session last? 1st (ref) 2nd 3rd 4th 5th 6th 7th 8th 9th 10th note. (panels 1, 2, 3). odd-ratios of frequency, intensity and duration of physical exercise (versus lowest categories displayed in figure 2, figure 3, and figure 4) associated with deciles of the positive affect (pa) subscale of panas organized by full scale (left) and the panas minus the word “active” (right). error bars represent 95% confidence intervals. discussion overall, this study replicates past findings indicating a strong association between pa and exercise in a large general population study of over 50,000 norwegian young adults, but it also adds a great deal of new information. first, we show for the first time a surprisingly clear and strong dose-response relationship between pa and physical exercise across all three self-reported assessments (i.e., duration, frequency, intensity). the magnitude and slope of the dose-response relationships were particularly driven by those participants who exercise regularly. for example, those training every day had a more than 20-fold increased odds of being in the top 10% of pa scores (versus those not exercising regularly), albeit with large confidence intervals. similarly, when indexing other measures of self-reported exercise, those reporting more than 1 hour per session had between six to eight times increased odds of scoring in the top decile of the pa-sub‐ scale. also, those who considered themselves to be elite athletes were overrepresented in the top 80th percentile of pa with approximately five to six times the odds of being in positive affect and physical exercise 14 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ these top groups versus non elite athletes. importantly, these effects were seen across all levels of body mass index indicating that this is not simply about physical fitness, but perhaps more about actual activity. relevant to this interpretation, removing the word active from the panas made a large difference in the size of the pa association with exercise, in some cases, cutting the linkage size by 50% in the highest and most consistent exercisers, but having less of a dramatic effect in the less active individuals. all together, these results indicate that high pa, as assessed by the panas, is in fact picking up on activity to a large extent, especially when assessing regular exercisers. that is, the majority of the most positive people are regular exercisers, and in some cases, elite athletes. the robust effect of removing the activity item from the panas highlights further this issue, that is, that the highest people in pa are the most active people, partially because, the panas measures activity. people who say they are feeling active, are by in large actually more active. clearly qualitative work is needed to explore what people are evaluating in their lives and emotions when they answer these panas pa items, as well as work tying objective fitness (e.g., as measured by v02max) to panas active and other pa items. we must also ask the more critical question of how these results impacts our interpre‐ tation of the literature connecting pa to better health? the findings clearly cast some doubt on health studies utilizing the panas pa or similarly active measures of pa (e.g., vigor), especially among results that don’t account for the effects of physical activity in some way. that said, even if they did, given the typically limited fitness measures used in some studies, more work is probably needed to ensure that it is not simply the most physically fit, active, and healthy people driving these findings or some other related third variable (e.g., cardiovascular health, mitochondrial function) (fuchs, 2015; picard, 2011; stevens, 2009). the study also raises questions about whether pa intervention studies in ill populations are in fact increasing the correct factors for health promotion since much of this work is based on past found associations between active pa and health. the current study points to the possibility that exercise may be a more important or sufficient target in some populations (a popular intervention in some diseased or high risk populations) (ornish et al., 1998; ryan, cassidy, noorduyn, & o’connell, 2017; theou et al., 2011; e.g., van der wardt et al., 2020) as opposed to focusing on emotion in interventions. in future research exploring the relationship between pa and health we recommend researchers consider taking extra effort to separate the effects of pa from physical activ‐ ity when exploring health outcomes. this might be done by utilizing objective fitness indicators such as vo2max, accelerometers, extensive exercise and activity self-reports, in addition to covarying perceived health which is likely to relate strongly to fitness. it is only with these deeper and more objective approaches that we will begin to understand when feelings of positivity are promoting health versus activity levels (i.e., healthiness) promoting health. pressman, petrie, & sivertsen 15 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ this study has both strengths and weaknesses. while it is well powered and has an array of physical exercise assessments, it is limited by its cross-sectional design and reliance on self-report. generalization is also limited to young, healthy, and primarily caucasian samples. given the high self-reported exercise levels of this sample, it would be interesting to also contrast these levels against objective activity assessments as well as to look at less active and older samples. in addition, the use of a state (current) affect scale was weaker than that of a trait (long lasting) affect scale, although the two are known to be highly correlated (diener & emmons, 1984). it should also be noted that some of the 95% confidence intervals were quite large, especially for the top deciles of the pa scale. this should be kept in mind when interpreting the results. finally, we could have opted to remove other active/high arousal affect items, such as the word “strong”, from the panas to examine the resulting change in association with exercise. we chose “active” due to its more regular use in affect and health assessments as well as due to past results revealing that it was clearly the most tied to health (specifically, all-cause mortality with a hazard ratio of ~1.9). the association of the word “strong”, for example, was comparable to many other pa items (hr ~ 1.4 which was similar to panas adjectives like interested and attentive) (petrie et al., 2018). overall, this study shows strongly that exercise and positive emotions are closely intertwined, especially for the healthiest and most fit individuals. future work should examine how the same effects are found with objective measures of activity and fitness, and should also further examine the implications for physical health outcomes. that is, when examining pa and health connections, to what extent do these change if we focus on pa measures that do not tap energy, felt vigor, and activity? what happens when we take great efforts to account for activity and fitness? from this data, we might infer that this would not have major implications for sedentary samples, however, for samples that include active individuals, effects may change drastically. it is essential that those of us interested in pa and health start measuring exercise well and that we take the possible different interpretations of high activity/arousal pa effects into account. the extent that we discover that activity levels underlie a large amount of previously observed pa health benefits, it may be the case that activity interventions (with or without pa) may be a more fruitful approach to improving health. positive affect and physical exercise 16 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ funding: shot2018 has received funding from the norwegian ministry of education and research (2017), and the norwegian ministry of health and care services (2016). competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors wish to thank all students participating in the study, as well as the three largest student welfare associations in norway (sio, sammen and sit) who initiated and designed the shot study. author note: twitter handles for authors: @sarahpressman @keithpetrie @borgesivertsen references arent, s. m., landers, d. m., & etnier, j. l. 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(2020). being happy and becoming happier as independent predictors of physical health and mortality. psychosomatic medicine, 82(7), 650-657. https://doi.org/10.1097/psy.0000000000000832 positive affect and physical exercise 20 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://doi.org/10.1002/14651858.cd011660.pub2 https://doi.org/10.1080/1612197x.2017.1295557 https://doi.org/10.1111/j.1464-0597.2008.00351.x https://doi.org/10.1136/bmjopen-2018-025200 https://doi.org/10.1073/pnas.1110892108 https://doi.org/10.2471/blt.09.070565 https://doi.org/10.1007/s00702-008-0092-x https://doi.org/10.4061/2011/569194 https://doi.org/10.1080/13607863.2019.1590308 https://doi.org/10.1037/0022-3514.54.6.1063 https://doi.org/10.1097/psy.0000000000000832 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. pressman, petrie, & sivertsen 21 clinical psychology in europe 2020, vol.2(4), article e3103 https://doi.org/10.32872/cpe.v2i4.3103 https://www.psychopen.eu/ positive affect and physical exercise (introduction) method participants measures statistical analyses results descriptive statistics is positive affect associated with physical exercise? what is the relationship between exercise and positive affect in top athletes? is this graded association true in both lean and overweight/obese participants? what happens when the word active is separated from the panas? discussion (additional information) funding competing interests acknowledgments author note references evidence-based psychodynamic therapies for the treatment of patients with borderline personality disorder latest developments evidence-based psychodynamic therapies for the treatment of patients with borderline personality disorder svenja taubner a, jana volkert a [a] university hospital heidelberg, university of heidelberg, heidelberg, germany. clinical psychology in europe, 2019, vol. 1(2), article e30639, https://doi.org/10.32872/cpe.v1i2.30639 received: 2018-10-17 • accepted: 2019-05-24 • published (vor): 2019-06-28 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: svenja taubner, university hospital heidelberg, university of heidelberg, institute for psychosocial prevention, bergheimer str. 54, 69115 heidelberg, germany. tel.: 0049(0)6221-56-4700. e-mail: svenja.taubner@med.uni-heidelberg.de abstract background: borderline personality disorder (bpd) is a serious health issue associated with a high burden for the individual and society. among the “big four” of evidence-based treatments for patients with bpd are two psychodynamic therapies that have evolved from classic psychoanalytic treatment with a change of setting and change of focus: transference-focused psychotherapy (tfp) and mentalization-based treatment (mbt). aims: this overview provides a comparison of the two treatments in terms of stance, clinical concepts, costs and key interventions. furthermore, the current literature on the efficacy of both treatments is reviewed. results: while tfp focuses on the content of disintegrated representations of self and other, mbt focuses on the processing of mental states. both treatments diverge in their clinical concepts and interventions for the treatment of bpd. conclusion: although both treatments are regarded as effective in treating bpd, no direct comparison of both treatments has been made so far. future studies are needed to investigate mechanisms of change and derive recommendations for a differential indication. keywords psychodynamic psychotherapy, borderline personality disorder, mentalization-based treatment, transferencefocused psychotherapy, efficacy, clinical concepts this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i2.30639&domain=pdf&date_stamp=2019-06-28 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • specialized therapies for bpd have favorable drop-out rates and outcome compared to non-specialized ones. • mbt and tfp have very diverse clinical concepts and interventions for the treatment of bpd. • both, mbt and tfp show efficacy in rcts. • no trial has directly compared mbt and tfp; there is no evidence base for differential indication. the cochrane review (stoffers et al., 2012) on psychological therapies for borderline per‐ sonality disorder (bpd) lists several approaches as ‘probably effective’ in treating bpd. four psychological treatments are described as evidence-based, the “big four”. among those two psychodynamic treatments are listed: mentalization-based therapy (mbt) and transference-focused psychotherapy (tfp). both represent the trend in psychodynamic therapies to develop disorder-specific treatments that can be tested for efficacy in con‐ trast to a classic, more transdiagnostic approach. furthermore, psychodynamic therapies have been developed that deviate from the classic freudian conceptualizations of ad‐ dressing unconscious conflict to improving personality functioning instead. in this paper, we will outline these current developments of psychodynamic treatments among the “big four” for bpd as the most prevalent disorder in clinical settings (torgersen, 2005), due to a lack of trials for other psychodynamic approaches (e.g. dynamic deconstructive psy‐ chotherapy or psychoanalytic interactional method). first, we will summarize the com‐ mon ground of psychodynamic therapies and, secondly, describe the clinical and change theory as well as therapeutic stance and key interventions of the two treatments. in a third step, tfp and mbt will be compared and contrasted with regard to their similari‐ ties and differences. the paper concludes with a summary of the current research find‐ ings on the efficacy of mbt and tfp for bpd and points out future directions for clinical research of these two approaches. differences in efficacy to classic psychodynamic treat‐ ment will be discussed. common features of psychodynamic psychotherapy the term psychodynamic psychotherapy was established to describe therapies following the core psychoanalytic principles but with a lower weekly session rate and using a faceto-face setting instead of the classic freudian couch setting (whitehorn, braceland, lippard, & malamud, 1953). furthermore, psychodynamic psychotherapies establish a treatment focus and limit treatment goals also with regard to symptomatic changes. par‐ psychodynamic treatments for bpd 2 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ allel to the development of psychodynamic psychotherapy, clinical theories were broad‐ ened from seeing symptoms not only as a manifestation of unconscious conflicts but also as impairments in personality functioning and disturbed relationships (opd-2, opd taskforce, 2008). following the demands of evidence-based medicine, disorder-specific treatment manuals were established, e.g. for the treatment of panic disorders (milrod et al., 2007) and depression (lemma, target, & fonagy, 2011). the core ideas of psychody‐ namic therapies remained the following (shedler, 2010): 1. focus on emotions and affect 2. exploration of aspects that patients tend to avoid (e.g. painful and threatening aspects of experience), which is called defense or resistance in psychoanalytic terms 3. identification of recurrent topics or themes with regard to self, other, relationships, etc. 4. discussion of past experiences that help to contextualize current experiences 5. focus on relationships, especially the therapeutic relationship 6. exploration of dreams, phantasies and wishes all of these aspects can also be found in mbt and tfp; however, there is a shift of focus in the treatment of bpd to emphasize the “here-and-now” instead of discussing past events. both treatments work very explicitly with the current therapeutic relationship and the exploration of dreams, phantasies and wishes is not central for the therapeutic process, at least at the beginning of treatment. furthermore, psychodynamic therapies follow the goal to change distorted representations of self, other or relationships in a quite comparable way to cognitive-behavioral therapy (cbt). these can be distinguish‐ ed at the level of intervention: while cbt aims to change patients’ dysfunctional beliefs at a micro level, psychodynamic therapies reach out to change personality aspects e.g. with regard to depression at a macro level (luyten, blatt, & fonagy, 2013). both aim to change the content of representations. however, because a large number of patients do not correspond to a treatment approach focusing on the content of representations, re‐ cently in both therapeutic schools, new therapies have been developed that shift from ad‐ dressing content to the processing of mental states itself (e.g. how we think and interpret instead of what we think). in this paper, we will regard tfp as a primarily content-fo‐ cused treatment, whereas mbt focuses more on the processing of mental states, which can be regarded in line with the third wave therapies in cbt. before comparing these two specific treatment approachestfp and mbt-, we will summarize the core symp‐ toms and burden of bpd. taubner & volkert 3 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ borderline personality disorder bpd is a severe health issue characterized by at least five of the following nine criteria (diagnostic and statistical manual of mental disorders [5th ed.; dsm–5]; american psychiatric association, 2013): a) unstable relationships, b) inappropriate anger, c) frantic effort to avoid abandonment, d) affective instability, e) impulsivity, f) self-harm/suicidali‐ ty, g) dysphoria, h) stress-related paranoid thoughts and i) identity disturbance and disso‐ ciation. point prevalence in community samples ranges from 0.7-3.9% (trull, jahng, tomko, wood, & sher, 2010), lifetime prevalence is around 6% (grant et al., 2008). in a recent meta-analysis with n = 66,914 included individuals from community samples of 9 studies in western countries the prevalence rate was 1.90% (volkert, gablonski, & rabung, 2018). furthermore, bpd is the most common personality disorder in clinical populations, with prevalence rates of around 10% in outpatient and 15-25% in inpatient settings (torgersen, 2005). bpd is often associated with both comorbid axis i and ii disor‐ ders: approx. 85% of bpd patients have a 12-months diagnosis of at least one axis i and 74% for another axis ii disorder (grant et al., 2008). 69-80% of bpd patients engage in sui‐ cidal behavior and 3-10% commit suicide with a 50 fold heightened risk in comparison to the general population (gunderson, weinberg, & choi-kain, 2013; leichsenring, leibing, kruse, new, & leweke, 2011; oldham, 2006). bpd accounts for 2.2% of all disability adjus‐ ted life years (dalys), 1.2% of all dalys (ranking 3rd in mental disorders in women, and 4th in men) and suicide accounts for 1.0-2.8% of all dalys (victorian government department of human services, 2005). the burden of bpd on society in terms of produc‐ tivity losses and other indirect costs is assumed to reach 76.3% of the total costs (olesen, gustavsson, svensson, wittchen, & jönsson, 2012). similarly, direct costs of bdp are con‐ sidered to be higher than in depression or diabetes (wagner et al., 2013), with average per capita costs ranging between 11,000€ and 14,000€ (salvador-carulla et al., 2014) per year. in sum, bpd is a severe treatment condition that comes with a high burden for the indi‐ vidual and society. however, treatment of bpd patients is emotionally challenging for therapists, and therapists often decline treatment with this group of patients; although 50% of therapists agree that a bpd-specific treatment qualification is useful, only 3% have such a qualification (jobst, hörz, birkhofer, martius, & rentrop, 2010). thus, there is a high need of training therapists in bpd-specific treatment approaches. the two ap‐ proaches that will be presented here, mbt (bateman & fonagy, 2016) and tfp (yeomans, clarkin, & kernberg, 2015), offer an additional training on top of a psychodynamic (or other) psychotherapeutic training that was created to treat bpd more effectively. psychodynamic treatments for bpd 4 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ a content-focused psychodynamic treatment – transference focused psychotherapy tfp was developed by frank yeomans, john clarkin, and otto kernberg (yeomans et al., 2015) and is associated with a new conceptual idea of identity formation and personality organization. the aim of treatment is to decrease the symptomatic burden and interper‐ sonal problems in patients with bpd by changing patients’ mental representations of others and self that underlies their behavior (clarkin, cain, & lenzenweger, 2018), to meaningfully improve functioning in the domains of work, studies and profession, and intimate relations (yeomans et al., 2015). clinical concept personality organization is described as comprising three aspects of personality function‐ ing: identity integration, level of defense mechanisms and degree of reality testing. fol‐ lowing kernberg (1967), borderline personality organization is marked by identity diffu‐ sion, low level of defenses but mainly intact reality testing. thereby, identity diffusion is considered central to the clinical understanding of bpd in tfp and is related to a lack of coherence in the individual’s experience and understanding of both self and others. fur‐ thermore, social signals are consistently misunderstood because the inner experience of a bpd patient is dominated by aggressive internalized object relations that are split from idealized ones. thus, identity diffusion is associated with defensive strategies involving dissociation of conscious aspects of conflicting experiences (splitting). the lack of an in‐ tegrated self is also seen as leading to internal distress and emptiness that lead to pa‐ tients’ attempts to relieve distress through impulsive acting out (kernberg, 1967). ker‐ nberg’s etiology follows the idea of object relation theory that early experiences of self and others are organized by splitting, meaning that positive and negative representations of self and other need to be gradually integrated to achieve normal functioning. in bpd, positive and negative representations of self and other remain separated/ disintegrated because negative representations contain traumatic affects that would possibly destroy positive representations. change theory the authors propose that tfp helps patients to establish an increased affect regulation achieved through the growing ability of the patient to psychologically reflect and inte‐ grate thoughts, emotions and behavior and to establish positive relationships with others (kernberg, 2016). this is achieved through a modification of personality structure by linking the dissociated parts of positive and negative representations that are enacted in the therapeutic relationship. the patient’s partial representations are experienced in the therapeutic relationship that mirror splitting in the patient (transference). this can lead to a rapid change in the therapeutic relationship, e.g. an idealization of the therapist fol‐ taubner & volkert 5 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ lowed by a fear of being dominated or threatened, which is outside of the patient’s awareness. the therapist describes these different states of the relationship and links this with the inner experience of the patient. this way an integration of the split off idealized and persecutory segments of experience can take place, i.e. identity diffusion can be re‐ solved. by addressing the different split-off representations of self and other the therapist engages the patient in thinking and reflecting about their emotional responses and be‐ havior and links this, moment by moment, to the experiences in the therapeutic relation‐ ship. this leads to a reflection in the here and now with another person and a growing awareness of how the perception of others is distorted by expectations derived from in‐ ternal representations. within this therapeutic process the patient’s view of current in‐ terpersonal realities becomes more accurate. setting tfp begins with a verbal contract that serves as a framework to discuss risks to a pa‐ tient’s life (suicidality, self-harm, drug abuse) as well as behavior that potentially limits or hinders the continuation of therapy (leaving a job, insurance, moving to another city). furthermore, the contract aims at reducing any gains that the patient would take from their symptoms with regard to negative reinforcements. after having agreed on a com‐ mon contract, two individual sessions weekly are carried out with weekly supervision. the average treatment duration is between two and three years. stance the therapist takes a more active stance in comparison to classic psychoanalytic treat‐ ment by paying more attention to the external reality of the patient (e.g. breaking the contract, antisocial behavior) and selects priority themes that need to be addressed in ev‐ ery session in the material the patient is presenting. the stance is characterized by the “technical neutrality”, focusing on the “here-and-now” as well as balancing between ex‐ ploring and confronting the patient with incompatible views on the one hand and regula‐ tion of arousal on the other hand. technical neutrality describes the general stance of continuously keeping the goal of therapy in mind with an attitude of objective inquiry, to clarify issues without being judgmental. contradictions in the patient’s perception or representations of self and others are observed at three levels: what the patient is saying, how the patient is acting (inside and outside session) as well as the counter-reactions and feelings of the therapist. the latter requires constant monitoring of what belongs to the patient, the therapist and/or their interaction. key interventions while the patient is asked to freely associate and disclose any idea that comes to mind, the therapist listens carefully and uses the three following interventions: clarification, psychodynamic treatments for bpd 6 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ confrontation and interpretation. clarification means to thoroughly explore the patient’s subjective experience with a special focus on contradictions or conflicts as well as affects in his/her perception of self and others. this intervention aims to promote mentalization of internal states (yeomans, levy, & caligor, 2013). confrontations take the therapeutic work to the second level of actively pointing out discrepancies between the three chan‐ nels of communication (verbal, non-verbal and counter-reactions of the therapist) (zerbo, cohen, bielska, & caligor, 2013). finally, interpretations aim to integrate contradictions by offering a hypothesis for a deeper understanding of the different self and other repre‐ sentations that dominate the patient’s thinking and feeling in relationships. in the begin‐ ning and middle parts of the treatment, tfp recommends to avoid so-called genetic inter‐ pretations that link childhood experiences to current states of mind but stay in the hereand-now. time and costs training comprises 34 weekly seminars over a duration of one year including supervi‐ sion. this is followed by 6 months’ home study and supervision. the cost of the training adds up to 3,000€ (tfp institute munich, germany). treatment costs for an individual pa‐ tient may vary from country to country. number, duration and frequency of therapeutic sessions may approximately range from a minimum of 180 hours (two weekly sessions for one year) to a maximum of 405 sessions (three sessions weekly for three years) based on data from trial therapies. a cost effectiveness study revealed average costs for tfp at about 46.000€ and concluded that sf was more cost-effective in comparison to tfp (van asselt et al., 2008). however, there is no time-limitation to tfp according to the manual, which makes cost calculation outside of research difficult. widening scope (disorders and age groups) tfp started to provide an adapted and manualized psychoanalytic treatment for bpd, and there are further adaptions for the treatment of adolescents with borderline features (tfp-adolescence, normandin, ensink, yeomans, & kernberg, 2014; adolescent identity treatment, foelsch et al., 2014) and other personality disorders such as narcissistic per‐ sonality disorder. furthermore, the treatment approach was adapted for implementation in an acute psychiatric setting (zerbo et al., 2013). a process-focused psychodynamic treatment – mentalization-based treatment mbt is a manualized treatment protocol developed by anthony bateman and peter fona‐ gy (bateman & fonagy, 2016). the treatment is based on validating the emotional experi‐ ence of patients within a significant therapeutic relationship and promotes several tech‐ taubner & volkert 7 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ niques that directly aim to stabilize or enhance mentalizing (bateman & fonagy, 2016). mentalization is the imaginative ability to interpret human behavior in terms of mental states (fonagy, gergely, jurist, & target, 2002). empirical research has shown that al‐ though social cognition is not necessarily impaired in bpd the construct of understand‐ ing others in emotionally intense relationships is highly impaired in bpd, which may un‐ derlie the core problems of these patients (fonagy, luyten, & strathearn, 2011). by pro‐ moting mentalizing, mbt addresses the interpersonal sensitivity in bpd. clinical concept effective mentalizing is characterized by a genuine curiosity about mental states’ under‐ lying behavior, a flexibility in interpreting self and others as well as the knowledge that mentalizing is inaccurate most of the time and needs communication with others to clari‐ fy intentions more precisely. furthermore, healthy mentalizing enables an individual to actively shift between different poles of mentalizing, e.g. self vs. others, integration of cognition and affect or implicit vs. explicit mentalizing. patients with bpd are often over‐ whelmed by their emotions, make over-quick assumptions and focus on thinking about others with fears of abandonment and rejection. in mbt, the prototypical problems for working with patients with bpd are regarded as a sign of vulnerability in mentalizing that goes along with a high interpersonal sensitivity. an attachment threat leads to a breakdown in mentalizing, which leads to a failure of affect regulation and impulsive be‐ havior. the vulnerability in mentalizing has been conceptualized as three different forms of inadequate mentalizing: teleological mode, psychic equivalence and pseudo-mentaliz‐ ing. teleological thinking overgeneralizes behavior as proof for internal states, whereas psychic equivalence generalizes from internal experience to the external reality. pseudo‐ mentalizing creates mental theories without a connection between internal and external experience. change theory the proposed mechanism of change in mbt is to stabilize mentalizing in certain focus areas to create a psychic buffer between affect and behavior to foster affect regulation, reduce impulsivity and promote functional supportive relationships. this is reached by employing “contrary moves” to create more flexibility in using the different poles of mentalizing. if the patient is stuck in thinking about the self, the therapist will try to shift him or her towards thinking about others. if the patient is too certain about quickly made assumptions, the therapist will try to slow down and question the first assumption, etc. by sharing or disclosing the therapist’s interpersonal experience with the patient from the beginning and throughout the process, the patient can find him/herself in the mind of the therapist and reflect on how the therapist is represented in the mind of the patient. using constant empathic validation of the patient’s affects and working slowly on cur‐ psychodynamic treatments for bpd 8 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ rent experiences with the therapist and other important others; the patient develops epis‐ temic trust and is able to generalize helpful mentalizing experiences with the therapist to other relationships outside of therapy. furthermore, by sharing a written case formula‐ tion, the patient learns about the therapist’s idea of the patient’s mentalizing failures and help him/her to establish more agency and responsibility for his/her behavior with re‐ gard to core symptoms e.g. self-harm, drug abuse. setting mbt was initially developed as an inpatient treatment with a duration of 18 months and evolved to an intensive outpatient program that is now commonly limited to 12 months. mbt sets off with a diagnostic phase. in addition to standard diagnostic assessment, the clinician is assessing mentalizing problems and interpersonal triggers that are associated with the core problem behavior. this is written down in a case formulation that summa‐ rizes the clinician’s current understanding of the patient’s vulnerabilities and mentalizing problems all set in the context of current relationships and behavior. the case formula‐ tion is shared with the patient, serves as a focus for treatment, and is revised approx. ev‐ ery three months. in addition to the case formulation, a crisis plan is developed together with the patient entailing information which the patient finds helpful or hindering dur‐ ing breakdowns for him/herself, professionals and significant others. after the diagnostic phase the patient participates in a psycho-education group that teaches core elements of the treatment including an understanding of the bpd diagnosis. after 12 sessions the group changes its format to a mbt-group therapy focusing on elaborating perspectives from each group member. parallel to the weekly group sessions patients have one weekly individual session. stance several aspects are essential for the mbt stance: being curious and enthusiastic for men‐ tal states, being authentic, empathic and validating as well as most importantly, taking a not-knowing stance. the latter is based on the modesty that no one can read minds and creates a less hierarchical relationship between therapist and patients. the therapist is not the expert for the patient’s mind but rather takes an inquisitive stance to explore to‐ gether with the patient what kind of thinking is helpful or unhelpful to have good rela‐ tionships with others. another focus is related to misunderstanding each other. misun‐ derstanding is considered as an opportunity to learn about perceptions, interpretations and experience. the therapist actively structures the session by focusing on topics related to the case formulation, management of arousal and monitoring the level of mentalizing. taubner & volkert 9 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ key interventions interventions start from the surface and work towards relational mentalizing of the ther‐ apeutic relationship if the current arousal and level of mentalizing allows. during times of high arousal it is recommended to intervene supportively by empathically validating the patient’s subjective experience and addressing non-mentalizing by exploring affects, certainties, quick assumptions, and by challenging pseudo-mentalizing. the techniques are called “stop and stand” or “stop, rewind and explore” that slow down the processing of current experiences. lower levels of arousal allow to start basic mentalizing around the focus of treatment such as triggers of strong affects and effect on behavior and others as well as linking different experiences to patterns of experience. finally, exploring the current affect during the session (affect focus) and the relationship between therapist and patient are seen as crucial change mechanisms as this allows an understanding of inter‐ personal processes in the here-and-now. mbt deviates from classic psychoanalytic inter‐ pretations as this is regarded aversive for bpd patients. thus, within the mbt frame‐ work it is recommended to contextualize affects and patterns of behavior in the hereand-now that should not be interpreted as a mere repetition of past relationships and ex‐ periences. time and costs training comprises 5 days and four supervised cases with at least 24 sessions each and four sessions of supervision per case. supervision and training add up to an overall cost of 1,600€ when following the requirements of the anna-freud-centre in london but may vary country wise. number, duration and frequency of mbt sessions based on one week‐ ly group and one individual session ranges between 90 sessions in twelve months or 120 sessions in 18 months. mbt was originally developed as an inpatient treatment, which is more costly than the outpatient program. however, exact numbers have not been repor‐ ted yet. a recent rct in the netherlands tested the efficacy between mbt outpatient and day-hospital, and reported a superiority in secondary outcomes for the more costly dayhospital treatment (smits et al., 2019). cost-effectiveness data comparing both settings is not available yet. widening scope (disorders and age groups) meanwhile, programs have been developed for adolescents with bpd (mbt-a), parents with bpd (mbt-lighthouse), conduct disorder, antisocial personality disorder, eating disorders, families (mbt-f), children (mbt-c) and hard to reach clients (ambit) (for an overview: bateman & fonagy, 2019). psychodynamic treatments for bpd 10 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ efficacy of pd treatments for bpd efficacy of tfp three rcts have demonstrated the efficacy of tfp. the first efficacy trial was conducted by giesen-bloo et al. (2006), with outpatients (n = 88) comparing tfp with schema-fo‐ cused therapy (sft) with 2 weekly sessions over a duration of 3 years. using an inten‐ tion-to-treat approach, statistically and clinically significant improvements were found for both treatments on all measures after 1-, 2-, and 3-year treatment periods. however, sft patients had a lower risk for drop-out (rr = 0.52) and after 3 years of treatment, sur‐ vival analyses demonstrated that significantly more sft patients recovered or showed re‐ liable clinical improvement. robust analysis of covariance (ancova) showed that they also improved more in general psychopathologic dysfunction and showed greater increa‐ ses in quality of life. arntz, stupar-rutenfrans, bloo, van dyck, and spinhoven (2015) reanalyzed the giessen-bloo study and identified the following predictors for drop-out and reduced recovery: initial burden of dissociation, hostility and childhood physical abuse, whereby in-session dissociation (observer-report) was identified as a mediator. another outpatient rct with n = 90 patients was conducted by clarkin, levy, lenzenweger, and kernberg (2007), who compared tfp (two individual weekly sessions) with dbt (weekly individual + group plus telephone consultation) and dynamic suppor‐ tive treatment (dst) (one individual weekly session) over a duration of 12 months. they found significant improvement for all three treatments on a number of outcomes: depres‐ sion, anxiety, global functioning and social adjustment. no differences were found be‐ tween the three different treatments; only tfp had a two times lower risk of drop-out (compare also oud, arntz, hermens, verhoef, & kendall, 2018, for a summary). thereby individual slopes differed with regard to within-patient effects. individual growth curve analysis showed that dbt and tfp had significant change rates compared to dst on sui‐ cidality, whereas tfp and dst had significant change rates compared to dbt on anger and impulsivity. furthermore, only tfp showed significant change rates in aggression (direct and verbal assault) and irritability. doering et al. (2010) investigated the efficacy of a tfp treatment compared to community treatment by experts (ctbe) over one year in n = 104 female patients with bpd. in this trial, tfp showed superiority to ctbe with re‐ gard to reduced drop-out (38.5% v. 67.3%), suicide attempts, borderline symptomatology, increased psychosocial functioning, personality organization and psychiatric inpatient admissions. no differences between the two treatment conditions were observed for de‐ pression, anxiety and general psychopathology. however, self-harming behavior did not change in either group. in a further analysis of the same data by fischer-kern et al. (2015) significant improvements in reflective functioning was also found for the tfp vs. the tau group with a medium between-group effect size (d = 0.45). taubner & volkert 11 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ efficacy of mbt four rcts have investigated the efficacy of mbt in comparison to psychiatric services (bateman & fonagy, 1999), structured clinical services including supportive psychothera‐ py (bateman & fonagy, 2009; jørgensen et al., 2013) and in adolescents with non-suicidal self-injury (nssi), who mainly fulfilled criteria for bpd (rossouw & fonagy, 2012). mbt proved to be superior to tau/ clinical management in nssi, suicide attempts, psychiatric symptoms, and hospitalization (bateman & fonagy, 1999, 2009; rossouw & fonagy, 2012) as well as core bpd symptoms (bales et al., 2012; rossouw & fonagy, 2012). one inde‐ pendent rct confirmed positive effects for mbt in comparison to supportive therapy for general functioning, suggesting that mbt may address core problems in bpd beyond nssi and suicidality (jørgensen et al., 2013). mbt is the only treatment for which superi‐ ority to clinical management was demonstrated in all primary outcome variables as well as achieving significantly higher levels of employment or academic/occupation training eight years after admission (bateman & fonagy, 2008). findings also demonstrate that mbt shows superiority over tau for interpersonal problems and general functioning (stoffers et al., 2012). in sum, mbt has demonstrated reliable improvements for psychiat‐ ric symptoms. a mediator analysis in an adolescent trial demonstrated that two changing variables were partially explaining differences in outcome between control and interven‐ tion group. these variables were changes in mentalizing and attachment avoidance, which were specific to the mbt effects (rossouw & fonagy, 2012). in a recent naturalistic study with a sample of 175 patients with bpd treated in an inpatient setting, changes of mentalizing operationalized with the reflective functioning questionnaire uncertainty scale (rfq) were significantly associated with changes in outcome (r = .89) (de meulemeester, vansteelandt, luyten, & lowyck, 2018). this can be regarded as first evi‐ dence for a proposed specific change mechanism, i.e. changes in mentalizing mediate symptom improvement in bpd. reviews and meta-analyses seven systematic reviews on the general efficacy of psychological therapies for bpd (brazier et al., 2006; cristea et al., 2017; juanmartí & lizeretti, 2017; leichsenring et al., 2011; oud et al., 2018; stoffers et al., 2012) and therapy retention have been conducted, respectively (barnicot, katsakou, marougka, & priebe, 2011). the cochrane review (stoffers et al., 2012) lists several approaches as ‘probably effective’ in treating bpd. among those treatment approaches, mbt is the most frequently investigated after dbt. the authors recommend to conduct future trials with more than one psychological treat‐ ment and to include quality of life and preference measures across different programs. in a recent meta-analysis investigating rcts on psychotherapy efficacy in reducing suicidal attempts and nssi (calati & courtet, 2016), efficacy was established only for mbt compared to dbt, cbt, cognitive therapy and interpersonal psychotherapy. how‐ psychodynamic treatments for bpd 12 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ ever, results were based on the inclusion of only two mbt rcts. in an updated metaanalysis, cristea et al. (2017) with k = 33 studies (n = 2,256 patients) conclude that only dbt and psychodynamic approaches were more effective than control interventions, however risk of bias was a significant moderator and publication bias was persistent par‐ ticularly at follow-up. mclaughlin, barkowski, burlingame, strauss, and rosendahl (2019) investigate in k = 24 rcts with over n = 1,500 patients the efficacy of group psy‐ chotherapy for bpd and find that group psychotherapy has a large effect on the reduc‐ tion of bpd symptoms and a moderate effect on suicidality/ parasuicidal symptoms. while the largest numbers of studies available have investigated dbt, theoretical orien‐ tation of treatment was not a significant moderator for bpd symptoms in this meta-anal‐ ysis. mclaughlin et al. (2019) conclude that dismantling studies, investigating the effect of various treatment components are promising. leichsenring et al. (2011) and the co‐ chrane review (stoffers et al., 2012) criticize the low study quality across bpd trials due to researcher allegiance, attention bias and small samples. they conclude that there is a strong need for confirmatory trials with high study quality and sufficient sample sizes. oud et al. (2018) summarize in their review and meta-analysis rcts on dbt, mbt, tfp and st to compare specialized therapies for bpds with non-specialized treatments. when pooling comparison data from specialized treatments vs. community treatment by experts, they demonstrate that specialized psychodynamic treatments like mbt or tfp are superior to non-specialized psychodynamic treatment with regard to overall bpd se‐ verity and drop-out. with regard to self-injury tfp showed no superiority and with re‐ gard to suicidality both dbt and tfp were no better than community expert therapists. however, these results have to be interpreted cautiously as they are based on three trials only. similarities and differences between mbt and tfp both treatment approaches are regarded as evidence-based and are gathering further proof in ongoing trials. so far, mechanisms of change have not been empirically estab‐ lished; however, this is, unfortunately, currently the case for all psychotherapies. as no study has directly compared tfp and mbt so far, it is unclear if one is more effective than the other or more suited for bpd and respective subgroups. thus, a differential indi‐ cation for the treatment of patients with bpd cannot be made based on empirical find‐ ings. there is no evidence that allows to choose which psychotherapy may be the most appropriate for which patient profile (fonagy, luyten, & bateman, 2017). aside from bpd, the widening scope of treating other personality disorders reveals recommenda‐ tions for treating patients with internalizing personality disorders with tfp (e.g. narcis‐ sistic pd) (kernberg, 2016) and patients with externalizing personality disorders with mbt (e.g. aspd) (bateman, o'connell, lorenzini, gardner, & fonagy, 2016). taubner & volkert 13 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ tfp and mbt are based on different clinical and theories of change. tfp is more stringently rooted in classic psychoanalytic theory and jargon, while mbt created a new conceptual framework by bridging several theoretical underpinnings from psychoanaly‐ sis, attachment theory and general developmental psychology. differences can also be found with regard to the setting: while tfp deviates from classic psychoanalysis only by not using the couch and reducing the weekly frequency to one to two hours, mbt has integrated psycho-education and group therapy which may create less pressure or inten‐ sity. however, the dyadic therapeutic work itself appears quite similar even though both approaches use different terminology for their interventions. especially, clarification and confrontation in tfp are very close to exploration, clarification and challenge in mbt. furthermore, establishing a contract and crisis plan at the beginning of therapy, working in the here-and-now, using the therapeutic relationship as a training ground and moni‐ toring the therapist’s counter-reaction is required in both therapies. major differences can be found in the general therapeutic stance that each approach is advocating. a tfp therapist is asked to remain in technical neutrality (not taking a stance towards or against any content discussed). on the contrary, the mbt therapist is asked to be enthusiastic and praising for mentalizing as well as disclosing his/her emo‐ tions if this is regarded as helpful to create a mentalizing process. while tfp is deploying a content-focused approach taking an interpretative expressive therapeutic stance, mbt focuses on the process of thinking about mental states based on a supportive therapeutic stance. yet again, there is also a considerable overlap: interestingly, tfp also increases mentalizing (fischer-kern et al., 2015; levy et al., 2006), which may be evidence that the core therapeutic work of clarification and confrontation and maybe also interpretation creates robust mentalizing. as mechanism of change studies in mbt reveal that increas‐ ing reflective thinking is indeed mediating symptomatic improvement in bpd, this could also be interpreted as a common change factor across treatments in bpd (goodman, 2013). hence, it would be worth investigating these specific differences and similarities in process research as well as within non-inferiority trials to test the efficacy. dissemination of mbt and tfp is a major challenge as many psychodynamic thera‐ pists are skeptical towards disorder-specific treatment and variations from a highly indi‐ vidualized and transdiagnostic approach that is typical for psychodynamic therapies (gonzalez-torres, 2018). furthermore, accredited supervisors and trainers are still scarce for both tfp and mbt, and this significantly hinders the international dissemination of training programs. however, considering the substantial burden of these patients, their need for adequate treatment and the substantial evidence supporting the efficacy of these treatments, advancing dissemination of treatment and empirical knowledge seems to be a worthwhile future investigation. psychodynamic treatments for bpd 14 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ funding: the authors received no financial support for the research, authorship, and/or publication of this article. competing interests: the authors declare no conflicts of interest. acknowledgments: the authors have no support to report. references american psychiatric association. 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(2013). transference-focused psychotherapy in the general psychiatry residency: a useful and applicable model for residents in acute clinical settings. psychodynamic psychiatry, 41(1), 163-181. https://doi.org/10.1521/pdps.2013.41.1.163 taubner & volkert 19 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://doi.org/10.1521/pedi.2010.24.4.412 https://doi.org/10.1192/bjp.bp.106.033597 https://doi.org/10.1192/bjp.2018.202 https://doi.org/10.1026/1616-3443/a000227 https://doi.org/10.1037/a0033417 https://doi.org/10.1521/pdps.2013.41.1.163 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. psychodynamic treatments for bpd 20 clinical psychology in europe 2019, vol.1(2), article e30639 https://doi.org/10.32872/cpe.v1i2.30639 https://www.psychopen.eu/ psychodynamic treatments for bpd (introduction) common features of psychodynamic psychotherapy borderline personality disorder a content-focused psychodynamic treatment – transference focused psychotherapy clinical concept change theory setting stance key interventions time and costs widening scope (disorders and age groups) a process-focused psychodynamic treatment – mentalization-based treatment clinical concept change theory setting stance key interventions time and costs widening scope (disorders and age groups) efficacy of pd treatments for bpd efficacy of tfp efficacy of mbt reviews and meta-analyses similarities and differences between mbt and tfp (additional information) funding competing interests acknowledgments references developments in psychotraumatology: a conceptual, biological, and cultural update scientific update and overview developments in psychotraumatology: a conceptual, biological, and cultural update andreas maercker a, mareike augsburger a [a] psychopathology and clinical intervention, department of psychology, university of zurich, zurich, switzerland. clinical psychology in europe, 2019, vol. 1(1), article e30294, https://doi.org/10.32872/cpe.v1i1.30294 received: 2018-10-03 • accepted: 2019-03-01 • published (vor): 2019-03-29 handling editor: winfried rief, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany corresponding author: andreas maercker, abstract background: this report discusses recent developments of psychotraumatology mainly related to the recently published icd-11, but also from a societal point of view. methods: the selected aspects of the development of this field will be presented as a scoping review. results: in the first section, the new concept of disorders specifically associated with stress and its relevant diagnostic groups (posttraumatic stress disorder [ptsd], complex ptsd, prolonged grief disorder, and adjustment disorder) are presented, with an emphasis on ptsd. the second section embeds these diagnostic concepts within a broader context. in particular, the concept of psychotraumatology is applied to the impact of adverse childhood experiences. more specifically, recent scientific developments are discussed with respect to biological stress research. in a third section, a global perspective is applied that reflects psychotraumatology as embedded in culturallyspecific concepts. lastly, societal developments are taken into consideration. this section focusses on recent processes of victim acknowledgement and compensation taking place in europe and beyond. examples are provided for how traumatic stress is perceived and processed in society. concepts such as continuous stress and historical trauma are also discussed. conclusion: demands and opportunities of basic research and psychological interventions with a global focus are outlined. keywords psychotraumatology, icd-11, posttraumatic stress disorder (ptsd), adverse childhood experiences, child abuse, acknowledgment of victims, cultural background, survivor status, compensation this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i1.30294&domain=pdf&date_stamp=2019-03-29 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • psychotraumatology is an expanding field including both basic research and intervention-related research. • starting points of this new research area are not only potential traumatic events but also adverse childhood experiences. • in a globalized world, cultural and societal factors play an increasingly important role in psychotraumatology. in the early 1980s, the scientific field of psychotraumatology arose with the first descrip‐ tion of posttraumatic stress disorder (ptsd) as a new diagnostic category in dsm-iii (american psychiatric association, 1987). today, this research area has been internation‐ ally recognized and well-accepted despite prevailing critical concerns and controversies (rosen, spitzer, & mchugh, 2008). from its initial description in the 1980s, concepts of psychotraumatology have continuously developed. this is also reflected by the growing number of scientific publications, the founding of thematically relevant journals, as well as increasing public awareness and perception (maercker & augsburger, 2017). in the following sections, recent developments in psychotraumatology will be descri‐ bed. first, we will focus on new diagnostic concepts and changes in stress-related disor‐ ders associated with the launch of icd-11. since icd is a major classification system used in clinical practice in many european countries, we will only briefly refer to alter‐ native concepts as presented in dsm. a more detailed and explicit comparison of icd-11 and dsm-5 extends beyond the scope of this review. second, we will describe recent developments in areas closely related to ptsd, mainly adverse childhood experiences (aces) and their biological impact. we focus on this spe‐ cific topic for two reasons: first, in clinical practice, aces remain an often-neglected area despite their frequent occurrence and large burden. second, technical advancements have resulted in a vast increase in recent years in studies focusing on biological markers asso‐ ciated with aces. in a third section, culturally-specific models of mental disorders will be discussed with a focus on global challenges. and, lastly, aspects of public discourses are considered. the aim of this report is to give a summarized overview of selective topics and con‐ cepts associated with recent developments in the field of psychotraumatology and in light of icd-11. thus, core areas were selected according to the authors’ personal re‐ search foci. developments in psychotraumatology 2 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ new conceptualizations of stress-related disorders in icd-11 the updated 11th version of the international classification of disorders (icd-11) of the world health organization (who, 2018) brought about a number of significant changes in the conceptualization of stress-related mental disorders. these changes are a marked contrast to the other major classification system, the diagnostic and statistical manual, version 5 (dsm-5), released by the american psychiatric association (apa, 2013). with icd-11, ptsd and two additional stress-related mental disorders can now be adequately diagnosed: a complex form of ptsd and prolonged grief disorder. moreover, a completely new symptom formulation was also grouped in this category, for adjustment disorder oc‐ curring after severe non-traumatic stressors (first, reed, hyman, & saxena, 2015; maercker et al., 2013). some years previously, these changes were discussed for dsm-5. but at this time the committee declared that sufficient evidence was not provided for an empirically valid distinction between ptsd and complex ptsd. as a consequence, the current ptsd diagnosis in dsm-5 also incorporates symptoms that are specified as com‐ plex ptsd in icd-11. in addition, prolonged grief disorder cannot be diagnosed as a “full disorder” in dsm-5, but exists as a provisional diagnostic concept in the appendix (under the term “persistent complex bereavement disorder”). concerning adjustment disorder, the concept has remained largely the same in its transition from dsm-iv to dsm-5. in the following sections, the four diagnoses (ptsd, complex ptsd, prolonged grief disorder, adjustment disorder) will be introduced and discussed. all criteria are based on the online version of the icd-11 (who, 2018). ptsd ptsd manifests itself after exposure to an extremely threatening adverse event or series of events. it is characterized by the following three symptom clusters: 1) re-experiencing of the traumatic event(s). this occurs in the form of vivid intrusive memories, such as flashbacks or nightmares. 2) avoidance of thoughts or reminders of the traumatic event(s) or avoidance of activities, situations, or persons that elicit memories. 3) persis‐ tent perception of heightened current threat, as characterized by an enhanced startle re‐ action or alertness. for a diagnosis of ptsd, all symptom clusters must persist for several weeks and lead to significant impairment in psychosocial functioning (who, 2018). in contrast to both dsm-5 and icd-10, the intrusion criterion of icd-11 is stricter and not only requires aversive memories of the traumatic event(s), but also stronger feelings of vivid re-experiencing. in addition, the definition of hyperarousal focuses on increased perception of threat. icd-11 prevalence rates of ptsd are lower than those for icd-10 and are also reduced in comparison to dsm-5 (brewin et al., 2017). results from the world mental health survey indicate a lifetime prevalence from 3.0-3.4% worldwide (stein et al., 2014). maercker & augsburger 3 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ complex ptsd (cptsd) cptsd can develop after exposure to an extreme and threatening event or a sequence of events, from which escape or flight is difficult or impossible. in order to give a diagnosis of cptsd, individuals first need to fulfill all symptoms of ptsd. in addition, difficulties in three further areas must be reported: 1) severe problems with affect regulation; 2) per‐ ception of oneself as diminished, worthless, or defective; and 3) persistent difficulties in establishing or maintaining relationships and the feeling of being close to others. as with ptsd, all symptoms need to lead to significant impairment in psychosocial functioning (who, 2018). this diagnosis is the successor of icd-10 personality disorder f62.0 (endur‐ ing personality change after catastrophic experience), but with an entirely new conceptu‐ alization. to date, limited information on prevalence rates is available for the us, den‐ mark, and germany. in these countries, the rates range between 0.5-1.0%, across 1-12 months (brewin et al., 2017; maercker, hecker, augsburger, & kliem, 2018). prolonged grief disorder (pgd) pgd can develop after the loss of a loved one. it is marked by a persistent and intense longing for the deceased, accompanied by a strong cognitive attachment. in addition, in‐ tense emotional suffering occurs, such as sadness, feelings of guilt, anger, denial, or diffi‐ culties in accepting the death (who, 2018). it is important to note that all these symp‐ toms can fall within the normal range of grieving. they may only be considered as pathological if they persistently occur over an atypically long period of time, in relation to what is considered as normative in the respective social, cultural, and religious setting. this aspect is important as it allows a broad range of culturally-related variability. for instance, in traditional western or european cultures, symptoms that present within one year of mourning may be perceived as acceptable within this setting. regarding prevalence rates, studies are still lacking with respect to the new icd-11 criteria. a recent meta-analysis on a preliminary concept of pgd reported a prevalence rate of 9.8% following the violent loss of a close person (lundorff, holmgren, zachariae, farver-vestergaard, & o'connor, 2017). in general, lower rates are expected for icd-11 (e.g., kersting, brahler, glaesmer, & wagner, 2011). adjustment disorder adjustment disorder manifests itself as an intense reaction towards a clearly identifiable psychosocial stressor. typically, it occurs within one month following the starting point of the stressor. a main symptom is the cognitive attachment towards the stressor or its consequences. this can be expressed as excessive worrying, persistent burdensome thoughts about the stressor, and constant rumination. for a diagnosis of adjustment dis‐ order, these symptoms must lead to significant impairment in psychosocial functioning. developments in psychotraumatology 4 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ improved functioning should only be possible with considerable effort. over the course of time, a symptom remission can occur within six months (who, 2018). in contrast to both icd-10 and dsm-5, this new concept of adjustment disorder brings significant changes: first, the core symptoms of preoccupation and failure to adapt are now clearly described and must be present for a diagnosis. and second, in the current formulation, the subtypes of adjustment disorder (e.g., depressive or anxious) were omitted, as previ‐ ous studies showed a high degree of overlap between the subtypes (maercker & lorenz, 2018). regarding prevalence rates, a recent study reported a one-year prevalence of 2% in a representative german sample (glaesmer, romppel, brahler, hinz, & maercker, 2015). however, rates are much higher in risk samples. for instance, rates ranged between 13.8-17.2% in a sample of individuals who had experienced involuntary job loss in swit‐ zerland (perkonigg, lorenz, & maercker, 2018). the above four stress-related diagnoses not only emphasize the considerable im‐ provements in clinical utility (maercker et al., 2013), but also reflect the fact that thera‐ peutic interventions for specific disorders have been developed and evaluated in recent years (schnyder & cloitre, 2015). for ptsd, trauma-focused specific psychotherapeutic interventions that incorporate a variant of exposure show the best evidence for treatment efficacy (e.g., narrative exposure therapy, trauma-focused cognitive-behavioral therapy). for complex ptsd, a phase-based intervention was developed and is currently being evaluated (e.g., cloitre, koenen, cohen, & han, 2002). for prolonged grief disorder, differ‐ ent treatment manuals are available (rosner et al., 2014). lastly, adjustment disorder is also benefitting from new interventions on a low-threshold level (maercker, lorenz, perkonigg, & kapfhammer, 2016). a remaining issue is the different conceptualizations of the disorders, specifically ptsd with respect to dsm-5 and icd-11. recent studies point to the fact that different subgroups of patients are being identified depending on the classification system used (e.g., barbano et al., 2019). however, these discrepancies also offer the opportunity for further scientific discourse. expanding the concept of psychotraumatology today, it is well recognized that traumatic experiences during childhood, such as sexual abuse or physical violence, can have a long-lasting and devastating impact on later life. more recently, less severe types of traumatic experiences, such as verbal abuse, have also gained awareness as a similarly potent form of maltreatment (teicher, samson, polcari, & mcgreenery, 2006). the term adverse childhood experiences (ace) incorporates a much broader range of these exposure types, including emotional or physical neglect, or peer violence. it is evident that some of these maltreatment types extend beyond the definition of a traumatic event, according to the classification of dsm or icd. maercker & augsburger 5 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ consequences of adverse childhood experiences the first systematic investigation of adverse childhood experiences (the so-called ace studies) incorporated a huge sample of 17,300 study participants and were a milestone for later research (anda et al., 2006; dube et al., 2001). for the first time, not only the longterm consequences of exposure to physical or sexual abuse were assessed, but also the impact of a broad range of other experiences, such as emotional abuse, physical or emo‐ tional neglect, and other risk factors in the child’s environment. the ace-studies resul‐ ted in overwhelming evidence for the significant negative impact of these experiences in later life: up to a 3.6-fold increased risk for depressive disorders, 2.4-fold increased risk for anxiety disorders, 2.7-fold increased risk for occurrence of hallucinations, 2.1-fold in‐ crease for sleeping disorders, and 7.2-fold increased risk for alcohol abuse. in addition, risk for somatic complaints was increased by 2.7-fold, and severe obesity showed up to a 1.9-fold increased risk (anda et al., 2006). these ace-studies not only led to the general acknowledgement of the detrimental effects of adverse childhood experiences, but also resulted in the development of standar‐ dized and validated measures to assess aces. today, the childhood trauma question‐ naire is one such questionnaire investigating adverse and traumatic childhood experien‐ ces, and has thus far been used in more than 500 studies (viola et al., 2016). several meta-analyses have provided further evidence and confirmed the risk for the development of mental and somatic diseases and behavioral problems as a result of ad‐ verse experiences (e.g., augsburger, basler, & maercker, in press; hughes et al., 2017; norman et al., 2012). additionally, a meta-review (summarizing previous reviews) on sex‐ ual abuse, demonstrated the devastating impact of sexual abuse on later life, showing an increased risk for a broad range of severe disorders and symptoms (e.g., personality dis‐ orders, eating disorders, psychotic symptoms, sexual dysfunction, and also somatic com‐ plaints, such as pelvic pain or non-epileptic seizures); as well as impairment in social in‐ teractions, and an increased risk for future exposure to sexual violence, but also involve‐ ment in aggressive acts (maniglio, 2009). this last aspect is particularly relevant for the field of pediatric and adolescent psychiatry (anda et al., 2006; augsburger, meyerparlapanis, bambonyé, elbert, & crombach, 2015). however, the sequela of aces also ex‐ pand to geronto-psychiatry, evident in an increased risk for cognitive deficits in older age (burri, maercker, krammer, & simmen-janevska, 2013). modulation of the biological stress response as mentioned above, adverse childhood experiences present an unspecific risk factor for increased vulnerability to later (psycho)pathology. they are assumed to have an impact on biological regulatory mechanisms in the human body. more specifically, exposure to aces may result in a cascade of neuro-endocrine and immunologic alterations that are associated with changes in the brain (nemeroff, 2016; teicher & samson, 2013, 2016). developments in psychotraumatology 6 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ these processes refer to disturbed regulation of the human stress reaction, and the hypo‐ thalamic–pituitary–adrenal axis (hpa axis). accordingly, structural changes are likely to occur in stress-sensitive brain regions with a high density of glucocorticoid receptors, to which the stress hormone cortisol binds (nemeroff, 2016). most evident is an increase in volume of the amygdala, as well as a reduction of the hippocampus, but structural changes in prefrontal regions have also been reported (nemeroff, 2016; teicher & samson, 2016). more recent studies investigating connectivity have demonstrated a strong connection between these brain regions. accordingly, the inhibition of brain re‐ gions, such as the amygdala, that are involved in the processing of fear stimuli, can act in a hyperactive manner. however, different types of adverse experiences can lead to differ‐ ential effects (see norman et al., 2012; teicher & samson, 2016). similarly, brain regions are likely to have sensitive phases during a specific age period, in which they are particu‐ larly vulnerable to the effect of adverse experiences. in addition, there may be a genderspecific component. for instance, the hippocampus of girls appears to be more stress-re‐ sistant than the hippocampus of boys (teicher & samson, 2016). all these aspects can be subsumed under the term “type-and-timing” as they relate to differential effects during specific age periods and for various types of aces (nemeroff, 2016; teicher & samson, 2016). these new developments complement the cumulative ef‐ fects of aces with a dose-response relationship that was reported in the initial acestudies (anda et al., 2006). teicher and samson (2013) even argue in favor of two biologi‐ cally distinct groups of patients with mental disorders that can be differentiated based on their specific neuro-biological alterations: those with exposure to aces and those with‐ out. this assumption has been taken up by other scientists (cf. nemeroff, 2016) and, if proven valid, would result in huge implications for diagnostic procedures as well as the treatment of disorders. whilst findings of altered biological circuits offer a powerful explanation for the longterm impact of aces, many studies rely on cross-sectional data, thus compromising cau‐ sality. however, a limited number of studies also provide evidence from a longitudinal perspective. for instance, trickett, noll, susman, shenk, and putnam (2010) investigated long-term hpa axis activity by assessing cortisol levels in two cohorts of young women with or without exposure to sexual violence, who were followed up from a mean age of 11 until the age of 24. in accordance with previous findings, cortisol levels and trajecto‐ ries between the two cohorts significantly differed. however, the sample size was rather small and potential confounders were not taken into account. epigenetic alterations the field of epigenetics investigates the direct impact of the environment on transcrip‐ tion of the human dna through the process of methylation, without changing the origi‐ nal dna-sequence (marinova et al., 2017; turecki & meaney, 2016). due to its involve‐ ment in the stress reaction, focus is placed on methylation in glucocorticoid receptor maercker & augsburger 7 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ genes (nemeroff, 2016). here, a large number of experimental studies with animals dem‐ onstrate increased methylation to be associated with a lack of maternal care (nemeroff, 2016; turecki & meaney, 2016). regarding humans, similar results have been reported with respect to adverse childhood experiences (nemeroff, 2016). a systematic review in‐ corporating 27 studies with humans supported the assumption of increased methylation, despite different methodological approaches (turecki & meaney, 2016). some researchers argue that alterations in methylation are not specifically induced by aces, but are rather a general effect associated with a broad range of mental disorders. however, previous research has provided evidence that patients with ptsd and addition‐ al exposure to aces showed increased rates of methylation compared to ptsd patients without exposure to aces (pape & binder, 2014). these results are in favor of effects spe‐ cifically induced by aces and support the previously discussed theory of a biologically distinct subtype (cf. teicher & samson, 2016). outlook on aces overall, these findings demonstrate the future potential of research involving biomarkers and epigenetic approaches. epigenetic processes can also aid in the identification of mechanisms involved in the trans-generational transmission of adverse experiences, as indicated by previous studies (yehuda et al., 2016). despite these significant findings, pre‐ mature conclusions should be avoided: many relevant studies did not incorporate poten‐ tial confounding variables, thus weakening causal explanations (nemeroff, 2016). fur‐ thermore, the majority of studies apply cross-sectional research designs, with retrospec‐ tive self-reports of aces (see hughes et al., 2017). regarding type and timing of aces, the heterogeneity of assessments (e.g., different scales, frequency versus severity of events) and restricted sample types further limit generalizability. additionally, epigenetic research itself suffers from methodological constraints: dif‐ ferent extraction methods (e.g., saliva versus serum), as well as non-standardized proce‐ dures for pre-processing, weaken empirical evidence. moreover, the previously men‐ tioned shortcomings in study designs, such as cross-sectional studies and the failure to include mediators, require a cautious interpretation of causality. finally, the implications of these findings for clinical practice remain less clear. nemeroff (2016) highlights two important aspects: first, can these biological alterations be prevented by psychotherapy or pharmacotherapy, if detected early? and second, it needs to be investigated, if these biological alterations are reversible following interven‐ tions. while preliminary studies with animals and also studies with war veterans support this view, evidence is far from conclusive (nemeroff, 2016). in sum, the majority of findings are consistent and provide strong evidence for in‐ creased later vulnerability towards mental disorders, with relative effects for specific types of events. further research is required in order to disentangle potential methodo‐ logical constraints and draw final conclusions. developments in psychotraumatology 8 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ modeling of culturally-specific trauma concepts focusing on european, us-american, and australian ptsd researchers (the so-called “global north”), one aspect that is often neglected concerns the cultural background of patients. thus, it is basically assumed that psychological processes and their social impli‐ cations work in a universal manner across all cultures. however, both clinical practice and (cross)-cultural clinical research still have to demonstrate if these assumptions are valid (hinton & good, 2016; maercker, heim, & kirmayer, 2019). this aspect is particu‐ larly relevant, as many patients with ptsd symptoms grow up in cultures other than the “global north”. examples include individuals from war-affected regions (e.g., afghani‐ stan, iraq, syria), those who have experienced political prosecution (e.g., in the case of the rohingya communities in myanmar in 2017), or natural catastrophes (e.g., banda aceh tsunami in 2004). within the context of the migration and refugee movement affecting europe in 2015, many countries began to tailor their psychological and psychotherapeutic interventions towards these groups (silove, ventevogel, & rees, 2017). however, there is still too little work on culturally-specific adaptations. this may lead to an over-simplification, which may account for the fact that many interventions developed in western communities show less efficacy in other samples, as a recent meta-analysis indicated (thompson, vidgen, & roberts, 2018). consequently, an extension of theoretical models is required, to help explain the development and maintenance of ptsd in a culturally-sensitive manner. thus far, the existence of these models is rather limited (bernardi, engelbrecht, & jobson, 2018; hinton, ojserkis, jalal, peou, & hofmann, 2013; maercker & horn, 2013). in our working group, the socio-interpersonal model of ptsd was developed, which explicitly takes cultural aspects into account (maercker & hecker, 2016; maercker & horn, 2013). more specifically, it works on three levels (cf. filipp & aymanns, 2018): 1. the traumatized individual is an interdependent self in relation to other human beings. this stands in contrast to the independent self – a traditional differentiation in cultural psychology. it is indisputable that the self is never completely independent from its social relations, but is always interdependent, also in individualized societies from the global north. this is mainly relevant with respect to exposure to traumatic events and the frequent arising of specific social emotions, such as guilt and shame, but also anger, rage, and thoughts of revenge. all these emotions reflect the interdependency between the self and others. moreover, the individual’s perception and self-labelling of the traumatic event and its sequela (e.g., “i am traumatized”, “i am diagnosed with ptsd”), relates to the interaction with and comparison to other persons. for example, as a result of this comparison, members maercker & augsburger 9 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ from disadvantaged communities frequently argue that their own personal experiences are not relevant as the whole community is suffering. as a consequence, they do not perceive themselves as individuals seeking help (rechsteiner, maercker, & tol, 2019). 2. the maintenance of trauma-related symptoms is embedded in a dialogical or communicative process. to date, research has mainly focused on procedures of service utilization in order to identify person-related internal and external barriers. here, a shift is needed towards the exploration of possibilities for individuals to selfdisclose their traumatic experiences, as well as the investigation of reactions from other persons towards this disclosure (pielmaier & maercker, 2011). as speechlessness and the inability to verbalize what happened is a significant facet of trauma-related disorders, this dialogue between individuals is essential. the tremendous value of relationships between two people or within a community is therefore reflected by the opportunity for individuals to overcome this speechlessness. on a more basic level, other individuals with similar experiences can additionally provide non-verbal support, resulting in feelings of emotional connection. these aspects fit well with the rationale of narrative exposure therapy, which has been successfully applied in diverse international settings (cf., schauer, neuner, & elbert, 2011). 3. from a broader perspective, the societal and cultural context play a significant role in relation to the impact of traumatic experiences. here the model becomes a sociocultural one, referring to cultural value orientation and religious or traditional cultural beliefs. for instance, cross-cultural studies indicate an association between traditional norms in the society (e.g., conformity, obedience, or benevolence) and increased rates of ptsd after exposure to interpersonal violence (maercker et al., 2009). this leads to the essential question, with great relevance for the respective health care system, if the status of a victim or survivor is ascribed to these affected individuals in their respective society. a refusal of this societal acknowledgement of the survivor status can result in feelings of being left alone, and may lead to increased helplessness, embitterment, and fatalism. this may also contribute to a cycle of ongoing violence in fragile regions, perpetuated by inter-generational transmission (elbert, rockstroh, kolassa, schauer, & neuner, 2006). inevitably, these contextual factors require a culturally-sensitive or even culturally-adapted treatment approach for patients from the “global south” (previously termed “non-western countries”) (dickerson et al., 2018; von lersner & kizilhan, 2017; whealin et al., developments in psychotraumatology 10 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ 2017). this cultural adaptation is visible when certain parameters are considered, such as setting, delivery mode, translation, treatment goals, local conceptualizations of disorders, the use of metaphors, and particularities of relationships (bernal & sáez‐santiago, 2006). currently, there are limited studies that consider the treatment of ptsd or complex ptsd, whilst also taking these aspects into account. however, a recent meta-analysis was published concerning e-mental health of common mental disorders and the so-called scalable psychosocial interventions. it demonstrates that treatment efficacy is linearly and positively associated with the number of culturally-adapted parameters (harper shehadeh, heim, chowdhary, maercker, & albanese, 2016). nevertheless, further research is needed, for instance, concerning culturally appropriate metaphors of adverse events (meili, heim, & maercker, 2018). following this socio-interpersonal model of ptsd, trauma-focused interventions also need to incorporate interventions on a group or community level (maercker & hecker, 2016). this corresponds to the who's demand for new theoretically derived, empirically verifiable interventions for the international arena (tol et al., 2011). public discussions nowadays, the field of psychotraumatology is not only limited to clinical psychology and psychiatry, but extends to the overall society: it is discussed among legal experts, histori‐ ans, anthropologists, politicians, the media, cultural scientists, as well as artists. in the public media, traumatic experiences and its sequela are present on a level similar to de‐ pression and substance abuse. in this section, public aspects of psychotraumatology will be discussed (cf. maercker, 2017, p. 70 et seq.). acknowledgement and compensation of survivors the general public has started to acknowledge the immense damage that traumatic expe‐ riences can cause to individuals’ mental and physical health. this is an important step in order to remedy past failures, for instance, with respect to institutional abuse. in germa‐ ny, austria, and switzerland, round table discussions were initiated and commissioners were implemented for specific topics, in order to collectively process these dark chapters of the past. an example in germany is the round table sexual child abuse in dependent relationships and power relations in private and public institutions and in the family, and the round table residential care in the 50s and 60s. in austria, the position of an independ‐ ent commissioner for victims of the catholic church was implemented in 2010. finally, in switzerland, there is the independent commission of experts on institutional care at the swiss federal parliament. the work of these institutions is based on state-of-the-art sci‐ maercker & augsburger 11 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ entific findings, which also incorporates the recent findings concerning the impact of aces. for instance, an investigation at the university of ulm in germany assessed the current health status of victims of sexual abuse, who were involved in the round table sexual child abuse. they reported a high rate of mental disorders, with 40% depressive disorders, 19% ptsd, and 18% anxiety disorders (spröber et al., 2014). as previously described, it is a political and societal necessity to acknowledge the suf‐ fering of survivor groups that have been previously neglected. however, it is not appro‐ priate to exclusively focus on the high incidence of trauma-related disorders in these groups. it is similarly important to investigate and emphasize results related to resilience, that is, reasons for overcoming traumatic stress. increased public awareness is needed for this second aspect. certainly, this must not imply that financial compensation is only ac‐ cessible for survivors suffering from their traumatic experiences, but must be offered to all survivors. thus, discussions about the criteria that need to be fulfilled in order to gain access to compensation need to continue (maercker & augsburger, 2017). continuous stress and historical aspects of traumatic experiences in the process of re-formulating the icd-11 grouping of disorders specifically associated with stress, a new diagnostic category was discussed: continuous trauma disorder. in many countries and regions, there is no clear onset and end of a traumatic event, but rather a constant and ongoing threat for human life (e.g. somasundaram, 2014). accord‐ ingly, the term “post-traumatic” is not feasible for these regions and the diagnosis of ptsd does not apply, if taken literally. from a biological viewpoint, in these circumstan‐ ces the body is in a state of constant high physiological alertness in order to survive – resulting in impaired body function and significant distress. currently, best-practice sug‐ gestions are available for dealing with these aspects (world health organization, 2016). however, in the relevant icd-11 working group, the incorporation of an entirely new di‐ agnostic concept was rejected, and was instead referred to the areas of emergency psy‐ chology and medicine. related to this is the term “historical trauma”, which describes the experiences of sys‐ tematic violent discrimination, persecution, and extermination of ethnic or religious groups. it is often called “historical” if public acknowledgment is not provided and if an “atonement” is not yet sufficient (kirmayer, gone, & moses, 2014). examples include col‐ lective traumatic experiences of the first nations and african-americans in the us, or the holocaust in europe. more recently, the term has also been used to describe nonman-made mass catastrophes, such as the tsunami in 2004, or the 2011 fukushima nucle‐ ar disaster in japan. some researchers suggest that collective perceptions and pathologi‐ cal alterations in thoughts and behavior emerge following these events, which can be dif‐ ferentiated from symptoms associated with ptsd or similar diagnoses. for instance, somasundaram (2014) reported the following changes, among others, in response to developments in psychotraumatology 12 clinical psychology in europe 2019, vol.1(1), article e30294 https://doi.org/10.32872/cpe.v1i1.30294 https://www.psychopen.eu/ these experiences: general mistrust, suspicion, brutalization, a drop in morals and values, passivity, and negativism. processing of trauma in other public areas perceptions and explanations related to traumatic stress also expand beyond the previ‐ ously discussed aspects and permeate into several other public areas. this is not only re‐ flected by topics such as cultures of memory, and the occurrence of several truth and reconciliation commissions following political violence; but also, art exhibitions featur‐ ing artists that try to process and integrate their biographical experiences and wounds into their artistic work. examples for the latter include the internationally renowned con‐ ceptual artists joseph beuys or marina abramović (see maercker, 2017). not surprisingly, within these settings, the conceptualizations of traumatic stress and psychotraumatology can differ from a scientific point of view. also, in this area, recent developments may not be sustainable. nevertheless, they have the potential to aid and support individuals in overcoming their personal experiences. funding: the authors have no funding to report. competing interests: the first author had previously chaired the work group on “disorders specifically associated with stress” for the icd revision at the world health organization from 2011-2018. however, he did not receive any reimbursement for this work. the views expressed in this article are those of the authors and do not represent the official policies or position of the who. the first author is member of the editorial board of clinical psychology in europe but played no editorial role for this particular article. acknowledgments: the authors have no support to report. general note: this article is a modified and substantially extended version of an article previously published in german (maercker & augsburger, 2017). references american psychiatric association. 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(2017). kultursensitive psychotherapie [cultural sensitive psychotherapy]. göttingen, germany: hogrefe. whealin, j. m., yoneda, a. c., nelson, d., hilmes, t. s., kawasaki, m. m., & yan, o. h. (2017). a culturally adapted family intervention for rural pacific island veterans with ptsd. psychological services, 14(3), 295-306. https://doi.org/10.1037/ser0000186 world health organization. (2016). problem management plus: individual psychological help for adults impaired by distress in communities exposed to adversity. geneva, switzerland: who. world health organization. (2018). icd-11 for mortality and morbidity statistics. retrieved from https://icd.who.int/browse11/l-m/en yehuda, r., daskalakis, n. p., bierer, l. m., bader, h. n., klengel, t., holsboer, f., & binder, e. b. (2016). holocaust exposure induced intergenerational effects on fkbp5 methylation. biological psychiatry, 80(5), 372-380. https://doi.org/10.1016/j.biopsych.2015.08.005 developments in psychotraumatology 18 psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. www.leibniz-psychology.org https://doi.org/10.1176/ajp.2006.163.6.993 https://doi.org/10.1016/j.cpr.2018.06.006 https://doi.org/10.1016/s0140-6736(11)61094-5 https://doi.org/10.1017/s0954579409990332 https://doi.org/10.1016/j.biopsych.2014.11.022 https://doi.org/10.1016/j.chiabu.2015.11.019 https://doi.org/10.1037/ser0000186 https://icd.who.int/browse11/l-m/en https://doi.org/10.1016/j.biopsych.2015.08.005 https://www.leibniz-psychology.org/ https://www.psychopen.eu/ developments in psychotraumatology (introduction) new conceptualizations of stress-related disorders in icd-11 ptsd complex ptsd (cptsd) prolonged grief disorder (pgd) adjustment disorder expanding the concept of psychotraumatology consequences of adverse childhood experiences modulation of the biological stress response epigenetic alterations outlook on aces modeling of culturally-specific trauma concepts public discussions acknowledgement and compensation of survivors continuous stress and historical aspects of traumatic experiences processing of trauma in other public areas (additional information) funding competing interests acknowledgments general note references third wave treatments for functional somatic syndromes and health anxiety across the age span: a narrative review scientific update and overview third wave treatments for functional somatic syndromes and health anxiety across the age span: a narrative review lisbeth frostholm a, charlotte ulrikka rask b [a] research clinic for functional disorders and psychosomatics, aarhus university hospital, aarhus, denmark. [b] child and adolescent psychiatry department, psychiatry, aarhus university hospital, skejby, denmark. clinical psychology in europe, 2019, vol. 1(1), article e32217, https://doi.org/10.32872/cpe.v1i1.32217 received: 2018-12-06 • accepted: 2019-02-13 • published (vor): 2019-03-29 handling editor: winfried rief, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany corresponding author: lisbeth frostholm, research clinic for functional disorders and psychosomatics, aarhus university hospital, aarhus c, denmark. e-mail: lisfro@rm.dk abstract background: functional disorders (fd) are present across the age span and are commonly encountered in somatic health care. psychological therapies have proven effective, but mostly the effects are slight to moderate. the advent of third wave cognitive behavioural therapies launched an opportunity to potentially improve treatments for fd. method: a narrative review of the literature on the application of mindfulness-based therapies (mbt) and acceptance & commitment therapy (act) in children and adult populations with fd. results: there were very few and mainly preliminary feasibility studies in children and adolescents. for adults there were relatively few trials of moderate to high methodological quality. ten mbt randomised trials and 15 act randomised trials of which 8 were internet-delivered were identified for more detailed descriptive analysis. there was no evidence to suggest higher effects of third wave treatments as compared to cbt. for mbt, there seemed to be minor effects comparable to active control conditions. a few interventions combining second and third wave techniques found larger effects, but differences in outcomes, formats and dosage hamper comparability. conclusions: third wave treatments are getting established in treatment delivery and may contribute to existing treatments for fd. future developments could further integrate second and third wave treatments across the age span. elements unambiguously targeting specific illness beliefs and exposure should be included. the benefit of actively engaging close relatives in the treatment not only among younger age groups but also in adults, as well as the effect of more multimodal treatment programmes including active rehabilitation, needs to be further explored. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i1.32217&domain=pdf&date_stamp=2019-03-29 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords functional disorders, functional somatic syndromes, health anxiety, somatic symptom disorder, third wave treatments, mindfulness, acceptance and commitment therapy, narrative review highlights • the methodological quality of third wave interventions for fd should be improved, especially in younger age groups. • the effect of act interventions may be comparable to cbt in adults with fd. • the evidence for third wave interventions in young people with fd is still very limited. • newer studies combining second and third wave treatments show some promise. • agreement on, and for child populations further development of, core outcomes, could help determine effect across studies. functional disorders (fd) can be defined as conditions where the individual’s experiences of physical symptoms cause excessive discomfort and/or worry and where no adequate organ pathology in terms of conventional medical disease can be determined to explain the symptoms (fink & rosendal, 2015). fd are a burden for sufferers and their families, they are difficult to treat and costly as they incur a high health expenditure and derived societal costs (henningsen, zipfel, sattel, & creed, 2018). diagnostic classification functional disorders can clinically be split into two overall categories (see table 1). the first category refers to conditions characterised by bodily distress, a now wellaccepted term to describe the phenomenon of clusters of disabling unspecific bodily symptoms often designated as functional somatic syndromes (fss); the best known being chronic fatigue syndrome (cfs), fibromyalgia/chronic pain (fm/cp) and irritable bowel syndrome (ibs) (fink & schröder, 2010). the second category refers to conditions domi‐ nated by health anxiety (ha), i.e. impairing illness worry and persisting ruminations about harbouring or getting serious illness (fink et al., 2004). although the two catego‐ ries overlap in their clinical presentations and can be comorbid, the primary problem dif‐ fers which has implications for the treatment focus. in the psychiatric classifications icd-10 (who, 1992) and dsm-iv (american psychiatric association, 1994), fd are mainly categorised under somatoform and related disorders. however, the terminology of these diagnoses has been criticised for being too exclusive in their diagnostic criteria as well as over-emphasising a mind-body dualism in contrast to the prevailing understanding of these disorders within an integrated biopsy‐ third wave treatments for functional disorders 2 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ chosocial framework (dimsdale, sharma, & sharpe, 2011; henningsen, zipfel, & herzog, 2007). in the more recent dsm-5 (american psychiatric association, 2013), fd are classi‐ fied primarily as somatic symptom disorders (ssd) with an added category of illness anxiety disorder designated to conditions with ha but without concurrent distressing bodily symptoms (in which case ssd is used). in contrast to icd-10, developmental as‐ pects are to some degree incorporated in dsm-5 as it specifies that in children, a single prominent symptom such as recurrent abdominal pain, headache, fatigue or nausea is more common than in adults. it also emphasises that parents’ response to the symptoms is crucial as this may determine levels of associated distress and the extent to which med‐ ical help is sought. in daily clinical practice, the psychiatric classifications are rarely used, as fd are pri‐ marily diagnosed in primary and specialised somatic health care. thus, each medical spe‐ cialty has developed its own classification leading to the use of a vast number of both unspecific symptom diagnoses as well as the previously mentioned fss diagnoses. as a consequence, management in both the paediatric and adult health care settings is very heterogeneous, often formed by biomedical practices in each medical specialty and often not evidence-based. in addition, it is well-established that excessive biomedical treatment efforts cause iatrogenic harm in these conditions (henningsen et al., 2007; lindley, glaser, & milla, 2005). table 1 two main categories of functional disorders characteristics disorders dominated by bodily distress (fss) health anxiety (ha) primary problem experience of disabling physical symptoms experience of worries and anxiety related to physical sensations functional impairment severe physical disability (e.g. sick leave, bedridden. in children and adolescents often long-term school absence) less severe physical disability (e.g. going to work serves as a distraction from distressing thoughts. in children and adolescents it will often be going to school or playing computer games) typical initial treatment expectations body can be fixed and the symptoms disappear wish for 100% reassurance that they do not harbour a severe or deadly illness. note. fss = functional somatic syndromes; ha = health anxiety. frostholm & rask 3 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ developmental aspects of fd young children usually present a single prominent symptom (domènech-llaberia et al., 2004; rask et al., 2009) such as abdominal pain, headaches, fatigue or muscle pains rather than the varied symptom presentation often seen in adults. the long-term prognosis var‐ ies from complete recovery to persistent symptoms into adulthood. with increasing age, full recovery seems to become more and more unlikely (joyce, hotopf, & wessely, 1997; norris et al., 2017). with respect to ha, key features such as symptom preoccupation and medical help seeking predominate mostly with the parents, although ha-like symptoms may present already in preschool children (rask, elberling, skovgaard, thomsen, & fink, 2012; schulte & petermann, 2011). also, preadolescents can report excessive illness worries with fears, beliefs and attitudes very similar to the cognitive and behavioural features of ha in adults (eminson, benjamin, shortall, woods, & faragher, 1996; rask et al., 2016; van geelen, rydelius, & hagquist, 2015; wright & asmundson, 2003). however, ha is still sparsely examined as a distinct concept in youth. epidemiology across the age span, the severity of both fss and ha varies on a spectrum from mild and moderate to severely disabling conditions. new studies suggest that fss affect 15% of the adult population, whereas approximately 2% of the population has very disabling condi‐ tions (eliasen et al., 2018). in comparison, 4-10% of the general child and adolescent pop‐ ulation experiences daily or high levels of impairing functional symptoms persisting for months or years (hoftun, romundstad, zwart, & rygg, 2011; janssens, klis, kingma, oldehinkel, & rosmalen, 2014; rask et al., 2009). the prevalence estimates for ha vary considerably across studies, but a recent study reported a prevalence of 3.4% (sunderland, newby, & andrews, 2013) in the general population. around 8-9% of the preadolescent general population reports high levels of illness worry (rask et al., 2016), but prevalence estimates for ha as a disorder are not available in young age groups. cognitive behavioural therapies for fd chronicity, severity and multiplicity of symptoms are all predictors of poor prognosis (rosendal et al., 2017). therefore, timely and evidence-based treatment is essential for improving the long-term physical, psychosocial and financial consequences. across age groups, patient-activating therapies are the most promising treatments, and cognitive be‐ havioural therapy (cbt) has so far been the most prevailing in intervention studies (abbott et al., 2018; bonvanie et al., 2017; henningsen et al., 2018). while moderate to large effect sizes (es) have been reported for cbt-based treatment for ha (hedman et al., 2011; newby et al., 2018; thomson & page, 2007; weck, neng, schwind, & hofling, third wave treatments for functional disorders 4 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ 2015), improvements are only small to moderate for fss in adults (henningsen et al., 2018; van dessel et al., 2014). in children and adolescents, the use of cbt for ha has only been reported in a single case study (roberts-collins, 2016). with regard to fss, existing studies have almost ex‐ clusively focused on cbt-based treatments for single symptoms or syndromes; primarily functional abdominal symptoms, chronic fatigue, tension-type headache, fibromyalgia or mixed pain complaints in children as young as 6 years of age (abbott et al., 2018; bonvanie et al., 2017). overall, the es are found to be somewhat larger than the corre‐ sponding estimates in adult studies (bonvanie et al., 2017). this may indicate that chil‐ dren and adolescents are more susceptible to psychological treatments than adults or that young people present less chronic and/or severe fss. however, the results should be in‐ terpreted with caution as the majority of these studies are quite small and heterogeneous with regard to e.g. inclusion criteria, setting, dose and type of delivered treatment and therapist experience (abbott et al., 2018; bonvanie et al., 2017). overall, these results, especially as to fss, suggest that the efficacy of existing psy‐ chological treatments for fd could be improved. this has spurred interest in studies ex‐ ploring the potential of the newer third wave behavioural therapies for these disorders. treatment with third wave psychological therapies for fd mindfulness-based therapies (mbt) mbt translate meditation from buddhism and other spiritual practices into clinical inter‐ ventions. while classical cbt approaches tend to prioritise changing the content of pri‐ vate experiences like thoughts, mbt emphasise the awareness of thoughts, feelings and sensations as transient events that can potentially be problematic but do not have to be. thus, compared to cbt, there is no explicit focus on behavioural activation or modifica‐ tion. in most interventions, mindfulness is taught in groups emphasising an experiential format with sharing of experiences in the enquiry phase after formal meditations. the most well-known mbt programmes are mindfulness based stress reduction (mbsr) and mindfulness based cognitive therapy (mbct). the primary homework in most mbt is daily mindfulness practice. mbt are proposed to work through at least four processes: 1) attention regulation, 2) body awareness, 3) emotion regulation and 4) change in self-perspective (hölzel et al., 2011) (see figure 1). frostholm & rask 5 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ figure 1. a model of proposed processes in mindfulness-based therapies. note. adapted from hölzel et al., 2011. mbt could potentially change the perception of bodily symptoms through changes in in‐ teroception at a subconscious level and carry reductions in negative appraisal of symp‐ toms. furthermore, mbt might improve emotion regulation, which is proposed to play a prominent role in fss (dahlke, sable, & andrasik, 2017) and as a by-product reduce co‐ morbid anxiety and depression. in ha especially, one may hypothesise that mindfulness exercises can function as a direct exposure to anxiety-provoking bodily sensations and that the development of a more non-judgmental and accepting stance towards these bod‐ ily sensations may alleviate the symptom experience. acceptance and commitment therapy the overarching goal of act is to increase psychological flexibility, defined as the ability to stay in contact with the present moment regardless of unpleasant thoughts, feelings and bodily sensations, while choosing one’s behaviours based on the situation and per‐ sonal values. in act, there are specific assumptions regarding the role of language for how human beings tend to handle ‘the universal experience of pain’ (loss, illness, con‐ flict, and trauma) with avoidance of inner experience (hayes, luoma, bond, masuda, & lillis, 2006). act proposes six core therapeutic processes which interact to promote psychological flexibility (see figure 2). experiential techniques such as mindfulness, defusion, meta‐ phors and self-as-context exercises are used to illustrate and teach these processes. com‐ pared to mbt, the kinship with second wave cognitive behavioural therapies is more ob‐ vious both in terms of format and content, e.g. the use of functional analyses, in which third wave treatments for functional disorders 6 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ behaviours are analysed in terms of shortand long-term consequences (hayes, 2016) and the focus on commitment to behaviour change. figure 2. a model of the six core processes of act. note. adapted from hayes et al., 2006. specifically for fss, a main treatment focus in act is on a behavioural shift from control and avoidance behaviours to choosing values-based actions even when aversive symp‐ toms are present. acceptance of bodily symptoms might both increase the engagement in behaviour change and lead to a reduction in symptom experience. in ha, where rumina‐ tions about bodily sensations are prominent (see table 1), the focus on defusion from dis‐ tressing illness-related thoughts could be helpful in alleviating the anxiety attached to ill‐ ness labels such as cancer or sclerosis. functional analysis may help foster a clearer un‐ derstanding of the negative long-term effects of control and avoidance behaviours typical for ha (e.g. bodily checking and seeking information on symptoms on the internet). the evidence-base for mbt and act for ha and fss an overview of the search methods and criteria for selection of studies for the current paper is provided in table 2. frostholm & rask 7 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ table 2 search methods and criteria for selection of studies • publications on treatment outcome using acceptance & commitment therapy or mindfulness-based therapies for health anxiety and various functional somatic syndromes were identified in searches performed in september 2018 on pubmed by the help of a research librarian. • the database was searched for english language studies using the terms 'third wave' or 'mindfulness-based stress reduction' or 'mindfulness-based cognitive therapy' or 'mbct' or 'mbsr' or 'acceptance and commitment therapy' or 'mindfulness' combined with 'chronic pain' or 'fibromyalgia' or 'fatigue syndrome' or 'irritable bowel syndrome' or 'abdominal pain' or 'functional gastrointestinal disorders' or 'somatoform disorders' or 'health anxiety' or 'hypochondriasis' or 'illness anxiety disorder' or 'somatic symptom disorder'. • for studies on adult populations, the search was restricted to systematic reviews and the reference lists of included studies were examined for additional eligible studies. the web of science was used for forward citation to identify additional papers. only studies which randomised ≥50 patients were includeda. with regard to chronic pain populations, studies were excluded if a substantial part of the population did not have an idiopathic or functional pain condition. pure online self-help programmes with no therapist contact were not included. • for child and adolescent papers the search terms were further combined with the terms 'child' or 'adolescent' or 'youth or 'paediatrics' or 'minor' or 'juvenile' or 'teen'. based on the overall small number of studies no restriction was here applied with regard to study type. • the methodological quality of the studies, including randomised controlled trials were rated using the psychotherapy outcome study rating scale (öst, 2008). athis cut-off was set in order to exclude studies which would better be classified as pilot trials (bell, whitehead, & julious, 2018). evidence for ha in adults and children mbt for ha the first preliminary results on the use of mbt in adults with ha were encouraging as a pilot study found significant improvements of mbct on disease-related thoughts and so‐ matic symptoms at 3-month follow-up (lovas & barsky, 2010), and a qualitative study re‐ ported mbct adapted to ha to be acceptable for the patients (mcmanus, surawy, muse, vazquez-montes, & williams, 2012; williams, mcmanus, muse, & williams, 2011). in the following rct (mcmanus et al., 2012), 74 patients were randomised to either mbct in addition to usual unrestricted service or usual unrestricted services alone (table 3). third wave treatments for functional disorders 8 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ ta bl e 3 o ve rv ie w o f i nc lu de d rc t st ud ie s tr ea tm en t fo rm at & do se c om pa ri so n se tt in g c on di ti on m ai n in cl us io n cr it er ia ex cl us io n cr it er ia d ur at io n of sy m pt om s/ di so rd er (s d )a d ia gn os ed co m or bi di ty a a ge , y (s d )a females % n o of su bj ec ts ra nd om is ed (d ro po ut a t la te st f u ) ig |c g m ai n ou tc om es b quality score (0-42) h a a du lt s tu di es m cm an us e t a l. (2 01 2) ; u k m bc t 1 in di vi du al se ss io n pl us 8 gr ou p se ss io ns ta u un iv er sit y se tti ng h a d ia gn os is of hy po ch on dr ia sis ac co rd in g to d sm iv -t r su bs ta nc e ab us e • s ev er e ps yc hi at ric co m or bi di ty • u ns ta bl e ps yc ho tro pi c m ed ic at io n 8.8 y (1 0.2 ) 50 %| 47 % 41 .3 (1 2.0 )| 43 .9 (1 1.0 ) 78 36 |38 (4 )|( 2) fu (1 2 m o) : h a co m po sit e (c om bi na tio n of se lfre po rt an d cl in ic ia n ra te d) : + (e s: 0 .48 ) 30 ei le nb er g et a l. (2 01 6) ; d en m ar k ac t 10 g ro up se ss io ns w l sp ec ia lis ed cl in ic fo r fu nc tio na l di so rd er s, un iv er sit y ho sp ita l h a se ve re h a a cc or di ng to cr ite ria b y fi nk e t al . ( 20 04 )) se ve re p sy ch ia tri c c om or bi di ty • o th er so m at ic /p sy ch ia tri c co nd iti on p rim ar y • p re gn an cy 10 .0 y (1 0.3 )| 11 .0 y (1 0.5 ) 60 %| 52 % 37 .0 (9 .9) | 35 .5 (7 .6) 71 63 |63 (1 1) |(8 ) fu (1 0 m o) : ill ne ss w or ry : + (e s: 0 .89 ) 24 m bt : f ss a du lt s tu di es a st in e t a l. (2 00 3) ; u sa m bs r/ q ig on g 8 gr ou p se ss io ns ed uc at io n su pp or t g ro up un iv er sit y se tti ng fm cl in ic al d ia gn os is of fm su bs ta nc e ab us e • s ev er e ps yc hi at ric co m or bi di ty • i m pe nd in g lit ig at io n/ ju dg m en t fo r d isa bi lit y co m pe ns at io n • s ev er e ch ro ni c m ed ic al co nd iti on • pr eg na nc y 4.9 y (4 .2) | 5.2 y (7 .3) n o of o th er di ag no se s: 2.2 (1 .6) | 2.0 (2 .0) 47 .7 (1 0.6 ) 99 64 |64 (to ta l: 63 ) fu (2 m o) : te nd er p oi nt co un t ( m ya lg ic sc or e) : = pa in a nd fu nc tio ni ng : = d ep re ss io n: = m ed ic al ca re : = 20 g ay lo rd e t a l. (2 01 1) ; u sa m bs r 8 gr ou p se ss io ns p lu s on e ha lfda y re tre at so ci al su pp or t gr ou p nr ib s ph ys ic ia n di ag no sis ac co rd in g to r o m eii cr ite ria m aj or p sy ch ia tri c d iso rd er • s ev er e ga st ro in te st in al w el lde fin ed il ln es s • p re gn an cy nr nr 44 .7 (1 2.5 )| 41 .0 (1 4.7 ) 10 03 6|3 9 (2 )|( 7) fu (3 m o) : ib s se ve rit y: + (e s: n r) h rq o l: + (e s: n r) 16 sc hm id t e t a l. (2 01 1) ; g er m an y m bs r 8 gr ou p se ss io ns p lu s 7 hr w or ks ho p ac tiv e co nt ro l gr ou p to co nt ro l fo r n on -s pe ci fic fa ct or s, or w l in te rd isc ip lin ar y pa in u ni t, un iv er sit y m ed ic al ce nt er fm d ia gn os is ac co rd in g to a cr cr ite ria pa rti ci pa tio n in o th er cl in ic al tri al • li fe -th re at en in g di se as e • s up re ss ed im m un e fu nc tio ni ng 14 .3 y (1 0.2 ) nr 52 .5 (9 .6) 10 05 9|5 9|5 9 (1 2) |(1 0) |(3 ) fu (2 m o) : fm im pa ct : = h rq o l: = 25 va n r av es te ijn e t a l. (2 01 2) ; n et he rl an ds m bs r 8 gr ou p se ss io ns p lu s 6 hr si le nt d ay co m bi ne d eu c an d w l un iv er sit y se tti ng fr eq ue nt at te nd an ce in g p fo r pe rs ist en t m us ≥ 6 m o sy m pt om du ra tio n sy m pt om s f ul ly ex pl ai ne d by m ed ic al co nd iti on • su bs ta nc e ab us e • m aj or p sy ch ia tri c di so rd er • co gn iti ve im pa irm en t • p rio r m bc t tre at m en t nr 81 % ≥ on e ph ys ic al di se as e 35 % an xi et y an d/ or de pr es sio n 47 .6 (1 1) | 46 .5 (1 2) 74 64 |61 (1 5) |(1 2) fu (9 m o) : ge ne ra l h ea lth st at us (v a s) : = sf 36 p cs : = sf 36 m cs : = 19 frostholm & rask 9 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ tr ea tm en t fo rm at & do se c om pa ri so n se tt in g c on di ti on m ai n in cl us io n cr it er ia ex cl us io n cr it er ia d ur at io n of sy m pt om s/ di so rd er (s d )a d ia gn os ed co m or bi di ty a a ge , y (s d )a females % n o of su bj ec ts ra nd om is ed (d ro po ut a t la te st f u ) ig |c g m ai n ou tc om es b quality score (0-42) ze rn ic ke e t a l. (2 01 3) ; c an ad a m bs r 8 gr ou p se ss io ns p lu s 3 hr w or ks ho p w l un iv er sit y se tti ng ib s o n st ab le m ed ic at io n se lfre po rte d di ag no se s o f m oo d, a nx ie ty , o r p sy ch ot ic di so rd er s • u se o f p sy ch ot ic s • p rio r p ar tic ip at io n in m bs r nr nr 45 .0 y (1 2.4 )| 44 .0 y (1 2.6 ) 90 43 |47 (2 3) |(1 3) fu (6 m o) : ib sse ve rit y: = ib sq o l: = 16 fj or ba ck e t a l. (2 01 3) ; d en m ar k m bs r 8 gr ou p se ss io ns p lu s 3 hr fo llo w -u p se ss io n eu c sp ec ia lis ed cl in ic fo r fu nc tio na l di so rd er s, un iv er sit y ho sp ita l m ul tior ga n bd s (i. e., m ul tip le fs s) d ia gn os is ac co rd in g to re se ar ch cr ite ria fo r b d s (f in k & sc hr öd er , 2 01 0) su bs ta nc e ab us e • m aj or ps yc hi at ric d iso rd er • pr eg na nc y12 .0 y (1 0.6 )| 15 .0 y (1 2.6 ) 22 %| 20 % m aj or de pr es sio n 24 %| 23 % an xi et y 38 .0 (9 .0) | 40 .0 (8 ) 80 59 |60 (1 3) |(1 6) fu (1 2 m o) : sf 36 p cs : = h rq o l: = 28 c as h et a l. (2 01 5) ; u sa m bs r 8 gr ou p se ss io ns p lu s ha lfda y m ed ita tio n re tre at w l un iv er sit y se tti ng fm ph ys ic ia nve rif ie d di ag no sis • a bl e to at te nd se ss io ns nr nr 73 % m ed ic al co m or bi di ty in cl ud in g ch ro ni c fa tig ue sy nd ro m e pe rim en op au sa l (a ge n r) 10 05 1|4 0 (1 0) |(1 3) fu (2 m o) : fm im pa ct q ue st io nn ai re , p hy sic al fu nc tio ni ng (p f) : = fm im pa ct q ue st io nn ai re , p ai n se ve rit y (p s) : + (e s: 0 .62 ) 13 la c ou r et a l. (2 01 5) ; d en m ar k m bs r 9 gr ou p se ss io ns p lu s 4½ h r f ol lo w up se ss io n w l sp ec ia lis ed p ai n cl in ic , un iv er sit y ho sp ita l n on sp ec ifi c ch ro ni c pa in co nd iti on s nr un st ab le m ed ic at io n • c og ni tiv e im pa irm en t 7.8 y (5 .2) | 11 .8 y (1 1.1 ) nr 46 .5 (1 2.4 )| 48 .8 (1 2.2 ) 72 54 |55 (1 4) |(2 2) pt (n o fu fo r c om pa ris on ): sf 36 v ita lit y sc or e: + (e s: 0 .39 ) pa in se ve rit y (p s) : = 14 a c t: f ss a du lt s tu di es w et he re ll et a l. (2 01 1) ; ac t 8 gr ou p se ss io ns cb t 8 gr ou p se ss io ns pr im ar y ca re se tti ng ch ro ni c no nm al ig na nt pa in ≥ 6 m on th s pa in in te rfe re nc e an d se ve rit y ≥ 5 on 1 0 po in t s ca le su bs ta nc e ab us e or m aj or ps yc hi at ric d iso rd er w ith in pr ev io us 6 m on th s • in te rfe rin g m ed ic al co nd iti on s • c ur re nt ly in p sy ch ot he ra py fo r p ai n 15 .0 y (1 3.5 ) 54 % cu rr en t ps yc hi at ric di so rd er 55 .0 (1 2.5 ) 51 57 |57 (6 )|( 8) fu (6 m o) : br ie f p ai n in ve nt or y sh or t f or m (b pi ), in te rfe re nc e sc al e: = sf 12 : = 28 m cc ra ck en e t a l. (2 01 3) ; u k ac t 4 gr ou p se ss io ns ta u pr im ar y ca re se tti ng m ix ed ch ro ni c pa in co nd iti on s ≥ 3 m o pa in if gp ju dg ed fu rth er m ed ic al te st s a nd p ro ce du re s n ec es sa ry • c on di tio ns in te rfe rin g w ith pa rti ci pa tio n in tr ea tm en t 10 .0 y (n r) 81 % ≥ on e co m or bi d di so rd er (so m at ic o r ps yc hi at ric ) 58 .0 (1 2.8 ) 69 37 |36 (9 )|( 8) fu (3 m o) : d isa bi lit y: + (e s: 0 .37 ) sf 36 p hy sic al fu nc tio ni ng : = d ep re ss io n: = pa in in te ns ity : = 19 bu hr m an e t a l. (2 01 3) ; s w ed en ac t 7 gu id ed on lin e m od ul es p lu s 2 ph on e ca lls o nl in e di sc us sio n fo ru m an d w l pa in c en tre , un iv er sit y ho sp ita l ch ro ni c pa in m ed ic al in ve st ig at io n w ith in p as t y ea r • i m pa irm en t c au se d by p ai n o ng oi ng m ed ic al in ve st ig at io ns or tr ea tm en t w hi ch co ul d in te rfe re w ith tr ea tm en t • a cu te ph ys ic al o r p sy ch ia tri c co nd iti on s 15 .3 y (1 1.7 ) 57 % m ed ic al co nd iti on 58 % ps yc hi at ric pr ob le m 49 .1 (1 0.3 ) 59 38 |38 (6 )|( 6) pt (n o fu fo r c om pa ris on ): ch ro ni c p ai n ac ce pt an ce q ue st io nn ai re (c pa q ): + (e s: 0 .41 ) pa in in te rfe re nc e: + (e s: 0 .56 ) 18 third wave treatments for functional disorders 10 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ tr ea tm en t fo rm at & do se c om pa ri so n se tt in g c on di ti on m ai n in cl us io n cr it er ia ex cl us io n cr it er ia d ur at io n of sy m pt om s/ di so rd er (s d )a d ia gn os ed co m or bi di ty a a ge , y (s d )a females % n o of su bj ec ts ra nd om is ed (d ro po ut a t la te st f u ) ig |c g m ai n ou tc om es b quality score (0-42) lu ci an o et a l. (2 01 4) ; s pa in ac t 8 gr ou p se ss io ns pr eg ab al in p lu s du lo xe tin e/ ot he r m ed ic at io ns , o r w l pr im ar y ca re se tti ng fm n o ph ar m ac ol og ic al tre at m en t • n o ps yc ho lo gi ca l tre at m en t d ur in g pr ev io us y ea r se ve re p sy ch ia tri c o r m ed ic al di so rd er s, dr ug /a lc oh ol a bu se 13 .0 y 25 % de pr es sio n 49 (6 .0) | 47 .8 (5 .9) | 48 .3 (5 .7) 96 51 |52 |53 (6 )|( 8) |(6 ) fu (6 m o) : fm im pa ct q ue st io nn ai re : + • a ct v s m ed ic at io n: (e s: 1 .43 ) • a ct v s. w l: (e s: 2 .11 ) pa in ca ta st ro ph iz in g: + • a ct v s m ed ic at io n: (e s: 0 .69 ) • a ct v s. w l: (e s: 0 .72 ) 27 tr om pe tt er e t a l. (2 01 5) ; h ol la nd ac t 9 gu id ed on lin e m od ul es ex pr es siv e w rit in g, o r w l un iv er sit y se tti ng ch ro ni c pa in pa in in te ns ity ≥ 4 • p ai n ≥ 3 da ys p er w ee k fo r ≥ 6 m o lo w p sy ch ol og ic al in fle xi bi lit y • l ow p sy ch ol og ic al d ist re ss & se ve re p sy ch ol og ic al d ist re ss • m aj or d ep re ss iv e di so rd er • c on cu rr en t c bt -b as ed tre at m en t ≥ 5 y du ra tio n: 59 %| 70 %| 61 % rh eu m at ic di se as e: 10 %| 8% |12 % 52 .9 (1 3.3 )| 52 .3 (1 1.8 )| 53 .2 (1 2.0 ) 76 82 |79 |77 (2 9) |(2 9) |(1 3) fu (6 m o) : pa in in te rfe re nc e: • g ui de d ac t vs . e xp re ss iv e w rit in g: + (e s: 0 .47 ) • g ui de d ac t vs . w l: = 24 k em an i e t a l. (2 01 5) ; s w ed en ac t 12 g ro up se ss io ns a pp lie d re la xa tio n sp ec ia lis ed p ai n cl in ic , un iv er sit y ho sp ita l m ix ed p ai n co nd iti on s ≥ 6 m o pa in co nc ur re nt c bt -b as ed tre at m en t • m aj or p sy ch ia tri c di so rd er • n ot a bl e to fi ll in qu es tio nn ai re s 9.9 y (7 .5) 20 % m aj or de pr es sio n • 2 0% g en er al an xi et y • 1 8% so ci al p ho bi a • 1 8% p an ic di so rd er 40 .3 (1 1.4 ) 73 30 |30 (1 1) |(1 2) fu (6 m o) : pa in d isa bi lit y: + (e s: 0 .63 ) h rq o l: = 31 li n et a l. (2 01 7) ; g er m an y ac t gu id ed o nl in e in tro p lu s 7 m od ul es n on -g ui de d on lin e ac t, o r w l h ea lth in su ra nc e pr ov id er ch ro ni c pa in ≥ 6 m o pl us in te rfe re nc e co m pu te r l ite ra cy tu m or -r el at ed p ai n • o ng oi ng or p la nn ed p sy ch ol og ic al p ai n in te rv en tio n • e le va te d su ic id e ris k 11 4.5 m o (1 21 ) 57 .3% m ed ic al co nd iti on s • 3 9.4 % m en ta l co nd iti on s 51 .7 (1 3.1 ) 84 10 0|1 01 |10 1 (4 6) |(4 5) |(2 6) fu (6 m o) : pa in in te rfe re nc e: • g ui de d ac t vs w l: + (e s: 0 .58 ) • g ui de d vs u ngu id ed a ct : = ph ys ic al fu nc tio ni ng : = 22 pe de rs en e t a l. (2 01 8) ; d en m ar k ac t 9 gr ou p se ss io ns br ie f a ct (g ro up w or ks ho p pl us 1 in di vi du al co ns ul ta tio n) , o r eu c sp ec ia lis ed cl in ic fo r fu nc tio na l di so rd er s, un iv er sit y ho sp ita l m ul ti or ga n bd s (i. e., m ul tip le fs s) d ia gn os is ac co rd in g to re se ar ch cr ite ria fo r b d s (f in k & sc hr öd er , 2 01 0) su bs ta nc e ab us e • m aj or ps yc hi at ric d iso rd er • pr eg na nc y9.8 y (8 .8) | 9.9 y (7 .3) | 9.3 y (6 .7) 22 % 38 .8 (8 .0) | 38 .7 (8 .6) | 40 .1 (8 .5) 82 59 |61 |60 (1 5) |(1 1) |(1 4) fu (1 4 m o) : se lfra te d gl ob al h ea lth im pr ov em en t (c gi ): + sf 36 p cs : = 25 si m is te r et a l. (2 01 8) ; c an ad a ac t 7 on lin e m od ul es ta u un iv er sit y se tti ng fm • se lfre po rte d pa in > 3 (0 -1 0) d ia gn os is ac co rd in g to a cr cr ite ria m aj or p sy ch ia tri c d iso rd er • s ev er e so m at ic d ise as e • c hr on ic fa tig ue sy nd ro m e 10 .2 y (7 .8) nr 39 .7 (9 .4) 95 33 |34 (8 )|( 9) fu (3 m o) : fm im pa ct q ue st io nn ai re re vi se d (f iq r) : + (e s: 1 .59 ) 6m in ut e w al k te st : = 18 frostholm & rask 11 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ tr ea tm en t fo rm at & do se c om pa ri so n se tt in g c on di ti on m ai n in cl us io n cr it er ia ex cl us io n cr it er ia d ur at io n of sy m pt om s/ di so rd er (s d )a d ia gn os ed co m or bi di ty a a ge , y (s d )a females % n o of su bj ec ts ra nd om is ed (d ro po ut a t la te st f u ) ig |c g m ai n ou tc om es b quality score (0-42) sc ot t e t a l. (2 01 8) ; u k ac t 45 m in in di vi du al se ss io n pl us 8 on lin e m od ul es p lu s 45 m in in di vi du al se ss io n ta u pa in m an ag em en t ce nt re , un iv er sit y ho sp ita l co m pl ex ch ro ni c pa in >3 m o pl us d ist re ss an d di sa bi lit y pr ev io us a ct o r c bt fo r p ai n • o th er cu rr en t p sy ch ol og ic al tre at m en t • s ev er e ps yc hi at ric di so rd er m ed ia n 6.8 y (ra ng e 0.8 -4 7.5 ) nr 45 .5 (1 4) 65 31 |32 (8 )|( 6) fu (9 m o) : fe as ib ili ty : + pa tie nt g lo ba l i m pr es sio n of ch an ge (p ci g) : = pa in in te rfe re nc e: + (e s: 0 .4) 20 c om bi ne d se co nd a nd th ir d w av e: f ss a du lt s tu di es lj ót ss on e t a l. (2 01 0) ; s w ed en cb t ba se d on ex po su re a nd m in df ul ne ss ex er ci se s (ic bt ), 5 on lin e m od ul es o nl in e di sc us sio n fo ru m un iv er sit y ho sp ita l s et tin g ib s pr io r d ia gn os ed w ith ib s by p hy sic ia n • f ul fil r o m eiii ib s cr ite ria d isp la yi ng "a la rm sy m pt om s" fo r o rg an ic g as tro en te ro lo gi ca l di se as e • c ur re nt o r p re vi ou s in fla m m at or y bo w el d ise as e • l ac to se o r g lu te n in to le ra nc e no t p ro pe r c or re ct ed w ith d ie t • s ub st an ce a bu se • m aj or ps yc hi at ric d iso rd er • < 2 y of ib s sy m pt om s 6.3 y (7 .3) nr 34 .6 (9 .4) 85 43 |43 (5 )|( 0) pt (n o fu fo r c om pa ris on ): ib s sy m pt om se ve rit y (g sr sib s) : + (e s: 1 .21 ) ib s to ta l p ai n: + (e s: 0 .64 ) ib sq o l: + (e s: 0 .93 ) 22 lj ót ss on e t a l. (2 01 1) ; s w ed en ic bt 5 on lin e m od ul es in te rn et de liv er ed st re ss m an ag em en t un iv er sit y ho sp ita l s et tin g ib s pr io r d ia gn os ed w ith ib s by p hy sic ia n • f ul fil r o m eiii ib s cr ite ria d isp la yi ng "a la rm sy m pt om s" fo r o rg an ic g as tro en te ro lo gi ca l di se as e • c ur re nt o r p re vi ou s in fla m m at or y bo w el d ise as e • l ac to se o r g lu te n in to le ra nc e no t p ro pe r c or re ct ed w ith d ie t • s ub st an ce a bu se • m aj or ps yc hi at ric d iso rd er • < 2 y of ib s sy m pt om s 14 .9 y (1 1.2 ) nr 38 .9 (1 1.1 ) 79 98 |97 (1 1) |(1 5) fu (6 m o) : ib s sy m pt om se ve rit y (g sr sib s) : + (e s: 0 .44 ) ib sq o l: (e s: 0 .31 ) 28 lj ót ss on e t a l. (2 01 4) ; s w ed en ic bt 5 m od ul es ic bt w ith ou t ex po su re co m po ne nt un iv er sit y ho sp ita l s et tin g ib s pr io r d ia gn os ed w ith ib s by p hy sic ia n • f ul fil r o m eiii ib s cr ite ria d isp la yi ng "a la rm sy m pt om s" fo r o rg an ic g as tro en te ro lo gi ca l di se as e • c ur re nt o r p re vi ou s in fla m m at or y bo w el d ise as e • l ac to se o r g lu te n in to le ra nc e no t p ro pe r c or re ct ed w ith d ie t • s ub st an ce a bu se • m aj or ps yc hi at ric d iso rd er • i ns uf fic ie nt la ng ua ge o r co m pu te r s ki lls 15 .9 y (1 2.4 ) nr 42 .4 (1 4.5 ) 80 15 6|1 53 (2 1) |(1 9) fu (6 m o) : ib s sy m pt om se ve rit y (g sr sib s) : + (e s: 0 .48 ) ib sq o l: (e s: 0 .26 ) 28 k le in st au be r et a l. (in p re ss ); g er m an y cb t w ith em ot io n re gu la tio n tra in in g (e n ce rt ), in di vi du al 20 -2 5 se ss io ns co nv en tio na l cb t 7 un iv er sit y m en ta l h ea lth ou tp at ie nt cl in ic s ss d d ia gn os is ac co rd in g to d sm -5 su bs ta nc e ab us e • m aj or ps yc hi at ric d iso rd er • sp ec ifi c ty pe s o f p sy ch op ha rm ac ol og ic al tre at m en t 14 .6 y (2 .9) 50 .4% 43 .4 (1 2.9 ) 64 12 7|1 28 (3 8) |(3 6) fu (6 m o) : sy m pt om se ve rit y: = d isa bi lit y: = 35 third wave treatments for functional disorders 12 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ tr ea tm en t fo rm at & do se c om pa ri so n se tt in g c on di ti on m ai n in cl us io n cr it er ia ex cl us io n cr it er ia d ur at io n of sy m pt om s/ di so rd er (s d )a d ia gn os ed co m or bi di ty a a ge , y (s d )a females % n o of su bj ec ts ra nd om is ed (d ro po ut a t la te st f u ) ig |c g m ai n ou tc om es b quality score (0-42) fs s ch ild s tu dy w ic ks el l e t a l. (2 00 9) ; s w ed en ac t 10 in di vi du al se ss io ns , 1 -2 pa re nt al se ss io ns m ul tid isc ip lin ar y tre at m en t sp ec ia lis ed p ai n cl in ic , un iv er sit y ho sp ita l m ix ed p ai n sy nd ro m es ≥ 3 m o pa in ex pl ai ne d by o rg an ic p at ho lo gy • m aj or p sy ch os oc ia l o r ps yc hi at ric is su es • m aj or co gn iti ve d ys fu nc tio ns • a lre ad y cb t tre at m en t • p re vi ou s a m itr ip ty lin e tre at m en t 32 m o (n r) nr 14 .8 (2 .4) 78 16 |16 (3 )|( 5) fu (4 .7 m o) : d isa bi lit y (f d i: pa re nt & ch ild ve rs io n) : = pa in -r el at ed fe ar (p a ir s) : + (e s: 0 .29 ) pa in in te rfe re nc e: = sf 36 p cs : = sf 36 m cs : = 20 n ot e. a cr = a m er ic an c ol le ge o f r he um at ol og y; a ct = a cc ep ta nc e an d co m m itm en t t he ra py ; b d s = bo di ly d ist re ss s yn dr om e; cb t = co gn iti ve b eh av io ur al th er ap y; c g = co nt ro l g ro up ; e s = ef fe ct s iz e; eu c = en ha nc ed u su al c ar e; fd i = f un ct io na l d isa bi lit y in ve nt or y; f m = f ib ro m ya lg ia ; f ss = f un ct io na l s om at ic sy nd ro m es ; f u = fo llo w -u p; g p = ge ne ra l p ra ct ic e; h a = h ea lth a nx ie ty ; h rq o l = h ea lth -r el at ed q ua lit y of l ife ; i bs = ir rit ab le b ow el s yn dr om e; ig = in te r‐ ve nt io n gr ou p; m bc t = m in df ul ne ss b as ed c og ni tiv e th er ap y; m bs r = m in df ul ne ss b as ed s tre ss r ed uc tio n; m bt = m in df ul ne ss -b as ed th er ap ie s; m cs = m en ta l co m po ne nt s um m ar y; m us = m ed ic al ly u ne xp la in ed s ym pt om s; nr = n ot re po rte d; p a ir s = pa in a nd im pa irm en t r el at io ns hi p sc al e; pc s = ph ys ic al c om po ne nt su m m ar y; p t = po st t re at m en t; sf 36 /1 2 = 36 -it em /1 2ite m s ho rt fo rm h ea lth s ur ve y; q o l = q ua lit y of l ife ; s sd = s om at ic s ym pt om d iso rd er ; t a u = tr ea tm en t as u su al ; v a s = vi su al a na lo gu e sc al e; w l = w ai t l ist . a n um be rs e ith er sh ow n fo r t he to ta l s tu dy sa m pl e or fo r e ac h tre at m en t a rm . b pl us si gn (+ ) i nd ic at es im pr ov em en t i n fa vo ur o f t he in te rv en tio n gr ou p, e qu al si gn (= ) in di ca te s n o ef fe ct . i f s ev er al fo llo w -u ps th e la te st ti m epo in t i s r ep or te d. frostholm & rask 13 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ a medium es of 0.48 was reported at one-year follow-up, which is at the lower end com‐ pared to existing cbt approaches. however, the drop-out rate was only 3%, which is no‐ ticeably lower than rates reported in some of the cbt-based treatments for ha (e.g. 25% from cbt in greeven et al. (greeven et al., 2007) and 35% from cbt in visser & bouman (visser & bouman, 2001)). act for ha only one rct study using act for ha has been reported (eilenberg, fink, jensen, rief, & frostholm, 2016) (table 3). the rct was preceded by an uncontrolled pilot study sug‐ gesting that act group therapy may be an effective and acceptable treatment of ha (eilenberg, kronstrand, fink, & frostholm, 2013). for the larger controlled study, the be‐ tween-group effect sizes were large (es = 0.89), and the treatment programme was well accepted by the patients. thus, only 9 out of 135 eligible participants declined participa‐ tion, and the drop-out rate in the act treatment was low as only 4 (6%) out of 63 pa‐ tients discontinued and one never attended the treatment. the programme was recently translated into an internet-based format, iact for ha, with promising feasibility and ef‐ ficacy reported in a pilot study (hoffmann, rask, hedman-lagerlof, ljótsson, & frostholm, 2018). the results from a subsequent larger rct with inclusion of 101 pa‐ tients randomized to either iact or an active control condition with an internet-deliv‐ ered discussion forum are pending (hoffmann, 2018). the literature search revealed no published treatment studies using any of the above approaches for children and adoles‐ cents with ha. evidence for fss in adults mbt for fss eight studies were located (table 3). three were on fm (astin et al., 2003; cash et al., 2015; schmidt et al., 2011). one study focused on chronic pain (la cour & petersen, 2015), 2 on ibs (gaylord et al., 2011; zernicke et al., 2013), 1 on persistent mus (van ravesteijn, lucassen, bor, van weel, & speckens, 2013) and 1 on multi-organ bds (fjorback et al., 2013). the smaller study on fm population found a potentially clinically relevant effect on symptom severity (cash et al., 2015) of the mbsr program compared to treatment as usu‐ al (tau). the two larger studies on fm (astin et al., 2003; schmidt et al., 2011) which both included an active control condition, an education support group and an education support including stretching and relaxation training, found no differences in their main outcomes (table 3). schmidt et al. thus concluded that mbsr cannot be recommended as a treatment for fm (schmidt et al., 2011). the study on chronic pain (la cour & petersen, 2015) used an mbsr programme on top of usual care in a hospital-based pain clinic and found moderate effects on the main third wave treatments for functional disorders 14 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ outcome of vitality, symptoms of anxiety and depression and control over pain immedi‐ ately post-treatment but did not include long-term outcomes. the two studies on ibs (gaylord et al., 2011; zernicke et al., 2013) both used mbsr and randomised 75 and 90 patients respectively. both studies found clinically relevant within-group changes on the ibs symptom severity and other outcome measures. how‐ ever, in the zernicke study (zernicke et al., 2013), which had a 6-month follow-up as op‐ posed to 3 months in the gaylord study (gaylord et al., 2011), there was no significant difference between the mbsr and the waitlist at this final follow-up. a dutch study on high utilizers with persistent medically unexplained symptoms in primary care employed mbct and found no effect on their primary outcome of general health status nine months after end of treatment. this also applied for the secondary out‐ comes except for the mindfulness skills of observing and describing (van ravesteijn et al., 2013). the other study in the more severe spectrum (fjorback et al., 2013) was also nega‐ tive as there was no difference between the two groups even though the mbsr group had improved more on the main outcome of sf-36 physical component summary to‐ wards the end of the active treatment period, whereas the enhanced treatment as usual caught up during the 1-year follow-up. act for fss the majority of act studies in fss have been conducted in chronic pain populations in‐ cluding fm, and the number of participants is surprisingly small. in the two most recent reviews on act for chronic pain, only five of 11 studies (veehof, trompetter, bohlmeijer, & schreurs, 2016) and six of 10 studies (hughes, clark, colclough, dale, & mcmillan, 2017) respectively randomised at least 50 participants. when including these larger trials, seven act studies were located for chronic pain, three of which were face-to-face (kemani et al., 2015; mccracken, sato, & taylor, 2013; wetherell et al., 2011) and four of which were guided internet-delivered studies (buhrman et al., 2013; lin et al., 2017; scott, chilcot, guildford, daly-eichenhardt, & mccracken, 2018; trompetter, bohlmeijer, veehof, & schreurs, 2015). two studies were specifically on fm of which one was face-to-face (luciano et al., 2014) and one guided internet-delivered (simister et al., 2018). for multiple fss, one study was located (pedersen et al., 2018). that is, all in all 10 studies on fss of which five were internetdelivered. on top of the above distinct act interventions, one very recent study examined cbt with or without added acceptance-based emotion-regulation strategies for multiple medi‐ cally unexplained symptoms (kleinstauber et al., in press). finally, three consecutive studies from one research group examined internet-delivered acceptance-based exposure therapy for ibs (ljótsson et al., 2010; ljótsson et al., 2011; ljótsson et al., 2014). kemani and colleagues (kemani et al., 2015) randomised 60 patients with chronic pain to either 12 90-minute weekly group sessions of act or applied relaxation (ar) but only frostholm & rask 15 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ obtained 6-month follow-up data on 37 participants. they found significantly larger ef‐ fects of the act intervention immediately post-treatment on pain disability, but the ar group caught up in the follow-up period. a pilot rct of a 4x4-hour primary care based act group intervention for chronic pain found only small effects compared to treatment as usual (mccracken et al., 2013). wetherell (wetherell et al., 2011) compared group cbt to the same amount of group act, all in all 12 hours, and overall found small and compa‐ rable effects of the two conditions on all outcomes (wetherell et al., 2011). interestingly, they found that participants assigned to cbt rated this as more credible after the first session, whereas act participants reported more satisfaction at the end of treatment. four studies examined the effect of guided internet-delivered act for chronic pain randomising 76, 238, 302, and 63 participants, respectively (buhrman et al., 2013; lin et al., 2017; scott et al., 2018; trompetter et al., 2015). the two largest trials were threearmed (lin et al., 2017; trompetter et al., 2015) (table 3). both of these studies found clin‐ ically relevant improvements of small to moderate effect of the act intervention com‐ pared to the control conditions, although the trompetter study found unexpected im‐ provements in the waitlist control (ibid). the results from these two larger internet-based studies were generally supported by the two smaller studies (buhrman et al., 2013; scott et al., 2018), even though the buhrman study (buhrman et al., 2013) included a large number of outcome measures given the small sample size. the two studies on fm both found promising effects (luciano et al., 2014; simister et al., 2018). a group-based intervention carried out at primary health care centres in spain was found superior on most outcome measures at 6-month follow-up compared to both recommended pharmacological treatment and to a waitlist control with large effects on fibromyalgia impact (luciano et al., 2014). this finding was generally supported by the smaller study randomising 67 participants to either online act or treatment as usual (simister et al., 2018). pedersen et al. (pedersen et al., 2018) conducted a tree-armed intervention study ex‐ amining group-based act with a brief act intervention (group workshop + individual session) and enhanced care (pedersen et al., 2018) for patients with multiple fss. they found effect of extended act on the primary outcome of patient-rated overall health im‐ provement 14 months after randomisation but failed to replicate this finding on any of the secondary outcomes such as illness, worry, emotional distress and health-related quality of life. a german multicentre study included patients with multiple medically unexplained symptoms (kleinstauber et al., in press) and compared two active treatments, namely conventional cbt for fss, which mainly focused on causing and maintaining factors and encert: encert was cbt with a primary focus on negative emotions as cause and consequence of fss. this treatment arm included emotion regulation strategies such as acceptance and mindfulness-based strategies and cognitive reappraisal (ibid). they found medium to high effects on most outcomes in both conditions but also superior outcomes third wave treatments for functional disorders 16 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ of encert on a number of secondary outcomes such as health anxiety, symptom dis‐ tress and emotion regulation skills. finally, a series of three studies on the same treatment programme for ibs (ljótsson et al., 2010; ljótsson et al., 2011; ljótsson et al., 2014) combined acceptance strategies with mindfulness training and exposure. in the first modules of the treatment, they intro‐ duced mindfulness training and acceptance of symptoms together with a psychological model of ibs with the core message that behaviours which serve to avoid or control symptoms often increase the intensity of, and attention given to, symptoms (ljótsson et al., 2010). the last phase of the treatment introduced exposure such as attending contexts where symptoms normally occur, exercises to provoke symptoms and abolishment of be‐ haviours to control the occurrence of symptoms (ibid.). they found high effects of this treatment compared to an online discussion forum (ljótsson et al., 2010). in a subsequent study, the treatment was found superior with medium effect sizes on several outcomes compared to stress management, which emphasised symptom control through relaxation, dietary changes and problem-solving skills (ljótsson et al., 2011). finally, in a disentan‐ glement study, they examined the effect of the intervention with and without the final exposure phase of the treatment programme and found a medium effect size in favour of the inclusion of systematic exposure (ljótsson et al., 2014). evidence for fss in children and adolescents mbt for fss our search identified 8 studies on mbt for fss in children; the first study published in 2013 (jastrowski mano et al., 2013). the studies were generally small (n, range 6-21). most used pilot designs and mainly examined a developmentally adapted version of the mbsr programme in tertiary care settings on children and adolescents in the age range from 12 to 18 years with mixed chronic pain conditions. only one smaller study has been on young patients with various fss including chronic fatigue (ali et al., 2017). attrition and recruitment problems were described in five of the studies (hesse, holmes, kennedy-overfelt, kerr, & giles, 2015; jastrowski mano et al., 2013; lovas et al., 2017; ruskin, gagnon, kohut, stinson, & walker, 2017; ruskin, kohut, & stinson, 2015) as well as problems with obtaining sufficient post test data to draw valid conclusion about outcome (ruskin, gagnon, kohut, stinson, & walker, 2017). however, three other recent studies indicate better feasibility results with low attrition and high acceptability but het‐ erogeneous results when it comes to potential efficacy (ali et al., 2017; chadi et al., 2016; waelde et al., 2017). ali et al. (ali et al., 2017) conducted an open trial on 18 adolescents with various fss and found preliminary evidence for the mbsr programme with regard to improvement of functional disability, symptom impact and anxiety with consistency between parent and child measures. chadi et al. (chadi et al., 2016) evaluated a combina‐ tion of mbsr and mbct on 20 female adolescents who were randomised to either an in‐ tervention group or a waitlist control group. they reported no improvements in psycho‐ frostholm & rask 17 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ logical or pain symptoms but did find significant reductions in pre and post-mindfulness session salivary cortisol levels. waelde et al. (waelde et al., 2017) conducted an open trial on 20 adolescents with chronic pain who received a six-week group intervention based on an adult programme named 'inner resources for stress' combining meditation practi‐ ces, breath-focused cue word repetition and visualisation. functional disability and fre‐ quency of pain complaints improved with small effect sizes (d = 0.2-0.3). though parents in the study did not receive any specific interventions, their worry about their child’s pain decreased with a large effect size (d = 0.75). act for fss also with regard to act, the evidence is still sparse in younger age groups. we identified 6 act studies (gauntlett-gilbert, connell, clinch, & mccracken, 2013; kanstrup et al., 2016; kemani, kanstrup, jordan, caes, & gauntlett-gilbert, 2018; wicksell, dahl, magnusson, & olsson, 2005; wicksell, melin, lekander, & olsson, 2009; wicksell, melin, & olsson, 2007) including only one smaller rct (wicksell et al., 2009) (table 3). a sev‐ enth study included several modalities, i.e. cbt, act and multi-family therapy (huestis et al., 2017). all studies relate primarily to adolescents diagnosed with various types of chronic idiopathic pain and four were performed at the same research centre. wicksell et al. were the first to describe an act-oriented outpatient intervention in young patients with high levels of pain-related disability; first in a case study (wicksell et al., 2005), next in a case series on 14 adolescents (wicksell et al., 2007) and subsequently in an rct on 32 adolescents (mean age 14.8 yrs). the rct compared 10 sessions of act and one to two parent sessions with a multidisciplinary treatment including amitripty‐ line medication (wicksell et al., 2009). overall significant improvements with decreased disability were observed in all three studies, and specifically in the rct, effects in favour of act were seen post-treatment in pain-related fear, pain interference and in quality of life. however, prolonged treatment in the control group complicated comparisons be‐ tween the groups at follow-up assessments where all primary outcomes except pain-rela‐ ted fear became comparable (table 3). the same research group later compared different formats of an extended version of this act programme, provided either individually (n = 18) or as group-based treatment (n = 12). medium to large effects post-treatment were reported in both formats on pain interference, depression, pain reactivity and psychologi‐ cal flexibility as well as in parent pain reactivity and psychological flexibility post-treat‐ ment (kanstrup et al., 2016). in an uncontrolled trial (gauntlett-gilbert et al., 2013), 98 adolescents (mean age 15.6 yrs) with non-malignant pain underwent a 3-week residential multidisciplinary act treatment (approx. 90 hrs) in a specialised setting. the programme comprised physical conditioning, activity management and psychotherapy with promotion of acceptance of pain and related distress as well as engagement in values-consistent behaviour. parent in‐ volvement was included in most sessions. the adolescents improved in self-reported third wave treatments for functional disorders 18 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ functioning and objective physical performance at a 3-month follow-up. they were less anxious and catastrophic, attended school more regularly and used health care facilities less often. the programme was re-evaluated on another 164 patients as regards both ado‐ lescent and parental variables and the relationship between parental psychological flexi‐ bility and adolescent pain acceptance (kemani et al., 2018). as in the former study, results indicated positive effects on the adolescents' functioning and pain acceptance but also a significant positive relationship between changes in parental psychological flexibility and adolescent pain acceptance. a last study from 2017 describes the utility and outcomes of a multimodal interven‐ tion (captives) including cbt, act and multi-family therapy in 17 youth (aged 13-17 years) with chronic pain and their parents (huestis et al., 2017). the programme included weekly concurrent 60 min. youth and parent groups, concluded with an additional 30 min. multi-family group session. the families found the programme engaging and con‐ structive and large effects were reported on pain catastrophising, acceptance and protec‐ tive parenting. similar effects were found for functional disability, pain interference, fati‐ gue, anxiety and depression. recently, a study protocol describing the design of a large rct comparing groupbased act with enhanced usual care for adolescents with various fss was published (kallesøe et al., 2016). however, the results are still pending (personal communication). discussion even though third wave treatments are employed increasingly, there are still relatively few intervention studies in adults of moderate to high methodological quality in fd. thus, in the updated 2016 review (veehof et al., 2016) of a 2011 review (veehof, oskam, schreurs, & bohlmeijer, 2011) on acceptance and mindfulness-based interventions, the authors concluded that the study quality had not improved in the five years since the first review, a finding supported by öst's review on act for a broad range of conditions (öst, 2014). as is the case with many emerging treatments, most studies in children and adolescents are small and uncontrolled in design. evidence for third wave treatment in ha for ha, the only two third wave rcts on adults found a medium effect of mbct tailored to ha (mcmanus et al., 2012) and high effect of act (eilenberg et al., 2016). there were no studies in children or adolescents. again, more studies are needed to replicate the findings from the above studies, especially the promising results of the act study, which reported high es on the primary outcome and medium to high effect on most secondary outcomes and high retention of patients. it is worth noting that this study did, together with the vast majority of act interventions, include elements from second wave cbt frostholm & rask 19 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ such as psychoeducation using the vicious circle of anxiety and interoceptive exposure http://funktionellelidelser.dk/fileadmin/www.funktionellelidelser.au.dk/publikationer/ act_manual.pdf with regard to younger age groups, ha is an emerging topic in the scientific litera‐ ture. integrating potential early childhood and family risk factors can help inform the de‐ velopment of specialised third wave therapies in children and adolescents (thorgaard, frostholm, & rask, 2018) as well as for parents with so-called health anxiety by proxy (thorgaard et al., 2017), i.e. parents who present with excessive and seemingly unreason‐ able concern about their child's symptoms. evidence for third wave treatment in fss overall, there seems to be only minor effects of mbt in fss. these findings are in line with the conclusions from a meta-analytic review that es were higher for act therapies compared to mbt for the majority of the examined outcomes (veehof et al., 2016). some of the mbt studies in both adults and younger age groups are hampered by attrition, which may also suggest that mbt does not offer an alternative to second wave treat‐ ments in terms of retention. the two studies on mbt for ibs in adults (gaylord et al., 2011; zernicke et al., 2013) might suggest a bigger potential for this subgroup of patients given the clinically relevant change on the main outcome, but the effects may be transi‐ ent. in children, there may be recruitment and retention problems for mbt programmes if the intervention is not properly modified and tailored according to developmental as‐ pects. children and adolescents in general require more explanation and rationale, short‐ er formal exercises (e.g. around 3-5 min compared to 20-45 min in adults) as well as a greater variety of practices if they are to engage fully (perry-parrish, copeland-linder, webb, & sibinga, 2016; thompson & gauntlett-gilbert, 2008). from a clinical viewpoint, quite a few patients seem to benefit from mbt formats, and some of the target processes such as body awareness and emotional regulation could have promise. however, the mindfulness training may need to be embedded with other methods to prevent attrition and to increase effect. there is no evidence to suggest that act is superior to cbt in fss. more high quality studies are needed to conclude whether act is just as effective as cbt since the smaller studies, which have been included in many reviews, inherently have an increased risk of bias. there seems to be a potential in act-based therapist-guided internet-delivered in‐ terventions with a number of studies in chronic pain conditions reporting effects compa‐ rable to that of face-to-face interventions. especially noteworthy here are the studies on acceptance-based exposure-based therapy for ibs (ljótsson et al., 2010; ljótsson et al., 2011), where acceptance-based techniques, mindfulness training and strict exposure training are combined to produce consistently large effects, and where the exposure ele‐ ment has been shown to add considerable effect (ljótsson et al., 2014). further studies third wave treatments for functional disorders 20 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 http://funktionellelidelser.dk/fileadmin/www.funktionellelidelser.au.dk/publikationer/act_manual.pdf http://funktionellelidelser.dk/fileadmin/www.funktionellelidelser.au.dk/publikationer/act_manual.pdf https://www.psychopen.eu/ could potentially benefit from tailoring symptom-specific exposure in the context of ac‐ ceptance methods. for conditions characterised by multiple symptoms from several organ systems, it was likewise the study which combined conventional cbt with third wave methods that had more convincing results (kleinstauber et al., in press). worth noting here is the dos‐ age of treatment with 20-25 individual sessions as compared to e.g. 9 group sessions in the other trial on multiple symptoms (pedersen et al., 2018). a secondary analysis of a group-based cbt intervention for multiple fss (schröder, sharpe, & fink, 2015b) found higher effect in the subgroup of patients with fewest symptoms. this suggests that illness severity should be taken into account when designing interventions, and more extensive interventions may be needed in the severe spectrum of fss. with regard to children, the evidence is surprisingly low with small and mostly un‐ controlled studies on paediatric chronic pain conditions. therefore, it remains unclear whether observed effects reflect differences in samples, designs, instruments used, meth‐ od of analysis or actual effects of different treatment modalities. however, the emphasis on experiential exercises and metaphors in act may render this approach particularly appropriate for children. concepts that would normally be too abstract for children can become accessible through experience and metaphorical language (coyne, mchugh, & martinez, 2011; murrell, coyne, & wilson, 2004). still, larger and well-designed trials are needed to compare act to cbt interventions to examine the potential superiority of this approach in youth with fss. involvement of family and close relatives in third wave treatment the paediatric studies specifically emphasised inclusion of caregivers in treatment. this is supported by a number of studies reporting that parents may inadvertently reinforce maladaptive illness perceptions and illness behaviours in their child (chow, otis, & simons, 2016; guite, mccue, sherker, sherry, & rose, 2011; palermo, valrie, & karlson, 2014; simons, smith, kaczynski, & basch, 2015). engaging parents may both help them ameliorate their own concerns and teach them how to reinforce and model adaptive be‐ haviours. recent studies have shown improvements in parental psychological flexibility of an 8-week act group programme (wallace, woodford, & connelly, 2016) and a onesession mbt workshop (ruskin, campbell, stinson, & ahola kohut, 2018) in parents of children with chronic pain, i.e. parents' abilities to accept their distress about their child's suffering and to focus on broader goals rather than being absorbed by worries about whether their child's pain improved. in adult patients with fss (cfs), their illness also seems to have a negative impact on the family (higgins et al., 2015; leonard & cano, 2006), and partners' responses may even influence the course of the disorder (schmaling, smith, & buchwald, 2000). dynamic management involving family systems and close relatives to promote adaptive function‐ frostholm & rask 21 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ ing, quality of life and resilience may therefore also be an interesting focus for future studies on adults. potential challenges with third wave treatment for fd, there is agreement that illness beliefs play a prominent role and that changes in beliefs such as perceived control (christensen, frostholm, ornbol, & schröder, 2015) and fear-avoidance beliefs (chalder, goldsmith, white, sharpe, & pickles, 2015) have been found to mediate the effect of cbt. one may speculate that there is a risk that the third wave meta-cognitive processes aimed at a general shift in perspective on inner experi‐ ence and the self may not sufficiently address the specific cognitive beliefs that may per‐ petuate the symptoms for each individual patient. this risk may be further enhanced by the fact that all the included act studies, which were not internet-based, were groupbased (kemani et al., 2015; luciano et al., 2014; mccracken et al., 2013; pedersen et al., 2018; wetherell et al., 2011). group-based therapy may have advantages in terms of pro‐ viding support, promoting social skills and mirroring processes etc. but may also have risks in terms of not properly addressing the specific needs of each patient. large differences exist in use of outcome domains making it difficult to compare stud‐ ies. some act studies have used pain interference and pain acceptance as primary out‐ comes taking the point of departure that greater acceptance of symptoms and less inter‐ ference of the pain in daily life are essential goals in act. even though that may ring true from a theoretical perspective, we need more knowledge of the clinical importance of such changes. other studies use syndrome-specific outcomes, hampering the compara‐ bility between syndromes. including as a minimum the two numeric analog scale items on symptom intensity and symptom interference recommended by the european net‐ work on somatic symptom disorders in future adult trials (rief et al., 2017) could have a major impact on the interpretation and comparability of studies. these scales encompass both the third wave focus on decreasing interference of symptoms as well as symptom reduction (see figure 3). for children and adolescent populations, the availability of validated questionnaires is ex‐ tremely scant, and much more work is needed to develop and test such measures. third wave treatments for functional disorders 22 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 https://www.psychopen.eu/ figure 3. two numeric rating scales recommended in future trials for fd. note. the scales are available at http://links.lww.com/psymed/a408 in more than 20 languages. conclusion and perspectives in sum, the evidence for third wave behavioural approaches for fd are still limited when it comes to larger controlled studies and very sparse and almost non-existing in younger age groups. there may have been hype surrounding the advent of third wave treatments which have hampered the ability among researchers and clinicians to communicate accu‐ rately about the advantages and disadvantages of these methods (van dam et al., 2018). especially for children and adolescents, much progress remains to be made in empirically evaluating the effectiveness of third wave treatment. thus, cbt-based programs still have much better evidence for this age group (bonvanie et al., 2017). there is often an unfortunate division between researchers and clinicians who study and treat adults with fd and those who work with children and adolescents with the same disorders. joint efforts with mutual exchange of experiences and results could pave the way for further development of existing programmes such as the involvement of the family system in adult programmes. even though the field of fd will continue to be challenged by problems with diagnos‐ tic classification, agreement on joint outcomes across syndrome diagnoses and possibly more dismantling studies using e.g. single-case designs and/or experimental studies could also be a way forward to further explore which patient characteristics are compatible with certain approaches and techniques, both when it comes to children, adolescents and adults. finally, more studies explicitly combining methods from second and third wave ap‐ proaches may be a promising avenue for patients across the age span. frostholm & rask 23 clinical psychology in europe 2019, vol.1(1), article e32217 https://doi.org/10.32872/cpe.v1i1.32217 http://links.lww.com/psymed/a408 https://www.psychopen.eu/ funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. references abbott, r. a., martin, a. e., newlove-delgado, t. v., bethel, a., whear, r. s., thompson coon, j., & logan, s. 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(2013). mindfulness-based stress reduction for the treatment of irritable bowel syndrome symptoms: a randomized wait-list controlled trial. international journal of behavioral medicine, 20(3), 385-396. https://doi.org/10.1007/s12529-012-9241-6 frostholm & rask 33 psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. www.leibniz-psychology.org https://doi.org/10.1016/j.janxdis.2015.05.008 https://doi.org/10.1016/j.pain.2011.05.016 https://doi.org/10.1016/s1077-7229(05)80069-0 https://doi.org/10.1016/j.pain.2008.11.006 https://doi.org/10.1016/j.ejpain.2006.02.012 https://doi.org/10.1111/j.2044-8260.2010.02000.x https://doi.org/10.1080/16506070310014691 https://doi.org/10.1007/s12529-012-9241-6 https://www.leibniz-psychology.org/ https://www.psychopen.eu/ third wave treatments for functional disorders (introduction) diagnostic classification developmental aspects of fd epidemiology cognitive behavioural therapies for fd treatment with third wave psychological therapies for fd mindfulness-based therapies (mbt) acceptance and commitment therapy the evidence-base for mbt and act for ha and fss evidence for ha in adults and children evidence for fss in adults evidence for fss in children and adolescents discussion evidence for third wave treatment in ha evidence for third wave treatment in fss involvement of family and close relatives in third wave treatment potential challenges with third wave treatment conclusion and perspectives (additional information) funding competing interests acknowledgments references the role of psychotherapy in the german health care system: training requirements for psychological psychotherapists and child and adolescent psychotherapists, legal aspects, and health care implementation politics and education the role of psychotherapy in the german health care system: training requirements for psychological psychotherapists and child and adolescent psychotherapists, legal aspects, and health care implementation nikolaus melcop ab, thomas von werder b, nina sarubin b, andrea benecke ac [a] federal chamber of psychotherapists, berlin, germany. [b] bavarian chamber of psychotherapists, munich, germany. [c] chamber of psychotherapists of rhineland-palatinate, mainz, germany. clinical psychology in europe, 2019, vol. 1(4), article e34304, https://doi.org/10.32872/cpe.v1i4.34304 received: 2019-03-05 • accepted: 2019-10-27 • published (vor): 2019-12-17 handling editor: anton-rupert laireiter, university of vienna, vienna, austria corresponding author: nikolaus melcop, bavarian chamber of psychotherapists, postfach 151506, d-80049 münchen, germany. tel.: 0049-89-515555-17. e-mail: melcop@ptk-bayern.de abstract in germany every citizen must acquire either public or private health insurance from companies which then cover the expenses for psychotherapeutic in-patient and out-patient treatments within a given set of regulations. since the commencement of the psychotherapists' law in 1999, psychological psychotherapists and child and adolescent psychotherapists are permitted to diagnose and treat mental disorders with psychotherapy under their own responsibility as a legally defined healing profession. psychotherapists have to use scientifically approved psychotherapeutic approaches for treatment. the qualification and licensure of psychotherapists are highly regulated by the psychotherapists' law, which is currently undergoing a process of change. keywords german mental health care system, psychotherapists' law, qualification and licensure, psychological psychotherapists, child and adolescent psychotherapists, guidelines for psychotherapy, federal chamber of psychotherapists, planning for demand this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i4.34304&domain=pdf&date_stamp=2019-12-17 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • 2.86 million patients are in outpatient or inpatient psychotherapeutic care per year in germany, tendency rising. • psychotherapeutic care is highly regulated, only scientifically approved approaches are admitted. • psychological and child and adolescent psychotherapists treat patients under their own responsibility. • future courses of study and advanced training for psychotherapists will be similarly structured to those of the medical profession. in germany with its 83 million inhabitants expenditures on health in 2015 totalled 343.5 billion euros, equalling 11.3% of the gross domestic product (gesundheitsberichterstattung des bundes, 2017). the costs caused directly by mental and behavioural disorders amounted to 44.3 billion euros (statistisches bundesamt, 2015). mental health care is becoming increasingly more important. health insurance is provided through either public or private health insurance. public health insurance is open to everybody, regardless of whether they are employed, self-em‐ ployed, or unemployed. german citizens who are mentally or physically ill are entitled to all available treatments necessary for healing. mental health care mental health care in germany is mainly provided by office-based psychotherapists, psy‐ chiatrists and eligible medical doctors, psychiatric hospitals, psychosomatic clinics and psychiatric outpatient clinics. in addition rehabilitation centres, community mental health care centres, and different types of residential facilities provide a broad spectrum of nonmedical vocational, residential, and psychosocial counselling services (salize, rössler, & becker, 2007). sundmacher et al. (2018) calculated that 1.9 million patients per year are treated in outpatient psychotherapeutic care. gallas, kächele, kraft, kordy, and puschner (2008) found a median therapy duration of 16 months, ranging from 13 months (cognitive be‐ havioral therapy) to 24 months (psychoanalytic psychotherapy). approximately a further 960,000 patients per year are treated in psychiatric and psychosomatic inpatient care. the average treatment duration for mental disorders in hospitals in 2017 was 24.2 days in to‐ tal, 27.4 days for female and 21.2 days for male patients, respectively (augurzky, hentschker, pilny, & wübker, 2018), with huge differences between psychiatric (23.8 days) and psychosomatic (42.9 days) inpatient care (statistisches bundesamt, 2017). psychotherapy in the german health care system 2 clinical psychology in europe 2019, vol.1(4), article e34304 https://doi.org/10.32872/cpe.v1i4.34304 https://www.psychopen.eu/ access to mental health care is basically free of (extra) charges for most people in germany which is an uncommon feature among member states of the european union (strauß, 2009). regulations for psychotherapists unlike some other european countries clinical psychology is not an independent profes‐ sion in germany. in 1999 the legal basis was laid for psychologists to ultimately practice independently and on their own authority. in germany the profession of psychotherapist has been regulated by law since 1999 (gesetz über die berufe des psychologischen psychotherapeuten und des kinderund jugendlichenpsychotherapeuten, psychthg, 1999). the psychotherapists' law (german: psychotherapeutengesetz, psychthg) regu‐ lates the practice of psychotherapy as well as the qualification and licensing procedure of nonmedical professions, e.g., psychologists. in this article, we specifically focus on the le‐ gal requirements for training and licensing psychological psychotherapists and child and adolescent psychotherapists. for medical doctors there are different regulations. the law (psychthg, 1999) legally created two new professions, namely psychological psychotherapists and child and adolescent psychotherapists (who are allowed to treat on‐ ly children and adolescents under the age of 21). in 2018 this law was undergoing a major change and will be set into place by the end of 2019. according to the new law in future there will be only one profession called psychotherapist. the old and the new law define psychotherapy as a practice using scientifically ap‐ proved psychotherapeutic approaches for the assessment, cure, or alleviation of mental disorders. this has implications for postgraduate training because the scientific advisory council for psychotherapy, which is formed in equal parts by scientific representatives of psychotherapists and specialised medical doctors, has currently only approved psycho‐ analysis, psychodynamic psychotherapy, cognitive behavioural therapy, and family ther‐ apy for the treatment of mental disorders. for the treatment of injuries or illnesses of the brain neuropsychological therapy is approved. consequently, students are restricted to becoming licensed in the aforementioned approaches. qualification and licensure – the current status according to the "old law" currrently the qualification of psychological psychotherapists and child and adolescent psychotherapists is regulated separately for each profession (ausbildungsund prüfungsverordnung für kinderund jugendlichenpsychotherapeuten, kjpsychth-aprv, 1998; ausbildungsund prüfungsverordnung für psychologische psychotherapeuten, psychth-aprv, 1998). academic social workers and educators who have obtained a master's degree complete an equivalent postgraduate training in child melcop, von werder, sarubin, & benecke 3 clinical psychology in europe 2019, vol.1(4), article e34304 https://doi.org/10.32872/cpe.v1i4.34304 https://www.psychopen.eu/ and adolescent psychotherapy, but the educational framework is identical to that of psy‐ chological therapists. overall, the qualification process has to have a minimum duration of three (full-time) or five (part-time) years of postgraduate specialist practical training in psychotherapy and certification in an approved psychotherapeutic approach. this long-term, postgradu‐ ate training for psychotherapists is unique within the european union (strauß & kohl, 2009). in order to register for the state examination, psychotherapists in training need to complete four modules comprising theoretical education, practical internships, practical supervised training, and self-experience (see table 1). in particular, students have to com‐ plete 600 hours of continuing coursework, 1,800 hours of clinical experience in an inpa‐ tient setting (a minimum of 1,200 hours in a psychiatric hospital and 600 hours in a reha‐ bilitation hospital or in a licensed outpatient setting), 600 supervised outpatient treat‐ ment sessions of at least 6 patients (including 150 hours of accompanying supervision), and an additional 930 hours of unspecified psychotherapy-related coursework. further‐ more, self-experience plays an important role in the training of psychotherapists, as fu‐ ture psychotherapists are required to complete 120 hours of one-to-one or group sessions or a mixture of both settings. in practice the described demands in training can be signifi‐ cantly higher, i.e. for the psychoanalytic approach. after these requirements are met, psychotherapists in training then need to pass a state examination comprising a written and an oral exam. after passing the state exami‐ nation, candidates are licensed. this structured postgraduate training in psychotherapy is organised by universities and state-licensed institutes. in total, 254 postgraduate training programs were offered by 215 state-licensed educational institutes and 39 universities (unith e.v., 2018). nearly 2,700 students took part in the written state exams in 2016, 1,900 for a license in psychological psychotherapy and around 800 for child and adolescent psychotherapy. this shows an increase of 17% of graduates compared to 2015 and an in‐ crease of 61% compared to the previous five-year period. qualification and licensure in the future the german psychotherapists' law had to undergo long-overdue adjustments and an ed‐ ucational reform for several reasons. the first reason is that the current graduation sys‐ tem is not adjusted to the structure of bachelor and master degrees which was not imple‐ mented in germany in higher education until 2013. the federal state government agen‐ cies need more precise legal specifications to be able to fulfil their statutory responsibili‐ ties (i.e. standardised admission requirements to the postgraduate training) and thus en‐ sure a high-quality standard of postgraduate psychotherapy training nation-wide. anoth‐ er area that needs significant improvement is the very low level of payment during post‐ graduation training. at the moment their legal employment status is not properly regula‐ ted (wissenschaftsrat, 2018). additionally psychotherapists in training have substantial psychotherapy in the german health care system 4 clinical psychology in europe 2019, vol.1(4), article e34304 https://doi.org/10.32872/cpe.v1i4.34304 https://www.psychopen.eu/ financial expenditures. students have to pay between 20,000 and 30,000 euros on average in tuition fees (strauß et al., 2009). furthermore, the development of psychotherapeutic knowledge is developing very rapidly and subsequently adaptations of the training ac‐ quirements are necessary. modernisation of current psychotherapy training in 2014, the german psychotherapists' meeting (german: deutscher psychotherapeuten‐ tag, dpt) passed a resolution, after a two-thirds vote, to campaign for a reform of the current psychotherapeutic training and a modernisation of the underlying psychothera‐ pists' law (bundespsychotherapeutenkammer, 2014). the core idea is to adapt the structure of the (postgraduate) training program for psy‐ chotherapists to the structure of education of medical doctors. a central part of this pro‐ posal is the implementation of a consecutive bachelor's and master's (of science) degree in psychotherapy studies as a requirement for the admission to the postgraduate ad‐ vanced training program. it is suggested that during this advanced training phase, psy‐ chotherapy trainees specialise in either the treatment of adults or of children and adoles‐ cents in an approved psychotherapy approach, e.g. psychodynamic, behavioural or sys‐ temic psychotherapy (bundespsychotherapeutenkammer, 2014). during the discussion of the role of future psychotherapists in the german health care system, the question arose of whether and to what extent traditional competences of psychotherapists should be expanded (e.g. regarding certificates for sick leave from work). in contrast to the current system, there is a given set of regulations for the mandatory contents of basic scientific and practical psychotherapeutic knowledge in the bachelor and master courses. in addition to the master's exam, a state-controlled exam is mandato‐ ry for receiving the formal psychotherapy licence (in german: "approbation"). this li‐ cence is the prerequisite for entering the subsequent advanced psychotherapy training. in the advanced training program psychotherapists will be employed in specialised hos‐ pitals or outpatient clinics (legally, the advanced training program will be officially regu‐ lated by the state chambers). currently, the federal chamber of psychotherapists consid‐ ers a duration of 5 years (full-time employment) as necessary for the advanced training (with a minimum of 2 years in an outpatient setting and 2 years in a hospital setting). the advanced training will contain the training in an approved psychotherapy approach and either in the treatment of adults or in the treatment of children and adolescents. the official licence of treatment for psychotherapists in an own practice (that allows for re‐ muneration by the insurance companies) will require a successful completion of ad‐ vanced training. melcop, von werder, sarubin, & benecke 5 clinical psychology in europe 2019, vol.1(4), article e34304 https://doi.org/10.32872/cpe.v1i4.34304 https://www.psychopen.eu/ the new law was passed by the german parliament (bundestag) in september 2019 and approved of the parliament of the governments in the federal states (bundesrat) in november 2019. the new educational system for psychotherapists is due to start in octo‐ ber 2020. table 1 current and future structure of the qualification and licensure of psychotherapists in germany current structurea future structure course of study psychology graduate degree: bachelor’s and master's degree psychotherapy focus: scientific and practical psychotherapeutic knowledge graduate degree: bachelor's and master's degree additional state examination: licensure ("approbation")education science graduate degree: bachelor's and master's degree social work graduate degree: bachelor's and master's degree training postgraduate training advanced training status during training apprentice employee duration minimum 3 years full-time minimum 5 years full-time payment very low level of payment regular salary components of the training • internship in a psychiatric hospital (1200 hours) and in a rehabilitation hospital or in a licensed outpatient setting (600 hours) • supervised outpatient treatment (minimum 600 sessions, at least six different patients) • self-experience / supervision / theory • psychotherapist in a (psychiatric) clinic (minimum 2 years) • outpatient treatment (minimum 2 years) • possible: specialiced centers (1 year) • self-experience / supervision / theory specialisation scientifically approved psychotherapeutic approach scientifically approved psychotherapeutic approach state examination: licensure ("approbation") exam (conducted by the state psychotherapist chambers) degree psychological psychotherapist / or / child and adolescent psychotherapist specialiced psychotherapist for: children and adolescents / or / for: adults admission admission to statutary health insurence care system admission to statutary health insurence care system aa successfully completed consecutive master's degree in either social work or education science only allows admission to postgraduate training in child and adolescent psychotherapy. a successfully completed consecu‐ tive master's degree in psychology allows admission to postgraduate training in psychotherapy for adults as well as children and adolescents. psychotherapy in the german health care system 6 clinical psychology in europe 2019, vol.1(4), article e34304 https://doi.org/10.32872/cpe.v1i4.34304 https://www.psychopen.eu/ professional organisation in germany, state law requires psychotherapists (psychological psychotherapists, child and adolescent psychotherapists and all future psychotherapists) to be compulsory members of a state psychotherapist chamber (heilberufe-kammergesetz, 2002). its princi‐ pal responsibility is the supervision of occupational standards. the state chambers, which are organised on a national level in the federal chamber of psychotherapists (bundespsychotherapeutenkammer, bptk), therefore work as public corporations. the bptk represents some 50,000 psychotherapists in germany and is thus the only professio‐ nal organisation to represent all psychological psychotherapists and child and adolescent psychotherapists in germany. in 2015, two thirds of its members were working in an out‐ patient setting and their mean age was 52 years; one third are even 60 years or older. sev‐ enty two percent of its members were female. this ratio is likely to shift even more in favour of female members in the next decade. among the age group of 35 year-olds and younger, the percentage of female psychotherapists is already close to 91% (bundespsychotherapeutenkammer, 2016). outpatient psychotherapy the federal joint committee (german: gemeinsamer bundesausschuss, g-ba) is the highest decision-making body of the joint self-government of physicians and psycho‐ therapists, dentists, hospitals, and health insurance funds in germany. it specifies which services in medical care are reimbursed for more than 70 million people within the statu‐ tory health system and also specifies measures for quality assurance in outpatient areas of the health care system. the guidelines for psychotherapy are published by the g-ba to ensure that all patients in outpatient psychotherapy are cared for in a qualified and adequate way (psychotherapie-richtlinie, 2017). nevertheless, psychotherapy is limited to specific diagnoses according to the international classification of diseases chapter 5 (f) german modification (icd-10 gm, dilling, mombour, & schmidt, 1991). indications are adjustment-, affective-, anxiety-, compulsive-, conversion-, dissociative-, eating-, sex‐ ual-, sleep-, somatoform-, personality-, and psychotic disorders as well as behavioural and emotional disorders in children. psychotherapy can also be approved if psychological factors are pathogenetic or impair somatic health. patients can choose their therapist freely from a pool of licensed psychotherapists. after consultation and possible probationary sessions, a subsequent application for psy‐ chotherapy is evaluated by an experienced psychotherapist based on a psychological re‐ port which includes anamnesis and biography, diagnosis, treatment planning, and prog‐ nosis. approval of psychotherapy is thus based on professional opinion rather than health insurance company personnel. for outpatient treatment of mental disorders, the statutory health system covers only psychoanalysis, psychodynamic psychotherapy, and melcop, von werder, sarubin, & benecke 7 clinical psychology in europe 2019, vol.1(4), article e34304 https://doi.org/10.32872/cpe.v1i4.34304 https://www.psychopen.eu/ cognitive behavioural therapy. the costs of neuropsychological therapy are also covered for the treatment of injuries or illnesses of the brain. limitations are set in terms of ses‐ sion quotas for each psychotherapeutic approach (e.g., for psychotherapy with adults in cognitive behavioural therapy: up to 80 individual sessions; psychodynamic therapy: up to 100 sessions; psychoanalysis: up to 300 individual sessions). as of 2018, systemic ther‐ apy has been approved by the g-ba and is in the process of becoming a psychological treatment which is eligible for reimbursement of treatment costs for adult patients (gemeinsamer bundesausschuss, 2018). even though many more methods and techni‐ ques of psychological treatment have become familiar in the field of psychotherapy re‐ search today, the g-ba's approval policy remains rather conservative. private insurance companies differ from each other in their medical service tariffs, but they are oriented towards the g-ba's guideline for psychotherapy. in contrast, there are less stringent regulations for psychological interventions in psy‐ chiatric and psychosomatic hospitals and rehabilitation centres because inpatient treat‐ ment expenses are assigned to another cost unit of health insurance funds. furthermore, in hospitals and rehabilitation centres the treatment responsibility is held by executive medical doctors. their ability to freely chose and adequately provide treatment is guar‐ anteed by a less narrow, i.e., less specific legal definition of medical practice in compari‐ son to psychotherapists. desirable changes to mental health care regulations changes need to be made in the areas of provision, planning for future demand and the educational training system for psychotherapists. health economic analyses of the ger‐ man mental health care system have shown that most of the financial resources are spent for inpatient treatment and outpatient drug prescriptions, while with approximately 2 billion euros only a small fraction of the budget is spent for outpatient psychotherapy (jacobi et al., 2014; kilian & salize, 2010). the planning for demand of psychotherapeutic outpatient practices through regula‐ tions by the g-ba is outdated. there are up to three times more psychotherapists li‐ censed per 100,000 inhabitants in urban areas than in rural areas (bundespsychotherapeutenkammer, 2018). consequently, the average waiting period for outpatient psychotherapy in the social insurance health system is around four months in metropolitan areas and five to six months in rural areas (bundespsychotherapeutenkammer, 2018). recently the g-ba decided to change these regulations to improve the situation. consequently, in the short term, there will be some improvement via additional psychotherapists but in the long term this new system im‐ plies a further deterioration of outpatient care of menatlly ill persons. psychotherapy in the german health care system 8 clinical psychology in europe 2019, vol.1(4), article e34304 https://doi.org/10.32872/cpe.v1i4.34304 https://www.psychopen.eu/ this discrepancy and an increasing economic burden of mental illness point to the need for further improvement (jacobi et al., 2014; murray & lopez, 1996; whiteford et al., 2013). it is expected that the effectiveness and efficiency of the german mental health care system can be significantly improved by an even further shift of resources from in‐ patient to outpatient care (karow et al., 2012). a reform of the regulation system for the admission of statutory health care providers should therefore lead to quotas based on morbidity instead of location. consequences of the german regulations for research in psychotherapy the establishment of outpatient services within postgraduate training programs makes it easier to include patients in research projects. most of the psychology departments in german universitites run a post-graduate program and thus have more possibilities to combine the outpatient service with research studies. but there are also some important limitations. as mentioned above the g-ba approved psychotherapeutic approaches are the basis for financing psychotherapy within the health care system. the admission to the health care system is also orientated on these traditional lines. clinical psychology units provide professional experience and training-programs mainly for cognitive behav‐ ioural therapy and therefore there is a huge lack in possibilities for research for the other psychotherapeutic approaches. in the process of the reform the chambers and other pro‐ fessional organisations demand, that there should be more personnel at the universities with specific qualifications for teaching these other psychotherapeutic approaches. conclusion since the psychotherapists' law came into effect in 1999, the professional title "psycho‐ therapist" has been protected by law and the training for becoming a psychotherapist is regulated on a high professional level. every german citizen can rely on this high quality of training and subsequently expect professional treatment. nationwide data show that more and more people with mental disorders are seeking help from psychotherapists. in consequence, the waiting period for professional treatment has become longer over the years. despite increasing numbers of psychotherapists, even more psychotherapists for outpatient treatment are needed, particularly in rural areas. this situation is very similar in hospitals and specialized clinics for mental disorders. consequently, evidence-based treatments following international guidelines cannot be offered to every patient due to a lack of qualified psychotherapists (both in outpatient and inpatient settings). the re‐ newed law is expected to improve the training conditions for future psychotherapists and also meet the necessities of the health care system. therefore, in the coming years the melcop, von werder, sarubin, & benecke 9 clinical psychology in europe 2019, vol.1(4), article e34304 https://doi.org/10.32872/cpe.v1i4.34304 https://www.psychopen.eu/ psychotherapeutic profession will appeal more to young students and will play an even more important role in the german health care system. funding: the authors have no funding to report. competing interests: nm is vice president of the federal chamber of psychotherapists in germany and president of the bavarian chamber of psychotherapists. tvw and ns are members of the bavarian chamber of psychotherapists. ab is vice president of the federal chamber of psychotherapists in germany and vice president of the chamber of psychotherapists of rhineland-palatinate. acknowledgments: the authors have no support to report. references augurzky, b., hentschker, c., pilny, a., & wübker, a. 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(2018). perspektiven der psychologie in deutschland. retrieved from https://www.wissenschaftsrat.de/download/archiv/6825-18.pdf clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. psychotherapy in the german health care system 12 clinical psychology in europe 2019, vol.1(4), article e34304 https://doi.org/10.32872/cpe.v1i4.34304 https://www.g-ba.de/downloads/39-261-3493/2018-09-20_endbericht-gutachten-weiterentwickklung-bedarfsplanung.pdf https://www.g-ba.de/downloads/39-261-3493/2018-09-20_endbericht-gutachten-weiterentwickklung-bedarfsplanung.pdf https://www.unith.de/unith-ev/ueber-uns https://doi.org/10.1016/s0140-6736(13)61611-6 https://www.wissenschaftsrat.de/download/archiv/6825-18.pdf https://www.psychopen.eu/ psychotherapy in the german health care system (introduction) mental health care regulations for psychotherapists qualification and licensure – the current status qualification and licensure in the future modernisation of current psychotherapy training professional organisation outpatient psychotherapy desirable changes to mental health care regulations consequences of the german regulations for research in psychotherapy conclusion (additional information) funding competing interests acknowledgments references no1likesu! – a pilot study on an ecologically valid and highly standardised experimental paradigm to investigate social rejection expectations and their modification research articles no1likesu! – a pilot study on an ecologically valid and highly standardised experimental paradigm to investigate social rejection expectations and their modification lisa d’astolfo a +, lukas kirchner a +, winfried rief a [a] department of clinical psychology and psychotherapy, philipps-university of marburg, marburg, germany. +these authors contributed equally to this work. clinical psychology in europe, 2020, vol. 2(2), article e2997, https://doi.org/10.32872/cpe.v2i2.2997 received: 2019-07-11 • accepted: 2020-04-22 • published (vor): 2020-06-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: lukas kirchner, philipps-university of marburg, department of clinical psychology and psychotherapy, gutenbergstraße 18, d-35032 marburg, germany. tel: +49 (0)6421 2824076. fax: +49 (0)6421 282-8904. e-mail: lukas.kirchner@uni-marburg.de abstract background: dysfunctional expectations have been suggested as core features in the development and maintenance of mental disorders. thus, preventing development and promoting modification of dysfunctional expectations through intervention might improve clinical treatment. while there are well-established experimental procedures to investigate the acquisition and modification of dysfunctional performance expectations in major depression, paradigms for investigating other important types of dysfunctional expectations (e.g. social rejection expectations) are currently lacking. we introduce an innovative associative learning paradigm, which can be used to investigate the development, maintenance, and modification of social rejection expectations. method: a pilot sample of 28 healthy participants experienced manipulated social feedback after answering personal questions in supposed webcam conferences. while participants repeatedly received social rejection feedback in a first phase, differential feedback was given in a second phase (social rejection vs. social appreciation). in a third phase, explicit social feedback was omitted. results: participants developed social rejection expectations in the first phase. for the second phase, we found an interaction effect of experimental condition; i.e. participants adjusted their expectations according to the differential social feedback. in the third phase, learned social expectations remained stable in accordance to the social feedback in the second phase. conclusion: results indicate that the paradigm can be used to investigate the development, maintenance, and modification of social rejection expectations in healthy participants. this offers broad applications to explore the differential acquisition and modification of social rejection this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i2.2997&domain=pdf&date_stamp=2020-06-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ expectations in healthy vs. clinical samples. further, the paradigm might be used to investigate therapeutic strategies to facilitate expectation change. keywords violex-model, expectation violation, expectation persistence, expectation modification, dysfunctional expectations, social rejection, no1likesu! highlights • this paradigm can be used to induce and modify social rejection expectations. • this allows to investigate differences in expectation acquisition, maintenance, and modification between clinical vs. healthy samples. • further, this paradigm enables research on interventions promoting expectation modification. recent developments in clinical psychology propose dysfunctional expectations (i.e. fu‐ ture-directed ‘if-x-then-y’-predictions, rief et al., 2015, p. 380) as an important factor in the development of mental disorders and as a promising target in clinical treatment (e.g. greenberg, constantino, & bruce, 2006; rief & glombiewski, 2017; rief et al., 2015). dysfunctional expectations have been shown to play a crucial role in mental health as they negatively impact future behaviour (e.g. excessive avoidance, krypotos, 2015), aggravate subjective suffering (e.g. pain perception, jepma, koban, van doorn, jones, & wager, 2018), and elicit potentially maladaptive anticipatory reactions (e.g. negative mood, davidson, marshall, tomarken, & henriques, 2000). further, dysfunctional expectations have been shown to impede important clinical outcomes (e.g. treatment success, constantino, vîslă, coyne, & boswell, 2018). as george a. kelly put it early in his theory of personal constructs: ‘a person’s processes are psychologically channelised by the ways in which he anticipates events’ (kelly, 1977, pp. 358-359). thus, preventing acquisition and promoting modification of dysfunctional expectations through intervention might improve clinical treatment (craske, treanor, conway, zbozinek, & vervliet, 2014; rief & glombiewski, 2016; rief & joormann, 2019). however, acquisition, maintenance, and modification of dysfunctional expectations is still little understood (rief & joormann, 2019). while there are promising theoret‐ ical approaches (kube, rief, & glombiewski, 2017; kube, schwarting, rozenkrantz, glombiewski, & rief, 2020) and well established experimental procedures concerning this issue with regard to dysfunctional performance expectations in major depression (kube, rief, gollwitzer, & glombiewski, 2018), experimental paradigms are lacking when it comes to other types of dysfunctional expectations (see liebke et al., 2018, for a laudable exception). since especially (dysfunctional) expectations of social rejection (e.g. ‘when i open myself to others, they will refuse me!”) have serious implications for mental health (e.g. no1likesu! – a social learning paradigm 2 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ bianchi, schonfeld, & laurent, 2015; gao, assink, cipriani, & lin, 2017) and the course of various mental disorders (e.g. bungert et al., 2015; de panfilis, riva, preti, cabrino, & marchesi, 2015; kimbrel, 2008; slavich, o’donovan, epel, & kemeny, 2010), ecologically valid experimental procedures are strongly needed for further investigation. the aim of the current study was to develop an experimental social rejection expect‐ ation paradigm (no1likesu!), which can be used to investigate the acquisition, mainte‐ nance and modification of social rejection expectations within a highly standardised and ecologically valid procedure. in contrast to existing paradigms on social exclusion (for an overview, see riva & eck, 2016), no1likesu! was especially designed to mimic key pro‐ cesses proposed by a recently published theoretical model on expectation development, maintenance, and modification – the so called ‘violex-model’ by rief and colleagues (2015). this model proposes that when entering concrete situations, individuals form situa‐ tion-specific predictions about these situations (drawn from more generalised expecta‐ tions) which become either (a) confirmed or (b) disconfirmed by experience. while repea‐ ted expectation confirmations should stabilise or reinforce the original situation-specific prediction (or respectively, the underlying generalised expectation), repeated expectation ‘violations’ should entail its modification (gollwitzer, thorwart, & meissner, 2018; rief et al., 2015). following the predications of the model, we hypothesise that (1) repeatedly expos‐ ing healthy individuals to situation-specific experiences of social rejection will increase levels of social rejection expectations over time. consistent with the violex-model, we further hypothesise that (2) repeatedly exposing healthy individuals with increased levels of social rejection expectations to situation-specific experiences of social rejection (‘stabilisation’) vs. appreciation (‘modification’) will lead to differential changes (i.e. to an increase vs. stabilisation) in social rejection expectation levels over time. method no1likesu! is an ecologically valid and highly standardised associative learning para‐ digm created to model the development, maintenance, and modification of social rejec‐ tion expectations. like the o-cam paradigm (godwin et al., 2014; goodacre & zadro, 2010), it relies on a cover story leading participants to believe that they are going to interact with real human beings via webcam. participants in no1likesu! are told that they are going to participate in a study investigating ‘how people socialise with and affect each other in virtual environments’. participants pass multiple supposed ‘web‐ cam-conferences’ (actually, realistic looking video stimuli) on a computer in which they answer personal questions to different ‘listeners’ (actually, pre-recorded and instructed confederates). afterwards, they receive written social feedback on their self-presentation d’astolfo, kirchner, & rief 3 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ (actually, manipulated feedback that induces experiences of social rejection vs. social appreciation). the local ethics committee (reference number 2018-36k) approved the study. all par‐ ticipants gave written informed consent before they started the experiment. this study was part of a parent study, which additionally investigates interventions for promoting the modification of dysfunctional expectations. in the present work, we focus on the effects of the paradigm on the development, maintenance, and modification of social rejection expectations in healthy participants. participants we recruited participants via e-mail lists, flyers, and the research participation system of our university. inclusion criteria were: (a) a minimum age of 18 years, (b) sufficient german language skills, (c) no severe visual impairment, (d) no serious physical illness, (e) no current psychological stress, (f) not in psychotherapeutic treatment, and (g) a sum score in beck’s depression inventory ii (bdi-ii; kühner, bürger, keller, & hautzinger, 2007) ≤ 13, indicating no to minimal depressive symptoms. until now, a pilot sample of 31 healthy participants could be included in the study, which provides sufficient power to investigate our hypotheses (huta, 2014). as men‐ tioned above, recruitment based on a priori power analyses continues as we test no1like‐ su! within an ongoing study addressing further research questions we do not fully report here (preregistered at ‘aspredicted’: https://aspredicted.org/g544c.pdf). since recruitment is currently faltering for the parent study, we would like to publish our pilot results on the paradigm contrary to preregistration in order to make them accessible to the research community. three participants had to be excluded due to technical problems with the experimental software. the final pilot dataset consisted of 28 healthy participants (82.10% female, mage = 23.39 years, sd = 6.51, range of age = 19–51 years). table 1 shows the demographic data of the sample. participants received credit points as compensation for their participation. alterna‐ tively, they got the chance to win gift vouchers for different online shops. procedure testing sessions started with participants reading the study information and signing informed consent (see figure 1 for an overview of the study design). afterwards, they completed paper-pencil pre-questionnaires. research assistants checked age as well as bdi-ii cut-off scores. participants who failed the inclusion criteria received partial compensation and were fully debriefed. participants who met the inclusion criteria received study information incorporating the cover story. to allay concerns about the authenticity of the webcam conference, participants were told that their listeners (who were announced as ‘students from an experimental intern‐ no1likesu! – a social learning paradigm 4 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://aspredicted.org/g544c.pdf https://www.psychopen.eu/ ship at the university’) were instructed ‘not to talk’ during conferences for ‘methodologi‐ cal reasons’. afterwards, research assistants started the paradigm on the computer and left the experimental room. the participants were fully randomised into two independent experimental conditions (group ‘stabilisation’ vs. group ‘modification’) and followed instructions presented on the computer screen, which guided through the paradigm. to model key processes of the ‘violex-model’, no1likesu! encompasses multiple trials (30) which are divided into three different experimental phases (acquisition phase, stabilisation vs. modification phase, test phase, see figure 1). figure 1 study design these phases are structurally based on fear conditioning paradigms (lissek et al., 2005; lonsdorf et al., 2017). during the acquisition and stabilisation phase, participants repeatedly form associations between introducing themselves to strangers (conditioned stimulus, cs) and being socially rejected (unconditioned stimulus, us) resulting into d’astolfo, kirchner, & rief 5 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ situation-specific social rejection expectations (conditioned response, cr). during modi‐ fication, opposing associations (cs-us’ [being socially appreciated]) are formed resulting into expectations of social appreciation. in order to enhance stability of expectations and ecological validity, no1likesu! provides partial reinforcement (70%) within these phases. to explore the stability of the social expectations learned within the experimental para‐ digm, no1likesu! ends with a test phase which did not provide written social feedback (retention test). after completing the paradigm, research assistants entered the experimental room and provided paper-pencil post-questionnaires to check for suspiciousness about the cover story and emotional distress due to participation. participants were then fully de‐ briefed about the true purposes of the study and the deceptions within the experimental manipulation. testing sessions lasted between 1.0 and 1.5 hours. measures note that we applied additional questionnaires to address further research questions in the parent study, which we do not describe here. situation-specific social expectations we assed situation-specific social expectations using a one-item 7-point bipolar likert scale (social expectation rating: ‘please indicate to what extent you expect your next listener to be interested or disinterested in you!’) ranging from -3 (maximal disinterest) to +3 (maximal interest) before each trial. thus, lower values indicate higher social rejection expectations. situation-specific social experience to examine how participants actually perceived a passed webcam conference, we used a one-item 7-point bipolar likert scale (social experience rating: ‘please indicate to what extent you experienced interest or disinterest from your last listener!’) ranging from -3 (maximal disinterest) to +3 (maximal interest) after each trial. thus, lower values indicate higher social rejection experiences. pre-questionnaires depressive symptoms — we assessed depressive symptoms using the beck depression inventory ii (bdi-ii; kühner et al., 2007 prior to running no1likesu!). participants responded to the 21 items on a 4-point scale ranging from 0 to 3. the sum score of the 21 items ranges between 0 and 63, whereby higher values indicate more depressive symptoms. no1likesu! – a social learning paradigm 6 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ socio-demographics — we used a brief self-report questionnaire in order to assess demographic variables like sex, age, nationality, relationship status, educational level, employment status, and living situation. post-questionnaires emotional distress due to participation — we assessed emotional distress due to participation by asking whether participants felt impaired due to the experimental procedures (‘do you feel impaired due to our investigation?’). further, we applied a one-item 5-point bipolar likert scale (‘please indicate to what extent you feel positive or negative in this moment!’) ranging from -2 (very negative) to +2 (very positive) to assess emotional distress. higher values indicate lower emotional distress due to participation. suspiciousness — in order to assess the credibility of the cover story, the video stimuli and the experimental manipulation, we asked participants whether 1) they knew any of their ‘webcam partners’, 2) what they believed was the aim and purpose of the study, and 3) how they experienced the experimental procedure. responses were rated on a 3-point likert scale ranging from 0 ("not suspicious at all") to 2 ("doubted the authenticity of the webcam conferences"). apparatus and stimuli participants were seated in front of a computer with an external microphone and a webcam connected to the computer. the paradigm, including instructions, video stimuli, and social feedback, was presented on the computer screen. participants used a mouse to interact with the computer. video stimuli were pre-recorded with 30 volunteers (15 male, 15 female, age: 25 – 35). volunteers were instructed to express nonverbal cues of either social rejection or social appreciation (see figure 2). we produced two sequences of each volunteer resulting into 30 sequences of social rejection and 30 sequences of social appreciation (50 seconds each). the nonverbal feedback during each trial was matched with the written feedback. the personal and self-related questions were adapted from various dating websites in order to promote positive self-disclosure (see appendix a in the supplementary materials). the video stimuli as well as the personal questions were presented fully randomised during experimental procedure in accordance with the partial reinforcement. for each participant, video stimuli and personal questions were never repeated twice. d’astolfo, kirchner, & rief 7 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ figure 2 video stimuli (left: social appreciation, right: social rejection) trial sequence figure 3 gives an overview of the trial sequence. each trial started with a situation-spe‐ cific social expectation rating. afterwards, participants received a personal, self-related question (e.g. ‘what are your hobbies?’) on the screen ostensibly asked by the ‘next liste‐ ner’ in order to pre-set the content of the next conference. following preparation time depicted by a countdown (20 seconds), participants received a short connection-signal on the screen (5 seconds) before the supposed ‘webcam conference’ started by showing a pre-recorded video stimulus. to ensure the authenticity of the conferences, participants were instructed to actively end conferences when they finished their self-presentation. after each conference, participants gave a situation-specific social experience rating before receiving written social feedback (e.g. ‘your last listener found you rather uninter‐ esting and would not like to get in touch with you again.’). this trial sequence was repeated (10 times) within each of the three experimental phases. however, written feedback was omitted in the last phase. no1likesu! – a social learning paradigm 8 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ figure 3 trial sequence statistical analyses before conducting the analyses, we checked for outliers to exclude influential data points. for each expectation rating, we calculated the mahalanobis distance which we checked against a χ2-cut-off of α = .001. we found no influential data points. all analyses were computed using r studio (r studio team, 2015) for r (r development core team, 2008). we used lme4 (bates, mächler, bolker, & walker, 2015), nlme (kuznetsova, brockhoff, & christensen, 2017), blme (chung, rabe-hesketh, dorie, gelman, & liu, 2013), and lmertest (kuznetsova et al., 2017) to perform a hierarchical mixed effects analysis of the relationship between social expectations, measuring time and experimental condition. since the times at which expectations were measured are separable into the three phases, we defined a contrast matrix for time, which accounted for the nested data structure. we used the contrast matrix for time as a level-1-fixed effect, and group as a level-3-fixed effect (including the interaction term). as random effect, we implemented intercepts for participants (level 2). we checked homoscedastic‐ ity and normality via the residual plots, which always showed expected patterns. we obtained p-values by likelihood ratio tests, testing the model with the additional level effect against the model without the additional level effect. subsequently, we analysed the phases individually to estimate effect sizes for each phase effect. we used linear models to investigate the relationship between social ex‐ pectations and group affiliation. we entered group as fixed effect. we inspected the residual plot to check homoscedasticity and normality. again, all plots showed patterns as expected. for all analyses, we applied sum contrasts to calculate intercepts and slopes. d’astolfo, kirchner, & rief 9 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ results sample characteristics participants were predominantly young (mage = 23.39, sd = 6.51), female (82.14%) and well-educated (100% general qualification for university entrance). the mean bdi-ii sum score was 4.54 (sd = 3.26), indicating that no participant exceeded the clinical threshold of depressive symptoms (kühner et al., 2007). table 1 gives an overview of the sample characteristics. there were no significant differences between the experimental conditions in any of the assessed variables. table 1 sample characteristics variable stabilisation (n = 14) modification (n = 14) difference between experimental conditions age in years, m (sd) 21.79 (3.02) 25.00 (8.57) t (26) = 1.32, p = .20 sex, n (%) χ2 = 2.19, p = .14 male 4 (28.57) 1 (7.14) female 10 (71.43) 13 (92.86) nationality, n (%) χ2 = 0.37, p = .54 german 13 (92.86) 12 (85.71) other 1 (7.14) 2 (14.29) romantic relationship, n (%) χ2 = 1.29, p = .26 yes 5 (35.71) 8 (57.14) no 9 (64.29) 6 (42.86) living situation, n (%)a χ2 = 0.01, p = .94 living alone 2 (14.29) 2 (15.38) living with others 12 (85.71) 11 (84.62) educational level, n (%) χ2 = 1.71, p = .19 university degree 2 (14.29) 5 (35.71) no university degree 12 (85.71) 9 (64.29) employment status, n (%) χ2 = 1.47, p = .23 employed 6 (42.86) 3 (21.43) not employed 8 (57.14) 11 (78.57) bdi-ii sum-score, m (sd) 4.86 (3.44) 4.21 (3.17) t (26) = 0.52, p = .61 mser before first trial, m (sd) 3.86 (1.29) 4.21 (1.12 t (26) = 0.78, p = .44 emotional distress after participation, m (sd) 3.21 (0.70) 3.57 (0.65) t (26) = 1.40, p = .17 note. bdi-ii = beck depression inventory ii; mser = mean social expectation rating. aone missing data point. manipulation check for the nonverbal social feedback we investigated whether the nonverbal social feedback (rejection vs. appreciation) dis‐ played in the videos affected the situation-specific social experience ratings of the sup‐ posed webcam conferences. participants provided these ratings after each conference and before receiving written social feedback. no1likesu! – a social learning paradigm 10 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ first, we performed a mixed anova using a linear model of the mean social expe‐ rience ratings as a function of group (between factor) and time (within factor) using greenhouse-geisser correction. we found a significant interaction of group and time (f(1, 33) = 5.09, p = .023) as well as a significant main effect for group (f(1, 26) = 4.68, p = .040), and time (f(1, 33) = 6.80, p = .009). next, we performed post-hoc analyses and pairwise comparisons to further analyse the significant interaction effect. the bonferroni adjusted p-values suggest that the main effect of group was signifi‐ cant during modification vs. stabilisation phase (f(1, 26) = 11.33, p = .006) but not during acquisition phase (f(1, 26) = 2.46, p = .387), and test phase (f(1, 26) = 0.64, p = 1.000). pairwise comparisons showed that the mean social experience rating between group ‘stabilisation’ and group ‘modification’ differed only during modification vs. stabilisation phase (p = .002) when differential nonverbal social feedback was applied (70% social rejection feedback in group ‘stabilisation’ vs. 70% social appreciation feedback in group ‘modification’). as expected, group ‘modification’ (m = 3.53, sd = 0.64) showed higher social experience ratings than group ‘stabilisation’ (m = 2.77, sd = 0.55), indicating more perceived social appreciation. regarding the main effect of time, the bonferroni adjusted p-values suggested signif‐ icant differences for group ‘modification’(f(1, 16) = 8.26, p = .014), but not for group ‘stabilisation’ (f(1,16) = 4.56, p = .080). pairwise comparisons revealed differences in mean social experience rating within group ‘modification’ between acquisition phase (m = 3.07, sd = 0.72) and modification vs. stabilisation phase (m = 3.53, sd = 0.64) as well as between modification vs. stabilisation phase and test phase (m = 3.27, sd = 0.58) with modification phase having the highest social experience ratings reflecting the highest nonverbal social appreciation feedback of 70%. we found no significant differences in social experience ratings between acquisition and test phase. these results indicate that the participants experienced the nonverbal social feedback as intended. main analyses first, we included all experimental phases in one statistical model and investigated changes in social expectation ratings across the course of the experiment. therefore, we performed a multilevel mixed effect multinomial linear regression on the social expecta‐ tion ratings as a function of group and time (i.e. the contrast matrix of individual social expectation ratings nested in each phase). time therefore consists of three variables each representing an experimental phase (acquisition phase, modification vs. stabilisation phase, test phase). unless otherwise stated, we used the standard bound optimisation by quadratic approximation (bobyqa) optimisation for the models. we calculated the linear regression of the social expectation ratings as a function of time (level 1). we then subsequently added the next-level effects until arriving at the full model including time (level 1), random intercept for participant (level 2), and group with interaction d’astolfo, kirchner, & rief 11 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ term for time (level 3). we compared mixed-effects models using likelihood ratio tests. here, we will describe the results of the level-3-model, the results for the level-1and level-2-models can be found in the supplementary material. figure 4 shows the course of the mean social expectation ratings across all phases of the experiment. figure 4 mean social expectation rating across all experimental phases as a function of experimental condition note. error bars indicate ± 1 se. the level-3-model revealed no significant group x acquisition phase interaction (β = -.00, t = -0.05, p = .585) but a trend for the group x test phase interaction (β = -.02, t = -1.96, p = .050) as well as a significant interaction for group x modification vs. stabilisation phase (β = .02, t = 2.12, p = .034) in accordance with our hypotheses. also, we found a main effect for group (β = .15, t = 2.00, p = .046), acquisition phase (β = -.06, t = -3.61, p < .001), and test phase (β = .04, t = 2.40, p = .016), but not for modification vs. stabilisation phase (β = -.00, t = -0.5, p = .572). in other words, there were no signifi‐ cant group differences in social expectation ratings during acquisition phase but during stabilisation vs. modification phase and test phase (retention test), whereby participants in group ‘stabilisation’ showed higher social rejection ratings than participants in group ‘modification’. also, social rejection ratings significantly increased during acquisition phase and slightly decreased during test phase for both groups. the non-significant main no1likesu! – a social learning paradigm 12 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ effect for stabilisation vs. modification phase can be explained with the opposing effect of the groups on social expectation ratings due to the inverted reinforcement rates. table 2 shows the model comparisons for the hierarchical linear regression. the models were sequentially tested against the previous models. table 2 analysis of variance for the hierarchical linear regression models model aic χ2 χdf p level 2 (random effect for participant) 2249.7 – – – level 3 (fixed effect for group) 2243.8 13.87 4 .007 note. aic = akaike information criterion. individual phases next, we used manova tests to investigate the effect of group on the social expectation ratings for each phase individually to investigate the effect sizes of the changes. hypothesis 1: main effect of acquisition phase we constructed a linear model of the social expectation ratings (as outcome matrix for ratings 1 to 10) as a function of group and baseline social expectation rating (with interaction term) to exclude differential learning for the groups and to account for inter-individual influences of baseline ratings on expectation rating during acquisition. we calculated a type-ii-manova using pillai’s test statistic for the linear model. as expected, we found no significant interaction between group and baseline social expect‐ ation rating, f(1,15) = 1.41, p = .264, and no significant main effect for group, f(1,15) = 0.85, p = .593, but a main effect of the baseline social expectation rating, f(1,15) = 3.53, p = .013. overall, the linear model accounted for 21% of variance (r 2 = .21), which constitutes a medium effect (ellis, 2010). hypothesis 2: main effect of group in stabilisation vs. modification phase following the significant interaction of group x stabilisation vs. modification phase in the main analyses, we constructed a linear model of the social expectation ratings (as outcome matrix for ratings 11 to 20) predicted by experimental condition to further investigate the main effect of group. the type-ii-manova revealed a marginally signif‐ icant main effect for group (f(1,17) = 2.38, p = .055). the model explained 19% of the variance (r 2 = .19) constituting a medium effect (ellis, 2010). d’astolfo, kirchner, & rief 13 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ exploratory analysis: stability of the social expectation ratings to test whether the social expectation ratings would remain consistent during test phase, we analysed a linear model of the social expectation ratings (outcome matrix for ratings 21 to 30) as a function of group. as expected, the type-ii-manova did not reveal a significant main effect for group, f(1,17) = 0.88, p = .568. for test phase, the linear model accounted for 7% of the variance (r 2 = .07) which constitutes a small effect (ellis, 2010). suspiciousness of the cover story additionally, we analysed suspiciousness of the cover story. seven participants reported doubts about the authenticity of the webcam conferences, six reported that they felt something ‘was off’ while 15 participants found nothing wrong with the webcam con‐ ferences. further, three participants knew some of their ‘webcam partners’. however, a sensitivity analysis excluding all suspicious participants did not reveal significant differences in the result patterns. therefore, we based our results on the whole sample. discussion while social rejection expectations play a crucial role in mental health, experimental re‐ search on the processes of how these expectations develop, maintain, and change is cur‐ rently lacking. our study addresses this gap by providing an ecologically valid and highly standardised experimental paradigm to investigate the acquisition, maintenance, and modification of situation-specific social rejection expectations in healthy samples. results indicate, that this paradigm can be used to successfully induce (hypothesis 1) as well as differentially change (hypothesis 2) situation-specific social rejection expectations in healthy participants as a function of social feedback (social rejection vs. social apprecia‐ tion). altogether these results are consistent with the predictions drawn from the ‘vio‐ lex-model’, which assumes modification of expectations after experiencing disconfirming results (e.g. positive social feedback after negative social feedback) as well as stabilisation of expectations after experiencing confirming results (e.g. rief et al., 2015). further, our results are in line with previous research on expectation development, maintenance, and modification in healthy participants. for example, liebke et al. (2018) showed that healthy participants increase (respectively reduce) expectations of social acceptance as a function of social feedback (acceptance vs. rejection). kube, rief, gollwitzer, and glombiewski (2018) as well as kube, kirchner, rief, gärtner, and glombiewski (2019) provided similar results concerning the modification of performance-related expectations as a function of performance-related feedback. kube, rief, gollwitzer, and glombiewski (2018) showed that healthy participants modify dysfunctional task-specific performance expectations in face of positive performance feedback. consistently, kube, kirchner, rief, gärtner, and glombiewski (2019) found that healthy as well as depressed participants no1likesu! – a social learning paradigm 14 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ update dysfunctional task-specific performance expectations in accordance to positive vs. negative feedback. moreover, our results resemble basic result patterns found in fear conditioning para‐ digms concerning the acquisition and modification of fear (lissek et al., 2005): repeatedly pairing self-presentation with social rejection led to higher social rejection expectation (i.e. higher ‘contingency awareness’, lonsdorf et al., 2017, pp. 268-269) while social rejection expectations decreased in turn when social rejection feedback was omitted. however, comparability is limited here, since social expectations formed in the real world might interfere with social expectations formed within no1likesu! (which is different from most typical fear conditioning procedures). concerning our test phase, results indi‐ cate no ‘return’ or ‘renewal’ of social rejection expectations which is normally a common phenomenon in classical fear conditioning ('return of fear', lonsdorf et al., 2017, p. 260). the stability of the associations learned within stabilisation vs. modification phase might be due to partial reinforcement during this phase as occasional reinforcement seem to attenuate return of fear in human fear conditioning (craske et al., 2014; culver, stevens, fanselow, & craske, 2018). limitations despite incorporating naturalistic stimuli, no1likesu! does not provide dynamic social interactions. while the pre-scripted video stimuli ensure standardised experimental ma‐ nipulation, these stimuli do not adapt to individual expressions of participants, threaten‐ ing its external validity. moreover, the paradigm only focuses on one specific social situation, i.e. self-disclosure in front of a stranger. thus, investigating the generalisation of social rejection expectations to other social situations might be difficult within this paradigm. additionally, a substantial amount of our participants seemed to be suspicious about the ‘webcam conferences’ and the social feedback we provided within no1likesu!. while this issue could be solved at the expense of standardisation (for example by using real time interactions with confederates), problems with suspiciousness should not be overestimated within the actual procedure. firstly, post-hoc questionnaires about the ‘aims and purposes’ of a study demand for suspiciousness by construction and therefore potentially overestimate actual suspiciousness of individuals during participa‐ tion. secondly, research on social exclusion shows that experiences of social exclusion stay impactful even if participants know that social feedback is simulated (e.g. zadro, williams, & richardson, 2004). further, we measured situation-specific social expectation only via self-report on a one-item scale. while expectations are usually assessed via self-report, more advanced self-report measures as well as multimodal indicators of social rejection expectation (e.g. avoidance behaviour) would improve validity of social rejection expectation assessment. further, while we incorporated general suggestions on fear conditioning paradigms, there are no clear instructions on how to set certain parameters in associative learning d’astolfo, kirchner, & rief 15 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ procedures (e.g. reinforcement rate or trial number). thus, changing these parameters might also influence the effects of the paradigm. also, while we focused on contingency learning of outcome expectations, we did not include valence ratings for social rejection and social appreciation. meta-analyses clearly show negative valence for social rejection (gao et al., 2017), however, individual valence ratings might influence contingency learning. outcome valence and outcome expectations might be coded differently in human brains (von borries et al., 2013). while many brain areas associated with contingency learning seem independent of valence, some brain areas are suggested to be more strongly activated when processing positively evaluated stimuli (bischoff-grethe et al., 2009). finally, while we incorporated the concept of ‘expectation violation’ (rief et al., 2015) in our paradigm, it could be argued that we did not provide real extinction training in our study as typically applied in fear conditioning (lonsdorf et al., 2017). since social rejection feedback was not only omitted but replaced by social appreciation feedback, we rather provided a ‘counterconditioning’ (de jong, vorage, & van den hout, 2000) approach in group ‘modification’. future directions no1likesu! provides options for broad applications to investigate the acquisition, main‐ tenance, and modification of social rejection expectations within a highly standardised and ecologically valid experimental procedure. it is adaptable to various research at‐ tempts. future research should use no1likesu! to identify differences in the develop‐ ment, maintenance, and modification of social rejection expectations between healthy and clinical samples (with special regards to patients with borderline personality disor‐ der, social anxiety or depression). to test whether clinical samples show to be differ‐ entially more sensitive to social rejection experiences during acquisition than healthy controls and show to be less responsive to social appreciation experiences during modifi‐ cation, has important implications for etiological considerations and clinical treatment. on the one hand, this could call for the development of expectation-focused etiologi‐ cal models (with special emphasise on dysfunctional social rejection expectations as connecting link) like kube, siebers, et al. (2018) as well as rief and joormann (2019) proposed for major depression. on the other hand, these results would stress the need for carefully designed expectation-focused psychological interventions specifically tar‐ geting dysfunctional social rejection expectations through contradictory experiences like kube, glombiewski, and rief (2019) elaborated for people with depressive symptoms. further, this would extend former findings on the ‘violex-model’ and clarify whether expectations of social rejection should be especially targeted in clinical practice. in order to develop proper interventions, researchers should apply no1likesu! to investigate whether different interventions on informational processing (e.g. verbalisation, function‐ al attention management) improve the modification of social rejection expectations in no1likesu! – a social learning paradigm 16 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ face of expectation violations. here, it would also be of interest to investigate behavioural changes in participants (healthy participants as well as clinical samples) following social appreciation vs. social rejection feedback. this could provide further insight in behaviou‐ ral expressions of social rejection expectations, which might also consolidate or even reinforce social rejection expectations. from an ethical point of view, screening for and treatment of emotional distress produced by the paradigm should be enhanced when investigating clinical samples but also healthy controls. researchers should provide extended debriefing and emotional af‐ tercare by trained psychotherapists in order to prevent clinical subjects from transferring negative social experiences from the paradigm to their real life. further, they should integrate phases of repeated positive social experiences at the end of their experiments by default in order to compensate for negative social experiences. conclusion no1likesu! is an ecologically valid and highly standardised experimental paradigm to investigate the development, maintenance, and modification of social rejection expecta‐ tions. participants pass multiple short ‘webcam-conferences’ (video stimuli) in which they answer personal questions to different ‘listeners’ (confederates). afterwards, they receive manipulated social feedback on their self-presentation. our results suggest that researcher can use no1likesu! to induce and alter social rejection expectations in healthy participants. future research should focus on differences in the acquisition, maintenance, and modification of social rejection expectations between healthy and clinical samples. additionally, incorporating interventions on expectation violation pro‐ cessing might improve the modification of social rejection expectations with implications for clinical treatment. funding: the authors have no funding to report. competing interests: winfried rief is editor-in-chief of clinical psychology in europe but played no editorial role for this particular article. apart from that, the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. acknowledgments: we thank rené herbstreit for providing technical support with programming the paradigm. supplementary materials the supplementary material contains an overview of the 30 questions used in the no1likesu! paradigm (appendix a). questions were adapted from various dating websites to promote positive self-disclosure. appendix b provides the results of the level-1and level-2-mixed effects models d’astolfo, kirchner, & rief 17 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://www.psychopen.eu/ within the multilevel mixed effect multinomial linear regression (for access, see index of supple‐ mentary materials below): index of supplementary materials d’astolfo, l., kirchner, l., & rief, w. 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(2004). how low can you go? ostracism by a computer is sufficient to lower self-reported levels of belonging, control, self-esteem, and meaningful existence. journal of experimental social psychology, 40(4), 560-567. https://doi.org/10.1016/j.jesp.2003.11.006 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. d’astolfo, kirchner, & rief 21 clinical psychology in europe 2020, vol.2(2), article e2997 https://doi.org/10.32872/cpe.v2i2.2997 https://doi.org/10.1097/yco.0000000000000184 https://doi.org/10.32872/cpe.v1i1.32605 https://doi.org/10.1007/978-3-319-33033-4 http://www.rstudio.com https://doi.org/10.1016/j.neubiorev.2010.01.003 https://doi.org/10.3758/s13415-013-0150-1 https://doi.org/10.1016/j.jesp.2003.11.006 https://www.psychopen.eu/ no1likesu! – a social learning paradigm (introduction) method participants procedure measures apparatus and stimuli statistical analyses results sample characteristics manipulation check for the nonverbal social feedback main analyses individual phases discussion limitations future directions conclusion (additional information) competing interests funding acknowledgments supplementary materials references one single question is not sufficient to identify individuals with electromagnetic hypersensitivity research article one single question is not sufficient to identify individuals with electromagnetic hypersensitivity renáta szemerszky a, zsuzsanna dömötör a, ferenc köteles a [a] institute of health promotion and sport sciences, elte eötvös loránd university, budapest, hungary. clinical psychology in europe, 2019, vol. 1(4), article e35668, https://doi.org/10.32872/cpe.v1i4.35668 received: 2019-04-23 • accepted: 2019-09-04 • published (vor): 2019-12-17 handling editor: omer van den bergh, university of leuven, leuven, belgium corresponding author: ferenc köteles, institute of health promotion and sport sciences, eötvös loránd university, budapest, bogdánfy ödön u. 10., h-1117 hungary. e-mail: koteles.ferenc@ppk.elte.hu abstract background: idiopathic environmental intolerance attributed to electromagnetic fields (iei-emf) is a self-reported condition where non-specific symptoms are attributed to weak non-ionizing electromagnetic fields. despite its expanding prevalence, there is no generally accepted diagnostic procedure or definition to identify patients with this condition, thus studies usually apply only one question as inclusion criterion. the aim of our study was to demonstrate the heterogeneity of a self-reported iei-emf group and to identify further self-report questions that could be applied as inclusion criteria. method: cross-sectional on-line survey study was carried out with 473 participants (76.3% women; age: 35.03 ± 13.24 yrs). self-diagnosed iei-emf (as assessed with a yes-or-no question), frequency of emf-related symptom and severity of the condition were assessed, as well as somatic symptom distress (patient health questionnaire somatic symptom severity scale, phq-15). results: 72 (15.2%) individuals labelled themselves as iei-emf, however only 61% of them remained in the iei-emf group after the use of three inclusion criteria instead of one. 21% of the individuals labelling themselves as iei-emf reported neither symptoms nor any negative impact on their daily life. conclusion: a minimum of two questions appear to be necessary as inclusion criteria for iei-emf in empirical research. instead of the widely used yes-or-no question on accepting the iei-emf label, occurrence of symptoms attributed to emf on a regular basis and at least a slight negative impact on daily life are required. keywords electrohypersensitivity, symptoms, assessment, idiopathic environmental intolerance attributed to electromagnetic fields, iei-emf this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i4.35668&domain=pdf&date_stamp=2019-12-17 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • electromagnetic hypersensitivity (iei-emf) is often assessed by one yes-or-no self-report question. • this practice is inappropriate from a conceptual and methodological point of view. • at least two questions, assessing frequency of symptoms and their impact, are needed. according to the definition of the world health organization, the term idiopathic envi‐ ronmental intolerance attributed to electromagnetic fields (iei-emf; formerly electro‐ magnetic hypersensitivity) refers to “symptoms that are experienced in proximity to, or during the use of, electrical equipment, and that result in varying degrees of discomfort or ill health in the individual and that an individual attributes to activation of electrical equip‐ ment” (who, 2004, p. 2). originally, iei was defined along the following criteria: (1) an acquired disorder with multiple recurrent symptoms (2) that could be associated with di‐ verse environmental factors tolerated by the majority of the population, and (3) cannot be explained by any other known disorder (medical or psychological) (lessof, 1997; staudenmayer, 2006). concerning iei-emf, however, some of the aforementioned criteria are unrealistic and practically irrelevant. first (criterion 1), why does one want and how can one distin‐ guish between acquired and inherited conditions in the modern era when the importance of epigenetics and environment-gene interactions is well described, and empirical find‐ ings concerning genetic factors (e.g. gene polimorphisms) behind environmental illnesses are accumulating (berg et al., 2010; caccamo et al., 2013; cui et al., 2013; de luca et al., 2015, 2014; mckeown-eyssen et al., 2004; schnakenberg et al., 2007)? moreover, what is the difference between individuals with acquired and (partly) inherited iei-emf from a therapeutic point of view? second (criterion 3), although it is well documented that ieiemf is often accompanied by co-morbid psychiatric disorders (e.g. depression, anxiety disorder) (frick et al., 2005; landgrebe et al., 2008; meg tseng, lin, & cheng, 2011; österberg, persson, karlson, eek, & ørbæk, 2007; rubin, cleare, & wessely, 2008) partici‐ pants with such comorbid disorder(s) are usually excluded from the investigations (baliatsas, van kamp, lebret, & rubin, 2012a). this practice leads to excessive sample loss, and, most importantly, sampling bias. third, as in other areas of medicine, diagnoses based on exclusionary definitions should be avoided. finally, certain salient aspects of the condition (most importantly, chronicity; m. witthöft, personal communication) are not included. the prevalence of iei-emf shows a considerable variability (between 1.5-20%) (eltiti et al., 2007; hillert, berglind, arnetz, & bellander, 2002; huang, cheng, & guo, 2018; infas, 2006; mohler et al., 2010; schreier, huss, & röösli, 2006; ulmer & bruse, 2006).this assessing iei-emf 2 clinical psychology in europe 2019, vol.1(4), article e35668 https://doi.org/10.32872/cpe.v1i4.35668 https://www.psychopen.eu/ variability could be partly explained by the lack of generally accepted medical diagnostic procedure or definition. in fact, more than half of the empirical studies on iei-emf ap‐ plied only participants’ self-report about their emf-hypersensitivity often assessed us‐ ing a simple yes-or-no question as inclusion criterion (baliatsas et al., 2012b). because of the striking similarities between ieis and medically unexplained symp‐ toms or functional somatic syndromes, many authors suggest that ieis should be man‐ aged as a sub-category of somatoform disorders, where symptoms are attributed to a spe‐ cific environmental factor (bailer, witthöft, paul, bayerl, & rist, 2005; henningsen & priebe, 2003; wiesmüller, ebel, hornberg, kwan, & friel, 2003). keeping in mind that ieiemf is officially often recognized as a functional impairment (johansson, 2015), and that the who definition considers the existence of symptoms and a negative impact on per‐ ceived health also essential to the condition, the use of further questions should be war‐ ranted from a theoretical point of view. in addition, an overly inclusive criterion can-hin‐ der not only the exploration of the aetiology and the treatment of iei-emf patients, but also raises difficulties for the integration of results gained up to the present (baliatsas et al., 2012a). the primary goal of the study reported here was the demonstration of heterogeneity within the category of self-reported iei-emf. we also attempted to identify self-report questions (items) that are necessary as inclusion criteria. method participants a non-representative hungarian community sample was used. participants (n = 473; 76.3% women; age: 35.03 ± 13.24) were recruited through various groups in the social me‐ dia that are thematically not connected to environmental intolerances. the study was ap‐ proved by the research ethics board of the university. participants received no reward for their participation; all signed an on-line informed consent form before completing the questionnaire on-line. questionnaires and questions the questions and the questionnaire were part of a larger study that investigated the connection between environment and health. self-diagnosis of iei-emf (iei-emf) was assessed with a single yes-or-no question (“many people experience unpleasant symptoms (e.g. headache, nausea, concentration prob‐ lems, palpitation, etc.) when staying in the vicinity of electromagnetic fields (e.g. near elec‐ tric devices, computers, electric power lines, or during mobile phone calls). this phenomenon is called electromagnetic hypersensitivity or electrosensitivity. do you consider yourself to be szemerszky, dömötör, & köteles 3 clinical psychology in europe 2019, vol.1(4), article e35668 https://doi.org/10.32872/cpe.v1i4.35668 https://www.psychopen.eu/ electrosensitive?”) (dömötör, doering, & köteles, 2016; köteles et al., 2013; szemerszky, gubányi, árvai, dömötör, & köteles, 2015). severity of the condition (impact) was assessed with the following question: “on the whole to what extent do emf-related symptoms affect your everyday life?” (0 = no impact at all, 1 = some impact, 2 = medium impact, 3 = high impact) (dömötör et al., 2016; dömötör, szemerszky, & köteles, 2019). frequency of emf-related symptoms (symptoms) was assessed with the following question: “how often do you experience symptoms in the proximity of electric devices?” (0 = never, 1 = it happened once, 2 = rarely, 3 = often, 4 = every time) (dömötör et al., 2019). the existence of somatic symptoms, regardless of their origin and assumed cause, were assessed with patient health questionnaire somatic symptom severity scale (phq-15) (kroenke, spitzer, & williams, 2002) which measures the prevalence and severi‐ ty of 15 common symptoms in a 3-point likert-scale from 0 (“not bothered at all”) to 2 (“bothered a lot”). higher scores refer to higher prevalence of disturbing symptoms in the past 4 weeks. scores of 5, 10, and 15 represent cut-off points for low, medium and high somatic symptom severity, respectively (kroenke et al., 2002). in clinical practice, phq-15 is often used to measure somatization tendency. the cronbach’s alpha coefficient of the scale in the present study was 0.80. statistical analysis statistical analysis was carried out with the spss v20 software. according to the results of shapiro-wilk tests, phq-15 scores showed a significant deviation from normal distri‐ bution, thus non-parametric methods were used throughout the analysis. groups with and without iei-emf were compared using mann-whitney-u-tests and chi-square tests (for gender ratio). results overall, 15.2% of the individuals (72 participants) labelled themselves as being hypersen‐ sitive to emf (iei-emf item). descriptive statistics and the results of group-level compari‐ sons are presented in table 1. mann-whitney-u-tests indicated a significant difference between the self-reported iei-emf and non-iei-emf group in phq-15 score, frequency of iei-emf related symp‐ toms, and impact of emf-related symptoms on everyday life. the iei-emf group was characterized by higher values in all cases, and it approached but did not reach the phq-15 cut-off point for medium symptom severity. there was no significant difference between the two groups with respect to gender ratio and age. assessing iei-emf 4 clinical psychology in europe 2019, vol.1(4), article e35668 https://doi.org/10.32872/cpe.v1i4.35668 https://www.psychopen.eu/ table 1 descriptive statistics of the measured variables (mean ± standard deviation) variable iei-emf (n = 72) non-iei-emf (n = 401) between-group comparison statistic p age 36.0 ± 13.54 34.86 ± 13.20 m-w u = 13579.50 > .05 gender ratio (women) 82% 75% χ2 = 1.49 > .05 somatic symptoms (phq-15) 9.17 ± 4.67 7.37 ± 4.47 m-w u = 10916.50 .001 impact on daily life 0.74 ± 0.69 0.1 ± 0.33 m-w u = 6894.50 < .001 frequency of symptoms 2.0 ± 1.08 0.4 ± 0.78 m-w u = 4328.50 .001 note. iei-emf = idiopathic environmental intolerance attributed to electromagnetic fields; phq-15 = patient health questionnaire; m-w u = mann-whitney u. if we apply another inclusion criterion, i.e., the rare (but already regular) occurrence of symptoms (symptoms > 1), altogether 25.37% of the 473 participants (120 individuals) re‐ ported that they had experienced symptoms attributed to electromagnetic field exposure at least occasionally. of these 120 individuals, however, only 47.5% (57 individuals) con‐ sidered themselves electrohypersensitive, whereas 63 did not. both groups’ phq-15 score was below the cut-off point (iei-emf: 9.30 ± 4.40; non-iei-emf: 8.54 ± 4.84), and showed no significant difference (mann-whitney u = 1586.00, p = .269). similarly, considering a minimal impact of the condition on everyday functioning (impact > 0), it turns out that 82 individuals of the 473 participants (17.34%) belong to this category. interestingly, only 53.7% (44 individuals) diagnosed themselves as iei-emf, while the remaining 38 did not use this label. in both groups, the phq-15 score exceeds the medium cut-off point (iei-emf: 10.02 ± 4.65; non-iei-emf: 10.13 ± 4.88), but they did not differ from each other (mann-whitney u = 831.50, p = .967). taken together, only 44 of the 72 individuals (61.1%) with self-reported iei-emf had symptoms attributed to electromagnetic devices at least rarely and suffered from the con‐ dition at least slightly. surprisingly, there were 15 individuals (20.8%) who had neither symptoms nor a negative impact on their everyday functioning but still considered them‐ selves iei-emf. in the non-iei-emf group, 25 individuals (6.2%) were characterized by both criteria (for details, see figure 1). within those, who reported symptoms and also an impact on daily life (69 individuals), the iei-emf group’s phq-15 score was slightly above the cut-off point (10.02 ± 4.65), while the non-iei-emf group scored a bit lower (9.76 ± 4.94). still, the difference between the two was not significant (mann-whitney u = 523.00, p = .735). finally, average phq-15 score of the group defined by symptoms and impact regardless of the iei-emf label was close to the threshold of 10 (9.93 ± 4.72). szemerszky, dömötör, & köteles 5 clinical psychology in europe 2019, vol.1(4), article e35668 https://doi.org/10.32872/cpe.v1i4.35668 https://www.psychopen.eu/ figure 1. the number of individuals (and their percentage of total) in the iei-emf and control group after applying additional inclusion criteria beyond self-reported electrohypersensitivity. discussion our results demonstrate that the use of one single yes-or-no question as inclusion criteri‐ on for self-reported iei-emf is not an acceptable practice. although the iei-emf group selected by this single question shows a higher average somatization tendency than the non-iei-emf group, this tendency is still under the accepted threshold of medium im‐ pact. beyond the widely applied yes-or-no question, the use of at least two additional ques‐ tions appears to be necessary for a more precise definition of the condition and the sam‐ ple. after the use of three inclusion criteria instead of one, only 61% of the individuals of the original iei-emf group remained there. the two additional criteria, i.e., experiencing symptoms attributed to emf on a regular basis and symptoms impacting everyday func‐ tioning, are in accordance with the who definition of the condition. moreover, this more strictly (still rather inclusively) defined group shows a score that indicates a non-negligi‐ ble somatization tendency. this latter finding is in line with the conceptualization of iei as a sub-category of functional somatic syndromes (frick, rehm, & eichhammer, 2002). in fact, self-diagnosis (i.e. the acceptance of the iei-emf label) is not part of the who definition thus the use of the yes-or-no question can be questioned. in our sample, 69 in‐ dividuals of the 473 (14.6%) belong to the iei-emf group as defined by the symptoms and impact question. somatization tendency of this group practically reached the threshold of medium severity, and applying the iei-emf label did not elevate this score substantially. in other words, using the criteria of symptoms and impact appears to be practically suffi‐ cient as well as in line with the definition of the condition. assessing iei-emf 6 clinical psychology in europe 2019, vol.1(4), article e35668 https://doi.org/10.32872/cpe.v1i4.35668 https://www.psychopen.eu/ beyond practical issues, the present findings demonstrate that individuals with selfdiagnosed iei-emf does not represent a homogeneous group. it is particularly striking that 21% of the individuals labelling themselves as iei-emf experience neither symptoms nor any negative impact on their daily life. this finding can be explained by two ap‐ proaches. first, stories about harmful effects of modern technologies are abundant in mass media and impact not only people’s worrying tendency (bräscher, raymaekers, van den bergh, & witthöft, 2017; petrie et al., 2001; witthöft et al., 2018), but also their auto‐ matic self-perception and self-categorization. second, as in the case of complementary and alternative medicine (astin, 1998), philosophical congruence might be a motive for those characterized by an experiential-intuitive thinking style to accept the iei-emf la‐ bel, even in the absence of symptoms. the most important limitation of the present study is that our sample was not repre‐ sentative of the population, therefore the results are not generalizable. additionally, the applied sampling method (online assessment) has well-known limitations. finally, identi‐ fication of people suffering from iei-emf based only self-report questions without any external criterion or assessment could be equivocal. in summary, a minimum of two questions appear to be sufficient as inclusion criteria for iei-emf in empirical research. instead of the widely used yes-or-no question on ac‐ cepting the iei-emf label, regular occurence of symptoms attributed to emf and at least a slight negative impact on daily life are required. funding: the authors received no financial support for the research, authorship, and/or publication of this article. competing interests: the authors declare no conflicts of interest. acknowledgments: this research was supported by the hungarian national scientific research fund (k 124132), the jános bolyai research scholarship of the hungarian academy of sciences (for r. szemerszky) and by the únkp-17-3 new national excellence program of the ministry of human capacities (for zs. dömötör). references astin, j. a. 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(2018). on the origin of worries about modern health hazards: experimental evidence for a conjoint influence of media reports and personality traits. psychology & health, 33(3), 361-380. https://doi.org/10.1080/08870446.2017.1357814 assessing iei-emf 10 clinical psychology in europe 2019, vol.1(4), article e35668 https://doi.org/10.32872/cpe.v1i4.35668 https://doi.org/10.1667/rr2153.1 https://doi.org/10.1177/0960327107070575 https://doi.org/10.1016/s0022-3999(01)00219-7 https://doi.org/10.1016/j.jpsychores.2007.05.006 https://doi.org/10.1186/1476-069x-6-6 https://doi.org/10.1007/s00038-006-5061-2 https://doi.org/10.1007/s12529-015-9477-z http://www.emf-forschungsprogramm.de https://doi.org/10.1016/s0306-9877(03)00185-3 https://doi.org/10.1080/08870446.2017.1357814 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. szemerszky, dömötör, & köteles 11 clinical psychology in europe 2019, vol.1(4), article e35668 https://doi.org/10.32872/cpe.v1i4.35668 https://www.psychopen.eu/ assessing iei-emf (introduction) method participants questionnaires and questions statistical analysis results discussion (additional information) funding competing interests acknowledgments references starc-sud – adaptation of a transdiagnostic intervention for refugees with substance use disorders latest developments starc-sud – adaptation of a transdiagnostic intervention for refugees with substance use disorders annett lotzin 1,2, jutta lindert 3,4, theresa koch 5, alexandra liedl 5, ingo schäfer 1,2 [1] department of psychiatry and psychotherapy, university medical center hamburg-eppendorf, university of hamburg, hamburg, germany. [2] centre for interdisciplinary addiction research, university of hamburg, hamburg, germany. [3] university of applied sciences, emden / leer, emden, germany. [4] women`s research center, brandeis university, waltham, ma, usa. [5] refugio münchen, munich, germany. clinical psychology in europe, 2021, vol. 3(special issue), article e5329, https://doi.org/10.32872/cpe.5329 received: 2020-12-01 • accepted: 2021-09-05 • published (vor): 2021-11-23 handling editor: eva heim, university of lausanne, lausanne, switzerland corresponding author: annett lotzin, department of psychiatry and psychotherapy, university medical center hamburg-eppendorf, martinistr. 52, 20246 hamburg, germany. phone: +49-(0)40-7410-55356. e-mail: a.lotzin@uke.de related: this article is part of the cpe special issue “cultural adaptation of psychological interventions”, guest editors: eva heim & cornelia weise, clinical psychology in europe, 3(special issue), https://doi.org/ 10.32872/10.32872/cpe.v3.si supplementary materials: data [see index of supplementary materials] abstract background: refugees often suffer from multiple mental health problems, which transdiagnostic interventions can address. starc (skills-training of affect regulation – a culture-sensitive approach) is a culturally sensitive transdiagnostic group intervention that has been developed for refugees to improve affect regulation. in refugees with substance use disorders (sud), the consideration of sud-specific elements might improve the acceptance and effectiveness of such an intervention. we aimed to adapt the starc program for refugees with sud in a culturally sensitive way. method: the conceptual framework of heim and kohrt (2019) was used to culturally sensitively adapt the starc program to the needs of syrian refugees with sud. the results of five focus group discussions with refugees on cultural concepts of sud and their treatment informed the adaption. an expert group suggested adaptions and decided by consensus on their implementation. two pilot groups were conducted with the adapted starc-sud program. interviews with the therapists of these pilot groups informed further adaption. results: the concepts related to sud identified in focus groups and therapists’ interviews that differed from western concepts were integrated into the starc intervention. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5329&domain=pdf&date_stamp=2021-11-23 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ discussion: further studies should assess the acceptance and effectiveness of the culturally sensitive starc-sud program for refugees with sud. keywords emotion regulation, affect regulation, substance use disorders, addiction, refugees, group treatment, cultural adaption, formative research highlights • the study offers insight into the adaptation process of a culturally sensitive group intervention. • we report the adaptation of a group intervention for refugees with substance use. • cultural concepts of syrian refugees related to substance use are considered in the adaptation. the rising global burden of forced migration is one of the most pressing public health issues (unhcr, 2019). forced migration is related to many stressors that increase the risk for sud, including loss of loved ones, different types of abuse, family separation, social and economic inequality, and discrimination in the host country (horyniak et al., 2016). in refugees, substance use disorders (sud) have received increasing awareness (horyniak et al., 2016), with a prevalence rate of hazardous or harmful alcohol use ranging from 4% to 7% in community settings (horyniak et al., 2016). the availability of substances and the often higher acceptance of substance use in the host country (e.g., drinking alcohol in public) might additionally increase the risk of sud (priebe et al., 2016). while there is a need for sud health care for refugees, this need often is not met (welbel et al., 2013). several barriers to access services exist. lack of knowledge about the mental health care system in the host country prevents access (posselt et al., 2017). in addition, refugees are often required to attend multiple psychosocial services before entering sud treatment, risking disengagement. interpreters are unavailable, or if availa­ ble, the health insurance does not cover the costs (jaeger et al., 2019). additional barriers to accessing sud health services concern different concepts of suffering and sud-related stigma (penka et al., 2012). the lack of knowledge and skills in cultural sensitivity in professionals further contributes to the sud health care gap among refugees. the culturally sensitive adaption of the existing western evidence-based interven­ tions seems central to reduce barriers to mental health care in refugees. the adaption of the language, culture, and context of an intervention to be compatible with the user’s cultural patterns, meanings, and values (bernal et al., 2009) may enhance its acceptability and effectiveness (hall et al., 2016). indeed, evidence has accumulated that cultural adaptations enhance the efficacy of treatments based on western psychotherapeutic ap­ starc-sud – adaptation of an intervention for refugees with sud 2 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://www.psychopen.eu/ proaches in populations with other cultural backgrounds (anik et al., 2021; chowdhary et al., 2014). as refugees often suffer from multiple mental disorders, the need for evidence-based transdiagnostic treatments has received increasing attention (martin et al., 2018). trans­ diagnostic interventions address mechanisms underlying common mental disorders. such interventions may be preferable to disorder-specific interventions, as therapists can apply them to a group of refugees with heterogeneous symptoms. group therapy with people who have survived the same experience seem to be more effective than individual therapeutic approaches (kira et al., 2012). a few transdiagnostic treatment approaches have been developed for non-western cultures. problem management plus (pm+; dawson et al., 2015) is a five-session low-in­ tensity intervention developed for low and middle-income countries targeting persistent distress and mild symptoms of depression and anxiety (dawson et al., 2015). pm+ was effective in reducing psychological distress (e.g., bryant et al., 2017), but no research ex­ amined its effects on sud. “common elements treatment approach” (ceta) is another brief intervention for common mental health disorders developed for low-resource set­ tings (murray et al., 2014). ceta effectively reduced hazardous alcohol use in an at-risk sample for interpersonal violence in zambia (murray et al., 2020). culturally sensitive evidence-based interventions for refugees in the middleor high-income countries are needed to target sud and other mental disorders in refugees. the starc intervention a culturally sensitive group intervention developed for refugees in the western mid­ dleor high-income countries is starc (skills-training of affect regulation – a cul­ ture-sensitive approach; koch & liedl, 2019). starc is a 14-session culture-sensitive transdiagnostic intervention to improve affect regulation in refugees. the intervention is based on western skills-based elements from skills training in affective and interperso­ nal regulation therapy (stair; cloitre & schmidt, 2015), the dialectic behavioral thera­ py (dbt; bohus et al., 2011), and the culturally adapted cognitive behavioral therapy (ca-cbt; hinton et al., 2011). the authors developed the starc program according to guidelines for developing culturally sensitive interventions (bernal & sáez-santiago, 2006). the manual includes culturally-sensitive metaphors and expressions and uses easy language. a pilot study in afghan refugees indicated preliminary evidence that the inter­ vention reduces difficulties in emotion regulation, general distress, and post-traumatic stress disorder symptoms (koch et al., 2020). difficulties in regulating emotions play a key role in sud (aldao et al., 2010). im­ proving emotion regulation via culturally sensitive interventions such as starc seems essential to reduce substance use and relapse in individuals with sud. such interventions need to address managing emotions effectively to regulate craving when the risk of substance abuse is high. previous research showed that individuals with sud benefited lotzin, lindert, koch et al. 3 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://www.psychopen.eu/ from tailored emotion regulation interventions that considered their specific needs, e.g., coping with craving beliefs (choopan et al., 2016). while emotion regulation strategies are a centerpiece of the starc intervention, it does not focus on the interrelations between emotion regulation and substance use. adapting the starc intervention for the specific needs of refugees with sud might further enhance its acceptance and effectiveness in this vulnerable group. therefore, the aim of this study was to adapt the starc program for syrian refugees with sud. method the adaption of the starc program was conducted in preparation of a randomized controlled trial of the starc-sud program in refugees with substance use problems (schäfer et al., 2020), which is part of a research network on the prevention and treat­ ment of substance use disorders in refugees (prepare, prevention, and treatment of substance use disorders in refugees; bmbf 01ef1805a). the ethics committee of the medical council of hamburg approved this study (pv7123). intervention the starc program (koch & liedl, 2019) was developed in a participatory approach with refugees. starc is a weekly group program conducted with six to eight refugees of the same gender and an interpreter if required. it consists of fourteen 90-min ses­ sions. the program contains four modules: 1) introduction and training of emotional perception; 2) training of specific emotion regulation strategies; 3) dealing with specific emotions, and 4) rehearsal and closure. module 1 aims at improving emotional awareness. emotions and their functions are discussed, and the interrelations between feelings, thoughts, and body reactions are ex­ plained. personal warning signals for different emotional intensities are also introduced. in module 2, emotion regulation strategies are conveyed, including cognitive approaches, body-based strategies, and strategies to cope with intense feelings. in module 3, coping with specific emotions, such as anger or fear, is discussed. in module 4, the group reviews the learned skills and celebrates program completion (for a more detailed de­ scription, see koch & liedl, 2019). procedure of adaption in the current study, we focused on syrian refugees as they represent one of the largest refugee groups in germany. due to restricted resources, we shortened the program to ten sessions. the sessions were reviewed with the authors of starc, sessions with overlapping content were merged. the shortened starc program was extended with sud-specific elements while keeping the basic concept of the program. the starc ses­ starc-sud – adaptation of an intervention for refugees with sud 4 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://www.psychopen.eu/ sions were adapted by referring to substance use as a dysfunctional emotion regulation strategy throughout the sessions. in addition, we integrated elements used in sud group treatment, such as discussions about the risk and protective factors of sud and the short and long-term consequences of substance use (körkel & schindler, 2003; lindenmeyer, 2016). in accordance with heim and kohrt (2019), cultural concepts of substance abuse were collected as a first step of the cultural adaption process. five focus groups with three to nine refugees were conducted to assess their core assumptions, beliefs, and concepts of sud. the focus group discussions were based on a published interview guideline and followed standard procedures for reporting qualitative studies (lindert et al., 2021). the focus groups included 19 purposively recruited male adult syrian refugees. they were aged 20 to 50 years and lived in germany in metropolitan, urban, or rural areas. a native-speaking professional translator and one facilitator conducted the focus groups. the facilitator was a female phd student in psychology with a background in ethnology. inductive content analysis (mayring, 2014) was applied to analyze the transcribed data and extract common themes. the results of the focus groups with refugees yielded culture-specific information about core assumptions, beliefs, and concepts related to sud and its treatment with refugees. the results of the focus groups were published in a separate paper (lindert et al., 2021). based on the results of the focus groups, three experts proposed adaptions in a standardized adaption sheet. the first expert (second author) was a researcher in the field of migration research; the second expert (first author) was a mental health professional and expert in the field of traumatic stress and psychotherapy research; the third expert was a mental health professional from afghanistan working with refugees with a flight history. in a consensus meeting, the three experts commented on the suggestions of each other and then discussed and decided on the adaptions. in case of disagreement, the suggestion was discussed together until an agreement between the discussants was reached. a starc-sud prototype was created and then piloted in two groups with syrian refugees with sud. the pilot groups were conducted by trained therapists in routine sud care facilities. the therapists had a german background. all content was translated simultaneously during the sessions. after completion of the program, the therapists were invited to an unstructured interview to provide feedback on their experience with the program. the interviews were conducted by a clinical psychologist experienced in the conduction of group therapies. the interviewer noted the key points in the adaption sheet during the interview. these interviews informed further adaption of the program that were documented and consented by the same expert group in a second consensus meeting. all adaptations are described in supplement 1. in accordance with the procedure of heim et al. (2021), this issue, and heim and knaevelsrud (2021), this issue, a standardized lotzin, lindert, koch et al. 5 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://www.psychopen.eu/ template was used to document the adaptations (see supplement 2). this template in­ cludes the following sections: i) target group; ii) formative research methods; iii) cultural concepts of distress (i.e., idioms of distress, explanatory models); iv) target intervention; v) deep structure adaptations (i.e., specific and unspecific elements and in-session techni­ ques); and vi) surface adaptations (i.e., mode of delivery, materials). results cultural adaption of starc-sud the adapted elements of the starc program are documented in supplement 2, the content of the different sessions of the adapted program is described in supplement 3. 1. unspecific elements the results of the focus group discussions and therapists’ interviews indicated that some refugees were unfamiliar with the western concept of psychotherapy which suggests that individuals solve mental health problems by themselves (rather than within the family) by consulting a mental health professional. in contrast to this approach, some refugees found it more appropriate to solve mental health problems collectively within the family system. hence, we included psychoeducation about the concept of western psychotherapy in the introductory session. furthermore, the therapists stressed that the approach to talk about mental health problems in a group with other patients needed to be introduced. therefore, we included psychoeducation about the group setting as a common intervention approach in western cultures to support and learn from each other in the introductory session. 2. sud-specific elements not all refugees shared the concept of sud as a treatable mental disorder. consequently, we added information on the western concept of addiction as a recognized treatable mental disorder and the availability of professional addiction services to the starc manual. most refugees stressed that rules and norms differed between the host and home country; the greater availability of substances was perceived as contributing to sud. the greater societal acceptance of substance use was frequently mentioned as another reason for sud. thus, we incorporated information about the substances commonly used in the host and home country, as well as their availability and acceptance in the starc-sud program. refugees and therapists reported refugee-specific risk factors for sud, e.g., traumat­ ic experiences in the home countries or during flight, worries about family members that remained in the home country, and not feeling accepted by the host country. refu­ gee-specific risk factors for sud were therefore included in the starc-sud program. starc-sud – adaptation of an intervention for refugees with sud 6 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://www.psychopen.eu/ in addition to these refugee-specific risk factors, refugees mentioned culture-specific protective factors for not developing sud, such as societal and family norms, and social support. these factors were incorporated into the manual. 3. other specific elements the therapists reported that some of the male refugees hesitated to play a group dynamic game with a ball of wool to get familiar with other group members in the introductory session. these male refugees perceived the game as more appropriate for women. hence, we changed the manual instruction recommending to be sensitive to gender-based pref­ erences regarding group games. some refugees participating in the pilot groups reported being unfamiliar with the relaxation exercises introduced in the program (breathing exercise and progressive mus­ cle relaxation) to regulate tension or intense feelings. rather, they preferred more active strategies (e.g., physical exercises and singing). we adapted the program to instruct the therapists to offer both relaxation exercises and alternative active strategies. according to the therapists’ feedback obtained in the interviews, some participants preferred religious statements of encouragement as a strategy to regulate emotions, while others preferred non-religious statements, as they were non-religious or persecu­ ted for religious reasons. therefore, it was more strongly emphasized in the manual to be mindful in proposing religious rituals, e.g., reading the koran or bible, or talking to god or allah. 4. treatment delivery some refugees with a high level of education found that the easy language used in the starc manual appeared unfamiliar to them. therefore, we added an instruction to the manual that therapists could adapt the complexity of the language according to the language skills and education of the participants. the therapists reported that the translator needed to have read the manual before the session to translate the content correctly. in addition, therapists emphasized the need of having sufficient time to ensure that all participants correctly understood the translation of the session content, e.g., by asking comprehension questions and providing additional information as needed. a briefing of the translators on the translation procedure before the session might also be helpful. therefore, we underlined these aspects more strongly in the introductory part of the program. discussion based on the focus group discussions with syrian refugees on cultural concepts of sud and its treatment, we integrated elements relevant for the treatment of sud in a culturally sensitive way into the starc program. after piloting the first version of the lotzin, lindert, koch et al. 7 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://www.psychopen.eu/ starc-sud prototype, we further adapted the program based on interviews with the therapists that conducted two starc-sud pilot groups. unspecific elements we found that some of the refugees were unfamiliar with the western concept to solve mental health problems with a mental health specialist. this finding is in line with the results of previous research showing that the western concept of psychotherapy, i.e., to consult a mental health professional to talk about mental health problems, may be unfamiliar to people from non-western cultures (gopalkrishnan, 2018). earlier research also revealed that provision of knowledge about (western) mental health services and how to access them may increase trust in refugees (duden et al., 2020; sandhu et al., 2013). furthermore, we found that the group setting (vs. individual setting) used for the starc program needed to be introduced in more detail. psychoeducation about the western concept of (psycho-)therapy as a common ap­ proach in german healthcare to cope with mental health problems seems important. this may include discussing the approach to solve problems individually in a professional setting with a health care specialist as an alternative or complementing strategy to collectivistic approaches to enhance understanding, acceptance, and adherence to the program. sud-specific elements in the focus groups that were conducted prior to the cultural adaptation, refugees out­ lined several sud-specific aspects as essential to be incorporated in a culturally sensitive intervention (lindert et al., 2021). these included different concepts and norms for addiction, as well as for substance use, their availability, and acceptance. the finding that some of the refugees were unfamiliar with western concepts of addiction as a recognized and treatable mental disorder is in line with the results of earlier qualitiatve research among afghan populations showing that the concepts of mental disorders, such as de­ pression (alemi et al., 2016) and posttraumatic stress disorder (yaser et al., 2016), differed from those reported by western populations. the acceptance of interventions addressing sud in refugees might be improved by introducing the western concept of addiction as a recognized treatable mental disorder, and by discussing differences and similarities with other concepts of addiction. psychoeducation about commonly used substances, their availability and acceptance in the host and home countries might also increase acceptance and adherence to the intervention. furthermore, our results indicated that refugee-specific risk and protective factors for sud needed to be considered to provide a relevant model of the development of sud, e.g., traumatic experiences or worries about family members. starc-sud – adaptation of an intervention for refugees with sud 8 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://www.psychopen.eu/ other specific elements gender-specific preferences for dynamic group games needed to be considered in the starc-sud program. previous studies with refugees also reported gender-specific pref­ erences for group therapy content that were related to gender-specific socialization experiences (kira et al., 2012). these results speak to the importance of conducting gender-separated therapy groups. we also found that the type of exercises to regulate emotions needed to be chosen culturally sensitively. a study by somasundaram (2010) indicated that relaxation techni­ ques might be an effective component in treating mental disorders in refugees if they include techniques known and used in the respective culture. the sensitive use of religious content in the program was another important finding of our study. while some refugees perceived religion as a source of strength, others experienced it as a source of threat. these results indicate the need to consider religious content carefully in mental health interventions for refugees. however, in refugees that perceive religion as a source of strength, religious content in a culturally sensitive intervention might be particularly helpful, as religious believes are an integral part of ones’ own understanding of the world in many non-western cultures (machleidt, 2019). consistent with this assumption, relaxation techniques (somasundaram, 2010) and thera­ peutic interventions (hasanović, 2017) including religious content have been perceived as helpful among refuges in previous research. treatment delivery while the easy language used in the program seemed essential to improve the compre­ hensiveness of the program content for non-native speakers, it became clear that easy language could appear artificial for high-educated refugees, indicating the need for indi­ vidual adaption of the used language to the participants of the respective intervention. we also found that the translations improved if the translators read the program sessions beforehand. these findings are consistent with a previous qualitative study by duden et al. (2020), which reported that patients and mental health providers were concerned that not everything said had been translated correctly. the quality of the translation could be increased by having interpreters that familiarize themselves with the session content in advance. our results also indicated that enough time-related resources are needed during the session to ensure that all refugees understood the translated content correctly. overall, this study identified a number of necessary adaptions of a therapeutic in­ tervention, developed within western cultures, to the needs of individuals from other cultural backgrounds. attention should be payed to the clarification of the underlying concepts. for refugees, it might be an unfamiliar concept that speaking about one's problems in groups is appropriate, and learning from others might have healing effects. lotzin, lindert, koch et al. 9 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://www.psychopen.eu/ moreover, if such therapies include skills-based approaches, there is a need to consider their appropriateness from a gender and culture-sensitive perspective. our results indicate implications concerning offering support for sud in refugees. when adapting western therapeutic approaches to the needs of refugees with sud, western concepts of mental disorders underlying the intervention should be discussed, such as the concept of addiction as a recognized and treatable mental disorder. in addition, the different societal norms for substance use, the types of substances, and their availability and acceptance in the host and home countries should be addressed. limitations there are limitations concerning the methodology of our cultural adaptation. the pro­ gram was culturally adapted by integrating non-western metaphors, opinions from non-western cultures about diseases and healing, and easy-to-understand language. nevertheless, it seems impossible to make psychotherapy a culture-free concept, as it is rooted in the western culture. the database used for our adaption is limited by only considering male refugees. future studies need to examine the appropriateness of the program for female refugees. another limitation is that we did not assess sociodemo­ graphic characteristics except age to guarantee confidentiality for the study participants. conclusion according to the results obtained from focus groups (lindert et al., 2021) and the thera­ pists’ interviews, we adapted several elements in a culturally sensitive way. although the original version of the starc manual had already been developed culturally sensitively (koch & liedl, 2019), further potentially beneficial adaptations could be made from the sources included in the present study. this suggests that qualitative research such as focus groups should be used to inform cultural adaptions of existing interventions to consider the specific needs of a target group, such as refugees with sud. further studies might evaluate whether the cultural and sud-specific adaptions increase the starc-sud intervention's acceptance and effectiveness. funding: this study was funded as a part of a research network on the prevention and treatment of substance use disorders in refugees (prepare, prevention, and treatment of substance use disorders in refugees; bmbf 01ef1805a). acknowledgments: we would like to thank nahid yakmanesh for reviewing, discussing, and consenting to the proposed manual adaptions. we also thank the starc-sud therapists, the participants of the starc-sud groups, and the participants of the focus groups for supporting this research. competing interests: the authors have declared that no competing interests exist. starc-sud – adaptation of an intervention for refugees with sud 10 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://www.psychopen.eu/ supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • supplement 1 describes the adaptation steps of the starc-sud intervention. • supplement 2 summarizes the results of the focus group discussions with refugees and the interviews with therapists, as well as the adaptations of the starc-sud intervention decided by consensus. • supplement 3 provides an overview of the adapted sessions of the starc-sud intervention. index of supplementary materials lotzin, a., lindert, j., koch, t., liedl, a., & schäfer, i. 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(2020). a randomized controlled trial of starc („skills training in affect regulation – a culture-sensitive approach“) in refugees with substance use problems. osf. https://doi.org/10.17605/osf.io/nhxd4https://doi.org/10.17605/osf.io/nhxd4 somasundaram, d. (2010). using cultural relaxation methods in post-trauma care among refugees in australia. international journal of culture and mental health, 3(1), 16-24. https://doi.org/10.1080/17542860903411615 unhcr. (2019). global trends. forced displacement in 2018. https://www.unhcr.org/5b27be547.pdf welbel, m., matanov, a., moskalewicz, j., barros, h., canavan, r., gabor, e., gaddini, a., greacen, t., kluge, u., lorant, v., esteban peña, m., schene, a. h., soares, j. j. f., straßmayr, c., vondráčková, p., & priebe, s. (2013). addiction treatment in deprived urban areas in eu countries: accessibility of care for people from socially marginalized groups. drugs education prevention & policy, 20(1), 74-83. https://doi.org/10.3109/09687637.2012.706757 yaser, a., slewa-younan, s., smith, c. a., olson, r. e., guajardo, m. g. u., & mond, j. (2016). beliefs and knowledge about post-traumatic stress disorder amongst resettled afghan refugees in australia. international journal of mental health systems, 10, article 31. https://doi.org/10.1186/s13033-016-0065-7 starc-sud – adaptation of an intervention for refugees with sud 14 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://doi.org/10.1371/journal.pmed.1003056 https://doi.org/10.1007/s00103-012-1538-8 https://doi.org/10.1186/s12889-017-4186-y http://www.ncbi.nlm.nih.gov/books/nbk391045/ https://doi.org/10.1007/s00127-012-0528-3 https://doi.org/10.17605/osf.io/nhxd4 https://doi.org/10.17605/osf.io/nhxd4 https://doi.org/10.1080/17542860903411615 https://www.unhcr.org/5b27be547.pdf https://doi.org/10.3109/09687637.2012.706757 https://doi.org/10.1186/s13033-016-0065-7 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. lotzin, lindert, koch et al. 15 clinical psychology in europe 2021, vol. 3(special issue), article e5329 https://doi.org/10.32872/cpe.5329 https://www.psychopen.eu/ starc-sud – adaptation of an intervention for refugees with sud (introduction) the starc intervention method intervention procedure of adaption results cultural adaption of starc-sud discussion unspecific elements sud-specific elements other specific elements treatment delivery limitations conclusion (additional information) funding acknowledgments competing interests supplementary materials references visual triggers of skin picking episodes: an experimental study in self-reported skin picking disorder and atopic dermatitis research articles visual triggers of skin picking episodes: an experimental study in self-reported skin picking disorder and atopic dermatitis linda marlen mehrmann a, alice urban a, alexander leopold gerlach a [a] institute of clinical psychology and psychotherapy, university of cologne, cologne, germany. clinical psychology in europe, 2020, vol. 2(4), article e2931, https://doi.org/10.32872/cpe.v2i4.2931 received: 2020-03-11 • accepted: 2020-11-03 • published (vor): 2020-12-23 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: linda marlen mehrmann, university of cologne, institute of clinical psychology and psychotherapy, pohligstraße 1, 50969 cologne, germany. phone: 0049-221-470-6854. e-mail: linda.mehrmann@unikoeln.de abstract background: skin picking disorder (spd) is a new diagnosis with limited information available about triggers of picking episodes. itch can be induced via audio-visual stimuli and the effect of contagious itch is stronger for those affected by atopic dermatitis. we examined if picking-related visual stimuli can trigger the urge to pick skin in self-reported spd. we compared itch and the urge to pick in a sample of ad and/or spd-affected to controls without either. method: urge to pick skin and/or scratch when viewing 24 itch-related, picking-related or neutral online pictures was assessed in adult females, who self-report skin-picking (spd-only, n = 147) and/or atopic dermatitis (ad-only, n = 47; ad+spd, n = 46) as well as in skin healthy controls (hc, n = 361). results: all participants reported a stronger urge to pick for picking-related pictures compared to neutral content (f[1, 597] = 533.96, p < .001, ηp2 = .472) and more itch for itch-related pictures compared to neutral stimuli (f[1, 597] = 518.73, p < .001, ηp2 = .465). spd-all (spd-only & ad+spd) reported stronger urges to pick for picking-related vs. other stimuli compared to the adonly and hc group (p < .001, ηp2 = .047). likewise, ad-all (ad-only & ad+spd) reported significantly stronger itching for itch-related vs. other stimuli compared to spd-only and hc (p = .001, ηp2 = .019). conclusions: analog to visual provocation of itch, the urge to pick can be triggered by visual stimuli. treatments for spd and ad may profit from addressing visual stimuli. keywords skin picking, excoriation disorder, body-focused repetitive behaviors, contagious itch, visual stimuli this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i4.2931&domain=pdf&date_stamp=2020-12-23 https://orcid.org/0000-0001-6794-5349 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • contagious itch can be induced with visual stimuli (videos or static pictures). • this effect is especially strong in individuals self-reporting atopic dermatitis. • the urge to pick can also be induced with visual stimuli (picking-related pictures). • this effect is especially strong in individuals self-reporting skin picking disorder. • treatment for skin picking disorder may profit from addressing visual stimuli. skin picking disorder (spd) has recently been included as official diagnosis in the diag‐ nostic and statistical manual of mental disorders (dsm). dsm-5 characterizes spd as recurrent skin picking resulting in lesions of the skin and repeated attempts to decrease or stop this behavior. additionally, for a diagnosis of skin picking disorder, skin picking must cause clinically significant distress or impairment in important areas of functioning (american psychiatric association, 2013). many people indulge in picking behavior from time to time, however, people with spd feel a strong urge to manipulate their skin and feel unable to resist this urge or to stop (american psychiatric association, 2013). clinical experience suggests that skin picking episodes can be triggered in various different ways (mansueto et al., 1997; neziroglu et al., 2008). however, mostly self-report studies of triggers for skin picking episodes have been published. in a clinical sample emotional triggers such as general anxiety, general stress, interpersonal rejection, a sense of emptiness, and teasing were reported (neziroglu et al., 2008). in terms of visual stimuli, skin imperfections were most commonly mentioned (80%), including pimples, scabs, scars, and mosquito bites. regarding somatosensory triggers, itchiness (40%), the feeling of something being underneath the skin surface (32%), and a “right feeling” sensation (40%) were described. the most common environmental triggers were looking in the mir‐ ror and checking one’s skin (52%; neziroglu et al., 2008). in a german nonclinical sample (bohne et al., 2002; n = 133), students reported cutaneous triggers to be pimples (93.2%), insect bites (63.9%), scabs (57.1%), itching (45.9%), inflammation (34.6%), warts (13.5%), healthy skin (18.0%), moles and scars (9.8%). participants with spd reported the feel (55%) and sight (26.7%) of the skin as the most common triggers to picking behavior (odlaug & grant, 2008). finally, houghton et al. (2018) investigated sensory processing in people affected by body-focused repetitive behaviors (bfrbs; e.g., hairpulling, skin picking, nail biting) via the adult/adolescent sensory profile (brown et al., 2001). participants with clinical bfrbs reported increased sensory sensitivity including visual stimuli compared to subclinical bfrbs and healthy controls. in summary, many of these triggers indicate visual perception of one’s skin (e.g., when looking in the mirror) to be one of various factors within the cycle of urge to pick and picking behavior. visual triggers of skin picking episodes 2 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ one fmri study examined visual symptom provocation in spd (schienle, ubel, & wabnegger, 2018). for pictures with skin irregularities, disgust, tension and urge to pick ratings were significantly higher in the spd-group. however, the same was true regarding disgust and urge to pick for pictures without skin irregularities. furthermore, when looking at skin imperfections, spd-patients showed greater activation in the left insula and in the amygdala with stronger insula-putamen coupling compared to matched controls. these brain regions are linked to visual disgust elicitation, process salience and the affective significance of stimuli. whereas experimental studies examining mechanisms underlying the urge to pick in spd are mostly lacking, some exist for pruritus, especially pruritus associated with atopic dermatitis (ad). ad presents several similarities with spd. ad patients suffer from a cutaneous hyperreactivity to environmental triggers resulting in a chronic inflammatory skin disease (leung, 2013). pruritus is the cardinal symptom of ad provoking the desire to scratch for relief from this unpleasant sensation but leading to skin damage and other negative consequences (mochizuki et al., 2014; ständer & steinhoff, 2002). however, the mechanical stimulation of the skin may provoke inflammation, which again exacerbates itch (itch-scratch-cycle; mochizuki et al., 2017). due to its negative impact on quality of life, most patients measure the severity of their ad by intensity of pruritus rather than visible skin damage (ständer & steinhoff, 2002). against this background, verhoeven et al. (2008) proposed a biopsychosocial model of itch in patients with chronic skin diseases: internal vulnerability factors (e.g., personality) interact with external environmental fac‐ tors (e.g., stressors). meanwhile, cognitive (e.g., illness cognitions), behavioral, and social factors are mediating and/or moderating factors to trigger a skin disease and enhance symptoms of itch. contagious itch (ci) can therefore be a cognitive psychological factor causal in pathological itch (verhoeven et al., 2008). itch sensations can be evoked through mechanical, electrical, thermal and chemical stimulation of free nerve endings in the skin (leknes et al., 2007; murota & katayama, 2017). apart from methods manipulating the skin to induce itch (e.g., histamine and allergen solutions), non-skin-manipulating methods also lead to itch sensations (leknes et al., 2007). for example, itch can be induced with audio-visual stimuli. niemeier, kupfer, and gieler (2000) held two different lectures (“itch lecture”, “relaxation lecture”) for participants with and without self-reported skin disease. self-reported itch sensation after the lecture as well as the number of scratch movements during the “itch lecture” (slides with pictures of fleas, allergic reactions etc.) were significantly higher compared to the “relaxation lecture”. however, there was only a trend with regard to the experience of itching sensations when comparing participants with and without skin conditions. ogden and zoukas (2009) replicated these results with college students without assessing skin conditions using purely visual stimulation (e.g., videos of lice, person scratching head) without audio. in 2011, papoiu et al. investigated whether exposure to visual cues of itch (5-minute video of people scratching their left forearm vs. people sitting idle) mehrmann, urban, & gerlach 3 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ can induce or intensify itch in ad patients and healthy controls. itch intensity increased slightly in healthy volunteers and significantly in ad patients. the latter also scratched more frequently while watching the itch video. schut et al. (2015) identified depression as an additional significant predictor of induced itch. furthermore, agreeableness and public self-consciousness were significant predictors of scratching in ad-patients. palani et al. (2018) asked healthy participants to watch videos picturing a demonstrator scratching in four body regions with and without sound and a control video with neutral content. results showed ci to be body-region dependent, with the craniofacial region being the predominant site for participants to experience itching sensations after watching the video compared to arm, chest, and back. these studies on ci used a lecture or video material to induce itch. lloyd et al. (2013) tested whether static images (i.e., visual cues alone) were able to induce ci. they used neutral (e.g., butterflies or healthy skin) or itch-related pictures (e.g., fleas or skin conditions). healthy participants reported higher itch intensity for itch-related pictures compared to neutral pictures, and scratching frequency when viewing the pictures was significantly higher for itch-related pictures. furthermore, more scratch movements for the “skin response” picture type (e.g., scratching an insect bite) were found. lloyd et al. (2017) tested whether a history of pruritic skin conditions moderates the ci effect when looking at static pictures. itch-related pictures again caused higher self-itch. furthermore, participants with a history of pruritic skin conditions gave higher self-itch ratings when viewing “skin response”-images. in summary, somatosensory perception in the absence of somatosensory stimulation (i.e., ci) can be induced via the presentation of sounds, pictures or videos (schut et al., 2015) and is enhanced in individuals suffering from chronic itch-related skin conditions. in the present study, we test if this type of effect (i.e., ci) can be replicated with other types of stimuli and reactions – specifically, with visual stimuli triggering the urge to pick one’s skin. we investigated whether picking-related visual stimuli compared to other stimuli (itch-related, neutral) trigger the urge to pick in spd-affected compared to persons without spd. comparably, we tested, whether itch-related visual stimuli compared to other stimuli (picking-related, neutral) trigger itch sensations in ad patients compared to participants without ad. our investigation could experimentally present a pathological mechanism previously mainly self-reported as a relevant trigger for skin picking episodes in spd. visual triggers of skin picking episodes 4 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ method design in a quasi-experimental study (stimulus type [3] ☓ group [4]), data was collected online with enterprise feedback suite survey. following the guidelines of the german psycho‐ logical society, all participants provided written informed consent prior to participation. procedure the survey was disseminated in several recruitment waves, among others the newsletter of a german self-help group for skin picking and in forums focusing on ad and pruritus. after the initial data collection of sp affected individuals (n = 307; spd: 74%, ad: 4%, hc: 22%, male gender was substantially underrepresented (9.5%). given that it was unlikely that we would be able to recruit a sufficient number of male participants, we thenceforth exclusively targeted female ad-patients and healthy controls in the following recruit‐ ment waves. after an introductory text and informed consent (following the ethical guidelines of the german psychological society, see appendix b5), sociodemographic information was assessed. derived from dsm-5 criteria for spd a three-question (criteria a-c) screening was conducted (kssp, n = 601, α = .86; mehrmann, hunger, & gerlach, 2017). as soon as participants reported feeling impaired due to spd, they were allocated to the spd group. additionally, participants were asked about skin diseases (e.g., ad, psoriasis, lice). when answering positive regarding ad (current symptoms or symptoms in the past three months), they were allocated to the ad-group. materials visual stimuli following a short explanation to german synonyms and difference between picking and scratching (see appendix b4), every participant looked at 24 visual stimuli (500x759 pixel) in random order (see additional information in appendix b1). the stimuli consisted of 24 static images of human skin sourced from google images and one photo specifically taken for this project. similar to the stimulus material used by lloyd et al. (2017) eight pictures represented one of three stimulus types each: (1) picking-related images depict‐ ing pimples, scabs, or loosening skin flakes, (2) itch-related images with skin conditions (e.g., eczema, mosquito bites), and (3) neutral images with pictures of intact, healthy skin. for each stimulus type, two images of four different body parts (head, torso, arm/hand, leg) were included. after looking at each stimulus a minimum time of three seconds the participants could click to the next page and answer four questions on a 5-point likert-type scale (0 = not at all, 4 = very strong): “how itchy do you feel?” (itch-self), “how itchy do you think the person in the picture feels?” (itch-other), “how strong is your urge to pick (not scratch)?” (urge-to-pick-self), “how strong do you think is the mehrmann, urban, & gerlach 5 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ urge to pick (not scratch) of the person in the picture?” (urge-to-pick-other). given that participants were free to look at the pictures as long as they wished, we checked for differences between viewing times. however, there was no main effect of viewing times for stimulus-type, pillai’s trace v = .002, f(2, 596) = .69, ns, ηp2 = .002; no effect for group, f(3, 597) = 1.93, ns, ηp2 = .01 and no interaction effect for stimulus-type ☓ group, pillai’s trace v = .004, f(6, 1194) = .42, ns, ηp2 = .002. questionnaires several questionnaires were used to assess ad and spd as well as general measures of psychopathology. ad or spd specific questionnaires were only presented if participants screened positive for one or both of them. msps-d — the modified skin picking scale, german version (mehrmann et al., 2017), is a translated and adapted version of the skin picking scale by keuthen, wilhelm, et al. (2001; snorrason et al., 2012) and the massachusetts general hospital (mgh) hairpulling scale (keuthen et al., 1995). nine items measure frequency and intensity of picking as well as impairment due to skin picking on a 5-point likert-type scale. scores can range from zero to 36 (n = 515, α = .95). currently, there is no clinical cut-off score for the german version available. msps-d-ad — to use a similar scale to explore the ad-sample, we modified the msps-d by exchanging the words “picking” and “skin picking” with “scratching” and “atopic dermatitis” (n = 105, α = .89). spis-d — the skin picking impact scale by keuthen, deckersbach, et al. (2001) was translated into german (mehrmann et al., 2017). a short version with four items (snorrason et al., 2013) measures psychosocial impairment due to skin picking on a 5point-likert-type scale (n = 515, α = .97). for the original version, keuthen, deckersbach, et al. (2001) propose a score ≥ 7 to determine clinical impairment. spis-d-ad — participants with ad symptoms answered an ad-adapted version (see above) of the spis-d items for psychosocial impairment (n = 105, α = .89). ad-scale — ad-affected answered a three-question scale on feeling itchy and actual scratching during the last two weeks as well as impairment due to ad via a 5-point likert-type scale (stangier, gieler, & ehlers, 2013; n = 105, α = .83). bsi-18 — the german short version of the brief symptom inventory (franke, 2000; spitzer et al., 2011) is a self-report symptom scale assessing levels of psychological distress. eighteen items with a 5-point likert-type scale result in a global severity scale (gsi) ranging between 0 and 72 (n = 598, α [gsi] = .91). visual triggers of skin picking episodes 6 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ sample primary inclusion criteria were consent to study participation, age > 18 years, female gender and completion of the online survey. altogether, 764 out of 1,406 participants met all primary inclusion criteria. 163 participants were excluded during data processing, be‐ cause they reported other skin conditions during the last three months, with symptoms that could be confounded with itch or the urge to pick, e.g. mycosis pedis, parasites. the final data set contained 601 participants. the four groups were represented as followed: n (adonly) = 47 (7.8%), n (spdonly) = 147 (24.5%), n (ad+spd) = 46 (7.7%), n (hc) = 361 (60.0%). post hoc tests showed the adonly-group to be significantly older than the spdonly-group (-5.05, 95%-ci [-9.77, -.34]).there was only a small negative correlation between age and the perception of itch (r = -.11, p = .04), or the urge to pick (r = -.16, p = .003) for the hc-group. see table 1 for questionnaire-scores (see additional information in appendix b2). table 1 descriptive statistics for all questionnaires with univariate analysis questionnaire adonly (n = 47) spdonly (n = 147) ad+spd (n = 46) hc (n = 361) f df1, df2 ηp2m sd m sd m sd m sd age 34.32 13.17 29.27 9.63 29.91 11.27 31.55 10.58 3.30* 3, 597 .016 msps-d – – 20.60 5.48 20.41 5.10 5.38 4.66a 565.01** 2, 509 .689 spis-d – – 10.59 4.19 6.85 4.60 0.74 1.88a 554.53** 2, 509 .685 msps-d-ad 17.21 7.24 – – 21.57 5.56 – – 10.54* 1, 91 .104 spis-d-ad 6.36 4.96 – – 8.41 4.55 – – 4.31* 1, 91 .045 bsi-18 13.81 9.93 18.41 11.64 b 16.26 10.29 8.14 9.41 40.07** 3, 595 .168 note. spdonly = skin picking disorder; adonly = atopic dermatitis; ad+spd = atopic dermatitis and skin picking disorder; hc = healthy control; msps-d = modified skin picking scale, german version; spis-d = skin picking impact scale, german version; msps-d-ad = modified sps-d for ad; spis-d-ad = modified spis-d for ad; bsi-18 = german short version of the brief symptom inventory. an = 319. bn = 145. *p < .05, two-tailed. **p < .001, two-tailed. analysis all participants were allocated to one of four groups (adonly, spdonly, ad+spd, hc). so‐ ciodemographic characteristics and questionnaires were tested using an anova and we used the bonferroni method as provided by spss to adjust for multiple comparisons in the post-hoc tests. in a repeated measures manova, itch-other and urge-to-pick-other ratings were analyzed for stimulus type (itch-related, picking-related, neutral), followed by univariate anovas and planned contrasts. in a repeated measures manova itch-self and urge-to-pick-self ratings were analyzed for stimulus type (3) ☓ group (4) with sepa‐ mehrmann, urban, & gerlach 7 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ rate univariate anovas and planned contrasts (see additional information in appendix b3). when sphericity was violated, the greenhouse–geisser adjustment was used. results manipulation check (urge-to-pick-other and itch-other ratings) a manova revealed a significant effect of urge-to-pick-other and itch-other ratings for stimulus type, pillai’s trace v = .92, f(4, 597) = 1714.56, p < .001, ηp2 = .920, indicating the experience of itch and the urge to pick varied based on picture content. urge-to-pick-other in the univariate anova a significant effect for stimulus type was revealed, f(1.89, 1135.54) = 1027.02, p < .001, ηp2 = .631. urge-to-pick-other ratings were significantly higher for picking-related stimuli (m = 1.64, sd = .77) than for neutral stimuli (m = .27, sd = .37), f(1, 600) =2344.64, p < .001, ηp2 = .796. urge-to-pick-other ratings were also significantly higher for picking-related stimuli than for itch-related stimuli (m = 1.41, sd = .95), f(1, 597) = 11.24, p = .001, ηp2 = .018. itch-other in the univariate anova a significant effect for stimulus type was revealed f(1.97, 1181.05) = 3465.76, p < .001, ηp2 = .852. itch-other ratings were significantly higher for itch-related stimuli (m = 2.34, sd = .67) than for neutral stimuli (m = .31, sd = .38), f(1, 600) = 6543.65, p < .001, ηp2 = .916. itch-other ratings were significantly higher for itch-related stimuli than for picking-related stimuli (m = 1.11, sd = .66), f(1, 597) = 1186.43, p < .001, ηp2 = .665. manova (stimulus type ☓ group; urge-to-pick-self and itchself ratings) the manova revealed a significant main effect for group (pillai’s trace v = .26, f[6, 1194] = 29.41, p < .001, ηp2 = .129), a significant main effect for stimulus type (pillai’s trace v = .53, f[4, 594] = 169.78, p < .001, ηp2 = .533), and a significant interaction effect for stimulus type ☓ group (pillai’s trace v = .25, f[12, 1788] = 13.41, p < .001, ηp2 = .083). urge-to-pick-self ratings univariate follow-up analyses of urge-to-pick-self ratings again found a significant main effect for stimulus type, f(1.96, 1172.76) = 304.54, p < .001, ηp2 = .338, and for group, f(3, 597) = 42.47, p < .001, ηp2 = .176. additionally, there was a significant interaction effect visual triggers of skin picking episodes 8 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ for stimulus type ☓ group, f(5.89, 1172.76) = 24.21, p < .001, ηp2 = .108 (see figure 1; additional tables on urge-to-pick-self and itch-self ratings in appendix a). figure 1 experienced urge to pick (0-4) by group and type of stimulus note. spdonly = skin picking disorder; adonly = atopic dermatitis; ad+spd = atopic dermatitis and skin picking disorder; hc = healthy control. error bars show standard errors. all participants experienced a stronger urge to pick when looking at picking-related compared to neutral stimuli, f(1, 597) = 533.96, p < .001, ηp2 = .472. they also reported a stronger urge to pick when looking at picking-related compared to itch-related stimuli, f(1, 597) = 112.41, p < .001, ηp2 = .158 and when looking at itch-related compared to neutral stimuli, f(1, 597) = 216.11, p < .001, ηp2 = .266. to check whether participants with spd reported a stronger urge to pick for pick‐ ing-related stimuli compared to other stimuli, we compared this difference in spd par‐ ticipants (spdall) with participants without spd (adonly & hc). planned contrast were calculated merging the spdonly and ad+spd group (spdall, n = 193). the difference in urge-to-pick-self ratings for pick-related vs. itch-related and neutral pictures was significantly higher in spdall participants compared to participants without spd (adonly & hc), with a mean difference of 1.59 (se = .29, p = .001, ηp2 = .047). likewise, the difference in urge-to-pick-self ratings for picking-related vs. neutral stimuli as well as for picking-related vs. itch-related stimuli was significantly higher in spdall participants compared to participants without spd (adonly & hc), with a mean difference of 1.11 (se = .18, p < .001, ηp2 = .062) and .48 (se = .16, p = .003, ηp2 = .015). when comparing urge-to-pick-self ratings from participants with spdonly to individuals affected by both mehrmann, urban, & gerlach 9 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ ad and spd, the difference between picking-related vs. itch-related and neutral stimuli is significantly larger for the spdonly group, with a mean difference of 1.28 (se = .22, p < .001, ηp2 = .055). for the group comparison spdonly vs. spd+ad the difference in urge-to-pick-self ratings between picking-related and neutral stimuli as well as between picking-related and itch-related stimuli was significantly higher for spdonly with a mean difference of .62 (se = .13, p < .001, ηp2 = .037) and .66 (se = .12, p < .001, ηp2 = .050). itch-self ratings there was a significant main effect on itch-self ratings for stimulus type, f(1.58, 940.90) = 391.95, p < .001, ηp2 = .396, for group, f(3, 597) = 14.17, p < .001, ηp2 = .066) and a significant interaction effect for stimulus type ☓ group, f(4.73, 940.90) = 8.06, p < .001, ηp2 = .039 (see figure 2). figure 2 experienced itch (0-4) by group and type of stimulus note. spdonly = skin picking disorder; adonly = atopic dermatitis; ad+spd = atopic dermatitis and skin picking disorder; hc = healthy control. error bars show standard errors. all participants experienced stronger itch-sensations when looking at itch-related com‐ pared to neutral stimuli, f(1, 597) = 518.73, p < .001, ηp2 = .465. they also reported stronger itch-sensations when looking at itch-related compared to picking-related stimuli, f(1, 597) = 293.72, p < .001, ηp2 = .330 and when looking at picking-related compared to neutral stimuli, f(1, 597) = 225.76, p < .001, ηp2 = .274. to check whether participants with ad reported greater perception of itch for itchrelated versus other stimuli, we compared this difference in participants with versus visual triggers of skin picking episodes 10 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ without ad. planned contrast were calculated merging the adonly and ad+spd group (adall, n = 93). the difference in itch-self ratings for itch-related vs. picking-related and neutral stimuli was significantly higher in adall compared to without ad participants (spdonly& hc), with a mean difference of 1.09 (se = .32, p = .001, ηp2 = .019). likewise, the difference in itch-self ratings for itch-related vs. neutral stimuli as well as for itch-related vs. picking-related stimuli was significantly higher in adall compared to without ad participants (spdonly & hc), with a mean difference of .48 (se = .20, p = .014, ηp2 = .010) and .61 (se = .15, p < .001, ηp2 = .027). discussion in the presented study, we investigated whether picking-related visual stimuli trigger the urge to pick in individuals affected by spd compared to persons without spd. correspondingly, we tested, whether itch-related visual stimuli trigger itch sensations in individuals with ad versus without ad. analog to the visual provocation of itch, we demonstrated that the urge to pick can also be triggered by visual stimuli. all participants experienced a stronger urge to pick looking at pictures with picking-related content compared to neutral stimuli. furthermore, individuals with self-reported spdall reported a significantly stronger urge to pick when looking at these stimuli compared to the adand hc-group. interestingly, the spdonly group showed a significantly stronger reaction to picking-related stimuli than the participants with both ad and spd. at the same time, the ad+spd group reported more itch-sensations to itch-related stimuli compared to the adonly group. thus, for the comorbid group the transmission of the urge to pick was less prominent than the transmission of itch-sensations. note that the burden of skin picking as measured by the spis-d was higher in the spdonly group (m = 10.59, sd = 4.19) compared to the comorbid group (m = 6.85, sd = 4.60). on the other hand, the psychosocial impairment due to ad (spis-d-ad) was higher in the comorbid group (m = 8.41, sd = 4.55) compared to the adonly group (m = 6.36, sd = 4.96). the combination of spd with comorbid ad regarding visual symptom provocation clearly requires further investigation. even though we disseminated the survey contacting many ad specific associations, online-groups and forums, it was difficult to acquire a larger ad-sample, which limits the generalizability of our results. this evidence for visual transmission for the urge to pick supports spd affected self-report of different visual cues acting as triggers for picking episodes (bohne et al., 2002; neziroglu et al., 2008; odlaug & grant, 2008). the results of our study document that visual stimuli may trigger specific experiences of somatosensory perception (itch and/or the urge to pick) in the absence of somatosensory stimulation. not surprisingly, we were also able to replicate visual transmission of itch (niemeier et al., 2000; ogden & zoukas, 2009; papoiu et al., 2011) with people reporting to ex‐ perience more itch when looking at itch-related pictures compared to other pictures mehrmann, urban, & gerlach 11 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ (neutral, picking-related pictures). this effect was stronger for ad patients, who reported more self-itch when exposed to itch-associated skin pictures. this is again in line with previous findings on people suffering from a skin condition like ad to be more prone to visual transmission of itch than healthy controls (papoiu et al., 2011; schut et al., 2015). when comparing transmission of itchiness with transmission of the urge to pick, overlapping concepts for the urge to scratch itchy skin vs. the urge to pick may be a problem. in the present sample, picking-related pictures gained significantly higher rat‐ ings for itch experience compared to neutral pictures. by presenting a short explanation including synonyms and an explanation of differences between picking and scratching, we tried to minimize the influence of this possible overlap effect. likewise, stimuli may trigger both sensations at the same time. furthermore, differentiating between the urge to scratch and pick may be even harder for people with both conditions (spd and ad). another limitation is that allocation to one of the four groups was conducted through self-report information and could not be validated by a clinician. there may have been be false-positive allocations to spd and/or ad and conclusions on treatment of the two diagnoses need to be considered carefully. overall, the adonly sample and ad+spd sample were underrepresented. also, the self-reports on itch and urge to pick perception were not compared to behavioral measures such as actual scratching or picking and the urges to itch or scratch elicited were only on an average level. finally, we recruited only female participants. consequently, implementation objectivity, sample representativeness and external validity may be somewhat limited. this is the first study to compare the effects of different visual stimuli as triggers for spd compared to ad and healthy controls. understanding the role of visual triggers for picking and/or itch episodes may help to improve treatment for both ad and spd. in a meta-analytic review looking at efficacy of treatments for spd (schumer, bartley, & bloch, 2016) cognitive behavioral therapy (cbt) and habit reversal training (hrt) were highlighted as efficacious treatments compared to waiting list and pharmacological treatment. cbt/hrt includes assessment of picking behavior, psychoeducation, and strategies to reduce picking (e.g., hrt, relapse prevention). while hrt is a strategy designed for dealing with the overwhelming need to pick, stimulus control can be used to avoid typical trigger situations. within stimulus control treatment, triggers are identified and then changed to reduce picking behavior (e.g., dimming the lights in the bathroom when standing in front of the mirror). this serves to strengthen alternative non-harm‐ ful behaviors. with this strategy individual visual trigger situations can be targeted specifically to prevent formation of an urge to pick (e.g., covering with clothing, limited mirror-time). behavioral therapy for ad includes similar modules to spd treatment. among others, they also include techniques to reduce scratching, like hrt and stimulus control techniques (scholz, 1999). further research on the transmission of itch and the urge to pick should consequently include additional (i.e., behavioral) measures for diagnoses and explore possible gender visual triggers of skin picking episodes 12 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ differences. for example, it would be helpful to check if the urge to pick induced by visual stimuli actually translates into picking episodes, which could be assessed in a laboratory setting. given that most ad patients report tactile triggers for their scratching rather than visual triggers, it may be also interesting to examine the sensation of touch in absence of a tactile stimulus in these two groups. this could be accomplished, by using the somatic signal detection task (ssdt; lloyd et al., 2008). the ssdt allows studying perceptual processes related to physical symptoms by provoking illusory tactile experiences. the number of such illusory tactile experiences may be associated with symptom severity in both ad and spd patients. within this online study, the transmission of itch and the urge to pick and scratch for those effected by spd and/or ad could be elicited using visual stimuli. the transmission of the urge to pick can serve to guide the development and improvement of interven‐ tions developed to treat spd in the future. the present findings help to understand the relevance of visual triggers for itch/scratch and picking behaviors in ad and spd, respectively. looking more closely at visual triggers will aid therapists when attempting to improve treatment components targeting the onset of skin picking episodes (e.g., stimulus control techniques, hrt). funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. references american psychiatric association. 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(2013). neurodermitis bewältigen: verhaltenstherapie dermatologische schulung autogenes training. berlin, germany: springer. https://doi.org/10.1007/978-3-642-47631-0 tabachnick, b. g., & fidell, l. s. (2013). using multivariate statistics (6th ed.). boston, ma, usa: pearson. verhoeven, e. w. m., de klerk, s., kraaimaat, f. w., van de kerkhof, p. c. m., de jong, e. m. g. j., & evers, a. w. m. (2008). biopsychosocial mechanisms of chronic itch in patients with skin diseases: a review. acta dermato-venereologica, 88(3), 211-218. https://doi.org/10.2340/00015555-0452 visual triggers of skin picking episodes 16 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://doi.org/10.1016/j.jocrd.2012.03.001 https://doi.org/10.1111/sjop.12057 https://doi.org/10.1055/s-0031-1281602 https://doi.org/10.1034/j.1600-0625.2002.110102.x https://doi.org/10.1007/978-3-642-47631-0 https://doi.org/10.2340/00015555-0452 https://www.psychopen.eu/ appendices appendix a table a1 urge to pick ratings (self) sample n stimulus type totalitch-related images picking-related images neutral images m sd m sd m sd m sd spdonly 147 1.14 .95 2.00 .91 .39 .47 1.18 .65 adonly 47 .63 .79 .82 .82 .16 .34 .54 .58 ad+spd 46 1.04 .87 1.25 .97 .26 .38 .85 .64 hc 361 .55 .75 .96 .86 .13 .28 .55 .55 total 601 .74 .85 1.23 .99 .20 .37 – – note. spdonly = skin picking disorder; adonly = atopic dermatitis; ad+spd = atopic dermatitis and skin picking disorder; hc = healthy control. scale ranging from 0 (= not at all) to 4 (= very strong). table a2 itch ratings (self) sample n stimulus type totalitch-related images picking-related images neutral images m sd m sd m sd m sd sponly 147 1.34 .99 .89 .89 .22 .35 .82 .66 adonly 47 1.38 1.01 .72 .77 .32 .66 .80 .72 ad+spd 46 1.79 1.00 .88 .70 .38 .48 1.02 .63 hc 361 1.01 .96 .49 .58 .14 .28 .55 .55 total 601 1.18 1.00 .63 .72 .19 .36 – – note. spdonly = skin picking disorder; adonly = atopic dermatitis; ad+spd = atopic dermatitis and skin picking disorder; hc = healthy control. scale ranging from 0 (= not at all) to 4 (= very strong). appendix b b1 the 24 pictures applied as visual stimuli in this investigation were selected from a pretest with 48 pictures on a student sample (n = 17) to control for valence and arousal of the pictures: in our pretest, we selected 48 pictures, four pictures of each body-part (head/face, torso/décol‐ leté, hands/arms and legs/feet) for each of the three stimulus-types (itch-related, picking-related and neutral skin). in an online study (n = 17) we asked students to rate valence and arousal for each picture using the five-scale self-assessment manikin (sam, bradley & lang, 1994). out of the four pictures for each body-part category, we choose the two pictures, which had the lowest valence and arousal ratings. the pictures will be provided by the first author upon request. mehrmann, urban, & gerlach 17 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ b2 an analysis with age as covariate showed a significant main effect for age with wilk’s λ = .981, f(2, 595) = 5.86, p = .003, ηp2 = .019. including age as covariate did not relevantly change the results of the main tests as well as the post hoc tests (i.e., all previously significant results remained significant). consequently, we decided not to include age as a covariate in the results presented. b3 initial exploratory analyses revealed a few outliers. however, there was no relevant change in the pattern of results when including vs. excluding outliers. thus, results from the complete data set are reported. the assumption of normality was not met. since the f-test is relatively robust for violation of assumption, especially in samples with more than 40 subjects, the results of the manova were reported (lindman, 1974; tabachnick & fidell, 2013). b4 short explanation to german synonyms and difference between picking and scratching (german version): wichtige vorabinformation skin picking bzw. dermatillomanie = erkrankung, bei der betroffene einen starken drang verspüren ihre haut zu bearbeiten. wird dem drang nachgegangen, wird die haut gezupft, gequetscht, an der haut gepult und geknibbelt, was zu hautschädigungen führen kann. kratzen, welches als reaktion auf einen neurodermitisschub erfolgt, fällt nicht unter skin picking. verwendete synonyme im weiteren verlauf: skin picking, hautzupfen/-quetschen, haut bearbeiten und knibbeln. short explanation to german synonyms and difference between picking and scratching (translated version): important preliminary information skin picking or dermatillomania = disorder, in which affected persons feel a strong urge to manipulate their skin. if a person succumbs to that urge, the skin is plucked, squeezed, nibbled at and skin parts are removed, which can lead to skin damage. scratching, which occurs as a reaction to an episode of neurodermatitis, does not fall under skin picking. used synonyms in the further course: skin picking, skin plucking/squeezing, skin manipulation and nibbling. visual triggers of skin picking episodes 18 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ b5 data collection for the research reported in this study started in december 2016. unfortunately, the local ethics committee responsible for our faculty, at that time, had not yet started to accept research proposals. the first opportunity to apply for ethical review was not possible until may 2018. given that the study was self-funded and no funds were available for outside ethical review, it was decided to follow the procedure commonly used at that time according to the ethical guidelines of the german psychological society. the following procedures were included in the implementation of the study: research participants were provided with adequate and complete information regarding participation, followed by informed consent. specifically, all participants were informed in advance of the type of pictures they were about to see and advised on possible reactions these pictures may elicit (itch, urge to pick, some disgust). furthermore, all participants were advised that participation was voluntary and that participants were free to end participation at any time without having to give any reasons and without having to worry about any negative consequences. furthermore, data was assessed anonymously and participants were advised in this regard. after having received this information, all participants provided informed consent prior to participation in the study. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. mehrmann, urban, & gerlach 19 clinical psychology in europe 2020, vol.2(4), article e2931 https://doi.org/10.32872/cpe.v2i4.2931 https://www.psychopen.eu/ visual triggers of skin picking episodes (introduction) method design materials sample analysis results manipulation check (urge-to-pick-other and itch-other ratings) manova (stimulus type ☓ group; urge-to-pick-self and itch-self ratings) discussion (additional information) funding competing interests acknowledgments references appendices appendix a appendix b indirect prevention and treatment of depression: an emerging paradigm? scientific update and overview indirect prevention and treatment of depression: an emerging paradigm? pim cuijpers 1 [1] department of clinical, neuro and developmental psychology, amsterdam public health research institute, vrije universiteit amsterdam, amsterdam, the netherlands. clinical psychology in europe, 2021, vol. 3(4), article e6847, https://doi.org/10.32872/cpe.6847 received: 2021-06-01 • accepted: 2021-08-18 • published (vor): 2021-12-23 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: pim cuijpers, department of clinical, neuro and developmental psychology, amsterdam public health research institute, vrije universiteit amsterdam, van der boechorststraat 7-9, 1081 bt amsterdam, the netherlands. e-mail: p.cuijpers@vu.nl abstract background: although depression is one of the main public health challenges of our time, the uptake of interventions aimed at the prevention and treatment is low to modest. new approaches are needed to reduce the disease burden of depression. method: indirect prevention and treatment may be one method to increase uptake of services. indirect interventions aim at problems related to depression but with lower stigma and prevent or treat depression indirectly. this paper describes the approach, the empirical support and limitations. results: a growing number of studies focus on indirect prevention and treatment. several studies have examining the possibilities to prevent and treat depression through interventions aimed at insomnia. several other studies focus on indirect interventions aimed at for example stress and perfectionism. digital ‘suites’ of interventions may focus on daily problems of for example students or the workplace and offer a broad range of indirect interventions in specific settings. conclusion: indirect prevention and treatment may be a new approach to increase uptake and reduce the disease burden of depression. keywords depression, disease burden, indirect treatment, stigma, prevention this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6847&domain=pdf&date_stamp=2021-12-23 https://orcid.org/0000-0001-5497-2743 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • effective treatments and preventive interventions are available for depression but uptake is low. • indirect prevention and treatment focus on problems related to depression. • uptake of indirect interventions is higher because they focus on daily problems. • indirect interventions may provide a new paradigm for prevention and treatment. depressive disorders are highly prevalent (alonso et al., 2004; kessler & bromet, 2013), have a high incidence (waraich et al., 2004), and are associated with a substantial loss of quality of life for patients and their relatives (saarni et al., 2007; vos et al., 2016), increased mortality rates (cuijpers et al., 2014), high levels of service use, and enormous economic costs (greenberg et al., 2003; smit et al., 2006). major depression is currently ranked fourth worldwide in disease burden, and it is expected to rank first in high-income countries by the year 2030 (mathers & loncar, 2006). there is no doubt that depression is one of the most important public health challenges in the coming decades (cuijpers et al., 2012). one of the main problems that limits the impact of attempts to reduce the burden of disease of depression is the low uptake of treatments. this uptake is low in the general population, with rates that are often lower than 30%, even in high income countries (chisholm et al., 2016). in some specific groups, such as adolescents, young adults, older adults and minority groups, the number of those seeking help is even considerably lower. for example, one study found that the uptake in college students in high income countries was only 30% for those with a 12-month depressive disorder (bruffaerts et al., 2019). the low uptake of treatment is related to several factors, such as lack of financial resources and availability of clinicians. this is an important reason why the uptake of services is low in low– and middle-income countries, where hardly any infrastructure for mental health care exists, too few trained clinicians are available and insufficient resources are available to pay for these services. however, also in high-income settings the uptake is low because of the stigma related to depression, being unaware that exist­ ing problems are indeed depression, lack of time and the preference of many patients to manage their problems on their own or with friends and family. the uptake of preventive services is even lower. in one study we estimated that about 1% of those meeting criteria for participation in indicated prevention actually participated, even when offered free or almost free of charge (cuijpers et al., 2010). reasons are comparable to those mentioned earlier for the low uptake of treatments and include stigma, and preference to solve problems her/himself instead of seeking help (cuijpers et al., 2010). another limiting factor in the reduction of the disease burden of depression is that interventions aimed at the prevention and treatment of depression are effective, but indirect prevention and treatment of depression: an emerging paradigm? 2 clinical psychology in europe 2021, vol. 3(4), article e6847 https://doi.org/10.32872/cpe.6847 https://www.psychopen.eu/ their effects are modest. the impact of interventions can be seen as the product of the uptake and the effects, and when both the uptake and the effects are small, the impact is also small. meta-analyses of psychological and pharmacological treatments usually find that the interventions improve outcomes in about 20 to 25% of patients, compared to control conditions (cipriani et al., 2018; cuijpers et al., 2021b). that means that most patients either improve regardless of treatment or do not respond to them (cuijpers, 2018). preventive interventions are also effective and can reduce the risk of developing a depressive disorder in the coming year with about 20% (cuijpers et al., 2021a), but despite these positive effects the majority of high-risk participants still develop a disorder. together with the low uptake of these services, it should not come as a surprise that the prevalence of depressive disorders has not been reduced over the past decades, despite the availability of services for prevention and treatment (ferrari et al., 2013). the indirect approach to prevention and treatment conventional methods to increase help-seeking rates include universal mental health awareness campaigns (salerno, 2016; yamaguchi et al., 2013), gatekeeper training (lipson et al., 2014) and specific interventions aimed at improving help-seeking behaviours (ebert et al., 2019). an alternative method to increase uptake is what could be called “indirect” prevention and treatment. the basic idea of these “indirect” interventions is that they focus on problems related to depression, but not directly on depression itself. at the same time the participants learn techniques which not only directly affect the problem, but also have an effect on depression or may prevent future depressive symptoms or disorders. for example, people with insomnia and depression receive an intervention aimed at insomnia, but also learn skills to manage their mood. insomnia is less stigmatising than depression to talk about or to seek treatment for, and if the inter­ vention aimed at insomnia is also effective in reducing depression, then the participant is still successfully “treated” for depression in an indirect way. the same idea can be applied to prevention. if someone with insomnia has subthres­ hold depression but no diagnosis for a depressive disorder, this person meets criteria for participation in an indicated prevention program. an intervention aimed at insomnia for this person could be considered as indicated prevention and has the potential to prevent the onset of depressive disorders in an indirect way. again, participation in an intervention on insomnia is probably less stigmatising as an intervention to prevent a depressive disorder. cuijpers 3 clinical psychology in europe 2021, vol. 3(4), article e6847 https://doi.org/10.32872/cpe.6847 https://www.psychopen.eu/ research on the indirect approach a growing number of studies is focusing on this strategy. for example, recent studies have shown that cognitive behaviour therapy for insomnia in patients with both insom­ nia and depression, reduces not only insomnia but also depression (van der zweerde et al., 2019). the effect sizes found for such interventions on depressive symptomatology are comparable to those of ‘regular’ treatment of depression. this is true even though the interventions are not directly aimed at depression, and the stigma to participate in inter­ ventions for insomnia is lower than interventions for depression. the generic cognitive behavioural strategies that participants learn for handling insomnia, are in many ways comparable to those that are used in cognitive behavioural therapies for depression. or it could be the case that improvement of insomnia is the first step to escape from a vicious circle of mood problems. other research has used the same principle as a preventive strategy. for example, one study found that participants with insomnia and subthreshold depression who receive cognitive behaviour therapy for insomnia had a smaller chance to develop major depression at follow-up (christensen et al., 2016). but this principle of ‘indirect’ prevention and treatment of depression is not limi­ ted to insomnia. one recent study examined the effects of an intervention aimed at perinatal women scoring high on perfectionism, with depression and anxiety as an outcome (lowndes et al., 2019). this study found that the intervention significantly reduced perfectionism, and path analyses demonstrated a significant indirect effect of the intervention on depression and anxiety. another study showed that a considerable part of the participants in interventions aimed at ‘stress management’ also suffer from depression, and that the effects of this stress management training on depression were considerable and comparable to the effects of psychological treatments of depression in general (weisel et al., 2018). interventions aimed at problems like perfectionism, procrastination, and low self-esteem have also been found to have considerable effects on depression in those suffering from depression at baseline (cuijpers et al., 2021). there is much research on interventions for such common psychological problems and for many high-risk groups, but not with a focus on indirect prevention and treatment of depression. one could argue that this approach is very similar to selective prevention. selective prevention is aimed at people who have an increased risk to develop a depressive disorder. selective interventions are for example aimed at children of depressed parents (clarke et al., 2001), pregnant women with an increased risk for postpartum depression (phipps et al., 2013; zlotnick et al., 2016), dementia caregivers (cheng et al., 2020) or patients with general medical disorders (rovner et al., 2014). interventions aimed at these high-risk groups may support participants in coping with their problems but may at the same time prevent or reduce existing depressive symptomatology. however, these studies usually first have the intention to support participants with their problems and have depression only as secondary outcome. they are hardly ever designed as indirect indirect prevention and treatment of depression: an emerging paradigm? 4 clinical psychology in europe 2021, vol. 3(4), article e6847 https://doi.org/10.32872/cpe.6847 https://www.psychopen.eu/ treatment or prevention of depression in the sense that they report the number of depressed participants at baseline and the effects of the intervention on depression in these participants. “suits” of indirect interventions for specific settings one important development in recent years may help in disseminating indirect interven­ tions. internet-based cognitive behavioural interventions have been developed for many different disorders, problems and target groups. because they can be easily adapted and broadly disseminated it could be possible to develop ‘suites’ of multiple interventions for problems with relatively low stigma that are related to depression. for example, it could be possible to develop a suite of interventions for college students on procrastina­ tion, perfectionism, low self-esteem, test-anxiety, stress, worry, and any other common problem that is brought forward by students themselves. or a suite of interventions for employees in large companies on stress, conflict resolution, assertiveness, time man­ agement and problem-solving. comparable suites could be developed for high-school students, perinatal women, or specific groups of patients in general hospitals. because such interventions are scalable and not expensive after first development, they could be offered to full populations, but are in fact meant to be early interventions for depression and potentially other common mental disorders. challenges and limitations it is possible that indirect interventions can be an option for mild depression, but not for moderate and severe depression. however, not every person with severe depression gets treatment, and it is very well possible that they are willing to participate in these ‘indirect’ interventions. it is an empirical question whether indirect treatments in these patients are still better than the current practice of not providing treatment at all if the patient cannot be motivated to get treatment. how other clinical issues, such as suicidality and comorbidity, should be handled is also not yet clear. if patients partici­ pate in interventions that are not directly aimed at depression, who will take care of suicide risks and correct diagnoses? in order to avoid risks in these domains extended baseline assessment could be needed for these indirect interventions. it is also uncertain whether such an approach would indeed lead to higher uptake rates of services. will interventions aimed at reducing insomnia, perfectionism or stress lead indeed to better outcomes then just offering mental health services? these are empirical question that have to be answered with future research, but at ‘face value’ they can lead to a higher uptake, especially when they are offered as ‘suits’ of interventions. cuijpers 5 clinical psychology in europe 2021, vol. 3(4), article e6847 https://doi.org/10.32872/cpe.6847 https://www.psychopen.eu/ conclusion depression is a highly heterogeneous condition with largely varying symptoms patterns and associations with other variables. this heterogeneity is typically seen as problematic and hampering progress in our understanding and management of depression. but it may also offer new possibilities for indirect prevention and treatment. a growing number of studies focuses on problems related to depression, and interventions focus not directly on depression itself, but participants learn techniques that not only affect such problems di­ rectly, but also depression. this may offer new possibilities to get effective interventions to people who usually do not get treatment for depression. much research is needed to examine whether this is possible, feasible and effective, but the first findings are hopeful. maybe we are witnessing the start of a new paradigm in the prevention and treatment of depression. funding: the author has no funding to report. acknowledgments: the author has no additional (i.e., non-financial) support to report. competing interests: the author has declared that no competing interests exist. twitter accounts: @pimcuijpers references alonso, j., ferrer, m., gandek, b., ware, j. e., jr., aaronson, n. k., mosconi, p., rasmussen, n. k., bullinger, m., fukuhara, s., kaasa, s., leplège, a., & iqola project group. 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(2016). randomized controlled trial to prevent postpartum depression in mothers on public assistance. journal of affective disorders, 189, 263-268. https://doi.org/10.1016/j.jad.2015.09.059 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. cuijpers 9 clinical psychology in europe 2021, vol. 3(4), article e6847 https://doi.org/10.32872/cpe.6847 https://doi.org/10.1111/josh.12461 https://doi.org/10.1017/s0033291718001149 https://doi.org/10.1016/s0140-6736(16)31678-6 https://doi.org/10.1177/070674370404900208 https://doi.org/10.2196/jmir.9387 https://doi.org/10.1097/nmd.0b013e31829480df https://doi.org/10.1016/j.jad.2015.09.059 https://www.psychopen.eu/ indirect prevention and treatment of depression: an emerging paradigm? (introduction) the indirect approach to prevention and treatment research on the indirect approach “suits” of indirect interventions for specific settings challenges and limitations conclusion (additional information) funding acknowledgments competing interests twitter accounts references biased perception of physiological arousal in child social anxiety disorder before and after cognitive behavioral treatment research articles biased perception of physiological arousal in child social anxiety disorder before and after cognitive behavioral treatment julia asbrand ab, andré schulz c, nina heinrichs d, brunna tuschen-caffier a [a] institute of psychology, albert ludwigs university of freiburg, freiburg, germany. [b] institute of psychology, humboldt-universität zu berlin, berlin, germany. [c] clinical psychophysiology laboratory, institute for health and behaviour, university of luxembourg, esch-sur-alzette, luxembourg. [d] department of psychology, university of bremen, bremen, germany. clinical psychology in europe, 2020, vol. 2(2), article e2691, https://doi.org/10.32872/cpe.v2i2.2691 received: 2020-01-16 • accepted: 2020-03-11 • published (vor): 2020-06-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: julia asbrand, department of child and adolescent clinical psychology and psychotherapy, institute of psychology, humboldt-universität zu berlin, unter den linden 6, 10099 berlin, germany. phone: +49 30 2093 9334. e-mail: julia.asbrand@hu-berlin.de abstract background: a biased perception of physiological hyperreactivity to social-evaluative situations is crucial for the maintenance of social anxiety disorder (sad). alterations in interoceptive accuracy (iac) when confronted with social stressors may play a role for sad in children. we expected a biased perception of hyperarousal in children with sad before treatment and, consequently, a reduced bias after successful cognitive behavioral therapy (cbt). method: in two centers, 64 children with the diagnosis of sad and 55 healthy control (hc) children (both 9 to 13 years) participated in the trier social stress test for children (tsst-c), which was repeated after children with sad were assigned to either a 12-week group cbt (n = 31) or a waitlist condition (n = 33). perception of and worry about physiological arousal and autonomic variables (heart rate, skin conductance) were assessed. after each tsst-c, all children further completed a heartbeat perception task to assess iac. results: before treatment, children with sad reported both a stronger perception of and more worry about their heart rate and skin conductance than hc children, while the objective reactivity of heart rate did not differ. additionally, children with sad reported heightened perception of and increased worry about trembling throughout the tsst-c compared to hc children, but reported increased worry about blushing only after the stress phase of the tsst-c compared to hc children. children with and without sad did not differ in iac. contrary to our hypothesis, after treatment, children in the cbt group reported heightened perception of physiological arousal and increased worry on some parameters after the baseline phase of the tsst-c, whereas actual iac remained unaffected. iac before and after treatment were significantly related. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i2.2691&domain=pdf&date_stamp=2020-06-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusions: increased self-reported perception of physiological arousal may play a role in childhood sad and could be an important target in cbt. however, further studies should examine if this is an epiphenomenon, a temporarily occurring and necessary condition for change, or indeed an unwanted adverse intervention effect. keywords bodily arousal, social phobia, cbt, therapy, interoceptive awareness, heartbeat perception highlights • biased perception of physiological arousal may play a role in child social anxiety disorder (sad). • faced with standardized social stress, biased perception of heart rate but not skin conductance. • no change in biased perception due to cognitive-behavioral treatment. • further research regarding the nature of biased perception (e.g. epiphenomenon) necessary. social anxiety disorder (sad) is a highly prevalent disorder (burstein et al., 2011) that leads to great impairment in the well-being and everyday life of affected children (rao et al., 2007). cognitive models of sad (e.g., clark & wells, 1995) point to the importance of an increased focus on cognitions, feelings, and behaviors. in addition, a person with sad is also alarmed by physiological reactions in social situations. in line with cognitive models, the subjective awareness of physiological and emotional arousal is interpreted negatively, which leads to an overall negative self-perception followed by elevated fear of and avoidance of social situations. a (physiological) anxiety reaction was required in the diagnostic and statistical man‐ ual for mental disorders (4th ed., text rev.; dsm-iv-tr; american psychiatric association [apa], 2000). this has been revised in the latest version, allowing to display any sign of fear, not necessarily physiologically (dsm-5, apa, 2013). this change reflects that the objective physiological reaction is not yet fully understood: several studies have shown tonic hyperarousal in children with sad (asbrand, blechert, nitschke, tuschen-caffier, & schmitz, 2017; krämer et al., 2012; miers, blöte, sumter, kallen, & westenberg, 2011; schmitz, tuschen-caffier, wilhelm, & blechert, 2013). however, research has failed to find heightened physiological reactivity to disorder-typical stress (for an overview see siess, blechert, & schmitz, 2014). still, both children and adults with sad have reported increased perception of physiological arousal (gerlach, mourlane, & rist, 2004; schmitz, blechert, krämer, asbrand, & tuschen-caffier, 2012). therefore, it has been hypothesized that cognitive factors (e.g., attention allocation and evaluation) are also relevant for physiological factors. that is, people with sad are more prone to shift their attention towards physiological arousal and evaluate this arousal as more threatening (clark & biased perception of physiology in child sad 2 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ wells, 1995; siess et al., 2014). attentional biases have previously been examined mostly for external cues, such as angry versus happy faces, with measures of reaction times or with eye tracking (for an overview in adults see bar-haim, lamy, pergamin, bakermanskranenburg, & van ijzendoorn, 2007). similar to studies of adults, a meta-analysis of anxious compared to nonanxious children (dudeney, sharpe, & hunt, 2015) showed a significant attentional bias to threat. while these findings on external attentional biases are in line with rapee and heimberg's (1997) theoretical model of sad, the importance of other biases, also suggested by current cognitive models (e.g., clark & wells, 1995; rapee & heimberg, 1997) have received less attention, specifically internal perceptional biases. the processing of internal perceptional information is likely dependent upon their (believed) visibility for others: certain internal symptoms (e.g. increased heart rate, nausea) are relevant for the experience of anxiety in general but are not overly visible (cognition: “my heart is racing, this must mean that i am anxious”). however, other physiological symptoms are clearly visible (e.g. blushing, sweating, trembling) and are, therefore, extremely relevant for the fear of being judged (cognition: “i am blushing, others can see how anxious i am”). as such, these physiological symptoms are relevant for the experience of sad specifically. one previous study in children aged 10 to 12 years with high versus low social anxiety (schmitz et al., 2012) manipulated heart rate visibility by applying a heart rate feedback tone while children told a story in a “private” condition (head phones) and a “public” condition (with adult observers present). children with high social anxiety perceived their heart rate as higher than low socially anxious children when they listened to their (supposedly own) heart rate both in private and in public with adult observers present. further, the public condition led to more worry about the heart rate visibility only in children with high social anxiety. this study demonstrated that both perception of and worry about visibility of physiological arousal (i.e. evaluation) is elevated in socially anxious children. as this study examined a subclinical sample, it is necessary to assess children with sad to assure the stability of this phenomenon in clinically affected children. additionally, as the study used a set-up specific to perception of and worry about heart rate, it should be tested if this finding is stable in a well-established social stress test, the trier social stress test for children (tsst-c; buske-kirschbaum et al., 1997) and using more than one physiological parameter (siess et al., 2014). to reveal the underlying processes of biased perception in children with sad, it is required to assess different facets of interoception: first, ‘interoceptive accuracy’ (iac) represents the correspondence between actual and perceived physical signals (e.g., heart‐ beats). second, the subjective tendency to be focused on physical signals is considered ‘interoceptive sensibility’ (is) (garfinkel, seth, barrett, suzuki, & critchley, 2015). third, ‘interoceptive evaluation’ (ie) reflects subjective affective valence of physical sensations such as worry about visibility (pollatos & herbert, 2018). while the attentional biases refer more closely to is and ie, iac should be additionally considered. the heartbeat asbrand, schulz, heinrichs, & tuschen-caffier 3 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ counting task (hct) has been established as most common approach to assess cardiac iac in adults and in school children with and without anxiety symptoms (eley, gregory, clark, & ehlers, 2007; eley, stirling, ehlers, gregory, & clark, 2004; georgiou et al., 2015; koch & pollatos, 2014; schandry, 1981; schmitz et al., 2012). for example, antony et al. (1995) assessed iac based on hct and heart rate (hr) in adult patients with panic disorder and sad compared to healthy controls (hc). groups did not differ in iac at rest or after exercise. however, self-reported anxiety was positively related to iac. in a child community sample (eley et al., 2004), children between 8 and 11 years completed the hct. after a distinction into good and poor heartbeat perceivers based on iac scores, good perceivers reported significantly higher panic and/or somatic symptoms and were more sensitive to anxiety. similarly, higher levels of panic and/or somatic symptoms were positively related to iac. both findings suggest that a proper perception of physical sensations (iac) enhances their interpretation as potentially threatening (ie) in sad. furthermore, schmitz et al. (2012) did not find differences in iac based on the hct between children with high and low social anxiety, which implies that iac and ie may dissociate under specific circumstances. the authors assume that socially anxious children overestimate their hr under stress (i.e. over-reporting of cardiac sensations) but are able to perceive their heartbeat correctly in the recovery period after stress (mauss, wilhelm, & gross, 2004; pollatos, traut-mattausch, schroeder, & schandry, 2007). in summary, the role of iac, is and ie (including over-reporting of cardiac sensations) in fully manifested sad remains unclear. if biased perception (is) and evaluation (ie) of physiological symptoms and/or iac are central factors in childhood sad, a longitudinal assessment measuring stability and changeability by treatment is a plausible next step (e.g., siess et al., 2014). once again, previous research focused on treatment effects on other biases, for example, interpreta‐ tion biases (leigh & clark, 2018). however, theoretical models placed the misperception of physiological symptoms as central for sad (e.g., clark & wells, 1995), which leads to the assumption that cognitive behavioral therapy (cbt) might change this perception bias. interestingly though, most treatments of sad do not explicitly focus on a biased perception of physiological symptoms but rather on general cognitions in and after social situations and on behavior in children (e.g., beidel & turner, 2007). however, as pointed out above, the importance of including specific treatment components targeting physiological reactions cannot be fully supported by empirical evidence, as findings on physiological hyperarousal are inconsistent (siess et al., 2014). the current study on objective measures (heart rate, electrodermal activity [eda]), we expected children with sad to show only tonic hyperarousal and no increased reactivity to social stress compared to children in a healthy control (hc) group (asbrand et al., 2017; schmitz et al., 2013). on subjective measures, we expected all children to report perception (i.e. is) biased perception of physiology in child sad 4 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ of and worry (i.e. ie) about physiological variables (heart rate, perspiration, blushing, trembling)1 that increases from baseline to stress and then decreases to recovery. this effect, that is, heightened perceived reactivity, has been hypothesized to be stronger in children with sad compared to hc children (schmitz et al., 2012). in line with previous findings, we expect a positive correlation between physiological activation (e.g., heart rate) and iac. after children with sad were assigned to a treatment (group cbt) or waitlist control (wlc) group, we expected only small differences in objective measures (heart rate, eda) on a second tsst-c. we expected differences in subjective measures, i.e. children in the cbt group reporting less perception of and worry about physiological variables compared to children in the wlc group and compared to results of the tsst-c before treatment. method trial design the study was designed as a randomized controlled trial (block randomization, in which half of the participants were allocated by drawing from a hat to an experimental condi‐ tion receiving immediate treatment and half to a wlc condition receiving treatment about 16 weeks later; for an overview see figure 1). randomization for each research center was conducted in a concealed fashion by the other center, based on subject codes, as soon as there were enough participants for one experimental and one wlc allocation. eligibility criteria were registered with the german research foundation (tu 78/5-2, he 3342/4-2) prior to recruitment and not changed during the study. this study was part of a larger project. the overall project consisted of experimental studies related to research questions of visual attention allocation or psychophysiological processes under (social) stress and it also aimed to measure treatment success by including several outcome variables (state anxiety, negative cognitions, physiological arousal, perception of and worry about physiological symptoms, perception of academic performance, neg‐ ative post-event processing, parental cognitions, parental fear of negative child evalua‐ tion, and related treatment outcome predictions). due to the extent of the project and limitations on length and foci in articles, not all treatment related results could be reported in a single manuscript. further results are reported elsewhere (treatment out‐ come, asbrand, heinrichs, schmidtendorf, nitschke, & tuschen-caffier, 2020; changes in post-event processing based on treatment, asbrand, schmitz, et al., 2019; stability of the cortisol response despite treatment, asbrand, heinrichs, nitschke, wolf, schmidtendorf, 1) heart rate and perspiration were chosen to be assessed objectively as well. while the project further included other physiological variables (e.g. cortisol; asbrand, heinrichs, nitschke, wolf, schmidtendorf, & tuschen-caffier, 2019), these do not have a subjective counterpart which can be assessed by self-report. due to technical limitations, we could not assess blushing and trembling as objective parameters. asbrand, schulz, heinrichs, & tuschen-caffier 5 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ figure 1 flowchart of study participants note. n1 = center 1, n2 = center 2; cbt = cognitive behavioral therapy; eda = electrodermal activity; hc = healthy control; hr = heart rate; sad = social anxiety disorder; tsst-c = trier social stress test for children; wlc = waitlist control. biased perception of physiology in child sad 6 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ & tuschen-caffier, 2019) or are being prepared for submission (social performance, detailed psychophysiological activity pre and post treatment). to ensure maximal transparency, all articles include cross-references to other reports on measures used to investigate potential treatment-related effects. the current study reports primary outcome variables relating to perception of (is) and worry about phys‐ iological symptoms heart rate and eda (ie). the inclusion of subjective perception of and worry about blushing and trembling as well as cardiac iac was included post-hoc. the sample size for the current study, based on a medium to large effect (schmitz et al., 2012) and power of (1 β) = .80, was set at n = 90 (each group n = 45). as the study was part of a larger research project (see footnote) requiring a larger sample size of n = 110, all children were included to increase power. because the data are being used in a large project, this method section has been reported before in a similar fashion (asbrand, heinrichs, et al., 2019; asbrand, schmitz, et al., 2019). participants we informed parents of anxious children (9 to 13 years) through advertisements in schools, medical facilities, and newspapers in two midsized german cities from january 2012 to november 2013 until the targeted sample size had been reached (for an overview see figure 1). no harms were reported. parents received €35, and children €25 in vouch‐ ers in compensation for participation in the laboratory study. ethical approval for this study was granted by an independent ethics committee (ethics committee of the german society for psychology). all participating children and their caregivers consented to participation in both oral and written form. inclusion criterion for children consisted of sad as a primary diagnosis in the sad group and no current or lifetime diagnosis of a mental disorder in the hc group. exclu‐ sion criteria entailed health problems or medication which could have interfered with psychophysiological assessment (e.g., asthma, cardiac arrhythmia, and methylphenidate). as can be seen in table 1, the groups did not differ in age, type of school, or any of the disorder-specific measures. social phobia and anxiety inventory for children (spai-c) scores exceeded suggested cut-offs for clinically relevant sad. table 1 participant characteristics of the experimental groups (social anxiety disorder vs. healthy controls) characteristic group statisticssad healthy controls n a 64 55 mean age (sd), in years 11.3 (1.4) 11.3 (1.4) t(117) = 0.06, n.s. female 63.6% 60.0% χ2(1) = 0.17, n.s. mean spai-c (sd) 23.3 (9.03) 4.2 (5.4) t(117) = -13.71*** asbrand, schulz, heinrichs, & tuschen-caffier 7 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ characteristic group statisticssad healthy controls net income (per month) χ2(8) = 11.42, n.s. n.a. 0% 1.3% < €1,000 0% 5.9% €1,001–1,500 1.9% 7.4% €1,501–2,000 11.1% 8.8% €2,001–3,000 35.2% 32.4% €3,001–4,000 14.8% 16.2% €4,001–5,000 14.8% 20.6% > €5,000 22.2% 7.4% mean (sd) state anxiety during tsst-c (before treatment) 6.6 (2.8) 4.5 (2.9) t(117) = 4.05*** note. table adapted from asbrand, schmitz, et al. (2019). reprinted with permission. spai-c = social phobia and anxiety inventory for children; tsst-c = trier social stress test for children; n.a. = not available. asample sizes differ as not all questionnaires were completed correctly. ***p ≤ .001, n.s. = not significant. further, in the sad group, children in the two conditions (cbt vs. wlc) did not differ in sociodemographic and psychopathological variables (see table 2). table 2 participant characteristics of children with social anxiety disorder allocated to the treatment versus waitlist group characteristic group statisticstreatment (cbt) waitlist control n a 31 33 mean age (sd), in years 11.5 (1.4) 11.2 (1.3) t(62) = 0.78, n.s. female 51.6% 67.6% χ2(2) = 1.88, n.s. mean spai-c (sd) 11.8 (7.3) 12.1 (7.1) t(62) = 0.18, n.s. net income (per month) χ2(7) = 6.65, n.s. n.a. 3.2% 0.0% < €1,000 6.5% 5.6% €1,001–1,500 9.7% 5.6% €1,501–2,000 6.5% 8.3% €2,001–3,000 41.9% 23.7% €3,001–4,000 16.1% 16.7% €4,001–5,000 9.7% 30.6% > €5,000 6.5% 8.3% mean (sd) state anxiety during tsst-c (before treatment) 6.7 (2.9) 6.6 (2.8) t(62) = 0.10, n.s. note. table adapted from asbrand, schmitz, et al. (2019). reprinted with permission. cbt = cognitive behavio‐ ral therapy; n.a. = not available; spai-c = social phobia and anxiety inventory for children; tsst-c = trier social stress test for children. asample sizes differ as not all questionnaires were completed correctly. ***p ≤ .001. n.s. = not significant. biased perception of physiology in child sad 8 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ procedure the study took place at two german universities. all analyses first considered site differ‐ ences, which were non-existent. following a short telephone screening for anxiety symp‐ toms, eligible children and their parents attended a diagnostic session (see flowchart in figure 1). both the child and a parent separately participated in the kinder-dips, a struc‐ tured interview that codes for mental disorders in children and adolescents (schneider, unnewehr, & margraf, 2008). diagnoses of sad and comorbid disorders (dsm-iv-tr, apa, 2000) were then reached through combining both interviews, supervised by an experienced clinical psychologist. diagnoses were assigned under supervision of the same licensed clinical psychologists per site throughout the project (one psychologist at the first, two psychologists at the second center). the kinder-dips is a validated interview for the most frequent mental disorders in children and adolescents (schneider et al., 2008). the kinder-dips is conducted by trained interviewers and the diagnosis is usually based on both child and parent reports. the authors have reported adequate interrater reliability (87% for anxiety disorders), good retest reliability (schneider et al., 2008), and successful validation with disorder-specific questionnaires. additionally, children and parents reported sociodemographic data, anxiety symptoms, and general psychopathology in online questionnaires. according to the diagnostic assessment, 65 children fulfilled the inclusion criterion of a primary diagnosis of sad; 55 children were included in the hc group. after the diagnostic interviews children participated in the first laboratory session, the tsst-c (buske-kirschbaum et al., 1997), which consists of a speech and a math task (see figure 2). in the speech task, children narrate a story in front of two observers after listening to the beginning of the story. in the following mental arithmetic task, children were asked to serially subtract the number 7 from 758 (9to 11-year-olds) or the number 13 from 1,023 (12to 13-year-olds) as fast and as accurately as possible again in front of two observers. both observers were instructed and trained to give neutral verbal and nonverbal feedback. the tsst-c elicits high social-evaluative stress in children (cf. allen et al., 2017). throughout the session, heart rate and skin conductance level were assessed. further, perception of (is) and worry about physiological symptoms (ie) were assessed after baseline, stress, and recovery (see figure 2). after a recovery period, children per‐ formed the hct to assess iac (see below). as the current project focused on the climax of social stress, only this time of measurement was included in the analyses. assessments of perception and worry were based on a previous study (schmitz et al., 2012): children were asked to rate their perceived level of physiological intensity during the task (e.g., “how strongly did you feel your heartbeat during the task?”) and their worry about their physiological symptoms (“how much did you worry that others could notice how fast your heart was beating?” on a scale of 0 (not at all) to 10 (extremely). after participating in a 12-week cbt program (cbt group) or waiting without treatment (wlc group), all children performed a parallel version of the first testing session. based on the original asbrand, schulz, heinrichs, & tuschen-caffier 9 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ tsst-c (buske-kirschbaum et al., 1997), the speech task was changed to a different story that was judged to be similarly interesting and difficult in a preevaluation. the math task was changed to a different start number (+10). the tsst-c reliably induces social anxiety in all children, even more so in children with sad compared to healthy control children, p < .001. figure 2 overall procedure including the trier social stress test for children (tsst-c) before (tsst-c 1) and after (tsst-c 2) treatment or waiting note. physio perception 1–3 refers to measurements of participants’ perceived level of physiological intensity and physio worry 1–3 to worry about their physiological symptoms. treatment treatment consisted of an exposure-based cbt treatment that was evaluated simultane‐ ously (asbrand, heinrichs, schmidtendorf, nitschke, & tuschen-caffier, 2020). it targets dysfunctional cognitions, possible social deficits, and social avoidance with a strong biased perception of physiology in child sad 10 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ focus on exposure. each session consisted of 100 min (including a 10-min break) in groups of five to seven children. standard cbt components were implemented in 12 sessions (psychoeducation, cognitive restructuring, social skills training, exposure, and relapse prevention). children were instructed to use their newly developed skills outside of treatment to ensure a transfer into everyday life. psychometric measure the spai-c (beidel, turner, hamlin, & morris, 2000) assesses behavioral characteristics specific to sad (26 items; e.g., “i am anxious when i meet new boys or girls”). children respond to each item using a 3-point likert-type scale ranging from “never or hardly ever” to “almost always or always.” validity and reliability were confirmed in the original sample (beidel et al., 2000) and a german sample (melfsen, walitza, & warnke, 2011). internal consistency and test–retest reliability after 4 weeks in the german sample was excellent (cronbach’s α = .92; rtt = .84). psychophysiological measures electrodermal and cardiovascular measures including heart rate were assessed at 400 hz using the varioport system (becker meditec, karlsruhe, germany). data inspection and artefact rejection were conducted offline using anslab (blechert, peyk, liedlgruber, & wilhelm, 2016). for the electrocardiogram, the cardiac interbeat interval (ibi), calculated as the interval in milliseconds between successive r waves, was extracted. for illustrative purposes the ibi was converted to heart rate (in beats per minute) for tables and figures but all statistical analyses were based on ibi values (quigley & berntson, 1996). eda, re‐ flecting electrodermal sympathetic activity (boucsein, 2012), was assessed by placing two electrodes on the middle phalanx of the middle and ring fingers of the left hand using 11-mm inner diameter ag/agcl electrodes filled with isotonic electrode paste (td-245, med associates, inc., st. albans, vermont). as a parameter of eda, skin conductance level was used. interoceptive accuracy (iac) we assessed iac using the hct. after a short training of about 10s, children were asked to silently count their heartbeats during three instructed intervals (25, 35, 45s in a fixed order), to indicate ‘zero’ if they had not perceived any, and not take their pulse or to use any other strategies such as holding their breath (eley et al., 2004). subjective reports of perceived heartbeats were checked for plausibility. for the first testing session, perceived heart beats ranged between 10 and 86 (25s interval), 10 and 90 (35s interval), and 13 and 600 (45s interval). based on the extreme value at the third interval, one child was excluded from further analyses as it is possible that the child did not understand the instructions correctly, leaving a range between 13 and 120 (45s interval). for the second asbrand, schulz, heinrichs, & tuschen-caffier 11 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ testing session, perceived heart beats ranged between 7 and 70 (25s interval), 1 and 85 (35s interval), and 6 and 105 (45s interval). to ensure comparability to an earlier study (koch & pollatos, 2014), iac was calcula‐ ted using the formula: iachct =  13   k = 1 3 1 − no. of recorded heartbeatsk − no. of perceived heatbeatsk no. of recorded heartbeatsk higher scores indicate higher iac, with a maximum score of ‘1’ reflecting perfect iac. as physical symptom reporting is related to the tendency to report false alarms in a somatosensory signal detection task (brown et al., 2012), we calculated a simple iac score to distinguish overfrom underreporting using the formula (rost, van ryckeghem, schulz, crombez, & vögele, 2017): iacsimple =  13   k = 1 3 no. of perceived heartbeatsk − no. of recorded heartbeatsk no. of recorded heartbeatsk a positive score reflects over-reporting and a negative score reflects underreporting of heartbeats. statistical analysis first, for objective measures, statistical outliers 2.5 sd above or below the mean were excluded. outliers were calculated separately for groups and time. to examine biases be‐ fore treatment, we conducted analyses of variance (anovas) with repeated measures on phase (baseline, stress, recovery), using group (sad, hc) as between-subjects factor. for objective physiology, eda and heart rate were used as dependent variables in separate anovas. for subjective perception, rating (perception, worry) was further added as a factor. we included first the heart rate and perspiration scales and then the blushing and trembling scales as dependent variables in separate anovas. including objective physiology as a covariate did not lead to any significances, ps > .05, and is therefore not further reported. to consider that objective physiology and subjective perception (is) and worry (ie) might depend on each other, multiple correlation analyses were conducted for both eda and heart rate including subjective and objective measures. iac scores (iachct and iacsimple) from the first laboratory session were compared using an independent sample t test with group (sad, hc) as independent variable. for treatment effects, we once again conducted anovas with repeated measures on session (pre, post) and phase (baseline, stress, recovery), using group (cbt, wlc) as between-subjects factor. for objective physiology, eda and heart rate were used as dependent variables in separate anovas. for subjective perception, perception and wor‐ ry of all physiology questionnaires (heart rate, perspiration, blushing, trembling) were biased perception of physiology in child sad 12 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ analyzed as dependent variables in separate anovas. once again, multiple correlation analyses were conducted for both eda and heart rate including subjective and objective measures. for the analysis of treatment effects on iac scores, an anova with repeated measures on time (pre, post) was used based on treatment (cbt, wlc) as independent variable. further, a moderation analysis was conducted testing treatment as potential moderator (cbt, wlc) between iac pre (iac_1) and post treatment (iac_2) using the process macro for spss (hayes, 2013). further exploratory analyses are reported in the supplementary materials. significant main effects and interactions for all anovas were further analyzed with post hoc t tests for independent groups for the group comparisons and with t tests for de‐ pendent groups for the time comparisons (phase, session) if relevant for the hypotheses. cohen’s d effect sizes are reported for the post hoc tests. results before treatment: objective physiology comparison of children with and without sad we found higher heart rate (hr) during the stress as compared to the baseline and post phases, wilk’s λ = .351, f(2,94) = 87.07, p < .001, ηp2 = .649, but hr did not differ between groups, f(1,95) = 0.87, p = .354. there was a significant interaction of phase × group, wilk’s λ = .870, f(2,94) = 87.07, p < .001, ηp2 = .130. post hoc tests showed a significantly higher hr in children in the sad group during the baseline phase, t(95) = -2.30, p = .023, d = 0.47, but no further group differences, ts < 1.33, ps > .187 (see figure 3a). in the sad group, hr increased significantly from baseline to stress, t(53) = 7.12, p < .001, d = 0.41, and decreased from stress to recovery, t(53) = -7.27, p < .001, d = 0.40. similarly, in the hc group, hr increased significantly from baseline to stress, t(42) = 11.31, p < .001, d = 0.67, and decreased from stress to recovery, t(53) = -10.40, p < .001, d = 0.61. the significant interaction between group and phase and the higher effect sizes for post-hoc tests in the hc than the sad group suggest a steeper increase and decrease in the hc group compared to the sad group. eda significantly increased over time, wilk’s λ = .586, f(2,91) = 32.17, p < .001, ηp2 = .414, and differed between groups, f(1,92) = 35.12, p < .001, ηp2 = .276. furthermore, we observed a significant phase × group interaction, wilk’s λ = .750, f(2,91) = 15.14, p < .001, ηp2 = .250. post hoc tests showed that in the sad group, eda increased signif‐ icantly from baseline to stress, t(49) = 7.17, p < .001, d = 0.31, but did not decrease from stress to recovery, t(49) = 1.30, p = .199, d = 0.02. similarly, in the hc group, eda increased significantly from baseline to stress, t(43) = 4.45, p < .001, d = 0.23, but did not decrease from stress to recovery, t(43) = 1.02, p = .311, d = 0.02 (see figure 3b). again, asbrand, schulz, heinrichs, & tuschen-caffier 13 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ the significant interaction and the higher effect sizes imply a steeper increase in the hc group compared to the sad group. before treatment: subjective physiology perception comparison of children with and without sad for subjective perception of heart rate (is), we found significant main effects of phase, wilk’s λ = .468, f(4,111) = 31.49, p < .001, ηp2 = .532, and group, wilk’s λ = .861, f(2,113) = 9.10, p < .001, ηp2 = .139, with a trend for a significant interaction of phase × group, wilk’s λ = .929, f(4,111) = 2.11, p = .084, ηp2 = .071. groups differed in both perception of and worry about heart rate in all phases (see figure 4; ps < .05). the increase from baseline to stress and the decrease from stress to recovery was significant in both groups, ps < .001. similar effects were found for subjective perception of perspiration, blushing, and trembling (see supplementary materials). figure 3 group comparisons of (a) heart rate (in beats per minute, bpm) and (b) electrodermal activity during the first trier social stress test for children for children with social anxiety disorder (sad) and healthy control (hc) children biased perception of physiology in child sad 14 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ figure 4 subjective perception of (a) and worry (b) about heart rate after all phases of the first trier social stress test for children note. for other parameters, see supplementary materials. before treatment: relations between objective and subjective physiology a multiple correlation analysis between objective heartrate and subjective perception of and worry about heart rate did not reveal any significant correlation, ps > .084. similarly, no effects were found for eda and subjective perception, ps > .105. for the first laboratory session, neither the iachct scores, t(96) = -1.29, p = .200, d = 0.26, nor the iacsimple scores differed significantly between groups, t(98) = -1.48, p = .142, d = 0.30. after treatment: objective physiology comparison of children with sad after treatment versus waiting comparable to the first measurement occasion, hr was higher during stress than during baseline and post phases, wilk’s λ = .355, f(2,37) = 33.55, p < .001, ηp2 = .645. all other effects remained nonsignificant, fs < 2.77, ps < .103. again, eda was higher during stress than during baseline and post phases, wilk’s λ = .388, f(2,37) = 29.15, p < .001, ηp2 = .612. all other effects remained nonsignificant, fs < 3.91, ps < .057. asbrand, schulz, heinrichs, & tuschen-caffier 15 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ after treatment: subjective physiology perception comparison of children with sad after treatment versus waiting for subjective perception of heart rate after treatment, the anova showed a significant main effect of phase, wilk’s λ = .364, f(4,48) = 20.94, p < .001, ηp2 = .636, and a trend for a significant effect of session, wilk’s λ = .891, f(2,50) = 3.07, p = .055, ηp2 = .109. all other fs < 2.27, ps > .113 (see figure 5). figure 5 subjective perception of and worry about heart rate after all phases of the first (a, b) and second (c, d) trier social stress test for children (tsst-c), comparing the cognitive behavioral therapy (cbt) and waitlist control (wlc) groups note. for other parameters, see supplementary materials. an analysis of the main effect of session for heart rate in both groups, using t tests for paired samples, showed an overall decrease in the perception, t(56) = 2.03, p = .047, d biased perception of physiology in child sad 16 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ = 0.28, and worry after the stress phase, t(56) = 2.22, p = .030, d = 0.30. all other ts < 1.33, ps > .191. so, heart rate perception and worry decreased in all children from tsst-c 1 to tsst-c 2. similar effects were found for subjective perception of trembling (see supplementary materials). after treatment: relations between objective and subjective physiology a multiple correlation analysis at tsst-c 2 between objective hr and subjective percep‐ tion (is) of and worry (ie) of hr did not reveal any significant correlation, ps > .077. similarly, no effects were found for eda and subjective perception, ps > .229. regular iachct did not change from preto post-measurement (main effect ‘session), independent of treatment group (interaction treatment × session, fs < 1.92, ps > .174). likewise, for iacsimple, no significant effects appeared for treatment, session or session × treatment, fs < 2.19, ps > .146. additionally, the moderation analysis showed an overall significant relation, r 2 = .382, f(3,35) = 7.2, p < .001. there was a significant relation between iac_1 and iac_2, while treatment was no significant moderator (table 3). table 3 prediction of iac at second laboratory session predictor b se b t p constant -0.12 [-0.75, 0.51] 0.31 -0.38 .703 iac_1 (standardized) 0.92 [0.03, 1.18] 0.44 2.09 .044 treatment (cbt, wlc; standardized) 0.27 [-0.19, 0.74] 0.23 1.20 .237 iac_1 × treatment (cbt, wlc) -0.25 [-0.90, 0.40] 0.32 -0.79 .437 note. iac_1 = interoceptive accuracy laboratory session 1, iac_2 = interoceptive accurarcy laboratory session 2. discussion the study aimed to assess alterations in perception of (is) and worry about (ie) physio‐ logical symptoms as well as iac in childhood sad. it further strived to examine possible changes after cbt. supporting our hypotheses at tsst-c 1, children with sad showed higher heart rate than children in the hc group during the baseline phase, and a lower reactivity to stress. further, eda was heightened throughout the testing session. these findings may indicate an autonomic hyperarousal and blunted stress reactivity in the sad group. moreover, children in the sad group reported heightened perception (is) of and increased worry (ie) about heart rate, perspiration, and trembling throughout the tsst-c. there seems to be no biased perception for eda. however, the pattern for the asbrand, schulz, heinrichs, & tuschen-caffier 17 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ objective and subjective side in heart rate differed: objectively, children in the hc group showed a steep increase and decrease throughout the tsst-c 1. subjectively however, hc children’s perception and worry remained below that of sad children. as blushing and trembling were not controlled on objective parameters, this effect can only be con‐ firmed for heart rate and perspiration. further, contrary to findings in adults (domschke, stevens, pfleiderer, & gerlach, 2010), no differences in iac were found between children with sad and hc children. findings after treatment were not in line with our hypotheses: objective physiolog‐ ical parameters (heart rate, eda) did not change. interestingly, children in the cbt group reported heightened perception of and increased worry about perspiration, and trembling after the baseline phase at tsst-c 2 compared to children in the wlc group. additionally, both before and after treatment subjective and objective parameters did not correlate. further, as no differences appeared between children with sad receiving treatment vs. waiting, no effects of treatment on iac can be assumed. before treatment: findings on children with sad compared to an hc group objectively in line with earlier studies (cf., asbrand et al., 2017), a tonic hyperarousal was shown in children with sad concerning eda. however, in contrast to earlier studies (schmitz et al., 2012), this was mirrored by subjective perception. part of the earlier findings in high socially anxious children (schmitz et al., 2012) still seems to be also found in our sample: concerning hr, children with sad perceived an increase in their physiological reaction that was not mirrored by the pattern of physiological reactivity. further, they worried more than children in the hc group that this physiological arousal might be observable. considering the point of (non)visibility of heart rate, children with sad might have more unrealistic worries that internal signals might be observable. as our paradigm was slightly altered to schmitz et al. (tsst-c instead of a speech task with public vs. private sound of heart rate), our findings are not replication in a narrow sense but show a robust effect in an established social stress test. however, mean scores on symptom perception intensity as well as worry were rather low (< 5 on a scale of 0 to 10). the pattern of results demonstrates that worry is linked to several physiological symptoms (but not all). further, it may be that some physiological sensations are more likely linked to sad (e.g., blushing; bögels, rijsemus, & de jong, 2002). these symptoms are more consistently associated with worry, reflecting a more general tendency to wor‐ ry about sad-related physiological symptoms instead of symptom-specific links between perception of and worry about these symptoms. this might be related to visibility of physiological symptoms. finally, a lack of correlation between iac, is and ie provides an interesting insight: it would be expected that a higher physiological arousal leads to the perception of – and possibly worry about – these symptoms. however, our results point to the independence of both sides. this might stem from the fact that children biased perception of physiology in child sad 18 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ struggle more with iac (koch & pollatos, 2014). the current study suggests that sad children do not show altered iac, but report higher subjective heart rates (is) and higher worries about cardiac perceptions (ie). sad in childhood may be reflected, therefore, by a selective increase in the subjective tendency to be focused on heart rate increases and a negative evaluation of these percepts, whereas the actual perception is unaffected. after treatment: findings on a treatment (cbt) versus a wlc group children in the cbt group reported higher perception of and more worry about perspi‐ ration as well as more worry about trembling after the baseline phase of tsst-c 2. in other words, children in the cbt group reported heightened perception of physiological arousal and increased worry on some parameters after the baseline phase. previous findings from this sample could show that cbt was in general successful in reducing the severity of sad as measured by a blind interview after treatment (cf., asbrand et al., 2020). further, some sad-relevant rumination processes such as post-event pro‐ cessing changed for the better as negative thoughts after a social situation decreased significantly after treatment (asbrand, schmitz, et al., 2019). still, cortisol levels did not change based on treatment; however, cortisol levels in the wlc group increased in the second tsst-c (asbrand, heinrichs, et al., 2019). overall, it would have been plausible that physiological awareness and biased perception also change with treatment. howev‐ er, instead of decreasing, children in the cbt group reported higher perception and worry about several physiological parameters before entering the social stress situation. it might be that children in the cbt group were sensitized to similar tasks as they had experienced exposure sessions beforehand. psychoeducation conveys a concept of anxiety that includes cognitions, behavior, and physiological reactions. often, this is the first time children are confronted with such a concept. it might direct their attention to these factors and, as such, support sensitization. further, our treatment was rather short (12 sessions), and recent research has argued that longer treatment is necessary in sad (e.g., hudson et al., 2015). as the main treatment component, exposure, had to be properly prepared (habituation rationale, first exposure in social skills sessions), only a few sessions remained to experience in-vivo exposure. thus, it is possible that treatment was already successful in reducing overall symptoms (asbrand, heinrichs, et al., 2020), but children were still in the process of handling high state anxiety. additionally, our treatment did not specifically target physiological symptoms and their interpretation. this treatment component is more common in treatment of panic disorders (e.g., clark et al., 1999; öst & westling, 1995) but should be considered for sad treatment as well, given our results. however, interpretation of these findings of elevated perception and worry in the cbt group should be evaluated cautiously as they were found only after the baseline phase of the tsst-c and not after the stress phase. in addition, even if the asbrand, schulz, heinrichs, & tuschen-caffier 19 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ pattern of results allows for interpretation of sensitization, the overall scores remain low at posttreatment (mean scores < 4 on a scale of 0 to 10). finally, while comparison of single intervals of the hct has shown high correlations between these (e.g., koch & pollatos, 2014), our study is the first to show stability over a longer period of time providing first evidence for iac as a trait marker in children. however, as we do not find differences in iac between children with and without sad in our study, iac may not play a key role for sad in children. possibly, a subsample of chil‐ dren with sad suffering from panic-like symptoms (cf. domschke, stevens, pfleiderer, & gerlach, 2010) in social situations might show both different iac scores and changes in iac based on treatment. future studies are warranted to investigate, which role other occasionor situation-specific factors, as well as error variance (wittkamp et al., 2018), contribute to iac in in children. limitations and conclusions while the study has several strengths, such as a clinical sample and inclusion of treat‐ ment, several limitations apply. first, we assessed a variety of dependent variables based on concerns to target physiological arousal broadly (siess et al., 2014). possibly, a lack of effects might stem from lack of power. however, the current sample was relatively large and could detect differences in treatment groups, even though they showed to be contrary to expectations. second, we did not assess all variables both subjectively and objectively but provide subjective data only for blushing and trembling. future studies might target these variables to examine the objective basis for subjective perception. pre‐ vious studies from adults, however, point to similar results for blushing, as this depends mainly on social anxiety instead of objective blood flow (drummond & su, 2012). third, we refrained from using an experimental setup (cf., gerlach et al., 2004; schmitz et al., 2012), instead opting for a standardized social stress task. thus, taking note of these earlier findings (gerlach et al., 2004; schmitz et al., 2012) on the importance of the per‐ ception of and worry about physiological arousal in social anxiety, we did not manipulate visibility of physiological arousal but chose to measure subjective and objective arousal in parallel during social stress. finally, we did not include a correlation analysis between a change in social anxiety symptoms and changes in perceptions of physiology as this would not have been based on a solid theoretical background. however, future studies could include this perspective to analyze a possible co-occurrence of change in anxiety and perception of physiology. in conclusion, our results indicate that sad children show a selective enhancement of subjective cardiac interoception, as proposed by cognitive models of sad (clark & wells, 1995), whereas behavioral indices of cardiac interoception and the perception of eda changes remain unaffected. cbt did not change this perception. thus, further inclusion of treatment components targeting this bias as currently proposed mainly by biased perception of physiology in child sad 20 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://www.psychopen.eu/ adult research (hofmann & otto, 2017; naim, kivity, bar-haim, & huppert, 2018; wong et al., 2017) should be considered. funding: this research was supported by a grant from the dfg given to the last authors (he 3342/4-2, tu 78/5-2). competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. supplementary materials the supplementary materials include additional exploratory analyses on subjective perception of perspiration, blushing and trembling before and after treatment (for access see index of supple‐ mentary materials below): index of supplementary materials asbrand, j., schulz, a., heinrichs, n., & tuschen-caffier, b. 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(2017). anticipatory processing, maladaptive attentional focus, and postevent processing for interactional and performance situations: treatment response and relationships with symptom change for individuals with social anxiety disorder. behavior therapy, 48(5), 651-663. https://doi.org/10.1016/j.beth.2017.03.004 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. asbrand, schulz, heinrichs, & tuschen-caffier 25 clinical psychology in europe 2020, vol.2(2), article e2691 https://doi.org/10.32872/cpe.v2i2.2691 https://doi.org/10.1016/j.jpsychores.2016.12.003 https://doi.org/10.1111/j.1469-8986.1981.tb02486.x https://doi.org/10.1080/15374416.2012.632349 https://doi.org/10.1007/s00787-013-0405-y https://doi.org/10.1007/s00787-013-0443-5 https://doi.org/10.1111/psyp.13055 https://doi.org/10.1016/j.beth.2017.03.004 https://www.psychopen.eu/ biased perception of physiology in child sad (introduction) the current study method trial design participants procedure treatment psychometric measure psychophysiological measures interoceptive accuracy (iac) statistical analysis results before treatment: objective physiology comparison of children with and without sad before treatment: subjective physiology perception comparison of children with and without sad before treatment: relations between objective and subjective physiology after treatment: objective physiology comparison of children with sad after treatment versus waiting after treatment: subjective physiology perception comparison of children with sad after treatment versus waiting after treatment: relations between objective and subjective physiology discussion before treatment: findings on children with sad compared to an hc group after treatment: findings on a treatment (cbt) versus a wlc group limitations and conclusions notes (additional information) funding competing interests acknowledgments supplementary materials references functional somatic symptoms and emotion regulation in children and adolescents research articles functional somatic symptoms and emotion regulation in children and adolescents stefanie m. jungmann 1 , louisa wagner 1, marlene klein 1 , aleksandra kaurin 2 [1] department of clinical psychology, psychotherapy, and experimental psychopathology, johannes gutenberguniversity mainz, mainz, germany. [2] department of clinical psychology and psychotherapy, university witten/ herdecke, witten, germany. clinical psychology in europe, 2022, vol. 4(2), article e4299, https://doi.org/10.32872/cpe.4299 received: 2020-09-04 • accepted: 2021-11-29 • published (vor): 2022-06-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: stefanie m. jungmann, johannes gutenberg-university mainz, department of clinical psychology, psychotherapy, and experimental psychopathology, wallstraße 3, 55122 mainz, germany. phone: +49 (0)6131 – 39 3920. e-mail: jungmann@uni-mainz.de supplementary materials: materials [see index of supplementary materials] abstract background: functional somatic symptoms (fss; i.e. symptoms without sufficient organic explanation) often begin in childhood and adolescence and are common to this developmental period. emotion regulation and parental factors seem to play a relevant role in the development and maintenance of fss. so far, little systematic research has been conducted in childhood and adolescence on the importance of specific emotion regulation strategies and their links with parental factors. method: in two studies, children and adolescents (study 1/study 2: n = 46/68; 65%/60% female, age m = 10.0/13.1) and their parents completed questionnaires on children's fss and adaptive and maladaptive emotional regulation (in study 2, additionally parental somatization and child/parental alexithymia). results: in both studies, child-reported fss were negatively associated with children's adaptive emotion regulation (r = -.34/-.31, p < .03; especially acceptance) and positively with children's maladaptive emotion regulation and alexithymia (r = .53/.46, p < .001). moreover, children’s maladaptive emotion regulation (β = .34, p = .02) explained incremental variance in child-reported fss beyond children’s age/sex, parental somatization and emotion regulation. in contrast, parental somatization was the only significant predictor (β = .44, p < .001) of parent-reported fss in children/adolescents. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4299&domain=pdf&date_stamp=2022-06-30 https://orcid.org/0000-0003-0201-9517 https://orcid.org/0000-0002-4131-1142 https://orcid.org/0000-0002-8687-4395 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: our results suggest that particularly rumination and alexithymia and parental somatization are important predictors of fss in children/adolescents. overall, the results showed a dependence on the person reporting children's fss (i.e., method-variance). so, for future studies it is relevant to continue using the multi-informant approach. keywords adolescents and children, alexithymia, emotion regulation, functional somatic symptoms, parents, transgenerational highlights • two studies found negative associations between child-reported fss and adaptive emotion regulation. • we found positive associations between child-reported fss and maladaptive emotion regulation. • parental somatization was the only significant predictor of parent-reported fss. • dependence on the rater stresses the importance of the multi-informant approach. about 10–25% of children and adolescents suffer from functional somatic symptoms (fss), i.e. bodily complaints such as abdominal pain or headaches that cannot be suffi­ ciently explained by an underlying physical condition (berntsson & köhler, 2001; rask et al., 2009). these bodily complaints interfere with daily activities and potentially impair academic and psychosocial functioning. children and adolescents suffering from bodily complaints report frequent absences from school, absent-mindedness, impaired leisure behavior, and lower levels of life quality (beck, 2008; hoftun et al., 2011; malas et al., 2017), fss represent a key feature of somatoform disorders (according to icd-10; world health organization, 1993) or somatic symptom disorders (according to dsm-5; american psychiatric association, 2013), (functional) somatic symptoms also co-occur with a variety of other disorders and are thus of transdiagnostic relevance (aldao et al., 2010; dufton et al., 2009; tegethoff et al., 2015). according to the perseverative cognition hypothesis (brosschot et al., 2006), a preoccu­ pation with stressful events or chronic stress may increase the likelihood to experience bodily symptoms through physiological activation. in adulthood, the importance of af­ fect-regulatory processes to fss and somatoform disorders is well established (bailer et al., 2017; schwarz et al., 2017). previous studies found that negative affect or depression and anxiety disorders are associated with reports of bodily symptoms (bekhuis et al., 2015; watson & pennebaker, 1989; wessely et al., 1999). moreover, difficulties in emotion processing, expression, and regulation have been reported to be related to higher levels of fss (okur güney et al., 2019; schwarz et al., 2017). adaptive emotion regulation strat­ egies such as reappraisal were negatively and maladaptive strategies such as expressive suppression and alexithymia were positively associated with fss (brooks et al., 2017; fss and emotion regulation 2 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ erkic et al., 2018). the construct alexithymia describes difficulties in recognizing and describing one's own feelings and is associated with deficits in emotional processing and dysfunctional emotion regulation (bagby et al., 1994; luminet et al., 2021). less attention has been paid to the relationship between emotional dysregulation and fss in childhood and adolescence. for instance, in a sample of youth with recurrent abdominal pain (7–18 years), coping strategies including regulating attention or cogni­ tions (“secondary control engagement” such as e.g., acceptance and distraction) were associated with fewer bodily symptoms, and involuntary engagement (including e.g., rumination and intrusive thoughts) with higher levels of bodily symptoms (thomsen et al., 2002). regarding emotion-focused (dealing with the emotional experience) and bodyfocused (dealing with bodily experience, e.g. taking a pill) regulation strategies, children with functional abdominal pain (8–13 years) showed the highest level of body-focused regulation compared to children with no/few and many bodily symptoms, whereas the three groups did not differ in emotion-focused regulation (rieffe et al., 2007). gilleland, suveg, jacob, and thomassin (2009) found that child-reported fss were associated with reduced emotional awareness. mother-reported fss in children/adolescents, in addition, was associated with low emotion regulation abilities including low emotion expression, empathy, and self-awareness. while there are hardly any studies on specific emotion regulation strategies in the context of fss in children and adolescents, some previous studies have focused on emotion awareness and alexithymia. a further study (jellesma et al., 2006) found that children with many somatic symptoms (highest 30% of a symptom scale) as well as a clinical group of children with functional abdominal pain (8–13 years) reported significantly stronger negative affect and more difficulties in differentiating and communicating feelings compared to children with few somatic symptoms (whereas the first two groups do not differ in that regard). according to a recent systematic review, seven of eight identified studies on self-reported alexithymia showed that children with fss reported significantly higher levels of alexithymic traits compared to healthy con­ trols (hadji-michael et al., 2019). in terms of a development perspective it is important to consider the development and maintenance of youth fss in interaction with parental and family factors (beck, 2008). models of transgenerational transmissions of psychopathology (hosman et al., 2009) and particularly those with a focus on pain or emotion regulation (morris et al., 2007; stone & wilson, 2016) suggest that parenting (especially e.g., regarding coping with affect) and children’s emotion regulation might account for the relationship between pa­ rental emotional dysregulation/psychopathology and children’s psychological outcomes. gilleland et al. (2009) found that parental somatization and youth deficits in emotion regulation were significant predictors of mother-reported child somatization and only parental somatization was a significant predictor of father-reported child somatization. in line with the transmission model (stone & wilson, 2016), the association between jungmann, wagner, klein, & kaurin 3 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ parental pain catastrophizing and adolescent symptom-related impairment was shown to be mediated by the pain catastrophizing of adolescents (wilson et al., 2014). so far, there is relatively little research on the relationship between emotion regula­ tion and fss in the field of clinical child and adolescent psychology. in particular, there is hardly any study on concrete emotion regulation strategies (e.g., reappraisal, suppres­ sion, see findings above in adulthood) and very little on the role of parental somatization. therefore, to narrow this gap in the literature, in two studies we aimed at systematically investigating the relationships between parent and child emotion regulation and parent and child somatization (parental somatization only assessed in study 2). study 1 was designed as a pilot study and investigated relationships between child and parental emotion regulation and children’s fss. we hypothesized that child and parental reappraisal and acceptance would be negatively associated and rumination and catastrophization would be positively associated with children’s fss. based on the transgenerational model (stone & wilson, 2016) and previous findings, suggesting that female gender and increasing age in youth are associated with fss (lieb et al., 2000; stone & wilson, 2016), it was assumed that beyond age and gender and parental emotion regulation, child emotion regulation is a significant predictor of fss in children and adolescents. study 2 aimed at replicating the results of study 1 in a second sample of youth and their parents (and child and parental alexithymia and parental somatization were assessed). in addition to the hypotheses in study 1, we expected a positive relationship between child and parental alexithymia and fss. to expect a specific relationship be­ tween emotion regulation and fss, we also hypothesized that beyond parental somatiza­ tion, parental and child emotion regulation would explain additional variance in fss in children and adolescents. in line with current dimensional-hierarchical approaches to psychopathology (hier­ archical taxonomy of psychopathology; hitop; conway et al., 2019) and the preference for the dimensional view especially of somatic symptoms (jasper et al., 2012), fss were investigated in the general population. method participants the participants of study 1 and 2 were recruited in the general population using flyers posted in schools in german cities. the inclusion criteria were an age of the children and adolescents between 7-14 (study 1)/8-17 years (study 2) and a consent of a parent or guardian. there was no drop-out in study 1. in study 2 (conducted online), originally n = 79 children and parents (each) participated. due to incorrect completion of the child version by parents and unassigned codes of child and parent, n = 11 cases had to be fss and emotion regulation 4 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ excluded. the socio-demographic data of both samples (n = 46/n = 68) are shown in table 1. table 1 sociodemographic characteristics of children/adolescents and their parents for study 1 (n = 46) and study 2 (n = 68) sociodemographic variables study 1 study 2 n (%) m (sd) n (%) m (sd) age children 9.96 (1.58) 13.09 (2.22) parents 44.74 (4.63) 44.97 (6.19) sex children (female) 30 (65.2%) – 41 (60.3%) – parents (female) 40 (87.0%) – 62 (91.2%) – children: type of school elementary school 29 (63.0%) – 6 (8.8%) – grammar school 15 (32.6%) – 25 (36.8%) – secondary school 1 (1.5%) – comprehensive school – – 35 (51.5%) – other school type/no statement 2 (4.3%) – 1 (1.5%) – parents: native languagea german 34 (73.9%) – 61 (89.7%) – others/no statement 12 (26.1%) 7 (10.3%) parents: family status married or partnership 34 (73.9%) – 57 (83.8%) – single/divorced/widowed 6 (13.0%) – 11 (16.2%) – no statement 6 (13.0%) – – – parents: education (% higher education) 24 (52.2%) – 29 (42.6%) – parents: occupation unemployed 1 (2.2%) – 1 (1.5%) – in training – – 1 (1.5%) – employee/civil servant 30 (65.2%) – 53 (77.9%) – self-employed 2 (4.3%) – 5 (7.4%) – housewife/-husband 10 (21.7%) – 7 (10.3%) – retired – 1 (1.5%) no statement 3 (6.5%) – – – astudy 2 also asked for nationality: 95.6% german or dual citizenship including german (e.g. czech, romanian, croatian), 1.5% american, 1.5% bulgarian and 1.5% czech. jungmann, wagner, klein, & kaurin 5 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ procedure the data collection of study 1 was part of a larger project on the behavioral assess­ ment of psychopathology in children and adolescents from the general population (in 2017-2018). the study took place on a single date in a research laboratory of the psychological institute. the study design required the accompaniment of one parent, which one was not pre-determined by the study, but according to the time capacity of the parents (in 87% of the cases the mother as accompaniment). as compensation, the children received a small game (e.g., board game) and the parents 10€ per hour. study 2 was an online study about body awareness and dealing with feelings (over 8 weeks in 2019). in both studies, parents and children/adolescents gave informed consent prior to participation. as compensation for their participation, children and parents were given the opportunity to take part in a lottery for 5 x 15 € gift vouchers. the study protocols of both studies were approved by the institutional review board of the psychological institute. measures children and adolescents the screening for somatoform disorders in children and adolescents (soms-ca; winter et al., 2018) is a validated self-reported measure for assessing fss. the soms-ca was used in study 1 and 2. participants report on 33 somatic symptoms (pain, gastrointestinal, cardiorespiratory, and pseudo-neurological symptoms) that have occurred in the last 6 months and for which the doctor has not found a clear medical explanation. a total number of complaints is calculated from the sum of the 33 bodily symptoms. this score showed high internal consistencies in both studies (cronbach’s α = .91/.84). additionally, the soms-ca assesses further characteristics of fss, such as illness-related behavior (e.g., doctor visits) and functional impairments. an additional score can be calculated includ­ ing these factors, whereby an earlier study (jungmann & witthöft, 2020) showed that this score can be ambiguous due to jump rules, so this study focused on the above-mentioned total number score of fss. the questionnaire to assess emotion regulation in children and youths (fragebogen zur erhebung der emotionsregulation bei kindern und jugendlichen, feel-kj; abler & kessler, 2009) is a validated 90-item self-report measure for assessing different strategies of emotion regulation when children and adolescents feel sad, anxious, and angry. emo­ tion regulation can be divided into the superordinate scales “adaptive” (e.g., acceptance and reappraisal), “maladaptive” (e.g., rumination), and “other strategies” (e.g., social sup­ port). a five-point likert scale (1 = almost never to 5 = almost always) is used to indicate the degree of agreement with each statement. the feel-kj showed acceptable to high reliability as well as construct and external validity (cracco et al., 2015). both studies focused on “adaptive” (α = .95/.85), “maladaptive emotion regulation” (α = .91/.77), and fss and emotion regulation 6 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ the individual strategies of “acceptance” (α = .75/.56), “reappraisal” (α = .76/.52), and “rumination” (α = .77/.46). based on previous studies on the links between depression, emotion regulation, and bodily complaints (allen et al., 2011), study 2 focused only on strategies in response to sadness (each strategy with two items). additionally, study 2 used the alexithymia questionnaire for children (aqc; rieffe et al., 2006), a 20-item self-report questionnaire for assessing alexithymia in children/ado­ lescents. the items (e.g., "i don't know what's going on inside me.") are rated on a three-point likert scale (0 = not true to 2 = often true). the internal consistency was α = .82. parents the screening for somatoform disorders in children and adolescents for parents (soms-p; voß, 2013) measures the severity of children’s fss from the parents’ perspective. the structure and scoring are analogous to the soms-ca (α = .82/.81). the cognitive emotion regulation questionnaire (cerq; loch et al., 2011) assesses cognitive emotion regulation strategies used in the context of negative experiences or life events. the frequency of using the different strategies is measured with a five-point likert scale (1 = almost never to 5 = almost always). based on our hypotheses, both studies focused on the superordinate scales “adaptive” (α = .93/.80) and “maladaptive emotion regulation” (α = .81/.72) and on the individual strategies “acceptance” (α = .84/.82), “reappraisal” (α = .85/.63), “rumination” (α = .66/.53), and “catastrophizing” (α = .65/.73). following garnefski and kraaij (2006), study 2 used a shortened version with two items per strategy. additionally, study 2 included the toronto alexithymia scale (tas; bagby et al., 1994; popp et al., 2008) and the brief symptom inventory (bsi; franke, 2000). the tas-20 is a 20-item self-report measure for assessing alexithymia in adults and comprises a five-point likert scale from 1 = not at all true to 5 = completely true (α = .85). the bsi is a 53-item screening questionnaire assessing various psychopathological characteristics within the last 7 days in adulthood. the items are rated on a scale from 0 = not at all to 4 = very strong. based on our hypotheses, we have focused on the subscale of somatization (7 items, α = .62). statistical analyses statistical analyses were carried out with spss 23.0. for study 2, an a priori power analysis using g*power with ρ h1 = .4, an alpha error = .05, and a statistical power = .90 for bivariate correlations resulted in a minimum sample size of n = 61 (not for study 2 due to a pilot study as a part of a larger project). in the online study (study 2), the survey response was set so that no questions could be omitted. in study 1, the pairwise deletion method was used for individual missing items. to test the relationships, we first calculated pearson correlation coefficients (most variables were approximately normally jungmann, wagner, klein, & kaurin 7 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ distributed). to examine the incremental variance explained by parental/child emotion regulation, multiple hierarchical regression models were computed for the dependent variable fss (once for child-reported/parent-reported fss). for regression analyses, first multicollinearity was checked (correlations of the predictors were each below r = .70; tabachnick & fidell, 1996). in study 1, sex and age were controlled for in step 1, parental adaptive and maladaptive emotion regulation were entered in step 2 (cerq), and child emotion regulation in step 3 (feel-kj) (order in line with the transgenerational model; stone & wilson, 2016). in study 2, parental somatization was added in step 2 and parental/child emotion regulation in steps 3 and 4 (cerq, feel-kj) (order in line with gilleland et al., 2009). results participant characteristics regarding fss and emotion regulation in study 1, boys and girls did not differ significantly in fss and emotion regulation (p ≥ .23, d ≤ 0.40). with regard to age of the children, significant positive correlations were found with children’s maladaptive emotion regulation (r = .38, p = .011) and children’s rumination (r = .33, p = .030). in study 2, girls showed higher scores compared to boys in reporting maladaptive emotion regulation, t(66) = -2.97, p = .004, d = 0.73, and rumination, t(66) = -3.18, p = .002, d = 0.78. children’s age correlated positively with the child-reported gastrointestinal symptoms (r = .30, p = .015) and maladaptive emotion regulation (r = .32, p = .008). appendix a (see supplementary materials) shows the participant characteristics of study 1 and 2. relationships between fss and emotion regulation study 1 as expected, in study 1 we found a negative correlation between children’s adaptive emotion regulation and child-reported fss (r = -.34, p = .026). at the level of individual strategies, there were no significant associations with reappraisal (r < .01, p > .99) and ac­ ceptance (r = -.26, p = .096). as hypothesized, there were significant positive correlations between children’s maladaptive emotion regulation (r = .53, p ≤ .001) and rumination (r = .41, p = .001) with child-reported fss. no significant correlations were found between children’s emotion regulation and parent-reported fss in children/adolescents (r ≤ |.20|, p ≥ .198). concerning parental emotion regulation, as expected, parental rumination was significantly positively associated with child-reported fss (r = .34, p = .028) and parental maladaptive emotion regulation (r = .37, p = .011) was well as parental rumination (r = .37, p = .011) were significantly positively correlated with parent-reported fss. appendix fss and emotion regulation 8 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ b (see supplementary materials) describes the correlations between child and parental somatization and child and parental emotion regulation. study 2 as in study 1, study 2 found a significant negative correlation between children’s adap­ tive emotion regulation and child-reported fss (r = -.31, p = .011). at the level of individ­ ual strategies, there was a significant negative association between children’s acceptance and child-reported fss (r = -.36, p = .003). children’s maladaptive emotion regulation (r = .46, p ≤ .001) and alexithymia (r = .39, p = .001) were significantly positively correlated with child-reported fss. additionally, children’s acceptance was significantly negatively correlated with parent-reported fss (r = -.25, p = .047). regarding parental emotion regu­ lation, parental acceptance showed a significant negative correlation with child-reported fss (r = -.30, p = .018). in addition, parental maladaptive emotion regulation (r = .29, p = .018) and alexithymia (r = .29, p = .018) were positively correlated with parental somatization (see appendix b in the supplementary materials). regression analyses for predicting fss in children and adolescents study 1 in study 1, children’s emotional regulation (∆r 2 = .34, p = .001) explained variance in child-reported fss over and above children’s age/gender and parental emotional regula­ tion (appendix c, supplementary materials). as the correlations showed, both child adaptive (β = -.30, p = .040) and maladaptive emotion regulation (β = .50, p = .002) were significant predictors of child-reported fss. to investigate specific regulation strategies, this multiple hierarchical regression was repeated by using the specific hypothesized emotion regulation strategies (acceptance, reappraisal, and rumination) instead of gener­ al adaptive and maladaptive emotion regulation. child acceptance (β = -.36, p = .028) was found to be a negative predictor and rumination a positive predictor (β = .46, p = .007) of child-reported fss. the same analyses were carried out for the dependent variable parent-reported fss (appendix d, supplementary materials). in this model, children’s emotional regulation showed no incremental explanation for variance in parent-reported fss (∆r 2 = .01, p = .892) in addition to age/gender, and parental emotional regulation. parental emotion regulation provided a significant explanation of variance in parent-reported fss (∆r 2 = .22, p = .010), which can be attributed to maladaptive emotion regulation as a significant predictor (β = .37, p = .025). including individual strategies (catastrophization and rumi­ nation), parental rumination (β = .48, p = .017) was found to demarcate a significant predictor of parent-reported fss. jungmann, wagner, klein, & kaurin 9 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ study 2 as in study 1, in study 2 children’s emotion regulation explained incremental variance in child-reported fss (∆r 2 = .14, p = .009) beyond age/sex, parental somatization, and pa­ rental emotion regulation (appendix c, supplementary materials). maladaptive emotion regulation (β = .34, p = .020) was shown to be a significant predictor of child-reported fss, whereby the assumed individual strategy rumination did not prove to be a signifi­ cant predictor (β = .04, p = .777) this analysis was repeated for the dependent variable parent-reported fss in chil­ dren/adolescents (appendix d, supplementary materials). as in study 1, in study 2 children’s emotion regulation did not explain significant incremental variance in parentreported fss (∆r 2 = .014, p = .594) beyond age/sex, parental somatization, and parental emotion regulation. in this model for predicting parent-reported fss, parental somatiza­ tion was the only significant predictor (β = .44, p < .001). discussion two studies were conducted to investigate the relationships between child and parental emotional regulation and child and parental somatization. based on previous research and the transgenerational model for the development of fss in children/adolescents (gilleland et al., 2009; stone & wilson, 2016), we hypothesized that children’s emotion regulation should explain additional variance in children’s fss beyond parental somati­ zation and emotional regulation. we tested our hypotheses in a pilot sample, and then replicated the findings in an independent sample. to evaluate the levels of fss in our studies, we have set them in relation with a previ­ ous study among children/adolescents in the general population (jungmann & witthöft, 2020). compared to the study by jungmann and witthöft (2020), in the present studies the total number of child-reported fss was higher (d = .31/.66). regarding socio-demo­ graphic data, the children in our two studies were on average younger (m = 10.0/13.1 vs. m = 14.2 in jungmann & witthöft, 2020), the gender distribution was comparable (59 – 65% female). there are inconsistent findings on the relationship between fss and age, lieb et al. (2000), for example, describe a steep increase between the ages of 8 and 12, other studies found no relationship between age and fss in children and adolescents (cerutti et al., 2017; dhossche et al., 2001). also, only study 2, but not study 1, found a significant correlation between age and gastrointestinal symptoms. presumably, additional factors or an interaction of factors can better explain the level of fss. since jungmann and witthöft's (2020) study used the same measuring instrument to record fss, situational factors (e.g., holidays), the type of survey (laboratory/at home), and/or parent-child interactions (e.g., parents’ reactions to child’s symptoms) would be conceivable. the latter point could also be in line with the transgenerational model fss and emotion regulation 10 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ (stone & wilson, 2016), which assumes that the parental influence on the perception and expression of body symptoms is greater in younger children. in accordance with the hypothesis and consistently in both studies, significant negative correlations were found between children’s adaptive emotion regulation and child-reported fss. this is also compatible with previous studies on bodily complaints in children and adolescents, whereby the present studies have examined more specifically adaptive emotion regulation in comparison with coping processes (thomsen et al., 2002) and emotion regulation abilities such as empathy and self-awareness (gilleland et al., 2009). as assumed, study 2 also found a negative association between acceptance and child-reported fss, in accordance with the study by thomsen et al. (thomsen et al., 2002) in which acceptance represented a kind of secondary control engagement. possible reasons why study 1 missed the significance level for this association (p = .096) could be the smaller sample, but also, for example, the younger age. possibly, younger children may use this strategy less or have less understanding of what it meant (e.g., "i accept what makes me angry."). in contrast to the study by erkic et al. (2018), which showed a reduced level of the reappraisal strategy in adults with ssd, no significant correlations between children’s reappraisal and child-reported fss were found in both studies. on the one hand, this strategy could be less developed in childhood, which is also shown by the fact that the mean scores for reappraisal were lower than those for acceptance; on the other hand, this correlation could also only become apparent in the pathological manifestation of ssd. as expected and consistent in both studies, positive associations between childhood maladaptive emotional regulation and child-reported fss were also found. only study 1 showed a significant positive correlation with rumination. in study 2, the subscale rumination showed a low internal consistency (α = .46), which could possibly be due to the fact that rumination in terms of the shortened version of the feel-kj was recorded with only two items. in addition, our study also confirmed the positive correlation between alexithymia and child-reported fss (hadji-michael et al., 2019). in comparison to the relationships between the child reports, only a significant asso­ ciation was found between child acceptance and parent-reported fss. this association might indicate that when children show higher acceptance, parents perceive or report less body symptoms of their children. moreover, in line with previous studies (de los reyes et al., 2015), this finding also suggests that the child's and parent's judgements can differ more significantly in the case of personal experiences and internalizing symptoms, and consequently it is relevant (even if the children are younger) to question the children themselves. explaining child-reported fss, children’s emotional regulation consistently showed the highest variance explanation in both studies (14–34%) and explained additional variance in addition to age/gender and parental emotional regulation. especially malad­ aptive emotion regulation was found to be a significant predictor. this suggests the jungmann, wagner, klein, & kaurin 11 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ importance of children’s emotional regulation for children’s fss and confirms findings in adults (erkic et al., 2018). like first approaches in adulthood (kleinstäuber et al., 2019), the promotion of adaptive emotion regulation/reduction of dysfunctional emotion regulation could be a promising approach for the psychotherapeutic treatment of fss in childhood and adolescence. for variance explanation of parent-reported fss, parental emotion regulation (22%), especially parental maladaptive emotion regulation, showed a significant incremental variance explanation in study 1, but when parental somatization was also included in study 2, it was the only significant predictor. thomsen et al. (2002) also found only parental somatization as a significant predictor of father-reported physical complaints in children. this result could indicate that the estimation/perception of childhood fss depends on the parents' own experience of physical complaints, which should also be taken into account, for example, when exploring/treating fss in children. the findings could also be consistent with current interoceptive predictive coding mod­ els of symptom perception (e.g., van den bergh et al., 2017) which assume that the perception and evaluation of body symptoms is influenced by previous experience. this could be the case not only for the perception of one's own body symptoms, but also for those of children. some limitations should be mentioned. the samples of both studies are rather small (especially study 1, see also power analysis) and not representative in terms of sociodemographic data (e.g., parents’ high education, 80–90% mothers). our cross-sectional design does not allow us to draw any causal conclusions; longitudinal studies would also be of interest, e.g., to examine the temporal course of deficits in the emotion regulation of fss and the transgenerational model more closely. the survey conditions (study 1/2: laboratory/online), samples (age), and, in some cases, the measuring instruments differ between study 1 and 2. we cannot exclude the influence of these factors on our results. for example, the partly found divergences of study 1 and study 2 might have resulted from different survey conditions. in study 2, the shortened version of the feel-kj found partially low internal consistencies of the individual strategies, which should be examined in further studies. in this context, it should also be mentioned that some questionnaires for children are not validated in german or for an age below 10/11 years. validation studies are needed here in the future. this could contribute to biases (e.g., too low scores) because the items are still too difficult for younger children (8-10 years). conclusion in summary, our studies indicate that in childhood and adolescence, emotion regulation is related to fss. thus, the promotion of functional emotion regulation/reduction of maladaptive emotion regulation likely represents a promising complementary approach for the treatment of fss in children and adolescents. in predicting parent-reported fss, parental somatization was the only significant predictor. this finding highlights the dependence on the perspective and previous experience with body symptoms of the fss and emotion regulation 12 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ person making the assessment. therefore, the consideration of parental factors is also relevant in the treatment of fss in children. furthermore, it shows the importance of multidimensional approaches, whereby in addition to a multi-informant approach the inclusion of experimental procedures could present a key source of information in future studies (e.g., promoting adaptive emotion regulation in children with fss). funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. twitter accounts: @steffi_jungmann, @m4rleneklein, @aleksakaurin supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below). • appendix a. participant characteristics regarding functional somatic symptoms (fss) and emotion regulation. • appendix b. pearson correlations between fss and emotion regulation. • appendix c. multiple hierarchical regression analyses for predicting child-reported fss in children and adolescents. • appendix d. multiple hierarchical regression analyses for predicting parent-reported fss in children and adolescents. index of supplementary materials jungmann, s. m., wagner, l., klein, m., & kaurin, a. 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(1993). the icd-10 classification of mental and behavioural disorders: diagnostic criteria for research. https://apps.who.int/iris/handle/10665/37108 jungmann, wagner, klein, & kaurin 17 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://doi.org/10.1097/j.pain.0000000000000637 https://doi.org/10.1016/j.jpain.2015.06.009 https://doi.org/10.1093/jpepsy/27.3.215 https://doi.org/10.1016/j.neubiorev.2017.01.015 https://doi.org/10.17169/refubium-16470 https://doi.org/10.1037/0033-295x.96.2.234 https://doi.org/10.1016/s0140-6736(98)08320-2 https://doi.org/10.1093/jpepsy/jst094 https://apps.who.int/iris/handle/10665/37108 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. fss and emotion regulation 18 clinical psychology in europe 2022, vol. 4(2), article e4299 https://doi.org/10.32872/cpe.4299 https://www.psychopen.eu/ fss and emotion regulation (introduction) method participants procedure measures statistical analyses results participant characteristics regarding fss and emotion regulation relationships between fss and emotion regulation regression analyses for predicting fss in children and adolescents discussion conclusion (additional information) funding acknowledgments competing interests twitter accounts supplementary materials references burnout subtypes: psychological characteristics, standardized diagnoses and symptoms course to identify aftercare needs research articles burnout subtypes: psychological characteristics, standardized diagnoses and symptoms course to identify aftercare needs gianandrea pallich 1,2 , martin grosse holtforth 3,4, barbara hochstrasser 1 [1] center for psychiatry and psychotherapy, private hospital meiringen, meiringen, switzerland. [2] department of clinical psychology and psychotherapy, university of zurich, zurich, switzerland. [3] department of clinical psychology & psychotherapy, university of bern, bern, switzerland. [4] psychosomatic medicine, department of neurology, inselspital, bern university hospital, university of bern, bern, switzerland. clinical psychology in europe, 2021, vol. 3(3), article e3819, https://doi.org/10.32872/cpe.3819 received: 2020-06-04 • accepted: 2021-05-09 • published (vor): 2021-09-30 handling editor: martin hautzinger, university of tübingen, tübingen, germany corresponding author: gianandrea pallich, university of zurich, department of psychology, binzmühlestrasse 14, box 1, 8050 zurich, switzerland. e-mail: g.pallich@psychologie.uzh.ch supplementary materials: materials [see index of supplementary materials] abstract background: to better understand individual differences between burnout inpatients and improve individually tailored treatments in a psychiatric hospital, cluster analysis based on a number of self-report measures was used to investigate psychosocial characteristics of 96 participants. method: group membership was analyzed regarding associations with standardized measures of psychiatric and personality disorders. moreover, symptom levels of burnout, depression, and general mental health were used to characterize the groups and to observe differential trajectories at admission, discharge, and follow-up. results: as in previous research, we identified four subtypes that differed in comorbidity, psychological characteristics and treatment outcome. this calls for tailored interventions for the more vulnerable patients. conclusion: the replicated and enriched characterization of burnout inpatients can help to optimally meet the differential needs of burnout patients. keywords depression, burnout, aftercare needs, diagnoses, symptoms, cluster analysis, subtypes this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3819&domain=pdf&date_stamp=2021-09-30 https://orcid.org/0000-0002-0673-4879 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • four burnout subtypes were found: functional, dysfunctional, straightforward pragmatist, and unhappy altruist. • psychosocial characteristics and symptom levels at admission, discharge, and followup were described to better characterize the subtypes. • the replicated and enriched characterization of burnout inpatients improves individually tailored treatments. the importance of burnout the term burnout was introduced to the scientific discussion of psychological ailments in the 1970s by freudenberger as a label of a negative affective state after having been ex­ posed to continued work-related stress experiences (freudenberger, 1974). later, maslach and colleagues (maslach & jackson, 1981) embossed the concept of burnout, recognizing emotional exhaustion, depersonalization, and a reduced sense of personal accomplish­ ment with a sense of a diminished level of performance to be the key dimensions of this phenomenon. criticisms of this definition notwithstanding, the related questionnaire, the maslach burnout inventory (mbi), has become the gold standard in research and literature (burisch, 2014). since then, the phenomenon of burnout has been described in more than 60 different professions and professional subgroups (kaschka, korczak, & broich, 2011), showing a prevalence of burnout varying between 3.5% and 50% (nil et al., 2010). not surprisingly, the conception and improvement of the clinical treatment of burnout inpatients have also become an important research focus (hochstrasser, von bardeleben, ruckstuhl, & soyka, 2008). long-term effects of an inpatient treatment program for burnout due to the heterogeneity and multifactorial etiology of burnout, a multimodal and individual treatment has been shown to be warranted (hochstrasser et al., 2008; schwarzkopf, conrad, straus, porschke, & von, 2016). yet, the majority of studies on burnout interventions have not been performed with clinical samples, but in groups of volunteers who exhibited a level of burnout allowing them to maintain active engage­ ment at work (ahola et al., 2017; awa et al., 2010; van der klink et al., 2001). patients with burnout who need inpatient care are those who are more afflicted, i.e., those who suffer from clinical burnout. despite the importance of an adequate and effective inpatient treatment for burnout, to date, only few studies have examined the shortor long-term effects of inpatient treatment programs for burnout (elkuch et al., 2010; perski et al., 2017; schwarzkopf et al., 2016). a previous study (elkuch et al., 2010) examining a multimodal inpatient treatment at a private psychiatric hospital has found evidence of positive effects. treatment included cognitive-behavioral individual and group psy­ chotherapy, various relaxation techniques, body therapy, physical exercise, and psycho­ burnout subtypes 2 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ pharmacological treatment. however, one limitation of the previous study was that assessments were performed only at admission and at follow-up, but not at discharge. moreover, it has to be considered that the potential long-term effects of the inpatient treatment program and its sustainability may develop in the period between discharge and follow-up. thus, assessing patients at admission, discharge, and at follow-up allows the examination of the short-term effects and the unfolding process of long-term effects more accurately. the expected results promise to yield valuable information serving the ongoing optimization of the future inpatient treatment of burnout. the importance of characterizing patients discharged from inpatient treatment for burnout identifying burnout patients’ subtypes is crucial to tailoring treatment to patient charac­ teristics and thereby improving burnout treatment. at an empirical level, some studies have identified subjects with burnout symptoms as one of several types of respondents in the workforce. schaarschmidt and fischer (2001) used self-report data on personal experiences with work-related stress and typical coping behaviors using the avem questionnaire (work-related behavior and experience patterns; german: arbeitsbezo­ genes verhaltensund erlebensmuster; schaarschmidt & fischer, 1996) to empirically categorize subjects in the workforce. the avem assesses stress experiences and coping behaviors in three domains and 11 subscales of six items each: work commitment, resist­ ance to stress/emotions, and subjective well-being (schaarschmidt & fischer, 2001). the domains and subscales were identified by factor analyses of responses of 1598 subjects of diverse professions, and the avem has been subsequently used in various studies (schulz et al., 2011; voltmer et al., 2007, 2010, 2011). in the original study, schaarschmidt and fischer (2001) empirically identified four types of subjects based on scores in the 11 subscales: healthy (pattern g), unambitious (pattern s), overexertion (risk pattern a), and burnout (risk pattern b). in a recent study based on a sample of 1766 health care employees, leiter and maslach (2016) proposed five empirical profiles emerging from latent profile analyses of their dimensions of burnout (i.e., emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment): burnout (high on all three dimensions), engagement (low on all three), overextended (high on exhaustion only), disengaged (high on cynicism only), and ineffective (high on inefficacy only). at a theoretical level, montero-marin and colleagues (montero-marín et al., 2009) proposed a three-partite classification of burnout patients based on a general proposal by farber (1991): frenetic (involved and ambitious subjects who sacrifice their health and personal lives for their jobs); under-challenged (indifferent and bored workers who fail to find personal development in their job); and worn-out (subjects who feel they have little control over results and that their efforts go unacknowledged). haberthür and colleagues (haberthür et al., 2009) empirically classified burnout inpatients using self-report data on various interpersonal and intrapersonal aspects of functioning, such pallich, grosse holtforth, & hochstrasser 3 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ as social support, interpersonal problems, coping styles, emotion regulation, and motiva­ tional incongruence. the authors identified four groups by cluster analyses: functional, dysfunctional, straightforward pragmatist, and unhappy altruist. for the current study, data were collected in the same private hospital and the same treatment unit as in the haberthür et al. study. to our knowledge, the results of haberthür et al.’s study (haberthür et al., 2009) have not been replicated yet. the study did not assess standardized clinical diagnoses of psychiatric disorders and personality disorders, or comorbid somatic diagnoses, nor did it assess outcome at discharge. the present study attempts to overcome these limitations and to replicate the former empirical classification of burnout inpatients to allow practitioners to tailor individual treatments to improve treatment outcomes. the self-reported person characteristics ex­ amined in haberthür et al.’s study were motivational incongruence (motive satisfaction), interpersonal problems, social support, regulation of emotions, and coping styles. in the current study, the self-report measures used for clustering were the same as those used by haberthür and colleagues, with the addition of as a self-report screening tool for personality dysfunction. refining the clinical assessment methodology, structured interviews for psychiatric diagnosis and personality disorder were conducted. at admis­ sion, discharge, and follow-up, we assessed levels of depression, general symptoms and burnout. aims the aims of this study are: 1. to constructively replicate and improve a previously empirically derived description and categorization of burnout inpatients in an analogous treatment setting according to psychosocial parameters; 2. to characterize the patients and patient groups according to psychiatric diagnostic criteria; 3. to observe how group membership corresponds to different levels of psychological symptoms (depression and burnout) and general mental health at admission, discharge, and follow-up. material and method sample, treatment, and recruitment the present study was approved by the ethics committee of the canton bern (switzer­ land) and was conducted in the private hospital meiringen. the sample comprised 96 inpatients of a specialized burnout ward. the therapeutic program includes individual psychotherapy, group therapy, relaxation techniques, body therapy, massages, sports activities and fitness instructions, psychopharmacotherapy, and selected interventions from complementary medicine (e.g., traditional chinese medicine). a detailed description of the treatment program can be found in hochstrasser et al. (2008). burnout subtypes 4 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ the specialized burnout ward admits only patients being referred by a physician, having a burnout syndrome that arose primarily in the context of the work environment, and with a diagnostically confirmed burnout syndrome at admission evaluated in a clini­ cal interview before admission. in this context, it is important to note that in the icd-10, burnout is not considered to qualify as an independent psychiatric disorder but is listed as a syndrome being associated with difficulties pertaining to life circumstances (i.e., icd-10, z.73.0). an association of burnout with mental disorders, especially depression, has often been described, such that a recent overview on the overlap between depres­ sion and burnout postulated that clinical burnout corresponds to an atypical depression (bianchi et al., 2015). consequently, various comorbid primary psychiatric diagnoses according to icd-10, chapter f, were given on the basis of a clinical interview and in accordance with the patients’ symptomatic presentation at admission. to be included, patients had to be at least 18 years old. patients were excluded if they exhibited current alcohol or drug addictions (if not stopped at admission), inability to participate in the treatment (e.g., due to psychological disorders or dementia), insufficient knowledge of the german language, or acute suicidality or psychotic symptoms. between february 2017 and december 2017, a total of 173 inpatients were asked to participate in the study, a total of 113 inpatients gave their consent, and, due to missing data in cluster-relevant questionnaires, a total of 96 individuals, n = 96, f = 33 (34.4%), m = 63 (65.6%), were included in the analyses. instruments during the first week after admission, participants completed paper-pencil versions of different questionnaires and participated in two clinical interviews (mini-dips and scid-ii) (fydrich et al., 1997; margraf, 2013) administered by the study psychologist. the discharge assessment was done in the last week of their stay, and the follow-up assess­ ment was administered three months after discharge via paper-pencil questionnaires sent by mail with a pre-paid return envelope. as in haberthür et al. (2009), psychological characteristics were measured using the following self-report instruments: first, a short version of the incongruence question­ naire (german: inkongruenzfragebogen, k-ink; grosse holtforth & grawe, 2003) was used to assess the degree of insufficient motivational satisfaction (approach incongru­ ence and avoidance incongruence). the german 32-item short version of the inventory for interpersonal problems was used to assess problematic interpersonal behaviors (iip­ sc; soldz, budman, demby, & merry, 1995; german: grosse holtforth, 2005). the 32 items are an equivalent subset of the german iip (iip-d; horowitz, strauss, & kordy, 2000). to measure the subjective appraisal of received or anticipated social support from persons in the social environment, the german short version of the questionnaire of social support was used (german: fragebogen zur sozialen unterstützung, f-sozu-k-22; fydrich, sommer, & brähler, 2007). to evaluate different ways of coping with stressful pallich, grosse holtforth, & hochstrasser 5 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ situations (task-oriented, emotion-oriented, avoidance-oriented), the german version of the coping inventory for stressful situations (ciss; kälin, 1995) was used. the ques­ tionnaire for the self-evaluation of emotional competency (german: fragebogen zur selbsteinschätzung emotionaler kompetenzen, sek; berking & znoj, 2008) was used to measure deficits and resources in emotion regulation with the following scales: attention, awareness of bodily sensations, clarity, understanding, regulation, acceptance, resilience, self-support, and goal-oriented readiness to confront. the scale scores can be summar­ ized by a total score. as mentioned before, previous studies did not assess personality and personality dysfunctions. to fill this gap, we added the inventory of personality or­ ganization (ipo-16; zimmermann et al., 2013) for clustering purposes. the 16-item short version of the inventory of personality organization (ipo-16) is a self-report measure assessing the severity of personality dysfunction. the level of symptoms and problems were assessed using the beck depression inventory (bdi; hautzinger et al., 1995), a brief version of the symptom checklist scl-90 (scl-9; klaghofer & brähler, 2001) and the maslach burnout inventory – human services survey (mbi-hss; maslach et al., 1997). the bdi is a self-report instrument assessing the degree of depressive symptomatology. the brief version of the symptom checklist assesses the general level of symptoms in one scale (hautzinger et al., 1995). the mbi-hss is considered the gold standard for burnout assessment and measures burnout in three dimensions (emotional exhaustion, depersonalization, and a sense of reduced personal effectiveness) (maslach et al., 1997). data analytical approach / statistical analysis all statistical analyses were performed using the spss program (version 23.0) and jamovi (version 0.8.6.0) (an interface program based on r). in a first step, a hierarchical cluster analysis (ward’s method) was performed to determine the appropriate number of clus­ ters. euclidean distance, which does not weigh outliers as strongly as the quadrated euclidean distance, was used. according to these criteria, a cluster solution of four groups was considered optimal. the following questionnaires and scales were used for clustering: the incongruence questionnaire (k-ink; approach and avoidance incongruence), the inventory for inter­ personal problems (iip-sc/iip-d; dominance and affiliation dimensions), the question­ naire of social support (f-sozu-k-22; general score), the self-report measure for the assessment of emotion regulation skills (sek; general score); the coping inventory for stressful situations (ciss; task-oriented coping, emotion-oriented coping, avoidance-ori­ ented coping) and the inventory of personality organization (ipo-16; general score). the number of clusters, i.e., four, corresponds to the number of clusters proposed by elkuch et al. (2010). on the basis of the solutions suggested by the hierarchical cluster analysis, we further calculated confirmatory k-means cluster analyses for four cluster solutions. to exclude bias resulting from differing scaling of the various variables, all burnout subtypes 6 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ cluster analyses were performed using z-standardized values. consequently, the values of the resulting groups were z-standardized and are presented as norm-related z-standar­ dized values (see figure 1). descriptive statistics were used to describe the frequencies of different clinical diagnoses and personality disorder diagnoses (see table 1). figure 1 z-standardized levels of psychological characteristics used for the formation of the four groups and duration of hospital stay (no grouping characteristic) bdi, scl-9, and mbi-hss were used to further characterize the groups (but not as factors to identify the groups) and to observe longitudinal development of symptoms. to evaluate differences in symptom levels among the resulting groups, we calculated a repeated measure analysis of variance (anova) (see figure 2). results sample description a total of 96 patients were included in the analyses. the mean age at admission was 48.02 years (sd = 8.78; 27.44 – 62.79 years). 33 (34.4%) of the participants were female, 63 (65.6%) were male. 50 married, 14 divorced, 25 singles, 3 separated, 1 widowed, and 1 unknown. the mean duration of the hospital stay was 57.31 days (sd = 16.04; 9 – 94 days). all the participants received medication during clinical stay. the duration between the time of discharge from the hospital and the follow-up assessment was 3 months. at follow-up, 14.6% participants were unemployed, 10.4% were fully employed, 33.3% were working part-time, 2.1% were working in their own household, 1.0% was in training for a different job, 3.1% were in a rehabilitation program, 6.3% were receiving a pension (i.e. an amount of money paid regularly by a government or company to somebody who has retired from work) or a disability pension (i.e. a form of pension given to those people who are permanently or temporarily unable to work due to a disability), and the employment status of 29.1% was unknown. in comparison to before the impatient stay, 6.3% were unemployed, 49.0% were fully employed, 20.8% were working part-time, pallich, grosse holtforth, & hochstrasser 7 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ table 1 main psychiatric diagnoses, presence of an additional psychiatric diagnosis, presence of an additional somatic diagnosis, and personality disorders for the four groups at admission total sample functionals dysfunctionals straightforward pragmatists unhappy altruists main psychiatric diagnoses (mini-dips) f31.x (bipolar disorder) 5.21% (n = 5) 5.88% (n = 1) 15.79% (n = 3) 0.00% (n = 0) 2.70% (n = 1) f32.x (major depressive disorder, single episode) 34.37% (n = 33) 17.65% (n = 3) 15.79% (n = 3) 43.48% (n = 10) 45.95% (n = 17) f33.x (major depressive disorder, recurrent) 46.87% (n = 45) 47.05% (n = 8) 57.90% (n = 11) 39.13% (n = 9) 45.95% (n = 17) f43.x (reaction to severe stress, and adjustment disorders) 6.25% (n = 6) 11.76% (n = 2) 5.26% (n = 1) 13.04% (n = 3) 0.00% (n = 0) missing 7.29% (n = 7) 17.65% (n = 3) 5.26% (n = 1) 4.35% (n = 1) 5.40% (n = 2) presence of comorbid psychiatric diagnoses (mini-dips) 33.33% (n = 32) 23.52% (n = 4) 42.08% (n = 8) 24.21% (n = 6) 37.80% (n = 14) presence of comorbid somatic diagnoses 33.33% (n = 32) 35.28% (n = 6) 31.56% (n = 6) 21.75% (n = 5) 40.50% (n = 15) avoidant personality disorder (pd) & obsessivecompulsive pd (possibly comorbid with additional pd) 6.25% (n = 6) 0.00% (n = 0) 21.05% (n = 4) 4.35% (n = 1) 1.70% (n = 1) avoidant pd (possibly comorbid with additional pd) 4.17% (n = 4) 5.88% (n = 1) 5.26% (n = 1) 0.00% (n = 0) 5.41% (n = 2) obsessive-compulsive pd (possibly comorbid with an additional pd) 23.96% (n = 23) 5.88% (n = 1) 21.05% (n = 4) 34.78% (n = 8) 27% (n = 10) other pd 5.21% (n = 5) 5.88% (n = 1) 10.52% (n = 2) 4.35% (n = 1) 1.70% (n = 1) no pd 60.42 (n = 58) 82.35% (n = 14) 42.11% (n = 8) 56.52% (n = 13) 62.16% (n = 23) burnout subtypes 8 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ 1.0% was working in their own household, none was in training, in a rehabilitation program, or receiving a pension / disability pension, and the employment status of 22.9% participants was unknown. psychosocial characteristics generally, the group labels are intended to be maximally comprehensive summaries of the respective characteristics. with the current sample and measures, we found that the obtained clusters corresponded closely to the previous grouping by haberthür et al. (2009), so that we decided to keep the previous labels: (a) functional, (b) dysfunctional, (c) straightforward pragmatist, and (d) unhappy altruist. functionals participants categorized in this group, n = 17, f = 3 (17.6%), m = 14 (82.4%), experienced little avoidance incongruence (z = -1.43) and approach incongruence (z = -1.36). the figure 2 repeated anovas for the four groups (functionals, dysfunctionals, straightforward pragmatists and unhappy altruists) at intake, discharge and follow-up for bdi and scl and at intake and follow-up for the three dimensions of mbi (emotional exhaustion, depersonalization and sense of reduced personal effectiveness) pallich, grosse holtforth, & hochstrasser 9 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ patients mentioned few interpersonal problems (z = -1.32) and having good social sup­ port (z = 0.43). in addition, they reported good emotional competences (z = 1.13). the functionals group used many task-oriented (z = 0.87) but just a few emotion-oriented (z = -1.45) coping strategies. they reported having little personality dysfunctions (z = -1.10). in general, they had a shorter stay in the hospital (z = -1.35). most of the participant in the group of functionals had an f33.x (i.e., major depres­ sive disorder, recurrent) diagnosis (n = 8, 47.05%), three (17.65%) had an f32.x (i.e., major depressive disorder, single episode) diagnoses, two (11.76%) an f43.x (i.e., reaction to severe stress, and adjustment disorders diagnoses) and one (5.88%) an f31.x (i.e., bipolar disorder) diagnoses. a total of four (23.52%) had a secondary psychiatric diagnosis (e.g., f10.1, f40.2, f41.0, f42.2). six participants (35.29%) of this group additionally had one or more somatic diagnoses (e.g., e78.0, g44.0, g44.2, h95.1, i10.90, i10.91, r05, r73.1, z61, z62, z73). for three participants it was not possible to use the mini-dips for assessing standardized diagnoses. most of the participants categorized in the group of the functionals showed no personality disorder (82.35%, n = 14). dysfunctionals compared to the other three groups, participants categorized in the group of dysfunc­ tionals, n = 19, f = 7 (36.8%), m = 12 (63.2%), showed the highest average approach incongruence (z = 0.87) as well as avoidance incongruence (z = 0.91). they showed strong interpersonal problems (z = 1.07). additionally, they reported least social support (z = -1.17), generally insufficient emotional competence (z = -0.43) and mainly emotional coping (z = 0.80) and little task-oriented (z = -1.19) and avoidance-oriented (z = -1.08) coping strategies. in addition, they reported many personality dysfunctions (z = 1.32). in general, they had a longer stay in the hospital (z = 1.06). most of the participants in this group had an f33.x diagnosis (n = 11, 57.90%), three (15.79%) had an f32.x diagnosis, three (15.79%) an f31.x diagnosis and one (5.26%) an f43.x diagnosis. a total of eight (42.12%) had a secondary psychiatric diagnosis (e.g., f13.2, f40.2, f41.0, f41.1, f42.1, f43.1, f50.5). six participants (31.59%) of this group additionally had one or more somatic diagnoses (e.g., a49.8, e03.9, e14.91, e78.5, g40.9, g43.9, g47.0, g47.39, i10.9, j45.0, m54.4, n48.0). one participant was not diagnosed systematically with mini-dips. the dysfunctionals showed the highest association with a combination of avoidant and obsessive-compulsive personality disorders (21.05%, n = 4), and a high percentage had an obsessive-compulsive personality disorder (21.05%, n = 4) or other personality disorders (10.52%, n = 2). burnout subtypes 10 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ straightforward pragmatists on average, this group, n = 23, f = 13 (56.5%), m = 10 (43.5%), showed more avoidance incongruence (z = 0.25) than approach incongruence (z = -0.13). generally, they reported a low level of interpersonal problems (z = -0.06). this group reported having good social support (z = 1.14). they generally had good emotional competences (z = 0.45). they reported using emotional coping (z = 0.46) and task-oriented coping (z = 0.78) at similar levels. this group showed average personality dysfunction (z = 0.00). the hospital stay was a little higher than average (z = 0.18). most of the participants in this group had an f32.x diagnosis (n = 10, 43.48%), nine (39.13%) had an f33.x diagnosis, three (13.04%) an f31.x diagnosis and none (0.00%) an f41.x diagnosis. a total of six (26.09%) had a secondary psychiatric diagnosis (e.g., f40.0, f40.2, f41.0, f44.4, f50.3). five participants (21.74%) of this group additionally had one or more somatic diagnoses (e.g., e66.99, g35.9, g43.9, g47.31, h93.1, i10.90, i49.8). for one participant it was not possible to use the mini-dips for assessing standardized diagnoses. the group of the straightforward pragmatists showed the highest prevalence of obsessive-compulsive personality disorder compared to the other groups. unhappy altruists the members of this group, n = 37, f = 10 (27.0%), m = 27 (73.0%), showed higher average approach incongruence (z = 0.62) than avoidance incongruence (z = 0.27). overall, they tended to show above-average scores in interpersonal problems (z = 0.31). additionally, they reported bad social support (z = -0.40). furthermore, this group showed an emotion­ al competence below the average (z = -1.16). the members of this group primarily used emotion-oriented coping strategies (z = 0.19) and few task-oriented coping strategies (z = -0.46). this group showed little personality dysfunction (z = 0.22). the hospital stay was a little longer than average (z = 0.10). seventeen participants (45.95%) of this group had an f32.x diagnosis. seventeen participants 45.95%) had an f33.x diagnosis, and one participant (2.70%) had an f31.x diagnosis. no participants were diagnosed with f43.x in this group. a total of fourteen patients in this group (37.83%) had a secondary psychiatric diagnosis (e.g., f10.1, f13.2, f40.1, f40.2, f41.0, f44.2, f61.0). fifteen participants (40.54%) had one or more somatic diagnoses in addition (e.g., d17.3, e11.90, e78.0, g25.0, g25.81, g43.0, g43.9, g47.1, g47.31, h93.1, h93.3, i10.90, k91.1, m17.9, m19.91, m53.0). for two participants it was not possible to use the mini-dips for assessing standardized diagnoses. the group of the unhappy altruists, similar to the group of the straightforward pragmatists, showed a higher percentage of obsessive-compulsive personality disorder compared to the other groups. pallich, grosse holtforth, & hochstrasser 11 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ symptom course in groups of burnout patients data were analyzed using repeated measures anovas for depression, general symp­ toms, and burnout with a within-subjects factor (admission, discharge, follow-up) and a between-subject factor of subtypes (functional, dysfunctional, straightforward pragma­ tist, and unhappy altruist). for missing values, list-wise deletion of cases was applied. for the three mbi dimensions, there were just two measured time points (admission and follow-up). only for the repeated measures anova for depression, the mauchly’s test indicated that the assumption of sphericity had been violated, therefore degrees of freedom were corrected using greenhouse-geisser estimates of sphericity (ε = 0.876). for the interested reader we report mean, median, standard deviation and range for bdi, scl and mbi for the four groups (i.e. functional, dysfunctional, straightforward pragmatist and unhappy altruist) in the supplementary material depression (beck depression inventory, bdi) a repeated measures anova (see figure 2) with a greenhouse-geisser correction showed that mean depression scores differed significantly between time points, f(1.75, 127.86) = 117.55, p < .001, ηp2 = .617, and between groups, f(3, 73) = 4.46, p < .01, ηp2 = .158. the interaction between time and groups was also significant, f(5.25, 127.86) = 2.51, p < .05, ηp2 = .093. post hoc tests revealed that the depression scores for the functionals group was the lowest and differed highly significantly from those of all other groups regarding (p < .001). for the remaining groups, depressive symptoms were higher at admission, all at similar and non-significantly different levels. at discharge, levels of depressive symptoms did not differ significantly between the four groups. however, at follow-up, the average depression levels of the functional and dysfunctional groups differed significantly (p < .05), and also a significant difference between functionals and unhappy altruists (p < .05) was found. all patient groups showed a significant decrease of depressive symptoms from admission to discharge (p < .05). whereas functionals, straightforward pragmatists, and unhappy altruists reported no significant increase of depressive symptoms between discharge and follow-up, the dysfunctionals showed a significant increase of depressive symptoms (p < .05). general symptoms (brief symptom checklist, scl) a repeated measures anova (see figure 2) showed that the mean general symptoms scores differed significantly between time points, f(2, 154) = 53.23, p < .001, ηp2 = .409, and between groups, f(3, 77) = 7.24, p < .001, ηp2 = .220. the interaction between time and groups was also significant, f(6, 154) = 2.60, p < .05, ηp2 = .092. the functionals had the lowest symptom level, and the dysfunctionals the highest at admission, discharge, and follow-up. straightforward pragmatists and unhappy altruists showed similar levels of general symptoms, with levels being lower than those of dysfunctionals but higher compared to the functional group at all three measurement points. post hoc tests burnout subtypes 12 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ revealed that at admission, the functionals differed highly significantly regarding the general symptoms from the dysfunctional and straightforward pragmatists (p < .01) and significantly from the unhappy altruists (p < .05). the group of dysfunctionals differed highly significantly from the group of unhappy altruists (p < .01) and significantly from the group of straightforward pragmatists (p < .05). regarding general symptoms at discharge, no significant differences could be found between the four groups. at follow-up dysfunctionals differed from all other groups (p < .05). all groups showed a significant decrease of symptoms between admission and discharge (p < .05). whereas dysfunctionals and straightforward pragmatists showed significant increases of symp­ toms between discharge and follow-up (p < .05), this was not the case for the functionals and the unhappy altruists. burnout (maslach burnout inventory, mbi) a repeated measures anova for the dimension of emotional exhaustion showed a sig­ nificant difference between admission and follow-up, f(1, 71) = 56.87, p < .001, ηp2 = .445, and between groups, f(3, 71) = 3.10, p < .05, ηp2 = .116. the interaction between time and groups was not significant. post hoc tests revealed that regarding emotional exhaustion, all groups showed a significant (p < .01) decrease between admission and follow-up. functionals and dysfunctionals showed a significantly different level of emotional ex­ haustion at admission (p < .01). a second repeated measures anova for mbi for the dimension of depersonalization showed a significant difference between admission and follow-up, f(1, 71) = 11.83, p < .001, ηp2 = .143, and between groups, f(3, 71) = 4.54, p < .01, ηp2 = .161. the interaction between time and groups was not significant. post hoc tests showed that functionals dif­ fered from dysfunctionals and unhappy altruists significantly concerning depersonali­ zation at admission (p < .05). additionally, dysfunctionals differend from straightforward pragmatists (p < .05). dysfunctionals’ and unhappy altruists’ level of depersonalization decreased significantly (p < .05) between admission and follow-up. a last repeated measures anova for the third mbi dimension, the sense of reduced personal effectiveness, showed a significant difference between admission and follow-up, f(1, 71) = 4.61, p < .05, ηp2 = .061, and no significant difference between groups. the interaction between time and groups was not significant. in a post hoc analysis, unhappy altruists reported, as the only group, a significant (p < .05) improvement in the sense of reduced personal effectiveness. discussion in the present study, we set out to reproduce the results and improve the previous descriptions of burnout inpatients of haberthür and colleagues (2009). first, a cluster analysis was used to group burnout patients. second, we characterized the burnout pallich, grosse holtforth, & hochstrasser 13 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ patients according to psychosocial parameters. additionally, the groups were described regarding their residual symptoms at admission, discharge, and follow-up. finally, we described the psychiatric, somatic, and personality disorder diagnoses of the sample. four groups were identified based on clustering (i.e., functional, dysfunctional, straight­ forward pragmatist, and unhappy altruist). the functional group was characterized by low levels of motivational incongru­ ence, interpersonal problems, emotion-oriented coping, and personality dysfunction and showed good social support, emotional regulation, and mainly task-oriented and avoid­ ance-oriented coping. the members of the dysfunctional group had an almost reversed profile showing high levels for incongruence, interpersonal problems, emotion-oriented coping, and personality dysfunction in addition to low social support, emotional reg­ ulation, taskand avoidance-oriented coping. the other two groups (straightforward pragmatists and unhappy altruists) did not show characteristically extreme values in the above-mentioned variables. straightforward pragmatists reported good social support, emotional competences, and using all three coping strategies. unhappy altruists repor­ ted levels of incongruence and interpersonal problems a little above average, low social support, and emotional competences as well as stronger use of emotion-oriented than task-oriented or avoidance-oriented coping strategies. all psychosocial characteristics of the functional group could be reproduced without exception as described by haberthür and colleagues (2009). the group of the dysfunc­ tionals had similar psychosocial parameters as found in the previous study, with the exception of task-oriented coping that was found to be low instead of average. for the other groups (i.e., straightforward pragmatists and unhappy altruists), we found similar psychosocial parameters as in the previous study. only the emotional competence of the straightforward pragmatists was found to be high and not average, and reported levels of emotional competence and social support of the unhappy altruists were found to be low instead of average. above and beyond replicating the description by psychosocial parameters, also psy­ chiatric, somatic, and personality disorder diagnoses were assessed for the four subtypes of burnout patients. the standardized assessment of psychiatric diagnoses showed most of the participants of the groups of functionals and dysfunctionals having a recurrent major depressive disorder. furthermore, most of the participants in the group of the straightforward pragmatists had a single major depressive disorder. finally, the partic­ ipants of the group of the unhappy altruists had the same frequency of recurrent major depressive disorder and single major depressive disorder. interestingly, all groups showed some comorbidity of somatic diagnoses. around one third of the functionals and dysfunctionals had, in addition to psychiatric diagnoses, also a somatic diagnosis, whereas around one quarter of the group of the straightforward pragmatists had a somatic diagnosis. finally, 40.50% of the unhappy altruists had a diagnosis of a somatic disorder. burnout subtypes 14 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ in previous studies, a high level of overlap between burnout and depression sympto­ matology was found in all groups of burnout patients, to the point that it has been suggested that clinical burnout may rather be a form of depression (bianchi et al., 2015). the dgppn (berger et al., 2012) proposed to consider depression as a common consequence of prolonged burnout. yet, the temporal relationship between burnout and depression remains unclear (ahola & hakanen, 2007). in order to require inpatient care, burnout patients are likely to be more strongly affected and more impaired regarding daily functioning, which might bias the sample we examined towards those with a depressive disorder or other mental disorders. functionals showed almost no personality disorders, dysfunctionals had a higher prevalence of personality disorders (especially avoidant pd in combination with obses­ sive-compulsive pd and obsessive-compulsive pd), and both straightforward pragma­ tists and unhappy altruists showed a high prevalence of obsessive-compulsive pd. the results of the ipo-16, assessing the severity of personality dysfunction, seem to confirm these findings, indicating similar personality dysfunctions as found through scid-ii for the four groups (very low for functionals, very high for dysfunctionals, average for straightforward pragmatists, and low for unhappy altruists). these findings could be relevant for planning tailored treatments for burnout patients considering that treatment of personality disorder is a major goal of psychotherapy interventions for all groups except the functionals. symptom level at admission, discharge, and follow-up was assessed for the four groups using the bdi, the scl, and the mbi. generally, all four groups improved signif­ icantly between admission and discharge regarding depressive symptoms and overall symptom level. dysfunctionals showed an increase of depressive symptoms between discharge and follow-up. dysfunctionals and straightforward pragmatists showed a sig­ nificant increase of general symptoms between discharge and follow-up. this worsening should be considered for discharge planning for the group of straightforward pragma­ tists and even more so for the dysfunctionals. particularly for dysfunctionals, increased attention to discharge planning and more intensive support after leaving the clinic seems indicated. practical implications this study suggests that it is of great importance to attend to the relevant psychological characteristics of burnout patients, and that applying our categorization early in the process could improve the success of treatment and discharge planning. this may be done by clinical judgment or, if available, also by using structured assessment tools. de­ pending on burnout group membership, the needs of inpatients are likely to be different. as indicated by group label, functionals generally show more benign characteristics and are more likely to improve during the inpatient treatment, an effect that appears sus­ tained during follow-up. under the perspective of optimal resource allocation, frequent pallich, grosse holtforth, & hochstrasser 15 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ monitoring of patients’ mental health might suffice to meet their needs for care after discharge. in contrast, our data suggest that the group of dysfunctionals may need the most in­ tensive inpatient treatment and well-organized psychosocial aftercare. our data suggest that increasing the level of a patient’s motivational satisfaction needs to be an important treatment goal, and the identification of the individual sources of motivational incongru­ ence will help to select targeted interventions. also, due to strong interpersonal prob­ lems, lower levels of perceived social support, and insufficient emotional competence, assertiveness training (rakos, 1991), activation of the patient’s social network (perry & pescosolido, 2015; pescosolido & levy, 2002; smith & christakis, 2008), as well as training of emotional skills (berking, 2015; cherniss, 2000; pallich et al., 2020) might be suitable interventions. the enhancement of a task-oriented coping style and related skills may be an important target for longer-term treatment of this group. whereas straightforward pragmatists showed rather unproblematic profiles at admis­ sion with regard to psychological characteristics, they showed significant increases of symptoms between discharge and follow-up. for this reason, assessment during inpatient treatment should exceed patient self-reports to not miss relevant stressors that patients might not be able or willing to report. in addition, the formulation of crisis-response plans may be indicated, as well as close symptom monitoring after discharge. finally, also unhappy altruists, who show interpersonal problems above the average, bad social support, and emotional competence below the average, could profit from as­ sertiveness training (rakos, 1991) and a training of emotional competence (berking, 2015; cherniss, 2000; pallich et al., 2020). this group, who showed higher levels of approach incongruence and avoidance incongruence, indicating dissatisfaction of motives, should be analyzed more deeply during treatment. targeted interventions may be selected after recognizing individual sources of motivational incongruence to increase the level of patients` motivational satisfaction. finally, especially for the group of unhappy altruists, who show the highest rate of comorbid somatic diagnoses, it is suggested to consider specific interventions and treatment for somatic problems. additionally, an assessment of personality disorders (fydrich et al., 1997) seems indi­ cated particularly for straightforward pragmatists and unhappy altruists, who generally show a high percentage of comorbidity with personality disorder diagnoses. during the inpatient stay and after discharge, a long-lasting psychotherapeutic treatment with a focus on personality disorder should be implemented (sachse, 2013). especially strategies for avoidant and obsessive-compulsive personality disorders could play an important role (sachse, 2013). the present findings should be considered in light of some methodological limita­ tions. first, the sample was relatively small and recruited in only one clinic, and sample sizes of the groups resulting from cluster analysis differed considerably (n = 17 to n = 37). second, because of the heuristic nature of this study, we omitted corrections of burnout subtypes 16 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ the significance levels for multiple testing (e.g., bonferroni). additionally, the intervals between assessments were different across the sample as the length of inpatient stay varied. this may have affected symptom scores at discharge and follow-up. furthermore, follow-up data were collected only three months after discharge and the patient sample consists of patients of an inpatient ward of one psychiatric hospital in one country and is therefore not representative for the population of burnout patients. future research should replicate the classification of former patients in different, larger, and more diverse samples. an additional follow-up later in time could be more informative regarding relapse and promote the development of tailored interventions for the different groups. following up inpatients months or even years after discharge could provide further information about potential difficulties patients may encounter in the long run regarding the course of symptoms and especially relapse risk for different groups. additionally, different and tailored intervention programs for acute treatment and maintenance care for the different burnout types should be developed and tested. those programs should focus on the individual needs and the tailored therapeutic interventions of the different groups, as mentioned above. we assume that observing such a differentiated treatment approach will increase the probability of an effective and long-lasting successful treatment outcome. further long-term data collection will allow evaluating the effects of more tailored programs on the basis of assessed burnout subtypes in service of further optimizing the acute treatment and aftercare of burnout patients. the development of tailored treatment programs for the different subtypes of burnout patients and their long-term evaluation will be an important next step to optimize the acute treatment and aftercare of burnout patients. conclusion to the best of our knowledge, this is the first study to constructively replicate and improve the attempt to categorize burnout inpatients of haberthür and colleagues (2009). overall, we were able to replicate and improve the characterization of the four different groups: functional, dysfunctional, straightforward pragmatist, and unhappy altruist. additionally, we described psychiatric, somatic, and personality disorder diagnoses. we further showed the symptoms course in the four groups of burnout patients. these findings support the proposition that burnout is a heterogeneous phenomenon. for clini­ cians it is necessary to consider these different characteristics of burnout inpatients in order to assure an individually tailored treatment program and corresponding discharge and aftercare planning. future research should focus on tailored treatment programs depending on different subtypes of burnout patients. pallich, grosse holtforth, & hochstrasser 17 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ funding: the project was funded by the private hospital meiringen. the private hospital meiringen was not involved in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. acknowledgments: we thank dr. roberto la marca from the university of zürich who provided expertise that greatly assisted the research, julia ricciardi for her support in the data collection, petra wehrli for her supervised support in data entry and analyses, and the participating patients for their cooperation. competing interests: gianandrea pallich and barbara hochstrasser worked at the burnout ward of the private hospital meiringen. martin grosse holtforth declares that he has no conflict of interest. supplementary materials in the supplementary materials we report mean, median, standard deviation and range for bdi, scl and mbi for the four groups (i.e. functional, dysfunctional, straightforward pragmatist and unhappy altruist) (for access see index of supplementary materials below). index of supplementary materials pallich, g., grosse holtforth, m., & hochstrasser, b. 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(2013). validierung einer deutschsprachigen 16-item-version des inventars der persönlichkeitsorganisation (ipo-16). diagnostica, 59(1), 3-16. https://doi.org/10.1026/0012-1924/a000076 pallich, grosse holtforth, & hochstrasser 21 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://doi.org/10.1111/j.1365-2850.2011.01691.x https://doi.org/10.1024/1661-8157/a002301 https://doi.org/10.1146/annurev.soc.34.040507.134601 https://doi.org/10.1177/1073191195002001006 https://doi.org/10.2105/ajph.91.2.270 https://doi.org/10.4414/smw.2007.11834 https://doi.org/10.1007/s00420-011-0632-9 https://doi.org/10.1026/0012-1924/a000076 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. burnout subtypes 22 clinical psychology in europe 2021, vol. 3(3), article e3819 https://doi.org/10.32872/cpe.3819 https://www.psychopen.eu/ burnout subtypes (introduction) the importance of burnout long-term effects of an inpatient treatment program for burnout the importance of characterizing patients discharged from inpatient treatment for burnout aims material and method sample, treatment, and recruitment instruments data analytical approach / statistical analysis results sample description psychosocial characteristics symptom course in groups of burnout patients discussion practical implications conclusion (additional information) funding acknowledgments competing interests supplementary materials references anxiety and depression in cardiac inherited disease: prevalence and association with clinical and psychosocial factors research article anxiety and depression in cardiac inherited disease: prevalence and association with clinical and psychosocial factors claire e. o’donovan a, jonathan r. skinner bc, elizabeth broadbent a [a] department of psychological medicine, university of auckland, auckland, new zealand. [b] green lane paediatric and congenital cardiac services, starship children’s hospital, auckland, new zealand. [c] department of paediatrics child and youth health, university of auckland, auckland, new zealand. clinical psychology in europe, 2019, vol. 1(4), article e38062, https://doi.org/10.32872/cpe.v1i4.38062 received: 2019-07-08 • accepted: 2019-10-28 • published (vor): 2019-12-17 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: elizabeth broadbent, department of psychological medicine, university of auckland, private bag 92019, auckland 1142, new zealand. e-mail: e.broadbent@auckland.ac.nz abstract background: the small number of published studies indicate increased rates of anxiety and depression among patients with cardiac inherited diseases (cid). this study aimed to assess the prevalence of anxiety and depression in a new zealand cid cohort and seek any associations with clinical and psychosocial factors. method: patients on a national cid register were sent a survey; 202 of 563 contactable patients participated (36% response rate). ages ranged from 16 to 83 years (median 53). most had long qt syndrome (43%) or hypertrophic cardiomyopathy (34%). questionnaires collected demographic and psychological variables, including anxiety (gad-7), depression (phq-9), illness perceptions, perceived risk and social support. the registry supplied clinical and genetic characteristics. results: 80 participants (42%) reported features of anxiety and/or depression. 24 (13%) reached clinical levels of depression, a greater proportion than that found in the general population. poorer perceived social support was associated with worse anxiety (p < .001) and depression (p < .001) scores. reporting more physical symptoms (p = .001) (commonly not caused by the cid) was associated with poorer depression scores and greater perceived consequences of the cid was associated with greater anxiety scores (p < .05). neither anxiety nor depression were associated with time since diagnosis, disease severity or type of disease. conclusion: forty percent of the cid population live with some degree of psychopathology but this did not correlate with disease severity, type of disease nor time since diagnosis. correlating factors which may be modifiable include illness perceptions, various physical symptoms and social support. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i4.38062&domain=pdf&date_stamp=2019-12-17 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords generalized anxiety, depression, cardiac inherited diseases, long qt syndrome, hypertrophic cardiomyopathy, health psychology highlights • rates of clinical levels of anxiety and depression in this cid sample were 10% and 13% respectively. • anxiety and depression were not associated with disease type, severity or time since diagnosis. • perceived lack of support, consequences, and symptoms were associated with depression and anxiety. • high rates of anxiety and depression in cid’s indicate the need for access to psychological support. cardiac inherited diseases are a group of genetic heart conditions that account for many sudden cardiac deaths in individuals aged 1 to 35 years (bagnall et al., 2016). these condi‐ tions generally fall into two categories, channelopathies, which affect the electrical pro‐ cesses of the heart, e.g. long qt syndrome (lqts); and cardiomyopathies which cause the heart muscle to become dysfunctional and electrically unstable e.g. hypertrophic cardiomyopathy (hcm). the last decade has seen a dramatic rise in the detection of peo‐ ple with cardiac inherited diseases, which is the result of effective international efforts to reduce sudden deaths in young people (bagnall et al., 2016; behr et al., 2008; hofman et al., 2013). however the psychological impact of such detection has been under researched and is only just starting to be explored. the few studies performed to date suggest these individuals are particularly vulnerable to anxiety and depression, with prevalence rates found to be as high as 38% and 21% respectively (ingles, sarina, kasparian, & semsarian, 2013; morgan, o'donoghue, mckenna, & schmidt, 2008; richardson et al., 2018). these rates are considerably higher than the prevalence of anxiety (6 – 9%) and depressive dis‐ orders (5 8%) in general populations (alonso et al., 2004; kessler, chiu, demler, & walters, 2005; wells et al., 2006). however, the rates are in line with clinical levels of anxiety (20-25%) and depression (20-40%) in other cardiac populations (celano & huffman, 2011; moser, 2007). cardiac inherited disease patients have shed some light on why this may be in two qualitative studies (andersen, øyen, bjorvatn, & gjengedal, 2008; subasic, 2013). patients report that they struggle with the uncertainty of the trajectory of their disease; their in‐ creased risk of sudden cardiac arrest; and identifying whether their symptoms are normal or sinister. patients report a physical burden associated with living with these conditions, including symptoms such as extreme fatigue, palpitations and headaches, and side effects from treatment, which can in some instances get in the way of fulfilling roles at home and/or work or engaging with their social network. anxiety and depression in cid 2 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ greater clinical severity and uncertainty of risk may therefore be associated with psy‐ chological outcomes. however, research on other hereditary heart diseases has found that disease severity is not the only predictor of psychological well-being (o’donovan, painter, lowe, robinson, & broadbent, 2016). physical symptoms (including those unrela‐ ted to the heart condition) and illness perceptions also contribute to psychological wellbeing. it is well accepted that anxiety and depression have a negative influence on patient engagement and clinical outcomes (andrássy et al., 2007; dimatteo, lepper, & croghan, 2000; ziegelstein et al., 2000). disengagement is particularly unhelpful with cardiac in‐ herited disease because it could impede the detection and management of the heart con‐ dition in other family members, and nonadherence can be life-threatening. therefore it is imperative to gain a better understanding of the psychological impact of these condi‐ tions. the aim of this study was to assess rates of anxiety and depression in the new zea‐ land cardiac inherited disease population and determine which clinical, demographic and psychological factors were associated with anxiety and depression. this study intention‐ ally focused on factors that may be amenable to amelioration, including illness percep‐ tions and social support, as these factors might help to inform the delivery of psychologi‐ cal interventions for this group (broadbent, ellis, thomas, gamble, & petrie, 2009). methods study design and study population the new zealand cardiac inherited diseases register was used to recruit participants (earle et al., 2019). eligible patients had a ‘definitely’ or ‘probably’ affected clinical status and a genetic status of ‘positive’, ‘uninformative testing’ or ‘unclassified variant’. over 15 years of age and proficiency in english were also required. multi-regional ethical appro‐ val was given 9th december 2016 (hdec ethics ref: 16/sth/200) there were 618 individuals who were identified as eligible; invitations were sent to them in may 2017. however, 55 of these eligible patients were non-contactable due to out of date contact details. a total of 202/563 contacted individuals returned questionnaires within three months (36% response rate); 361 patients did not participate ‘non-partici‐ pants’. demographic information for participants is shown in table 1. the questionnaire collected data on anxiety and depression and a number of other psychological and clini‐ cal variables, as follows. o’donovan, skinner, & broadbent 3 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ table 1 demographic and clinical variables of cardiac inherited disease participants characteristic n (%) demographic characteristics age: range (median) 16 83 (53) sex: female 103 (54.2) ethnicity nz european 151 (74.8) māori & pacific 21 (10.4) māori 19 (9.4) samoan 0 (0) cook island maori 1 (0.5) tongan 1 (0.5) other 16 (7.9) chinese 3 (1.5) indian 4 (2.1) other 9 (4.5) clinical characteristics inherited cardiac condition long qt syndrome 86 (42.6) hypertrophic cardiomyopathy 69 (34.2) dilated cardiomyopathy 12 (5.9) brugada 6 (3.0) other 21 (8.5) arvc 5 (2.5) cpvt 6 (3.0) sudden cardiac arrest syndrome 3 (1.5) progressive cardiac conduction disorder 3 (1.5) diagnosis missing 12 (5.8) clinic status definitely affected 145 (71.8) probably affected 42 (21.8) genetic status positive 110 (54.5) testing uninformative 57 (28.2) unclassified variant 20 (9.9) anxiety and depression in cid 4 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ characteristic n (%) proband true 121 (59.9) false 66 (32.7) β-blocker use 131 (64.9) number of years since diagnosis: range (median) 0 – 51 (9) note. participants n = 202. measures depression was assessed using the patient health questionnaire – 9 (phq-9) (kroenke, spitzer, & williams, 2001). this tool has 9 items that measure how often, in the last two weeks, symptoms of depression have occurred. responses are recorded on a 4-point scale from 0 – “not at all” to 3 – “nearly every day”. the phq-9 has been validated against clinical interviews with the following cut-off scores, 5 – 9 ‘mild cases’; 10 – 14 ‘moderate cases’; 15 – 19 ‘moderately severe cases’; and ≥20 ‘severe cases’ (kroenke et al., 2001). anxiety was measured using the generalized anxiety disorder – 7 (gad-7) (spitzer, kroenke, williams, & löwe, 2006). this assessment tool has 7 items and follows the same structure as the phq-9 asking how often symptoms of anxiety have occurred. the gad-7 has been validated against clinical interviews and the following cut-off scores were established, 5 – 9 ‘mild cases’; 10 – 14 ‘moderate cases’; 15 – 21 ‘severe cases’ (spitzer et al., 2006). the brief illness perception questionnaire (brief ipq) (broadbent, petrie, main, & weinman, 2006) assesses an individual’s cognitive and emotional representations of their illness. it contains eight items, with a 0 – 10 response format; assessing people’s experi‐ ence of symptoms (identity); perceptions of personal and treatment control; perceived timeline for the illness, the consequences it has on their life; how concerned they are about it; how much they understand the illness (coherence) and how much it affects them emo‐ tionally (emotional representation). the ninth item measures perceptions around cause and was not used in the analysis of this study. perceptions of risk were measured using questions based on bjorvatn and colleagues’ (2007) risk questions. one item was used in the analysis, which asked participants to re‐ port their perceived chance (0-100%) of experiencing severe symptoms (e.g. cardiac ar‐ rest, sudden cardiac death). the problem list is an assessment tool used to identify sources of distress in oncolo‐ gy patients (holland & bultz, 2007). minor changes were made to the problem list for this study so items were specific to this cardiac population. for example, mouth sores were removed and palpitations were added. it includes practical problems with ‘changes to fi‐ nances’, ‘work or school’ and taking medication; family problems with ‘communicating with extended family’, ‘fulfilling roles within the family’ and ‘planning to have children’; emotional problems such as ‘distress’, ‘isolated/feeling alone’ and ‘worried’; physical o’donovan, skinner, & broadbent 5 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ problems such as ‘blackouts/faints’, ‘breathing’ ‘cold hands and feet’, and ‘fatigue/tired‐ ness’; and spiritual/religious concerns such as ‘loss of purpose’ and ‘why me?’. each item was either scored zero if not identified as a problem or 1 if it was identified as a problem. subtotals for each subscale, and an overall total were then created by the number of problems selected. this tool is a practical way for patients to highlight aspects of their life contributing to their distress levels, so support provisions can be put in place. the stop-d is a five item screener used commonly in cardiac populations (young, ignaszewski, fofonoff, & kaan, 2007; young, nguyen, roth, broadberry, & mackay, 2015). the five items measure depression, anxiety, stress, anger and social support, participants are asked how much they have been bothered by each item over the last two weeks on a 10-point scale 0 – ‘not at all’ to 9 – ‘severely’. in this instance the whole measure was not used; we utilized the social support single item which asked how much participants had been bothered by: ‘not having the social support you feel you need?’ clinical information was extracted from the registry including the type of diagnosis, clinical status (level of certainty of their diagnosis, i.e. definitely affected vs probably af‐ fected), genetic status (genotype positive, unclassified variant or uninformative genetic test) and proband status (proband or cascade family member). participants responded to clinical questions in the questionnaire including, how long since their diagnosis, whether they had been prescribed β-blockers, how many of their family members had a cardiac inherited disease diagnosis and whether any family mem‐ bers had died from the condition. participants also completed demographic questions in‐ cluding age, gender, ethnicity and employment status. statistical analysis missing data were left out of analysis on a case by case basis. of the 202 participants, 20 had either missing ethnicity and beta-blocker data, clinical, genetic or proband status or did not indicate whether a death had occurred within their family. in total, 17 partici‐ pants had missing data for anxiety scores, three participants could have scores imputed as no more than two items were missing. in these cases the mean of the completed five items was used as a replacement for the missing items, leaving 14 participants without an anxiety score. in total 28 were missing for depression, 15 participants had scores imputed as no more than three items were missing, again the mean of the remaining items was used as a replacement, leaving 13 participants without a depression score. of these par‐ ticipants with missing data, 10 did not complete both measures. analyses were conducted on spss version 24 software. non-parametric tests were used due to non-normally dis‐ tributed data and medians were used when reporting findings. spearman correlations were conducted to determine associations between psychological variables and age, anxi‐ ety and depression. mann-whitney tests were performed to assess differences in anxiety and depression between those taking and not taking β-blockers, probands versus family members, and those with a definite versus probable clinical status. comparisons were al‐ anxiety and depression in cid 6 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ so made using the kruskal-wallis test to assess whether anxiety and depression differed between genetic status and a death in the family status. hierarchical multiple regression analysis was performed using the significant variables from the above tests along with age and gender given they are consistently associated with anxiety and depression (baxter, scott, vos, & whiteford, 2013; stordal, mykletun, & dahl, 2003). a total of 160 cases were included in the anxiety regression and 158 for the depression regression. a significance level of .05 was maintained apart from when post-hoc tests were performed during which a bonferroni correction was made. results participants did not differ from non-participants on gender, genetic, proband and clinical status and type of condition; but they did differ based on age (p < .001) and ethnicity (p < .001). those who participated were significantly older (median 53 years) compared to those who did not (median 45 years) and new zealand europeans were over represented in the study compared to other ethnicities (see table 1). means and standard deviations for all the psychological variables are reported in ta‐ ble 2. table 2 means and standard deviations of the psychological variables psychological variable m sd anxiety 3.37 4.28 depression 4.62 4.60 perceived social support 0.87 1.62 perceived risk 32.28 30.50 ip consequence 3.73 2.96 ip timeline 9.60 1.55 ip personal control 4.30 3.27 ip treatment control 4.59 3.35 ip identity 2.92 2.76 ip concern 4.50 3.23 ip coherence 7.17 2.54 ip emotional representation 3.30 3.12 problem list – practical 1.91 2.60 problem list family 0.69 1.09 problem list – emotional 1.62 2.61 problem list – physical 2.26 2.35 problem list spiritual 0.21 0.52 o’donovan, skinner, & broadbent 7 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ depression and anxiety scores ranged from 0 to 21 and 0 to 19 respectively. there were 27/192 (14%) individuals reporting clinical levels of anxiety and/or depression. of these individuals 16 (8%) reported clinical levels of both, 4 (2%) just depression, and 7 (4%) clinical levels of one and mild levels of the other. there were, 53/192 (28%) individuals who reported subclinical (mild) levels of anxiety and/or depression. of these individuals 23 (12%) reported subclinical levels of both, 22 (12%) just mild depression and 8 (4%) just mild anxiety. accordingly, 112/192 (58%) participants fell in the ‘non-clinical range. table 3 displays the proportion of people with at least mild levels of anxiety and depression by type of condition. there was no significant difference in anxiety and depression levels between the two most common conditions lqts and hcm, χ2(1, n = 146) = 3.87, p = .273. levels of anxiety and depression did not differ significantly based on gender or age (table 3). table 3 the proportion of participants with at least mild anxiety and/or depression by the type of cid condition condition n (%) anxiety only depression only anxiety & depression total long qt syndrome 6 (7) 7 (8) 23 (27) 36 (42) hcm 1 (1) 12 (17) 16 (23) 29 (42) dcm 0 (0) 2 (17) 1 (8) 3 (25) arvc 0 (0) 1 (20) 1 (20) 2 (40) cpvt 0 (0) 0 (0) 1 (17) 1 (17) brugada 1 (17) 1 (17) 0 (0) 2 (33) sudden cardiac arrest syndrome 0 (0) 1 (33) 1 (33) 2 (67) missing diagnosis 0 (0) 1 (8) 3 (25) 4 (33) totals 7 (4) 26 (13) 46 (24) 79 (41) anxiety bivariate analyses (table 4) showed that ethnicity was the only demographic variable as‐ sociated with anxiety u = 1919.5, z = -2.28, p < .05. a smaller proportion of new zealand european participants (7.5%) scored above the clinical threshold for anxiety compared to non-new zealand european participants (17%). a kruskal-wallis test on ‘death of a fami‐ ly member due to a cardiac inherited disease’ was found to be significantly related to anxiety h(2) = 6.31, p < .05; however mann whitney post hoc tests using a bonferroni correction did not reach significance between the groups (‘yes’, ‘no’, or ‘i don’t know’). participants on beta-blockers had significantly greater clinical anxiety u = 2952, z = -2.93, p < .01, compared to participants not on beta-blockers (14% vs 3% respectively). clinical, genetic and proband status and channelopathy versus cardiomyopathy were not related anxiety and depression in cid 8 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ to anxiety. there was also no significant correlation between anxiety and time since di‐ agnosis. table 4 bivariate analyses (pearson correlations, mann-whitney and kruskal-wallis tests) of the relationship between psychological, clinical and demographic variables with scores on the anxiety and depression scales phq-9 depression gad-7 anxiety spearman correlations rs p rs p age -.03 .677 -.13 .079 time since diagnosis .01 .939 -.09 .230 percentage of life with diagnosis .00 .963 -.04 .574 problem list – total .69 < .001 .66 < .001 problem list – physical .55 < .001 .44 < .001 problem list – emotional .62 < .001 .71 < .001 problem list – practical .50 < .001 .53 < .001 bipq – consequence .54 < .001 .53 < .001 bipq –timeline .01 .874 .00 .968 bipq – personal control -.21 .004 -.17 .019 bipq – treatment control -.02 .832 -.08 .317 bipq – identity .52 < .001 .40 < .001 bipq – concern .45 < .001 .53 < .001 bipq – understand .01 .892 -.07 .352 bipq – emotional representation .51 < .001 .62 < .001 perceived social support .39 < .001 .48 < .001 risk perceptions for severe symptoms (%) .38 < .001 .40 < .001 mann whitney tests u (z) p u (z) p beta-blockers (prescribed) 3179 (-2.32) .02 2952 (-2.93) .003 parent (not being a) 2585.5 (-1.61) .107 2428.5 (-1.95) .051 gender 3709.5 (-1.04) .297 3850.5 (-0.53) .596 cardiomyopathy vs channelopathy 3923.5 (-0.47) .637 3839.5 (-0.58) .563 proband (true) 2885 (-2.34) .019 3095.5 (-1.72) .085 clinical 2749 (-0.35) .730 2372.5 (-1.44) .150 ethnicity (non-european) 1935 (-2.58) .010 1919.5 (-2.28) .022 kruskal wallis tests h(2) p h(2) p genetic status 0.53 .777 0.09 .958 death of a family member (don’t know vs no) 9.42 .007 6.31 .043 note. z = z score. the psychological variables associated with anxiety in the bivariate analyses (table 4) in‐ cluded the number of physical and practical problems reported, illness perceptions (con‐ sequences; personal control; identity, concern, and emotional representation), percep‐ tions of risk and social support. o’donovan, skinner, & broadbent 9 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ hierarchical multiple regression analysis (table 5) was conducted and significant var‐ iables from the bivariate analyses and age and gender were entered into the model to predict anxiety. table 5 regression analysis to investigate predictors of anxiety in individuals with a cardiac inherited disease steps b se b β 95% ci for b ll ul step 1 (constant) 5.68 1.98 1.78 9.59 age -0.04 0.02 -.18* -0.08 -0.01 gender 0.31 0.64 .04 -0.95 1.57 ethnicity (european vs non-european) 0.90 0.80 .09 -0.68 2.47 prescribed beta-blockers -1.85 0.67 -.21** -3.18 -0.52 deaths within the family yes 0.79 0.70 .10 -0.59 2.18 deaths within the family – don’t know 0.69 0.90 .07 -1.09 2.47 step 2 (constant) 3.18 1.75 -.28 6.64 age -0.03 .02 -.10 -0.06 0.01 gender 0.05 0.52 .01 -0.97 1.07 ethnicity (european vs non-european) 0.08 0.69 .01 -1.29 1.46 prescribed beta-blockers -1.01 0.56 -.12 -2.12 0.11 deaths within the family yes -0.89 0.61 -.11 -2.09 0.31 deaths within the family – don’t know -0.68 0.74 -.06 -2.16 0.79 pl physical symptoms 0.32 0.17 .17 -0.01 0.65 pl – practical problems 0.16 0.15 .10 -0.14 0.46 ip – personal control -0.08 0.08 -.07 -0.23 0.08 ip – consequence 0.33 0.14 .24* 0.05 0.61 ip – identity -0.11 0.15 -.08 -0.39 0.18 ip – concern 0.15 0.11 .12 -0.08 0.37 risk perception – severe symptoms -0.00 0.01 -.03 -0.03 0.02 perceived social support 0.79 0.17 .34*** 0.47 1.12 note. ci = confidence interval; ll = lower limit; ul = upper limit. *p < .05. **p < .01. ***p < .001. all significant brief ipq items were included in the regression except emotional repre‐ sentation due to its conceptual overlap with the outcome variable. ethnicity, age, gender, beta-blocker and death of a family member variables were entered in model 1, and ex‐ plained 9% of the variance in anxiety scores f(6, 153) = 2.65, p = .018. being younger and prescribed beta-blockers (p = .007) were significant independent predictors in model 1. anxiety and depression in cid 10 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ after entering physical (symptom reports) and practical problems, perceptions of person‐ al control, consequences, identity, concern, risk and social support at model 2, the total variance explained by the model as a whole was 46% (r 2 = .46, adjusted r 2 = .41), f(14, 145) = 8.76, p < .001. the variables in model 2 explained an additional 37% of the variance in anxiety, fchange(8, 145) = 12.18, p < .001. in the final model higher perceptions of conse‐ quences (p = .021) and perceptions of poorer social support (p < .001) were significantly associated with greater anxiety. depression ethnicity was the only demographic variable related to depression u = 1935, z = -2.58, p < .05 (table 4). overall, more non-new zealand european participants (16%) reported clinical levels of depression than new zealand european participants (11%). reports of whether a family member had died due to a cardiac inherited disease was significantly related to depression h(2) = 9.42, p < .01. mann whitney post hoc tests us‐ ing a bonferroni correction showed a significant difference between those who had lost a family member and those who reported they had not (13% vs 11% respectively reported clinical levels of depression) u = 1963.5, p = .008; and between those who didn’t know if they had lost a family member and those who reported they had not (16% vs 11% respec‐ tively reported clinical levels of depression) u = 812.5, p = .014. those participants prescribed beta-blockers had significantly greater depression scores than those not prescribed them u = 3179, z = -2.32, p < .05 (16% vs 6% respectively reported clinical levels of depression). probands had significantly greater depression scores compared to family members u = 2885, z = -2.34, p < .05 (14% vs 8% respectively reported clinical levels of depression). clinical and genetic status, channelopathy versus cardiomyopathy, and time since diagnosis were not significantly related to depression. the psychological variables associated with depression in the bivariate analysis (ta‐ ble 4) mirrored the anxiety results. depression scores were significantly related to the number of physical and practical problems participants reported, illness perceptions (consequences, personal control, identity, concern, and emotional representation), per‐ ceptions of risk and social support. a hierarchical multiple regression analysis (table 6) was conducted using significant variables from the bivariate analysis (again, the emotional representation item from the brief ipq was left out due to its conceptual similarity with the outcome variable) and age and gender. ethnicity, age, gender proband status, beta-blocker and death of a family member variables were entered in model 1; they explained 12% of the variance in depres‐ sion scores f(7, 150) = 3.04, p = .005. a death in the family (p = .006) and being a proband (p = .035) were significant variables in model 1. in model 2, physical and practical prob‐ lems, perceptions of personal control, consequences, identity, concern, risk and social support were entered, and the total variance explained by the model as a whole was 50% (r 2 = .50, adjusted r 2 = . 45), f(15, 142) = 9.39, p < .001. the variables in model 2 ex‐ o’donovan, skinner, & broadbent 11 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ plained an additional 38% of the variance in depression, fchange(8, 142) = 13.21, p < .001. in the final model greater reported physical problems (p < .001) and perceptions of poorer social support (p < .001) were significantly associated with greater depression scores. table 6 regression analysis to investigate predictors of depression in individuals with a cardiac inherited disease steps b se b β 95% ci for b ll ul step 1 (constant) 7.21 2.39 2.48 11.94 age -0.03 0.02 -.12 -0.08 0.01 gender 0.00 0.73 .00 -1.45 1.45 ethnicity (european vs non-european) 1.43 0.89 .13 -0.34 3.19 prescribed beta-blockers -1.24 0.78 -.12 -2.78 0.29 deaths within the family yes 2.24 0.80 .24** 0.66 3.82 deaths within the family – don’t know 1.14 1.02 .09 -0.88 3.16 proband status -1.63 0.77 -.17* -3.15 -0.12 step 2 (constant) 4.04 2.13 -0.16 8.25 age -0.02 0.02 -.08 -0.06 0.01 gender -0.54 0.59 -.06 -1.71 0.62 ethnicity (european vs non-european) 0.48 0.78 .04 -1.05 2.01 prescribed beta-blockers -0.35 0.63 -.04 -1.60 0.90 deaths within the family yes 0.42 0.68 .05 -0.92 1.76 deaths within the family – don’t know -0.33 0.83 -.03 -1.96 1.31 proband status -0.77 0.63 -.08 -2.01 0.47 pl physical symptoms 0.72 0.19 .35*** 0.35 1.10 pl – practical problems 0.08 0.16 .04 -0.24 0.40 ip – personal control -0.07 0.09 -.05 -0.24 0.11 ip – consequence 0.29 0.16 .18 -0.02 0.60 ip – identity 0.06 0.16 .04 -0.26 0.38 ip – concern -0.04 0.12 -.03 -0.29 0.20 risk perception – severe symptoms 0.00 0.01 .02 -0.02 0.03 perceived social support 0.75 0.18 .28*** 0.39 1.12 note. ci = confidence interval; ll = lower limit; ul = upper limit. *p < .05. **p < .01. ***p < .001. discussion this study found an increased prevalence of depression and anxiety in patients with a cardiac inherited disease, which supports findings from the small number of earlier stud‐ anxiety and depression in cid 12 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ ies with this patient population. eighty (42%) participants had features of at least mild depression and/or anxiety. time since diagnosis and milder clinical severity did not di‐ minish the likelihood of either anxiety or depression symptoms. the diagnostic levels of depression and anxiety (13% and 10% respectively) and subclinical levels of depression (24%) in this cardiac inherited disease population were found to be higher than that in general populations (alonso et al., 2004; kessler et al., 2005; wells et al., 2006). treating psychopathology is important not only for patients’ quality of life but evidence suggests even subclinical levels of depression and anxiety can be detrimental for engagement and health outcomes (lewinsohn, solomon, seeley, & zeiss, 2000; roest, martens, de jonge, & denollet, 2010) and can be risk factors for more severe future psychopathology (cuijpers & smit, 2004). this study found that perceptions of social support were associated with both anxiety and depression scores in the hierarchical regression models. perceptions of social support are consistently associated with mental health and wellbeing across many different ill‐ ness groups including cardiac populations (hughes et al., 2004; thoits, 2011). the current study focused on perceived social support, a subjective feeling of being supported, as op‐ posed to received social support, the actual support provided. a perceived lack of support has been found to be a stronger predictor of greater depression than the actual support received, with studies showing a perceived sense of good social support plays a protec‐ tive role in the association between chronic illness and depression (santini, koyanagi, tyrovolas, mason, & haro, 2015). given these heart conditions are hereditary, multiple people within a family can be affected. it would be easy to assume there would be an inbuilt support network for pa‐ tients, and this is likely the case for the majority of study participants who reported hav‐ ing the social support they felt they needed. however this study suggests an important minority of patients feel they do not have the social support they feel they need and this group is doing poorer psychologically. further research is needed to better understand perceptions of social support with this specific patient population. janney (2011) provides some insight in a qualitative study in which lqts patients reported a perceived lack of emotional support from their social networks due to a poor understanding of the condi‐ tion (i.e. the absence of visible symptoms). the number of physical symptoms individuals reported was significantly associated with depression. the association between physical symptoms and depression is also well documented across different conditions, (katon, lin, & kroenke, 2007) and likely related to the limitations physical symptoms can cause. the items most commonly endorsed by participants in this study were fatigue, palpitations, insomnia, shortness of breath with exercise, and dizziness. these are common symptoms, many of which are reported in pri‐ mary care populations, and are highly correlated with anxiety and depression (kroenke et al., 1994). it is therefore important to be aware that patient-reported symptoms may not always be related to their heart condition. indeed, some of these symptoms would o’donovan, skinner, & broadbent 13 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ not generally be caused by a channelopathy at all, and may in fact provide an indication that anxiety and/or depression is present. as the common sense model of illness (csm) indicates (leventhal, meyer, & nerenz, 1980), patients attempt to make sense of their symptoms, even mild ones, and may misat‐ tribute unrelated symptoms (or side effects from medication) to their cardiac condition which will affect the mental model the patient holds for their cardiac inherited disease. although certain patient-reported symptoms may not be of direct clinical relevance to the medical management of the heart condition, it is important they get addressed. further support for the common sense model was provided by this study, in that ill‐ ness perceptions were strongly related to psychological distress. the consequence do‐ main was a significant individual contributor to the regression model for anxiety. this is in line with a meta-analysis that included different health conditions, which found the consequence domain consistently predicted the presence of anxiety (broadbent et al., 2015). other illness perceptions (personal control, identity and concern) and risk percep‐ tions were associated with anxiety and depression as well. illness perceptions represent malleable aspects of a patient’s experience that could be targeted in an intervention (broadbent et al., 2009). longitudinal research is needed to better understand the rela‐ tionship between perceived social support and illness and risk perceptions and anxiety and depression over time. this study found that time since diagnosis (median 9 years) and disease severity were not associated with depression or anxiety. it is intuitive to think that the longer someone has a health condition the better they will become at integrating it into their life and cop‐ ing with its consequences (morgan et al., 2008). however, studies of other cardiac condi‐ tions have shown similar findings (pelletier et al., 2014), indicating even patients with mild disease can be vulnerable. this study also supports research that found the preva‐ lence of anxiety and depression does not differ between the two most common cardiac inherited diseases, long qt syndrome and hypertrophic cardiomyopathy (hamang, eide, rokne, nordin, & øyen, 2011) which is worth investigating further, given the very differ‐ ent disease trajectories these conditions have. hcm is a progressive condition of heart muscle thickening and dysfunction and reminder symptoms such as shortness of breath on exertion are common in advanced disease. lqts is non-progressive, and the only symptoms anticipated are syncope, or cardiac arrest. further research may help to estab‐ lish which features in common are the most important (such as hereditability and risk of sudden death), as well as the dominant findings here which seem to be common to many diseases in general, such as the importance of a good social support infrastructure. although cardiac inherited disease patients are likely to be vulnerable to distress ear‐ ly on (which research shows usually dissipates) (hendriks et al., 2008), living with these conditions day to day may create an on-going vulnerability to anxiety and depression re‐ gardless of severity or how long someone has had the condition. the american heart as‐ sociation and american college of cardiology recommend that there is an integration of anxiety and depression in cid 14 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ psychological screening, assessment and intervention into cardiac care across the life span of patients with a congenital heart disease (warnes et al., 2008). the existing re‐ search would suggest it is time to consider similar recommendations for cardiac inherited disease patients. clinical implications the fact that 14% of patients had clinical levels of psychopathology and 28% had subclini‐ cal levels regardless of clinical severity or time with the condition, suggests that psycho‐ logical support should be made available to this patient population. the finding that noneuropeans had higher psychological morbidity indicates that ethnic minorities, most no‐ tably māori and polynesian peoples in this study, will need specific attention. limitations there are some limitations to this research. although a 36% response rate is in accord‐ ance with postal and web based surveys (shih & fan, 2008), it means this sample may not be representative of the population as a whole. it is difficult to know whether anxiety and depression are therefore underrepresented or overrepresented in this study. when people are choosing to take part in a voluntary survey they balance the interest, value, and personal relevance of it with the cost in time, energy and resources required to com‐ plete it (groves, cialdini, & couper, 1992). it is feasible that individuals suffering from anxiety and depression could come to a decision from either side of that equation. com‐ pounding this issue of sample representativeness is the fact that younger and ethnic mi‐ norities were under-represented and the questionnaire was only provided in english, cre‐ ating a potential bias around english language proficiency. this is also cross-sectional data and no direction of relationship can be determined. conclusion this study found anxiety and depression were more prevalent in the cardiac inherited disease population than in the general population and a perceived lack of social support was significantly associated with both. in addition the presence of more physical symp‐ toms (not necessarily specific to the heart condition) was associated with an increased risk of depression and more severe perceptions of the consequences of the heart condi‐ tion was associated with anxiety. the presence of a mild cardiac phenotype, and having had the condition for a long time do not appear to be protective of poor psychological wellbeing. future research should investigate these associations in a longitudinal study to help inform psychological interventions with this patient population. o’donovan, skinner, & broadbent 15 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ funding: dr. skinner receives salary support from cure kids. claire o’donovan receives a phd scholarship from the university of auckland. competing interests: the authors declare no 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(2000). patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. archives of internal medicine, 160(12), 1818-1823. https://doi.org/10.1001/archinte.160.12.1818 o’donovan, skinner, & broadbent 19 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://doi.org/10.1016/j.jacc.2010.03.034 https://doi.org/10.1016/j.jad.2014.12.049 https://doi.org/10.1177/1525822x08317085 https://doi.org/10.1001/archinte.166.10.1092 https://doi.org/10.1034/j.1600-0447.2003.02056.x https://doi.org/10.1111/jnu.12040 https://doi.org/10.1177/0022146510395592 https://doi.org/10.1016/j.jacc.2008.10.001 https://doi.org/10.1080/j.1440-1614.2006.01903.x https://doi.org/10.1097/01.jcn.0000297383.29250.14 https://doi.org/10.1177/1474515114548649 https://doi.org/10.1001/archinte.160.12.1818 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. anxiety and depression in cid 20 clinical psychology in europe 2019, vol.1(4), article e38062 https://doi.org/10.32872/cpe.v1i4.38062 https://www.psychopen.eu/ anxiety and depression in cid (introduction) methods study design and study population measures statistical analysis results anxiety depression discussion clinical implications limitations conclusion (additional information) funding competing interests acknowledgments ethics approval data availability references correction of abeditehrani, h., dijk, c., sahragard toghchi, m., & arntz, a. (2020). integrating cognitive behavioral group therapy and psychodrama for social anxiety disorder: an intervention description and an uncontrolled pilot trial correction correction of abeditehrani, h., dijk, c., sahragard toghchi, m., & arntz, a. (2020). integrating cognitive behavioral group therapy and psychodrama for social anxiety disorder: an intervention description and an uncontrolled pilot trial clinical psychology in europe, 2021, vol. 3(4), article e7727, https://doi.org/10.32872/cpe.7727 published (vor): 2021-12-23 correction note to: abeditehrani, h., dijk, c., sahragard toghchi, m., & arntz, a. (2021). integrating cognitive behavioral group therapy and psychodrama for social anxiety disorder: an intervention description and an uncontrolled pilot trial. clinical psychology in europe, 2(1), article e2693. https://doi.org/10.32872/cpe.v2i1.2693 in the originally published version of the above mentioned article, there was a typo­ graphical error in table 4. in the second row ("lsas"), an incorrect value in the "p" column was provided (.19). instead, the correct data for "lsas" under the "p" column is: .019. this change has no effect on the conclusions drawn in the article as the authors had already explained correctly that there was a significant decrease (p = .019) in social anxiety symptoms assessed with the lsas. the corrected table can be found below (see table 4). the authors apologize for any inconveniences caused. table 4 pretest and posttest comparison for the cbpt intervention scale pre post t (4) m difference [ci 99%] cohen’s d hedges’ gm sd m sd ll ul p bfne 35.60 7.02 28.40 4.10 2.86 -4.39 18.79 .046 1.03 0.82 lsas 99.40 16.99 58.40 24.81 3.82 -8.44 90.44 .019 2.41 1.93 sads 14.40 5.64 11.80 7.73 1.31 -6.56 11.76 .261 0.46 0.37 pas 133.20 13.88 131.60 17.21 0.20 -34.67 37.87 .849 -0.12 -0.09 opq 56.20 23.18 35.80 16.63 3.22 -8.74 49.54 .032 0.88 0.70 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7727&domain=pdf&date_stamp=2021-12-23 https://doi.org/10.32872/cpe.v2i1.2693 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ scale pre post t (4) m difference [ci 99%] cohen’s d hedges’ gm sd m sd ll ul p ocq 64.80 23.47 47.00 26.67 5.95 4.03 31.57 .004 0.76 0.61 bdi 19.60 5.86 12.60 8.20 2.03 -8.82 22.82 .111 1.19 0.96 qoli 29.40 21.31 36.00 25.17 -0.88 -41.13 27.93 .429 0.31 0.25 note. observed means (m) and standard deviations (sd) for the pre and post assessment points; results of t-test analyses (t, p-value) and effect sizes cohen’s d and hedges’ g. bfne = brief fear of negative evaluation; lsas = liebowitz social anxiety scale; sads = social avoidance and distress scale; pas = personal attitude scale-ii; opq = social cost and probability by the outcome probability questionnaire; ocq = outcome cost questionnaire; bdi = beck depression inventory; qoli = quality of life inventory. cohen’s d was estimated as d = (mean pre-post change)/(pretest sd). hedges’ g was calculated as follows: g = j*d, with d = cohen’s d; j = (1 – 3/(4*df-1)); df = n-1. the sign of the effect size was chosen so that a positive effect size indicates improvement and negative effect size represents worsening. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. correction of abeditehrani, h., dijk, c., toghchi, m. s., & arntz, a. (2020) 2 clinical psychology in europe 2021, vol. 3(4), article e7727 https://doi.org/10.32872/cpe.7727 https://www.psychopen.eu/ social impairments in mental disorders: recent developments in studying the mechanisms of interactive behavior scientific update and overview social impairments in mental disorders: recent developments in studying the mechanisms of interactive behavior konrad lehmann a, lara maliske a, anne böckler bc, philipp kanske ac [a] clinical psychology and behavioral neuroscience, faculty of psychology, technische universität dresden, dresden, germany. [b] institute of psychology, julius-maximilians-universität würzburg, würzburg, germany. [c] max planck institute for human cognitive and brain sciences, leipzig, germany. clinical psychology in europe, 2019, vol. 1(2), article e33143, https://doi.org/10.32872/cpe.v1i2.33143 received: 2019-01-16 • accepted: 2019-05-22 • published (vor): 2019-06-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: lara maliske, clinical psychology and behavioral neuroscience, faculty of psychology, technische universität dresden, chemnitzer str. 46, 01187 dresden, germany. e-mail: lara.maliske@tu-dresden.de abstract background: most mental disorders are associated with impairments in social functioning. paradigms developed to study social functioning in laboratory settings mostly put participants in a detached observer point of view. however, some phenomena are inherently interactive and studying full-blown reciprocal interactions may be indispensable to understand social deficits in psychopathology. method: we conducted a narrative review on recent developments in the field of experimental clinical psychology and clinical social neuroscience that employs a second-person approach to studying social impairments in autism spectrum disorder (asd), personality disorder, social anxiety disorder (sad), and schizophrenia. results: recent developments in methodological, analytical, and technical approaches, such as dual eye-tracking, mobile eye-tracking, live video-feed, hyperscanning, or motion capture allow for a more ecologically valid assessment of social functioning. in individuals with asd, these methods revealed reduced sensitivity to the presence of a real interaction partner as well as diminished behavioral and neural synchronicity with interaction partners. initial evidence suggests that interactive paradigms might be a powerful tool to reveal reduced interpersonal sensitivity in personality disorders and increased interpersonal sensitivity in individuals with sad. conclusion: a shift towards adapting a second-person account has clearly benefitted research on social interaction in psychopathology. several studies showed profound differences in behavioral and neural measures during actual social interactions, as compared to engaging participants as mere observers. while research using truly interactive paradigms is still in its infancy, it holds great potential for clinical research on social interaction. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i2.33143&domain=pdf&date_stamp=2019-06-28 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords social interaction, social cognition, second-person approach, mental disorders, social immersion, ecological validity highlights • we review studies adopting a second-person account of social interaction in clinical psychology. • studies show profound differences between actual social interactions and mere observations. • the full extent of impairments in social functioning unfolds only in complex social interactions. • new methodological developments hold great potential for research on social interaction deficits. most mental disorders are associated with impairments in social functioning. social diffi‐ culties are both diagnostic criteria for several disorders such as autism, schizophrenia, social anxiety disorder, or personality disorders (kennedy & adolphs, 2012; skodol et al., 2002) and also constitute risk factors for developing, sustaining, and exacerbating clinical symptoms (cacioppo, hawkley, & thisted, 2010; fowler, allen, oldham, & frueh, 2013; hawkley & cacioppo, 2010). though social functioning is complex and challenging to assess, several recent methodological advancements may allow to directly study so‐ cial-interactive behavior and its underlying (neural) mechanisms in more ecologically valid ways. the goal of this update article is to delineate these developments and their relevance for understanding mental disorders. deficits in social functioning can be based on impairments in the underlying social affective and cognitive processes (amodio & frith, 2006) that range from basic social at‐ tention and memory to empathy and theory of mind (tom; also termed mentalizing; happé, cook, & bird, 2017; kanske, 2018). while empathy allows access to other minds via directly sharing other persons’ emotional states (de vignemont & singer, 2006), men‐ talizing enables the understanding of others through abstract inference of their thoughts and beliefs (frith & frith, 2005). the typical approach to studying these phenomena in experimental clinical psychology and social neuroscience has been criticized as assessing individual minds as detached observers (fuchs & de jaegher, 2009). paradigms ask partic‐ ipants, for instance, to predict the behavior of cartoon characters, classify emotions of static pictures of eyes, or judge the trustworthiness of face photographs. while these tasks have certainly provided valuable insight into the mechanisms of social functioning, they lack the reciprocal nature of full-blown interactions (bird et al., 2010; dziobek et al., 2008; kanske, böckler, trautwein, & singer, 2015; von dem hagen, stoyanova, rowe, baron-cohen, & calder, 2014; walter et al., 2009). social impairments in mental disorders 2 clinical psychology in europe 2019, vol.1(2), article e33143 https://doi.org/10.32872/cpe.v1i2.33143 https://www.psychopen.eu/ in contrast to this observer account of social cognition, recent developments in philos‐ ophy, experimental psychology, and neuroscience call for a second-person account that en‐ gages participants in real dynamic interactions (e.g., de jaegher, di paolo, & gallagher, 2010; gallagher, 2008; konvalinka & roepstorff, 2012; schilbach et al., 2013). researchers argue that making sense of another person during an embodied and ongoing social inter‐ action occurs implicitly by making use of enactive perception that takes the context of a shared, intersubjective world into account. in real-time social interaction, implicit pro‐ cesses seem to be more relevant than the explicit forms that have been especially empha‐ sized in previous research (schilbach, 2016). accordingly, the full extent of deficient so‐ cial functioning in psychopathology may only manifest in complex social interactions. for instance, autistic individuals report more problems with direct and immediate social interactions than situations involving slow-paced interactions (e.g., email) or social ob‐ servation. recent research has advanced paradigms originating from an observer account of so‐ cial interaction towards implementing interactions (or at least interactive elements) with one or more real other persons. in addition to examining real, reciprocal interaction, au‐ thors suggested that even the potential for reciprocal interaction constitutes an impor‐ tant step forward, as one becomes actively engaged through another person that is expe‐ rienced as active and salient (krach, müller-pinzler, westermann, & paulus, 2013; risko, richardson, & kingstone, 2016) – a process that is also referred to as social immersion. among the novel approaches, research on gaze behavior has taken a leading role. one prominent paradigm makes use of anthropomorphic virtual characters who respond in a contingent way to participants’ eye movements, resulting in reciprocal interaction (wilms et al., 2010). comparably, redcay et al. (2010) developed a paradigm using live video-feed that allows for gaze based face-to-face interaction between an experimenter outside and a participant inside a magnetic resonance imaging (mri) scanner. yet another setup even enables two participants to interact via live video-feed while simultaneously tracking their eye-movements (hessels, cornelissen, hooge, & kemner, 2017). such a du‐ al eye-tracking method has also been implemented in setups wherein two individuals are lying in mri scanners (e.g., saito et al., 2010), enabling the simultaneous acquisition of brain activation of two interacting persons (referred to as hyperscanning). other ap‐ proaches rely less on technical means but establish real live interaction between partici‐ pants with, for instance, free eye contact or structured conversations while measuring the allocation of visual attention or indicators of arousal (e.g., freeth, foulsham, & kingstone, 2013; myllyneva, ranta, & hietanen, 2015). while these paradigms sometimes differ substantially in the way they operationalize social interactions, they can be classi‐ fied along different dimensions, such as complexity of interaction, temporal dynamics, social presence, and embodiment (table 1). lehmann, maliske, böckler, & kanske 3 clinical psychology in europe 2019, vol.1(2), article e33143 https://doi.org/10.32872/cpe.v1i2.33143 https://www.psychopen.eu/ table 1 classification of studies task / study social presence interaction complexity temporal dynamics embodiment disorder measure joint attention (oberwelland et al., 2017; redcay et al., 2013; including dual eye-tracking: bilek et al., 2017; tanabe et al., 2012) yes medium low high medium high visual information autism / borderline personality disorder neural activity & gaze behavior mutual eye-gaze (hessels et al., 2018; myllyneva et al., 2015) yes low high medium high visual information autism / social anxiety disorder gaze behavior listening to short stories (rice & redcay, 2016) yes vs. no (experimental condition) low low medium auditory information autism neural activity listening to short stories (von dem hagen & bright, 2017) yes vs. no (experimental condition) no interaction high visual + auditory information autism gaze behavior live face-to-face interaction (freeth & bugembe, 2019; freeth et al., 2013; hanley et al., 2015; hanley et al., 2014; magrelli et al., 2013; nadig et al., 2010) yes high high very high physically present autism gaze behavior live interaction (fitzpatrick et al., 2017a, 2017b; romero et al., 2018) yes high high very high physically present autism movement kinematics performance task, audience present (chib et al., 2018; müller-pinzler et al., 2015) yes vs. no (experimental condition) no interaction medium high visual information social anxiety disorder neural activity touch anticipation (scalabrini et al., 2017) yes low high medium tactile information narcissistic personality disorder neural activity conversation (takei et al., 2013) yes high high very high physically present schizophrenia neural activity note. the table summarizes how the reviewed studies (clustered by the kind of task) vary on features of social interaction. these features encompass the social presence of the interaction partner or audience in a mutual social situation; the interaction complexity expresses how much information is transferred during the interac‐ tion; the temporal dynamics of the interaction provides information about how quick responses have to be inte‐ grated and reacted upon; and the embodiment of the interaction partner expresses how rich s/he is perceived by the participant. this update article shortly reviews recent laboratory studies that adopt a second-person account of social interaction within clinical experimental psychology and clinical social neuroscience. we want to delineate how novel and ecologically valid measures have hel‐ social impairments in mental disorders 4 clinical psychology in europe 2019, vol.1(2), article e33143 https://doi.org/10.32872/cpe.v1i2.33143 https://www.psychopen.eu/ ped to gain new insight into impairments of social interaction, with a particular focus on studies employing advanced experimental and methodological approaches. this kind of research in the context of mental disorders is still scarce and we will focus on autism spectrum disorders, personality disorders, social anxiety disorder, and schizophrenia. autism spectrum disorder autism spectrum disorder (asd) is a developmental disorder manifested particularly in persistent patterns of deficient social interactive and communicative behavior (e.g., irreg‐ ular eye contact, behavioral inflexibility in social contexts) (american psychiatric association [apa], 2013). deficits in joint attention are one of the core impairments in asd (dawson, bernier, & ring, 2012). establishing joint attention – for instance, by directing or following anoth‐ er’s gaze to an object – is a simple, but inherently interactive process (redcay, kleiner, & saxe, 2012) that can easily be implemented in truly interactive settings. using a live vid‐ eo-feed, tanabe and colleagues (2012) employed a dual eye-tracking joint attention task in dyads of asd and typically developed (td) participants during mri hyperscanning. asd participants showed reduced accuracy at detecting gaze direction, corresponding with reduced neural activation in the left occipital pole, suggesting altered early visual gaze processing. furthermore, mixed pairs of td and asd participants revealed lower neural synchronization in the right inferior frontal gyrus (ifg) than td-td pairs, which the authors attributed to problems integrating selfand other-oriented attention in asd participants. in another joint attention study using a live video-feed, asd participants did not differ behaviorally from td participants (redcay et al., 2013). however, on the neural level, asd participants (in contrast to td participants) did not show differential activity between social and non-social conditions in the dorsomedial prefrontal cortex (dmpfc) and left posterior superior temporal sulcus (lpsts), which might play a role in mutual engagement with a social partner. similar patterns were observed using virtual interacting avatars (oberwelland et al., 2017). beyond simple joint attention, one study used task-independent dual eye-tracking, in‐ structing participants to look at each other for five minutes (hessels, holleman, cornelissen, hooge, & kemner, 2018). pairs high in autism displayed less two-way eye gaze (i.e., eye contact), but, interestingly, more one-way eye gaze (only one participant looking in the eyes of the other). the interactive nature of this study design could pro‐ vide support for the so-called gaze aversion model (i.e., avoidance of eye contact) over the gaze indifference model (i.e., insensitivity to others’ eyes) (moriuchi, klin, & jones, 2017). directly targeting the role of true interaction, some studies investigated how different degrees of ecological validity differentially influence behavior along autistic traits. rice and redcay (2016) implemented a simulated live interaction between participants in an mri scanner and an experimenter, examining how brain activity is altered depending on lehmann, maliske, böckler, & kanske 5 clinical psychology in europe 2019, vol.1(2), article e33143 https://doi.org/10.32872/cpe.v1i2.33143 https://www.psychopen.eu/ whether participants think speech is addressed to them live versus pre-recorded. increas‐ ing scores in subclinical autism went along with reduced differential dmpfc activation for live compared to pre-recorded speech, presumably reflecting lower perceived liveness of the speaker in high autistic individuals. similarly, von dem hagen and bright (2017) manipulated participants’ belief whether the video of a person telling a story was prerecorded or live. while these different beliefs resulted in modulated attention towards the eye region in low autistic individuals, they did not affect the attention of persons with high autistic traits. using mobile eye-tracking, freeth et al. (2013) involved participants in a structured conversation with an experimenter whose social presence varied (live faceto-face interaction versus pre-recorded video). during the pre-recorded video ‘interac‐ tion’, the amount of time looked at the experimenter correlated negatively with subclini‐ cal autistic traits, whereas there was no such correlation in the face-to-face interaction. these studies suggest that individuals with asd display reduced sensitivity to the cues of online versus offline interaction compared to td individuals. several other studies have used mobile eye-tracking in the context of a more natural social environment. during a semi-structured conversation, children with asd looked less to the face of the experimenter (particularly to the eyes) than children without asd (hanley et al., 2014; magrelli et al., 2013). children were mostly listening in hanley and colleagues’ (2014) study, and this pattern of reduced looking at their interaction partner’s face was not found when children were primarily speaking (nadig, lee, singh, bosshart, & ozonoff, 2010). during a structured face-to-face conversation, adults with asd showed fewer fixations on the eyes and more fixations on the mouth as compared to td adults, however, they showed no alterations in fixation on the face in general (hanley et al., 2015). similarly, freeth and bugembe (2019) found no difference in fixations on the face when the social partner’s gaze was averted. however, when participants were being looked at directly, individuals with asd fixated the face for a shorter time than td indi‐ viduals. these interactive studies have helped to reveal factors that modulate social at‐ tention of autistic individuals, such as conversational phase or gaze direction of the inter‐ locutor. to capture nonverbal interpersonal behavior beyond eye gaze, several recent studies employed videoor device-based motion tracking (e.g., fitzpatrick et al., 2017a; romero et al., 2018). using a motion-tracking device, fitzpatrick and colleagues (2017a) imple‐ mented a battery of imitation and motor synchronization tasks to capture dynamical measures of synchronicity. children with asd showed reduced social synchronization abilities and had difficulties producing consistently timed movements over the course of an interaction. interestingly, synchronization abilities correlated with performance on a false-belief tom task (fitzpatrick et al., 2017b). romero and colleagues (2018) objectively quantified synchronization of whole-body movement from video recordings of live inter‐ actions, showing that complex whole-body synchronicity between children with asd and clinicians was above chance level, and correlated negatively with asd severity, that social impairments in mental disorders 6 clinical psychology in europe 2019, vol.1(2), article e33143 https://doi.org/10.32872/cpe.v1i2.33143 https://www.psychopen.eu/ is, children with higher social-cognitive abilities exhibited more behavioral synchronici‐ ty. such dynamic measures of interpersonal behavior and coordination provide interest‐ ing insights into more complex components of social interaction. in summary, these results underline how asd research benefits from implementing a second-person approach: being addressed by a social partner modulates social attention in response to different contextual factors. depending on the type of paradigm (e.g., joint attention, manipulation of the degree of ecological validity), asd compared to td indi‐ viduals show reduced sensitivity to the presence versus absence of a real-interaction partner, both in neural and in behavioral measures. in addition, asd participants re‐ vealed diminished levels of neural and behavioral synchronicity with td interaction partners. personality disorders personality disorders comprise a number of maladaptive behavioral patterns and cogni‐ tive styles (apa, 2013). based on previous research, we will focus on borderline personal‐ ity disorder (bpd) and narcissistic personality disorder (npd). bpd is characterized by unstable affect and self-image as well as impulsivity, account‐ ing for severely impaired everyday social functioning (apa, 2013). investigating social interactions through a joint attention task, bilek and colleagues (2017) assessed live inter‐ acting dyads in mri hyperscanning. neural coupling at the site of right temporo-parietal junction (rtpj), a core region for mentalizing processes, was lowest in bpd-healthy con‐ trol (hc) dyads, which might be a cause for difficulties in social interactions in everyday life. interestingly, coupling in dyads of remittent bpd and hc was at the level of hc-hc dyads, suggesting a state specificity or reversibility of low neural coupling in bpd. npd is characterized by the need for admiration, a lack of empathy as well as pro‐ nounced self-absorbedness. in subclinical narcissism, scalabrini and colleagues (2017) re‐ ported higher scores on narcissistic grandiosity going along with reduced activation in the right anterior insula (rai) in anticipation of touching a human hand. the rai is a main structure of the so-called salience network that is assumed to switch attention away from internal towards external stimuli, indicating that narcissists might be less respon‐ sive to others and rather remain in self-reflective internal processes. taken together, though studies employing truly interactive tasks are still sparse in personality disorders, initial evidence indicates the power of these paradigms in revealing reduced interpersonal sensitivity in the respective populations. lehmann, maliske, böckler, & kanske 7 clinical psychology in europe 2019, vol.1(2), article e33143 https://doi.org/10.32872/cpe.v1i2.33143 https://www.psychopen.eu/ social anxiety disorder the diagnostic criteria for social anxiety disorder (sad) include fear in social perform‐ ance situations and the fear of behaving embarrassingly, leading to avoidance of the re‐ spective situations altogether (apa, 2013). experimental settings that use socially immersive environments in order to induce the feeling of being observed by others are particularly suitable to study social evaluative threat and embarrassment in sad populations. in doing so, müller-pinzler and colleagues (2015) applied a value estimation task to investigate neural pathways of em‐ barrassment. participants were led to believe that feedback regarding their performance in the experimental task was shared with three confederates outside the scanner room. when feedback on their performance was made public, participants with higher levels of sad showed heightened visual attention towards their observers’ faces, as well as in‐ creased activation in medial prefrontal cortex (mpfc) and the right fusiform face area, possibly indicating increased attention to others and mentalizing about how oneself is perceived by the audience. similar results were reported for the performance in a motor task under observation (chib, adachi, & o’doherty, 2018). in a behavioral task using dual eye-tracking, pairs of participants were instructed to look at each other for five minutes (hessels et al., 2018; see section on autism above). pairs high in subclinical social anxiety were engaged in more frequent, but shorter oneway eye gaze than low social anxiety pairs. myllyneva et al. (2015) had a person sitting opposite the participant with an lcd screen in between that could be either transparent or opaque. when the switching between transparent and opaque was computer control‐ led, both sad adolescents and controls showed higher arousal to direct gaze than to averted gaze by the other person. however, when participants were forced to initiate the social interaction themselves by controlling when the screen turned transparent/opaque, this difference only remained in individuals with sad. hence, self-initiated interaction reduced direct-gaze related arousal in healthy participants, but not in sad participants. overall, these results corroborate clinical descriptions of sad regarding a higher con‐ cern of one’s public appearance, resulting in increased neural activation of areas associ‐ ated with mentalizing and face processing. the possibility to actively initiate contact with an interaction partner could reveal different arousal patterns in response to direct (versus averted) gaze between sad patients and healthy controls. schizophrenia schizophrenia (scz) is a mental disorder characterized by profound changes in behavior, communication, and cognition, with symptoms including hallucinations, disorganized speech and behavior, and delusions that greatly impair interpersonal functioning (apa, 2013; tandon et al., 2013). social impairments in mental disorders 8 clinical psychology in europe 2019, vol.1(2), article e33143 https://doi.org/10.32872/cpe.v1i2.33143 https://www.psychopen.eu/ to investigate neural activation in scz during live face-to-face conversation, takei and colleagues (2013) used functional near infrared spectography (fnirs) in a sample of scz patients and controls to investigate neural patterns during live interaction. specifi‐ cally, participants and experimenters spoke for fixed intervals about a previously speci‐ fied topic. scz participants exhibited less appropriate speech, lower production of new topics, and spoke less overall. on a neural level, scz participants showed decreased ac‐ tivity in bilateral temporal lobes and right inferior frontal gyrus, co-varying with nega‐ tive symptoms and disorganization, where the authors suggest a causal role of these brain areas. while the field of scz research is still underrepresented regarding the implementa‐ tion of truly interactive paradigms, these results show an interesting trend that could not have been revealed in other, less interactive tasks. conclusion a shift towards applying a second-person account has clearly benefitted research on so‐ cial interaction in psychopathology, with the case of autism taking a prominent role. sev‐ eral studies showed profound differences in behavioral and neural measures during ac‐ tual social interactions, as compared to engaging participants as mere observers. this pattern suggests that the full extent and the nature of impairments in social functioning unfolds only in complex social interactions. furthermore, many social phenomena are inherently interactive and can therefore only manifest themselves in paradigms implementing real dynamic interactions. the sec‐ ond-person account aims at capturing the underlying mechanisms of these phenomena in their entirety. a few published studies employed hyperscanning with dyads consisting of healthy and psychopathological participants during live interaction, enabling the in‐ vestigation of co-activation patterns and synchronization of brain activity. however, the possibilities to interact while lying in an mri scanner are highly restricted and para‐ digms used in this context are limited in their degree of ecological validity. likewise, the implementation of paradigms employing more complex social interactions introduces new methodological problems, such as complexity of data and reduced experimental con‐ trol. here, economic games offer the chance to study social interactions in a controlled environment but with limited flexibility within the interaction. the use of virtual reality bears potential to regain experimental control as the behavior of a virtual character can be manipulated gradually. usually, this comes at the price of the participants being aware that they interact not with another human but a virtual agent as has been done in experi‐ mental studies addressing autism and psychotic symptoms (e.g., forbes, pan, & hamilton, 2016; veling, pot-kolder, counotte, van os, & van der gaag, 2016). this prob‐ lem could, however, be overcome by applying a cover story making participants believe lehmann, maliske, böckler, & kanske 9 clinical psychology in europe 2019, vol.1(2), article e33143 https://doi.org/10.32872/cpe.v1i2.33143 https://www.psychopen.eu/ that they interact with a virtual avatar that is controlled by another human (e.g., wilms et al., 2010). outside the scanner, paradigms with real life face-to-face interaction allow assessing the embodied and implicit nature of interactions. the use of technical means such as mo‐ bile eye-tracking or motion capturing devices as well as advanced analytical methods represent an advancement in objective quantification of social interactions. however, it should be noted that although these advanced methods enhance the ecological validity of social interactions in the laboratory, assessing factors like emotions or the dynamics of interpersonal relations remains challenging. here, field methods and self-report measures are still the means of choice: ecological momentary assessment (ema) – the collection of various types of data via portable technical devices – has the advantage of capturing reallife social interactions while (or shortly after) they are happening. furthermore, they can be complemented with more objective measures such as the electronically activated re‐ corder (ear). here, participants wear a portable audio recorder that periodically records the acoustic environment, allowing for the analysis of, for instance, the words or prosody used during social interaction or the number of interaction partners. in conclusion, paradigms employing a second-person approach to the study of social interactions in mental disorders have yielded promising results. while research using truly interactive paradigms is still in its infancy, it holds great potential for clinical re‐ search on social interaction. funding: pk is supported by german federal ministry of education and research within the asd-net (bmbf fkz 01ee1409a), the german research council (heinz maier-leibnitz prize ka 4412/1-1) and die junge akademie at the berlin-brandenburg academy of sciences and humanities and the german national academy of sciences leopoldina. competing interests: the authors declare no conflicts of interest. acknowledgments: the authors have no support to report. author contributions: the first and second author contributed equally to this work. references american psychiatric association. 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(2010). it’s in your eyesusing gaze-contingent stimuli to create truly interactive paradigms for social cognitive and affective neuroscience. social cognitive and affective neuroscience, 5(1), 98-107. https://doi.org/10.1093/scan/nsq024 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. lehmann, maliske, böckler, & kanske 15 clinical psychology in europe 2019, vol.1(2), article e33143 https://doi.org/10.32872/cpe.v1i2.33143 https://doi.org/10.1093/cercor/bht003 https://doi.org/10.1093/scan/nsn047 https://doi.org/10.1093/scan/nsq024 https://www.psychopen.eu/ social impairments in mental disorders (introduction) autism spectrum disorder personality disorders social anxiety disorder schizophrenia conclusion (additional information) funding competing interests acknowledgments author contributions references further specifying the cognitive model of depression: situational expectations and global cognitions as predictors of depressive symptoms research article further specifying the cognitive model of depression: situational expectations and global cognitions as predictors of depressive symptoms tobias kube ab, philipp herzog a, charlotte m. michalak a, julia a. glombiewski ab, bettina k. doering ac, winfried rief a [a] department of clinical psychology and psychotherapy, philipps-university of marburg, marburg, germany. [b] department of clinical psychology and psychotherapy, university of koblenz-landau, landau, germany. [c] department of psychology, catholic university eichstätt-ingolstadt, ingolstadt, germany. clinical psychology in europe, 2019, vol. 1(4), article e33548, https://doi.org/10.32872/cpe.v1i4.33548 received: 2019-01-31 • accepted: 2019-04-16 • published (vor): 2019-12-17 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: tobias kube, department of clinical psychology and psychotherapy, philipps-university of marburg, gutenbergstraße 18, d-35032 marburg, germany. e-mail: tobias.kube@uni-marburg.de abstract objectives: the cognitive model of depression assumes that depressive symptoms are influenced by dysfunctional cognitions. to further specify this model, the present study aimed to examine the influence of different types of cognitions on depressive symptoms, i.e., situational expectations and global cognitions. it was hypothesized that situational expectations predict depressive symptoms beyond global cognitions. design: the present study examined a clinical (n = 91) and a healthy sample (n = 80) using longitudinal data with a baseline assessment and a follow-up five months later. although the study was not designed as an interventional trial, participants from the clinical study received nonmanualized cognitive-behavioral treatment after the baseline assessment. methods: we examined situational expectations, intermediate beliefs, dispositional optimism, and generalized expectancies for negative mood regulation as predictors of depressive symptoms. hypotheses were tested using multiple hierarchical linear regression analyses. results: results indicate that, although there were significant correlations between the cognitive factors and depressive symptoms, in both samples neither global cognitions, nor situational expectations significantly predicted depressive symptoms at the five-month follow-up. conclusions: the present study could, contrary to the hypotheses, not provide evidence for a significant impact of cognitive vulnerabilities on depressive symptoms, presumably due to high drop-out rates at follow-up. limitations of the study and directions for future research are critically discussed. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i4.33548&domain=pdf&date_stamp=2019-12-17 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords expectation, expectancy, depression, cognitive model, behavioral experiment highlights • situational and global cognitions were examined as predictors of depressive symptoms. • in a healthy and a clinical sample, cognitive factors were correlated with depressive symptoms. • however, in both samples depressive symptoms at follow-up were not predicted by cognitive factors. since beck’s early studies from the 1960s (beck, 1963, 1964), numerous studies have pro‐ vided evidence for cognitive vulnerabilities among people suffering from major depres‐ sive disorder (mdd) (mathews & macleod, 2005; scher, ingram, & segal, 2005; wenze, gunthert, & forand, 2010). in particular, it has been assumed that people suffering from mdd have dysfunctional cognitions such as negative automatic thoughts, intermediate beliefs and dysfunctional core beliefs. these cognitions are supposed to influence the de‐ velopment and maintenance of depressive symptoms (beck, rush, shaw, & emery, 1979). this cognitive model of depression has significantly influenced research on depression for decades and has promoted the development of cognitive-behavioral treatment. re‐ cently, however, it has been argued that the concept of “cognition” in the traditional cog‐ nitive model might be too broad and could benefit from further specification (rief & joormann, 2019). in fact, the precise influence of different types of cognitions on depres‐ sive symptoms has rarely been studied directly up to now. therefore, the present study aimed to examine the influence of different types of cognitions that differ in their gener‐ alizability vs. specificity and the extent to which they relate to future events or experien‐ ces. on a temporal level, cognitions can be related either to the past, the present or the future. the subgroup of cognitions that relates to future events or experiences is referred to as expectations (kirsch, 1985; olson, roese, & zanna, 1996). more specifically, expecta‐ tions may relate both to the probability of occurrence of a particular event or experience and to the consequences thereof; this can be conscious or unconscious (laferton, kube, salzmann, auer, & shedden mora, 2017). while human beings are quite trained in coping with momentary unpleasant feelings, such as pain or sadness, this dramatically changes if people expect these unpleasant conditions to last forever, or to be repeated frequently in the future (rief & joormann, 2019). therefore, rief and joormann have argued that ex‐ pectations regarding the stability of future experiences may have considerable impact on human well-being. in line with this notion, several studies have shown that negative fu‐ ture expectations influence the development of depressive symptoms (horwitz, berona, expectations as predictors of depressive symptoms 2 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ czyz, yeguez, & king, 2017; strunk, lopez, & derubeis, 2006; vilhauer et al., 2012). this is consistent with beck’s ‘cognitive triad’ (beck et al., 1979). the impact of negative ex‐ pectations on future well-being is also supported by research on ‘affective forecasting’ (wilson & gilbert, 2003). according to this literature, dysphoric people tend to be biased in predicting future emotional states towards the overestimation of negative emotional reactions to future events (hoerger, quirk, chapman, & duberstein, 2012; marroquín & nolen-hoeksema, 2015). according to laferton et al. (2017), expectations can vary in their degree of specificity vs. generalizability. situation-specific expectations (also referred to as ‘situational expect‐ ations’) such as, “when i ask someone for help, i will be rejected”, represent predictions of specific events or experiences in a particular situation. in contrast, generalized or glob‐ al expectations can apply to various areas of life (e.g., “i hardly ever expect things to go my way”). relatedly, due to their “if-then” structure, situational expectations might be more easily amenable to an empirical test of their validity compared to global expecta‐ tions, e.g., through behavioral experiments. with reference to the cognitive model of de‐ pression (beck et al., 1979), it has been hypothesized that situational expectations may constitute an important link between global beliefs, such as intermediate beliefs and dis‐ positional optimism, and depressive symptoms. this hypothesis could recently be con‐ firmed: the effects of both intermediate beliefs and dispositional optimism on depressive symptoms were mediated via situational expectations (kube et al., 2018a, 2018b). to add to this line of research, the present study used longitudinal data of both healthy and de‐ pressed people to compare the predictive values of situational vs. more global cognitions in the context of depressive symptoms. in the current work, three constructs were used as indicators for generalized cogni‐ tions. these three constructs were chosen because they have often been studied in de‐ pression research, and because there are well validated measurement tools to assess them. first, we considered dispositional optimism, arguably the most prominent concept of generalized expectations (laferton et al., 2017). dispositional optimism has been de‐ fined as ‘the tendency to believe that one will generally experience good vs. bad out‐ comes in life’ (scheier & carver, 1985). previous research has consistently linked opti‐ mism to depression (korn, sharot, walter, heekeren, & dolan, 2014; strunk et al., 2006; thimm, holte, brennen, & wang, 2013). dispositional optimism can be assessed with the life orientation test, the most recent form of which was presented by scheier, carver, and bridges (1994). second, another construct reflecting rather generalized expectations has been introduced by catanzaro and mearns (1990): they focused on generalized ex‐ pectancies for negative mood regulation, and defined this construct as ‘the generalized expectancy that some behavior or cognition will alleviate a negative mood state’. similar to dispositional optimism, these expectancies, assessed with the generalized expectan‐ cies for negative mood regulation scale (catanzaro & mearns, 1990), have been found to be associated with depressive symptoms (backenstrass et al., 2006). third, we considered kube, herzog, michalak et al. 3 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ intermediate beliefs, a central construct of the traditional cognitive model reflecting global attitudes and assumptions regarding oneself and life in general. intermediate be‐ liefs can be measured using the dysfunctional attitudes scale (oliver & baumgart, 1985). it has been shown that intermediate beliefs predict the development of depressive symp‐ toms (alloy, abramson, whitehouse, & hogan, 2006; jarrett et al., 2012), and are associ‐ ated with the severity of depressive symptoms in both healthy and clinical samples (burns & spangler, 2001). importantly, although the dysfunctional attitudes scale in‐ cludes items that do partly measure expectations of future events or experiences, it also comprises a considerable amount of items assessing more general attitudes without a clear focus on the future. therefore, it cannot completely be regarded as a measure of expectations. besides these generalized cognitions, the current study focused on situation-specific dysfunctional expectations in depression. to assess this relatively new construct, the de‐ pressive expectations scale has been developed (kube, d'astolfo, glombiewski, doering, & rief, 2017). using a consequent “if-then” structure, this scale assesses situational ex‐ pectations for different areas of personal and interpersonal life, such as expectations con‐ cerning social rejection, social support, mood regulation, and personal performance (see appendix 1 for some sample items). the scale has been developed from a clinical point of view, with the aim of developing a tool that could be helpful in planning psychothera‐ peutic interventions to evaluate the validity of patients' expectations through behavioral experiments. aims and hypotheses the primary aim of the study was to examine situational expectations and more global cognitions as predictors of depressive symptoms. dispositional optimism, generalized ex‐ pectancies for negative mood regulation, and intermediate beliefs represent dysfunction‐ al cognitions and have therefore conceptual similarities with situational expectations. further, since all of these constructs reflect a negative view of an individual on different areas of personal and interpersonal life, they may only slightly differ with regards to their contents. they do differ, however, in terms of their situational specificity vs. gener‐ alizability: dispositional optimism, generalized expectancies for negative mood regula‐ tion, and intermediate beliefs represent more global cognitions while situational expecta‐ tions are characterized by a higher level of situational specificity. we argue that due to this clear situational focus, situational expectations may predict depressive symptoms be‐ yond global cognitions; situational expectations reflect specific predictions of everyday events, and therefore the actual occurrence of anticipated negative events (or the nonoccurrence of anticipated positive events) may result in negative emotions such as disap‐ pointment or frustration, thus providing the breeding ground for symptoms of depres‐ sion. global cognitions, however, are often more abstract and less closely linked to every‐ day experiences, so that they are less often perceived as confirmed or disconfirmed and expectations as predictors of depressive symptoms 4 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ thus less obviously related to depression. in particular, it was hypothesized that situa‐ tional expectations at baseline predict the later severity of depressive symptoms at fol‐ low-up independently from the aforementioned more global cognitions in both a healthy and a clinical sample. method this study was part of a larger research project. recently, first data from this project us‐ ing a clinical sample have recently been published (kube et al., 2018b). the present study used the same clinical sample as the previous article. while the previous article analyzed only cross-sectional data, the present study reports the longitudinal data. additionally, the present study reports data from a healthy sample, which have not previously been published. participants and procedure healthy sample healthy individuals were recruited via mailing lists and postings at public spaces. inclu‐ sion criteria for the healthy sample were: absence of a currently diagnosed mental disor‐ der (self-report), age of at least 18 years, and sufficient knowledge of the german lan‐ guage (self-evaluation of the participants). at baseline, 80 healthy people participated in the study and completed the questionnaires online via the commercial survey platform unipark®. five months after the first measurement, participants were contacted by the study coordinator via email, and they were asked to complete the questionnaires from the follow-up measure. the follow-up questionnaires were completed by 47 participants (completion rate: 58.8%). the main reason for not completing the follow-up in the healthy sample was that participants could not be contacted again due to changes in their email address (the healthy sample consisted mainly of students, and most participants used their university e-mail address, which were no longer available if they had left the university in the meantime). participants who completed the entire study did not signifi‐ cantly differ from those who completed only the baseline assessment (all p values > .05; detailed statistical data can be found in the appendix 2). clinical sample participants were recruited at two inpatient hospitals (n = 53 and n = 18) and one outpa‐ tient clinic (n = 24) in germany. the following inclusion criteria were used: current diag‐ nosis of mdd according to icd-10, age of at least 18 years, sufficient knowledge of the german language (self-evaluation of the participants). in the outpatient clinic, partici‐ pants were diagnosed using the scid interview by clinical psychologists who were ap‐ propriately trained in this interview (wittchen, zaudig, & fydrich, 1997). in the inpatient kube, herzog, michalak et al. 5 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ hospitals, participants were also diagnosed by trained clinical psychologists using semistructured interviews based on scid; these semi-structured interviews were, however, short-forms of the scid and not validated in previous studies. if patients were interested in participating in the study, they received detailed study information and gave written informed consent. next, participants could complete the paper-pencil questionnaires on their own. of note, in order to control for effects of later treatment (e.g. psychotherapy), participants could only participate in the study during the first two weeks after their in‐ take at the hospital or in diagnostic phase before the beginning of the outpatient therapy, respectively. though the study was not an interventional trial, all participants from the clinical sample received non-manualized individual cognitive-behavioral treatment after the baseline assessment. five months after completing the first questionnaire, patients from the inpatient clin‐ ics were sent the second questionnaire via postal service and completed it at home. par‐ ticipants from the outpatient clinic received the questionnaires by their therapists or the study coordinator. completed follow-up questionnaires were sent back to the study coor‐ dinator, which was done by 52 persons (completion rate: 54.7%). the reasons for not com‐ pleting the follow-up assessment in the clinical sample included: participants could not be contacted again; participants were not willing to complete questionnaires again; al‐ though the participants initially agreed to complete the follow-up questionnaires, they did not return the questionnaires in the end. completers did not significantly differ from non-completers (all p values > .05; detailed statistical data can be found in the appendix 2). data collection lasted from may 2016 to november 2017. for 14 participants, there were difficulties in contacting them since their contact data had changed or were incor‐ rect. therefore, the period of five months for the follow-up measure could not be ensured for these participants, resulting in a follow-up measure six to fourteen months after the first measurement. for both samples, the questionnaire used at the follow-up was shorter than the one used at the first measurement, and included only the measure of situational expectations and depressive symptoms in order to decrease the anticipated drop-out rate due to addi‐ tional strains. to give an incentive for participation, participants had the chance to win gift vouchers for a popular bookshop. the study was approved by local ethics committee (reference number 2016-04k) and has been conducted in accordance with ethical stand‐ ards as laid down in the 1964 declaration of helsinki and its later amendments. all par‐ ticipants gave written informed consent and all procedures were in accordance with the ethical guidelines of the german psychological society. expectations as predictors of depressive symptoms 6 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ measures situation-specific dysfunctional expectations (sdes) we used the depressive expectations scale (des) to assess situation-specific dysfunc‐ tional expectations. the des is a 25-item scale that was developed by kube et al. (2017) to measure mdd-specific expectations. the construction principle was, according to the method of domain sampling (nunnally, 1978), to use common dysfunctional core beliefs (e.g., “i am not likable”) to deduce situation-specific predictions thereof (e.g., “when i try to make new acquaintances, i will get to know kind people” (inverted)). the majority of the items are formulated in such a way that at the beginning of each sentence a certain everyday situation is presented, and the participants’ task is to indicate what behavioral, emotional, or cognitive consequences they expect to occur in this situation (see some ex‐ amples in appendix 1). specifically, participants are asked to assess on a five-point likert scale to what extent each of the possible completions would apply to them personally. importantly, the completions can refer to both the likelihood of occurrence of a particular event or its emotional consequences; the main purpose of item development was simply to formulate a specific prediction that could be tested in a behavioral experiment. since depression has been linked to both lack of positive expectations (horwitz et al., 2017) and overly negative expectations (strunk et al., 2006), it was important for us to balance posi‐ tively and negatively worded items. originally, 75 items had been developed, and item reduction was performed in an on‐ line survey (n = 175), as described in detail in kube et al. (2017). it resulted in a 25-item version of the des, and a factor analysis revealed four factors: expectations of social re‐ jection, social support, personal performance, and negative mood regulation. high sum scores of the des reflect a greater endorsement of dysfunctional expectations. in three previous studies, the des has shown good psychometric properties (kube et al., 2017, 2018a, 2018b). specifically, internal consistency ranged in previous studies between α = .87 and α = .93; one-year retest reliability was r = 0.430; correlations with measures of depressive symptoms were high (correlation with the phq 9: r = .754, correlation with the bdi-ii: r = .572 and r = .527, respectively). in the current study, internal consistency for the clinical sample was α = .89 at the first measurement (for the healthy sample: α = .89) and α = .92 at follow-up (for the healthy sample: α = .94). five-months retest reli‐ ability was r = .509 for the clinical sample, and for the healthy sample r = .693. after a previous study examined the factorial structure of the des using a convenience sample (kube et al., 2017), we performed an exploratory factor analysis to analyze the factor structure using the clinical sample from the present study. the results of this factor anal‐ ysis revealed in general a similar factor structure as in the previous study, with the ex‐ ception that an additional fifth factor was found, labelled ‘approval by others’. the meth‐ ods, results, and discussion of this factor analysis can be found in the supplementary ma‐ terials. kube, herzog, michalak et al. 7 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ dispositional optimism we assessed dispositional optimism with the german version of the life orientation test revised (lot-r), originally developed by (scheier et al., 1994) and translated into ger‐ man by glaesmer et al. (2012). the lot-r is a 10-item self-report scale, of which four items are distractor items and excluded when computing the sum scores. the items are rated on a five-point likert scale. high values indicate positive outcome expectations. the lot-r has been shown to have good reliability and validity (glaesmer et al., 2012; reilley, geers, lindsay, deronde, & dember, 2005; scheier et al., 1994). for the clinical sample from the present study, internal consistency of the lot-r was α = .80, and for the healthy sample it was α = .73. generalized expectancies for negative mood regulation we used the generalized expectancies for negative mood regulation (nmr) scale (backenstrass et al., 2006; catanzaro & mearns, 1990) to examine incremental validity of the des over this existing measure, since the nmr scale also assesses one specific aspect of mdd-specific expectations (i.e. generalized expectancies for negative mood regula‐ tion). the nmr scale includes 30 items, and is rated using a five-point likert scale. high values reflect positive expectations. the nmr scale has been shown to be associated with depressive symptoms, and there is evidence for good reliability of this scale (backenstrass et al., 2006). in the current study, internal consistency for the clinical sample was α = .90 (for the healthy sample: α = .89). intermediate beliefs intermediate beliefs were assessed using a shortened version of the dysfunctional atti‐ tudes scale (das), originally developed by weissman and beck (1978) and translated into german by hautzinger, joormann, and keller (2005). the 26-item version of this scale is based on those items which have consistently been shown to belong to the dimensions “performance evaluation” and “approval by others” (cane, olinger, gotlib, & kuiper, 1986; joormann, 2004; prenoveau et al., 2009). previous studies have revealed good relia‐ bility and validity of the das (joormann, 2004; nelson, stern, & cicchetti, 1992). internal consistency for the clinical sample was α = .92 (for the healthy sample: α = .88). depressive symptoms we assessed depressive symptoms with the beck depression inventory-ii (beck, steer, ball, & ranieri, 1996). this well-established 21-item scale assesses somatic, cognitive and affective symptoms of depression (ranging from 0 to 63) with higher scores reflecting more severe symptoms of depression. the bdi-ii has shown good psychometric proper‐ ties (beck et al., 1996). expectations as predictors of depressive symptoms 8 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ sociodemographic variables socio-demographic variables were assessed in a self-report questionnaire including age, sex, education, and employment status. statistical analyses data screening was conducted according to the recommendations by tabachnick and fidell (2014). for four participants from the clinical sample, more than 40% of all data were missing. according to tabachnick and fidell (2014), these participants were exclu‐ ded. univariate outliers were inspected via standardized values of measured variables and their histograms (kline, 2005). according to cohen, cohen, west, and aiken (2003) and stevens (2002), multivariate outliers were examined via mahalanobis distance and cook’s distance. data from the participants who completed the follow-up questionnaire (52 participants from the clinical sample and 47 participants from the healthy sample) were used to perform a multiple linear hierarchical regression for the two samples, sepa‐ rately, according to the suggestions made by tabachnick and fidell (2014). the mcar test (little, 1988) yielded non-significant results in the respective samples, indicating that the values were missing completely at random. missing values were estimated using the expectation maximization procedure according to tabachnick and fidell (2014). a multi‐ variate analysis of variance (manova) examined differences between the healthy and the clinical sample. assumptions of multiple hierarchical linear regression analysis were carefully exam‐ ined. regression analysis was performed with the bdi-ii sum scores at follow-up as de‐ pendent variables. baseline bdi-ii sum scores were included as predictors in the first block. lot-r sum scores, nmr sum scores, and das sum scores from the first measure‐ ment were entered as predictors in the second block. baseline des sum scores were en‐ tered in the third block. importantly, although the aforementioned constructs des, lot-r, nmr expectancies and das represent dysfunctional cognitions, there was no multi-collinearity between the predictors, indicated by the variance inflation factor (all values < 10). in the results of the regression analyses, the standardized beta coefficients (β) are reported. type-1 error levels were set at 5%. all analyses were conducted with ibm spss statistics version 25. results sample characteristics healthy sample the mean participant sum score in the bdi-ii at baseline was 10.10 (sd = 9.07) indicating minimum levels of depression (beck et al., 1996). at follow-up, mean sum score in the bdi-ii was 8.57 (sd = 10.24), indicating the absence of clinically relevant symptoms of kube, herzog, michalak et al. 9 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ depression. bdi-ii sum scores at baseline ranged from 0 to 50, and eleven participants re‐ ported at least moderate levels of depression (bdi-ii ≥ 20), of which five participants completed the follow-up questionnaire. at follow-up, bdi sum scores ranged from 0 to 46, and four participants reported a sum score ≥ 20. as will be shown below, the results of the main analysis are strongly influenced by whether or not the five participants who reported elevated levels of depression at baseline and completed the follow-up are inclu‐ ded in the analysis. a paired samples t-test indicated that depressive symptoms in the healthy sample did not significantly change from baseline to follow-up, t(46) = 1.054, p = .297, d = 0.188. sim‐ ilarly, des sum scores did not change from baseline (m = 49.45; sd = 12.21) to follow-up (m = 49.06; sd = 15.96), t(46) = 0.227, p = .821, d = 0.032. sample characteristics regarding socio-demographic variables are presented in table 1. table 1 sociodemographic sample characteristics variable clinical sample (n = 91) healthy sample (n = 80) age in years, m (sd) 40.8 (13.2) 23.05 (5.32) sex, n (%)a male 28 (31.5) 20 (25.0) female 61 (68.5) 60 (75.0) educational level, n (%)b no educational degree 1 (1.2) 0 primary education 41 (47.7) 3 (3.8) secondary education 16 (18.6) 57 (71.3) higher education 28 (32.6) 20 (25.0) employment status, n (%)c full-time working 15 (17.2) 16 (20.0) part-time working 6 (6.9) 10 (12.5) in training 12 (13.8) 49 (61.3) unemployed 9 (10.3) 5 (6.3) disabled 14 (16.1) 0 be off sick 24 (27.6) 0 pensioners 5 (5.7) 0 homemaker 2 (2.3) 0 a2 missing values in the clinical sample; b5 missing values in the clinical sample; c4 missing values in the clinical sample. clinical sample in our sample, 36.7% of the participants were diagnosed with a major depressive episode, 55.7% with a recurrent depressive disorder, 3.8% with a bipolar disorder, and 3.8% with a expectations as predictors of depressive symptoms 10 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ “double depression” (dysthymia plus current depressive episode). about a quarter of all participants (24.7%) had at least one comorbid mental disorder with anxiety disorders be‐ ing most frequent (13.5%). the mean bdi-ii sum score at baseline was 28.7 (sd = 9.18) indicating severe levels of depression (beck et al., 1996). at the follow-up, the mean bdiii score was 19.25 (sd = 11.02) indicating moderate levels of depression. a paired samples t-test indicated that depressive symptoms significantly decreased from baseline to followup, t(50) = 5.205, p < .001, d = 0.922, reflecting a large effect according to cohen (1988). sdes also significantly changed from baseline (m = 68.71; sd = 13.25) to follow-up (m = 61.40; sd = 15.42), t(50) = 3.583, p = .001, d = 0.551, reflecting a medium effect according to cohen (1988). all sample characteristics regarding sociodemographic variables can be found in table 1. differences between samples a manova indicated significant differences between the two samples (clinical vs. healthy) at baseline, f(5, 165) = 73.315, p < .001, ηp 2 = .690. participants from the healthy sample had significantly fewer depressive symptoms, f(1, 169) = 175.818, p < .001, ηp 2 = .510, less pronounced situation-specific dysfunctional expectations, f(1, 169) = 68.775, p < .001, ηp 2 = .289, and less pronounced generalized expectancies for negative mood regulation, f(1, 169) = 51.518, p < .001, ηp 2 = .234. they were also more optimistic, f(1, 169) = 93.246, p < .001, ηp 2 = .356, and significantly younger than those from the clini‐ cal sample, f(1, 113) = 124.846, p < .001; ηp 2 = .425. frequency analyses revealed that par‐ ticipants from the two samples did not differ on sex distribution, χ2 = .865, p = .352. how‐ ever, healthy participants had significantly higher educational degrees, χ2 = 59.371, p < .001, and had, unlike the clinical sample, predominantly a student status, χ2 = 69.446, p < .001. main analysis: prediction of depressive symptoms using data from both samples, correlational analyses revealed significant inter-correla‐ tions of the scales used in this study, which can be found in table 2. table 2 correlational analyses from the healthy and clinical sample at baseline sample / variable bdi des nmr lot-r das healthy sample bdi .608** -.550** -.486** .289* des -.745** -.690** .512** nmr .685** -.490** lot-r -.371* das kube, herzog, michalak et al. 11 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ sample / variable bdi des nmr lot-r das clinical sample bdi .641** -.520** -.522** .534** des -.672** -.561** .634** nmr .497** -.468** lot-r -.535** das note. bdi = beck’s depression inventory ii; des = depressive expectations scale; nmr = generalized expect‐ ancies for negative mood regulation scale; lot-r = life orientation test revised; das = dysfunctional atti‐ tudes scale. *p < .05. **p < .001. healthy sample for the bdi-ii sum scores from the follow-up as dependent variable, the baseline levels of depression explained 10.9% of the variance, and had significant effects (β = .331; p = .023). the second set of predictors added another 14.7% of the explained variance which did not reach significance (p = .054); none of the predictors had significant effects. including the des sum scores as predictors in the third block added another 5.6% of the variance, which was not significant either (p = .074). the results of the regression analysis for the healthy sample can be found in table 3. when excluding the aforementioned five participants with elevated levels of depression, the pattern of results changed considerably. neither bdi sum scores at baseline (∆r 2 = .057; p = .127), nor the sum scores of the lot-r, das, nmr (∆r 2 = .011; p = .934), nor the sum scores of the des at baseline (∆r 2 = .001; p = .874) predicted depressive symptoms five months later. the overall explained variance was only 6.9%. clinical sample using the bdi-ii sum scores from the follow-up as dependent variables, the baseline bdiii sum scores explained 14.9% of the variance, p = .005; β = .387. the second set of predic‐ tors added another 7.2% of the variance (p = .240). in this step, none of the predictors had significant effects. when including the des sum scores in the third block, another 6.0% of the variance could be explained (p = .057). though there was a trend indicating the im‐ portance of des sum scores (β = .420; p = .057), none of the predictors in this step had significant effects. results of the multiple hierarchical linear regression analysis are pre‐ sented in table 3. expectations as predictors of depressive symptoms 12 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ table 3 prediction of depressive symptoms in the healthy sample (n = 47) and the clinical sample (n = 52) samples / predictors criterion: bdi-ii t2 β r 2 r 2 adj. ∆r 2 ∆f model healthy sample block 1 .109 .090 .109* 5.523* bdi-ii t1 .331* block 2 .256 .185 .147 2.766 bdi-ii t1 .103 das t1 .051 nmr t1 -.172 lot-r t1 -.281 block 3 .313 .229 .056 3.366 bdi-ii t1 .031 das t1 .026 nmr t1 -.003 lot-r t1 -.089 des t1 .455 clinical sample block 1 .149 .132 .145* 8.784* bdi-ii t1 .387* block 2 .221 .155 .072 1.450 bdi-ii t1 .256 das t1 .182 nmr t1 .162 lot-r t1 -.217 block 3 .281 .203 .060 3.804 bdi-ii t1 .173 das t1 .019 nmr t1 .332 lot-r t1 -.232 des t1 .420 note. t1 = baseline assessment; t2 = follow-up assessment; bdi-ii = beck depression inventory ii; des = de‐ pressive expectations scale; das = dysfunctional attitudes scale; nmr = generalized expectancies for nega‐ tive mood regulation scale; lot-r = life orientation test revised. *p < .05. kube, herzog, michalak et al. 13 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ discussion the aim of the present study was to examine situational expectations and more global cognitive vulnerabilities (i.e., dispositional optimism, generalized expectancies for nega‐ tive mood regulation and intermediate beliefs) as predictors of depressive symptoms in a longitudinal design. in doing so, we aimed to provide a contribution to a further specifi‐ cation of the cognitive model of depression (beck et al., 1979) by directly comparing the predictive values of negative global cognitions, which have been well studied in depres‐ sion (horwitz et al., 2017; strunk et al., 2006), and situational expectations, which have recently received increasing attention (rief et al., 2015). the results of the regression analyses indicate that for the healthy sample, none of the cognitive variables, whether global or situational, had significant effects on depressive symptoms five months later. there were only non-significant trends regarding the additionally explained variance when entering global cognitions (p = .054) and situational expectations (p = .074) as pre‐ dictors. these trends, however, completely disappeared when excluding five participants who reported elevated levels of depression at baseline, presumably due to the thus re‐ duced variance. in the clinical sample the effects of all cognitive variables on depressive symptoms did not reach significance either. there was merely a trend indicating the pre‐ dictive value of situational expectations above global cognitions (p = .054). thus, the present study failed to provide evidence for the significance of cognitive factors as pre‐ dictors of depressive symptoms. this is in contradiction with previous studies indicating the importance of both global (czyz, horwitz, & king, 2016; horwitz et al., 2017; strunk et al., 2006) and situational ex‐ pectations (kube et al., 2018b). further, it is inconsistent with findings from studies ex‐ amining cognitions other than expectations as predictors of depressive symptoms, such as dysfunctional attitudes (alloy et al., 2006; burns & spangler, 2001; jarrett et al., 2012). arguably, the absence of significant findings in the present study is, at least in the clini‐ cal sample, most likely due to the low attendance rate at follow-up. indeed, a post-hoc power analysis indicated that the power for, e.g., detecting an incrementally significant effect of situational expectations in the clinical sample was only 43%. in view of the ex‐ tremely low explained variance when considering the healthy sample without partici‐ pants with elevated depressive symptoms, the results of the healthy sample can best be interpreted in such a way that cognitive factors seem to have no influence whatsoever on depressive symptoms as long as there is low variability in depressive symptoms. the non-significant results of the current study could possibly be seen as an opportu‐ nity to shift the focus away from the effects of cognitions themselves on depressive symptoms to their change in the further investigation of the cognitive model of depres‐ sion. an excellent overview of directions for future research in this regard has been pro‐ posed by lorenzo-luaces, german, and derubeis (2015). in line with this notion, a series of recent studies has shown that depression is related to the absence of an optimistic bias in updating beliefs about the future (korn et al., 2014) and inflexibility in adjusting nega‐ expectations as predictors of depressive symptoms 14 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ tive interpretations after novel positive information (everaert, bronstein, cannon, & joormann, 2018). these findings are also in line with neurophysiological studies indicat‐ ing that depression is associated with difficulty in processing unexpected events (“predic‐ tion errors”) (garrett et al., 2014; gradin et al., 2011). limitations first and foremost, the results of the regression analyses have to be interpreted with cau‐ tion due to the small sample sizes at follow-up. given that the cognitive variables failed to reach significance in predicting depressive symptoms in the clinical sample, it is par‐ ticularly important to further explore the trend regarding the importance of situational expectations as a predictor in future studies. moreover, the small sample size at follow-up could account for the null findings regarding the influence of negative global cognitions on depressive symptoms. therefore, future studies should aim to examine the predictive values of these variables using larger samples, ideally also including more sophisticated diagnostic procedures incl. the determination of interrater-reliability. second, it has to be noted that the two samples considerably differed on sociodemographic variables. there‐ fore, it is difficult to draw inferences from the comparison of the samples. third, given the three different clinical subsamples, multilevel methods could be considered a more sophisticated approach of analysis. however, according to a simulation study on suffi‐ cient sample sizes for multilevel analyses (maas & hox, 2005), the sample size of the present study would have been at high risk of leading to biased estimates of the secondlevel standard errors, which is why we refrained from it. fourth, as the bdi-ii is a selfreport questionnaire for the measurement of depressive symptom severity, it might be useful in future studies to additionally use e.g. the hamilton depression rating scale (hamilton, 1960) as an observer-rated assessment. fifth, for some participants from the clinical sample, the follow-up interval was longer than five months, possibly resulting in additional variability among all participants regarding the prediction of depressive symp‐ toms. sixth, since all participants from the clinical sample received psychotherapeutic treatment between the two assessments, the prediction of depressive symptoms was pos‐ sibly influenced by the effects of later treatment. since the present study was not de‐ signed as an interventional study, it could not unravel specific mechanisms that may have impacted change in depressive symptoms. in sum, the current study aimed to further specify the cognitive model of depression by directly comparing the influence of global cognitions and situational expectations on depressive symptoms. in a healthy sample and a clinical sample, the present study found neither evidence of a significant influence of global cognitions nor of situational expecta‐ tions on depressive symptoms at follow-up. given the high drop-outs at follow-up, future studies should aim to investigate larger samples in order to examine the influence of dif‐ ferent cognitions on depressive symptoms. special attention might also be paid in future kube, herzog, michalak et al. 15 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ studies to changes in dysfunctional cognitions and their influence on symptoms, which could be analyzed using structural equation modeling. funding: the authors have no funding to report. competing interests: winfried rief is editor-in-chief of clinical psychology in europe but played no editorial role for this particular article. acknowledgments: the authors have no support to report. supplementary materials the methods, results, and discussion of the exploratory factor analysis for this study are provided in the supplementary materials (for access, see index of supplementary materials below). index of supplementary materials kube, t., herzog, p., michalak, c. m., glombiewski, j. a., doering, b. k., & rief, w. 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(1997). structured clinical interview for dsm-iv. göttingen, germany: hogrefe. appendices appendix 1: sample items of the des • expectations regarding social rejection: e.g., “when i ask someone for help, i will be rejected” • expectations regarding social support: e.g., “when i talk to someone about my problems, i will feel better afterwards” (inverted) • expectations regarding mood regulation: e.g., “when i’m feeling guilty, i will feel better when i lie down in my bed” • expectations regarding personal performance: e.g., “when i have to get an important task done, i will fail at it” appendix 2: completer analyses participants from the healthy sample who completed the entire study did not significantly differ from those healthy people who completed only the baseline assessment in baseline depressive symptoms, f(1, 78) = 0.066, p = .798; ηp 2 = .001; situational expectations, f(1, 78) = 2.811, p = .098; ηp 2 = .035; dispositional optimism, f(1, 78) = 3.164, p = .079; ηp 2 = .039; intermediate beliefs, f(1, 78) = 0.683, p = .411; ηp 2 = .009; expectancies for negative mood regulation, f(1, 78) = 0.476, p = .492; expectations as predictors of depressive symptoms 20 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://doi.org/10.1016/j.brat.2005.07.001 https://doi.org/10.3389/fpsyg.2013.00470 https://doi.org/10.1111/j.1755-5949.2011.00235.x https://doi.org/10.1007/s10608-010-9299-x https://doi.org/10.1016/s0065-2601(03)01006-2 https://www.psychopen.eu/ ηp 2 = .006; age, f(1, 78) = 0.105, p = .746; ηp 2 = .001; sex, χ2(1) = 2.080, p = .149; education, χ2(2) = 0.560, p = .756; or employment status, χ2(3) = 2.674, p = .445. similarly, in the clinical sample completers did not significantly differ from non-completers in baseline depressive symptoms, f(1, 89) = 2.384, p = .126; ηp 2 = .026; situational expectations, f(1, 89) = 0.126, p = .723; ηp 2 = .001; dispositional optimism, f(1, 89) = 0.598, p = .442; ηp 2 = .007; inter‐ mediate beliefs, f(1, 89) = 0.058, p = .810; ηp 2 = .001; expectancies for negative mood regulation, f(1, 89) = 0.050, p = .823; ηp 2 = .001; age, f(1, 89) = 3.702, p = .058; ηp 2 = .040; primary diagnosis, χ2(3) = 4.095, p = .251; comorbid diagnosis, χ2(7) = 4.195, p = .757; sex, χ2(1) = 1.975, p = .160; education, χ2(5) = 6.715, p = .243; or employment status, χ2(7) = 3.738, p = .809. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. kube, herzog, michalak et al. 21 clinical psychology in europe 2019, vol.1(4), article e33548 https://doi.org/10.32872/cpe.v1i4.33548 https://www.psychopen.eu/ expectations as predictors of depressive symptoms (introduction) aims and hypotheses method participants and procedure measures statistical analyses results sample characteristics main analysis: prediction of depressive symptoms discussion limitations (additional information) funding competing interests acknowledgments supplementary materials references appendices appendix 1: sample items of the des appendix 2: completer analyses towards integration and impact: clinical psychology takes action for mental health in europe editorial towards integration and impact: clinical psychology takes action for mental health in europe tanja endrass a, philipp kanske ab [a] institute of clinical psychology and psychotherapy, faculty of psychology, technische universität dresden, dresden, germany. [b] max planck institute for human cognitive and brain sciences, leipzig, germany. clinical psychology in europe, 2019, vol. 1(4), article e49194, https://doi.org/10.32872/cpe.v1i4.49194 published (vor): 2019-12-17 corresponding author: tanja endrass, technische universität dresden, faculty of psychology, insititute of clinical psychology and psychotherapy, chair of addiction research, 01062 dresden, germany. phone +49 351 463 32460, fax +49 351 463 39830. e-mail: tanja.endrass@tu-dresden.de from october 31 to november 2, 2019, the first conference of the new european associa‐ tion of clinical psychology and psychological treatment (eaclipt) took place at tech‐ nische universität dresden, germany (beesdo-baum et al., 2019). it was a historic mo‐ ment that brought together clinical psychologists from many different regions of the world. about 300 researchers and psychotherapists discussed the most recent develop‐ ments in clinical psychology, possibilities for outreach, collaboration across countries, improvement of therapy delivery and the science-policy dialogue. with their inspiring presentations, they brought to life one of the main goals of eaclipt: fostering exchange among clinical psychologists from all over europe (andersson, 2019). the five renowned keynote speakers reflected the diversity of topics at #eaclipt2019: claudi bockting (university of amsterdam) called for more engagement with european politicians to raise awareness for mental health and the efficacy of psychological treatments. present‐ ing the improving access to psychological therapies program (iapt; clark, 2018), david clark (university of oxford) demonstrated that such engagement can be extremely fruit‐ ful. new developments in psychotherapy were presented by susan bögels (university of amsterdam) on mindfulness in families and by maria karekla (university of cyprus) on e-mental-health tools. stefan hofmann (boston university) integrated different novel ap‐ proaches in his talk on modern process-based cognitive behavioral therapy. the scientific program included symposia and posters on novel developments in the field of mechanisms underlying mental disorders, epidemiology, prevention, diagnostics, psychotherapeutic treatment, and methods. thus, the full spectrum of clinical psycholo‐ gy and psychological intervention was represented at the conference. the program also this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i4.49194&domain=pdf&date_stamp=2019-12-17 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ included three stimulating panel discussions on current topics of clinical psychology. the first discussion addressed the theme of the conference “no health without mental health” and focused on how to move forward in research as well as on how clinical psy‐ chology can contribute to european initiatives. the discussion on "psychotherapy and psychotherapy training across europe" addressed the problem of immense heterogeneity in national regulations of clinical psychology and psychological treatment. the differen‐ ces across european countries pose problems for collaborative research initiatives and exchange in education; potential solutions were discussed (laireiter & weise, 2019). "challenges and innovations for psychotherapy" was the topic of the final panel which focused on transdiagnostic research strategies as well as new innovative mechanismbased interventions and online therapies. although we can only transmit a brief idea of the rich panel discussions, we can subsume that they covered highly relevant topics and stimulated reflections about the current situation in clinical psychology, and brought to‐ gether knowledge, experiences and insights into future perspectives by professionals from diverse fields and different countries. figure 1. panel discussion "no health without mental health", discussants: tanja endrass, philipp kanske, stefan hofmann, claudi bockting, agnieszka popiel, martin grosse holtforth. photo and copyright by michael höfler, published under a cc-by 4.0 license. besides the official scientific program, additional preand post-conference workshops were held on “psychopathology and the social brain” (philipp kanske and jan haaker, funded by die junge akademie), “suicide prevention in germany” (susanne knappe, fun‐ ded by the federal ministry for health), “ubiquity new perspectives on experienced traumata” (philipp kanske and miriam akkermann, funded by die junge akademie), and an early career research workshop (lara maliske and susanne knappe, supported towards integration and impact 2 clinical psychology in europe 2019, vol.1(4), article e49194 https://doi.org/10.32872/cpe.v1i4.49194 https://www.psychopen.eu/ by springer nature). during the members meeting, claudi bockting was elected as the new president of eaclipt. with her motivation for more political engagement she will push for increasing awareness for mental health at the european level. finally, we would like to highlight the great posters presented at the conference and congratulate the two young researchers who were awarded the first eaclipt poster prize: marie-christin atzor (poster title: “tell me something good! the influence of experience reports on atti‐ tude towards psychotherapy”, university of marburg, germany) and marike van vugt (poster title: “using computational process of depressive rumination to predict cognitive deficits”, university of groningen, netherlands; funded by wiley). figure 2. postersession at the eaclipt conference. endrass & kanske 3 clinical psychology in europe 2019, vol.1(4), article e49194 https://doi.org/10.32872/cpe.v1i4.49194 https://www.psychopen.eu/ beyond these specific events, most participants will keep a great memory of the stimulat‐ ing and warm ambience of this meeting. people were standing together, engaged in com‐ munication and exchanging ideas, and new projects and collaborations were started. fi‐ nally, the conference would not have been possible without the great help of our collea‐ gues in the organizing team, hannah niermann, katja beesdo-baum, jürgen hoyer, and corinna jacobi, as well as many other contributors and everyone, who presented their work, making the conference a fantastic start for now yearly meetings of eaclipt. funding: financial support for the conference was granted by the german academic exchange service, the german research foundation, and the technische universität dresden. references andersson, g. (2019). the european association of clinical psychology and psychological treatment (eaclipt): a new organization for the future! clinical psychology in europe, 1(1), article e33241. https://doi.org/10.32872/cpe.v1i1.33241 beesdo-baum, k., endrass, t., hoyer, j., jacobi, c., & kanske, p. (2019). no health without mental health – european clinical psychology takes responsibility. clinical psychology in europe, 1(1), article e34220. https://doi.org/10.32872/cpe.v1i1.34220 clark, d. m. (2018). realizing the mass public benefit of evidence-based psychological therapies: the iapt program. annual review of clinical psychology, 14(1), 159-183. https://doi.org/10.1146/annurev-clinpsy-050817-084833 laireiter, a.-r., & weise, c. (2019). the heterogeneity of national regulations in clinical psychology and psychological treatment in europe. clinical psychology in europe, 1(1), article 34406. https://doi.org/10.32872/cpe.v1i1.34406 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. towards integration and impact 4 clinical psychology in europe 2019, vol.1(4), article e49194 https://doi.org/10.32872/cpe.v1i4.49194 https://doi.org/10.32872/cpe.v1i1.33241 https://doi.org/10.32872/cpe.v1i1.34220 https://doi.org/10.1146/annurev-clinpsy-050817-084833 https://doi.org/10.32872/cpe.v1i1.34406 https://www.psychopen.eu/ optimizing expectations about endocrine treatment for breast cancer: results of the randomized controlled psy-breast trial research articles optimizing expectations about endocrine treatment for breast cancer: results of the randomized controlled psy-breast trial meike c. shedden-mora ab, yiqi pan a, sarah r. heisig b, pia von blanckenburg c, winfried rief c, isabell witzel d, ute-susann albert e, yvonne nestoriuc abf [a] department of psychosomatic medicine and psychotherapy, university medical center hamburg-eppendorf, hamburg, germany. [b] department of clinical psychology and psychotherapy, hamburg university, hamburg, germany. [c] department of clinical psychology and psychotherapy, philipps-university of marburg, marburg, germany. [d] department of gynecology, university medical center hamburg-eppendorf, hamburg, germany. [e] department of gynecology, university medical center würzburg, würzburg, germany. [f] department of clinical psychology, helmut schmidt university hamburg, hamburg, germany. clinical psychology in europe, 2020, vol. 2(1), article e2695, https://doi.org/10.32872/cpe.v2i1.2695 received: 2019-06-20 • accepted: 2019-11-05 • published (vor): 2020-03-31 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: meike c. shedden-mora, department of psychosomatic medicine and psychotherapy, university medical center hamburg-eppendorf, martinistraße 52, 20246 hamburg, germany. phone: +49-40-7410-54323. fax: +49-40-7410-54975. e-mail: m.shedden-mora@uke.de abstract background: medication side effects are strongly determined by non-pharmacological, nocebo mechanisms, particularly patients’ expectations. optimizing expectations could minimize side effect burden. this study evaluated whether brief psychological expectation management training (expect) optimizes medication-related expectations in women starting adjuvant endocrine therapy (aet) for breast cancer. method: in a multisite randomized controlled design, 197 women were randomized to expect, supportive therapy (support), or treatment as usual (tau). the three-session cognitivebehavioral expect employs psychoeducation, guided imagery, and side effect management training. outcomes were necessity-concern beliefs about aet, expected side effects, expected coping ability, treatment control expectations, and adherence intention. results: both interventions were well accepted and feasible. patients’ necessity-concern beliefs were optimized in expect compared to both tau and support, d = .41, p < .001; d = .40, p < .001. expected coping ability and treatment control expectations were optimized compared to tau, d = .35, p = .02; d = .42, p < 001, but not to support. adherence intention was optimized compared to support, d = .29, p = .02, but not to tau. expected side effects did not change significantly. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i1.2695&domain=pdf&date_stamp=2020-03-31 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: expectation management effectively and partly specifically (compared to support) modified medication-related expectations in women starting aet. given the influence of expectations on long-term treatment outcome, psychological interventions like expect might provide potential pathways to reduce side effect burden and improve quality of life during medication intake. keywords expectation management, nocebo effect, psychological intervention, side effect, adjuvant endocrine treatment, breast cancer, oncology highlights • expectation management (expect) optimizes expectations prior to endocrine therapy for breast cancer. • expect improved necessity-concern beliefs, coping and control expectations and adherence intention. • expect was partly more effective than the supportive therapy control condition. • expectation management provides a pathway to reduce side effect burden during long-term medication. medication side effects are substantially determined by mechanisms which are not di‐ rectly attributable to the pharmacodynamics of the treatment. these non-specific side effects are well-known from the nocebo phenomenon which manifests itself when ad‐ verse effects occur after placebo intake (barsky, saintfort, rogers, & borus, 2002). nocebo effects may also emerge as part of routine treatments. hence, non-specific medication side effects might aggravate the impact of specific side effects (rief, bingel, schedlowski, & enck, 2011). nocebo-related side effects are predominantly determined by psychological mech‐ anisms, most relevantly patients’ expectations (webster, weinman, & rubin, 2016). expectations are influenced by treatment information, social observation, and other learning processes through negative experiences with prior medication intake (colloca & miller, 2011). analogous to expecting treatment benefits, patients also develop expecta‐ tions about potential adverse events (laferton, kube, salzmann, auer, & shedden-mora, 2017), and form beliefs about their medication’s necessity and possible concerns (horne, weinman, & hankins, 1999). these side effect expectations and medication beliefs are linked to the actual occurrence of side effects of cancer treatments (colagiuri & zachariae, 2010; nestoriuc et al., 2016), and other therapies (faasse & petrie, 2013; nestoriuc, orav, liang, horne, & barsky, 2010). importantly, side effect expectations and medication beliefs not only predict long-term quality of life, but also medication non-adherence (horne et al., 2013; nestoriuc et al., 2016; pan et al., 2018). optimizing expectations about cancer treatment 2 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ as expectations are potentially modifiable factors, optimizing patients’ treatment expectations has been put forward as a novel strategy to improve treatment outcome and minimize side effect burden (bingel, 2014; heisig, shedden-mora, hidalgo, & nestoriuc, 2015; laferton et al., 2017; nestoriuc et al., 2016). first evidence from experimental studies suggests that psychological expectation management can effectively improve par‐ ticipants’ expectations regarding anti-cancer treatments (heisig, shedden-mora, hidalgo, & nestoriuc, 2015), reduce pain (peerdeman et al., 2016) and even reverse nocebo effects (bartels et al., 2017). to date, the psy-heart-trial (rief et al., 2017) showed that brief expectation management prior to open-heart surgery successfully changes expectations (laferton, auer, shedden-mora, moosdorf, & rief, 2016), improves long-term disability, quality of life and reduces the length of hospital stay (auer et al., 2017). this study employs expectation management in patients undergoing adjuvant en‐ docrine therapy (aet) for breast cancer. aet is the state-of-the-art treatment for hor‐ mone-receptor-positive breast cancer. intake for at least five years improves disease-free survival and time to recurrence (burstein et al., 2014). despite its proven clinical efficacy, non-adherence rates ranging from 28% to 73% within the 5-year intake period have been reported (murphy, bartholomew, carpentier, bluethmann, & vernon, 2012). as low adherence is associated with poorer survival (hershman et al., 2011), ensuring patients’ adherence is crucial. side effects such as arthralgia, hot flushes, weight gain, and loss of libido can substantially reduce quality of life (cella & fallowfield, 2008) and cause treatment discontinuation (demissie, silliman, & lash, 2001). side effects occur related to the specific pharmacodynamics of aet (e.g., hot flushes are caused by the deprivation of estrogen), but can also be treatment-unrelated (e.g., dizziness) (gibson, lawrence, dawson, & bliss, 2009). relevantly, side effect expectations predict the actual occurrence of cancer treatment side effects (colagiuri & zachariae, 2010), long-term quality of life, and non-adherence in aet (nestoriuc et al., 2016; pan et al., 2018). the aim of this study was to evaluate whether a three-session psychological ex‐ pectation management training (expect; von blanckenburg, schuricht, albert, rief, & nestoriuc, 2013; von blanckenburg et al., 2015) optimizes patients’ aet-related expecta‐ tions when starting aet. this study reports the preto post-intervention change of expectations of the psy-breast trial (expectation-focused psychological pre-treatment intervention to improve outcome in breast cancer treatment). expect was compared to a psychological control intervention (supportive therapy, support), and treatment as usual (tau). it is hypothesized that expect but not support and tau improves expectations regarding the prescribed aet medication and its side effects, the expected ability to cope with potential side effects, and treatment control expectations. secondly, it is hypothesized that only expect improves the intention to adhere to aet. shedden-mora, pan, heisig et al. 3 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ method study design this was a three-arm multisite (two centers with four clinics), randomized controlled tri‐ al. it was registered at clinicaltrials.gov (nct01741883). ethical approval was obtained from the respective local ethics committees (marburg, hamburg). outcomes for this analysis were compared between baseline and post-intervention (figure 1). a detailed de‐ scription of the design is provided in the study protocol (von blanckenburg et al., 2013). after study inclusion, patients were randomly assigned to receive expect, support, or tau. treatment as usual (tau) in all groups consisted of the general guideline-based oncologic regime in the certified breast cancer centers, usually surgery and radiation, followed by adjuvant endocrine treatment with tamoxifen or third-generation aromatase inhibitors (kreienberg et al., 2012). the decision of the type of aet mainly depended on the women’s menopausal status. all patients were offered one session basic psycho-on‐ cological support by a trained psycho-oncologist of the hospital staff. after discharge, patients were treated in an outpatient setting by a gynecologist, general practitioner, and if desired, a psycho-oncologist with up to 12 sessions. patients were allocated in a 1:1:1 ratio stratified according to the hospital anxiety and depression scale (sum score ≤13 vs. >13) and type of medication (aromatase inhibitor vs. tamoxifen). participant enrollment data were collected between november 2012 and may 2015 at the philipps university of marburg and the university medical center hamburg-eppendorf, germany. patients were recruited post-surgery during their hospital stay. included were women aged 18-80 years, with hormone-receptor-positive breast cancer or ductal carcinoma in situ to whom first-line adjuvant endocrine treatment with tamoxifen or third generation aromatase inhibitors was prescribed. further inclusion criteria were the ability to give informed consent and sufficient german language skills. exclusion criteria were advanced breast cancer, the presence of any other cancer or comorbid somatic illness causing predomi‐ nant disability, severe psychiatric illness (e.g., psychosis, checked by structured psychiat‐ ric interview, mini-dips), and adjuvant chemotherapy. after providing written informed consent, all patients received a medication infor‐ mation leaflet accompanied by an oral briefing by trained research assistants. this previously validated information illustrated the mode of action, the desired effects, and potential side effects of aet in order to homogenize knowledge (heisig, shedden-mora, von blanckenburg, et al., 2015). the information briefing was followed by baseline assessment and randomization. outcome assessors (trained research assistants) were blinded to group allocation throughout the study. for this analysis, the sample of n = 197 patients will allow the detection of small effect sizes, f(v) = .11, with 80% power and α = .05. optimizing expectations about cancer treatment 4 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ psychological interventions patients received three individual weekly or bi-weekly treatment sessions of 50-75-mi‐ nutes by a clinical psychologist, followed by up to three 15-minutes booster phone calls at one, three, and six months. a detailed description of the interventions can be found in the study protocol (von blanckenburg et al., 2013) and case report (von blanckenburg et al., 2015). all therapists received regular supervision by experienced psycho-oncologists. therapist allegiance evaluated via video ratings was considered as high (appendix). expect – expectation management training expect is based on cognitive-behavioral therapy and aims to prevent nocebo-related side effects from aet by optimizing treatment-related expectations. the focus on side ef‐ fects is counterbalanced by therapeutic work towards strengthening beliefs of treatment control, benefit, and necessity. expect is manualized; however, topics are adapted to the patient’s individual expectations using a personalized intervention booklet. the three sessions have the following goals and topics: session 1. psychoeducation about aet (mode of action, benefits, potential side effects) is given. the impact of expectations and the nocebo effect are discussed. the aim is to strengthen beliefs about aet’s necessity while keeping concerns at a realistic minimum (heisig, shedden-mora, von blanckenburg, et al., 2015). an imagery exercise guides the patients towards visualizing the expected benefits of aet. session 2. coping strategies for managing the three individually most feared side effects are developed (mann et al., 2012). these include behavioral techniques, cognitive strategies, and management of specific triggers. strategies are summarized in a written problem-solving scheme, and patients are encouraged to create a practical ‘tool-box’. session 3. to strengthen resources for the medication intake period, resourceful activi‐ ties (e.g., gardening) are encouraged. to support defocusing from side effects, attention control strategies are discussed. to enhance effective patient-doctor communication, patients receive a communication skills training. at the end of the session, the tool-box and all previous topics are reviewed. booster calls. the three booster calls aim to provide therapeutic support during the first months of medication intake. patients are encouraged to apply the learned coping strategies for side effects, which are adapted if necessary. supportive therapy (support) supportive therapy was designed as an active psychological control condition to account for general therapeutic factors such as the therapist’s attention and the patient-thera‐ pist relationship (markowitz, manber, & rosen, 2008). it allows distinguishing specific effects of expect from psychological placebo effects. it applies common factors of psychotherapy such as elicitation of affect, empathy, and reflective listening. in contrast to expect, no explicit theoretical framework and no expectation-targeted interventions shedden-mora, pan, heisig et al. 5 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ are provided. each session is structured into three phases: the beginning (inquiring about relevant topics), the therapeutic dialog (encouraging the patient to talk about any theme of affective valence), and the ending (revising addressed themes). the booster calls are conducted analogously to expect, with focus on the patient’s emotional state. assessment patients’ expectations medication-related expectations about aet were assessed using the necessity-concern balance as measured by the beliefs about medicines questionnaire (bmq; horne et al., 1999). a difference score ranging from -4 to 4 is calculated by subtracting the mean expected necessity scale (5 items) from the mean expected concerns scale (6 items) (horne et al., 2013). positive scores indicate stronger necessity beliefs than concerns (≈ functional balance). the mean intensity of 44 expected side effects was assessed using the general assess‐ ment of expected side effects scale (gase-expect; nestoriuc et al., 2016) which measures the expected intensity of 23 general and 21 aet-specific side effects on a 0 (‘not present’) to 3 (‘severe’) scale. the expected ability to cope with the potential 44 expected side effects in case of their presence was assessed on a 1 (‘expect to cope badly’) to 4 (‘expect to cope very well’) scale. treatment control expectation was assessed with the respective item (‘how much do you think your aet can help your breast cancer?’) from the brief illness percep‐ tion questionnaire (b-ipq), ranging from 0 (‘not at all’) to 10 (‘extremely helpful’). (broadbent, petrie, main, & weinman, 2006) adherence intention adherence intention was assessed with the question ‘how certain are you about starting the endocrine therapy?’ rated on a 7-point scale (from 1 ‘very unsure’ to 7 ‘very sure’). sociodemographic and medical variables age, education, and marital status were assessed. medical variables, namely menopausal status, and breast cancer tumor stage were retrieved from the hospitals’ patient records. patients provided information on their prescribed aet and existing medical comorbidi‐ ties. the presence and intensity of 44 current somatic complaints were assessed on a 0 to 3 scale using the gase (rief, barsky, et al., 2011). patients’ evaluation of the intervention patients evaluated the intervention on nine statements rated from 1 (‘do not agree at all’) to 6 (‘fully agree’). the general satisfaction with the intervention, specific components optimizing expectations about cancer treatment 6 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ of expect, and therapeutic components imminent to supportive therapy were assessed. potential adverse events of the interventions were assessed with an open-ended question. treatment fidelity was assessed by asking patients how often they practiced the im‐ agery exercise on one 1 (‘daily’) to 5 (‘not at all’) scaled item. additionally, participation in booster sessions was assessed. therapeutic alliance was rated by patients and therapists after each session with two questions (the intervention has helped me / the patient, the psycho-oncologist un‐ derstands me / the patient felt understood) from 1 (‘do not agree at all’) to 6 (‘fully agree’). data analysis to examine whether expect resulted in improved expectations compared to support and tau, we computed linear mixed models with treatment group, time (prevs. postintervention) and treatment group by time as fixed effects and a random intercept for subject-specific effects with a restricted maximum likelihood estimation and an autoregressive residual matrix. all analyses were adjusted for study site, age, type of aet, breast cancer tumor stage, and physical symptoms (gase) as fixed effects. for the hypothesized treatment group by time interaction, pairwise comparisons were reported. pre-post-tests were performed to indicate improvements within a group. missing values on single items ranged from 0 to 3.5% and were imputed using the em-algorithm. missing data points at post-intervention were estimated within the linear mixed model using the full intention-to-treat sample. effect sizes were calculated as differences in mean growth rates between the groups, divided by the product of standard error by square rooted number of participants in tau (feingold, 2009). significance level for all analyses was set at α = .05. statistical analyses were performed using spss statistics 24. results participant flow of 506 women assessed for eligibility, 271 were eligible for study participation, 197 patients were randomized analyzed as the itt-sample (figure 1). of those, 165 completed post-intervention assessment (83.8%). women who discontinued aet before post-intervention assessment (expect: n = 0; support: n = 4; tau: n = 2), and women who did not start the intervention (expect: n = 5, support: n = 10), but completed post-assessment were included in the analyses to avoid selection bias. fifty-four women (79.4%) in expect and 55 women (80.9%) in support received all three sessions. shedden-mora, pan, heisig et al. 7 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ figure 1 patient flow (consort) note. aet = adjuvant endocrine treatment; tau = treatment as usual; support = supportive therapy; expect = expectation management training. aof n = 203 randomized patients, 6 were identified as non-eligible post-randomization and therefore excluded. baseline characteristics all baseline sociodemographic and clinical characteristics were comparable across the groups (table 1). optimizing expectations about cancer treatment 8 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ table 1 demographic and clinical sample characteristics variable expect (n = 68) support (n = 68) tau (n = 61) comparison f | χ2 p demographics age in years, m (sd) 56.46 (8.92) 58.44 (8.40) 59.64 (10.74) f(2, 197) = 1.92 .15 at least 13 years of education, n (%) 24 (35.8) 28 (41.8) 21 (34.4) χ2(2) = 0.85 .65 married/with partner, n (%) 42 (61.8) 45 (66.2) 36 (59) χ2(2) = 0.72 .70 clinical symptoms peri-/post-menopausal, n (%) 49 (72.1) 53 (77.9) 48 (78.7) χ2(2) = 0.96 .62 tumor stage uicc, n (%) χ2(4) = 3.49 .48 i 41 (60.3) 42 (61.8) 44 (72.1) ii 23 (33.8) 24 (33.8) 16 (26.2) iii 4 (5.9) 2 (2.9) 1 (1.6) type of aet, n (%) χ2(2) = 2.19 .34 tamoxifen 37 (54.4) 35 (51.5) 39 (63.9) aromatase inhibitors 31 (45.6) 33 (48.5) 22 (36.1) medical comorbidities, n (%) χ2(4) = 0.76 .94 0 25 (36.8) 23 (33.8) 19 (31.1) 1 or 2 35 (51.5) 38 (55.9) 36 (59) ≥ 3 8 (11.8) 7 (10.3) 6 (9.8) number of current somatic complaints (gase) m (sd) 11.10 (6.70) 9.34 (6.20) 9.98 (7.11) f(2, 197) = 1.22 .30 range 0 31 0 26 0 29 intensity of current somatic complaints (gase) m (sd) 0.33 (0.24) 0.30 (0.25) 0.31 (0.25) f(2, 197) = 0.32 .73 range 0 3 0 3 0 3 note. expect = expectation management training; support = supportive therapy; tau = treatment as usual; aet = adjuvant endocrine therapy; uicc = union for international cancer control; gase = general assessment of side effects scale. the majority of the women were diagnosed with tumor stage i (64.5%). the most frequent comorbidities were hypertension (32.0%), thyroid diseases (25.9%), and joint or dorsal pain (18.3%). most common baseline somatic symptoms comprised pain or sensitivity of the breast (71.6%), sleeping problems (52.3%), and fatigue (50.5%). changes in patients’ expectations the necessity-concern balance at baseline was rather positive in all groups (table 2). shedden-mora, pan, heisig et al. 9 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ table 2 outcome measures at baseline and post-intervention outcome expect support tau expect vs. tau expect vs. support t p d t p d medication beliefs: necessity-concern balance (bmq; range -4-4) 3.33 < .001 0.43 3.15 < .001 0.40 baseline 0.68 [0.43, 0.93] 0.82 [0.57, 1.06] 0.77 [0.51, 1.04] post-intervention 1.06 [0.79, 1.33] 0.63 [0.36, 0.90] 0.54 [0.27, 0.83] expected side effects, mean intensity (gase-expect; range 0-3) -1.69 .092 -0.22 -0.66 .51 -0.09 baseline 0.56 [0.48, 0.64] 0.50 [0.42, 0.59] 0.47 [0.38, 0.55] post-intervention 0.53 [0.44, 0.62] 0.51 [0.42, 0.60] 0.54 [0.45, 0.63] expected coping ability, mean (gase coping; range 1-4)a 2.45 .015 0.35 1.44 .15 0.21 baseline 3.49 [3.39, 3.58] 3.53 [3.44, 3.63] 3.61 [3.51, 3.72] post-intervention 3.63 [3.53, 3.74] 3.56 [3.46, 3.66] 3.55 [3.44, 3.66] expected treatment control (b-ipq; range 0-10) 3.27 < .001 0.42 1.65 .10 0.21 baseline 7.43 [6.89, 7.98] 7.51 [6.97, 8.05] 7.91 [7.33, 8.48] post-intervention 7.73 [7.14, 8.31] 7.11 [6.53, 7.69] 6.79 [6.18, 7.40] adherence intention (range 1-7) 1.85 .065 0.24 2.27 .024 0.29 baseline 6.05 [5.73, 6.37] 6.37 [6.05, 6.69] 6.32 [5.98, 6.66] post-intervention 6.66 [6.30, 7.01] 6.27 [5.91, 6.62] 6.33 [5.97 -6.70] note. values indicate estimated marginal means [95% ci]. analyses are adjusted for study side, age, type of aet, breast cancer tumor stage, and baseline physical symptoms. statistical comparisons (tand p-values) refer to the pairwise comparisons of the treatment group by time interaction. expect = expectation management training; support = supportive therapy; tau = treatment as usual. asample size for analysis n = 172 (25 patients did not expect any side effects). a significant group by time interaction indicated an improved necessity-concern balance in expect compared to both tau and support, estimated mean difference = 0.61, 95% ci [0.25, 0.98], p = .001; 0.57, 95% ci [0.21, 0.93], p = .002, respectively (figure 2). pre-post within-group comparisons indicated that significant improvements in the necessity-concern balance only occurred in expect but not in tau and support, 0.38, 95% ci [0.13, 0.64], p = .003; -0.23, 95% ci [-0.49, 0.03], p = .085; -0.19, 95% ci [-0.44, 0.07], p = .147. when the scales were analyzed separately, expect showed an increase of necessity beliefs compared to support and in trend to tau, 0.27, 95% ci [0.00, 0.54], p = .049; 0.25, 95% ci [-0.03, 0.53], p = .075, respectively. expect reported a reduction of concerns compared to tau and support, -.37, 95% ci [-.59, -.14], p = .002; -.30, 95% ci [-.53, -.08], p = .008. mean expected side effects at baseline were low. non-significant group by time interac‐ tions indicated that the groups did not differ, expect vs. support: -0.04, 95% ci [-0.16, 0.08], p = .51; vs. tau: -0.11, 95% ci [-0.23, 0.02], p = .092. pre-post comparisons showed no significant change over time in any group. the mean expected ability to cope with potential side effects, which was analyzed for 172 patients who expected at least one of the 44 side effects, was high at baseline. a optimizing expectations about cancer treatment 10 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ significant group by time interaction indicated improved coping expectations in expect compared to tau, but not to support, 0.22, 95% ci [0.04, 0.39], p = .015; 0.12, 95% ci figure 2 expectations at baseline and post-intervention note. values shown are estimated marginal means (error bars: ± 1 standard error) from linear mixed models. tau = treatment as usual, support = supportive therapy, expect = expectation management training. numbers after scale names indicate the range. *p < .05. **p < .01 shedden-mora, pan, heisig et al. 11 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ [-0.05, 0.29], p = .15. pre-post comparisons indicated that coping expectations significant‐ ly improved in expect, but not in tau or support, 0.15, 95% ci [0.03, 0.27], p = .013; -0.07, 95% ci [-0.20, 0.06], p = .30, 0.03, 95% ci [-0.09, 0.15], p = .65. treatment control expectations at baseline were moderately high. a significant group by time interaction indicated that expect developed significantly higher treatment control expectations compared to tau, but not to support, 1.41, 95% ci [0.56, 2.27], p = .001; 0.70, 95% ci [-0.14, 1.54], p = .10. pre-post comparisons indicated that treatment control expectations declined in tau, but did not change in expect or support, -1.12, 95% ci [-1.73, -.51], p < .001; 0.30, 95% ci [-0.30, 0.89], p = .33; -0.40, 95% ci [-1.00, 0.19], p = .18. changes in adherence intention adherence intention at baseline was high (table 2). expect developed a significantly higher intention to adhere to their aet compared to support, and in trend compared to tau, 0.71, 95% ci [0.09, 1.33], p = .024; 0.59, 95% ci [-0.04, 1.22], p = .065 (figure 2). pre-post comparisons indicated that adherence intention significantly increased in expect, but not in tau and support, 0.61, 95% ci [0.17, 1.04], p = .007; 0.01, 95% ci [-0.44, 0.47], p = .96; -0.11, 95% ci [-0.54, 0.33], p = .63, respectively. patients’ evaluation of the intervention the general satisfaction was very high in both groups, while the expect-specific components (e.g., feeling more prepared to face aet side effect) were evaluated more positively in expect (figure 3). support-specific components (e.g., easier to cope with emotions) were evaluated non-significantly better in support. regarding adverse events of the interventions, 14 patients in expect and 13 patients in support reported at least one adverse event. in expect, patients reported: organiza‐ tional issues (4), the number of sessions being too few (4) or too many (1), too much focus on adverse events (2), emotional distress (1), needing more recommendations on coping with side effects (1), and having no need for the intervention (1). in support, patients reported: organizational issues (4), too little focus on aet (3), too much focus on possible adverse events (1), the number of sessions being too few (1), needing more recommendations on coping with side effects (1), emotional distress (1), and wish for being asked more questions (1). regarding treatment fidelity, 39 patients in expect (70.9%, 55 datasets available) practiced their individual protective image developed in the intervention at least once a week. moreover, at least one booster session was taken up by 52 patients (76.5%) in expect and 51 patients (75%) in support. regarding therapeutic alliance, patients in both groups highly agreed that the inter‐ vention had helped them, expect: m (sd) = 5.70 (0.40); support: 5.62 (0.47), and that optimizing expectations about cancer treatment 12 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ they felt understood, 5.43 (0.52); 5.30 (0.61). therapists fully agreed that the intervention might have helped the patient, expect: 5.07 (0.75); support: 4.73 (1.09), and that patients felt understood, 5.27 (0.70); 5.32 (0.61). patient and therapist ratings showed medium correlations across both groups, item help: r = .408, p < .001; item understanding: r = .317, p < .001). discussion this randomized controlled trial investigated whether a brief expectation-focused psy‐ chological intervention (expect) optimizes patients’ medication-related expectations before starting aet for breast cancer. in summary, patients’ necessity-concern beliefs about aet were significantly optimized in expect as compared to both tau and figure 3 patients’ evaluation of expect and support interventions note. general = general satisfaction with the intervention; expect-specific = specific components of expectation management training; support-specific = therapeutic components imminent to supportive therapy. statistics are between-group comparisons (anovas). *p < .05. **p < .01. shedden-mora, pan, heisig et al. 13 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ support. expected coping with side effects and expected treatment control were sig‐ nificantly optimized compared to tau but not to support. expected adherence was significantly optimized compared to support but not to tau. expected side effects did not change significantly. as predicted, patients receiving expect developed more positive aet-related ex‐ pectations compared to both support and tau. in particular, patients in expect increased their necessity beliefs and reduced their concerns, while necessity-concern beliefs remained unchanged in the other groups. this result is highly relevant given that dysfunctional necessity-concern beliefs are associated to poorer medication adherence (horne et al., 2013), which in turn predicts morbidity and mortality in breast cancer (hershman et al., 2011). the relevance of these changes is underpinned by the increase in adherence intention compared to support and in trend to tau, which is a good predictor of actual adherence (manning & bettencourt, 2011). accordingly, compared to tau, patients receiving expect expected to cope better with possible side effects and had higher expectations that aet could control their illness. to our knowledge, this is the first study investigating expectation change in cancer treatment. our findings are in line with previous evidence from the psy-heart trial targeting expectations prior to cardiac surgery (laferton et al., 2016; rief et al., 2017), an rct addressing illness perceptions after myocardial infarction (broadbent, ellis, thomas, gamble, & petrie, 2009), and experimental pain research (peerdeman et al., 2016). all showed that patients’ expectations can be effectively changed through brief interventions using expectation management, verbal suggestions, imagery, or conditioning. in breast cancer, an acupressure band combined with expectation-enhancing information reduced nausea after chemotherapy in patients with high levels of expected nausea, but the au‐ thors did not report expectation change (roscoe et al., 2010). in our opinion, thoroughly assessing expectation changes is highly relevant to understand how interventions work, and whether postulated etiological mechanisms are actually targeted. while there are effective approaches to support patients in coping with cancer-associated stress, pain, and fatigue (antoni et al., 2009), few directly address coping with side effects of cancer treatment (mann et al., 2012) and target patients’ expectations as a relevant etiological factor. with small to moderate effect sizes, expect was specifically superior to our psy‐ chological control condition (support) in changing medication beliefs and improving adherence intention. in contrast, changes in coping and treatment control expectations did not significantly differ between expect and support. while most effects indicated in the assumed direction, proving superiority to a strong, active control condition like supportive therapy might need larger sample sizes. thus, expect can be considered effective compared to tau and partly superior to support for some of the expectation measures. optimizing expectations about cancer treatment 14 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ contrary to our hypothesis, the mean intensity of expected side effects did not change significantly, for which two aspects might be relevant. firstly, discussing side effects might not actually reduce their expected intensity. importantly, our study shows that the guided therapeutic attention on side effects is not harmful, as might be feared by physicians and patients. this is in line with studies showing that the assessment of side effect expectations does not increase their occurrence (colagiuri et al., 2013). however, we will carefully monitor the occurrence of adverse effects in our trial (von blanckenburg et al., 2013). secondly, ceiling effects due to low baseline side effect expectations might explain the lack of changes. it is possible that our provision of standardized comprehensive information about aet to all patients already lowered side effect expectations (heisig, shedden-mora, von blanckenburg, et al., 2015). with regard to the patients’ evaluation, both interventions were well accepted and perceived as highly helpful, while all expect-specific elements were rated as more achieved in expect. thus, the interventions can be regarded as specific in targeting the aimed mechanism from the patients’ perspective. importantly, the therapeutic alliance from both the patients’ and the therapists’ perspective was perceived as very supportive. few patients experienced adverse events of the intervention, of which most were of organizational nature. two patients in expect feared that the focus on possible adverse events might make them more sensitive to actually experiencing them. while there was no overall increase in side effect expectations in our study, these concerns need to be taken seriously and addressed in nocebo-focused expectation management interventions. taken together, the evaluation shows that both interventions were well accepted and feasible within guideline-based breast cancer care. study limitations the results of this rct need to be interpreted in light of potential limitations. first, while the sample was recruited from four independent sites and resembled a typical early-stage breast cancer sample (burstein et al., 2014; murphy et al., 2012), a sample selection bias due to declining participation or non-initiation of aet might limit generalizability. second, the gase-expect scales need further psychometric evaluation. lastly, larger samples might be needed to detect smaller differences between expect and support. clinical implications in conclusion, this rct is the first study to show that expectations regarding breast can‐ cer treatment can be effectively changed via a brief psychological intervention. expecta‐ tion management proved to be a feasible, well-accepted, effective intervention that was partly superior to the psychological control condition. it could easily be implemented in routine care for women with early-stage breast cancer. shedden-mora, pan, heisig et al. 15 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://www.psychopen.eu/ in this study, certain aspects of expectations such as the necessity-concern balance, coping and treatment control expectations seemed more amenable to change. certainly, more validated assessment methods of patients’ expectations are needed, for which our proposed integrative model of patients’ expectations (laferton et al., 2017) might provide a framework. moreover, patients’ expectations result from a dynamic interaction of cognitive processes and experiences with medication intake (wiech, 2016) and thus might change with the actual experience of aet intake. therefore, investigating expecta‐ tion change more systematically seems worthwhile (heisig, shedden-mora, hidalgo, & nestoriuc, 2015; kube, rief, gollwitzer, & glombiewski, 2018). the long-term effects of these optimized expectations within the psy-breast trial regarding side effect burden, quality of life, and medication adherence (von blanckenburg et al., 2013) will be reported elsewhere. moreover, the course of expectations during long-term aet intake and their impact on the above mentioned outcomes will be repor‐ ted elsewhere. investigating whether expectations and beliefs can be effectively changed through brief interventions is the first important step towards improving long-term outcomes during aet treatment, and allows for analyzing the effects of expectations changes on clinical outcomes. funding: this study was funded by the german research foundation (dfg) (pi: yvonne nestoriuc, ne 1635/2-1) as a subproject of the dfg research unit (for 1328) “expectation and conditioning as basic processes of the placebo and nocebo response: from neurobiology to clinical applications”. competing interests: winfried rief is editor-in-chief of clinical psychology in europe but played no editorial role for this particular article. apart from that, the authors have declared that no competing interests exist. previously presented: this study has been previously presented at the 15th international congress of behavioral medicine; the abstract has been published (shedden-mora et al. 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(2016). deconstructing the sensation of pain: the influence of cognitive processes on pain perception. science, 354(6312), 584-587. https://doi.org/10.1126/science.aaf8934 appendix: therapist allegiance video ratings of 46 (of 330 available) randomly selected therapy session videos (14%; 24 of expect, 22 of support equally selected from the three sessions) were performed by two trained inde‐ pendent raters following a standardized protocol. ten specific items for expect and support assessed objective allegiance on a 1 (‘not present’) to 3 (‘strongly present’) rating-scale (e.g., adherence to manual and structure of sessions, therapeutic attitude). overall, the mean ratings (with standard deviations in parenthesis) of treatment allegiance in expect and support were 2.91 (0.11), and 2.98 (0.05). the percentage in which the two raters fully agreed in their rating of a video was 92% for expect and 99% for support. subjective allegiance was rated by the therapist after each session on one item scaled from 1 (‘low’) to 4 (‘high’). the mean subjective allegiance ratings in expect and support were 3.25 (0.78), and 2.94 (0.33). thus, therapist subjective and objective allegiance to the respective manuals can be regarded as high. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. optimizing expectations about cancer treatment 20 clinical psychology in europe 2020, vol.2(1), article e2695 https://doi.org/10.32872/cpe.v2i1.2695 https://doi.org/10.1186/1471-2407-13-426 https://doi.org/10.1159/000377711 https://doi.org/10.1037/hea0000416 https://doi.org/10.1126/science.aaf8934 https://www.psychopen.eu/ optimizing expectations about cancer treatment (introduction) method study design participant enrollment psychological interventions assessment data analysis results participant flow baseline characteristics changes in patients’ expectations changes in adherence intention patients’ evaluation of the intervention discussion study limitations clinical implications (additional information) funding competing interests previously presented acknowledgments references appendix: therapist allegiance successful aging in individuals from less advantaged, marginalized, and stigmatized backgrounds scientific update and overview successful aging in individuals from less advantaged, marginalized, and stigmatized backgrounds myriam v. thoma ab, shauna l. mc gee ab [a] psychopathology and clinical intervention, institute of psychology, university of zurich, zurich, switzerland. [b] university research priority program “dynamics of healthy aging”, university of zurich, zurich, switzerland. clinical psychology in europe, 2019, vol. 1(3), article 32578, https://doi.org/10.32872/cpe.v1i3.32578 received: 2018-12-20 • accepted: 2019-03-27 • published (vor): 2019-09-20 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: myriam v. thoma, department of psychology, university of zurich, binzmühlestrasse 14/17, 8050 zurich, switzerland. tel.: +41 635 73 06. e-mail: m.thoma@psychologie.uzh.ch abstract background: health and well-being in later life are heavily influenced by behaviors across the life course, which in turn are influenced by a variety of wider contextual, social, economic, and organizational factors. there is considerable potential for inequalities in health-promoting behaviors and health outcomes, arising from poverty, social, and environmental factors. this suggests that individuals from disadvantaged backgrounds and circumstances may have more exposure to (chronic) stressors, coupled with reduced access to resources, and increased susceptibility to risk factors for ill-health and mental disorders in later life. this drastically decreases the likelihood for successful aging in individuals from less advantaged backgrounds. nevertheless, despite these adverse circumstances, some high-risk, disadvantaged individuals have been shown to achieve and maintain good health and well-being into later life. method: this scientific update provides an overview of recently published research with samples that, against expectations, demonstrate successful aging. results: favorable personality traits, cognitive strategies, and a high-level of intrinsic motivation, paired with a supportive social environment, have been found to build a prosperous basis for successful aging and positive health outcomes in later life for individuals living in aversive environmental circumstances. conclusion: for clinical psychologists, the movement towards the investigation of underlying mechanisms of successful aging from a psychological perspective, particularly in disadvantaged individuals, may be a critical step towards understanding the vast heterogeneity in aging. keywords successful aging, disadvantaged backgrounds, marginalization and stigmatization, lgbt, disparities in racial and ethnic minorities this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i3.32578&domain=pdf&date_stamp=2019-09-20 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • successful aging is possible in disadvantaged individuals. • psychological and social resilience resources may compensate for the impact of disadvantage. • the application of multi-level resilience models can aid future research on successful aging. old age is a life stage characterized by a high degree of diversity between individuals. a growing body of literature has been dedicated to understanding this heterogeneity in ag‐ ing. special focus has been placed on the positive end of the aging spectrum. at the mo‐ ment, there exists no universally-accepted definition for what constitutes this “positive end of the aging spectrum”. the “successful aging” (sa) construct, which is often used in research to examine positive aging research questions, is currently defined and opera‐ tionalized in more than 100 different ways (cosco, prina, perales, stephan, & brayne, 2014). however, despite the current lack of a commonly-accepted definition, experts in the field generally agree that the sa construct should consist of several different dimen‐ sions, including a (mental and physiological) health facet, a (subjective) well-being facet, as well as a social (engagement) facet (kleineidam et al., 2018). nevertheless, despite its broad variety of operationalizations, the sa construct as a whole constitutes a meaning‐ ful and useful construct that can be applied to examine why some individuals are more likely than others to remain predominantly healthy and maintain a high level of physical functionality and social activity even into older age (kleineidam et al., 2018). in this regard, it is particularly useful to examine what factors can be identified in connection with more favorable aging processes and outcomes. previous research on sa has uncovered a range of predictors, including socio-demographic factors and specific be‐ haviors linked to sa. socio-economic status (ses; including income and wealth), educa‐ tion, and health-promoting behaviors (e.g., non-smoking, healthy diet, physical activity), are among the frequently identified predictors for sa (e.g., daskalopoulou et al., 2018; gopinath, kifley, flood, & mitchell, 2018; kok, aartsen, deeg, & huisman, 2016; vauzour et al., 2017; whitley, benzeval, & popham, 2018). other branches of health-related re‐ search can also provide additional evidence for potential risk and protective factors that are essential in predicting sa. for instance, an important line of research on the (longterm) impact of early-life stress suggests that childhood neglect and abuse can increase the risk of future ill health and mental disorders, and may thus diminish the probability of sa (jones, nurius, song, & fleming, 2018; nurius, fleming, & brindle, 2017). in fact, supporting this, a recently published large-scale longitudinal study found a meaningful link between early-life stress and sa trajectories (kok, aartsen, deeg, & huisman, 2017). upon closer examination of the factors that may promote or hinder sa, it appears as if sa may be a rather elitist paradigm, seemingly reserved for more advantaged and al‐ successful aging in disadvantaged individuals 2 clinical psychology in europe 2019, vol.1(3), article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ ready healthy individuals. that is, those who grow up in more functional families, who were provided with the opportunity for a good education, and the necessary access to health-literacy and services, coupled with the essential assets and time required to imple‐ ment health-promoting behaviors. this leaves a rather pessimistic prospect for individu‐ als who grew up and lived in poverty or come from underprivileged educational back‐ grounds; as well as for those who experienced early misfortune in the form of childhood stressful life events, abuse and neglect, or those living with chronic health conditions (e.g., bøe, serlachius, sivertsen, petrie, & hysing, 2018; kok et al., 2017; lê-scherban et al., 2018). are these individuals deprived of the opportunity to age successfully? this scientific update aims to answer this question by providing an overview of the latest research dedicated to the investigation of sa in individuals from less advantaged backgrounds. for this, a list of 'disadvantaged' groups was first compiled and the search was then limited to articles on older adults. a search of the databases was conducted for articles published since 2017. given the wide diversity in how the sa construct is cur‐ rently defined in the scientific literature, the search was not restricted by applying a par‐ ticular sa definition or operationalization. successful aging within the context of socioeconomic disadvantage and childhood adversity the research group of kok and colleagues (kok, van nes, deeg, widdershoven, & huisman, 2018) qualitatively examined sa in dutch individuals (n = 11; agerange = 78-93 years) who had a low lifetime socio-economic position (sep). more specifically, the au‐ thors were interested in the identification of resilience factors that protected those indi‐ viduals from the potentially negative impact of chronic socio-economic adversity. several resilience-enhancing factors were identified, including ‘social support’, ‘generativity’, ‘pro-active management’, ‘cognitive restructuring’, ‘enduring’, and ‘surrendering’. con‐ firming, but also expanding the resilience conceptualization for low sep individuals pre‐ viously proposed by chen and miller (2012), the authors concluded that in addition to mental re-evaluation of the disadvantaged background, it also appears to be necessary to have a supportive social environment (which also requires pro-social behaviors) and the will to actively confront the external circumstances in question, i.e., by changing the ad‐ verse environment with one’s own actions (kok et al., 2018). another recent study (scelzo et al., 2018) examined a sample of very old individuals living in rural villages in the southern part of italy (n = 29; agerange = 90-101 years). ru‐ ral areas tend to show health-disparities due to a disproportionate lack of services in medically underserved areas, issues of access to existing services, differences in patient expectations and health-seeking behaviors, as well as the delivery of health care (douthit, kiv, dwolatzky, & biswas, 2015). while not directly assessing sa in this study, thoma & mc gee 3 clinical psychology in europe 2019, vol.1(3), article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ (extreme) longevity can be regarded (and has previously been used) as a proxy to assess (the consequences of) sa (see cosco et al., 2014). the qualitative part of this mixed-meth‐ od study examined themes related to (extreme) longevity. common themes associated with sa were identified, including ‘positivity’, i.e., resilience and an optimistic outlook on life (also including self-efficacy and perseverance); being a ‘controlling’ or ‘strong’ per‐ sonality; being socially active and engaged, i.e., having tight bonds with family members; religious beliefs; as well as being hard working; and having a “love of the land” (p. 33). altogether, the above findings show some parallels to those reported by kok et al. (2018): in addition to the importance of having mental resources, such as the capacity for accept‐ ance/perseverance (facilitated by religious beliefs or particular personality traits), there is also the necessity of actively engaging with or changing the external environment (e.g., by being hard working), which is framed within the context of a functional and close so‐ cial network. another example of sa despite adverse life circumstances can be seen in the case of swiss former indentured child laborers (i.e., former verdingkinder). due to extreme pov‐ erty, death of a parent, divorce, or single motherhood, children were taken away from their parents and placed in foster families (mostly farmers), where they had to work for their living (leuenberger & seglias, 2008). given that, in those times, the foster-care sys‐ tem was still poorly controlled, these children (in most cases forcefully separated from their families of origin) often experienced little to no protection. documented by individ‐ uals who came forward publicly with their experiences, and corroborated by contempo‐ rary witnesses, these biographies are filled with reports of (extreme levels of) childhood abuse and neglect. a qualitative study (höltge, mc gee, maercker, & thoma, 2018a) in‐ vestigated sa in former verdingkinder (n = 12; mage = 71 years; agerange = 59-88). sa was defined as (self-rated) good health, feelings of happiness, balance and/or calmness most of the time, and a high level of satisfaction with (social) life. the factors ‘light-hearted‐ ness’, ‘social-purpose’, and ‘self-enhancement’ were identified as predictors for sa. these individuals, after what they had endured in early-life, took on a positive perspective fol‐ lowing conscious reflection (i.e., a proxy for a resilience resource). while striving to ex‐ perience positive feelings, they nevertheless kept a realistic perspective on life by ac‐ knowledging that negative experiences are part of a normal existence (i.e., cognitive reevaluation). in general, participants could be classified as stress-resilient, a resource that was described to be developed through active coping and by coming to terms with their difficult past. they strongly valued (harmonic) social relationships and had the altruistic desire to help others (i.e., social component). furthermore, they developed a strong moti‐ vation for self-improvement that pushed them to work hard and to continuously engage in further education (i.e., active engagement with external environment). successful aging in disadvantaged individuals 4 clinical psychology in europe 2019, vol.1(3), article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ successful aging in racial and ethnic minorities similar to individuals from disadvantaged backgrounds or adverse childhood circumstan‐ ces, individuals from minority groups often face issues of marginalization and stigma, which can influence their health and well-being into later life. one such example can be seen in racial and ethnic minorities, who, in addition to potentially higher levels of disad‐ vantages and inequalities (zubair & norris, 2015), can also face problems with exclusion and discrimination, which may compound health issues and ultimately hinder sa (ferraro, kemp, & williams, 2017). however, despite these additional stressors, evidence is emerging that some individuals can experience good health into older age. for exam‐ ple, a study of perceived discrimination and psychological well-being in african ameri‐ can older adults (n = 397; agerange = 65-89) found that the characteristic of ‘self-accept‐ ance’, an awareness and acceptance of personal strengths and weaknesses, was shown to buffer the negative effect of discrimination on depressive symptomology, an indicator of psychological well-being (yoon, coburn, & spence, 2019). another study (klokgieters, van tilburg, deeg, & huisman, 2018a) examined the potential buffering effect of various religious activities against the negative impact of disadvantage (e.g., no/low resources) in older turkish and moroccan immigrants (n = 455; agerange = 55-66 years). while a posi‐ tive relationship was found between well-being and private religious activities, there was no indication of a buffering effect for any of the religious activities against the experi‐ enced disadvantage. successful aging in individuals living with hiv another minority group that has experienced much stigma and discrimination is that of individuals living with the human immunodeficiency virus (hiv). hiv is a chronic ill‐ ness, associated with a higher risk of experiencing psychosocial challenges and physio‐ logical issues. however, with advances in medicine, individuals with hiv are living longer, better lives and research has started focusing on sa and sa-related factors in this population. a qualitative study in individuals with hiv (n = 30; agerange = 50-73) as‐ sessed barriers to and strategies for sa (emlet, harris, furlotte, brennan, & pierpaoli, 2017). results showed that while stigma, prejudice, and discrimination were identified as potential sa barriers, a number of sa-related themes emerged, including resilience com‐ ponents, such as self-care, mastery, and spirituality; social support; and the importance of the environmental context, such as structural support, social networks, and communities. another qualitative study on sa in individuals with hiv (n = 24; agerange = 50-73) identi‐ fied similar themes, emphasizing components over which persons had individual control (solomon et al., 2018). these included staying positive, maintaining social support and connectedness with others, taking responsibility and being self-reliant for one’s well-be‐ ing, and engaging in meaningful activities. these findings indicate that a combination of thoma & mc gee 5 clinical psychology in europe 2019, vol.1(3), article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ individual characteristics, such as control and mastery, and external influences, such as social and structural support, are important in fostering sa in this marginalized popula‐ tion. successful aging in lgbt older adults a population that also faces additional barriers to sa, are lesbian, gay, bisexual, and transgender (lgbt) older adults. despite the risks of ill-health and social isolation for lgbt older adults (wright et al., 2017), discrimination is often reported as a barrier to the utilization of health and community services (alencar albuquerque et al., 2016). a large-scale study of n = 2,415 lgbt older adults identified risk and resilience pathways to positive health outcomes in later life (fredriksen-goldsen, kim, bryan, shiu, & emlet, 2017). results showed that marginalization was a risk factor associated with fewer social resources and poorer mental health outcomes. however, resilient pathways were identi‐ fied in which psychological (e.g., positive identity appraisal) and social (e.g., social con‐ nectedness) resources were associated with health-promoting behaviors, which in turn facilitated good physical health into older age. these findings suggest that the interaction of social and psychological factors can help lgbt older adults to maintain good health and foster sa, even within an environmental context of marginalization. the above research suggests that sa is possible for individuals from less advantaged, marginalized, and stigmatized backgrounds. however, as this is a relatively new and emerging topic, the exact mechanisms through which sa is fostered in these disadvan‐ taged populations are not yet known. some theories and models are presented in the next section, which may be applied to help explain the underlying mechanisms of this process of sa. underlying mechanisms of successful aging the ‘steeling effect’ is one theory that may explain positive health in the face of adversi‐ ty (liu, 2015; rutter, 2006, 2012). this theory proposes that previous exposure to adversi‐ ty (e.g., disadvantaged circumstances, discrimination) may have a ‘steeling’ or strength‐ ening effect on individuals, which can increase their resistance to later stress or adversi‐ ty. it further suggests that moderate adversity may be more beneficial than no or high adversity, as it is adequately challenging to facilitate the development of coping skills and the utilization of resources (for a review see höltge, mc gee, maercker, & thoma, 2018b). however, there is a lack of research applying this model in human studies (for one such study see höltge, mc gee, & thoma, 2018), particularly with older adults, and the role of steeling for sa remains poorly understood. furthermore, while some studies have exam‐ ined aspects of adverse circumstances as part of a larger assessment, such as exposure to successful aging in disadvantaged individuals 6 clinical psychology in europe 2019, vol.1(3), article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ social and environmental stress (seery, holman, & silver, 2010), future research is needed to apply this steeling model specifically to individuals from disadvantaged populations. the above literature suggests that a combination of psychological and individual fac‐ tors (e.g., mastery and control, self-efficacy) and external social factors (e.g., social en‐ gagement, connectedness with others) can contribute to resilience and sa in disadvan‐ taged populations. however, it is also important to consider the enabling environmental and context factors, which are particularly important in this specific population due to their adverse backgrounds and circumstances. supporting this is the social ecological model of resilience, which emphasizes the role of environmental factors in health and well-being, and suggests that resilience is facilitated by the interaction between the indi‐ vidual and their environment (ungar, 2012). specifically, this model suggests that the en‐ vironment can facilitate access to resilience-promoting resources; that resilience may dif‐ fer as a result of the complex and changing nature of an individual’s circumstances and the interaction with their personal traits; and that the resilience process is culturally and temporally embedded and is therefore influenced by the cultural norms of the time, which is particularly important for specific cultural groups such as minorities (ungar, 2011). the importance of the individual-environment interaction for the well-being of disadvantaged populations can be seen in the reoccurring finding that environmental and contextual factors, such as social support and social engagement, were significant in sup‐ porting individual resilience and sa (e.g., emlet et al., 2017; kok et al., 2018; scelzo et al., 2018). further support comes from a resilience conceptualization in the field of sociology (schafer, shippee, & ferraro, 2009). schafer and colleagues (2009) argue that in order to actively buffer or overcome disadvantage, several processes must take place: first, an in‐ dividual must become aware (i.e., recognition/subjective evaluation) of one’s undesirable position, adversity, or misfortune. second, the individual must take action (i.e., construc‐ tive adaptation) to counteract or amend the adverse situation and/or to avoid negative consequences. third, to efficaciously face disadvantage, one must activate and apply ade‐ quate and effective resources. these resources may be located within oneself (e.g., iq, re‐ siliency traits) and/or within the socio-economic system, in the form of social relation‐ ships, ses, and economic resources (schafer et al., 2009). as in the social ecological model of resilience, this conceptualization highlights the importance of both individual and so‐ cial-context factors in overcoming disadvantage. the interaction between individual and environment is also reflected in and suppor‐ ted by another model of resilience by liu, reed, and girard (2017). this model proposes that resilience is dynamic and is formed through the interaction of factors across multi‐ ple, interconnected levels. these levels include core resilience, which are inherent, stable characteristics and traits, such as gender, race, and ethnicity; internal resilience, which are learnable and changeable factors, such as active coping, mastery, and self-acceptance; and external resilience, which are contextual and environmental factors, such as social thoma & mc gee 7 clinical psychology in europe 2019, vol.1(3), article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ resources and support. this model could be applied in future research to better under‐ stand the multi-level mechanisms underpinning the processes of resilience and sa. in addition, the construct ‘sense of coherence-revised’ (soc-r) could be examined in conjunction with liu et al.’s (2017) model. this construct may help explain how individu‐ als can utilize these multi-level factors to facilitate resilience and sa, as it is the ability to integrate and balance positive and negative experiences in order to maintain and develop health and well-being following stress or adversity (bachem & maercker, 2016; mc gee, höltge, maercker, & thoma, 2018a, 2018b). it is based on the salutogenic theory, which views health as a continuum, and proposes that soc-r can help individuals to utilize re‐ sources (e.g., personality traits, mastery, social support) appropriate for their current cir‐ cumstances and move them towards good health on this continuum (antonovsky, 1987). in this way, soc-r can positively influence the aging process and foster sa (bachem & maercker, 2016). the above theories and models provide a theoretical basis for future re‐ search to examine the mechanisms and factors associated with resilience and sa, particu‐ larly in populations with disadvantaged backgrounds. it should be emphasized that this article constitutes a short, current update and over‐ view of the latest developments and publications in this particular field. as such, a sys‐ tematic review of the literature was not conducted. this may have resulted in a non-com‐ prehensive or even biased delineation of existing literature and the deduction of oversimplified conclusions. it is possible that additional mechanisms and factors exist, which were not discussed in this short update that links sa to adverse experiences and disad‐ vantaged backgrounds. the association between sa and disadvantage is complex and un‐ derlying mechanisms are still poorly understood. disadvantage can have multiple forms and can also hide behind alleged “advantaged” circumstances. for instance, a large-scale longitudinal study on sa (kok et al., 2017) showed that not only low, but also high sep, was linked to stressful life events (e.g., higher divorce rate). it is also important to note that the potential buffering impact of psychological resources may depend on the partic‐ ular context, such as the cultural background (klokgieters, van tilburg, deeg, & huisman, 2018b). conclusion research on sa is continuously uncovering predictors for more favorable aging process‐ es and outcomes. this scientific update and overview focused on very recent develop‐ ments and trends in this area, examining sa in less advantaged populations. findings from these studies highlight the importance of considering a combination of psychologi‐ cal and individual resilience factors, as well as external social and environmental compo‐ nents. individual, psychological, and social factors can play a compensatory role for indi‐ viduals living with negative environmental influences. for clinical psychologists, the movement towards the investigation of underlying mechanisms of sa from a psychologi‐ successful aging in disadvantaged individuals 8 clinical psychology in europe 2019, vol.1(3), article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://www.psychopen.eu/ cal perspective, particularly in disadvantaged individuals, may be a critical step towards understanding the vast heterogeneity in aging. funding: this work was supported by the swiss government excellence scholarship (eskas-nr. 2016.0109) which funded slmg’s position. competing interests: the authors have declared that no competing interests exist. acknowledgments: during the work on her dissertation, shauna l. mc gee was a pre-doctoral fellow of life (international max planck research school on the life course; 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(2015). perspectives on ageing, later life and ethnicity: ageing research in ethnic minority contexts. ageing & society, 35(5), 897-916. https://doi.org/10.1017/s0144686x14001536 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. successful aging in disadvantaged individuals 12 clinical psychology in europe 2019, vol.1(3), article 32578 https://doi.org/10.32872/cpe.v1i3.32578 https://doi.org/10.1037/a0021344 https://doi.org/10.1177/0956462417721439 https://doi.org/10.1111/j.1939-0025.2010.01067.x https://doi.org/10.1016/j.ypmed.2012.07.021 https://doi.org/10.1016/j.arr.2016.09.010 https://doi.org/10.1177/0898264316665208 https://doi.org/10.1093/fampra/cmx005 https://doi.org/10.1080/13607863.2017.1423034 https://doi.org/10.1017/s0144686x14001536 https://www.psychopen.eu/ successful aging in disadvantaged individuals (introduction) successful aging within the context of socio-economic disadvantage and childhood adversity successful aging in racial and ethnic minorities successful aging in individuals living with hiv successful aging in lgbt older adults underlying mechanisms of successful aging conclusion (additional information) funding competing interests acknowledgments author contributions references revisiting the cognitive model of depression: the role of expectations scientific update and overview revisiting the cognitive model of depression: the role of expectations winfried rief* a, jutta joormann b [a] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. [b] department of psychology, yale university, new haven, ct, usa. clinical psychology in europe, 2019, vol. 1(1), article e32605, https://doi.org/10.32872/cpe.v1i1.32605 received: 2018-12-21 • accepted: 2019-02-18 • published (vor): 2019-03-29 handling editor: cornelia weise, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany corresponding author: winfried rief, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, gutenbergstraße 18, 35032 marburg, germany. fax: +49 6421 28 28904. e-mail: rief@uni-marburg.de abstract background: the cognitive model of depression was highly stimulating for a better understanding and development of treatment for depression. however, the concept of “cognition” is rather broad and unspecific, and we suggest to focus on the cognitive subset of expectation. method: we conducted a narrative review on the role of expectations, and present an expectationfocused model of explaining why depression tends to persist despite the occurrence of positive events. results: several results from basic neuroscience to effects in clinical interventions indicate that expectations play a special role not only for the understanding of the development of mental disorders and the effects of treatment approaches, but especially for an improved understanding of the persistence of mental disorders. if expectations are a major mechanism of depression, the treatment of depression must maximize the violation of dysfunctional expectations. we also introduce the concept of immunization that describes any cognitive or behavioral strategies to reduce the effect of expectation violation experiences, and hereby contributing to expectation maintenance despite expectation contradicting events. we postulate that the development of immunization strategies could help to better understand the transition from episodic to chronic depression. conclusion: while in early periods of depression development, a focus on expectation change might be sufficient in treatment, the treatment of patients with chronic depression requires addressing these cognitive and behavioral immunization strategies more intensively. further implications for treatment and research are outlined that are derived from this balance between expectation violation and cognitive immunization in depression. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i1.32605&domain=pdf&date_stamp=2019-03-29 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords depression, persistence, expectation, expectation violation, cognitive immunization highlights • a focus on “expectations” helps to better understand the maintenance of depression • we offer a model that explains why depression persists even in the presence of positive experiences. • many psychological treatments focus on the violation of negative expectations, but cognitive immunization can hinder treatment success • we suggest strategies on how to improve psychological treatments for depression by maximizing expectation violation, and minimizing cognitive immunization expectations as subsets of cognitions the cognitive model of depression has had tremendous impact on our understanding of cognition as an underlying mechanism of psychopathology and on the development of successful treatment approaches. cognition as a construct, however, is extremely broad, starting from perceptions, automatic thoughts, intermediate beliefs, up to schemas, selfconcepts, existential life goals and more generalized concepts (beck & haigh, 2014). moreover, the cognitive model does not differentiate among cognitions concerning the past, present, and future. in this manuscript, we will focus on the role of expectations. we will argue that expectations play a specific role in our understanding of depression and other forms of psychopathology and we will discuss advantages of an in-depth per‐ spective of this specific construct for understanding and treating depression. the importance of expectations as specific subsets of cognition are obvious in the def‐ inition of this construct. expectations are estimations of the likelihood of future events, and they are triggered by internal or external events (“priors”). expectations are by defi‐ nition cognitions that deal with the future, and impact future well-being. most people have impressive abilities to cope with momentary unpleasant feelings, pain, earache and social rejection, as long as they do not expect these aversive experiences to last forever, or to be frequently repeated in the future. thus, expectations regarding the stability of these experiences may have considerable impact on the emotions they elicit. considering that psychological interventions are not able to change the past, and that addressing is‐ sues of the present is only of relevance if it impacts on the future, one major goal of psy‐ chological interventions should focus on improving the quality of life in the future of pa‐ tients. expectations offer the link between present state and future well-being. revisiting the cognitive model of depression 2 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ other observations support the special role of expectations. placeboand nocebo-re‐ search has shown that a patient´s expectations determine the success of various medical interventions, ranging from antidepressant pills to heart surgery (enck, bingel, schedlowski, & rief, 2013; rief, bingel, schedlowski, & enck, 2011). therefore, expecta‐ tions can be considered the most frequently investigated mechanism of treatment success in health care systems because this mechanism has been shown to play a role in nearly all fields of medicine (schedlowski, enck, rief, & bingel, 2015). a meta-analysis of the association between treatment expectations and treatment outcome for psychological treatments confirmed the special role of patients’ treatment outcome expectations (constantino, arnkoff, glass, ametrano, & smith, 2011), a result that was also found for psychological treatments of mental disorders or chronic pain (cormier, lavigne, choiniere, & rainville, 2016; delgadillo, moreea, & lutz, 2016). expectations predict the transition from acute pain to chronic pain, and the persistence of pain symptoms (gehrt et al., 2015; holm, carroll, cassidy, skillgate, & ahlbom, 2008). modern neuroscience further supports the importance of focusing on predictions/ expectations. whereas former models of the brain mainly considered its function as pas‐ sively waiting for sensory input before processing it, modern models consider the brain a “prediction coding machine”, continuously creating predictions about what will happen next (seth, suzuki, & critchley, 2012). “prediction errors” trigger selective attention, and they are able to stimulate learning processes. thus, the brain`s predictions steer percep‐ tion, attention, and information processing in general. the parallel between the neuro‐ scientific concepts of prediction and prediction error versus the more applied concepts of expectation and expectation violation is obvious (d’astolfo & rief, 2017). of further rele‐ vance is the blunted reward processing in depression (pizzagalli, 2014; wilson et al., 2018), which could help to understand why depressed patients do not update negative ex‐ pectations. the “bayesian brain” offers a computational perspective on mood as creating and updating “priors” over uncertainty (clark, watson, & friston, 2018). finally, expecta‐ tions also offer a link between mind and body: they trigger anticipatory physiological re‐ actions. the anticipation of threat triggers physiological fight-flight-reactions. the antic‐ ipation of pain activates the somatosensory fields that are responsible for pain perception (koyama, mchaffie, laurienti, & coghill, 2005), but also brain functions that are respon‐ sible for pain control (wager, scott, & zubieta, 2007). whereas expectations as mechanisms of treatment success are frequently investiga‐ ted, the specific role of expectations as a mechanism of disorders and in the maintenance of mental problems is a less frequently studied topic. however, expectations can play a special role in improving our understanding of transdiagnostic processes, hereby offering a link to the rdoc-approach (insel, 2014). anxiety disorders and phobias are by defini‐ tion expectation disorders, and also for associated fields such as ocd-associated disor‐ ders, expectations can be considered a core feature contributing to the persistence of rief & joormann 3 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ clinical problems (rief & glombiewski, 2017). however, the role of expectations in de‐ pression is less obvious, and this will be discussed in the next section. the cognitive model and the specific role of expectations in depression the cognitive model of mental disorders goes back to formulations of ancient greek phi‐ losophers, such as epiktet (born about 50 a.d.). it postulates that negative affective states develop not because of direct external influences (e.g., social rejection), but because of the interpretation of these external and internal events. it was the merit of a.t. beck to translate this approach to improve our understanding of depression. beck’s original for‐ mulation of the cognitive triad in depression can be easily transformed to expectations: negative expectations for outcomes relevant to the self, negative expectations about oth‐ er’s behavior, and finally negative expectations about future events. the cognitive model was supported by various experimental studies, summarized elsewhere (gotlib & joormann, 2010; joormann & quinn, 2014). the standard assessment of dysfunctional attitudes (dysfunctional attitudes scale das; oliver & baumgart, 1985) targets various expectations, but also covers other cogni‐ tions considered to be specific to depression. however, the question arises whether other cognitions have explanatory value for depression beyond the value of depression-specific expectations. to investigate this question, we developed a self-rating scale to assess de‐ pression-specific expectations. using a path analytical approach, we analyzed whether other cognitive aspects of depression explain additional variance, if the role of depres‐ sion-specific expectations was controlled (kube et al., 2018c). in this study, depressionspecific expectations had a clear association with depression, while other cognitions did not significantly add to this association. this confirms the special illness-relevant role of expectations as an important subgroup of cognitions. kube and colleagues (kube, d’astolfo, glombiewski, doering, & rief, 2017) developed a depressive expectations scale that allows to assess situation-specific expectations in major depression. this scale includes 25 items. the depression-specific expectations can be clustered in‐ to four subgroups: expectation of social rejection, expectation of (lack of) social support, expectation of ability to regulate mood, and expectations about the ability to perform cognitive tasks and about the likelihood of professional achievements. the advantage of this scale is that all its specific items can be directly translated into behavioral experi‐ ments, which offer the opportunity to assess expectations in depressed patients, to moti‐ vate them to test them, and to modify expectations after expectation violation experien‐ ces. thus treatment of depression can be reformulated as an intervention to change dys‐ functional expectations, mainly via the exposure to expectation violating situations (see figure 1). revisiting the cognitive model of depression 4 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ while typical cbt approaches also cover some of these strategies, our plea is to better focus on expectation change not only in anxiety treatment (craske, treanor, conway, zbozinek, & vervliet, 2014), but also in depression treatments. one future gain of focus‐ ing on expectation could be the development of more effective and economic interven‐ tions for depression. figure 1. psychological treatment as expectation violation. depression has been also linked to reward expectancy (greenberg et al., 2015). not expecting reward and not expecting positive events is closely associated with depressive states. moreover, it has been postulated that depression is mainly characterized by a lack of positive expectations (instead of increased negative expectations); a concept that was also confirmed using longitudinal designs (horwitz, berona, czyz, yeguez, & king, 2017). the role of cognitive immunization in depression if negative expectations are a core part of depression, the crucial question is why these negative expectations persist, even after new positive experiences (“expectation violating situations”). whereas difficult life conditions or critical life events can lead to the devel‐ opment of negative expectations, and thereby contribute to the development of episodes of depression (heim, newport, mletzko, miller, & nemeroff, 2008; mclaughlin et al., 2017; nelson, klumparendt, doebler, & ehring, 2017), the process of persistence of these negative expectations is still poorly understood. even patients with depression experi‐ ence positive life events, positive interactions, successful performances, but most of these events do not lead to a change in negative expectations, and development of positive ex‐ pectations. therefore, we introduced another construct in our depression model that helps to understand the persistence of negative expectations even if positive experiences occur. this concept is “(cognitive) immunization”. it describes all cognitive (and some‐ times also behavioral) processes to invalidate the effect of positive, expectation violating experiences. while we will focus on cognitive immunization processes, behavioral strat‐ egies can also contribute to immunization: avoiding expectation-violating situations, se‐ lective attention and ignoring stimuli that transport the contradicting information are just a few examples. rief & joormann 5 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ these processes can also be observed in psychological interventions. it happens when psychotherapists try to induce positive, disconfirming experiences, but patients continu‐ ously invalidate them. typical invalidation strategies are declaring these experiences as exceptions to the rule (“if someone is friendly with me, this is only the exception to the rule that people dislike me”; “you, as a psychotherapist, are only friendly with me be‐ cause you are getting paid for it”), or invalidation of a positive situation in general (“al‐ though i succeeded in this exam, in other, much more important exams, i will fail”). many psychological interventions aim to violate negative expectations of patients. they can be even optimized in optimizing expectation violation experiences. however, as shown in figure 2, cognitive immunization can contribute to the invalidation of expecta‐ tion violation effects. thus treatment aims should be reformulated to maximize expecta‐ tion violation effects, and to minimize (cognitive) immunization processes. figure 2. expectation violation and cognitive immunization. a stochastic understanding of expectation change the neuroscientific prediction error paradigms have been extended by stochastic ap‐ proaches, and this extension is also helpful to better understand expectation maintenance versus expectation change in depressed patients. if healthy people develop the expecta‐ tion that most people are quite friendly, they interpret a broad variety of the behavior of the person with whom they’re interacting as confirmation of their expectations (see fig‐ ure 3, top). even neutral events (see arrow) confirm the positive expectations about the behavior and intentions of others. this is a potential explanation for the reported opti‐ mism bias of healthy people to memorize neutral events as being positive, and to expect positive outcomes even without any information supporting this expectation (sharot, riccardi, raio, & phelps, 2007). expectations form an interpretation bias towards their confirmation, and this sticking to expectations can be postulated to have an evolutionary meaning, providing stability in humans’ life. moreover, expectation confirmation can be postulated to be a typical automatic process, not requiring much cognitive resources, while the revision of expectations can be more demanding. to really challenge long-held expectations, other highly discrepant and powerful experiences are necessary. in healthy revisiting the cognitive model of depression 6 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ people, this means that only very harsh social rejection or traumatizing events really challenge their positive expectations about future events. figure 3. a stochastic model of expectation maintenance. when developing depression, the curve of expectations appears to move to the more negative part (see figure 3, bottom). most events are interpreted as confirmation of a negative view of the world. even neutral experiences may be considered as confirmation of negative expectations (see arrow). in other words: the very same experience that con‐ firms positive expectations in healthy persons can confirm negative expectations in de‐ pressed patients. again, to change negative expectations of depressed patients, very pow‐ erful, clearly distinguishable positive experiences are necessary. this example highlights why normal experiences and their attribution (e.g. in cognitive work) sometimes do not lead to any changes of negative expectations; effortful cognitive evaluations do not auto‐ rief & joormann 7 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ matically lead to changing automatic processes of confirmations of negative expecta‐ tions. experimental studies investigating expectation and cognitive immunization in depression kube et al. (kube, rief, gollwitzer, & glombiewski, 2018b) investigated the interplay of expectation manifestation and expectation change in depression quite elegantly using an experimental paradigm. participants received a negative performance expectation (“the following test on emotional intelligence is hard to succeed”). afterwards, participants re‐ ceived different tasks on emotional intelligence that are difficult to evaluate which an‐ swers are correct. during the first trials, participants received the feedback that they were not successful, as expected. both healthy controls and depressed patients developed similar negative expectations after these experiences (kube, rief, gollwitzer, gärtner, & glombiewski, 2018a). however, after several failures, performance feedback switched to more frequent positive results (“expectation violation”). in accordance with the depres‐ sion model mentioned above, healthy controls changed their negative expectation to pos‐ itive, while negative expectations of depressed patients persisted despite positive feed‐ back. in a second experiment, the same authors introduced either instructions that suppor‐ ted cognitive immunization strategies (“the following test is not really valid, but just a weak indicator of performance”), while others received strategies aimed to inhibit cogni‐ tive immunization (“this is a really powerful and valid test”). if depressed patients re‐ ceived strategies that inhibited cognitive immunization, the change to positive feedback resulted also in a change of negative expectations to positive expectations (kube et al., 2018a). in other words: if cognitive immunizations are blocked in depressed patients, pa‐ tients can benefit from positive experiences. this offers new foci for treatment planning and prevention of treatment failures in depression. these effects are in line with other studies investigating cognitive adaptation process‐ es in depression. depressed persons have less favorable success expectations, and show a tendency to self-confirmation of negative attitudes (morris, 1997). further evidence comes from a study of everaert and others (everaert, bronstein, cannon, & joormann, 2018) who found that depressed patients do not only have a negative interpretation bias, but also showed a reduced revision of negative interpretations by disconfirmatory posi‐ tive information. liknaitzky and colleagues confirmed that patients with depression have a reduced ability to update interpretations after receiving expectation violating informa‐ tion (liknaitzky, smillie, & allen, 2017). of note, this effect was independent of the direc‐ tion of expectation violations. revisiting the cognitive model of depression 8 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ treatment implications of the expectation model of depression the implications for psychological treatments can be reduced to two main strategies: am‐ plifying the effect of expectation violations if positive experiences occur, and reducing the effect of cognitive immunization. first experiences with these foci in the work with patients were quite encouraging: patients can easily adapt this expectation model, and understand what is meant by cognitive immunization. after such a psychoeducational period, both typical expectations associated with the depressive disorder, but also cogni‐ tive immunization strategies that occur in everyday experiences when positive events oc‐ cur, can be collected. instead of continuing with cognitive dispute techniques like in cog‐ nitive therapy, patients are informed that humans often maintain negative expectations even if positive experiences occur. therefore, they are encouraged to develop more open‐ ness for experiences that are not in accordance with current expectations. considering the reduced motivation for complex and effortful cognitive processes in many patients with depression, we are working on developing more and more attention-based strat‐ egies that do not require complex cognitive reasoning. patients must be sensitized for the perception of relevant information, before starting with behavioral experiments. what would be the first stimuli indicating that expectations could be wrong? what kind of immunization strategies can be expected by this patient, if expectation violation occurs? what could be possible strategies to avoid the negative ef‐ fect of cognitive immunization? only after such a cognitive preparation period, are be‐ havioral experiments testing negative expectations executed. this strategy can easily be extended with a behavioral component. what kind of pa‐ tient’s behavior would maximize the likelihood of confirmations of negative expectations (e.g., avoiding eye contact although you hope for positive interaction with others; not preparing for an exam because expecting to fail anyway; …). after collecting behavioral patterns that serve to confirm negative expectations, the question can be reversed: what would be behavior patterns that minimize the likelihood of fulfillment of negative ex‐ pectations? not surprisingly, these kinds of behaviors should be shown during subse‐ quent behavioral experiments. table 1 shows a structure of such an expectation focused psychological intervention; further details can be found elsewhere (rief & glombiewski, 2016, 2017). this brief guideline shows that expectation-focused psychotherapy is not a complete‐ ly new approach, but more like an improved focus on most relevant cognitive and behav‐ ioral aspects in depression. while full evaluation trials in depression are lacking, we have positive evidence for expectation-focused approaches from other clinical fields. exposure therapy in anxiety disorders has been reformulated as a therapy to disconfirm negative expectations, and to increase inhibition of avoidance behavior (craske, 2015; craske et al., 2014). in pain disorder, many patients report “fear avoidance” behavior which can be considered as a special expectation pattern of chronic pain. if these patients were treated rief & joormann 9 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ with a highly focused expectation-based exposure intervention, they showed the most impressive improvements even in treatment arms with less treatment sessions than com‐ parative treatments (glombiewski et al., 2018). obviously, the improved focusing in pain patients led to more effective, but also more economic interventions. an expectation-focused approach was also used for a better preparation of patients undergoing heart surgery. pre-operatively, patients received an optimization of expecta‐ tions about how life can continue after successful heart surgery. such an expectation-fo‐ cused intervention was compared to an emotionally-supportive intervention, and to standard medical care. although the expectation-focused intervention was just two ses‐ sions in person, two phone calls (before surgery) and one booster phone call after sur‐ table 1 the steps of expectation-focused psychological interventions why are expectations maintained despite contradicting information? examples of queries and patients' reflections as part of the psychoeducation what are my specific expectations? others don’t like me. how can i check whether my expectations are valid? go to a party and check whether people talk to me. what are signals, perceptions, observations, that would show me that my expectations are disconfirmed? others talk to me; others initiate eye contact what kind of immunization strategies do i typically use in such a situation? thought: “they only look at me because they have negative thoughts about me”; i look away; if somebody talks to me, this is just on account of being polite – s/he has no special interest in me. how can i deal with my immunization strategies? accept negative thoughts, but be open for contradicting experiences; don’t look away results of behavioral test people came and talked to me what are further situations to test my expectations? at work during coffee breaks how should i behave to make my negative expectations come true? avoid eye contact; stand away from others, facial expression of bad mood how should i behave to make my negative expectations not come true? stand closer [...]; search eye contact; don't walk away [...] results of reality checks i was concerned that others don't like me. however, i made it quite difficult for them to show me some sympathy. and i use a lot of “immunization strategies” if positive events occur. revisiting the cognitive model of depression 10 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ gery, patients in this arm showed the lowest disability scores six month after surgery (rief et al., 2017). it is most impressive that such a low dose intervention achieved these striking effects. with more than 120 patients in this trial, it can be postulated that many risk factors and life problems were prevalent in these patients that were not addressed at all during the psychological interventions (e.g., marital conflicts, adverse early life expe‐ riences); however, quality of life improved substantially just by improving expectations. this is a further argument to better focus on crucial mechanisms that maintain mental, behavioral and even physical disorders (holmes et al., 2018). current depression treat‐ ments should be optimized to change dysfunctional expectations according to the princi‐ ples outline above, and these treatments should be subject to further evaluation. implications for research several hypotheses can be derived from the expectation model of depression that should be a further subject of investigation. first, it is postulated that healthy individuals show more immunization strategies to prevent them from the effects of negative experiences than depressed patients. if healthy individuals are repeatedly exposed to positive events, and subsequently negative experiences occur, we expect them to stick to positive expect‐ ations, and to activate immunization strategies. this is in line with some studies indicat‐ ing that depressed patients are sometimes more “realistic” than healthy individuals, be‐ cause healthy individuals show an optimism bias (sharot, korn, & dolan, 2011). this can be also considered as a resilience mechanism of healthy people (brown, 2012). with the first depressive episodes, the expectation curve is hypothesized to move to a more negative level. this change could be induced by negative experiences that trigger the first depressive episode, but also the depressive episode itself is associated with a change of expectations. if the expectation curve has been moved to the more negative side, this could receive a self-maintaining functionality and is resistant to change. after this move has happened, depressed patients could tend to interpret neutral events as con‐ firmation of their negative expectations, while healthy controls interpret the same neu‐ tral experiences as confirmation of their positive view of the world. again this dynamic can be subject to experimental, cross-sectional and longitudinal studies, to better under‐ stand and confirm ongoing mechanisms. another hypothesis is that only very salient positive information is able to modify negative expectations in depressed patients. this could be studied with experimental de‐ signs to investigate the effects of expectation development, expectation persistence and change to the positive or to the negative direction. the above described expectation model may also be a model to better understand the process of persistence of depressive episodes. we hypothesize that patients with persis‐ tent depression show more immunization strategies than patients with episodic depres‐ sion, in particular to invalidate the effects of positive experiences. this sticking to nega‐ rief & joormann 11 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ tive expectations is further supported by automatic information processes, while expecta‐ tion change is frequently associated with effortful cognitive processes. again, this has implications for treatment planning. the more chronic the depressive state is, the more relevant it might be to address cognitive immunization strategies in patients. to summarize, several hypotheses of the expectation model of depression can be ex‐ tracted that can be subject to further evaluation. it not only invites observational studies, but also more mechanistic research using experimental designs. further paradigms should be developed to establish and modify expectation processes that should have spe‐ cial ecological validity for affective disorders. linking the expectation model of depression with other psychological concepts the suggested expectation model of depression focuses on aspects of how negative ex‐ pectations develop, how they contribute to depression-specific symptoms and disability, and why negative expectations are maintained even if contradicting positive events oc‐ cur. such a focus offers various links to other prominent depression concepts, and a few of them will be addressed. neuroscience has shown that the expectation of negative emotions (e.g. pain) acti‐ vates brain areas that are responsible for this emotion, and hereby facilitates the expected perception of the corresponding negative experience (atlas & wager, 2012; keltner et al., 2006; koyama et al., 2005; wager et al., 2004). this implies that the manifestation of ex‐ pectations supports the persistence of negative mood that is associated with the expected negative experience. for the development of expectations, associative learning processes (rheker, winkler, doering, & rief, 2017), observational learning (vögtle, barke, & könerherwig, 2013) or instructional learning can contribute. to overcome negative expectations, powerful expectation-violating positive experien‐ ces are necessary. however, this requires an individual to attend to this new information, to react to its positive content, and to modify and memorize the revised version of ex‐ pectations. for this process, reward sensitivity, a concept that is closely linked to neuro‐ physiological processes in depression, can be crucial (alloy, olino, freed, & nusslock, 2016). blunted reward sensitivity was also found in relatives of depressed patients (liu et al., 2016). the postulated role of reward insensitivity is in line with recent findings that patients with depression show reduced revision of negative interpretations by disconfir‐ matory positive information (everaert, bronstein, cannon, & joormann, 2018). a revision of negative expectations requires a detailed perception and memorization of expectation-violating experiences. however, many patients with depression suffer from unspecific autobiographical memory reports (kim, yoon, & joormann, 2018; sumner, griffith, & mineka, 2010). according to the violex-model of revising expecta‐ tions (rief et al., 2015), a revision of expectations requires a very specific definition of revisiting the cognitive model of depression 12 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ specific expectations a priori, and a clear comparison of expected versus experienced spe‐ cific outcomes. if experiences are memorized only vaguely, their potential power to stim‐ ulate expectation violations is only low. this notion is in accordance with the fact that abstract ruminations lead to more regrets about past decisions than concrete ruminations (dey, joormann, moulds, & newell, 2018). repetitive negative thinking, ruminations and worrying are also major features of de‐ pression (gotlib & joormann, 2010; mcevoy et al., 2018). these strategies can be consid‐ ered as preventing the change of negative expectations, even when positive events occur. therefore, a close link between these cognitive processes and immunization strategies exists. persistent depressive disorder is frequently associated with negative early life experi‐ ences and the development of insecure attachment styles. while negative life events can trigger the establishment of various negative expectations directly, insecure attachment styles can be also reformulated as negative relationship expectations. an association be‐ tween attachment and depression was frequently shown; this association is mediated via social anxieties (manes et al., 2016). social anxieties (like all anxiety disorders) can be mainly understood as expectation disorders. several psychological interventions try to address these relationship expectations, and the active formulation of a “transference hy‐ pothesis” in cbasp is a typical example (mccullough, 2000; mccullough et al., 2011). ob‐ viously, many psychological interventions include explicit or implicit interventions at‐ tempting to change relationship expectations, although an even more focused and explic‐ it work with relationship expectations seems promising. with this subchapter, we wanted to highlight that the expectation model of depres‐ sion is able to integrate other evidence-based approaches of depression research, and it invites to link this concept with others. while these are just a few examples, further con‐ ceptual work is possible and needed. closing remarks while the cognitive model of depression was highly stimulating for a better understand‐ ing, improved conceptualization and development of treatment for depression, we sug‐ gest that it is time to better specify this approach. several results from basic neuroscience regarding effects in clinical interventions indicate that expectations can play a special role not only for the understanding of the development of mental disorders and effects of treatment approaches, but especially for an improved understanding of persistence of mental disorders. therefore, we also introduced the concept of immunization to describe any cognitive or behavioral strategies to reduce the effect of expectation violation experi‐ ences, and hereby contributing to expectation maintenance despite expectation contra‐ dicting events. we postulate that the development of immunization strategies could, in particular, be of relevance for the transition from episodic to chronic depression. while in rief & joormann 13 clinical psychology in europe 2019, vol.1(1), article e32605 https://doi.org/10.32872/cpe.v1i1.32605 https://www.psychopen.eu/ early periods of depression development, a focus on expectation change might be suffi‐ cient in treatment approaches as long as it respects some of the principles mentioned above, the treatment of patients with persistent depressive disorder requires more and more to address these cognitive and behavioral immunization strategies. we understand our manuscript mainly as stimulating further research and using this conceptual framework, instead of presenting a final model. first experimental results confirm its usability, and first clinical experiences encourage this approach as something that is easily explained to patients who found it very helpful. however, the model of the interplay between expectation processes and immunization strategies should be subject to further evaluation. funding: the authors have no funding to report. competing interests: winfried rief is editor-in-chief of clinical psychology in europe but played no editorial role for this particular article. acknowledgments: the authors have no support to report. references alloy, l. b., olino, t., freed, r. d., & nusslock, r. 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[b] centre for psychiatry research, department of clinical neuroscience, karolinska institutet & stockholm health care services, stockholm county, stockholm, sweden. clinical psychology in europe, 2020, vol. 2(2), article e2913, https://doi.org/10.32872/cpe.v2i2.2913 published (vor): 2020-06-30 corresponding author: per carlbring, department of psychology, stockholm university, 106 91 stockholm, sweden. e-mail: per@carlbring.se inelegant as they may look to the outsider, the white boxy samsung gear vr goggles with a smartphone strapped to the front, have the power to change lives. in the last few years our research team at stockholm university have used the device to treat nearly 100 spider phobic patients with virtual reality exposure therapy (vret) using the itsy application, developed alongside vr-startup mimerse (miloff et al., 2016). the real tears patients shed may be indication enough that the animated spiders and computer-gener‐ ated world are helping them face their deepest fears. however, evidence shows large reductions in self-reported fear and avoidance around live spiders. in fact, the positive behavior change is very nearly as powerful as the gold-standard treatment for spider phobia that ends with handling a 3-centimeter spider with their hands (miloff et al., 2019). the boundary for how we perceive real and artificial may not be as large as we think. today, the biggest tech companies are still pouring enormous resources into making virtual a reality. facebook purchased oculus, shipped the rift, the mobile go and now quest, google had the daydream-standard and is now moving onto augmented-reality, sony the playstation vr and even apple is said to be working on a device. still, there is a feeling in this industry that it isn’t really clear what virtual reality is good for. there are entertaining games available sure, mostly shooters and rhythm games. there is the extremely enjoyable feeling of awe to be dropped into a virtual world somewhere, flying in a fighter jet or swimming with divers. new ways of storytelling are certainly possible and are being created. however, there is the persistent feeling that something is missing. the technology is just too powerful for the limited experiences we’ve developed so far. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i2.2913&domain=pdf&date_stamp=2020-06-30 https://orcid.org/0000-0002-9125-8060 https://orcid.org/0000-0002-3061-501x https://orcid.org/0000-0002-2172-8813 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ to understand what is possible, it may be best to look at the way our reality generating system functions and work backwards. our eyes, ears, taste and touch are geared towards favoring certain information over others (bayle et al., 2009; erlich et al., 2013; öhman & mineka, 2001). sudden movement in the corner of our eye evokes a fear response, as does the sound of a potentially violent individual above the din of a crowd, or the unexpected irritation of a wriggling bug on our skin. see a certain shape walk by and lust towards an attractive mate might cause butterflies in the stomach. the most common use of virtual reality in clinical treatments is for phobias and similar to face-to-face treatment is almost always seen through the lens of stimulus-emotion pairs and exposure therapy (turner & casey, 2014). with virtual reality, however, we might be able to explore not only working to modify basic emotions using simple stimuli but higher order functions of the mind using complex simulations as well. for millions of years we sat on the savannah around open fires. the rustling and movement in tall grasses at the far edge of the camp may be just the wind but our minds see a leaping lion ready to disembowel us. gifted with large brains capable of complex pattern recognition and learning, we’ve developed immense capabilities of prediction. for want of a better word, this is the power of imagination and at its most vivid. we see in our mind’s eye a disaster before we experience it. we feel ourselves drowning before we ever get on the boat. we feel the wind on our face and the sensation of hitting the ground before we ever step onto the airplane. in the right frame of mind, we may have even pictured the previous two sentences in our imagination as we read them. although this capacity is one of the ways we define ourselves as human, it’s also responsible for great suffering, catastrophic fears, debilitating anxiety; its moderation actually one of the ways we define treatment success in specific phobia, i.e., no longer believing your catastrophic fears (davis et al., 2012). we are just at the beginning of exploring the many uses of vr and its practical application to clinical psychology. tremendous progress has been made at importing what we know from traditional formats for psychological treatments (e.g., exposure ther‐ apy), but new and more innovative leaps in understanding and technique are possible. the capacity of imagination is something we take for granted and generalized solutions for dealing with its problematic aspects limited. virtual reality offers a nearly limitless world in which to create, restricted only by development costs and again, the more useful aspects of our imagination. the industry driving development of the technology is searching for the killer app that could convince new users to jump in, and clinical applications that converge with the gaming industry and storytelling might offer such an opportunity. whether such generalized solutions are possible is uncertain, however what is certain is that the future of clinical treatment and virtual reality is more than just simple exposures. editorial 2 clinical psychology in europe 2020, vol.2(2), article e2913 https://doi.org/10.32872/cpe.v2i2.2913 https://www.psychopen.eu/ funding: the authors have no funding to report. competing interests: author pl has consulted for mimerse but holds no financial stake in the company. no potential conflict of interest was reported by am or pc. acknowledgments: the authors have no support to report. references bayle, d. j., henaff, m.-a., & krolak-salmon, p. 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(2014). outcomes associated with virtual reality in psychological interventions: where are we now? clinical psychology review, 34(8), 634-644. https://doi.org/10.1016/j.cpr.2014.10.003 miloff, lindner, & carlbring 3 clinical psychology in europe 2020, vol.2(2), article e2913 https://doi.org/10.32872/cpe.v2i2.2913 https://doi.org/10.1371/journal.pone.0008207 https://doi.org/10.1111/desc.12091 https://doi.org/10.1016/j.brat.2019.04.004 https://doi.org/10.1186/s13063-016-1171-1 https://doi.org/10.1037/0033-295x.108.3.483 https://doi.org/10.1016/j.cpr.2014.10.003 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. editorial 4 clinical psychology in europe 2020, vol.2(2), article e2913 https://doi.org/10.32872/cpe.v2i2.2913 https://www.psychopen.eu/ integrating cognitive behavioral group therapy and psychodrama for social anxiety disorder: an intervention description and an uncontrolled pilot trial research articles integrating cognitive behavioral group therapy and psychodrama for social anxiety disorder: an intervention description and an uncontrolled pilot trial hanieh abeditehrani a, corine dijk a, mahdi sahragard toghchi b, arnoud arntz a [a] department of clinical psychology, university of amsterdam, amsterdam, the netherlands. [b] department of psychology, payame noor university, tehran, iran. clinical psychology in europe, 2020, vol. 2(1), article e2693, https://doi.org/10.32872/cpe.v2i1.2693 received: 2018-11-26 • accepted: 2019-11-16 • published (vor): 2020-03-31 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: hanieh abeditehrani, university of amsterdam, department of clinical psychology, po box 15933, 1001 nk amsterdam, the netherlands. e-mail: h.abeditehrani@uva.nl abstract background: cognitive behavioral therapy (cbt) is generally considered to be the most effective psychological treatment for social anxiety disorder (sad). nevertheless, many patients with sad are still symptomatic after treatment. the present pilot study aimed to examine integrating cbt, with a focus on cognitive and behavioral techniques, and psychodrama, which focuses more on experiential techniques into a combined treatment (cbpt) for social anxious patients in a group format. this new intervention for sad is described session-by-session. method: five adult female patients diagnosed with social anxiety disorder participated in a twelve-session cbpt in a group format. pretest and posttest scores of social anxiety, avoidance, spontaneity, cost and probability estimates of negative social events, depression, and quality of life were compared, as were weekly assessments of fear of negative evaluation. results: results demonstrated a significant reduction of the fear of negative evaluation and social anxiety symptoms. it is noteworthy that also the scores of the probability and cost estimates decreased. however, there were no significant differences between pre and post measures in any of other measures. conclusion: the current study suggests that group cbpt might be an effective treatment for sad. however, our sample size was small and this was an uncontrolled study. therefore, it is necessary to test this intervention in a randomized controlled trial with follow-up assessments. keywords integrating therapies, cognitive behavioral therapy, psychodrama, social anxiety disorder, clinical trial this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i1.2693&domain=pdf&date_stamp=2020-03-31 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • this study describes integrating cognitive behavioral therapy and psychodrama (cbpt). • cbpt significantly reduced fear of negative evaluation and social anxiety. • three of the five patients have a clinically significant change on the lsas after the treatment. • cbpt also changed estimates of social cost and the probability of negative social events. social anxiety disorder (sad) is one of the most common mental disorders, with a 13% lifetime prevalence (kessler, petukhova, sampson, zaslavsky, & wittchen, 2012). recent research shows that the prevalence of sad in iran is approximately 10% (talepasand & nokani, 2010). depression is highly comorbid with sad and more than half of the pa‐ tients report lifetime major depression (brown, campbell, lehman, grisham, & mancill, 2001). sad is associated with increased functional disability, substantial economic inac‐ tivity, and a lower quality of life (patel, knapp, henderson, & baldwin, 2002). therefore, it is important to treat sad effectively. several meta-analyses show that cognitive behavioral therapy (cbt) is the most effective psychotherapy for sad (hofmann & smits, 2008; mayo-wilson et al., 2014). cbt is an eclectic approach based on a combination of techniques from cognitive and behavioral theories (harwood, beutler, & charvat, 2001). cognitive behavioral group therapy (cbgt), as developed by heimberg and becker (1991, 2002) is an efficacious and evidence-based treatment for sad. the effect of cbgt on social anxiety symptoms has been demonstrated in meta-analyses (barkowski et al., 2016; mayo-wilson et al., 2014). cbgt usually consists of cognitive restructuring, exposure and homework assignments (coles, hart, & heimberg, 2005; heimberg & becker, 2002). judgmental biases such as beliefs about the cost and probability of negative social events play an important role in the maintenance of sad (clark & wells, 1995; heimberg, brozovich, & rapee, 2010; hofmann, 2007; morrison & heimberg, 2013). there is an association between cbt treatment and a reduction in probability or cost estimates for individuals with sad (foa, franklin, perry, & herbert, 1996; gregory, peters, abbott, gaston, & rapee, 2015; hofmann, 2004; lucock & salkovskis, 1988; poulton & andrews, 1994). hence, cb(g)t is an effective treatment for sad. however, 25-50% of patients with sad show little or no improvement after treatment (davidson et al., 2004; heimberg et al., 1998; hofmann & bögels, 2006). thus, many patients remain symptomatic after completing treatment, and it is clear that there is room to improve interventions to enhance clinical outcomes for sad. we propose that cbt and psychodrama can be integrated to enhance treatment effects. psychodrama is an action-based method of group psychotherapy, developed integrating cbt and psychodrama 2 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ by jacob levy moreno (moreno, 1946). in psychodrama, patients use role-playing to dramatize their psychological and social problems rather than just talking about them (blatner, 2000). furthermore, psychodrama can enhance the potency of therapeutic alli‐ ance and create a therapeutic bond between group members by letting patients engage in role-playing and the playing of auxiliaries in the other members’ enactment, and by evoking emotions during action (orkibi, azoulay, regev, & snir, 2017). several studies with non-sad samples on the combination of cbt and psychodrama demonstrated that cbt and psychodrama could be integrated (boury, treadwell, & kumar, 2001; hamamci, 2002, 2006; treadwell, kumar, & wright, 2002). there are several reasons why psychodrama techniques can enhance therapy outcome for sad patients as well. first, several acting techniques in psychodrama do not occur in cbgt but might be helpful, because they involve experiential learning (see table 2 for a description of typical psychodrama techniques and their goals for treatment of sad), whereas the focus of traditional cbt is on cognitive and behavioral learning. second, there is increasing evidence that (traumatic) childhood experiences contribute to the development of sad (arrindell, emmelkamp, monsma, & brilman, 1983; blöte, miers, & westenberg, 2015; bruch & heimberg, 1994; kuo, goldin, werner, heimberg, & gross, 2011; simon et al., 2009). psychodrama provides an opportunity to reenact a negative social interaction from the past as if it occurs in the present, but now in the safe setting in which the patient has more control over what is said and done. this might, in turn, change the patient's beliefs, feelings, and attitudes about the traumatized situation (treadwell & kumar, 2002). third, socially anxious people devote effort to control the expression of feelings and suppress their emotions to minimize the chance of making social transgressions and elicit rejection by others (kashdan & steger, 2006). they also report a fear of experiencing emotions and more negative beliefs about the consequences of emotional expression (spokas, luterek, & heimberg, 2009). in psychodrama, a safe environment is created which can help patients to express their inhibited emotions and examine the accuracy of their beliefs about the negative outcomes of this. finally, according to moreno’s theory, anxiety decreases by increasing spontaneity. in cbt-terms, spontaneity can be seen as the opposite of avoidance and inhibition that is central to sad. one of the aims of psychodrama is to increase spontaneity. there is no research to demonstrate that cbt and psychodrama can be integrated in‐ to the treatment of social anxiety disorder. the main aim of this pilot study is to describe the intervention and examine the integrated group cbt-psychodrama protocol (labelled cbpt) to treat social anxious patients and to get a first impression of its effectiveness. we hypothesized that cbt and psychodrama can be successfully integrated and that this integration is effective in improving fear of negative evaluation, the characteristic feature of sad, which was measured by the brief fear of negative evaluation scale (bfne), and social anxiety symptoms, which were measured by the liebowitz social anxiety scale (lsas). furthermore, integrating psychodrama and cbgt might be efficacious for sad abeditehrani, dijk, sahragard toghchi, & arntz 3 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ because they focus on separate mechanisms. psychodrama focuses on increasing sponta‐ neity and decreasing avoidance behavior through role-playing. cbgt, on the other hand, focuses on decreasing cognitive biases associated with sad and decreases avoidance behavior through exposure. the cbpt, therefore, might offer a broader treatment which might also affect depression, an often comorbid disorder with sad, and increase the quality of life in patients suffering from sad. method participants six patients with a primary diagnosis of social anxiety disorder were included in this study; all were diagnosed with the structured clinical interview for dsm 4th ed (scidi, farsi version; first, spitzer, gibbon, & williams, 2012). participants were recruited through the media and poster advertisements. one participant dropped out of the study because she found a full-time job before the first session, and was therefore not included in the analysis. all the patients were females, living in tehran. the mean age of the five patients was 36.6 (age range = 21-63; sd = 17.89). three of them were diagnosed with generalized and two of them with specific sad. an iranian ethical committee (reference number ir.umsha.rec.1394.521) approved the protocol on february 27, 2016, and all patients gave their written informed consent prior to their inclusion in the study. this study is a preparatory pilot for an rct that included the cbpt protocol as an arm. the rct was preregistered at a trial register (irct2016032321385n1). inclusion criteria were sad as a primary diagnosis, age between 18 and 65 years, ability to read and understand the questionnaires and the interview. exclusion criteria were comorbid psychotic or bipolar disorder, lifetime history of schizophrenia or bipolar disorder, a high suicidality risk, antisocial or borderline personality disorder, a comorbid diagnosis of substance abuse or dependence. furthermore, unwillingness to stabilize medication for the duration of the study was an exclusion criterion as well. procedures and measures social anxiety was assessed with the clinician-administered version of the lsas (liebowitz, 1987) at pre and posttests by an independent assessor and the brief fear of negative evaluation scale (bfne; rodebaugh et al., 2004; weeks et al., 2005) was completed before the treatment and also after every treatment session (thus in total there were 13 measurements). additionally, the patients were assessed at pre and posttests on the following outcomes: social avoidance with the social avoidance and distress scale (sads; watson & friend, 1969); spontaneity with the personal attitude scale-ii (pas; kellar, treadwell, kumar, & leach, 2002); and cost and probability estimates of negative social events with the outcome probability questionnaire (opq; uren, szabó, integrating cbt and psychodrama 4 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ & lovibond, 2004) and the outcome cost questionnaire (ocq; uren et al., 2004). depres‐ sion was measured with the beck depression inventory (bdi; beck, steer, & brown, 1996), and quality of life was measured with the quality of life inventory (qoli; frisch, cornell, villanueva, & retzlaff, 1992). for the several questionnaires, no persian version existed (e.g., quality of life inven‐ tory, outcome probability questionnaire, outcome cost questionnaire, and personal attitude scale-ii). therefore, these were translated and back-translated to ensure the adequacy of the translation. finally, therapists used a session report form to record the procedures used in the session, such as the name of the protagonist and the auxiliaries, the type of therapeutic techniques that were used (e.g., role reversal, cognitive challenging), and also patients’ feedback on the therapy session. primary outcomes the brief fear of negative evaluation scale (bfne; rodebaugh et al., 2004; weeks et al., 2005), is a self-report measure consisting of 12 items on a 5-point likert scale (1 = strongly disagree, 5 = strongly agree). an example question is: “i am afraid that others will not approve of me”. the bfne has excellent internal consistency (cronbach's alpha > .92) and validity in clinical samples (weeks et al., 2005). the liebowitz social anxiety scale – clinician-administered version (lsas; liebowitz, 1987) is a 24-item interview that assesses fear and avoidance, in social interac‐ tions (e.g., talking with people you don’t know very well) and performance situations (e.g., returning goods to a store). the items are on a 4-point-likert scale (0 = never, 3 = usually). the lsas has shown good test–retest reliability, internal consistency, and convergent and discriminant validity (baker, heinrichs, kim, & hofmann, 2002; fresco et al., 2001; oakman, van ameringen, mancini, & farvolden, 2003; rytwinski et al., 2009). secondary outcomes the social avoidance and distress scale (sads; watson & friend, 1969) is a self-report inventory with 28-item that includes 14 items to assess social avoidance (e.g., i often want to get away from people) and 14 items to assess social anxiety (e.g., i often feel on edge when i am with a group of people). all items are rated as true or false. cronbach's alpha reliability coefficient was .90 and the test-retest reliability was .77 in a study by watson and friend (1969). the personal attitude scale-ii (pas; kellar, treadwell, kumar, & leach, 2002) is a self-report measure of spontaneity. an example item is: “i am at ease when meeting new people”. it has 66 items on a 5-point likert scale (0 = strongly disagree; 4 = strongly agree). cronbach's alpha reliability coefficient of internal consistency was .92 and the test-retest reliability was .86 in a study by kellar et al. (2002). abeditehrani, dijk, sahragard toghchi, & arntz 5 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ the outcome probability questionnaire (opq) and the outcome cost questionnaire (ocq) (uren, szabó, & lovibond, 2004) are two self-report questionnaires consisting of 12 items. the opq assesses an individual’s probability estimate of the occurrence of negative social events (e.g., how likely would be for you at a party, others will notice that you are nervous?). the ocq then asks about the same negative social events but here individuals are asked to indicate how costly it would be if these events were actually to occur (e.g., how distressing would be for you if at a party, others will notice that you are nervous?). both questionnaires have items on a 9-point likert scale (0 = not at all likely/distressing; 8 = extremely likely/distressing). the internal consistency of both instruments is good (cronbach’s alpha ≥ .90) (uren et al., 2004). the beck depression inventory-ii (bdi-ii; beck, steer, & brown, 1996) is a 21-item self-report inventory that measures the severity of symptoms of depression in the previous two weeks (e.g., loss of energy, worthlessness). a good internal consistency (cronbach’s alpha = .92), and test-retest reliability have been shown in several studies (beck, steer, & carbin, 1988; beck et al., 1996). the quality of life inventory (qoli; frisch, cornell, villanueva, & retzlaff, 1992) is a 16-item self-report questionnaire that includes 16 areas that are related to the overall happiness of life (e.g., work, health). the survey asks the participants to describe first the importance (0 = not at all important, 2 = very important) and then satisfaction (+3 = very satisfied, -3 = very dissatisfied) of each area. for each area quality of life is measured by multiplying the importance with the satisfaction which can range from -6 to +6. the internal consistency is high, cronbach’s alpha between α = 0.77 and α = 0.89, and the one month test-retest reliability is between r = 0.80 and r = 0.91 (frisch et al., 1992). intervention the cbpt therapists integrated cognitive restructuring and exposure with psychodrama techniques. the cbpt group underwent 12 weekly sessions each lasting 2.5 hours with five patients and two therapists (one male and one female). the therapists received train‐ ing in the integrated psychodrama and cbt protocol, were trained in and had experience with conducting both psychodrama and cbgt. furthermore, an expert in cbpt had weekly supervision meetings with the therapists to ensure the quality of the treatment. the cbpt treatment consisted of four phases: (1) an initial preparatory interview (2) building group cohesion and introduction of cognitive restructuring (sessions 1 and 2), (3) cbt and psychodrama (sessions 3 through 11), and (4) conclusion (the 12th session). the treatment starts with an individual treatment orientation interview in which group treatment procedures and fear of participation in group sessions are discussed. this interview prepares patients for group sessions and makes them familiar with one of the therapists (heimberg & becker, 2002). session 1 and 2 are devoted to creating a safe atmosphere in which patients can share their feelings and thoughts with other members of a group, and to the building of group cohesiveness. the sessions are based integrating cbt and psychodrama 6 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ on heimberg and becker's (2002) cbgt protocol and are used as basic training in cogni‐ tive restructuring. in the first session, the therapists present cbpt therapy for social anxiety and briefly explain the primary treatment techniques. next, the session focuses on the identification of automatic thoughts. at the end of the session, patients share their individual problems, and goals and homework are assigned, which is a recording of automatic thoughts during the following week. the second session is devoted to developing cognitive restructuring skills of patients and to introduce thinking errors by practicing with the recorded automatic thoughts form. the therapists teach patients how to dispute cognitions and replace negative automatic thoughts with more helpful cognitions. therapists also inform and prepare patients for initiation of the role-playing in the third session. at the end of the session, homework is assigned again, which is to label thinking errors in the identified automatic thoughts and to practice with cognitive restructuring (heimberg & becker, 2002). session 3 to 11 follow the stages of classical psychodrama, which includes warm-up, action, and sharing. before the warm-up stage, the therapists review homework in order to identify automatic thoughts and thinking errors and use socratic questioning to help patients with finding a more rational response. the warm-up stage facilitates a safe, supportive and creative atmosphere at the beginning of every session by doing warm-up techniques to prepare patients for action. during the warm-up stage, the therapists ask patients to do a verbal or non-verbal warm-up practice (weiner & sacks, 1969). for example, patients are encouraged to get up, move around and select someone to meet as if they have never met them before, but to meet them without using words. after this warm-up stage, the individual who will act as the protagonist is identified (see table 1 for a description of typical psychodrama roles). table 1 description of typical psychodrama roles roles description protagonist the main character, the session is focused on his/her problem. auxiliary ego an auxiliary ego is a person that has an important role in the situation chosen by the protagonist in the group and is played by a group member. audience other patients who observe the action are called audience. stage a semi-circle of chairs is put in the room to create a stage so that the protagonist can act in front of the patients. each patient is protagonist at least once during the treatment. the therapist can ask who is ready to work as a volunteer. alternatively, the therapists can select a protagonist abeditehrani, dijk, sahragard toghchi, & arntz 7 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ based on what they observed during the preparation in warm-up stage (e.g., sometimes patients express their performance anxiety in the warm-up stage verbally or non-verbal‐ ly which is appropriate for the selection of the protagonist) or based on information revealed during sharing phase of the previous session (kumar & treadwell, 1986). in the action stage of the therapy sessions, the therapists create a scene with the protagonist, in which an anxiety-provoking situation is acted out. although role-playing can be an element of cbt, the most important difference between psychodrama and cbt is the aim of role-playing and the manner in which it is executed. in cbgt, role-playing focuses on the thinking process and is used as exposure to change irrational thoughts. in psychodrama, role-playing focuses on emotional expression and it is used to evoke and release emotions (fisher, 2007). the role-playing can involve past as well as future situations but also feared situations that did not actually happen (karp & farrall, 2014). the protagonist can select the auxiliary ego (see table 1) from the group members. during the action stage, therapists can use various psychodrama techniques, as described in table 2. however, during this stage therapists use cbt techniques as well. for example, thera‐ pists might shortly stop the scene and use cognitive restructuring to provide alternative thoughts so role-playing can be continued with these alternative thoughts. which psy‐ chodrama technique is used depends on the type of anxiety-provoking situation and is chosen by the therapists with the protagonist’s agreement. for example, role reversal is suitable for social interactions (e.g., talking with strangers, dating, and meeting unfa‐ miliar people), and mirroring is suitable for performing in front of others (e.g., public speaking). double is used to identify automatic thoughts that can be used for cognitive restructuring and is often used in situations in which someone feels observed (e.g., eating or drinking in front of others, writing in public, going to parties, being at the center of attention, and using public toilets). finally, empty chair and soliloquy are suitable for traumatic situations where it is helpful to express suppressed emotions. the last part of each session is sharing or closure. this is a time for patients to discuss the effects the action of the scene had on them and share their feelings and thoughts with the group. the therapists use cognitive restructuring techniques after the action stage to identify automatic thoughts and help patients to correct thinking errors that occurred during role-playing. at the end of each session, the therapists ask patients to provide feedback on therapy session. they also assign exposure in vivo as homework for the protagonist. the other participants not receive homework. the twelfth and last session is again based on heimberg and becker's (2002) proto‐ col and is divided into two parts. the first half is used for practicing with additional exposure, role-playing, and cognitive restructuring. in the second half, the therapists and patients review their development during treatment. that is, they discuss situations that may still be problematic and suggest rational responses can be beneficial in these integrating cbt and psychodrama 8 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ situations. finally, therapists help patients to set goals for situations after the end of the formal treatment (heimberg & becker, 2002). table 2 description of psychodrama techniques and their goals for treatment of sad description techniques goal role reversal two individuals first roleplay a situation. next, the protagonist and the antagonist are asked to change the positions and play the other's role. experiencing the role of the other person results in cognitive change. it helps to correct biased beliefs about how one comes across to others. double a patient of the group plays the protagonist’s inner self and gives a voice to the protagonist’s feelings, thoughts or needs, usually by standing behind the protagonist. the protagonist can accept or reject double’s offers. identify automatic thoughts and express suppressed thoughts and feelings during roleplaying. it helps the protagonist to explore and expose his/her cognitive distortions. empty chair the protagonist can talk to an imaginary person that is represented by an empty chair. express negative as well as positive feelings. mirroring the auxiliary ego plays the role of the protagonist for a short time. the protagonist stands aside and watches an immediate action and see his/her own behavior, body language and interactions with the other as in a mirror. observe themselves through the eyes of the audience works as immediate feedback from the audience (hammond, 2014) to gain a more realistic view from others’ judgment about his/her performance. soliloquy a monologue in which the patients can express their thoughts and feelings to the audience. practice expressing their suppressed thoughts and feelings to the audience to relieve negative beliefs about emotional expression and decrease emotional suppression. statistical analysis in total, there were 10 missing values in the bfne score that were completed each session (6.5 percent). we used a linear mixed model to handle these missing values, which allowed us to still examine if there was an effect of time on the session-by-session bfne scores. the fixed part included an intercept and a linear effect of time (the pretest bfne and the scores after completing each treatment session coded as 0, 1, 2, …, 12), the repeated part an autoregressive arma11 covariance structure. the effect size of the fixed time effect was expressed as r (r = t/√(t 2 + df)). we also estimated the effect size of the pre-post change in terms of cohen’s d which is pre-post change calculated on the basis of the estimated effects of the linear mixed model, divided by the pretest standard deviation (morris, 2008). the pretest and posttest scores of the other outcomes were abeditehrani, dijk, sahragard toghchi, & arntz 9 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ compared with paired sample t-tests (see de winter, 2013, for the validity of the t-test with small samples). pre-post effect sizes were calculated in terms of cohen’s d = mean pre-post change divided by pretest standard deviation (morris, 2008), and hedges’ g (see table 4 note for the formula). hedges’ g is smaller than conventional cohen’s d but has less bias. results primary outcomes a linear mixed model analysis showed that the intervention resulted in a significant reduction of fear of negative evaluation, see table 3. the pre-post effect size estimated from the linear mixed model on the bfne was cohen’s d = 1.16. table 3 linear mixed model estimates [and 95% confidence interval] of fixed effects with bfne as dependent variable parameter b se df t (n) p 95% ci effect size ll ul r cohen’s d (bl) cohen’s d (ml) intercept 37.64 2.46 6.64 15.28 < .001 31.75 43.53 time -0.68 0.22 11.94 -3.16 .008 -1.15 -0.21 .67 1.16 1.32 note. ci = confidence interval; ll = lower limit; ul = upper limit; effect size for the fixed effect r = t/√(t 2 + df). cohen’s d (bl) = |b (time)* 12/sd baseline|. cohen’s d (ml) = |standardized beta (time) * (standardized time at pretest – standardized time at posttest)| (lorah, 2018). figure 1 illustrates that although the mean score of the bfne increased after the second session, it then decreased till the end of the treatment. figure 2 shows the individual bfne scores per assessment and indicates that in 4 of the 5 participants there was a reduction in bfne scores. the dots in the figure show at which session each participant had a protagonist role. in 7 of the 10 instances, there was an immediate reduction in bfne scores after the session. there was also a significant decrease in social anxiety symptoms assessed with the lsas (see table 4). integrating cbt and psychodrama 10 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ figure 1 observed and estimated (by the linear mixed model) mean and standard deviation (sd) of bfne every session by assessment note. there was a significant linear decrease over time in bfne scores. figure 2 individual bfne scores over the period of treatment note. dots show who is a protagonist in the session. abeditehrani, dijk, sahragard toghchi, & arntz 11 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ table 4 pretest and posttest comparison for the cbpt intervention scale pre post t (4) m difference [ci 99%] cohen’s d hedges’ gm sd m sd ll ul p bfne 35.60 7.02 28.40 4.10 2.86 -4.39 18.79 .046 1.03 0.82 lsas 99.40 16.99 58.40 24.81 3.82 -8.44 90.44 .19 2.41 1.93 sads 14.40 5.64 11.80 7.73 1.31 -6.56 11.76 .261 0.46 0.37 pas 133.20 13.88 131.60 17.21 0.20 -34.67 37.87 .849 -0.12 -0.09 opq 56.20 23.18 35.80 16.63 3.22 -8.74 49.54 .032 0.88 0.70 ocq 64.80 23.47 47.00 26.67 5.95 4.03 31.57 .004 0.76 0.61 bdi 19.60 5.86 12.60 8.20 2.03 -8.82 22.82 .111 1.19 0.96 qoli 29.40 21.31 36.00 25.17 -0.88 -41.13 27.93 .429 0.31 0.25 note. observed means (m) and standard deviations (sd) for the pre and post assessment points; results of t-test analyses (t, p-value) and effect sizes cohen’s d and hedges’ g. bfne = brief fear of negative evaluation; lsas = liebowitz social anxiety scale; sads = social avoidance and distress scale; pas = personal attitude scale-ii; opq = social cost and probability by the outcome probability questionnaire; ocq = outcome cost questionnaire; bdi = beck depression inventory; qoli = quality of life inventory. cohen’s d was estimated as d = (mean pre-post change)/(pretest sd). hedges’ g was calculated as follows: g = j*d, with d = cohen’s d; j = (1 – 3/(4*df-1)); df = n-1. the sign of the effect size was chosen so that a positive effect size indicates improvement and negative effect size represents worsening. secondary outcomes there was a significant decrease in outcome probability and outcome cost question‐ naires. however, there was no significant difference in social avoidance, spontaneity, depression, and quality of life after completing treatment. the test statistics, as well as the effect sizes, are presented in table 4. reliable change and clinical significant change to estimate the rates of clinical significant improvement, we computed the reliable change, clinical significant change, and cutoffs as suggested by jacobson and truax (1991) on the primary outcome measures. moreover, because our sample is too small, we used standard error and test-retest values of two iranian studies with large samples for bfne (se bfne 4.49 from tavoli, melyani, bakhtiari, ghaedi, & montazeri, 2009), and lsas1 (se lsas 11.07 from atrifard et al., 2012). reliable change (rc) was calculated as difference between post and pretest divided by standard error of change. an rc rate greater than 1.96, is considered as improvement (jacobson & truax, 1991; see table 5). clinically significant change (csc) consists of reliable change and a posttest score that falls within mean ± two standard deviations of non-anxious sample, which was 39.86 ± 1) this was self-report lsas. integrating cbt and psychodrama 12 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ 2*18.98 for lsas, and 28.7 ± 2*5.9 for bfne, again using data from two larger studies (atrifard et al., 2012; tavoli et al., 2009). as can be seen in table 5, three of the five patients with lsas and two of the five patients with bfne have a clinical significant change after the treatment. table 5 within-participant changes for the cbpt intervention on the primary outcomes participants bfne lsas pre post change rc below c = 30.97 pre post change rc below c = 57.57 1 30 25 5 n y 80 52 28 y y 2 45 35 10 y n 104 86 18 y n 3 35 29 6 n y 83 34 49 y y 4 28 28 0 n y 116 37 79 y y 5 40 25 15 y y 114 83 31 y n note. rc = reliable change; bfne = brief fear of negative evaluation; lsas = liebowitz social anxiety scale (lsas); y = yes; n = no. feedback from patients in the course of the treatment, role reversal and double were the most frequently used techniques in cbpt based on therapists’ post-session reports. after sessions, patients re‐ ported that role reversal was a helpful technique that enables them to expose themselves to anxiety-provoking social situations. they further reported that cognitive restructuring as it was integrated into techniques in the action stage, helped them to understand cbt concepts in a more experiential way. patients also experienced some warm-up techniques (e.g., forming a band by playing their invisible musical instruments) as anxiety-provoking and embarrassing situations, but they finally evaluated them as helpful warm-up techni‐ ques to decrease anxiety. discussion cbpt balances a focus on cognition and behavior through cbt techniques, and emotion during psychodrama techniques in action. the results from this pilot study supported that integrating cbgt and psychodrama might be considered as a new treatment for patients diagnosed with sad. also, the fact that patients continued the treatment until the last session indicates that cbpt was acceptable for patients. the pilot indicated that the treatment was effective in the core area of sad. social anxiety, as assessed by the lsas, reduced significantly from pre to posttest. the current study showed a high effect size on the lsas (pre-post effect size hedges’ g = 1.93) in comparison to the pre-post effect sizes of other studies using heimberg’s cbgt on the abeditehrani, dijk, sahragard toghchi, & arntz 13 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ lsas (blanco et al., 2010, g = 0.56; bjornsson et al., 2011, g = 0.61; hayes-skelton and lee, 2018, g = 0.82; hedman et al., 2011, g = 0.99; heimberg et al., 1998, g = 0.75). significant improvements were also found on the two cognitive measures of cost and probability estimates of negative outcomes. this suggests that cbpt can change cognitive processing biases to decrease social anxiety in sad. our findings are in line with research that reported changes in probability or cost estimates after cbt, which in turn related to therapeutic changes in social anxiety symptoms (foa et al., 1996; gregory et al., 2015; hofmann, 2004; lucock & salkovskis, 1988). hamamci (2002) also showed that integrating cbt and psychodrama techniques leads to a reduction in cognitive distortions related to interpersonal relationships. it is conceivable that the use of psy‐ chodrama techniques contributed to a decrease in estimated social cost and probability because it helped patients to experience a disconfirmation of their expectations. howev‐ er, because in the current study cbt and psychodrama techniques were integrated, it is not clear how much change results from psychodrama techniques alone. future research should reveal if that cbpt is more effective in decreasing negative beliefs than cbt or psychodrama alone. likewise, fear of negative evaluation also reduced during treatment with a pre-post effect size of hedges’ g = 0.82 on bfne scores, which is in line with the pre-post effect sizes of studies using cbgt in the treatment of sad (bjornsson et al., 2011; heimberg et al., 1998). the decline of fear of negative evaluation was not consistent in the course of treat‐ ment. after the second session, there was an increase in fear. this might be due to the announcement in the second session of the start of in-session exposure and role-playing in the third session. however, the increase was only temporary, and social anxiety decreased significantly till the end of treatment. fear of negative evaluation decreased immediately after 7 of the 10 sessions in which a patient was the protagonist, showing an overall immediate positive effect of being protagonist on social anxiety symptoms in a small sample. why being a protagonist was not always followed by a decrease in bfne is not clear. this might be due to the patients’ attitude toward role-playing or the level of expression of emotions, or other factors. clearly, further work in large clinical trials is required to gain a better understanding of the effects of being the protagonist in social anxious patients. next to social anxiety outcomes there were several other outcomes measures. these showed that there were no significant differences between pre and posttest in avoidance, spontaneity, depression symptoms and quality of life. the lack of significant effects on the measure of spontaneity is rather surprising, given the prominent position spontane‐ ity has in the theory of psychodrama. perhaps the spontaneity measure that we used is not sensitive to change because the items that were used describe spontaneity more as a stable personality trait than a characteristic that can easily be changed during a short cbpt treatment. however, moreno (1953) noted that especially spontaneity can be integrating cbt and psychodrama 14 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://www.psychopen.eu/ enhanced during psychodrama and that it is an important mechanism of clinical change (moreno, 1953). further research is required to examine if the current lack of change in spontaneity is due to the type of measure or if the short integrated cbpt is not suitable to change spontaneity. the lack of significant effects on avoidance, depression, and quality of life might relate to the limited power of this pilot study, as the changes are in the direction of improvement, and are in the range of effect sizes of previous studies, or exceed them. that is, the finding on avoidance, depression, and quality of life are consistent with previous studies: avoidance with a pre-post effect size of hedges’ g = 0.37 on sads scores, while heimberg’s studies using cbgt in the treatment of sad resulted in a pre-post sads effect size of hedges’ g = 0.29 (heimberg et al., 1990), and hedges’ g = 0.17 (heimberg et al., 1998); depression with a pre-post effect size of hedges’ g = 0.96 on bdi scores, which is in line with previous studies using cbgt in the treatment of sad that found pre-post bdi effect sizes of hedges’ g = 0.78 (heimberg et al., 1990), and hedges’ g = 0.82 (koszycki, benger, shlik, & bradwejn, 2007); quality of life with a pre-post effect size of hedges’ g = 0.25 on qoli scores, which is in line with other studies using cbgt in the treatment of sad finding small pre-post qoli effect sizes of hedges’ g = 0.28 (hayes-skelton & lee, 2018), and hedges’ g = 0.44 (koszycki et al., 2007). an important limitation of the present study is that our sample size was small (5 patients) limiting the external validity of the results. besides, this was an uncontrolled study and the internal validity study is limited by the lack of a control group. moreover, the lsas assessors were not blind to the timing of the interviews (before or after treatment). there was no follow-up assessment into also, thus it is unclear whether the results were maintained or whether there were further changes. this is in particular important for outcomes like avoidance, depression, and quality of life that might show a delayed response to treatment. furthermore, integrating psychodrama and cbt in therapeutic practice usually includes 16 sessions (treadwell, dartnell, travaglini, staats, & devinney, 2016). however, the current cbpt protocol consists of twelve sessions to make it comparable to cbgt in future random clinical trials. nevertheless, the effects of cbpt might be larger with 16 sessions. future studies might investigate different lengths of treatment. the results of this pilot are promising, but it is necessary to do research in a randomized controlled trial with follow-up assessments to compare this treatment to cbgt alone and psychodrama alone. funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to 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(1969). warm-up and sum-up. group psychotherapy, 22(1-2), 85-102. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. abeditehrani, dijk, sahragard toghchi, & arntz 21 clinical psychology in europe 2020, vol.2(1), article e2693 https://doi.org/10.32872/cpe.v2i1.2693 https://doi.org/10.3200/jgpp.55.2.51-53 https://doi.org/10.3200/jgpp.55.2.55-65 https://doi.org/10.1016/s0887-6185(03)00028-8 https://doi.org/10.1037/h0027806 https://doi.org/10.1037/1040-3590.17.2.179 https://www.psychopen.eu/ integrating cbt and psychodrama (introduction) method participants procedures and measures results primary outcomes secondary outcomes reliable change and clinical significant change feedback from patients discussion (additional information) funding competing interests acknowledgments references the emerging role of clinical pharmacopsychology scientific update and overview the emerging role of clinical pharmacopsychology fiammetta cosci ab, jenny guidi c, elena tomba c, giovanni a. fava cd [a] department of health sciences, university of florence, florence, italy. [b] department of psychiatry & neuropsychology, maastricht university, maastricht, the netherlands. [c] department of psychology, university of bologna, bologna, italy. [d] department of psychiatry, state university of new york at buffalo, buffalo, ny, usa. clinical psychology in europe, 2019, vol. 1(2), article 32158, https://doi.org/10.32872/cpe.v1i2.32158 received: 2018-12-04 • accepted: 2019-01-17 • published (vor): 2019-06-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: giovanni a. fava, department of psychology, university of bologna, viale berti pichat, 5 40127 bologna, italy. e-mail: giovanniandrea.fava@unibo.it abstract background: clinical pharmacopsychology is an area of clinical psychology that is concerned with the application of clinimetric methods to the assessment of psychotropic effects of drugs on psychological functioning, and the interaction of such drugs with specific or non-specific treatment ingredients. clinical pharmacopsychology derives its data from observational and controlled studies on clinical populations and refers to the therapeutic use of medical drugs, not to the effects of substances used for other purposes. method: domains and operational settings of clinical pharmacopsychology are illustrated. results: the domains of clinical pharmacopsychology extend over several areas of application which encompass the psychological effects of psychotropic drugs (with particular emphasis on subclinical changes), the characteristics that predict responsiveness to treatment, the vulnerabilities induced by treatment (i.e., side effects, behavioral toxicity, iatrogenic comorbidity), and the interactions between drug therapy and psychological variables. a service for clinical pharmacopsychology is here proposed as an example of the innovative role of clinical psychology in medical settings. conclusion: clinical pharmacopsychology offers a unifying framework for the understanding of clinical phenomena in medical and psychiatric settings. its aim is to provide a comprehensive assessment of the clinical important changes that are concerned with wanted and expected treatment effects; treatment-induced unwanted side effects; and the patient's own personal experience of a change in terms of well-being and/or quality of life. it is now time to practice clinical pharmacopsychology, creating ad hoc services in europe. keywords clinical pharmacopsychology, antidepressant drugs, psychotropic medication, clinical service, psychopharmacology this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i2.32158&domain=pdf&date_stamp=2019-06-28 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • clinical pharmacopsychology assesses the effects of medications on psychological functioning • since clinical psychologists visit medicated patients, a comprehensive clinical evaluation is crucial • vulnerabilities induced by psychotropic drugs are an important area of application of clinical pharmacopsychology the term “pharmacopsychology” was introduced by kraepelin to indicate the effects of medical drugs on psychological functioning (kraepelin, 1892). he thought it was impor‐ tant to describe the psychological changes induced by pharmacotherapy. later, pierre pi‐ chot edited a volume of psychological measurements in psychopharmacology (pichot, 1974) outlining new needs that derived from measuring the changes induced by psycho‐ tropic medications. two categories of instruments were collected by pichot (pichot, 1974) for psychometric measurement in psychopharmacology: self-rating instruments (e.g., the hopkins symptom checklist hscl) (derogatis, lipman, rickels, uhlenmuth, & covi, 1974) and clinician-reported rating scales (e.g., the hamilton depression scale) (hamilton, 1974). over time, experimental pharmacopsychology was also defined, thus contributing to differentiate pharmacopsychology from psychopharmacology and intro‐ ducing psychology into the clinical and psychiatric field (eysenck, 1963; janke, 1983; janke, debus, & erdmann, 2000; janke & netter, 2004; lipton, di mascio, & killam, 1977). the term “clinical pharmacopsychology” has been introduced to indicate the clinical psychology approach to pharmacology (fava, tomba, & bech, 2017). clinical pharmaco‐ psychology was defined as the application of clinimetric methods to the assessment of psychotropic effects of medications, and the interaction of drugs with specific and nonspecific treatment ingredients (fava, tomba, & bech, 2017). it should be differentiated from the approach of experimental psychology to pharmacology, i.e., experimental phar‐ macopsychology. clinical pharmacopsychology derives its data from observational and controlled studies on clinical populations, whereas experimental pharmacopsychology derives its data mainly from the laboratory and does not necessarily involve clinical pop‐ ulations. clinical pharmacopsychology refers to the therapeutic use of medical drugs and should be differentiated from the study of the effects of substances used for other purpo‐ ses (fava, tomba, & bech, 2017). in experimental psychology the distinction between pharmacopsychology and psy‐ chopharmacology is very clear. pharmacopsychology is defined as the use of drugs as tools to discover or explain psychological functions or to detect differences in drug re‐ sponsiveness, mostly in healthy persons serving as models for psychiatric diseases (eysenck, 1963; janke, 1983; janke, debus, & erdmann, 2000) while psychopharmacology the emerging role of clinical pharmacopsychology 2 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.psychopen.eu/ is defined as the discipline investigating psychological effects of drugs usually in clinical groups; it also includes treatment prediction, drug responsiveness and side effects, al‐ ways in the context of clinical investigations (lipton, di mascio, & killam, 1977). an essential characteristic of clinical pharmacopsychology is that it refers to a clini‐ metric, instead of a psychometric, conceptual model. clinimetrics has a set of rules which governs the structure of indices, the choice of component variables, the evaluation of consistency and validity, and differs from classical psychometrics (bech, 2016; fava, tomba, & sonino, 2012; feinstein, 1987). an essential clinimetric requisite for an assess‐ ment method is its discrimination properties (i.e., responsiveness/sensitivity), which means that the tool should be able to detect clinically relevant changes in health status over time (fava, tomba, & bech, 2017). just as important is incremental validity which refers to the unique contribution (or incremental increase) in predictive power associated with a particular assessment procedure in the clinical decision process (fava, rafanelli, & tomba, 2012). we will here describe the most important domains which pertain to clinical pharma‐ copsychology and propose a setting for clinical pharmacopsychology. domains of clinical pharmacopsychology the domains of clinical pharmacopsychology extend over several areas of application which encompass the psychological effects of psychotropic drugs, the characteristics that predict responsiveness to treatment, the vulnerabilities induced by treatment (i.e., side ef‐ fects, behavioral toxicity, iatrogenic comorbidity), and the interactions between drug therapy and psychological variables. psychological effects of psychotropic drugs in 1968, dimascio and shader criticized the tendency “to select, from among the many pharmacologic actions that a drug may possess, a specific effect to consider as the main (therapeutic or beneficial) effect and to describe all others as side-effects” (dimascio & shader, 1968, p. 617). they noted that a drug effect such as sedation or motor stimulation may be considered adverse for one patient, and yet therapeutic and desired for another one. similarly, within the same patient it may be of value at one stage of an illness and adverse at a later stage. in clinical trials, a limited number of symptoms is usually selected to test efficacy and psychological measurements are targeted. these pragmatic needs have limitations since excessive reliance on symptoms that are part of diagnostic criteria of mental disorders (e.g., major depressive disorder and generalized anxiety disorder) has impoverished clini‐ cal assessment. cosci, guidi, tomba, & fava 3 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.psychopen.eu/ indices may be observer-rated or self-rated. while observer-rated methods make full use of the clinical experience and comparison potential of the interviewer, self-rating methods allow a more direct assessment of the patient’s subjective perceptions. for in‐ stance, when the aim is to assess quality of life, research in this area seeks essentially two kinds of information: the functional status of the individual and the patient’s appraisal of their own health. indeed, the subjective perception of health status (e.g., lack of well-be‐ ing, demoralization, difficulties fulfilling personal and family responsibilities) is as valid as that of the clinician in evaluating outcomes (bech, 1990; topp, østergaard, søndergaard, & bech, 2015). the emphasis on patient-reported outcomes, any report coming directly from patients about how they function or feel in relation to a health con‐ dition or its therapy (clancy & collins, 2010), is in line with this conceptualization. an interesting example of standard assessment of psychological effects of antidepres‐ sant drugs can be found in placebo-controlled studies which observed that antidepres‐ sants decrease reactivity to social environment in depressed patients as assessed by the clinical interview for depression (guidi, fava, bech, & paykel, 2011). the decrease may certainly be beneficial in an acute depressive state. however, it is conceivable, even though yet to be adequately investigated, that in a residual phase the same effect may entail apathy (rothschild, raskin, wang, marangell, & fava, 2014). to ascertain this, however, one needs to rate reactivity to environmental stimuli and apathy, something that is omitted in standard clinical trials (guidi et al., 2011; rothschild et al., 2014). fur‐ ther, high sensitivity is required for detecting residual symptomatology, which was found to characterize most of the patients who were judged to be remitted according to the dsm criteria and no longer in need of active treatment (fava, rafanelli, & tomba, 2012). excessive reliance on symptoms that are part of diagnostic criteria of mental disorders (e.g., major depressive disorder, generalized anxiety disorder) does not reflect the broad spectrum of variables that affect clinical presentations: subclinical distress (fava, rafanelli, & tomba, 2012), such as demoralization and irritable mood (fava, cosci, & sonino, 2017), psychological well-being and euthymia (fava & bech, 2016), mental pain (de leon, baca-garcia, & blasco-fontecilla, 2015; verrocchio et al., 2016), social adjust‐ ment (bech, 2005) and neuroticism (tyrer, tyrer, & guo, 2016). likelihood of responsiveness richardson and doster (2014) underscored that, in the process of evidence-based deci‐ sion, one should include: 1. baseline risk of poor outcomes from an index disorder with‐ out treatment, which is important to identify if the treatment produced benefits; 2. re‐ sponsiveness to the treatment option, which is important to verify if remission has been obtained; 3. vulnerability to the adverse effects of treatment, which is important to verify if the treatment triggered an iatrogenic comorbid disorder or if the treatment caused re‐ versible or irreversible side effects. the emerging role of clinical pharmacopsychology 4 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.psychopen.eu/ the likelihood of responsiveness to a certain drug treatment and the clinical charac‐ teristics that predict response are a crucial issue in psychopharmacology, even though, in recent years, excessive emphasis on the treatment of the average patient has decreased interest in these aspects (bech, 2016; fava, 2017; richardson & doster, 2014). while there is a clinical need to have the broadest picture of the effects of a drug, de‐ termination of responsiveness may be based on selected items (bech, 2016). in addition, it has become common practice in clinical trials to quantify the number of participants who, after a pharmacologic and/or psychotherapeutic trial, achieve response or remission according to specific cut-off points of rating scales (guidi et al., 2018). remission can be expressed either as a categorical variable (e.g., present/absent) or as a comparative cate‐ gory (e.g., non-recovered, slightly recovered, moderately recovered, or greatly recovered) which refers to the clinical distance between the current state of the patient and his pretreatment position (bech, 1990). this method of research has limitations and makes diffi‐ cult the translation of the research results into practice. for instance, an improvement ac‐ cording to specific cut-off points of rating scales might not mirror a real clinical improve‐ ment of the patients as it is perceived by the patient or observed by the clinician. in the same vein, many studies are concerned with relapse and recurrence as primary outcome measures, even though adequate criteria are not available for all mental health conditions and clinicians and researchers in clinical psychiatry often confuse response to treatment for full recovery (bech, 1990; fava, 1996). finally, where differentiation according to cogent subgroups is made in clinical trials, a treatment which is helpful on average in the average patient might be ineffective in some patients (i.e., no difference with placebo) and even harmful in someone else (i.e., worse than placebo) (horwitz, hayes-conroy, & singer, 2017; horwitz, singer, makuch, & viscoli, 1996). in this framework, clinimetrics can offer an accurate method to measure responsive‐ ness to a treatment. this method is based on staging an assessment of the longitudinal development and of the longitudinal rollback of mental disorders (cosci & fava, 2013). staging differs from the conventional diagnostic practice in that it does not only define the extent of progression of a disorder at a particular point in time but also where a per‐ son is currently along the continuum of the course of illness. staging defines prodromes (e.g., early symptoms and signs that differ from the acute clinical phase) and residual symptoms (e.g., persistent symptoms and signs despite apparent remission or recovery). more specifically, stage 1 is the prodromal phase -that is the time interval between the onset of prodromal symptoms and the onset of the characteristic manifestations of the fully developed illness (cosci & fava, 2013). after the acute phase (stage 2), it might be difficult to assess whether partial or full remission has occurred, and attenuated symp‐ toms, the so-called residual symptoms, might be observed (stage 3); they are due to parti‐ al persistence of the disorder or an aggravation of a pre-existing abnormal personality trait. stage 4 represents chronicity of the psychiatric disorder (cosci & fava, 2013). cosci, guidi, tomba, & fava 5 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.psychopen.eu/ there appears to be a relationship between residual and prodromal symptoms. detre and jarecki (1971) provided a model defined as the rollback phenomenon: as the illness remits, it progressively recapitulates, albeit in reverse order. certain prodromal symp‐ toms may be overshadowed by the acute manifestations of the disorder, but they persist as residual symptoms and progress to become prodromes of relapse. prodromal symp‐ toms of relapse tend to mirror, in fact, those of the initial episode (cosci & fava, 2013). according to the rollback model, there is also a temporal relationship between the time of development of a disorder and the duration of the phase of recovery. this has several exemplifications in clinics. for instance, the persistence of residual symptoms after an antidepressant treatment administered to treat a major depressive episode represents a risk of relapse which should be considered by clinicians and considered as a partial re‐ sponse to the antidepressant treatment administered (tomba & fava, 2012). assessing side effects evidence based medicine is focused on the potential benefits that therapy may entail as to baseline risk, but it is likely to neglect, in addition to responsiveness, also vulnerabili‐ ties (fava, 2017; richardson & doster, 2014). a rational approach to treatment considers the balance between potential benefits and adverse effects applied to the individual pa‐ tient (fava, 2017; vandenbroucke & psaty, 2008). the achievement of such balance is hin‐ dered by the difficult integration of different sources of information. several side effects of psychotropic medications are transient and may disappear after a few weeks following treatment initiation, but potentially serious adverse events may persist or ensue later. antidepressants’ side effects encompass gastrointestinal symptoms (e.g., nausea, diarrhea, gastric bleeding, dyspepsia), hepatotoxicity, weight gain and meta‐ bolic abnormalities, cardiovascular disturbances (e.g., heart rate, qt interval prolonga‐ tion, hypertension, orthostatic hypotension), genitourinary symptoms (e.g., urinary re‐ tention, incontinence), sexual dysfunction, hyponatremia, osteoporosis and risk of frac‐ tures, bleeding, central nervous system disturbances (e.g., lowering of seizure threshold, extrapyramidal side effects, cognitive disturbances), sweating, sleep disturbances, affec‐ tive disturbances (e.g., apathy, switches, paradoxical effects), ophthalmic manifestations (e.g., glaucoma, cataract) and hyperprolactinemia (carvalho, sharma, brunoni, vieta, & fava, 2016). long-term use of antidepressants such as serotonin selective reuptake inhibitors (ssri) may induce weight gain, after an initial period characterized by reduced appetite, and the increased weight does not necessarily recede upon the drug discontinuation (carvalho et al., 2016). it has been suggested that an increase in exposure to antidepres‐ sants via a multitude of mechanisms may be a driving force for the obesity pandemic (lee, paz-filho, mastronardi, licinio, & wong, 2016). similarly, the prevalence of sexual side effects can be as high as 50-70% among individuals taking ssris and such effects the emerging role of clinical pharmacopsychology 6 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.psychopen.eu/ may persist even after discontinuation (carvalho et al., 2016), the so-called post-ssri sex‐ ual dysfunction (bala, nguyen, & hellstrom, 2018). negative effects may also occur as a result of psychotherapeutic treatment, whether due to technique, patient or therapist variables, or inappropriate use (barlow, gorman, shear, & woods, 2000; linden, 2013; scott & young, 2016). the side effects of psycho‐ therapy are difficult to recognize because of the number of variables involved, including the various stages of the psychotherapeutic process (linden, 2013). targets of assessment have predominantly involved the desired effects of a medica‐ tion while the evaluation of adverse events has been often neglected, although they can be measured via both interviews and self-rated instruments. assessing the side effects that occur with any type of drug treatment requires a careful clinimetric collection of symptoms in addition to medical laboratory and investigational methods. the uku side effect rating scale (lingjærde, ahlfors, bech, dencker, & elgen, 1987) is an example of scale that considerably improved the detection of side effects, because of its comprehen‐ sive nature. for instance, sexual side effects are common and yet are some of the most under-reported adverse effects associated with the use of antidepressants, and a growing body of evidence indicates that such side effects should be monitored by use of specific instruments (balon & segraves, 2008; carvalho et al., 2016). further, karch and lasagna (1975) noted that the history of toxicology reminds us vividly of the lag that often occurs between the first introduction of a drug into humans and the recognition of certain ad‐ verse events from that drug. there is a need to update specific instruments for side ef‐ fects with findings that may derive from case reports and clinical observations. for in‐ stance, the wide range of side effects that may ensue with long-term treatment with sec‐ ond generation antidepressants (carvalho et al., 2016) would require specific methods of investigation. behavioral toxicity in 1968, dimascio and shader provided a conceptual framework for behavioral toxicity of psychotropic drugs and defined behavioral toxicity as the pharmacological actions of a drug that, within the dose range in which it has been found to possess clinical utility, may produce alterations in mood, perceptual, cognitive, and psychomotor functions, which limit the capacity of the individual or constitute a hazard to his well-being (dimascio & shader, 1968). in 1980, perl and colleagues pointed out that psychotropic drugs can cause behavioral toxicity through the extension of their primary therapeutic action and/or the onset of secondary actions as well as withdrawal, dependence, and tol‐ erance symptoms (perl, hall, & gardner, 1980). the concept of behavioral toxicity encompasses adverse events that may be limited to the period of drug administration and/or persist long after their discontinuation. any type of psychotropic drug treatment, particularly after long-term use, may increase the risk of experiencing additional psychopathological problems that do not necessarily sub‐ cosci, guidi, tomba, & fava 7 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.psychopen.eu/ side with discontinuation of the drug or of modifying responsiveness to subsequent treat‐ ments (fava, cosci, offidani, & guidi, 2016). these latter phenomena can be subsumed under the rubric of iatrogenic comorbidity (fava et al., 2016). “iatrogenic comorbidity” refers to unfavorable modifications in the course, character‐ istics, and responsiveness of an illness that may be related to treatments administered previously (fava et al., 2016). such vulnerabilities may occur during treatment adminis‐ tration and/or manifest themselves after its discontinuation. the changes can be persis‐ tent and not limited to a short phase, such as in the case of withdrawal reactions, and cannot subsume under the generic rubrics of adverse events or side effects. behavioral toxicity may ensue with any type of medical drug. examples related to an‐ tidepressant drug use may be the onset of suicidality and aggression, switching from uni‐ polar to bipolar course, withdrawal phenomena upon discontinuation, post-withdrawal persistent disorders (carvalho et al., 2016; fava et al., 2016). such phenomena require ad‐ equate clinimetric indices for their detection, as the late recognition of withdrawal syn‐ dromes after antidepressant discontinuation teaches (chouinard & chouinard, 2015). behavioral toxicity may apply also to drugs directed to medical conditions (shader, 1972; tisdale & miller, 2010; whitlock, 1981), which may induce depression, anxiety, and other psychiatric symptoms. examples of behavioral toxicity that are concerned with the use of antidepressant drugs encompass switching into mania or hypomania during treatment, both in bipolar disorder (tondo, vázquez, & baldessarini, 2010) and in allegedly unipolar patients (joseph, youngstrom, & soares, 2009; offidani, fava, tomba, & baldessarini, 2013); with‐ drawal symptoms following reduction or discontinuation of antidepressant treatment, in the form of acute withdrawal symptomatology or persistent post-withdrawal disorders (chouinard & chouinard, 2015). such manifestations of behavioral toxicity may be easily misinterpreted as a sign of impending relapse or the need to keep the antidepressant at the same dosage. untreated symptoms may be mild and resolve spontaneously in one to three weeks; in other cases, they may persist for months or even years (chouinard & chouinard, 2015). their prevalence is unknown at the moment, due to their very recent definition. the high prevalence of mental disorders in the general population may also be an effect of the presence of disorders that are a consequence of previous pharmacological treatments (cosci, guidi, balon, & fava, 2015). for instance, much of the refractoriness to treatment of anxious depression may be actually due to persistent post-withdrawal disor‐ ders that are secondary to the use of antidepressant drugs in anxiety disorders (fava & tomba, 2014). all these phenomena may be explained based on the oppositional model of tolerance. continued drug treatment may recruit processes that oppose the initial acute effect of a drug. when drug treatment ends, these processes may operate unopposed, at least for some time and increase vulnerability to relapse (fava & offidani, 2011). the emerging role of clinical pharmacopsychology 8 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.psychopen.eu/ interaction of medical drugs with behavioral variables and psychotherapy each therapeutic act may be a result of multiple ingredients that can be specific or nonspecific: expectations, preferences, motivation, illness behavior and patient-doctor inter‐ actions are examples of variables that may affect treatment outcome (fava, guidi, rafanelli, & rickels, 2017; rickels, 1968; schedlowski, enck, rief, & bingel, 2015). such variables may be the object of study of clinical pharmacopsychology. in 1969, uhlenhuth, lipman, and covi examined the combinations of pharmacothera‐ py and psychotherapy in psychiatric disorders. they outlined four models of interaction: a) addition (i.e., the effects of two interactions combined equals the sum of their individu‐ al effects); b) potentiation (i.e., the effect of two interventions combined is greater than the sum of their individual effects); c) inhibition (i.e., the effect of two interventions com‐ bined is less that each individual effect); d) reciprocation (i.e., the effect of the two inter‐ ventions combined equals the individual effect of the more potent intervention). most of the studies are compatible with the additive and reciprocal concepts of interaction (cuijpers et al., 2014; forand, de rubeis, & amsterdam, 2013; guidi et al., 2018; uhlenhuth et al., 1969). there are, however, some high quality and well-designed individ‐ ual studies suggesting that addition of a benzodiazepine or an antidepressant to cognitive behavioral treatment of anxiety disorders could be detrimental compared to placebo at follow-up (barlow et al., 2000; haug et al., 2003; marks et al., 1993; nordahl et al., 2016), thus indicating an inhibitory effect of the interaction. again, clinical pharmacopsycholo‐ gy could be crucial for disclosing the nature of these relationships. the setting for clinical pharmacopsychology we illustrate here a clinical pharmacopsychology service as an example of an innovative application of clinical psychology in the medical setting. a clinical pharmacopsychology service the service has been operating since 2018 at the department of health sciences, univer‐ sity of florence (florence, italy). this outpatient clinic is addressed to patients who are looking for treatment programs allowing to rationalize, reduce, and discontinue psycho‐ tropic medications. the service is run by an experienced clinical psychologist from the university of florence who has a special interest and training in psychopharmacology, psychotherapy, and psychosomatic medicine. the outpatient facility is open one day a week with space for a maximum of eight patients and at least one hour dedicated to each patient. the clinical psychologist works jointly with two psychologists (providing psycho‐ therapy) and two consultants (one internist and one psychiatrist with a strong back‐ cosci, guidi, tomba, & fava 9 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.psychopen.eu/ ground in psychopharmacology). the clinical psychologist makes the initial assessment and monitors treatment choices. team members work in close coordination, with re‐ peated assessments and sequential combination of treatments (fava, park, & dubovsky, 2008). the main source of referral is the webpage1 of the service that was created to dissem‐ inate knowledge on the clinical phenomenon of withdrawal after discontinuation of anti‐ depressants. usually, the patients already looked for an aide in their environment (e.g., the psychiatrist or the general practitioner who prescribed the medication) without suc‐ cess before asking for an aide at the service. the first visit at the service is conducted as follows, although the order of the sched‐ ule could be changed as required: • complete history of psychiatric/psychological aspects according to the principles of macro-analysis (see below); • formulation of the case, also on the basis of clinimetric tools (fava, tomba, & sonino, 2012, fava, rafanelli, & tomba, 2012), staging (cosci & fava, 2013), subtyping of diagnostic categories (see below); • in addition to psychiatric diagnoses according to the dsm, the patient is evaluated via the diagnostic clinical interview for drug withdrawal 1 (did-w1) (cosci, chouinard, chouinard, & fava, 2018) and the discontinuation-emergent signs and symptoms (dess) (rosenbaum, fava, hoog, ascroft, & krebs, 1998) (see below); • the clinical psychologist goes over the patient’s documents and previous workup; • appraisal of the present situation, based on all findings (including answers to the didw1 and the dess) and patient education; • discussion of treatment choices and prescriptions. the diagnostic clinical interview for drug withdrawal 1 (did-w1) – new symptoms of selective serotonin reuptake inhibitors (ssri) or serotonin norepinephrine reuptake in‐ hibitors (snri) is a semi-structured interview assessing withdrawal syndromes according to chouinard’s diagnostic criteria (cosci et al., 2018). such criteria identify three different withdrawal syndromes: new withdrawal symptoms, rebound syndrome, and persistent post-withdrawal disorder. the discontinuation-emergent signs and symptoms (dess) is a self-administered checklist of signs and symptoms which might occur after the discon‐ tinuation of ssri. we will give an exemplification of this approach with the following case. the case of miss x. in order to illustrate, in practice, the activities at the service of pharmacopsychology, we present a clinical case. 1) https://www.smettereglipsicofarmaci.unifi.it/changelang-eng.html the emerging role of clinical pharmacopsychology 10 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.smettereglipsicofarmaci.unifi.it/changelang-eng.html https://www.psychopen.eu/ miss x. came to our attention after having been visited by several psychiatrists who suggested she should maintain paroxetine, which had been prescribed 10 years earlier for a panic disorder diagnosis. she received this suggestion each time she tried to reduce pa‐ roxetine and had the occurrence of anxiety, panic attacks, and depressed mood. at first visit, the patient did not satisfy dsm diagnostic criteria for psychiatric disor‐ ders. she was strongly determined to reduce paroxetine for the following reasons: she gained about 10 kilograms of weight in 10 years, she had dampened sexual desire, she had mild hyperglycaemia and she did not want to live with paroxetine any longer. the clinical psychologist performed the macro-analysis (fava & tomba, 2014; tomba & fava, 2012), which allows to establish a relationship between co-occurring syndromes and problems based on where treatment should begin in the first place and assuming that there are functional relationships among problematic areas and that the targets of treat‐ ment may vary during the course of disturbances. for miss x., the problematic areas were: past attempts to reduce paroxetine which invariably produced the reappraisal of anxiety, panic attacks, depressed mood, and failure to discontinue paroxetine weight gain; hyperglycaemia and sexual dysfunction. thereafter, microanalysis, a detailed analysis of symptoms for functional assessment (emmelkamp, bouman, & scholing, 1993), was performed. it requires consideration of the onset of complaints, their course, circumstances that aggravate or ameliorate symptoms, short-term and long-term impact of symptoms on quality of life, and work and social ad‐ justment (emmelkamp et al., 1993), and may include specific tests and rating scales (bech, 1993) which must be integrated into the rest of the assessment and not viewed in isolation (emmelkamp et al., 1993). in the framework of the micro-analysis, both dess and did-w1 were proposed to miss x. the dess did not provide additional information. the did-w1 disclosed that the patient met the criteria for past rebound syndrome. thus, the problematic areas in the macro-analysis were updated as follows: past attempts to re‐ duce paroxetine which failed; lifetime rebound syndromes; weight gain; hyperglycaemia and sexual dysfunction. on the basis of the macroand the micro-analysis, the clinical psychologist asked for the consultation of the internist and the psychiatrist. it was decided to taper and discon‐ tinue paroxetine. the aim was to limit weight gain, help to normalize the hyperglycae‐ mia (probably due to an excessive intake of carbohydrates) and verify whether paroxe‐ tine discontinuation improved sexual dysfunction. the clinician deferred to a second stage assessment the determination of whether paroxetine reduction triggers a with‐ drawal syndrome (chouinard & chouinard, 2015). at a second visit, which occurred eight days later and seven days after the reduction of paroxetine from 40 mg to 35 mg daily, miss x. presented also anxiety and mood swings. the clinical psychologist ran again the macroand micro-analysis, administered again did-w1 and dess and updated the problematic areas as follows: past attempts to reduce paroxetine which failed; lifetime rebound syndromes; weight gain; hyperglycae‐ cosci, guidi, tomba, & fava 11 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.psychopen.eu/ mia; sexual dysfunction; current rebound syndrome characterized by anxiety and mood swings. via the diagnosis of rebound syndrome the clinician was able to subtype and dif‐ ferentiate within the broader diagnostic entity of withdrawal syndrome. at re-assess‐ ment, the clinical reasoning was also used and let the clinical psychologist go through a series of “transfer stations” where potential connections between presenting symptoms and pathophysiological process are drawn (feinstein, 1973). based on the re-assessment as well as on the clinical reasoning, the clinical psychologist proposed miss x. the psy‐ chotherapeutic management suggested by fava and belaise (2018). accomplishments and shortcomings in brief, the assessment provided to patients incorporates variables such as type and du‐ ration of psychotropic medication treatment, patterns of symptoms, stage of illness, co‐ morbid conditions, timing of phenomena, responses to previous attempts to discontinue, and other clinical distinctions that demarcate major prognostic and therapeutic differen‐ ces among patients who otherwise seem to be deceptively similar since they share the same diagnosis and the same drug treatment. such variables are filtered by the clinical judgment (fava & tomba, 2014; tomba & fava, 2012) which provides the following as‐ sessment strategies: the use of diagnostic transfer stations instead of diagnostic end‐ points using repeated assessments, subtyping versus integration of different diagnostic categories, staging, macroand micro-analysis (fava, rafanelli, & tomba, 2012). during the treatment path, patients are reassessed after the first line of treatment has been com‐ pleted to reconfirm the diagnosis and refine the treatment plan. this service fills gaps that are left with ordinary psychiatric care, and provides a com‐ prehensive assessment which goes beyond the dsm and includes clinimetric tools. of course, difficulties might emerge from a comprehensive assessment of this kind. at least two main practical issues should be raised. the first is that it is not easy to have these kinds of services as part of the national health system which commonly imposes a time constraint of 15-20 minutes per visit. second, there is an economic load for the na‐ tional health system or for the patient due to the high level of engagement of clinicians. however, if we use a medium/long-term perspective, we may see that the cost is only apparently high since the patients in the majority of cases stop medications and maintain a symptoms-free condition without needing further visits in future years. finally, a potential shortcoming of the service is that it does not cooperate with a lab‐ oratory which monitors drug blood levels which could be related to psychological with‐ drawal or treatment responses. the emerging role of clinical pharmacopsychology 12 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://www.psychopen.eu/ conclusions clinical pharmacopsychology offers a unifying framework for the understanding of clini‐ cal phenomena in medical and psychiatric settings (fava, tomba, & bech, 2017). its do‐ mains encompass the clinical benefits of psychotropic drugs, the characteristics that pre‐ dict responsiveness to treatment, the vulnerabilities induced by treatment (i.e., side ef‐ fects, behavioral toxicity, iatrogenic comorbidity), and the interactions between drug treatment and psychological variables. its aim is to provide a comprehensive assessment of the clinical important changes that are concerned with wanted and expected treatment effects; treatment-induced unwanted side effects; and the patient's own personal experi‐ ence of a change in terms of well-being and/or quality of life. it is now time to practice clinical pharmacopsychology, creating ad hoc services in europe. funding: the authors have no funding to report. competing interests: fc is the director of the service of clinical pharmachopsychology of the university of florence, which is presented in this article. acknowledgments: the authors have no support to report. references bala, a., nguyen, h. m. t., & hellstrom, w. j. g. 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(1981). adverse psychiatric reactions to modern medication. the australian and new zealand journal of psychiatry, 15(2), 87-103. https://doi.org/10.3109/00048678109159417 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. the emerging role of clinical pharmacopsychology 18 clinical psychology in europe 2019, vol.1(2), article 32158 https://doi.org/10.32872/cpe.v1i2.32158 https://doi.org/10.1111/j.1600-0447.2009.01514.x https://doi.org/10.1159/000376585 https://doi.org/10.1159/000444196 https://doi.org/10.1097/00005053-196901000-00006 https://doi.org/10.1001/jama.2008.723 https://doi.org/10.3389/fpsyt.2016.00108 https://doi.org/10.3109/00048678109159417 https://www.psychopen.eu/ the emerging role of clinical pharmacopsychology (introduction) domains of clinical pharmacopsychology psychological effects of psychotropic drugs likelihood of responsiveness assessing side effects behavioral toxicity interaction of medical drugs with behavioral variables and psychotherapy the setting for clinical pharmacopsychology a clinical pharmacopsychology service the case of miss x. accomplishments and shortcomings conclusions (additional information) funding competing interests acknowledgments references fear of becoming infected and fear of doing the wrong thing – cross-cultural adaptation and further validation of the multidimensional assessment of covid-19-related fears (mac-rf) research articles fear of becoming infected and fear of doing the wrong thing – cross-cultural adaptation and further validation of the multidimensional assessment of covid-19-related fears (mac-rf) branka bagarić 1 , nataša jokić-begić 2 [1] croatian association for behavioral-cognitive therapies (cabct), zagreb, croatia. [2] department of psychology, faculty of humanities and social sciences, university of zagreb, zagreb, croatia. clinical psychology in europe, 2022, vol. 4(1), article e6137, https://doi.org/10.32872/cpe.6137 received: 2021-02-11 • accepted: 2021-10-27 • published (vor): 2022-03-31 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: branka bagarić, croatian association for behavioral-cognitive therapies (cabct), šenoina 25, 10 000 zagreb, croatia. e-mail: branka.bagaric1@gmail.com supplementary materials: data [see index of supplementary materials] abstract background: with the covid-19 infection speeding around the world, many experience fear and anxiety. to detect those at risk of psychopathology and provide treatment, valid instruments are needed. the aim of this study was to cross-culturally validate the theory-based instrument multidimensional assessment of covid-19-related fears (mac-rf) in croatian and to further examine the scale’s validity by exploring its relationship with relevant constructs. method: a total of 477 participants completed an online survey during a rapid rise in new daily covid-19 cases in croatia and while new restrictions were being imposed. results: mac-rf had a stronger association with health anxiety, cyberchondria, and anxiety sensitivity compared to depression, attesting to its convergent and divergent validity. however, a 2-factor structure was revealed in this sample: fear of infection and fear of using an inadequate strategy in dealing with pandemic. fear of infection had a stronger association with health anxiety and covid-19 anxiety and was a better predictor of covid-19 related protective health behaviors. fear of choosing an inadequate strategy had a stronger association with cyberchondria, fear of consequences of the epidemic on mental health, as well as financial consequences, and loss of civil liberties. conclusion: fear of infection captures negative emotional states due to feared consequences on personal somatic health and the health of loved ones, while fear of choosing an inadequate this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6137&domain=pdf&date_stamp=2022-03-31 https://orcid.org/0000-0002-1786-0993 https://orcid.org/0000-0003-2597-535x https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ strategy in dealing with the pandemic reflects a metacognitive aspect. treatments may have to target both aspects of covid-19 related fear. keywords covid-19 fear, mac-rf, health anxiety, cyberchondria, scale validity highlights • mac-rf is a theory-based instrument for measuring covid-19 related fears. • mac-rf has two factors: fear of infection and fear of using an inadequate strategy in dealing with the pandemic. • first factor had a stronger association with heath anxiety and protective health behaviors. • second factor had a stronger association with cyberchondria and fear for mental health. with over 200 million people infected and over 4 million dead from covid-19 around the world, in addition to the social restrictions that affect our everyday life, the rise of fear, anxiety and distress is to be expected. although somatic health has the focus of attention, it has become evident that psychological consequences of the epidemic may be equally severe (e.g., kumar & nayar, 2021), but more difficult to detect. the development of instruments that measure psychopathology associated with covid-19 is an important step in identifying individuals at risk and developing treatments. during 2020, several measures focused on different aspects of negative psychological reactions to covid-19 pandemic emerged. the fear of covid-19 scale (fcv-19s; ahorsu et al., 2020) is a 7-item instrument measuring a single factor. the coronavirus anxiety scale (cas; lee, 2020) and covid-19 anxiety scale (cas5; lauri-korajlija & jokić-begić, 2020) are both 5-item scales, both measuring a single factor. the covid-19 anxiety syndrome scale (c-19ass; nikčević & spada, 2020) is a 9-item scale measuring two factors: perseveration and avoidance. the covid-19 phobia scale (c19p-s; arpaci et al., 2020) is a 20-item instrument measuring four factors: psychological, psycho-somatic, economic, and social. finally, the covid stress scales (css; taylor et al., 2020) is a 36-item instrument, measuring 5-factors: danger and contamination fears, fears about economic consequences, xenophobia, compulsive checking and reassurance seeking, and traumatic stress symptoms about covid-19. considering differences in the breadth of focus of these scales, it is not surprising that different structures of the underlying construct have been reported. determining which aspects of psychological experience should be captured in such an instrument might be aided by a theoretical framework. this type of theory-based instrument has been recently developed – the multidimensional assessment of cov­ id-19-related fears (mac-rf). according to the model behind the mac-rf, as proposed covid-19 related fears 2 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ by schimmenti, billieux, and starcevic (2020), four mutually linked domains are involved in fear experiences during a pandemic: bodily, relational, cognitive, and behavioral. these domains are assumed to be organized in a dialectical structure. as such, the bodily domain involves 1) fear of the body and 2) fear for the body; the interpersonal domain involves 3) fear of others and 4) fear for others; the cognitive domain involves 5) fear of knowing and 6) fear of not knowing; and the behavioral domain involves 7) fear of action and 8) fear of inaction. the mac-rf appears to be a useful instrument in assessing pathological levels of fear during pandemics (schimmenti, starcevic, et al., 2020). however, more studies of its validity are needed. fear related to covid-19 is found to be associated with general psychopatholo­ gy, general anxiety, health anxiety and depression (ahorsu et al., 2020; schimmenti, starcevic, et al., 2020; taylor et al., 2020), functional impairment and dysfunctional coping (lee, 2020; nikčević & spada, 2020). several studies have suggested that anxiety sensitivity (fear of consequences of anxiety) and cyberchondria (excessive online search for health information followed by distress) might explain problematic responses to pandemic (hashemi et al., 2020; manning et al., 2021; mckay et al., 2020). specifically, it is suggested that because people with high anxiety sensitivity believe their physical sensations produced by anxiety to be harmful, they might experience more distress. those who are more distressed may be prone to searching for information about their health on the internet, resulting in even more distress due to the frightening information they encounter (hashemi et al., 2020). anxiety sensitivity may be associated with fear of and for the body, whereas cyberchondria may reflect the fear of knowing and not knowing, as proposed in schimmenti, billieux, and starcevic’s (2020) model. although the pandemic is a global crisis, there are differences in how a given country will respond to an outbreak in the type and duration of restrictions, in addition to economic, societal and cultural differences, which may affect how individuals experience and cope with pandemic. hence, the aim of this study was to: 1) cross-culturally validate the croatian version of the mac-rf; and 2) to further examine the scale validity by exploring its relationship with relevant constructs: health anxiety, anxiety sensitivity, cyberchondria, covid-19 safety behaviors, health care use and fear of different covid consequences. we predicted that the mac-rf would: 1) have a single-factor solution, as reported by the scale’s authors; 2) be associated with general psychopathology, as reported by the authors; 3) have a strong correlation with a previously validated measure of fear of covid-19 (concurrent validity); 4) have a stronger association with health anxiety, anxi­ ety sensitivity and cyberchondria as compared to depression (converged and divergent validity); and 5) have a positive association with covid-19 safety behaviors, health care utilization and fear of different covid consequences. the results of this study would inform the possibility of cross-cultural generalization of findings in the field. furthermore, this study may shed further light on possible bagarić & jokić-begić 3 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ predictors, mechanisms and consequences of fear of pandemic, and hence inform future experimental, longitudinal and intervention research. method participants there were 477 participants in this study (an additional 25 participants filled out sociode­ mographic items only and were excluded from the data set), of which 74.8% were female. the mean age was 34.70 years (sd = 9.71; total range [tr] = 18-71). with respect to education, 25.99% were high school graduates, 10.27% held a bachelor’s degree, 53.46% held a master’s degree, and 10.27% held a phd. furthermore, 8.17% of participants were employed in the health care system and an additional 1.26% were trained in health sciences but were not employed in the health system. a total of 11.94% of participants reported suffering from a chronic condition, most commonly from thyroid diseases, asthma, allergies, depression, diabetes and anxiety. in regards to their experiences with covid-19, most participants reported personally knowing five (mode = 5; m = 7.05; tr = 0-200) people who tested positive for covid-19, 12.88% reported they themselves had tested positive for covid-19 at some point, and an additional 18.03% believed they had had covid-19 although this was not confirmed by a test. participants who tested positive for covid-19 on average estimated their symptoms to be mild (m = 32.04, sd = 22.90, tr = 0-83) and this experience to be only mildly uncomfortable (m = 34.63, sd = 27.88, tr = 0-100), although there was great variability in responses. instruments multidimensional assessment of covid-19-related fears (mac-rf) the mac-rf (schimmenti, starcevic, et al., 2020) is a newly developed 8-item measure of clinically relevant domains of fear during the covid-19 pandemic. items cover four domains of fear: bodily, relational, cognitive, and behavioral and are scored on a scale ranging from 0 (very unlike me) to 4 (very like me). authors reported a single-factor structure, satisfactory reliability (cronbach’s alpha = .84), whereas convergent validity was based on its positive correlation with overall psychopathology. cronbach’s α in this study was .72. covid-19 anxiety scale (cas5) the cas5 (lauri-korajlija & jokić-begić, 2020) is a recently developed 5-item instrument inspired by the swine flu anxiety scale (wheaton et al., 2012) that assesses worrying about covid, perceived likelihood of contracting the virus (oneself and others), per­ ceived severity of infection, and the degree to which a person believes covid is a more serious illness than the flu. each item is rated on a 5-point scale (1 = not at all; 5 = very covid-19 related fears 4 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ much). authors reported a cronbach’s alpha coefficient of 0.76 and 0.78. this is the only covid-19 distress scale that has been validated in the croatian language. cronbach’s α in this study was 0.74. dsm-5 self-rated level 1 cross-cutting symptom measure—adult (ccsm) the ccsm (apa, 2013) consists of 23 questions assessing 13 psychiatric domains: de­ pression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory problems, repetitive thoughts and behaviors, dissociation, personality functioning, and substance use. the respondent rates their experiences during the last two weeks on a scale ranging from 0 (none or not at all) to 4 (severe or nearly every day). the instrument has demonstrated good psychometric properties (narrow et al., 2013). cronbach’s α in this study was 0.89. short health anxiety inventory (shai) the shai (salkovskis et al., 2002) consists of 18 items measuring two factors: health anxiety (14 items) and fear of negative consequences of illness (4 items). it uses a multiple choice format with response options ranging from 0 to 3 (from no pathology to severe pathology; alberts et al., 2013). the instrument demonstrated good psychometric properties in both clinical and non-clinical samples (alberts et al., 2013). cronbach’s α in this study was 0.85 for the health anxiety factor and 0.86 for the full scale. short cyberchondria scale (scs) the scs (jokić-begić et al., 2019) consists of four items (e.g., after searching for health information, i feel frightened) rated on a 5-point likert scale. the scs has demonstrated satisfactory psychometric properties, has a unidimensional structure and measures the same latent construct as the significantly longer instrument developed by mcelroy and shevlin (2014); cyberchondria severity scale, (jokić-begić et al., 2019). cronbach’s α in this study was 0.80. anxiety sensitivity index – 3 (asi-3) the asi-3 (taylor et al., 2007) consists of 18 items measuring fear of anxiety and its consequences that are rated from 0 (very little) to 4 (very much). the asi has three subscales measuring the fear of physical (it scares me when i become short of breath), cognitive (when i feel “spacey” or spaced out i worry that i may be mentally ill) and social (when i tremble in the presence of others, i fear what people might think of me) aspects of anxiety. asi has demonstrated good psychometric properties. cronbach’s α in this study was 0.92. bagarić & jokić-begić 5 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ depression, anxiety and stress scale 21 (dass) the dass (lovibond & lovibond, 1993) is a short form of the original dass instrument and consist of 21 items measuring depression, anxiety, and stress during the last week, each rated on a scale ranging from 0 (did not apply to me at all) to 3 (applied to me very much or most of the time). only the depression subscale was used in this study (dass-d), which consists of seven items describing dysphoria, hopelessness, lack of interest etc. (e.g., i couldn’t seem to experience any positive feeling at all). all three subscales demonstrated good psychometric properties in both clinical and non-clinical populations (parkitny & mcauley, 2010). cronbach’s α in this study was 0.92. covid safety behavior checklist (csbc) the csbc (lauri-korajlija & jokić-begić, 2020) consists of 13 items measuring safety be­ haviors that people engage in to avoid covid infection, such as thorough and frequent hand washing, avoiding people that appear ill, avoiding leaving home etc., each rated on a 5-point scale (1 = not at all; 5-very much). the csb was inspired by the ebola safety behavior checklist (blakey et al., 2015). cronbach’s α in this study was 0.86. health care use (hcu) hcu was measured using a single item where participants assess the number of doctor visits (both gp and specialists) they attended in the last two months. fear of covid-19 consequences (fccc) fccc was developed for the purposes of this study and consisted of six items covering fear of consequences on: physical health, mental health, loved ones’ health, financial loss, loss of civil liberties and disturbed relationships. respondents rated how much they feared each of these consequences from 1 (very little) to 5 (very much). procedure we followed the procedure for instrument cross-validation described in the literature (van widenfelt et al., 2005). the mac-rf was first translated into croatian by the two authors (professor in clinical psychology and a doctoral student in clinical psychology) and by another colleague (professor in biological psychology). all three versions were reviewed and compared and a final version was agreed upon. next, a bilingual professor in health psychology translated the final version back into english. small differences were discussed by all four psychologists and minor alterations were made. this revised version was assessed by another two colleagues: a psychotherapist with a phd in clinical psychology and a doctoral student in cognitive psychology. neither reviewer found any issues. finally, this version was completed and its content discussed by a small sample of laypersons known to the researchers, who found the items clear and easy to respond to. covid-19 related fears 6 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ data were collected via an online survey using the surveymonkey software. this survey consisted of the aforementioned instruments and several questions regarding sociodemographic data and experiences with covid-19 described in the “participants” section. the data collection period was limited to four weeks from the date the survey was published. data was collected during the second wave of the covid-19 pandemic in croatia (november and december 2020), when a steady rise in new daily cases was being registered and new restrictions were being introduced. the survey was advertised using social media (several open groups dealing with different topics), the website of a cbt counseling center in croatia and the authors’ personal contacts. this study was approved by the ethical committee of department of psychology, faculty of humanities and social sciences, university of zagreb (epop – 2021 – 005). data analyses analyses were performed using the lavaan r package (rosseel et al., 2017). to explore the underlying structure of the mac-rf, we performed confirmatory factor analyses. to determine the fit of the model, several goodness-of-fit criteria were used: the stand­ ard root mean square residual (srmr), the root mean square error of approximation (rmsea) with 90% confidence intervals, and the comparative fit index (cfi). a model is considered to have a good fit to the data if the srmr is close to or below 0.08, if rmsea is close to or below 0.06, (the upper limit of the 90% rmsea confidence interval should be below 0.10), and if cfi is close to or above 0.95 (brown, 2015; hu & bentler, 1999; kline, 2015). to explore scale’s reliability and validity, we calculated cronbach’s alpha and correlations with relevant measures. results descriptive data for the mac-rf items is presented in table 1. preliminary analysis because it was treated as a single question by the program, there were no missing data within the mac-rf matrix. single multivariate and nine univariate outliers were detected and subsequently omitted from the data set. no indications of collinearity were detected (maximum variance inflation factor value = 2.11; minimum tolerance value = .47). all items were non-normally distributed (kolmogorov-smirnov z = 4.16-8.52, all p values < .001). model generation we specified three alternative models: a single factor model suggested by the authors, a 4-factor model with each domain of fear bodily, relational, cognitive, and behavioral bagarić & jokić-begić 7 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ comprising its own factor, and a 2-factor model with fear of infection comprising one factor (items 1-4; fear for/of the body, fear of/for others) and fear of choosing an inadequate strategy in dealing with pandemic comprising the other factor (items 5-8; fear of knowing and not knowing, fear of action/inaction). confirmatory factor analyses due to non-normal data, the maximum likelihood estimation method with robust stand­ ard errors (mlr) was employed (brown, 2015). mlr is recommended for variables that have five or more categories (rhemtulla, brosseau-liard, & savalei, 2012). according to the proposed criteria (brown, 2015; hu & bentler, 1999), the good­ ness‐of‐fit indices for three tested models suggested that a single factor solution fits the data poorly, whereas 2and 4-factor solutions both provided a good fit to the data (table 2). since the difference in the fit of these two models was not statistically significant, χ2(5) = 4.08, p = 0.54, we preserved the more parsimonious 2-factor model. table 2 goodness of fit indices for the three tested cfa models of mac-rf (n = 477) model χ2 (df) p (χ2) srmr rmsea [90% ci] cfi 1-factor 204.13 (20) < .001 0.10 0.14 [0.12, 0.16] 0.78 2-factor 32.06 (19) .031 0.04 0.04 [0.01, 0.06] 0.99 4-factor 28.27 (14) .013 0.03 0.05 [0.02, 0.07] 0.98 note. srmr = standardized root mean square residual; rmsea = the root mean square error of approxima­ tion; cfi = comparative fit index. table 1 descriptive statistics for mac-rf items item and domain m (sd) tr skewness kurtosis 1. fear of the body 1.17 (1.13) 0-4 .643 -.612 2. fear for the body 1.60 (1.29) 0-4 .133 -1.326 3. fear of others 1.93 (1.29) 0-4 -.156 -1.271 4. fear for others 2.55 (1.24) 0-4 -.754 -.464 5. fear of knowing 1.82 (1.34) 0-4 -.009 -1.264 6. fear of not knowing 0.55 (0.86) 0-3 1.436 1.000 7. fear of action 0.80 (1.05) 0-4 1.110 .122 8. fear of inaction 1.05 (1.17) 0-4 .724 -.788 total score 11.48 (5.47) 0-27 .11 -.56 covid-19 related fears 8 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ all indicators had a meaningful saturation with their corresponding factor, apart from item 5 whose saturation was somewhat low (figure 1). a correlation of 0.40 (p < .001) between the two factors suggests that the mac-rf measures two related but clearly distinct aspects of covid fears; one describing fear of being infected with the virus, oneself or a person’s loved one, and the other describing fears related to choosing an inadequate strategy in dealing with the pandemic, including informing oneself too much or too little about the pandemic. figure 1 standardized parameter estimates of the accepted 2-factor model of the mac-rf (n = 477) note. all parameters are significant at p < .001. scale reliability and validity in accordance with the cfa results, two subscales for mac-rf were created. the cron­ bach’s alpha for mac-rf 1 is .77 and for the mac-rf 2 is .65. the correlation between the two subscales is r = 0.29, p <.001. to inspect associations with psychopathology, correlations between the mac-rf (subscales and total score) and the ccsm (domains and total scores) were calculated. as seen in table 3, the highest correlations were detected between the anxiety domain of the ccsm and mac-rf, falling in the range of a moderate correlation. other correlations were mostly small in magnitude or, in the case of suicidal ideation and psychosis, non-significant. to further explore the construct of fear of covid-19, we examined the associations between the two subscales of the mac-rf (and total score) and a similar measure of covid-19 anxiety (cas5), health anxiety (shai), cyberchondria (scs), three aspects of anxiety sensitivity (asi-3), depression (dass-d), protective health behaviors (hb) and health care utilization (hcu). bagarić & jokić-begić 9 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ table 3 correlations between the mac-rf and ccsm (n = 346) ccsm subscale mac-rf 1 2 total depression .23** .30** .33** anger .24** .27** .31** mania .01 .11* .07 anxiety .27** .40** .40** somatic symptoms .15** .24** .23** suicidal ideation -.02 .06 .02 psychosis -.02 .05 .02 sleep problems .12* .18** .18** memory problems .11* .15** .15** obsession/compulsion .08 .16** .14** dissociation .09 .18** .16** maladaptive personality .08 .20** .16** substance use .09 .10 .11* total score .20** .33** .32** note. ccsm = dsm-5 self-rated level 1 cross-cutting symptom measure—adult. mac-rf = multidimensional assessment of covid-19-related fears. *p < .01. **p < .001. as seen in table 4, the two aspects of fear of covid-19 measured by the mac-rf appear to have varying associations with a number of these constructs. for example, the cas5 captures only one aspect of fear of covid-19 – the fear of infection – and not the second aspect the fear of choosing the wrong strategy in coping with pandemic. this explains the fact that a correlation of only .58 was detected between the two measures. as expected, a stronger correlation was found between the mac-rf total score and health anxiety (.39) and cyberchondria (.44) than with depression (.28). fear of infection had a stronger correlation with health anxiety and fear of choosing the wrong strategy in coping with pandemic had a stronger correlation with cyberchondria and depression. with respect to anxiety sensitivity, a somewhat stronger correlation was found between the social domain of asi and the fear of infection subscale of the mac-rf, which includes the fear of others and for others. furthermore, protective health behaviors were strongly correlated with fear of infection (.64), but not with fear of choosing the wrong strategy in dealing with pandemic (.26). finally, neither aspect of fear of covid-19 correlated with the number of doctor visits in the previous two months. covid-19 related fears 10 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ table 4 correlations between mac-rf subscales and related constructs measure mac-rf 1 2 total n cas5 .65 .23 .58 477 shai .33 .29 .39 346 scs .32 .42 .44 321 asi physical .28 .31 .36 346 asi cognitive .20 .25 .27 346 asi social .36 .21 .29 346 dass-d .17 .29 .28 346 hb .64 .26 .58 346 hcu .04ns .05ns .06ns 346 note. mac-rf = multidimensional assessment of covid-19-related fears; cas5 = covid-19 anxiety scale; shai = short health anxiety inventory; scs = short cyberchondria scale; asi = anxiety sensitivity index; dass-d = depression, anxiety and stress scale 21; hb = protective health behaviors; hcu = health care use. all correlations are significant at p < .001 except correlations with hcu, which are all non-significant. with respect to the scs, participants who reported never searching for health information online were excluded from the analyses because including these participants would obscure the definition of cyberchondria at the low end. finally, correlations between the mac-rf subscales and fear of different types of conse­ quences related to covid-19 are presented in table 5. table 5 correlations between the mac-rf and fear of different types of consequences related to covid-19 feared consequences related to covid-19 m (sd) mac-rf 1 2 total physical health 2.70 (1.13) .49** .27** .49** mental health 2.74 (1.25) .27** .46** .44** loved ones health 3.64 (1.12) .47** .29** .48** financial loss 3.18 (1.21) .06 .22** .16** loss of civil liberties 3.10 (1.38) -.20** .18** -.05 disturbed relationships 3.07 (1.32) .02 .28** .16** note. mac-rf = multidimensional assessment of covid-19-related fears. *p < .01. **p < .001. bagarić & jokić-begić 11 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ the fear of infection subscale had a stronger correlation with the fear of consequences for one’s physical health and the health of loved ones and a small negative correlation with the fear of loss of civil liberties. conversely, fear of choosing inadequate strategy had a stronger correlation with the fear of consequences for mental health and was also positively correlated with fear of financial loss, loss of civil liberties and disrupted relationships with others. discussion the aim of this study was to validate a theoretically based measure of covid-19 related fear – the mac-rf – in a croatian sample and to further explore its validity. in contrast to the 1-factor structure reported by the authors of the scale (schimmenti, starcevic, et al., 2020), a 2-factor structure was revealed in the croatian sample. with regards to the scale’s general properties, its association with general psychopathology as measured by the ccsm was similar to that reported by the authors. furthermore, the stronger associations between the mac-rf and health anxiety and cyberchondria than with depression found in this study further attest to its convergent and divergent validity and expands previous findings regarding the instrument. additionally, with respect to concurrent validity, we found a moderate to strong association between the mac-rf and a previously validated scale of covid anxiety (mac5). however, total scale reliability was lower in our study (.72; original study = .84). this might be the consequence of the 2-factor structure registered in this study. consid­ ering that each subscale has only four items, low cronbach’s alpha (.77 and .65) is not surprising. therefore, it would be more suitable to assess test-retest reliability. the two items from the cognitive domain showed the lowest factor saturations in both studies, suggesting that there may be issues with item formulation. furthermore, informing oneself about covid-19 may also be seen as an action (behavioral domain). finally, cognitive domain is maybe too narrowly defined since knowing and not knowing can be achieved through different means besides informing oneself in an explicit way; such as through talking vs. not talking about covid-19 or maybe even through ruminating about the information one has attained vs. suppressing it. the two mac-rf factors identified in this study are: fear of infection, which reflects emotional-interpersonal feature, and fear of choosing an inadequate strategy, which re­ flects cognitive-behavioral feature form the schimmenti, billieux, and starcevic’s model (2020). the two factors were only moderately associated (.40), suggesting that they measure two distinct aspects of covid-19 related fears. this is further confirmed by a somewhat different patterns of association that the two subscales shared with several relevant constructs. for example, fear of infection has a stronger correlation with health anxiety and covid-19 anxiety, suggesting that this factor captures negative emotional states related to covid-19 and primarily deals with feared consequences for one’s covid-19 related fears 12 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ somatic health and the health of others. this aspect of covid-19 fear also appears to be a much stronger predictor of safety behaviors. furthermore, this subscale is more strongly related to the social aspect of anxiety sensitivity, which may reflect the fear of embarrassment due to revealing covid-19 anxiety. on the other hand, fear of choosing an inadequate strategy when dealing with pandemic has a stronger association with cyberchondria, which is itself a dysfunctional strategy for dealing with health fears. according to a recently proposed metacognitive model of cyberchondria (fergus & spada, 2018), the vicious cycle of excessive online health information and distress is maintained due to conflicting metacognitive beliefs about this strategy: it is deemed helpful in protecting one’s somatic health, but harmful to one’s mental health. similarly, the second mac-rf subscale may reflect a metacogni­ tive aspect of covid-19 fear (beliefs about strategies for dealing with pandemic) that is dialectical in nature: fear of doing too much or too little, reading too much or too little. furthermore, this subscale shares the strongest correlation with the fear of consequences of pandemic for mental health. this finding, together with the dialectic nature of this subscale, may explain its weak correlation with safety behaviors. this subscale is also associated with the fear of disturbed relationships due to pandemic. besides dealing with evaluation of one’s knowledge and action in respect with covid-19, this subscale also deals with tolerating uncertainty so its association with this aspect needs to be explored in further studies. finally, an important aspect of this subscale is considering responsible social action as discussed in the schimmenti, billieux, and starcevic’s model (2020). although, we did not find correlation between this subscale and safety behaviors, it seems probable that only certain items or their combination is predictive of taking action. a lack of association between number of doctor’s visits with either of the mac-rf subscales may be explained by the fact that some people might avoid doctors due to the fear of contracting the coronavirus, while others may go “doctor shopping” to get reassurance. also, it should be noted that over 60% of the sample have not visited a doctor during the last two months. the different underlying structure of the mac-rf in our sample may suggest cultur­ al, social or economic differences, but might also be due to fact that the two studies were conducted in different epidemiological circumstances. in the original study (schimmenti, starcevic, et al., 2020), data was collected a month after restrictions were lifted, while our data was collected during a period in which new restrictions were being imposed and a significant growth in new cases was being registered. it is possible that there are differences in the definition of this construct depending on epidemiological circumstan­ ces. further studies should examine a bifactor structure for the mac-rf having in mind that both a single and two-factor structure may co-exist and may both have a meaningful interpretation as suggested for other psychopathology constructs (bornovalova et al., 2020). bagarić & jokić-begić 13 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ finally, the different instruments developed in this field capture different aspects of problematic psychological reactions to covid-19. while some emphasize emotional (lauri-korajlija & jokić-begić, 2020), behavioral (nikčević & spada, 2020) or physiolog­ ical (lee, 2020) aspects, others encompass a combination of emotional, physiological, cognitive and behavioral components (e.g., taylor et al., 2020; ahorsu et al., 2020). others even go beyond the fear of illness and include fear of economic consequences (arpaci et al., 2020). an instrument’s scope will certainly affect its associations with other relevant constructs: predictors, mediators and outcomes of fear. developing a theoretical approach to covid-19 related distress can help in achieving a consistent definition of this construct (or constructs), developing adequate measurement tools, integrating knowledge form different studies, and developing targeted interventions. this study supports the dialectical nature of covid-19 fears (schimmenti, billieux, & starcevic, 2020), since items describing opposing fears reflect a single construct, and attests to the complexity of human experiences in the time of a global health crisis. several strategies for addressing covid-19 anxiety have been suggested by the authors of mac-rf (schimmenti, billieux, & starcevic, 2020); practicing mindfulness to improve appraisal of the body and to adopt acceptance and self-compassion, delivering targeted interventions to foster attachment security, using strategies to improve emotion regu­ lation, and promoting responsibility. the results of this study further emphasize that treatment might need to focus not only on fear of becoming infected, but also on a metacognitive aspect that reflects conflicting beliefs about strategies used when dealing with the pandemic. using a combination of cognitive continuum and listing advantaging and disadvantages of extreme strategies (e.g., reading about covid too much or not at all), as a form of cognitive restructuring within cognitive-behavioral therapy, could help adopting appropriate intensity of health-related behaviors. it may also be necessary to modify metacognitive beliefs about strategies in dealing with pandemic and practice tolerating uncertainty which fuels covid-19 anxiety. the disadvantages of this study that place limits on its findings include: a non-repre­ sentative sample (certain groups are underrepresented), a self-selection bias (people more affected by covid-19 might have been more likely to participate) and the cross-sectional design (no causal associations can be claimed). conclusions this study suggests that the mac-rf might be a useful instrument in assessing cov­ id-19 fears. in a croatian sample and at a time of a rapid increase in daily cases, this instrument appears to measure two distinct, but related factors: fear of infection (emo­ tional aspect) and fear of choosing an inadequate strategy when dealing with pandemic (metacognitive aspect). further studies using the mac-rf across different cultures and different epidemiological circumstances are needed. covid-19 related fears 14 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://www.psychopen.eu/ funding: this research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. ethics statement: this study was approved by the ethical committee of the department of psychology, faculty of humanities and social sciences, university of zagreb (epop – 2021 – 005). the study was conducted in accordance with the 1964 helsinki declaration and its later amendments or comparable ethical standards. data availability: for this article, a data set is freely available (bagarić & jokić-begić, 2022) supplementary materials the research data is collected in the validation study of multidimensional assessment of covid-19-related fears (mac-rf) – croatian version. a total of 477 participants completed the online survey during the covid-19 pandemic. for access see index of supplementary materials below. index of supplementary materials bagarić, b., & jokić-begić, n. 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(2012). psychological predictors of anxiety in response to the h1n1 (swine flu) pandemic. cognitive therapy and research, 36(3), 210–218. https://doi.org/10.1007/s10608-011-9353-3 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. covid-19 related fears 18 clinical psychology in europe 2022, vol. 4(1), article e6137 https://doi.org/10.32872/cpe.6137 https://doi.org/10.1007/s10608-011-9353-3 https://www.psychopen.eu/ covid-19 related fears (introduction) method participants instruments procedure data analyses results preliminary analysis model generation confirmatory factor analyses scale reliability and validity discussion conclusions (additional information) funding acknowledgments competing interests ethics statement data availability supplementary materials references shifting our perspective for the future of assessment and intervention science editorial shifting our perspective for the future of assessment and intervention science maria karekla a [a] department of psychology, university of cyprus, nicosia, cyprus. clinical psychology in europe, 2021, vol. 3(1), article e6197, https://doi.org/10.32872/cpe.6197 published (vor): 2021-03-10 corresponding author: maria karekla, 1 panepistimiou avenue, 2109 aglantzia, nicosia, cyprus. e-mail: mkarekla@ucy.ac.cy a big chunk of my early years in graduate school was spent learning about psychopa­ thology and the diagnostic systems that categorize these. we learned about prevalence, contributing factors, how to assess and differentially diagnose individuals with psycho­ pathological problems. when i started my clinical work, i was shocked to encounter that the reality of clinical practice was far from the information i learned in my psy­ chopathology courses. almost all clients, would not fit properly under one diagnosis, comorbidity was the norm, and i discovered that assigning a diagnosis was not par­ ticularly helpful for my case conceptualizations and choice of treatment. since those days, even though i have seen hundreds of patients, i am still looking for the classic book example of a panic patient. as for depression, it is fascinating to me that i can give the same diagnosis to a patient who presents with loss of appetite, low energy, excessive sleepiness, and catatonic-like symptoms, as to a patient who presents with concentration difficulties, increased appetite, difficulty sleeping, and restlessness. how does our training in a topographical approach to psychological suffering with the search for syndromes (collection of signs and symptoms) prepare us for clinical practice and ef­ fective intervention? what are our diagnostic systems useful for? interestingly, even the task force on dsm-5 (american psychiatric association, 2013) acknowledges the shortfall of this approach in “uncovering etiologies”, recommending intervention strategies, and have gone as far as to propose that a “paradigm shift may need to occur” (kupfer, first, & regier, 2002). beyond assessment and diagnosis, in the realm of treatment, psychological interven­ tion training is driven by theories, traditions, or schools of thought (e.g., cognitive-be­ havioral, humanistic, psychodynamic). in training and education, we focus on teaching students’ tools, techniques, and approaches, almost like cookbooks, ignoring that the this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6197&domain=pdf&date_stamp=2021-03-10 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ reality of practice or even cooking, is far from the strict following of a specific mech­ anistically applied set of tools. inflexible and strict devotion to a particular approach has hindered scientifically based development of psychotherapy, has propagated bias and impeded progress and communication among therapists, and has prevented the investigation of common mechanisms that may drive therapeutic changes in individuals who suffer and seek services (hofmann, 2020; rief, 2021). going back to the reality of human suffering, if we examine the world health organizations’ top 10 diseases causing the most deaths worldwide (who, 2020a, 2020b), we will notice that these include heart disease, stroke, chronic obstructive pulmonary disease, respiratory infections, neonatal conditions, lung-related cancers, alzheimer’s and dementia, diarrheal diseases, diabetes, and kidney diseases. what is common among all these top killers? common to all these are maladaptive health-related behaviors, dysfunctional coping, and behaving and all can be aided with the realm of the work we do as clinical psychologistsbehavior change. yet, despite important scientific advances, current treatments are hindered by these dysfunctional behaviors and clinicians' inability to help patients overcome them. therefore, a change of perspective is needed on how we approach human suffering, and under what circumstances, how and where we intervene. one such new perspective shift came from the national institute of health (nimh, 2021) rdoc framework. this approach aimed to examine psychopathology as dysregu­ lation of particular neurobiological and behavioral systems, including affective valence systems, cognitive systems, social systems, attachment processes, and arousal systems (cuthbert, 2014). the goal is to translate progress in behavioral and neuroscience to improve understanding of psychopathology and develop new and tailored treatments. it remains to be seen whether this framework will prove helpful in remedying the problems posed above. another recent development comes from hofmann and hayes (2019, p. 47), who are extending the question posed by gordon paul in 1969 and ask: “what core biopsychosocial processes should be targeted with this client given this goal, in this situation, and how can they most efficiently and effectively be changed?”. with this question and their new conceptual developments of a process-based approach couched within the umbrella of evolutionary science, they raise a different claim (see hayes, hofmann, & ciarrochi, 2020). in this approach, assessment procedures and therapy can and should be linked via mechanisms of action implicated in the maintenance and treatment of suffering and the promotion of well-being. research from my laboratory and others around the world are presently attempting to establish necessary parameters so as to be able to result in directly linking mecha­ nisms of action (change processes via which psychotherapeutic change can occur) with intervention choices and outcomes in an iterative, bottom-up manner. we recently pro­ posed that a successful coupling of assessment and treatment depends on the basic core mechanisms of action identified and measured (gloster & karekla, 2020). such candidate mechanisms need to: 1) be malleable and amenable to experimental manipulation, 2) editorial 2 clinical psychology in europe 2021, vol.3(1), article e6197 https://doi.org/10.32872/cpe.6197 https://www.psychopen.eu/ demonstrate robustness across contexts, 3) be tested across time ideographically, and 4) be tested across multiple levels of analysis (e.g., biological, genetic, psychophysiological, and behavioral). adopting such a multi-method, multi-level perspective in the explora­ tion of mechanisms of action can move us towards functional process-based alternatives to approaching human suffering. when this is couched within a coherent theory such as that of evolutionary science (see hayes, hofmann, & ciarrochi, 2020), we may be able to achieve meaningful progress towards our aim of better serving the humans who suffer and seek our services. i hope that as a field we will shift our perspective to a more functional, contextualistic, and process-based approach for the future of our assessment and intervention science. funding: the author has no funding to report. competing interests: the author has declared that no competing interests exist. acknowledgments: the author has no support to report. references american psychiatric association. (2013). diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 cuthbert, b. n. (2014). the rdoc framework: facilitating transition from icd/dsm to dimensional approaches that integrate neuroscience and psychopathology. world psychiatry, 13(1), 28-35. https://doi.org/10.1002/wps.20087 gloster, a. t., & karekla, m. (2020). a multi-level, multi-method approach to testing and refining intervention targets. in s. hayes & s. g. hofmann (eds.), beyond the dsm: toward a processbased alternative for diagnosis and mental health treatment (pp. 226-249). oakland, ca, usa: context press/new harbinger publications. hayes, s. c., hofmann, s. g., & ciarrochi, j. (2020). creating an alternative to syndromal diagnosis: needed features of processes of change and the models that organize them. in s. c. hayes & s. g. hofmann (eds.), beyond the dsm: toward a process-based alternative for diagnosis and mental health treatment (pp. 1–22) oakland, ca, usa: context press/new harbinger publications. hofmann, s. g. (2020). imagine there are no therapy brands, it isn’t hard to do. psychotherapy research, 30(3), 297-299. https://doi.org/10.1080/10503307.2019.1630781 hofmann, s. g., & hayes, s. c. (2019). the future of intervention science: process-based therapy. clinical psychological science, 7(1), 37-50. https://doi.org/10.1177/2167702618772296 kupfer, d. j., first, m. b., & regier, d. a. (2002). introduction. in d. j. kupfer, m. b. first, & d. a. regier (eds.), a research agenda for dsm-v (pp. xv–xxiii). washington, dc, usa: american psychiatric association. karekla 3 clinical psychology in europe 2021, vol.3(1), article e6197 https://doi.org/10.32872/cpe.6197 https://doi.org/10.1176/appi.books.9780890425596 https://doi.org/10.1002/wps.20087 https://doi.org/10.1080/10503307.2019.1630781 https://doi.org/10.1177/2167702618772296 https://www.psychopen.eu/ national institute of mental health. (2021, february 21). research domain criteria (rdoc). retrieved from https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/index.shtml paul, g. l. (1969). behavior modification research: design and tactics. in c. m. franks (ed.), behavior therapy: appraisal and status (pp. 29–62). new york, ny, usa: mcgraw-hill. rief, w. (2021). moving from tradition-based to competence-based psychotherapy. evidence-based mental health. advance online publication. https://doi.org/10.1136/ebmental-2020-300219 world health organization. (2020a). the top 10 causes of death. retrieved february 21, 2021 from https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death world health organization. (2020b). who reveals leading causes of death and disability worldwide: 2000-2019. retrieved february 21, 2021 from https://www.who.int/news/item/09-12-2020-who-reveals-leading-causes-of-death-anddisability-worldwide-2000-2019 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. editorial 4 clinical psychology in europe 2021, vol.3(1), article e6197 https://doi.org/10.32872/cpe.6197 https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/index.shtml https://doi.org/10.1136/ebmental-2020-300219 https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death https://www.who.int/news/item/09-12-2020-who-reveals-leading-causes-of-death-and-disability-worldwide-2000-2019 https://www.who.int/news/item/09-12-2020-who-reveals-leading-causes-of-death-and-disability-worldwide-2000-2019 https://www.psychopen.eu/ the paths to children’s disordered eating: the implications of bmi, weight-related victimization, body dissatisfaction and parents’ disordered eating research articles the paths to children’s disordered eating: the implications of bmi, weight-related victimization, body dissatisfaction and parents’ disordered eating marilou côté a, maxime legendre a, annie aimé b, marie-christine brault c, jacinthe dion c, catherine bégin a [a] laval university, québec, canada. [b] université du québec en outaouais, st-jérôme, canada. [c] université du québec à chicoutimi, chicoutimi, canada. clinical psychology in europe, 2020, vol. 2(1), article e2689, https://doi.org/10.32872/cpe.v2i1.2689 received: 2019-07-25 • accepted: 2019-11-10 • published (vor): 2020-03-31 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: marilou côté, pavillon f-a.-savard, 2325, rue des bibliothèques, local 1116, laval university, quebec (qc), canada, g1v 0a6, phone: +1 418 656-2131. e-mail: marilou.cote.2@ulaval.ca abstract background: being the target of peer victimization is frequent among children categorized as overweight and obese and is thought to play a central role in disordered eating behavior development. in accordance with a previous theoretical model, this cross-sectional study aimed to replicate among children the mediating role of weight-related victimization from peers and body dissatisfaction in the association between body mass index (bmi) and children’s disordered eating attitudes and behaviors (cdeab), while also taking into account the contribution of parents’ disordered eating attitudes and behaviors (pdeab). methods: participants were 874 children aged between 8 and 12 years old who were recruited in elementary schools. height and weight were measured and used to calculate bmi. self-reported questionnaires were used to measure weight-related victimization, body dissatisfaction, cdeab and pdeab. results: for both girls and boys, a path analysis showed no direct effect of bmi on cdeab, but a significant indirect effect was found, indicating that weight-related victimization and body dissatisfaction mediated this relationship. in addition, the indirect effect of weight-related victimization and body dissatisfaction remained significant even when controlling for pdeab. conclusion: while weight itself appears to be insufficient to explain cdeab, weight-related victimization may lead children to see their weight as problematic and develop disordered attitudes and behaviors toward eating. this suggests that weight-related victimization from peers and body dissatisfaction must be taken seriously and that preventive and intervention efforts must be pursued. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i1.2689&domain=pdf&date_stamp=2020-03-31 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords weight-related victimization, disordered eating behaviors, body dissatisfaction, body mass index, children, cross-sectional study highlights • body weight per se seems insufficient to explain children’s disordered eating attitudes and behaviors (cdeab). • weight-related victimization and body dissatisfaction mediate the association between bmi and cdeab. • parents‘ deab is associated with cdeab. • the tested paths from bmi to cdeab appear to be globally the same for boys and girls. despite decades of efforts to prevent overweight and obesity, its prevalence is on the rise among children in developed and in developing countries (ng et al., 2014). children cate‐ gorized as overweight or obese are at an elevated risk for disordered eating (tanofskykraff et al., 2004). some public health programs designed to prevent overweight actually use weight stigmatization as a tool to sensitize people to the consequences of obesity (e.g., georgia’s strong4life campaign; teegardin, 2012). however, these programs may be counterproductive and instead increase weight-related victimization. in return, experi‐ encing weight-related victimization may contribute to disordered eating among youth who present with overweight or obesity (libbey, story, neumark-sztainer, & boutelle, 2008). although there is existing literature linking weight-related victimization and eating behaviors, no research has examined this association while taking into account parents’ disordered eating, which has been extendedly related to children’s disordered eating (scaglioni, salvioni, & galimberti, 2008). the current study mostly replicates pre‐ vious work by assessing the mediating roles of weight-related victimization from peers and body dissatisfaction in the association between body mass index (bmi) and children’s disordered eating, and extends past reports by controlling for parents’ disordered eating. weight-related victimization includes cognitive and behavioral aspects. the cognitive aspect covers bias and stereotyping based on one’s weight. this leads to the belief that individuals categorized as overweight are lazy, lack self-discipline, have poor willpower, and show defects of intelligence and character. the behavioral aspect of weight-related victimization can materialize in verbal, physical and relational victimization, such as teasing, bullying, pushing and social exclusion (puhl & latner, 2007). some studies demonstrated that children as young as 3 years old may be victimized because of their weight (cramer & steinwert, 1998; rodgers, wertheim, damiano, gregg, & paxton, 2015). therefore, weight-related victimization may start at a very young age. during the school years, weight-related victimization behaviors become frequent and mostly impact over‐ weight children (see puhl & heuer, 2009; puhl & latner, 2007 for a review). for instance, the paths to children’s disordered eating 2 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://www.psychopen.eu/ many studies have shown that children and adolescents categorized as overweight are at a greater risk of being teased about their weight by school peers, educators, family members and peers of family members compared to their counterparts categorized as normal weight (brixval, rayce, rasmussen, holstein, & due, 2012; hayden-wade et al., 2005; neumark-sztainer et al., 2002). among all weight-related victimization behaviors, teasing has been largely studied, most likely because it is common among youth (hayden-wade et al., 2005). weight-rela‐ ted teasing is associated with various negative psychosocial consequences in children and adolescents, such as loneliness and preference for sedentary-isolative activities, social anxiety, poor quality of life and depression (hayden-wade et al., 2005; juvonen, lessard, schacter, & suchilt, 2017; stevens, herbozo, morrell, schaefer, & thompson, 2017). weight-related teasing also seems to be the starting point for many negative consequences related to eating and weight problems in adolescents. for example, parents, siblings and peer teasing were linked to body dissatisfaction in girls and to drive for muscularity in boys (schaefer & blodgett salafia, 2014). furthermore, weight-related teasing has been linked to the drive for thinness and disordered eating behaviors such as binge-eating, compensatory behaviors, and dietary restraint (cook-cottone et al., 2016; haines, 2006; neumark-sztainer et al., 2002; zuba & warschburger, 2017). a recent longitudinal study noted that weight-related teasing in adolescence predicted resorting to disordered eating behaviors as a coping strategy, which in turn resulted in a higher body mass index (bmi) or into obesity 15 years later (puhl et al., 2017). recently, the effect of weight-related teasing on disordered eating behaviors was validated in a few prospective studies. most of these studies seemed to build their prospective design on a pioneering study by thompson, coovert, richards, and johnson (1995). thompson and colleagues (1995) proposed a path analysis with a sample of girls aged 13-18 years old. in their model, the level of obesity at the baseline influenced weight-related teasing at the baseline, which further influenced body image (weight and appearance dissatisfaction) at the 3-year follow-up. furthermore, body image at the 3-year follow-up influenced disordered eating behaviors such as bulimic behaviors and dietary restraint at the 3-year follow-up. jendrzyca and warschburger (2016) presented a similar comprehensive model of disordered eating behaviors in children. in their prospec‐ tive design, 1,486 children aged 6-11 years old in germany completed height and weight measurements (used for bmi calculation) and questionnaires related to eating, weight and body image (weight-related stigmatization, including weight-related teasing, body dissatisfaction and disordered eating behaviors) twice with a one-year interval. for girls, bmi at the baseline was significantly associated with the baseline weight-related stigma, which predicted body dissatisfaction one year later, which in turn predicted disordered eating behaviors, also at the one-year follow-up. for boys, a different pattern was found. bmi at the baseline was significantly associated with the baseline weight-related stigma, and body dissatisfaction at the one-year follow-up predicted disordered eating behaviors côté, legendre, aimé et al. 3 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://www.psychopen.eu/ at the one-year follow-up, but baseline weight-related stigma did not predict body dissatisfaction at the one-year follow-up. using a similar model, pryor and colleagues (2016) found that children categorized as overweight and targeted by peers’ victimization between 6 and 12 years old tended to be less satisfied with their bodies (they wanted to be thinner) and to report increased depression and anxiety at 13 years old. thereby, some authors implied that weight-related victimization should be included in a comprehensive model of disordered eating behaviors development (jendrzyca & warschburger, 2016). however, most available studies have only targeted adolescent pop‐ ulations. furthermore, studies tend to report mixed results regarding possible sex specific effects, and parental influences are often overviewed. however, parents’ eating behaviors have a major influence on their children’s eating behaviors, especially at a younger age (scaglioni, et al., 2008; ventura & birch, 2008; wertheim, martin, prior, sanson, & smart, 2002; wertheim, mee, & paxton, 1999). therefore, to better assess (and not overestimate) the influence of weight-related victimization and body dissatisfaction in a comprehensive model of disordered eating behaviors in children categorized as overweight or obese, the influence of parents’ eating behaviors should be considered. the present study aimed to examine the mediating role of 1) weight-related victimiza‐ tion from peers, as perceived by children, and 2) body dissatisfaction in the association between bmi and children’s disordered eating attitudes and behaviors (cdeab) among 8-12 years old boys and girls, controlling for parents’ disordered eating attitudes and behaviors (pdeab). it was expected that a higher bmi would be associated with greater cdeab, mediated by perceived weight-related victimization and body dissatisfaction (serial) for both boys and girls. moreover, it was hypothesized that pdeab would be positively associated with cdeab. method participants participants were 874 children aged between 8 and 12 years old and one of their parents. they were recruited from 27 public elementary schools located in two urban areas in the province of quebec, canada. the sample was composed of 44% boys and 56% girls. their mean age was 10.29 (sd = 1.19). among the sample, 1.5% of the children could be classified in the underweight category, 69.3% in the normal weight category, 20.9% in the overweight category and 8.3% in the obese category. regarding weight-based victimiza‐ tion, 24.4% of children reported having been teased about their weight at least once. the participating parents were mostly mothers (86%). their mean age was 39.65 years old (sd = 5.69), and their mean bmi was 26.23 (sd = 5.04). almost all of the children were born in canada (95%) and came from a family where their parents were either married or living in a common-law relationship (83%). on average, these children came from wealthy and the paths to children’s disordered eating 4 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://www.psychopen.eu/ educated families. nearly a third had an annual family income of $100,000 or more, which was over the average wage (approximately $73,000) in the province of quebec (statistics canada, 2019). furthermore, almost the half of the children had a parent with a university diploma, while about 35% of the population of the province of quebec had achieved an academic degree (crespo, 2018). procedure the children were recruited to participate in a study about body weight, body image and eating and physical activity habits. the study was presented to them in class. interested children were given an envelope containing both parents and children questionnaires, as well as informed consent form. both the children and parents were asked to complete questionnaires at home (approximately 45 minutes for parents and 30 minutes for chil‐ dren). parents were instructed to let their children fill autonomously the questionnaires. children returned the completed questionnaires to their teacher, and were met individ‐ ually at school by a trained research assistant to collect their anthropometric (height and weight) measures. all of the parents gave written informed consent (approved by university’s institutional review board of laval university) prior to their inclusion in the study, and children provided their assent to participate. the children who completed the questionnaires were included in a lottery drawing to win a $100 gift card to a sports shop. measures children’s bmi height and weight were measured individually and out of sight of the children’s peers and only one time as recommended by lohman, roche, and martorell (1988), and trained research assistants used a metric scale and a numeric weighing scale. height was measured to the nearest 0.1 centimeter and weighed to the nearest 0.2 pound. measure‐ ments in pounds were then transformed into kilograms. gender specific bmi-for-age z scores were computed based on the world health organization recommendations (who multicentre growth reference study group, 2006). the children’s bmi was classified into four categories (underweight, normal weight, overweight, or obese) still according to the who recommendations. these categories were used to describe the sample and for the mean comparisons, and bmi z-scores were used as a continuous variable in the path analyses. perceived weight-related victimization by peers perceived weight-related victimization was measured with a question adapted from the children's social experience questionnaire (crick & grotpeter, 1996). the question “how often does another child say negative things about your weight?” was answered on a côté, legendre, aimé et al. 5 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://www.psychopen.eu/ 5-point likert scale ranging from 1 (never) to 5 (all the time). a higher score indicated a higher level of perceived weight-related victimization by peers. body dissatisfaction body dissatisfaction was evaluated with two questions inspired by collins (1991). one evaluated actual body perception (how would you describe your body? with answers ranging from 1 “far too thin” to 5 “far too big”), while the other evaluated desired body (how would you like your body to be? with answers ranging from 1 “a lot thinner” to 5 “a lot bigger”). we further subtracted the desired body from the actual body perception. the discrepancy between the perceived and the desired body provided an indication of the level of body dissatisfaction, with a negative score reflecting a desire for a thinner body and a positive score reflecting a desire for a larger body. children’s eating attitudes test the children’s version of the eating attitudes test (cheat; maloney, mcguire, & daniels, 1988) was used to measure disordered eating attitudes and behaviors. the cheat is a 26-item self-report questionnaire, with a 6-point likert scale ranging from 1 (never) to 6 (always). the total score was used. a higher score reflects more disordered eating attitudes and behaviors. its reliability and concurrent validity have been demon‐ strated previously (maloney, mcguire, daniels, & specker, 1989; smolak & levine, 1994). the cronbach’s alpha was .79 in the present sample. eating attitudes test the eating attitudes test (eat-26; garner, olmstead, bohr, & garfinkel, 1982) was used to measure parents’ disordered eating attitudes and behaviors. the eat is a 26-item self-report questionnaire which uses a 6-point likert scale ranging from 1 (never) to 6 (always). the total score was used. a higher score reflects more disordered eating attitudes and behaviors. the questionnaire has adequate reliability (koslowsky et al., 1992). the cronbach’s alpha was .87 in the present study. statistical analyses prior to analyses, all variables’ distributions were inspected, and appropriate transforma‐ tions were applied when needed in order to respect the basic assumptions. first, t-test and anova analyses were run to compare the children on the three study dependent variables (weight victimization, body dissatisfaction and cdeab) based on their sex and bmi category. afterward, the proposed model was tested with a path analysis using mplus version 7.0 (muthén & muthén, 2012). path analysis is a statistical method that allows the simultaneous testing of both direct and indirect associations among different variables (kline, 2011). the paths to children’s disordered eating 6 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://www.psychopen.eu/ in this model, bmi was used as an independent variable with both weight-related victimization and body dissatisfaction as mediators (serial mediation), and cdeab was used as the dependent variable. pdeab was included as a control variable. because standard errors underlying indirect effects (i.e., product terms) are known to be skewed, we instructed mplus to generate 1000 bootstrap samples from the data to create indirect effects with bias-corrected 95% confidence intervals (cis; mackinnon, lockwood, & williams, 2004). indirect effects would only be found to be significant if the cis would not include zero. to determine whether the model provided a good fit for the data, three indices recommended by hu and bentler (1999) were used: the comparative fit index (cfi), the standardized root mean square residual (srmr), and the root mean square error of approximation (rmsea). the determined threshold values indicating a good fit are cfi ≥ .95, srmr ≤ .08, and rmsea ≤ .06 (hu & bentler, 1999). a good fit of the model can also be identified by a nonsignificant χ2 value (tabachnick & fidell, 2001). results mean comparisons the results from t-tests and anovas, as well as means and standard deviations, are presented in table 1. weight-related victimization was similar for boys and girls but significantly differed across weight statuses. children categorized as obese reported more frequent weight-related victimization compared to children categorized as underweight, normal weight and overweight (all p values < .001). children categorized as overweight also reported more victimization than peers categorized as normal weight (p < .001). body dissatisfaction differed between boys and girls, as well as across weight statuses. as expected, girls were significantly more dissatisfied with their body than boys. children categorized as obese were more dissatisfied with their body than children categorized as underweight, normal weight and overweight (all p values < .01). children categorized as overweight were also more dissatisfied than children categorized as normal weight (p < .001). finally, for cdeab, girls reported significantly higher scores than boys. across weight statuses, children categorized as obese reported more disordered eating attitudes and behaviors than children categorized as overweight or normal weight (all p values < .01). côté, legendre, aimé et al. 7 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://www.psychopen.eu/ table 1 means and standard deviations by sexes and by weight categories variable sex weight category t f girls boys under‐ weight normal over‐ weight obesity sex weight categorym sd m sd m sd m sd m sd m sd weight-related victimization 1.40 0.80 1.36 0.74 1.23 0.60 1.24 0.58 1.53 0.88 2.17 1.19 -0.72 39.50*** body dissatisfaction 0.62 0.95 0.49 0.84 0.75 1.29 0.36 0.74 0.80 0.94 1.64 1.05 -2.17* 59.04*** cdeab 6.44 5.56 5.55 3.98 5.62 4.31 5.52 4.19 6.49 5.50 9.40 7.59 -1.60* 10.20*** note. n = 874 children. cdeab = children’s disordered eating attitudes and behaviors. *p < .05. ***p < .001. path analyses pearson’s correlations between the variables studied are presented in table 2. the pro‐ posed theoretical model was first tested with path analyses separately for both boys and girls. the results showed very similar patterns among boys and girls. therefore, we expected the models to be invariant with regard to sex and we performed multigroup tests. the nonsignificant adjusted difference of the chi-square, χ2(5) = 6.579, p = .254, showed that the model was invariant by sex on all the tested paths except the bmi-body dissatisfaction one. that is, the tested paths were similar for boys and girls, but the path between bmi and body dissatisfaction was slightly different regarding the strength of the association, β = .33 (p < .0001) for girls and β = .18 (p = .003) for boys. since this minor sex difference did not affect the direction nor the signification of the association between bmi and body dissatisfaction, a single model will be presented for girls and boys for the sake of parsimony. table 2 pearson’s correlations between studied variables variable 1 2 3 4 5 1. cdeab – .09** .16** .22** .29** 2. pdeab – .08* .04 .05 3. bmi – .21** .32** 4. weight-related victimization – .31** 5. body dissatisfaction – note. n = 874 children. cdeab = children’s disordered eating attitudes and behaviors. pdeab = parents’ disordered eating attitudes and behaviors. *p < .05. **p < .01. the paths to children’s disordered eating 8 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://www.psychopen.eu/ the fit indices revealed that the tested model provided a good fit to the data: cfi = .99, srmr = .02, rmsea = .03. the nonsignificant chi-square value also indicated that the data were adequately represented by the model, χ2(3) = 5.59, p = .133. the model with standardized path coefficients is presented in figure 1. the model explained 11% of the variance of the main dependent variable (cdeab; r 2 = .11). figure 1 relationships among studied variables in boys and girls, with standardized coefficients note. n = 874 children. *p < .05. **p < .01. ***p < .001. in this model, bmi did not have a direct effect on cdeab (β = .06; p = .097). rather, three different paths (indirect effects) were statistically significant: 1) bmi was associated to cdeab through weight-related victimization and body dissatisfaction (β = .01, 95% bootstrap ci [.001, .005]; 2) bmi was associated to cdeab through perceived weight-re‐ lated victimization (β = .03, 95% bootstrap ci [.003, .012]; and 3) bmi was associated to cdeab through body dissatisfaction (β = .06, 95% bootstrap ci [.010, .021]. the results of the path analyses further confirmed the relevance of adding the control variable pdeab, since its positive association with cdeab was significant (β = .07; p < .05). discussion the aim of this study was to mostly replicate previous work (jendrzyca & warschburger, 2016; thompson et al., 1995) by examining the mediating role of weight-related victimi‐ zation from peers as perceived by children aged 8 to 12 years old and body dissatisfaction in the association between bmi and cdeab, and to extend previous studies by taking in‐ to account the contribution of pdeab. overall, the results confirmed our hypotheses and côté, legendre, aimé et al. 9 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://www.psychopen.eu/ revealed that bmi was associated with disordered eating only through its associations with perceived weight-related victimization and body dissatisfaction. parental disordered eating was also associated with higher disordered eating among children. first, the level of perceived weight-related victimization and body dissatisfaction were significantly different across weight statuses. children categorized as overweight or obese reported more weight-related victimization and body dissatisfaction compared to children categorized as normal weight. this is consistent with what others have previously reported (brennan, lalonde, & bain, 2010; neumark-sztainer et al., 2002; puhl & latner, 2007). the level of perceived weight-related victimization was similar for boys and girls, but girls were significantly more dissatisfied with their body than boys were. this may be because girls, even at this age, present a higher risk of being exposed to media and beauty pressure, resulting in higher preoccupation with their weight and body shape. it could also be that for boys, body dissatisfaction kicks in later or that it may be more about looking fit and muscular than looking thin (barlett, vowels, & saucier, 2008; brennan et al., 2010; dion et al., 2016; thompson & chad, 2000). even though girls reported more body dissatisfaction than boys did, the same trajec‐ tory from bmi to cdeab applied for both sexes, since the model was, globally, statisti‐ cally invariant in regard to sex. considering that bmi had no direct effect on cdeab, weight per se appears to be insufficient to explain the development of disordered eating attitudes and behaviors. most likely, it is the negative experience, mostly interpersonal, associated with being categorized as overweight or obese that may influence children and adolescents to see their weight as problematic. as demonstrated in this study, high bmi was associated with cdeab through the indirect effect of perceived weight-rela‐ ted victimization and body dissatisfaction. furthermore, bmi was also associated with cdeab through the indirect effect of perceived weight-related victimization and body dissatisfaction separately. along with the findings of jendrzyca and warschburger (2016), the present results suggest that weight-related victimization and body dissatisfaction might play a key role in the likelihood of developing disordered eating attitudes and behaviors for children who present as overweight or obesity. this highlights the need to fit in, as children grow older, and the important effect that these relationships with peers have on children. in addition, it may provide a clue about why body dissatisfaction is different between girls and boys. this might be likely because the importance of inter‐ personal experiences may change greatly from childhood to adolescence and differently for girls and boys. however, the cross-sectional design of the present study calls for caution, and additional prospective studies are needed to confirm those hypotheses. the fact that our study took into account the contribution of pdeab was an impor‐ tant strength. while the association between pdeab on cdeab does not need to be proven further (scaglioni et al., 2008; ventura & birch, 2008; wertheim et al., 2002; wertheim et al., 1999), it still has to be considered when predicting cdaeb in order to avoid overestimating the effect that weight-related victimization has on it. had we not the paths to children’s disordered eating 10 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://www.psychopen.eu/ statistically controlled for pdeab, one could have thought that the association between bmi, weight-related victimization, body dissatisfaction and cdaeb may be explained by parental influences. however, although parents may influence the development of disordered eating in their children as they approach adolescence, these youths may be even more affected by their experiences with peers. as they get older, negative experiences such as weight-related victimization can seriously affect the way children evaluate themselves and push them to try to modify their weight and appearance to like themselves better and better fit in their peer group (vander wal, 2012). another strength of this study was to target elementary school girls and boys. studies that focus on weight-related victimization and body dissatisfaction have previously targeted, for the most part, high school adolescents. it appeared important to replicate the results from adolescents’ studies with younger children since disordered eating attitudes and behaviors can be adopted early and can be especially harmful (goldschmidt, aspen, sinton, et al., 2008). the recruiting process is another important element of this study. to favor a diversified sample, 874 children from 27 public elementary schools were included in our path analysis. finally, it was a great strength to use objective anthropometric measures because parents are likely to misreport their children's weight and height (brault, turcotte, aimé, côté, & bégin, 2015). some limitations of this study should be considered. first, as mentioned earlier, the cross-sectional design does not allow for drawing causal conclusions. however, the paths proposed follow a logical cascade in time that has already been demonstrated in a pro‐ spective design (jendrzyca & warschburger, 2016). second, weight-related victimization from peers and body dissatisfaction were measured with single items. moreover, no specific time frame was given in the question assessing victimization. the use of valida‐ ted questionnaires for our two mediating variables would have significantly enhanced internal validity. since the same measurement limitation applies to the prospective study of jendrzyca and warschburger (2016), future studies may benefit from testing weightbased victimization and body dissatisfaction with complete validated scales. nonetheless, despite the limitation that represents the use of single item measures (i.e., underestima‐ tion of the strength of the tested associations; menzel et al., 2010), the present study successfully detected statistically significant effects between studied variables, which suggests robust associations. another limitation stems from the representativeness of the sample. indeed, higher-educated wealthy families were over represented. since disor‐ dered eating behaviors and body dissatisfaction have been previously found to be higher in high socioeconomic status (ses) children compared to low ses children (adams et al., 2000; o’dea & caputi, 2001), it would be of great interest to replicate our results in a more diversified sample in terms of ses. additionally, it would be of great interest to assess victimization from different points of view, (i.e., reported not only from children but also from teachers and parents) to verify whether it is weight victimization per se which is associated with negative psychological outcomes or feeling victimized. different côté, legendre, aimé et al. 11 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://www.psychopen.eu/ sources of comments should also be studied, since parental comments on weight might be very harmful for young people (neumark-sztainer et al., 2010). conclusion this study adds to the limited data currently available in the field of the early develop‐ ment of disordered eating behaviors (before adolescence). an important contribution of this study was to consider the implication of pdeab in a comprehensive model of eating attitudes and behaviors in children. a model in which weight-related victimization experienced by children was associated with body dissatisfaction and disordered eating attitudes and behaviors was replicated. while weight itself appears to be insufficient to explain disordered eating, interpersonal experiences might be what influence children to see their weight as problematic and adopt disordered attitudes and behaviors toward eat‐ ing. this suggests that weight-related victimization from peers and body dissatisfaction must be taken seriously and that prevention and intervention efforts must be pursued. funding: this work 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(2008). does parenting affect children’s eating and weight status? international journal of behavioral nutrition and physical activity, 5(1), article 15. https://doi.org/10.1186/1479-5868-5-15 wertheim, e. h., martin, g., prior, m., sanson, a., & smart, d. (2002). parent influences in the transmission of eating and weight related values and behaviors. eating disorders, 10(4), 321-334. https://doi.org/10.1080/10640260214507 wertheim, e. h., mee, v., & paxton, s. j. (1999). relationships among adolescent girls’ eating behaviors and their parents’ weight-related attitudes and behaviors. sex roles, 41(3-4), 169-187. https://doi.org/10.1023/a:1018850111450 who multicentre growth reference study group. (2006). who child growth standards: length/ height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-forage: methods and development. geneva, switzerland: world health organization. zuba, a., & warschburger, p. (2017). the role of weight teasing and weight bias internalization in psychological functioning: a prospective study among school-aged children. european child and adolescent psychiatry, 26(10), 1245-1255. https://doi.org/10.1007/s00787-017-0982-2 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. the paths to children’s disordered eating 16 clinical psychology in europe 2020, vol.2(1), article e2689 https://doi.org/10.32872/cpe.v2i1.2689 https://doi.org/10.1007/bf03404273 https://doi.org/10.1002/1098-108x(199511)18:3<221::aid-eat2260180304>3.0.co;2-d https://doi.org/10.1016/j.ehb.2012.04.011 https://doi.org/10.1186/1479-5868-5-15 https://doi.org/10.1080/10640260214507 https://doi.org/10.1023/a:1018850111450 https://doi.org/10.1007/s00787-017-0982-2 https://www.psychopen.eu/ the paths to children’s disordered eating (introduction) method participants procedure measures results mean comparisons path analyses discussion conclusion (additional information) funding competing interests acknowledgments references long-term stability of benefits of cognitive behavioral therapy for obsessive compulsive disorder depends on symptom remission during treatment research articles long-term stability of benefits of cognitive behavioral therapy for obsessive compulsive disorder depends on symptom remission during treatment björn elsner a, frieder wolfsberger a, jessica srp a, antonia windsheimer a, laura becker a, tanja jacobi a, norbert kathmann a, benedikt reuter a [a] department of psychology, humboldt-universität zu berlin, berlin, germany. clinical psychology in europe, 2020, vol. 2(1), article e2785, https://doi.org/10.32872/cpe.v2i1.2785 received: 2019-09-03 • accepted: 2020-02-04 • published (vor): 2020-03-31 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: björn elsner, humboldt-universität zu berlin, rudower chaussee 18, 12489 berlin, germany, tel.: 0049 30 2093-9338. e-mail: bjoern.elsner@hu-berlin.de abstract background: cognitive behavioral therapy (cbt) is an effective treatment for obsessivecompulsive disorder (ocd) and may afford stable long-term improvements. it is not clear, however, how stability or symptom recurrence can be predicted at the time of termination of cbt. method: in a 1-year follow-up intention-to-treat study with 120 ocd patients receiving individual cbt at a university outpatient unit, we investigated the predictive value of international consensus criteria for response only (y-bocs score reduction by at least 35%) and remission status (y-bocs score ≤ 12). secondly, we applied receiver-operating characteristic (roc) curves in order to find an optimal cut-off score to classify for deterioration and for sustained gains. results: response only at post-treatment increased the likelihood of deterioration at follow-up compared to remission at an odds ratio of 8.8. moreover, roc curves indicated that a posttreatment score of ≥ 13 differentiated optimally between patients with and without symptom deterioration at follow-up assessment. the optimal cut-off score to classify for any sustained gains (response, remission, or both) at follow-up relative to baseline was 12. importantly, previous findings of generally high long-term symptom stability after treatment in ocd could be replicated. conclusion: the findings highlight the clinical importance of reaching remission during cbt, and suggest that a recently published expert consensus for defining remission has high utility. keywords obsessive-compulsive disorder, y-bocs, cut-off score, expert consensus, follow-up this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i1.2785&domain=pdf&date_stamp=2020-03-31 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • a 1-year follow-up study with ocd patients having received a cbt trial was conducted. • achieving a y-bocs score ≤ 12 at termination of treatment decreases the risk of future deterioration. • the study supports a rationale to treat ocd patients until reaching remission status. • the study confirms the criterion for remission in ocd recently published as an expert consensus. cognitive behavioral therapy (cbt) is an effective treatment for obsessive-compulsive disorder (ocd). its efficacy in randomized-controlled trials (rct; olatunji, davis, powers, & smits, 2013; öst, havnen, hansen, & kvale, 2015) and its effectiveness in routine clinical practice (hans & hiller, 2013) have been confirmed in meta-analyses. according to follow-up data, treatment gains are largely maintained after treatment, but in randomized controlled trials, slight increases of average symptom scores from post-treatment to follow-up are observed at group level (olatunji et al., 2013; öst et al., 2015). however, follow-up data from routine care are still rare, especially for individual outpatient therapy (cabedo, carrió, & belloch, 2018; hans & hiller, 2013; hansen, kvale, hagen, havnen, & öst, 2019). the yale-brown obsessive-compulsive scale (y-bocs) interview (goodman et al., 1989a; goodman et al., 1989b) has been established as the "gold standard" to measure ocd symptom severity, and is commonly used as a primary outcome measure (öst et al., 2015). effect sizes based on y-bocs group mean scores are therefore useful for com‐ parisons between studies and interventions, and allow observing within-group changes. however, group mean scores do not reflect individual improvement (hiller, schindler, andor, & rist, 2011; jacobson, follette, & revenstorf, 1984), which is especially important in research on routine clinical practice. in order to address this issue, jacobson and truax (1991) proposed a definition of clinically significant improvement by combining statistically significant changes in individual symptoms (reliable change index, rci) with subclinical symptom levels. this makes it possible to determine individual response (without remission), remission, and deterioration. since clinically significant change de‐ pends on the reliability of the measure and the variance in the relevant population, cut-off scores for remission varied between 7 and 16 across published studies (öst et al., 2015). subsequently, mataix-cols et al. (2016) published an international expert consensus on change assessment in ocd, in which treatment response was defined as a reduction in y-bocs scores by at least 35% and an improvement score of 1 (“very much improved”) or 2 (“much improved”) on the clinical global impression scale (cgi, guy, 1976). for remission, a y-bocs score of < 13 and cgi severity ratings of 1 (“normal, long-term stability of cbt benefits in ocd 2 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ not at all ill”) or 2 (“borderline mentally ill”) must be achieved. these criteria have been adopted in recent research (hansen et al., 2019) and may prove influential for future clinical decisions in ocd treatment. yet, it remains unclear whether these consensus criteria have clinical utility and are able to predict individual long-term stability. prediction of post-treatment response and remission on the basis of pre-treatment y-bocs scores has been investigated by means of signal detection analyses (farris, mclean, van meter, simpson, & foa, 2013). criteria evaluation for predicting outcome at follow-up, however, is missing. prospective studies on depressive disorder and social phobia suggest that incomplete remission at post-treatment predicts relapse at follow-up (judd et al., 1998; paykel et al., 1995; van ameringen et al., 2003). in line with these results, two studies with ocd patients have shown that “partial remission” compared to “full remission” at the end of treatment predicts relapse during follow-up periods of one to five years (braga, cordioli, niederauer, & manfro, 2005; braga, manfro, niederauer, & cordioli, 2010; eisen et al., 2013). one of these studies (eisen et al., 2013), however, did not use y-bocs scores for the evaluation of clinical status. in the other, full remission required a y-bocs score of < 8 (braga et al., 2005; braga et al., 2010), which is much stricter than the consensus y-bocs cut-off score for remission (≤ 12). it is therefore unclear whether the protective effect of “full remission” can also be found when apply‐ ing the less strictly defined remission criterion. prediction of long-term stability is of major importance for clinical practice, because under routine conditions the criterion for terminating individual psychotherapy is often not specified in advance. treatment may be continued until a “good enough level” (gel) is achieved (barkham et al., 2006; falkenström, josefsson, berggren, & holmqvist, 2016), which is often defined subjectively by patient and therapist. clinical decisions, however, should also be informed by empir‐ ical research. in addition to testing the predictive value of categorical variables such as remission or response, it is also worthwhile to determine the exact post-treatment y-bocs scores that separate patients with stable treatment gains from those with loss of gains in the follow-up period, or patients with long-term improvements in relation to pre-treatment levels from those without such improvements. if good prediction is possible on the basis of a single, widely-used and easy-to-apply instrument, the cut-off scores can inform clinical decisions on whether to terminate or to continue cbt. in the present study, we conducted a 1-year follow-up assessment in a relatively large sample of ocd patients, who had received individual cbt under routine conditions of the german health care system. our main goals were: 1.) testing whether patients achieving the consensus y-bocs cut-off score for remission at post-treatment are less likely to experience significant symptom increase at follow-up compared to unremitted responders, 2.) determining a post-treatment y-bocs cut-off score that differentiates optimally between patients who deteriorate from post-treatment to follow-up and those whose initial improvement remains stable, and 3.) determining a post-treatment y-bocs cut-off score that predicts for any sustained gains (response, remission, or both) at elsner, wolfsberger, srp et al. 3 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ follow-up. a secondary aim was to provide further data for evaluations of average and individual symptom changes from preand post-treatment to follow-up in a treatment setting typical for routine care in many countries. method participants study participants had terminated individual cognitive behavioral therapy (cbt) at a uni‐ versity outpatient unit (hochschulambulanz für psychotherapie und psychodiagnostik der humboldt-universität zu berlin) between december 2013 and may 2017. referrals to the outpatient unit were made according to routine clinical care procedures. patients who prematurely discontinued cbt (non-completers) were not excluded and the last observation was carried forward to estimate post-treatment scores (interim-assessments were done every 20 sessions). general study inclusion criteria were: primary diagnosis of ocd, age between 18 and 70 years, and a minimum pre-treatment y-bocs total score of 16. due to general admission policies of the outpatient unit, patients with comorbid psychotic disorders, borderline personality disorder, or substance dependency (life time) were not referred. three patients were excluded from analysis due to missing y-bocs-data at both preand post-treatment. during the study period, a total of 207 patients fulfilled the inclusion criteria and were contacted by telephone for follow-up assessments. among these, 51 (24.6%) patients could not be reached and 36 (17.4%) declined to participate. 120 patients participated in the phone interview (58.0% of the total sample), and 96 of them completed additional online questionnaires (46.4% of the total sample). participants (n = 120, 75 female, 104 therapy completers) and non-participants (n = 87, 49 female, 70 therapy completers) in the follow-up interview did not differ significantly in terms of gender (p = .392), therapy completer status (p = .252), or other demographic and clinical variables (see table 1). for both participants and non-participants, the most common comorbid mental disorders were present or remitted depressive disorders and anxiety disorders. twenty-four patients of the total sample suffered from personality disorders (see table 2). 73 patients took psychotropic medications at admission (35.3%), 55 at post-treatment (26.6%); the most common medications were selective serotonin reuptake inhibitors (ssris) and other antidepressants. the study protocol was approved by the local review board of humboldt-universität zu berlin (protocol number 2016-33) and met the ethical standards of the revised declaration of helsinki. all participants provided written informed consent. long-term stability of cbt benefits in ocd 4 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ table 1 demographic and clinical variables of participants and non-participants in follow-up assessments variable participants assessment tfu non-participants assessment tfu t-test for independent samples n m (sd) n m (sd) df t p age 120 32.3 (9.5) 87 31.5 (9.9) 181.0 0.59 .558 age of symptom onset 109 17.1 (8.8) 81 17.1 (7.6) 183.2 0.02 .986 age of disorder onset 110 23.1 (9.6) 78 22.4 (8.5) 117.3 0.58 .558 duration of therapy (hours) 119 41.0 (17.6) 87 42.3 (20.7) 167.4 -0.45 .653 socio-economic status 112 9.6 (3.7) 79 9.2 (4.2) 154.2 0.77 .443 gaf tpre 118 55.8 (10.1) 86 53.3 (11.2) 171.0 1.66 .099 y-bocs tpre 120 23.3 (4.6) 87 24.4 (4.7) 182.0 -1.74 .083 y-bocs tpost 120 11.9 (7.3) 87 13.7 (7.7) 178.8 -1.69 .092 oci-r tpre 118 27.1 (13.0) 87 29.4 (12.4) 190.1 -1.31 .193 oci-r tpost 120 14.4 (12.0) 85 17.7 (13.5) 167.2 -1.78 .078 bdi-ii tpre 119 18.9 (11.2) 87 20.4 (10.8) 188.8 -0.97 .336 bdi-ii tpost 120 9.8 (8.7) 84 10.9 (11.3) 148.6 -0.78 .438 bsi-gsi tpre 119 0.98 (0.5) 87 1.01 (0.6) 178.0 -0.37 .712 bsi-gsi tpost 120 0.60 (0.5) 85 0.70 (0.6) 163.2 -1.17 .245 note. gaf = global assessment of functioning; y-bocs = yale-brown obsessive-compulsive scale interview score; oci-r = obsessive compulsive inventory revised; bdi-ii = beck depression inventory ii; bsi-gsi = global severity index of the brief symptom inventory; pre = pre-treatment; post = post-treatment; fu = 1-year follow-up. table 2 most common comorbid mental disorders and medication status at tpre and tpost. condition participants assessment tfu non-participants assessment tfu n % n % ≥ 1 comorbid mental disorder 76 63.3 51 58.6 present depressive disorder 40 33.3 29 33.3 remitted depressive disorder 28 23.3 20 23.0 any anxiety disorder 41 34.2 15 17.2 personality disorder 12 10.0 12 13.8 psychotropic medications tpre 45 37.5 28 32.2 psychotropic medications tpost 35 29.2 20 23.0 note. pre = pre-treatment; post = post-treatment; fu = 1-year follow-up. elsner, wolfsberger, srp et al. 5 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ treatment cbt was administered by nineteen licensed psychotherapists, who had completed at least three years of training in cbt. treatments were bound to the general conditions for psychotherapy in the public german health care system. the legal framework allowed up to 66.7 hours (80 units of 50 minutes each) per treatment. therapists were instruc‐ ted to apply cbt including exposure and response prevention (erp) according to the national guideline for evidence-based treatment (hohagen, wahl-kordon, lotz-rambaldi, & muche-borowski, 2014). adherence was not formally controlled and treatment was not manualized, but therapists received weekly supervision by one of four experienced cbt therapists. therapy sessions usually lasted 50 minutes and took place once or twice weekly, yet therapists were free to adjust session length when implementing exposure and to reduce session frequency at the end of treatment. treatment was terminated by consensus of patient and therapist based on clinical criteria. patients who abandoned treatment without the approval of their therapist were classified as non-completers. assessment one-year follow-up status of patients (tfu) was assessed by telephone-based interviews and internet-based self-report questionnaires. analyses also included data from routine assessments at admission (tpre) and termination of therapy (tpost), and for non-completers, from interim-assessments. telephone interviews were conducted by trained master level psychology students, who were supervised by an experienced psychotherapist (b.r.). interviews included the german version of the y-bocs interview to assess ocd symptom severity (goodman et al., 1989a; goodman et al., 1989b; hand & büttner-westphal, 1991). internet-based assessments included the obsessive compulsive inventory revised (oci-r, foa et al., 2002) as a secondary outcome measure of ocd symptoms, the beck depression invento‐ ry ii (bdi-ii, beck, steer, & brown, 1996) to measure current depression, and the brief symptom inventory (bsi, derogatis & melisaratos, 1983) to assess general psychological distress using its global severity index. routine assessments at admission (tpre) included the german version of the struc‐ tured clinical interviews for dsm-iv mental disorders and personality disorders (scid-i, scid-ii, first, gibbon, spitzer, williams, & benjamin, 1997; first, spitzer, gibbon, & williams, 1995), and a socio-economic status scale (lampert & kroll, 2009). in order to assess symptom course, y-bocs interview, oci-r, bdi-ii, bsi, the clinical global impression scale (cgi, guy, 1976) and the global assessment of functioning (gaf, jones, thornicroft, coffey, & dunn, 1995) were administered before the first and after the final therapy session. interim assessments were conducted every 20 sessions and used to estimate post-treatment data for non-completers without post-treatment assessments (n = 10; last-observation-carried-forward method). interim assessments were also used long-term stability of cbt benefits in ocd 6 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ to estimate post-treatment scores for four therapy completers with missing data. all clinical interviews at admission and post-treatment were conducted by trained clinical psychologists. data analysis we analyzed data using r version 1.0.44. participants and non-participants were com‐ pared using independent two sample t-tests (two-sided). fisher’s exact test was applied to compare nominal data. effect sizes were calculated using cohen’s d with pooled standard deviations. changes over time were compared with paired t-tests (two-sided). we used the expert consensus criteria (mataix-cols et al., 2016) for y-bocs scores to define remission (total score ≤ 12), response (reduction ≥ 35%), and non-response (reduction < 35%), but did not apply the cgi improvement scale (see also hansen et al., 2019). we used the reliable change index (rci, jacobson et al., 1984) to define statistically meaningful deterioration (e.g. bablas, yap, cunnington, swieca, & greenwood, 2016; han, geffen, browning, kenardy, & geffen, 2011; kraus, castonguay, boswell, nordberg, & hayes, 2011). to calculate the rci, an internal consistency of α = .79 (moritz et al., 2002) was used as the reliability of the y-bocs. stability was defined as the absence of significant deterioration. logistic regression analysis was used to contrast response with‐ out remission (response only) and remission at post-treatment to predict deterioration at follow-up. as we were interested in stability after initial improvement, patients with no response during treatment were not considered in this analysis. additionally, we ap‐ plied receiver-operating characteristic (roc) curves using r package optimalcutpoints (lópez-ratón, rodríguez-álvarez, cadarso-suárez, & gude-sampedro, 2014) in order to find the best post-treatment y-bocs score classifying for deterioration versus stability at follow-up. roc curves were also used to find the optimal post-treatment cut-off score classifying for sustained gains (response, remission, or both; n = 77) at follow-up. the score that reached a maximum youden index (j = sensitivity + specificity 1; youden, 1950) was considered as optimal cut-off. results average symptom change on group level, the y-bocs score decreased significantly from pre-treatment to posttreatment, t(119) = 17.23, p < .001, with a mean reduction of 11.4 points and a large effect size of cohen’s d = 1.87 (figure 1a, table 3). symptom severity was also significantly reduced from pre-treatment to one-year follow-up, t(119) = 13.75, p < .001, d = 1.46. the increase of the mean y-bocs score from post-treatment to follow-up was small, but close to significance, t(119) = -1.79; p = .076, d = -0.12 (see figure 1a). elsner, wolfsberger, srp et al. 7 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ figure 1 average and individual symptom change note. a) mean y-bocs total scores at pre-treatment (tpre), post-treatment (tpost) and follow-up (tfu). b) individual remission, response only and non-response at post-treatment (according to the expert consensus) and significant deterioration (according to reliable change index) from post-treatment to follow-up. error bars indicate standard deviations. ***p < .001. similarly, secondary outcome parameters showed significant reductions from pre-treat‐ ment to post-treatment (oci-r: t(234) = 7.82; p < .001, d = 1.01; bdi-ii: t(222.99) = 7.03; p < .001, d = 0.91 and bsi-gsi: t(236.01) = 5.62; p < .001, d = 0.73), and from pre-treatment to follow-up (oci-r: t(208.32) = 8.40, p < .001, d = 1.14; bdi-ii: t(196.88) = 4.15; p < .001, d = 0.57; and bsi-gsi: t(207.95) = 5.21; p < .001, d = 0.71). no significant change from post-treatment to follow-up was observed for oci-r, t(205.13) = 0.83, p = .409, d = 0.11; for bdi-ii, t(168.30) = -1.71, p = .089, d = -0.24; and for bsi-gsi, t(204.06) = -0.12, p = .903, d = -0.02; (see table 3). long-term stability of cbt benefits in ocd 8 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ table 3 mean differences and effect sizes from pre-treatment and post-treatment to follow-up measure nfu mfu (sd) mpost (sd) dpost-fu mpre (sd) dpre-fu y-bocs 120 12.9 (9.0) 11.9 (7.3) -0.12 23.3 (4.6) 1.46 oci-r 94 13.1 (11.3) 14.4 (12.0) 0.11 27.1 (13.0) 1.14 bdi-ii 96 12.3 (12.0) 9.8 (8.7) -0.24 18.9 (11.2) 0.57 bsi-gsi 96 0.61 (0.5) 0.60 (0.5) -0.02 0.98 (0.5) 0.71 note. y-bocs = yale-brown obsessive-compulsive scale interview score; oci-r = obsessive compulsive inventory revised; bdi-ii = beck depression inventory ii; bsi-gsi = global severity index of the brief symptom inventory; pre = pre-treatment; post = post-treatment; fu = 1-year follow-up. individual improvement the course of symptoms from pre-treatment to post-treatment and follow-up was het‐ erogeneous across patients (figure 1b). table 4 displays the numbers of patients with non-response, response without remission (response only), and remission at post-treat‐ ment and follow-up. adopting the rci for deterioration, table 5 shows the numbers of participants with y-bocs score stability and deterioration at follow-up broken down by their outcome category at post-treatment. the relationship between outcome category (remission, response only, non-response) at post-treatment and stability at follow-up is illustrated in figure 1b. table 4 number of non-responders, responders without remission and remitters for post-treatment and follow-up outcome category at tpost outcome category at 1-year follow-up (tfu) no response response only remission σpost no response 27 3 7 37 (30.8%) response only 8 4 2 14 (11.7%) remission 8 9 52 69 (57.5%) σfu 43 (35.8%) 16 (13.3%) 61 (50.8%) 120 (100%) note. response only = response without remission; post = post-treatment; fu = 1-year follow-up. elsner, wolfsberger, srp et al. 9 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ table 5 change during follow-up: number of stable and deteriorated participants at follow-up broken down by their outcome category at post-treatment outcome category at tpost change during 1-year follow-up (tfu) stability deterioration σpost no response 34 3 37 (30.8%) response only 10 4 14 (11,7%) remission 66 3 69 (57.5%) σfu 110 (91.7%) 10 (8.3%) 120 (100%) note. response only = response without remission; post = post-treatment; fu = 1-year follow-up. prediction of long-term outcomes compared to remission, response only significantly predicted deterioration at follow-up (b = 2.17, se = 0.84, χ2(1) = 6.58, p = .010, odds ratio (or) = 8.8, ci = 1.71 50.65, wald χ2 = 6.77, p = .009). nagelkerke's r-squared of this model was .174 (hosmer-lemeshow r2 = .137, cox-snell r2 = .076). the inclusion of y-bocs scores at pre-treatment as predictor did not improve the model significantly, b = 0.13 (se = 0.11), p = .235. initial y-bocs scores did not predict deterioration, or = 1.1 (ci = 0.92 1.44, wald χ2 = 1.41, p = .245). cut-off scores the y-bocs score at post-treatment that best predicted significant deterioration versus stability was 13 (sensitivity = .70; specificity = .60), indicating that participants with a score higher than or equal to 13 were more likely deteriorated at follow-up (see figure 2a). interestingly, the optimal cut-off score predicting sustained gains (relative to baseline) was 12 (sensitivity = .83; specificity = .78), suggesting that a y-bocs score of 12 or less at the time of treatment termination predicts sustained benefits at one year follow-up (see figure 2b). long-term stability of cbt benefits in ocd 10 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ figure 2 cut-off points on the y-bocs note. receiver-operating characteristic (roc) curves with optimal cut-off points on the y-bocs at post-treatment to classify a) for deterioration (vs. stability) at follow-up and b) for sustained gains (response, remission, or both) at follow-up. auc = area under the roc curve. medication and subsequent outpatient therapy sixty-seven patients were free of psychotropic medications from post-treatment to fol‐ low-up. twenty patients discontinued medications after post-treatment, but seven of them were again medicated at follow-up. thirty patients were medicated continuously from post-treatment to follow-up. for three patients, data about medication at follow-up was missing. most common were ssris (n = 33). a significant association between medication status (no medication, discontinued, discontinued and medicated again, con‐ tinuously medicated) and outcome category at follow-up was observed (p = .015), with higher remission rates for medication-free patients and discontinuers (61.2% and 69.2%) than for continuously medicated patients (26.7%). no significant association could be observed for medication status and deterioration (p = .402) at follow-up assessment. eighteen patients sought additional outpatient therapy of more than five sessions after post-treatment. subsequent therapy was neither correlated with outcome category at post-treatment (p = .067), nor at follow-up assessment (p = .086), but at both assess‐ ment points, patients without remission sought additional therapy more frequently than remitters on a trend level. elsner, wolfsberger, srp et al. 11 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ discussion the present study aimed to examine whether remission status and symptom levels at post-treatment are predictive for long-term stability of improvements after cognitive be‐ havioral therapy for ocd. in addition, we intended to evaluate the general effectiveness of individual cognitive behavioral therapy in a sample of 120 patients by conducting a follow-up assessment one year after termination of treatment in routine clinical practice. applying the recently published y-bocs consensus criteria (mataix-cols et al., 2016) to classify patients as non-responders, responders, or remitters showed that response only at post-treatment was associated with a significantly higher likelihood for deteriora‐ tion. among the patients who benefited from cbt, those who achieved remission by the end of treatment had a considerably higher chance of maintaining initial improvement. given the fact that stability and deterioration were defined by absence or presence of reliable changes (rci), the criterion variable was not confounded with the consensus criteria. while similar findings have been shown in previous studies, these applied different remission criteria (braga et al., 2005; braga et al., 2010; eisen et al., 2013). to our knowledge, the present findings are the first to show the predictive value of the consensually recommended y-bocs cut-off score, and thus confirm its validity in terms of long-term stability. considering that different cut-off scores have proven to predict long-term stability, we sought to determine a y-bocs score at post-treatment that best predicts deterioration versus stability one year later. receiver-operating characteristic (roc) curves pointed to a cut-off point of ≥ 13 for classifying for future deterioration. as stability until follow-up may not be sufficient to assume long-term improvement, we finally determined a cut-off score to classify for sustained benefits at follow-up relative to pre-treatment. the result‐ ing cut-off score of ≤ 12 implies that patients with a y-bocs score of twelve or lower at post-treatment are likely to show long-term therapy benefits compared to patients with higher scores. notably, the identified critical symptom levels are almost identical to the proposed expert consensus cut-off score for remission. these findings highlight the utility of a y-bocs cut-off score of ≤ 12 for defining remission status at post-treatment and add to previous evidence that subthreshold symp‐ tom severity protects patients with mental disorders from later deterioration (braga et al., 2005; braga et al., 2010; judd et al., 1998; paykel et al., 1995; van ameringen et al., 2003). the results have implications for both etiological models and clinical practice. differ‐ ent etiological models (kalanthroff, abramovitch, steinman, abramowitz, & simpson, 2016; robbins, gillan, smith, de wit, & ersche, 2012; salkovskis, 1999) emphasize that compulsions contribute to the maintenance or worsening of symptoms. a reduction of symptom severity below a critical threshold may therefore weaken these dynamics. in clinical practice, the question of how to proceed if patients achieve response but not remission during the scheduled duration of psychotherapy is central. ethical considera‐ tions may support continuation of treatment until remission is achieved. however, while long-term stability of cbt benefits in ocd 12 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ there is research on treatment of non-responders to pharmacological therapy (albert et al., 2018; denys, van megen, van der wee, & westenberg, 2004; pallanti, hollander, & goodman, 2004), there is little data on the treatment of patients who failed to reach remission status during cbt. as we observed large effect sizes for pre-post (d = 1.87) and pre-fu (d = 1.46) periods, we were able to confirm previous findings of long-term effectiveness of indi‐ vidual outpatient cbt in ocd (cabedo et al., 2018; hans & hiller, 2013; hansen et al., 2019). although our results suggest that reduced symptom levels are maintained from post-treatment to follow-up, we did observe a slight, non-significant increase in symptoms. recurrence of ocd symptoms after treatment termination has been found in previous follow-up studies (anderson & rees, 2007; barrett, healy-farrell, & march, 2004; bolton & perrin, 2008), yet not consistently (rufer et al., 2005). the slight increase in the present study may be explained by inferior long-term symptom stability of the small group of patients that achieved response without remission: while most patients who remitted (75.4%) or did not respond (73.0%) at post-treatment remained in the same outcome category at follow-up, only 28.6% of responders remained in this category one year later. very few patients with response (without remission) at post-treatment achieve remission one year later (14.3%), which illustrates again that response only at post-treatment indicates insufficient treatment. one limitation of the present study stems from the treatment setting under routine conditions. particularly, treatment did not follow a specific manual and therapy adher‐ ence was not controlled. the mean duration of therapy was longer than in most rcts. note, however, that “high intensity interventions” with more than 30 therapist-hours per patient have been found to yield superior effect sizes for treatment outcome compared to low and medium intensity (national collaborating centre for mental health, 2006). in the present study, the relatively long duration results from individual treatment planning, consideration of comorbid disorders, and termination of treatment on the basis of a consensual decision of patient and therapist. the duration is comparable to the average duration of outpatient psychotherapy in the public health care system in germany (lutz, wittmann, böhnke, rubel, & steffanowski, 2012). thus, our data derive from treatment conditions that are typical for the german and similar health care systems and may provide high ecological validity. sample size constitutes another limitation, as, at post-treatment, we observed only 14 patients in the category of response without remission, and only ten participants with deterioration at follow-up. although, considering the large number of remitted patients that indicates an overall very successful treatment, larger sample sizes would increase the statistical power of predictions of critical subgroups. future follow-up studies should also address life events, other therapies, and medications that may influence symptom stability. furthermore, longer follow-up intervals might enable us to make conclusions about predictors of long-term treatment benefits. elsner, wolfsberger, srp et al. 13 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://www.psychopen.eu/ in summary, the present results suggest that the symptom level reached when termi‐ nating treatment is critical for the future course of illness. a post-treatment y-bocs score < 13 optimally predicts higher individual likelihood for stability one year later. this cut-off almost perfectly fits with the expert consensus criterion for remission of ocd. thus, such a remission criterion may be a useful instrument in aiding decision making in routine clinical practice, in particular for terminating or continuing treatment. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors. competing interests: the authors have declared that no competing interests exist. acknowledgments: we thank katharina schwaiger for language editing. references albert, u., marazziti, d., di salvo, g., solia, f., rosso, g., & maina, g. 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(1999). understanding and treating obsessive-compulsive disorder. behaviour research and therapy, 37(suppl 1), s29-s52. https://doi.org/10.1016/s0005-7967(99)00049-2 van ameringen, m., allgulander, c., bandelow, b., greist, j. h., hollander, e., montgomery, s. a., . . . swinson, r. p. (2003). wca recommendations for the long-term treatment of social phobia. cns spectrums, 8(8, suppl. 1), 40-52. https://doi.org/10.1017/s1092852900006933 youden, w. j. (1950). index for rating diagnostic tests. cancer, 3(1), 32-35. https://doi.org/10.1002/1097-0142(1950)3:1<32::aid-cncr2820030106>3.0.co;2-3 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. long-term stability of cbt benefits in ocd 18 clinical psychology in europe 2020, vol.2(1), article e2785 https://doi.org/10.32872/cpe.v2i1.2785 https://doi.org/10.1007/s00406-004-0544-8 https://doi.org/10.1016/s0005-7967(99)00049-2 https://doi.org/10.1017/s1092852900006933 https://doi.org/10.1002/1097-0142(1950)3:1<32::aid-cncr2820030106>3.0.co;2-3 https://www.psychopen.eu/ long-term stability of cbt benefits in ocd (introduction) method participants treatment assessment data analysis results average symptom change individual improvement prediction of long-term outcomes cut-off scores medication and subsequent outpatient therapy discussion (additional information) funding competing interests acknowledgments references an overview of the evidence for psychological interventions for psychosis: results from meta-analyses scientific update and overview an overview of the evidence for psychological interventions for psychosis: results from meta-analyses tania m. lincoln a, anya pedersen b [a] institute of psychology, universität hamburg, hamburg, germany. [b] institute of psychology, christian-albrechtsuniversität, kiel, germany. clinical psychology in europe, 2019, vol. 1(1), article e31407, https://doi.org/10.32872/cpe.v1i1.31407 received: 2018-11-06 • accepted: 2019-02-13 • published (vor): 2019-03-29 handling editor: winfried rief, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany corresponding author: tania m. lincoln, universität hamburg, institut für psychologie, klinische psychologie und psychotherapie, von-melle-park 5, 20146 hamburg, germany. e-mail: tania.lincoln@uni-hamburg.de abstract background: there are numerous psychological approaches to psychosis that differ in focus, specificity and formats. these include psychodynamic, humanistic, cognitive-behavioural and third-wave-approaches, psychoeducation, various types of training-based approaches and family interventions. method: we briefly describe the main aims and focus of each of these approaches, followed by a review of their evidence-base in regard to improvement in symptoms, relapse and functioning. we conducted a systematic search for meta-analyses dating to 2017 for each of the approaches reviewed. where numerous meta-analyses for an approach were available, we selected the most recent, comprehensive and methodologically sound ones. results: we found convincing shortand long-term evidence for cognitive behavioural approaches if the main aim is to reduce symptom distress. evidence is also strong for psychoeducative family interventions that include skills training if the main aim is to reduce relapse and rehospitalisation. acceptance and commitment therapy, mindfulness-based approaches, meta-cognitive and social skills training, as well as systemic family interventions, were also found to be efficacious, depending on the outcome of interest, but meta-analyses for these approaches were based on a comparatively lower number of outcome studies and a narrower selection of outcome measures. we found no convincing evidence for psychodynamic approaches, humanistic approaches or patient-directed psychoeducation (without including the family). conclusions: an array of evidence-based psychological therapies is available for psychotic disorders from which clinicians and patients can choose, guided by the strength of the evidence and depending on the outcome area focused on. increased effort is needed in terms of dissemination and implementation of these therapies into clinical practice. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i1.31407&domain=pdf&date_stamp=2019-03-29 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords psychosis, schizophrenia, psychological therapy, intervention, evidence highlights • meta-analyses show convincing evidence for cbt if the main target is psychotic symptoms. • meta-analyses show convincing evidence for family interventions if the main target is relapse. • effects are promising for act, mindfulness-based and systemic approaches, but more research is needed. • the array of effective approaches allows clinicians and patients to select the most appropriate one. patients with psychotic disorders often face a diverse and complex set of problems. one part of these problems are the symptoms as such. these include persecutory delusions, hearing voices and feeling driven, or negative symptoms, such as the loss of drive. not only do these symptoms tend to cause severe distress (lincoln, 2007; woodward et al., 2014), they can also be accompanied by an array of interpersonal problems or social withdrawal (depp et al., 2016; mondrup & rosenbaum, 2009). accordingly, relatives and other people involved also often report difficulties in communication or feeling helpless (treanor, lobban, & barrowclough, 2013). moreover, an acute episode that might have in‐ volved voluntary or involuntary hospitalisation can be traumatizing (paksarian et al., 2014) and many patients and relatives report continuous worry about possible relapse (gumley et al., 2015; lal et al., 2019). unsurprisingly, therefore, many patients and their relatives seek professional help. since the discovery of antipsychotic drugs in the early 1950s, this help has been pri‐ marily pharmacological in nature. although medication is valuable in the acute phase, the effect sizes in randomised trials for medication alone are only small to moderate (leucht et al., 2012) and may come at the cost of disadvantageous long-term side effects (murray et al., 2016). also, medication is not well accepted by many patients (wade, tai, awenat, & haddock, 2017). based on the requirement to inform evidence-based additions and alternatives to antipsychotic medication (morrison, hutton, shiers, & turkington, 2012), and an increasingly better understanding of the psychological mechanisms that cause and maintain psychotic symptoms (for a comprehensive and service-user oriented overview of this research see cooke, 2014) different psychological approaches have been developed over the past decades. these differ in their focus and formats, but ultimately all aim to help patients to either overcome or to cope better with symptoms and to im‐ prove functioning and well-being. psychological interventions for psychosis 2 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ methods of the review the scope of the present review covers the efficacy of different psychological approaches for psychosis offered in combination with pharmacotherapy as reflected in meta-analy‐ ses. a systematic search for methodologically sound meta-analyses via web of science, psycinfo, psyndex, and medline was conducted to establish a german guideline for the psychological treatment of schizophrenia and psychotic disorders (lincoln, pedersen, hahlweg, wiedl, & frantz, 2019). this guideline was initiated by the german society for clinical psychology and psychotherapy as an adjunct to the s-3 german guideline, which has a broader focus. considering recommendations by the association of the scientific medical societies in germany (awmf), evidence derived for the different psychological approaches is based on recent meta-analyses including well-conducted randomised con‐ trolled trials (rcts). starting out from the comprehensive meta-analysis on the treatment and management of psychosis and schizophrenia in adults (national collaborating centre for mental health [nccmh], 2014 [update]) conducted for the nice-guidelines (national institute for health and care excellence) in 2009 we searched the literature from 2010 to 2017 for additional meta-analyses (note. the guideline covered research un‐ til 2016. for the present overview we updated this search to cover meta-analyses publish‐ ed up to the end of 2017). when a psychological approach was not covered in the niceguidelines (nccmh, 2014), we additionally searched for meta-analyses published before 2010. the identified meta-analyses were critically appraised for methodological quality as well as overlap and we selected the most recent, comprehensive and methodologically sound analyses (e.g. conducted by the cochrane collaboration or other independent re‐ searchers). a complete list of the reviewed and selected meta-analyses is added in the appendix. meta-analyses were included if they focused on schizophrenia, delusional dis‐ orders, schizoaffective disorders and acute and transient psychotic disorders following dsm-iii-r, dsm-iv or dsm-5 criteria. the outcome measures covered include improvement in symptoms (overall symp‐ toms, positive symptoms and negative symptoms), relapse rates and rehospitalisations as well as psychosocial functioning. psychological approaches reviewed covered individual and group interventions con‐ ducted within inand out-patient settings. we report the effectiveness of each approach on the basis of randomised-controlled trials that compared the approach either to the usual treatment (tau; e.g. pharmacotherapy and consultation) condition alone or to a tau plus an active control condition (e.g. supportive therapy or psychoeducation) at post-treatment and/or at follow-up (ranging from weeks to years). in order to be able to compare the effectiveness of these approaches we focus on comparisons to “any control”, because meta-analyses on approaches which have not been comprehensively investigated often do not differentiate between comparisons to tau versus active controls. only ef‐ fect sizes based on at least two independent original studies were considered. lincoln & pedersen 3 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ description of the reviewed approaches and their respective evidence basis cognitive behavioural therapy for psychosis description cognitive behavioural interventions for psychosis (cbtp) build on the assumption that psychotic symptoms lie on a continuum with normal experiences. they are also informed by research suggesting that psychotic experiences result from normal, though exagger‐ ated, mechanisms of perception and reasoning. this understanding has formed the basis for cognitive models of psychosis. as one of the most influential of these models, garety, kuipers, fowler, freeman, & bebbington (2001) postulate that psychotic symptoms devel‐ op when stressors overload a person, causing them to have unusual experiences. accord‐ ing to this model, not the unusual experience itself is crucial but its appraisal. a variety of approaches within the cbtp-framework have been described (fowler, garety, & kuipers, 1995; morrison, renton, dunn, williams, & bentall, 2004). most descriptions converge in stressing the importance of building a stable therapeutic relationship through the process of listening and validating, of taking a collaborative approach and of working with an individual case formulation. the use of cognitive and behavioural inter‐ ventions for working with psychotic symptoms as well as for changing dysfunctional be‐ liefs and interventions to prevent relapse are also essential elements. evidence base beyond the nice-meta-analysis conducted in 2009 our review is based on seven further meta-analyses (burns, erickson, & brenner, 2014; jauhar et al., 2014; jones, hacker, cormac, meaden, & irving, 2012; lutgens, gariepy, & malla, 2017; turner, van der gaag, karyotaki, & cuijpers, 2014; van der gaag, valmaggia, & smit, 2014; velthorst et al., 2015) selected from a larger pool of 13 meta-analyses. as can be seen in table 1, with the exception of the cochrane-analysis by jones et al., (2012), the meta-analyses consistently detected small effects on overall symptoms at posttreatment and at various follow-up periods favouring cbtp over tau. the findings were less consistent, however, when cbtp was compared to active control. the picture is simi‐ lar for positive symptoms, with jones et al. (2012) reporting mixed findings, while the oth‐ er meta-analyses consistently revealed effects in favour of cbtp compared to tau, both at post-treatment and at follow-ups. again, the comparisons to active control groups were less consistent. for negative symptoms there were small post-therapy effects (jauhar et al., 2014; lutgens et al., 2017) and small follow-up effects (nccmh, 2014), overall, however, the non-significant findings outweighed the significant ones. relapse rates, re‐ hospitalisations and functioning were only investigated in two meta-analyses (jones et al., 2012; nccmh, 2014), and are based on a smaller number of studies. neither meta-analy‐ psychological interventions for psychosis 4 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ sis showed an effect on relapse and the effects for rehospitalisations and functioning were mixed. third-wave-approaches to psychosis description third-wave-approaches are new developments in cbt which emphasise the relevance of acceptance, mindfulness and emotions, the relationship, values, goals, and meta‐cogni‐ tion (hayes & hofmann, 2017). in psychosis, adaptations of mindfulness-based therapy, acceptance and commitment therapy (act) and compassion focused therapy (cft) have been studied most. in order to ease distress and achieve acceptance as well as to support the regaining of control, mindfulness-based interventions for psychosis guide patients to notice sensations and their own emotional and cognitive reactions to them with aware‐ ness (chadwick, 2014). in meditation-based practices, patients learn to observe their thoughts, feelings and symptoms in an accepting and non-judgmental way. mindfulness interventions for psychosis have been implemented as single treatments (e.g. chadwick, 2014) or combined with cbt (e.g. wright et al., 2014). in act (hayes, strosahl, & wilson, 1999) experiential avoidance and cognitive fusion are suggested to be the core processes of suffering. in order to increase psychological flexibility and reduce distress associated with psychotic symptoms, patients are guided to develop a balance between committed value-guided action when solving actual problems and acceptance when control of thoughts and feelings is limited (e.g. in the case of hallu‐ cinations). act has been adapted for the treatment of psychosis (o’donoghue, morris, oliver, johns, & hayes, 2018; combined with cbt, wright et al., 2014). compassion-focused therapy (cft, gilbert & procter, 2006) encourages patients to be more compassionate towards themselves and others while reducing shame and self-criti‐ cism. compassionate mind training includes appreciation and imagery exercises as well as aspects of mindfulness and aids the patient to experience different aspects of compas‐ sion in order to promote mental wellbeing. cft has been adapted for the treatment of psychosis (brähler, harper, & gilbert, 2013). evidence base we selected two (cramer, lauche, haller, langhorst, & dobos, 2016; louise, fitzpatrick, strauss, rossell, & thomas, 2018) from an identified pool of four meta-analyses. no metaanalysis reported effects-sizes for cft based on more than one original study, hence, on‐ ly mindfulness-based interventions and act are reviewed. both meta-analyses revealed no significant effect of act, but a significant small effect of mindfulness-based interventions on overall symptoms at post-treatment (cramer et al., 2016; louise et al., 2018). one meta-analysis analysed the effect at follow-up and reported an even increased effect (cramer et al., 2016). lincoln & pedersen 5 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ act showed a significant moderate effect on positive symptoms, but not on negative symptoms at post-treatment (cramer et al., 2016). the number of rehospitalisations was only investigated for act, revealing a signifi‐ cant small effect (based on two studies; cramer et al., 2016). relapse and functioning were not analysed. psychodynamic therapy for psychosis description early psychoanalytic conceptions of psychosis understand psychotic symptoms as a man‐ ifestation of the mind being invaded by the unconscious and by dreams (federn, 1928/1952). more contemporary approaches underline the importance of early relation‐ ship patterns (e.g. bion, 1962; winnicott, 1991). internal representations of experiences with significant others and current relationships are assumed to result in tension and psychotic symptoms are considered as a “constructive” way of dealing with this tension (von haebler & freyberger, 2013). psychodynamic therapy focuses on these processes and helps the patient to gain self-awareness and understanding of the influence of the past on present behaviour and it fosters new positive relationship experiences. an em‐ pathic, respectful and supportive attitude allows re-enactment of internalised relational patterns in the therapist-patient interaction (lempa, montag, & von haebler, 2013). evidence base we identified two meta-analyses. however, both the meta-analysis conducted for the nice-guidelines (nccmh, 2014) and the one of the cochrane collaboration (malmberg, fenton, & rathbone, 2001) were based on four original studies only. the aggregated data of the two analyses did not indicate significant improvement in overall symptoms, func‐ tioning (nccmh, 2014) or rehospitalisations (malmberg et al., 2001) in patients treated with psychodynamic therapy compared to any control. the inclusion criteria for the present review were not fulfilled as none of the relevant outcome measures were covered by more than one original study; hence, psychodynamic therapies are not included in table 1. humanistic or client-centred approaches description in client-centred or humanistic therapy, unconditional positive regard, accurate empathy and genuineness are assumed to help a patient to increase the congruence between the real self and the ideal self (rogers, gendlin, kiesler, & truax, 1967). rogers and collea‐ gues’ concept of “actualizing tendency” points to an inherent tendency to achieve per‐ sonal growth and reach one’s full potential. in this framework psychotic symptoms are understood as a distortion of this actualising tendency. client-centred therapy focuses on psychological interventions for psychosis 6 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ personal experiences, whereas relieving specific symptoms is secondary. thus, no specif‐ ic therapeutic strategies have been established for psychosis. however, therapists are rec‐ ommended to pay particular attention to understanding the client’s perspective, ensuring that the patient is being heard and emphasising the personal relationship (gendlin, 1962). evidence base client-centred or humanistic therapy for psychosis has not been covered in a meta-anal‐ ysis and the only known rct dates back to 1967 (rogers) and did not reveal convincing effects. psychoeducation for patients description to enhance knowledge and understanding of psychosis and to improve coping skills psy‐ cho-educational interventions are routinely offered in the treatment of psychosis. mainly in group format, patients receive systematic and structured information on psychosis and its consequences, early warning signs, triggering and maintaining factors, relapse pre‐ vention, and modalities of treatment. psychoeducation aims to help patients to increas‐ ingly take personal responsibility and improve coping skills. evidence base two comprehensive meta–analyses (nccmh, 2014; turner et al., 2014) that provided sub-analyses on the effect of psychoeducation for patients without involving family members did not show any significant effect of psychoeducation on overall symptoms, positive or negative symptoms (turner et al., 2014), relapse rates or rehospitalisations (nccmh, 2014). training-based approaches description from the range of different training-based approaches that cannot be fully covered with‐ in the scope of this review, we exemplarily focus on two widely used training-based in‐ terventions – one targeting positive symptoms (metacognitive training) and one primari‐ ly addressing negative symptoms (social skills training). metacognitive training (mct; moritz & woodward, 2007) was designed to address positive symptoms in patients with schizophrenia. as cognitive biases have been related to positive symptoms (e.g. jumping to conclusions or externalizing attributional bias, see garety & freeman, 1999), mct aims to extent patient’s knowledge of cognitive biases and to provide corrective experiences. implementing a wide range of examples and exer‐ cises, patients participating in a mct group training are encouraged to identify and gain lincoln & pedersen 7 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ insight into these cognitive biases and reduce conviction in delusional ideas. mct is mainly administered in group format. social skills trainings (sst) build on the observation that patients with psychotic dis‐ orders tend to show impaired social skills. sst involve therapist modelling and instruct‐ ing socially confident behaviour in specific situations combined with role-plays. patients receive supportive feedback from the therapist and video feedback can also be used. dur‐ ing the end of the training that usually takes place in group-format patients are encour‐ aged to practice the newly learnt skills in daily life. a frequently used treatment manual was published by bellack, mueser, gingerich, and agresta (2013). evidence base for mct a significant small effect on positive symptoms was reported in two of three identified meta-analyses on the effect of mct in psychosis (eichner & berna, 2016; jiang, zhang, zhu, li, & li, 2015), whereas one did not reveal a significant effect at post-treatment (van oosterhout et al., 2016). regarding overall and negative symptoms, relapse / rehospitali‐ sations and functioning no aggregated effect sizes were reported. evidence base for social skill trainings we identified and included three meta-analyses: the nice meta-analysis (nccmh, 2014), the cochrane meta-analysis (almerie et al., 2015) and the meta-analysis by turner et al. (2014). there was no effect of sst on overall symptoms compared to control conditions at post-therapy in any of the meta-analyses, follow-up effects were not reported. there was also no effect in favour of sst for positive symptoms (turner et al., 2014). for nega‐ tive symptoms there were significant post-therapy effects (nccmh, 2014; turner et al., 2014). a significant follow-up effect for sst versus tau was found in one meta-analysis (almerie et al., 2015). for relapse and rehospitalisation, the findings were mixed. there was no significant effect for functioning, neither at post-assessment nor at follow-up. family interventions description interventions that include the family are subsumed under the term “family intervention”. the patient may be included in all, some, or – in some programmes – no sessions. de‐ pending on the approach, a family intervention will involve 12 to 25 treatment sessions during the course of a year or longer and accompany the family through the remission phase. the diverse approaches can be broadly subdivided into psycho-educative family interventions, comprehensive interventions that combine information with problemsolving, social and communication skills, and systemic family interventions. the psychoeducational approach builds on the observation that patients with psycho‐ sis often rely on relatives for support (dixon, adams, & lucksted, 2000) and the assump‐ psychological interventions for psychosis 8 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ tion that involved family members thus require information and assistance to cope with the challenges posed to the family system. it thus conveys basic knowledge about psy‐ chosis, building on the vulnerability-stress models. it sees psychosis as mental illness and enlists family members as therapeutic agents, taking care not to make the relatives feel blamed (lucksted, mcfarlane, downing, & dixon, 2012). it aims to convey the relevance of medical and psychosocial treatment, reduce misconceptions and provide a basis on which to promote the self-management skills, improve family coping and reduce relapse. the skill-training approach builds on findings showing higher rates of relapse if a pa‐ tient’s family displays a communication style characterised by high levels of criticism, hostility, or emotional over-involvement (“high expressed emotion”, butzlaff & hooley, 1998). it builds on the assumption that problems that arise from caring for a mentally ill family member can be solved if the family develops good problem solving strategies and a supportive way of communicating. the therapist models the verbal and non-verbal communication rules and assists the family to use the communication skills in a series of role-plays. the improved skills are then used to solve practical problems within the fami‐ ly context, using a problem solving approach. a well-established program of this type is described by falloon, boyd, and mcgill, (1984). systemic approaches assume that relationships within the family (or other relevant so‐ cial systems) influence the feelings, beliefs and behaviour of the “index patient” and vice versa and therefore, that psychotic symptoms may have arisen from specific interaction patterns within the family. the therapy aims to identify and change these patterns in or‐ der to reduce symptoms. if, for example, family members have stopped communicating about relevant issues with the patient, the therapist would attempt to re-include the pa‐ tient in the communication processes. changes in interactions are promoted by specific systemic questioning and reframing (e.g. retzer, 2004). evidence base for family interventions in general we selected three meta-analyses (claxton, onwumere, & fornells-ambrojo, 2017; nccmh, 2014; pharoah, mari, rathbone, & wong, 2010) from a pool of four available ones. these did not differentiate between different types of family interventions and thus report omnibus effects, with the bulk of the interventions covered in these analyses being psychoeducational in nature, with or without additional skill training. as can be seen in table 1, short-term benefits were mixed, but family interventions demonstrated significant long-term benefits over any control conditions on overall symp‐ toms in any of the three meta-analyses. the effects on positive and negative symptoms were short-term in nature (nccmh, 2014). for relapse and rehospitalisation the majority of the effects were significant and in the moderate to large range, both at post therapy and at follow-ups, although the long-term effects were non-consistent. small to moderate effects were also found for short(claxton et al., 2017; nccmh, 2014) and long-term functioning (nccmh, 2014; pharoah et al., 2010). lincoln & pedersen 9 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ in order to provide a picture on differential effectiveness, we reviewed three addition‐ al meta-analyses each focusing on one of the three specific subtypes, psychoeducative family interventions (lincoln, wilhelm, & nestoriuc, 2007), comprehensive programs in‐ cluding skilltraining (pfammatter, junghan, & brenner, 2006) and systemic approaches (pinquart, oslejsek, & teubert, 2016). moreover, the nice meta-analysis (nccmh, 2014) provided a sub-analysis for psychoeducative interventions that included the family. as can be seen in table 1, psychoeducative family interventions demonstrated no sig‐ nificant effect on any of the symptom measures (lincoln et al., 2007; nccmh, 2014), but a significant small follow-up effect on relapse and rehospitalisation (combined) in one meta-analysis (es = 0.48; lincoln et al., 2007) but not in the other (nccmh, 2014). for comprehensive programmes including skill-trainings, one meta-analysis (pfammatter et al., 2006) demonstrated a small follow-up effect on general psychopathol‐ ogy, relapse and rehospitalisation and a short-term benefit on functioning. for systemic family approaches there was an overall significant effect on all outcome measures combined, without differentiating between the different outcomes (pinquart et al., 2016). psychological interventions for psychosis 10 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ ta bl e 1 re su lts f ro m m et aa na ly se s on th e ef fic ac y of p sy ch ol og ic al a pp ro ac he s to p sy ch os is m et aan al ys is g en er al p sy ch o‐ pa th ol og y (e s) po si ti ve sy m pt om s (e s) n eg at iv e sy m pt om s (e s) r el ap se (r r ) r eh os pi ta li‐ sa ti on (r r ) fu nc ti on in g (e s) po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps c og ni ti ve -b eh av io ur al th er ap y (c bt p) n cc m h , 2 01 4 (n ic e, k = 1 9) co m pa ris on : t a u 0.2 7* 0.2 3* 0.4 0* 0.1 9* 0.1 7* 0.1 5* 0.5 1* n. s. 0.1 6* 0.3 8* n. s. n. s. 0.7 6* * n. s. n. s. n. s. 0.2 0* n. s. n cc m h , 2 01 4 (n ic e, k = 1 4) co m pa ris on : a ct iv e tre at m en ts n. s. n. s. n. s. n. s. n. s. n. s. n. s. n. s. n. s. n. s. n. s. n. s. 0.5 0* n. s. jo ne s e t a l., 2 01 2 (c oc hr an e, k = 20 ) co m pa ris on : a ny co nt ro l n. s. n. s. * * n. s. n. s. n. s. * n. s. n. s. n. s. n. s. n. s. n. s. n. s. n. s. n. s. n. s. * a n. s n. s. bu rn s e t a l., 2 01 4 (k = 1 2) co m pa ris on : a ny co nt ro l 0.5 2* 0.4 0* 0.4 7* 0.4 1* ja uh ar e t a l., 2 01 4 (k = 5 0) co m pa ris on : a ny co nt ro l 0.3 3* 0.2 5* 0.1 3* va n de r g aa g et a l., 2 01 4 (k = 1 8) co m pa ris on : a ny co nt ro l 0.4 4* 0.3 6* ve lth or st e t a l., 2 01 5 (k = 3 0) co m pa ris on : a ny co nt ro l n. s. n. s. n. s. tu rn er e t a l., 2 01 4 (k = 2 2) co m pa ris on : a ct iv e tre at m en ts 0.1 6* 0.1 6* n. s. lu tg en s e t a l. (2 01 7) co m pa ris on : t a u 0.3 4* lincoln & pedersen 11 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ m et aan al ys is g en er al p sy ch o‐ pa th ol og y (e s) po si ti ve sy m pt om s (e s) n eg at iv e sy m pt om s (e s) r el ap se (r r ) r eh os pi ta li‐ sa ti on (r r ) fu nc ti on in g (e s) po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps m in df ul ne ss -b as ed in te rv en ti on s cr am er e t a l., 2 01 6 (k = 4 ) co m pa ris on : t a u 0.6 2* 1.2 7* 1.4 0* lo ui se e t a l., 2 01 7 (k = 4 ) co m pa ris on : a ny co nt ro l 0.4 6* a cc ep ta nc e an d co m m it m en t t he ra py (a c t) cr am er e t a l., 2 01 6 (k = 4 ) co m pa ris on : t a u n. s. 0.6 3* n. s. 0.4 1* lo ui se e t a l., 2 01 7 (k = 4 ) co m pa ris on : a ny co nt ro l n. s. ps yc ho dy na m ic th er ap y – h um an is ti c ap pr oa ch es – ps yc ho ed uc at io n no t i nv ol vi ng fa m ily m em be rs n cc m h , 2 01 4 (n ic e, su ban al ys es , k = 1 2) co m pa ris on : a ny co nt ro l n. s n. s. n. s. tu rn er e t a l., 2 01 4 (k = 8 ) co m pa ris on : a ct iv e tre at m en ts n. s. n. s. n. s. psychological interventions for psychosis 12 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ m et aan al ys is g en er al p sy ch o‐ pa th ol og y (e s) po si ti ve sy m pt om s (e s) n eg at iv e sy m pt om s (e s) r el ap se (r r ) r eh os pi ta li‐ sa ti on (r r ) fu nc ti on in g (e s) po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps m et ac og ni ti ve tr ai ni ng jia ng e t a l., 2 01 5 (k = 4 ) co m pa ris on : a ny co nt ro l * ei ch ne r & b er na , 2 01 6 (k = 1 5) co m pa ris on : a ny co nt ro l 0.3 4* va n o os te rh ou t e t a l., 2 01 6 (k = 1 1) co m pa ris on : a ny co nt ro l n. s. so ci al s ki lls tr ai ni ng n cc m h , 2 01 4 (n ic e, k = 2 0) co m pa ris on : a ny co nt ro l n. s. 0.3 7 n. s n. s. n. s. n. s. po st n .s. ; f ol lo w -u p n. s.b a lm er ie e t a l., 2 01 5 (c oc hr an e, k = 10 ) co m pa ris on : t a u * 0.5 2* a lm er ie e t a l., 2 01 5 (c oc hr an e, k = 3) co m pa ris on : a ct iv e tre at m en ts n. s. n. s. tu rn er e t a l., 2 01 4 (k = 1 6) co m pa ris on : a ct iv e tre at m en ts n. s. n. s. 0.2 7* fa m ily in te rv en ti on s o v er a ll n cc m h , 2 01 4 (n ic e, k = 3 2) co m pa ris on : a ny co nt ro ls 0.3 6* 0.3 0* 0.4 6* n. s. 0.2 6* n. s. 0.5 5* 0.6 6* 0.6 2* 0.8 0* 0.5 3* 0.5 7* * n. s. * n. s. n. s. n. s. 0.2 2* 0.3 8* 0.5 8* n. s. ph ar oa h et a l., 2 01 0 (c oc hr an e, k = 53 ) co m pa ris on : a ny co nt ro ls * n. s. 0.5 5* 0.6 4* 0.6 4* n. s. 0.7 8* 0.4 6* n. s. * * * lincoln & pedersen 13 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ m et aan al ys is g en er al p sy ch o‐ pa th ol og y (e s) po si ti ve sy m pt om s (e s) n eg at iv e sy m pt om s (e s) r el ap se (r r ) r eh os pi ta li‐ sa ti on (r r ) fu nc ti on in g (e s) po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps po st fo llo w -u ps cl ax to n et a l., 2 01 7 (k = 1 4) co m pa ris on : a ny co nt ro ls n. s. 0.8 5 co m bi ne d an al ys is of re la ps e an d re ho sp ita lis at io n: p os t: *; fo llo w -u p: n. s. 0.7 4 fa m ily p sy ch oe du ca ti on li nc ol n et a l., 2 00 7 (k = 6 ) co m pa ris on : a ny co nt ro ls n. s. co m bi ne d an al ys is of re la ps e an d re ho sp ita lis at io n at fo llo w -u p: 0 .48 * n cc m h , 2 01 4 (n ic e, k = 2 ) co m pa ris on : a ny co nt ro ls n. s. fa m ily c om pr eh en si ve p ro gr am s pf am m at te r e t a l., 2 00 6 (k = 3 1) co m pa ris on : a ny co nt ro ls 0.4 0* 0.4 2* 0.2 2* 0.5 1* 0.3 8* sy st em ic fa m ily in te rv en ti on s pi nq ua rt et a l., 2 01 6 (k = 7 ) co m pa ris on : t a u a na ly sis o f d iff er en t o ut co m e m ea su re s c om bi ne d at p os t: 0.6 9* a nd fo llo w -u p: 0 .69 * n ot e. e ffe ct si ze s b as ed o n at le as t t w o in de pe nd en t o rig in al st ud ie s a re re po rte d. c om pa ra bl e ef fe ct si ze s ( co he n’ s d , h ed ge ’s g, a nd st an da rd ise d m ea n di ffe re nc es ) ar e de no te d as e s (e ffe ct si ze ) w ith ou t r ep or tin g co nf id en ce in te rv al s. if on ly o dd s r at io , r isk ra tio s, pa rti al e ta sq ua re d an d no t-s ta nd ar di se d m ea n di ffe re nc es w er e re po rte d in a m et aan al ys is w e on ly in di ca te d if th e ef fe ct w as st at ist ic al ly si gn ifi ca nt a t p < 0 .05 (* ) v s n on -s ig ni fic an t ( n. s.) . i f a va ila bl e, ef fe ct s c om pa re d to “a ny co nt ro ls” a re re po rte d, if th es e da ta w er e no t a va ila bl e ef fe ct s c om pa re d to tr ea tm en t a s u su al (“ ta u” ) o r “ ac tiv e tre at m en ts ” ( fo r i ns ta nc e ot he r p sy ch ol og ic al a p‐ pr oa ch es fo r p sy ch os is or u ns pe ci fie d tre at m en ts ) a re re po rte d. p os t = p os t-t re at m en t; fo llo w -u p = al l f ol lo w -u p tim epo in ts co m bi ne d; k = n um be r o f s tu di es re ‐ vi ew ed in th e m et aan al ys is or su ban al ys is, a “a ny co nt ro l” w as su pe rio r t o th e tre at m en t. b ef fe ct si ze s b as ed o n st ud ie s r ep or tin g co m bi ne d an al ys is of re la ps e an d re ho sp ita lis at io n on ly . psychological interventions for psychosis 14 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ discussion as has become apparent from this review, there are now a variety of different psycholog‐ ical interventions available, of which the majority have a good evidence base for the out‐ comes that they focus on primarily. if the aim is to reduce general psychopathology or positive symptoms, cbt has the strongest evidence-base both in terms of the number of studies conducted and in regard to the robustness of effects over follow-up periods. oth‐ er approaches, such as acceptance and commitment therapy, mindfulness-based ap‐ proaches, and meta-cognitive training are also promising for these outcomes. negative symptoms, however, appear to respond better to social skills trainings. family interventions are also well-researched and appear to be effective for a broader array of outcomes, including relapse and rehospitalisation as well as functioning. within family interventions, the strongest effects are found for a combination of psychoeduca‐ tive and skill-training with families, although it needs noting that this specific combina‐ tion was only the focus in one meta-analysis. systemic approaches are also promising, but more high-quality randomised controlled trials are necessary to ascertain their effec‐ tiveness for different types of outcomes. there was no convincing evidence for patientdirected psychoeducation (without family involvement) despite the fact that this ap‐ proach is widespread. however, it may be more difficult to construct a fair evaluation of this approach in rcts because any control condition is likely to involve psychoeducation to a certain extent. psychodynamic therapies and humanistic approaches were also not found to be effective, but more rcts are required in order to draw definite conclusions in this regard. no approach has a consistently good evidence-base for the entire range of outcomes investigated. this may be partly due to the fact that different types of interventions have focused on different types of outcomes. for example, family interventions have a tradi‐ tional focus on relapse, whereas cbt focusses on the positive symptoms. thus, studies investigating these approaches did not consistently include a wider spectrum of outcome measures. more rcts focusing on the full spectrum of outcome areas are required in or‐ der to understand whether different approaches are truly differentially effective. also, with the exception of a few large effect sizes for family interventions, the effect sizes were largely in the small to marginally moderate range – and thus no higher than those found for pharmacotherapy. however, all original studies in the meta-analyses included here are based on designs that compare psychological interventions combined with medi‐ cation to medication alone or to medication combined with an additional control condi‐ tion. thus, the effects need to be interpreted as “add-on” effects to medication and can‐ not be directly compared with the effect sizes for medication. so far, it is unclear whether psychological therapy would fare better or worse without the combination with medica‐ tion as this question has not been investigated. lincoln & pedersen 15 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ limitations of this analysis the wide scope of interventions reviewed comes at the price of detail. for reasons of space, we did not include the specific search-terms or provide a full account of each of the meta-analyses excluded along with the reasons for inor exclusion. also, we did not report the evidence available for questions regarding specific subgroups, formats (e.g. group versus individual, short versus long) or settings (e.g. is family intervention more effective when delivered to individual families versus in groups of families). in table 1, we focused on the comparison to all control conditions for reasons of brevity and in or‐ der to be able to compare different approaches for which such distinctions were not al‐ ways available. naturally, differentiating between comparisons to tau versus active con‐ trols is more conclusive and therefore these distinctions were made in the section on cbt for which they are consistently available. moreover, we abstained from detail in the reporting of effect-sizes (e.g., we did not report standard-deviations, the type of effects, or the number of studies for each comparison). finally, we disregarded any reported ef‐ fect-size based on one original study only. readers seeking more detailed evidence re‐ ports are referred to the british or german guidelines (lincoln et al., 2019; nccmh, 2014), and to the original meta-analyses cited. the method as such, a summary of meta-analyses, also has its limitations due to the overlap between meta-analyses. moreover, the differences in methodological rigour, the inclusion criteria, and the classification of therapy approaches (e.g. inconsistency in what is counted as cbt) result in high levels of heterogeneity in the findings and make it diffi‐ cult to directly compare different meta-analyses. we attempted to control this bias to a certain extent by disregarding meta-analyses with strong overlap or questionable quality. another limitation is that the focus on meta-analyses does not provide information on psychological approaches, that are not represented well in the meta-analytic literature. finally, the continuous accumulation of further evidence renders meta-analyses and re‐ views outdated at an increasing speed and several new ones have been published since finalizing the selection for this overview. in this context, it is also worth mentioning a recent meta-analysis that also approach‐ ed the question of the effectiveness of different psychological approaches to psychosis (bighelli et al., 2018). this network meta-analysis aggregated data on the level of individ‐ ual trials on cbt, metacognitive training, mindfulness and acceptance and commitment therapy among other approaches. similar to our findings, cbt was the most represented among the included treatments and was found to have significant efficacy in comparison with treatment as usual for positive, overall and negative symptoms and functioning. it also showed higher efficacy in comparison with inactive control conditions for positive symptoms whereas there was no convincing proof of efficacy of other treatments. thus, cbt fared slightly better, even, than in our approach, while third-wave approaches and meta-cognitive therapy were less well supported. family interventions were not inclu‐ ded. psychological interventions for psychosis 16 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://www.psychopen.eu/ final conclusions the variety of efficacious interventions available for psychotic disorders is reassuring. unfortunately, however, efficacy studies and clinical guidelines alone do not guarantee the implementation of evidence-based interventions, in routine clinical practice (pilling & price, 2006). for example, despite the nice guideline recommendation to offer cbt to all patients with psychosis, only a minority of eligible patients with psychosis are being of‐ fered cbt in the uk (prytys, garety, jolley, onwumere, & craig, 2011). in germany, studies indicate that only a minority of psychosis patients have access to evidence-based psychotherapy (schlier & lincoln, 2016). to our knowledge, this serious implementation problem of evidence-based interventions is not restricted to germany and the uk. thus, although further high quality rcts focusing on the full spectrum of outcomes are nee‐ ded, the most relevant challenge to date is that of implementation. funding: the authors have no funding to report. competing interests: tl is section editor of clinical psychology in europe but played no editorial role for this particular article. acknowledgments: the authors have no support to report. references almerie, m. q., al marhi, m. o., jawoosh, m., alsabbagh, m., matar, h. e., maayan, n., & bergman, h. 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(2014). treating psychosis: a clinician’s guide to integrating acceptance and commitment therapy, compassionfocused therapy, and mindfulness approaches within the cognitive behavioral therapy tradition. oakland, ca, usa: new harbinger publications. appendix: not included meta-analyses cognitive-behavioral therapy (cbtp) bird, v., premkumar, p., kendall, t., whittington, c., mitchell, j., & kuipers, e. (2010). early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. the british journal of psychiatry, 197(5), 350–356. https://doi.org/10.1192/bjp.bp.109.074526 lynch, d., laws, k. r., & mckenna, p. j. (2010). cognitive behavioural therapy for major psychiatric disorder: does it really work? a meta-analytical review of well-controlled trials. psychological medicine, 40(1), 9–24. https://doi.org/10.1017/s003329170900590x mehl, s., werner, d., & lincoln, t. m. (2015). does cognitive behaviour therapy for psychosis (cbtp) show a sustainable effect on delusions? a meta-analysis. frontiers in psychology, 6, article 1450. https://doi.org/10.3389/fpsyg.2015.01450 naeem, f., khoury, b., munshi, t., ayub, m., lecomte, t., kingdon, d., & farooq, s. (2016). brief cognitive behavioral therapy for psychosis (cbtp) for schizophrenia: literature review and meta-analysis. international journal of cognitive therapy, 9(1), 73–86. https://doi.org/doi.org/10.1521/ijct_2016_09_04 newton-howes, g., & wood, r. (2013). cognitive behavioural therapy and the psychopathology of schizophrenia: systematic review and meta-analysis. psychology and psychotherapy: theory, research and practice, 86(2), 127–138. https://doi.org/10.1111/j.2044-8341.2011.02048.x sarin, f., wallin, l., & widerlöv, b. (2011). cognitive behavior therapy for schizophrenia: a metaanalytical review of randomized controlled trials. nordic journal of psychiatry, 65(3), 162–174. https://doi.org/10.3109/08039488.2011.577188 psychological interventions for psychosis 22 clinical psychology in europe 2019, vol.1(1), article e31407 https://doi.org/10.32872/cpe.v1i1.31407 https://doi.org/10.1016/j.cpr.2016.10.009 https://doi.org/10.1093/schbul/sbu014 https://doi.org/10.1192/bjp.bp.109.074526 https://doi.org/10.1017/s003329170900590x https://doi.org/10.3389/fpsyg.2015.01450 https://doi.org/doi.org/10.1521/ijct_2016_09_04 https://doi.org/10.1111/j.2044-8341.2011.02048.x https://doi.org/10.3109/08039488.2011.577188 https://www.psychopen.eu/ mindfulness-based interventions khoury, b., lecomte, t., gaudiano, b. a., & paquin, k. (2013). mindfulness interventions for psychosis: a meta-analysis. schizophrenia research, 150(1), 176–184. https://doi.org/10.1016/j.schres.2013.07.055 tonarelli, s. b., pasillas, r., alvarado, l., dwivedi, a., & cancellare, a. (2016). acceptance and commitment therapy compared to treatment as usual in psychosis: a systematic review and meta-analysis. journal of psychiatry, 19(3), article 1000366. https://doi.org/10.4172/2378-5756.1000366 psychodynamic therapy malmberg, l., fenton, m., & rathbone, j. (2001). individual psychodynamic psychotherapy and psychoanalysis for schizophrenia and severe mental illness. cochrane database of systematic reviews, 3. https://doi.org/10.1002/14651858.cd001360 nccmh. (2014). psychosis and schizophrenia in adults: the nice guideline on treatment and management (nice clinical guideline 178). london, united kingdom: nice. psychoeducation without family xia, j., merinder, l. b., & belgamwar, m. r. (2011). psychoeducation for schizophrenia. cochrane database of systematic reviews, 6. https://doi.org/10.1002/14651858.cd002831.pub2 zou, h., li, z., nolan, m. t., arthur, d., wang, h., & hu, l. (2013). self-management education interventions for persons with schizophrenia: a meta-analysis. international journal of mental health nursing, 22(3), 256–271. https://doi.org/10.1111/j.1447-0349.2012.00863.x family interventions overall bird, v., premkumar, p., kendall, t., whittington, c., mitchell, j., & kuipers, e. (2010). early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. the british journal of psychiatry, 197(5), 350–356. https://doi.org/10.1192/bjp.bp.109.074526 okpokoro, u., adams, c. e., & sampson, s. (2014). family intervention (brief) for schizophrenia. cochrane database of systematic reviews, 3. https://doi.org/10.1002/14651858.cd009802.pub2 lincoln & pedersen 23 psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. www.leibniz-psychology.org https://doi.org/10.1016/j.schres.2013.07.055 https://doi.org/10.4172/2378-5756.1000366 https://doi.org/10.1002/14651858.cd001360 https://doi.org/10.1002/14651858.cd002831.pub2 https://doi.org/10.1111/j.1447-0349.2012.00863.x https://doi.org/10.1192/bjp.bp.109.074526 https://doi.org/10.1002/14651858.cd009802.pub2 https://www.leibniz-psychology.org/ https://www.psychopen.eu/ psychological interventions for psychosis (introduction) methods of the review description of the reviewed approaches and their respective evidence basis cognitive behavioural therapy for psychosis third-wave-approaches to psychosis psychodynamic therapy for psychosis humanistic or client-centred approaches psychoeducation for patients training-based approaches family interventions discussion limitations of this analysis final conclusions (additional information) funding competing interests acknowledgments references appendix: not included meta-analyses no health without mental health – european clinical psychology takes responsibility letter to the editor | commentary no health without mental health – european clinical psychology takes responsibility 1st european congress on clinical psychology and psychological treatment in dresden, germany, october 31 – november 2, 2019 katja beesdo-baum a, tanja endrass a, jürgen hoyer a, corinna jacobi a, philipp kanske a [a] institute of clinical psychology and psychotherapy, technische universität dresden, dresden, germany. clinical psychology in europe, 2019, vol. 1(1), article e34220, https://doi.org/10.32872/cpe.v1i1.34220 published (vor): 2019-03-29 corresponding author: philipp kanske, institute of clinical psychology and psychotherapy, technische universität dresden, chemnitzer str. 46, 01187 dresden, phone +49 (0)351 463-42225, fax +49 (0)351 463-36984. e-mail: philipp.kanske@tu-dresden.de the european association of clinical psychology and psychological treatment (eaclpt) was founded in 2017 with the goal of promoting european collaborations on research and education about mental health problems as well as their treatment. in 2019, the association’s first congress will take place to foster such collaborations from october 31st to november 2nd in dresden, germany. it will be the first international meeting in the field of clinical psychology at a european level. the conference theme “no health without mental health european clinical psy‐ chology takes responsibility” expresses our goal of moving mental health into societal focus. mental disorders are among the most debilitating conditions and clinical psycholo‐ gy offers a wide range of preventive and therapeutic interventions. the discussion of these, as well as underlying etiological models, will be at the heart of the conference. keynote speakers include claudi bockting, susan bögels (university of amsterdam), da‐ vid clark (university of oxford), stefan hofmann (boston university) and maria karekla (university of cyprus). we invite submissions for symposia and poster presentations on the full range of clin‐ ical psychological research: diagnostics and classification, psychological and psychobio‐ logical mechanisms, psychological treatments, prevention and rehabilitation. we particu‐ larly encourage early career researchers to join the conference. targeted pre-conference workshops, mentoring and financial support can be offered. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i1.34220&domain=pdf&date_stamp=2019-03-29 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ the conference will be a unique chance to discuss current challenges for mental health in europe and initiate collaborations and joint projects with colleagues from all over the continent. we look forward to seeing you in dresden! for details on the conference and registration visit: www.clinicalpsychologycongress2019.eu no health without mental health 2 psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. www.leibniz-psychology.org http://www.clinicalpsychologycongress2019.eu https://www.leibniz-psychology.org/ https://www.psychopen.eu/ social media use and mental health in young adults of greece: a cross-sectional study research articles social media use and mental health in young adults of greece: a cross-sectional study epameinondas leimonis 1, katerina koutra 1 [1] department of psychology, school of social sciences, university of crete, rethymno, greece. clinical psychology in europe, 2022, vol. 4(2), article e4621, https://doi.org/10.32872/cpe.4621 received: 2020-10-30 • accepted: 2022-02-08 • published (vor): 2022-06-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: katerina koutra, department of psychology, school of social sciences, university of crete, gallos campus 74100 – rethymno, crete, greece. telephone: ++30 2810324999/++30 6977357108. e-mail: koutra.k@gmail.com abstract background: social media use has vastly increased during the past few years, especially among young adults. studies examining the relationship of social media use with mental health have yielded mixed findings. additionally, such studies are extremely limited in greece. the present study aimed to investigate the association between social media use, depressive symptoms and self-esteem among greek young adults. method: a total of 654 individuals (50.5% male) aged 18-30 years (μ = 23.62, sd = 2.71) completed self-reported questionnaires regarding social media use, depressive symptoms and self-esteem. results: increased daily use of youtube (more than five hours) showed a significant association with higher depressive symptomatology, b = 2.99, 95% ci [.78, 5.20], p = .008, while daily use of facebook between two and five hours was related to significantly higher self-esteem, b = 1.61, 95% ci [.78, 2.44], p < .001, after adjusting for participants’ gender, age, educational level and employment status. the association of increased daily use of youtube with depressive symptoms was more pronounced in males than in females. moreover, self-reported active use of facebook and instagram were linked with significantly lower depressive symptoms and higher self-esteem compared to passive involvement. conclusion: the results suggest that social media use is closely related to self-esteem and depressive symptomatology in young adults. these findings may contribute to a deeper clinical understanding of the association between electronic social networking and mental health. keywords social media, mental health, self-esteem, depressive symptoms, young adults this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4621&domain=pdf&date_stamp=2022-06-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • increased daily time spent in youtube (more than five hours) was significantly associated with higher depressive symptomatology. • youtube daily use of more than five hours showed a stronger association with depressive symptoms for males than for females. • daily use of facebook between two and five hours was related to significantly higher self-esteem. • self-reported active use of facebook and instagram were linked with significantly lower depressive symptoms and higher self-esteem compared to passive involvement. electronic social networking is undoubtedly a worldwide technological phenomenon with various extensions in modern human life. through social media people are able to communicate and interact with each other, while they also have the opportunity to develop and share electronic data (ellison et al., 2007; kaplan & haenlein, 2010). during the past few years, social media have become extremely popular, especially among young adults (pew research center, 2015). specifically, 90% of u.s. adults aged 18-29 are frequent users of at least one online social network, while youtube and facebook are the most popular platforms (pew research center, 2019). in greece, almost 60% of total population are involved in social media use (hootsuite & we are social, 2020), while young adults constitute the vast majority of users (belenioti, 2015). similarly to other countries, facebook and youtube are the two most widely used social networks in greece (drosos et al., 2015). due to the fast and constantly increasing penetration of social media in everyday life, their association with mental health has gained considerable attention within the scien­ tific community. recent studies have provided mixed results, either indicating harmful effects of social networks on users’ psychological well-being (e.g. rasmussen et al., 2020; sujarwoto et al., 2019) or suggesting non-significant associations (e.g. coyne et al., 2020). social media users facing mental health difficulties appear to experience both benefits, such as easy social interaction, access to peer support, increased involvement in various services, and negative consequences, including increased symptoms and exposure to aggressive online behaviour (naslund et al., 2020). overall, international research has showed that social networking can affect mental health both positively and negatively (sharma et al., 2020). depression is a mood disorder considered as the primary cause of disability and one of the most common causes of death between the ages of 15 and 29 years, since it is responsible for more than 800,000 annual suicides (world health organization, 2020). the relationship between social media use and depression has been in the spotlight of research for about a decade, with many studies suggesting that increased involvement in online social networking is associated with higher levels of depressive symptomatology (ivie et al., 2020; mcdougall et al., 2016; pantic et al., 2012; woods & scott, 2016). elon­ social media use and mental health 2 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ gated daily time spent in social media has been linked to higher odds of depression in young adults (lin et al., 2016), while the use of multiple social networking platforms has been related to increased depressive symptoms (primack et al., 2017). in a recent study, the reduction of time spent in social networks was linked to significantly less negative mental health outcomes, including less depressive symptoms, in young adults (hunt et al., 2018). social comparison has often mediated the aforementioned associations (e.g. brown & tiggemann, 2016; lup et al., 2015), while envy has displayed a mediating effect on the relationship between social comparison and adult users’ depressive symptoms (wang et al., 2020). finally, addiction to social media has been significantly associated with depression (donnelly & kuss, 2016). despite what appears to be evidence for a negative association between social media and depressive symptomatology, other studies have showed that social media use can have positive effects on individuals’ well-being. communication and interaction through these networks have been found to contribute to an increase in social capital and, thus, a reduction in depressive symptoms (bessière et al., 2010; de la peña & quintanilla, 2015; ellison et al., 2007). platforms such as snapchat, twitter, instagram and facebook provide opportunities for participation in positive social interactions among various sources of social support, which can alleviate depressive symptoms (bessière et al., 2010). moreover, these platforms may help people form connections with other individuals suffering from stigmatised health conditions such as depression (merolli et al., 2014). in a similar vein, active use of social networks (e.g. sharing content and communicating with other users) has been linked with decreased depressive symptoms and pertinent outcomes compared to passive use (e.g. avoiding posting new content, visiting other users’ profiles and following their posts) (escobar-viera et al., 2018; verduyn et al., 2015). in general, the relationship between social media use and depressive symptoms appears to be complicated and influenced by various individual and psychosocial factors (baker & algorta, 2016). previous studies have suggested a negative association between depressive symptoms and self-esteem (conti et al., 2014; franck et al., 2007). self-esteem is defined as the subjective way in which individuals perceive their personal value (macdonald & leary, 2012). with respect to the association between social media use and self-esteem, findings appear to be mixed. specifically, recent research indicates that increased involvement in social networks is linked to lower self-esteem in adolescents and young adults (e.g. bergagna & tartaglia, 2018; vogel et al., 2014; woods & scott, 2016). on the contrary, some researchers have found that social media use is related to higher self-esteem (e.g. gonzales & hancock, 2011; wilcox & stephen, 2013). two mechanisms that seem to ex­ plain or mediate such relationships include the kind of feedback that users receive from online social networks (valkenburg et al., 2017; valkenburg et al., 2006) as well as social comparison (bergagna & tartaglia, 2018; vogel et al., 2014). moreover, cyberbullying through social media has been related to lower self-esteem levels (palermiti et al., 2017). leimonis & koutra 3 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ little research has been conducted so far regarding electronic social networking and aspects of mental health in the greek population. recent findings suggest that almost 34% of greek adolescent users report intense activity in social networks, while approximately 10% display problematic use, which refers to addictive behaviour (boer et al., 2020). with regard to greek young adults, excessive social media use has been linked with higher levels of loneliness and decreased life satisfaction (vasilikou, 2016). in addition, excessive use of social networking sites has been significantly associated with personality factors, such as neuroticism, along with increased depressive sympto­ matology in young greeks (giota & kleftaras, 2013). although little research has been conducted, recent findings have suggested that the frequency of social media use, such as facebook, is not associated with self-esteem in adolescents (botou & marsellos, 2018). however, cyberbullying has been related to low self-esteem in university students of greece (giovazolias & malikiosi-loizos, 2016). there is considerable evidence that social media use is linked with mental health, including depressive symptomatology and self-esteem, positively or negatively (e.g. bessière et al., 2010; lin et al., 2016). however, approximately half of previous studies have examined social media use in general (schønning et al., 2020), and many of them as a single variable, without providing results regarding the use of different platforms (e.g. escobar-viera et al., 2018; lin et al., 2016; woods & scott, 2016). studies assessing the use of specific social networks in relation to mental health outcomes have focused mainly on facebook (e.g. bergagna & tartaglia, 2018; wilcox & stephen, 2013). furthermore, the amount of greek data concerning the relationship between social networks and human behaviour is extremely limited. taking into consideration the above-mentioned gap in the literature, the aim of the present study was to investigate the association of different popular social media with self-esteem and depressive symptoms in a large greek sample of emerging adults. we hypothesised that increased time of social media use was significantly associated with higher depressive symptoms and lower self-esteem in young adults. we, also, hypothesised that active social media users would have lower symptoms of depression and higher self-esteem compared to passive social media users. method participants to be eligible for inclusion in the study, participants had to meet the following criteria: (i) to be between 18 and 30 years old, (ii) to use at least one electronic social network, and (iii) to have a good understanding of the greek language. the sample included 654 young adults (50.5% male and 49.5% female) aged 18-30 years (μ = 23.62, sd = 2.71). the vast majority of them were greek (98.9%) and residents of urban areas (94.3%). the sample composition of participants’ highest level of education completed was: 58.3% social media use and mental health 4 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ high school/vocational education and training, 33.9% university/college degree, and 7.8% postgraduate studies. furthermore, 98.6% of the participants were unmarried and 59.9% reported a low monthly income (up to 500€). regarding employment status, 59.5% of participants were not working. the sociodemographic characteristics of the participants are presented in table 1. table 1 sociodemographic characteristics of participants and associations with depressive symptoms and self-esteem (n = 654) sociodemographic variables depressive symptoms self-esteem n % m sd p m sd p gender .330 .140 male 330 50.5 9.24 7.98 30.86 4.59 female 324 49.5 9.85 8.18 30.31 4.97 nationality .514 .079 greek 647 98.9 9.50 7.99 30.62 4.79 other 7 1.1 13.29 14.44 27.43 3.74 place of origin .086 .496 urban 527 80.6 9.28 8.09 30.65 4.78 rural 127 19.4 10.65 7.96 30.33 4.81 place of residence .167 .483 urban 617 94.3 9.43 8.11 30.62 4.81 rural 37 5.7 11.32 7.27 30.05 4.43 educational level .396 .610 high school/v.e.t. 381 58.3 9.85 8.25 30.67 4.61 university/college 222 33.9 8.94 7.49 30.36 5.01 postgraduate studies 51 7.8 9.88 9.19 30.98 5.09 employment status .191 .448 working 265 40.5 10.04 8.23 30.76 5.03 non-working 389 59.5 9.20 7.96 30.47 4.62 net monthly income .396 .051 0 € 500 € 392 59.9 9.70 8.35 30.29 4.73 > 500 € 249 38.1 9.15 7.49 31.05 4.86 marital status .097 .814 unmarried 645 98.6 9.60 8.10 30.59 4.81 married 9 1.4 5.11 5.09 30.78 2.28 m sd minmax r p r p participants' age 23.62 2.71 18–30 -.043 .273 .058 .139 note. t-test and anova were used for differences between continuous variables; pearson’s r was used for correlation between continuous variables. leimonis & koutra 5 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ measures sociodemographic characteristics sociodemographic variables included participants’ gender, age, nationality (greek or other), place of origin and residence (urban vs. rural), educational level that each partic­ ipant had completed (high school/vocational education and training, university/college degree, postgraduate studies), employment status (working vs. non-working), marital status (unmarried vs. married), and net monthly income (0-500€ vs. 501€ and above). social media use we assessed participants’ social media involvement based on daily time use and type of user (active/passive user), influenced by recent studies (escobar-viera et al., 2018; lin et al., 2016). due to the lack of greek standardised psychometric tools concerning the above-mentioned variables, we designed a brief self-reported questionnaire consisting of three items based on a previous study about internet and social media use in relation to consumer behaviour (koutsogiannopoulou, 2013). first, participants were asked whether they had been using social media (“do you use social media?”), responding to an alterna­ tive form question (“yes” or “no”), and provided estimates about their daily use of specific popular platforms, including facebook, twitter, instagram, youtube, tumblr, linkedin, skype, and blogs. four response choices were offered in a likert-type scale (“not at all”, “less than two hours”, “two to five hours”, “more than five hours”). moreover, individuals were asked to characterise their involvement on each one of these networks as “pas­ sive” or “active” after explanation of these two terms was offered. specifically, passive users were considered those who maintained activities such as limited communication and sharing of electronic content, along with passive following of other users’ posts. conversely, individuals who engaged more in interaction with others and sharing of various types of content were considered as active users. to ensure participants’ best comprehension of these patterns of activity, we used definitions and examples based on previous studies (e.g. escobar-viera et al., 2018). self-esteem self-esteem was measured by means of the rosenberg self-esteem scale (rses; rosenberg, 1965). the rses consists of 10 items in form of statements which are related to self-esteem (e.g. “i feel i do not have much to be proud of”). of these statements, five are positively graded (1, 2, 4, 6, 7) and five are negatively graded (3, 5, 8, 9, 10). each individual is asked to respond to a four-point likert scale, ranging from 1 (“strongly disagree”) to 4 (“strongly agree”). total score ranges from 10 to 40 with higher scores indicating higher levels of self-esteem. high self-esteem scores suggest that individuals have self-respect and consider him or herself worthy. low self-esteem scores suggest an unfavorable opinion of oneself and self-dissatisfaction. the scale has been translated and social media use and mental health 6 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ validated for the greek population by tsagarakis et al. (2007). in the present study, the scale demonstrated satisfactory internal consistency (α = .84). depressive symptoms depressive symptomatology was measured using the beck depression inventory-ii (bdiii; beck et al., 1996). the bdi-ii is a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression (beck et al., 1996), while it taps major depression symptoms according to diagnostic criteria listed in the diagnostic and statistical manual for mental disorders (american psychiatric association, 2000). each item is assessed on a four-point scale (0–3). the total score indicates whether the individual presents a mild, moderate or major depression (possible range 0-63). the bdi-ii has been translated and validated in greek by giannakou et al. (2013). in the present study, the scale showed satisfactory internal consistency (α = .86). procedure participants were recruited through the research team contacting different academic departments, and disseminating a web link to each student which provided details of the study. moreover, non-university student participants were recruited via online posts at social media groups. information about anonymous and voluntary participation was pro­ vided to participants prior to data collection. confidentiality was assured and informed consent was obtained from the participants. finally, participants were given written instructions for filling out the questionnaires and were informed about the estimated time needed for completing the measures (approximately 15 minutes). the study was conducted in accordance with the ethical standards delineated in the 1964 declaration of helsinki and its later amendments or comparable ethical standards. ethical approval was granted by the psychology department’s research ethics committee. informed consent was obtained from all individual participants included in the study. data analysis with regard to descriptive data, we computed percentages of sociodemographic varia­ bles, daily time use of social networks and type of social media use (active and passive use). in terms of descriptive indices, we calculated means (m) and standard deviations (sd) in order to better frame our results. social media use was not assessed as a single numeric variable, since we focused our analyses on daily time of use (less than two hours, two to five hours, more than five hours) and self-reported type of use (passive vs. active). considering that youtube, facebook and instagram showed by far the highest percentages of daily users, our analyses were focused on the specific platforms. t-test and anova were used for the comparison of independent groups. specifically, we employed one-way anovas, including post-hoc comparisons using tukey, to sepa­ leimonis & koutra 7 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ rately investigate differences in depressive symptomatology and self-esteem between categories regarding daily use of youtube, facebook and instagram (less than two hours, two to five hours, more than five hours). moreover, we used independent samples t-tests to assess differences in depressive symptoms and self-esteem between categories concerning self-reported type of youtube, facebook and instagram use (active and pas­ sive). pearson’s r correlation coefficient was used to estimate the strength of the associ­ ation between self-esteem and depressive symptoms. multiple linear regression models were also implemented to further and separately examine the associations of youtube, facebook and instagram use (daily time and type of use) with depressive symptoms and self-esteem, after adjusting for confounding variables. potential confounders related with both the outcome and/or the independent variables in group comparisons with a p-value < .2 were included in the models. therefore, each model was adjusted for participants’ gender, age, educational level and employment status, while estimated asso­ ciations were described in terms of b-coefficients (beta). we were also able to examine effect modification stratifying by gender. for interaction terms, we considered p-value < .05 as nominally significant. all other hypotheses testing was conducted assuming a .05 significance level and a two-sided alternative hypothesis. all analyses were conducted by means of the ibm spss statistics 26 software. results prevalence of social media use in terms of daily time of engagement in social media, youtube was the most popular platform with respect to users (97.6%), followed by facebook (93.3%), instagram (81.8%), blogs (15.9%), skype (12.1%), linkedin (10.9%), twitter (4.3%) and tumblr (3.1%). only 17.7% of the participants reported using some other platform except for the specific ones. overall, 99.4% of the participants were found to use more than one platform daily. concerning the self-reported type of social media use, 65.8% of daily youtube users reported being passive, while 51.3% of daily facebook users mentioned being active. instagram demonstrated the highest self-reported active online engagement (75%). additionally, more than 50% of daily users of blogs, skype, linkedin and twitter stated passive involvement in these platforms, whereas half of tumblr everyday users reported being active. associations between sociodemographic characteristics and study variables tables 1 and 2 show associations between participants’ sociodemographic characteristics and the outcome variables of our study. specifically, non-significant relationships were found between sociodemographic variables, depressive symptomatology and self-esteem social media use and mental health 8 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ at a level of p-value < .05 (table 1). according to table 2, significant differences between men and women were found in terms daily use of youtube, χ2(2, n = 638) = 10.11, p = .006, and instagram, χ2(2, n = 535) = 11.74, p = .003, as well as self-reported type of instagram use, χ2(1, n = 535) = 9.20, p = .002. in addition, participants’ age was significantly related to all social media use variables, while educational level showed significant associations with self-reported type of youtube, facebook and instagram use. employment status was linked with daily use of youtube, χ2(2, n = 638) = 11.17, p = .004, along with self-reported type of youtube, facebook and instagram use. individuals’ net monthly income was significantly associated with daily use of youtube, χ2(2, n = 625) = 6.59, p = .037. table 2 participants’ sociodemographic characteristics and social media use (n = 654) sociodemographic variables social media daily use social media user type youtubea facebooka instagrama youtubeb facebookb instagramb χ2 pc χ2 pc χ2 pc χ2 pc χ2 pc χ2 pc gender 10.11 .006** 4.50 .105 11.74 .003** 3.79 .053 1.51 .219 9.20 .002** nationality 1.58 .455 1.02 .602 1.05 .592 .00 .965 1.99 .160 .00 1.000 place of origin 2.48 .289 .01 .995 1.38 .501 .04 .837 .69 .406 1.36 .244 place of residence 2.07 .356 .16 .923 1.20 .548 .22 .638 .47 .494 .70 .404 educational level 5.41 .247 6.18 .186 5.09 .278 40.78 < .001*** 18.02 < .001*** 16.91 < .001*** employment status 11.17 .004** 1.26 .532 1.55 .461 9.54 .002** 4.78 .029* 4.22 .040* net monthly income 6.59 .037* 1.72 .422 1.81 .405 1.04 .307 2.40 .121 3.11 .078 marital status 2.19 .700 1.00 .911 6.14 .189 .62 .733 1.68 .431 5.72 .057 f pd f pd f pd t pe t pe t pe participants' age 3.78 .023* 5.33 .005** 4.78 .009** 4.77 < .001*** 3.93 < .001*** 4.94 < .001*** aincludes daily use of less than 2 hours, 2-5 hours, and more than 5 hours. bincludes self-reported active user and passive user. cp value derived using chi-square analysis. dp-value derived using one-way anova. ep-value derived using independent samples t-test. *p < .05. **p < .01. ***p < .001. differences in depressive symptomatology and self-esteem by social media groups table 3 shows differences in depressive symptomatology and self-esteem by social media groups. one-way anova results indicated a statistically significant difference in the mean score of self-esteem between the different categories of facebook daily use, f(2, 607) = 6.88, p = .001, η2 = .02. particularly, a post-hoc tukey test showed that individuals who reported two to five hours of facebook everyday use had significantly higher self-esteem (n = 185, m = 31.62, sd = 4.87) compared to those who had been using facebook for less than two hours daily (n = 365, m = 30.04, sd = 4.51, p = .001). leimonis & koutra 9 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ table 3 group differences in depressive symptomatology and self-esteem by social media use (n = 654) social media use depressive symptomatologya self-esteema n m sd f pb η2 m sd f pb η2 youtube daily use 2.94 .053 .01 .35 .703 .00 less than 2 hours 316 9.23 7.59 30.63 4.69 2-5 hours 262 9.33 7.87 30.73 4.68 more than 5 hours 60 11.90 10.31 30.15 5.67 facebook daily use .94 .391 .00 6.88 .001** .02 less than 2 hours 365 9.59 7.98 30.04 4.51 2-5 hours 185 9.03 7.60 31.62 4.87 more than 5 hours 60 10.62 8.56 30.72 5.33 instagram daily use .74 .477 .00 1.00 .370 .00 less than 2 hours 215 9.37 8.07 30.33 4.59 2-5 hours 254 9.69 7.91 30.95 4.91 more than 5 hours 66 10.74 8.35 30.86 5.30 n m sd t p c d m sd t p c d youtube user type .47 .641 .04 -1.56 .119 .13 active users 218 9.32 7.97 31.03 4.96 passive users 420 9.63 8.05 30.41 4.68 facebook user type 2.55 .011* .21 -4.30 < .001*** .35 active users 313 8.73 7.27 31.18 4.75 passive users 297 10.36 8.51 29.75 4.61 instagram user type 3.33 .001** .32 -2.32 .021* .23 active users 401 9.03 7.61 30.97 4.81 passive users 134 11.67 8.91 29.86 4.84 adepressive symptomatology and self-esteem were treated as continuous numeric variables. bp-value derived using one-way anova. cp-value derived using independent samples t-test. *p < .05. **p < .01. ***p < .001. according to t-test results, a significant mean difference was found between self-repor­ ted active facebook users (n = 313, μ = 8.73, sd = 7.27) and passive facebook users (n = 297, μ = 10.36, sd = 8.51), t(583) = 2.55, p = .011, d = .21. there was also a significant difference in depressive symptoms between self-reported active instagram users (n = 401, μ = 9.03, sd = 7.61) and passive instagram users (ν = 134, μ = 11.67, sd = 8.91), t(533) = 3.33, p = .001, d = .32. a significant difference was observed in self-esteem between self-reported active facebook users (ν = 313, μ = 31.38, sd = 4.75) and passive facebook users (ν = 297, μ = 29.75, sd = 4.61), t(608) = -4.30, p < .001, d = .35. likewise, there was a significant difference in self-esteem between active instagram users (ν = 401, μ = 30.97, sd = 4.81) and passive instagram users (ν = 134, μ = 29.86, sd = 4.84), t(533) = -2.32, p = .021, d = .23. finally, self-esteem was significantly and negatively correlated with depressive symptomatology, r(652) = -.55, p < .001. social media use and mental health 10 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ multivariable associations of social media daily use and user type with depressive symptomatology and self-esteem according to multiple linear regression results (table 4), daily youtube use of more than five hours was associated with significantly higher bdi-ii scores, after controlling for gender, age, educational level and employment status, b = 2.99, 95% ci [.78, 5.20], p = .008. the model explained 2% (adjusted 1.1%) of the variance in bdi-ii scores (r 2 = .02). daily use of facebook and instagram showed non-significant associations with depressive symptoms. table 4 adjusted associations of social media daily use and user type with depressive symptomatology and self-esteem (n = 654) modelsa depressive symptomatologyb self-esteemb bc se b 95% cic p bc se b 95% cic p youtube daily use 2-5 hours vs. < 2 hoursd .30 .67 [-1.01, 1.62] .652 .09 .40 [-.70, .88] .819 > 5 hours vs. < 2 hoursd 2.99 1.13 [.78, 5.20] .008** -.45 .68 [-1.78, .89] .512 facebook daily use 2-5 hours vs. < 2 hoursd -.60 .71 [-1.99, .80] .402 1.61 .42 [.78, 2.44] < .001*** > 5 hours vs. < 2 hoursd .70 1.11 [-1.47, 2.87] .525 .83 .66 [-.46, 2.12] .205 instagram daily use 2-5 hours vs. < 2 hoursd .01 .75 [-1.46, 1.47] .995 .82 .45 [-.06, 1.70] .068 > 5 hours vs. < 2 hoursd 1.04 1.13 [-1.17, 3.26] .356 .81 .68 [-.53, 2.14] .236 youtube user type active vs. passived -.60 .69 [-1.96, .75] .383 .64 .41 [-.17, 1.45] .122 facebook user type active vs. passived -1.92 .65 [-3.18, -.65] .003** 1.74 .38 [.99, 2.49] < .001*** instagram user type active vs. passived -3.25 .81 [-4.83, -1.66] < .001*** 1.45 .49 [.49, 2.41] .003** aall models adjusted for participants’ gender, age, educational level, and employment status. bdepressive symptomatology and self-esteem were treated as continuous numeric variables. cb-coefficients and 95% ci of b retained from linear regression. dreference variable. *p < .05. **p < .01. *** p < .001. daily facebook use of two to five hours was associated with significantly higher self-es­ teem, after controlling for gender, age, educational level and employment status, b = 1.61, 95% ci [.78, 2.44], p < .001. the model explained 2% (adjusted 1%) of the variance in depressive symptoms (r 2 = .02). daily use of youtube showed non-significant results regarding self-esteem. leimonis & koutra 11 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ active facebook use was significantly associated with lower bdi-ii scores, after con­ trolling for gender, age, educational level and employment status, b = -1.92, 95% ci [-3.18, -.65], p = .003. the model explained 2% (adjusted 1.5%) of the variance in depressive symptoms (r 2 = .02). likewise, self-reported active instagram use was related to signifi­ cantly reduced depressive symptoms, after controlling for gender, age, educational level and employment status, b = -3.25, 95% ci [-4.83, -1.66], p < .001). the model explained 4% (adjusted 3.4%) of the variance in bdi-ii scores (r 2 = .04). self-reported type of youtube use showed non-significant results concerning depressive symptoms. active facebook use was associated with significantly increased levels of self-esteem, after controlling for gender, age, educational level and employment status, b = 1.74, 95% ci [.99, 2.49], p < .001. the model explained 4% (adjusted 3.4%) of the variance in depressive symptoms (r 2 = .04). similar results were also found concerning active use of instagram, after controlling for gender, age, educational level and employment status, b = 1.45, 95% ci [.49, 2.41], p = .003). the model explained 3% (adjusted 2.5%) of the variance in depressive symptoms (r 2 = .03). self-reported type of youtube use showed non-significant results regarding self-esteem. interaction effect analyses youtube daily use of more than five hours showed a stronger association with depressive symptoms for males than for females (p for interaction = .026). discussion the present study investigated the association of social media use with self-esteem and depressive symptomatology in young adults. according to the results, increased daily time spent in youtube (more than five hours) showed a significant association with higher depressive symptoms, while daily use of facebook between two and five hours was related to significantly increased self-esteem, after adjusting for gender, age, educational level and employment status. youtube daily use of more than five hours showed a stronger association with depressive symptoms for males than for females. additionally, self-reported active use of facebook and instagram were associated with significantly lower depressive symptoms and higher self-esteem as compared to passive use. in accordance with previous findings from greece (drosos et al., 2015), youtube and facebook displayed the highest percentages of everyday involvement with regard to our sample. moreover, in line with our first hypothesis and previous studies (e.g. lin et al., 2016; pantic et al., 2012), daily youtube use of more than five hours was associated with increased depressive symptomatology. recent research has suggested that youtube, unlike facebook and instagram, has been linked to increased perceived information social media use and mental health 12 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ overload for users due to the great amount of available video content. in addition, information overload in social media has been associated with higher depressive symp­ toms overtime (matthes et al., 2020). on the other hand, depression is often associated with social withdrawal (girard et al., 2014), hence it is possible that individuals with high depressive symptomatology tend to use youtube more in comparison with other platforms, as it encourages less interactive involvement (burgess & green, 2009). we also found that the association of increased daily time use of youtube with de­ pressive symptoms was more pronounced in males than in females. conversely, twenge and martin (2020) have recently indicated that the relationship between increased time of social media use and low levels of psychological well-being is stronger in females. women appear to use social media more in order to sustain their existing relationships compared to men (muscanell & guadagno, 2012), which has been associated with higher self-esteem (wilcox & stephen, 2013). therefore, female users could exhibit lower de­ pressive symptomatology compared to male, given that self-esteem is negatively related to depressive symptoms (conti et al., 2014). additionally, men with increased depressive symptoms have been found to be more susceptible to internet overuse compared to women (liang et al., 2016), which could also apply to social media use. in contrast with our first hypothesis and recent studies (bergagna & tartaglia, 2018; woods & scott, 2016), our results showed that increased daily use of facebook is sig­ nificantly related to higher self-esteem, although the effect size is small. according to walther’s hyperpersonal model of computer-mediated communication (walther, 2007) and previous research (gonzales & hancock, 2011), selective self-presentation on face­ book can lead to higher self-awareness and, therefore, an increase in users’ self-esteem. moreover, individuals focusing on close friendly relationships on social networks have exhibited higher levels of self-esteem (e.g. wilcox & stephen, 2013). a possible mecha­ nism explaining this relationship could be the positive feedback that users receive from their online friends, as it has been related to increased self-esteem levels (valkenburg et al., 2017; valkenburg et al., 2006). this study also indicated that self-reported active use of facebook and instagram are linked with significantly lower depressive symptoms and higher self-esteem compared to passive use. these results correspond to recent findings (escobar-viera et al., 2018; verduyn et al., 2015) and align with our second hypothesis. according to previous re­ search, passive use of social networks has been related to feelings of envy and decreased life satisfaction (krasnova et al., 2013), while envy on social media, such as facebook, has significantly predicted depressive symptoms (tandoc et al., 2015). on the other hand, higher self-esteem has been linked with increased life satisfaction (moksnes & espnes, 2013), and decreased feelings of envy (vrabel et al., 2018). thus, it appears that social comparison as a mechanism might provide explanation concerning our findings, since it could induce feelings of envy, while being related to passive activity in social media (rozgonjuk et al., 2019). furthermore, it is possible that high self-esteem encourages leimonis & koutra 13 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ active behaviour in social media, as previous data has suggested a significant association between decreased feelings of self-worth and passive activities on platforms such as facebook (tazghini & siedlecki, 2013). strengths and limitations to our knowledge, the present study was one of the few focusing on the investigation of the association between social media use and mental health in a greek sample of young adults. the large sample size along with the equal distribution of men and women provided adequate power to detect small effects. additionally, self-esteem and depressive symptomatology were measured via standardised, valid and reliable psychometric tools displaying good psychometric properties with regard to our sample. finally, the simulta­ neous assessment of different social networking platforms, instead of examining social media as a whole or focusing exclusively on a specific platform, was an additional strength of this study. our fine-grained assessment of multiple platforms likely improved our measurement of overall frequency of social media use. we acknowledge that there are also some limitations in our study. given the crosssectional design of the study, we are not able to establish the direction of the observed associations. furthermore, even though both university students from various academic departments and non-university students from different regions in greece were included in our study, generalizability in the greek population may be limited. moreover, due to the lack of a standardised greek scale assessing social media use we used three items with specific artificial categories to measure daily time of social media involvement, which could be a noteworthy limitation as well. a number of methodological studies highlight a substantial loss of information as well as biased estimates when a continuous measure is broken up in artificial categories. it is also important to note that there are many different types of interactions that can be observed over social media, and our study assessed only overall time spent and type of use (active vs. passive) to social media sites. the type of social media use in terms of activity/passivity was examined only through self-reported questions, which could have relied our results and deductions exclusively on participants’ understanding of the terms “passive use” and “active use”. additionally, the assessment of self-esteem and depressive symptomatology through self-reported scales instead of interviewing techniques, combined with our focus on non-clinical population, could restrict the possible clinical extensions of our findings. furthermore, the small effect size reported was obtained in a sample of the general popu­ lation which is expected to underestimate the effect size expected to occur in a clinical sample comprising persons displaying higher variability in self-reported symptom scales such as the bdi-ii and rses, and are in principle more vulnerable to social stressors. additionally, the results from the multivariate linear regression analyses should be inter­ preted with caution given that the explained variance ranges between 1% and 4%; thus, if reported the other way around 96% to 99% of variance is not explained by the predictors social media use and mental health 14 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://www.psychopen.eu/ in that model. finally, although in our regression models we were able to adjust for a large number of confounding factors, because of the observational study design, residual confounding of other unmeasured confounders such as home environment or negative life events may still occur. conclusion the present study showed that there is a significant association between social media use and young adults’ mental health in terms of self-esteem and depressive symptoma­ tology. overall, our results add strength to previous research and could contribute to a deeper understanding of the association between social networks and human behaviour. however, a longitudinal investigation of this association is required to fully understand the temporal relationships aiding early identification of youth at risk and thus effective management of the social media use that lead to negative outcomes in mental health. in addition, future research could further explore gender differences concerning the relationship between social networking and young adults’ mental health. moreover, up­ coming studies could investigate the potential moderating or mediating effect of different patterns of use (e.g. passive and active involvement) on the relationship between time of social media use and mental health. funding: the authors have no funding to report. acknowledgments: we are very grateful to all participants of the study. competing interests: the authors have declared that no competing interests exist. references american psychiatric association. 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(2020). depression. geneva, switzerland. https://www.who.int/news-room/fact-sheets/detail/depression clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. social media use and mental health 20 clinical psychology in europe 2022, vol. 4(2), article e4621 https://doi.org/10.32872/cpe.4621 https://doi.org/10.26253/heal.uth.4875 https://doi.org/10.26253/heal.uth.4875 https://doi.org/10.1037/xge0000057 https://doi.org/10.1037/ppm0000047 https://doi.org/10.1016/j.paid.2017.11.001 https://doi.org/10.1016/j.chb.2006.05.002 https://doi.org/10.1016/j.jad.2020.03.173 https://doi.org/10.1086/668794 https://doi.org/10.1016/j.adolescence.2016.05.008 https://www.who.int/news-room/fact-sheets/detail/depression https://www.psychopen.eu/ social media use and mental health (introduction) method participants measures procedure data analysis results prevalence of social media use associations between sociodemographic characteristics and study variables differences in depressive symptomatology and self-esteem by social media groups multivariable associations of social media daily use and user type with depressive symptomatology and self-esteem interaction effect analyses discussion strengths and limitations conclusion (additional information) funding acknowledgments competing interests references a brief history of aaron t. beck, md, and cognitive behavior therapy editorial a brief history of aaron t. beck, md, and cognitive behavior therapy judith s. beck 1,2, sarah fleming 1 [1] beck institute for cognitive behavior therapy, philadelphia, pa, usa. [2] perelman school of medicine, university of pennsylvania, philadelphia, pa, usa. clinical psychology in europe, 2021, vol. 3(2), article e6701, https://doi.org/10.32872/cpe.6701 published (vor): 2021-06-18 corresponding author: sarah fleming, beck institute for cognitive behavior therapy, po box 2152, bala cynwyd, pa 19004-6152, usa. e-mail: sfleming@beckinstitute.org on july 18th, 2021, the medical and mental health community around the world will celebrate the 100th birthday of aaron t. beck, md. dr. beck is globally recognized as the father of cognitive behavior therapy (cbt) and is one of the world’s leading researchers in psychopathology. since he developed cbt in the 1960s and 1970s, this revolutionary treatment has been found to be effective in over 2000 clinical trials for a wide range of mental disorders, psychological problems, and medical conditions with psychological components. a prolific and productive researcher with a career spanning more than 70 years, dr. beck has published over 600 articles and authored or co-authored 25 books. he is also the recipient of numerous awards, including the 2006 albert lasker award for clinical medical research and the gustave o. lienhard award from the institute of medicine for “outstanding national achievement in improving personal health care services in the united states.” he has dedicated his life to alleviating human suffering through the development of an evidence-based psychological therapy and continues his work to this day. cbt is based on the psychological construct that individuals’ interpretations of situations influence their reaction (emotional, behavioral, physiological), more so than the situation itself. further, people’s interpretations may be distorted, inaccurate or unhelpful, particularly when psychopathology is present. these interpretations, termed “automatic thoughts”, are often linked to maladaptive underlying beliefs that individuals have about themselves, other people, the world, or the future. dr. beck found that when he helped his patients evaluate and change their distorted thinking, they felt better and were able to modify their behavior. when he helped them evaluate and change their underlying beliefs, their improvement was long-lasting. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6701&domain=pdf&date_stamp=2021-06-18 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ dr. aaron t. beck and dr. judith s. beck co-founded beck institute in 1994 photo © 2019 beck institute for cognitive behavior therapy the development of cognitive therapy as a young psychiatrist in the 1950s, dr. beck wholly subscribed to the dominant psy­ chotherapeutic modality at the time: psychoanalysis. his earliest research sought to vali­ date psychoanalytic constructs. he was surprised when his research appeared to refute the underlying tenets of psychoanalytic theory. rather than confirm the psychoanalytic theory that depressed clients felt an innate need to suffer, dr. beck’s initial studies with depressed patients seemed to point to underlying negative beliefs associated with loss and failure. he soon began to understand that these underlying beliefs were consistent with the patients’ automatic thoughts, which could be accessed and collaboratively eval­ uated in session. dr. beck moved his patients from the couch to a chair, where he worked with them to examine their automatic thoughts and identify cognitive distortions. by helping patients correct negative information processing biases, he was able to help them feel better and engage in more adaptive behaviors. he called his new therapy “cognitive therapy”. in 1977, the results of the first major clinical trial comparing cognitive therapy to anti-depressant medication were published (rush et al., 1977). cognitive therapy became the first talking therapy shown to be more efficacious than medication for the treatment of depression. when a second study, conducted in the uk and published in 1981, appeared to replicate the results (blackburn et al., 1981), interest in the approach grew nationally and internationally. a brief history of aaron t. beck, md, and cognitive behavior therapy 2 clinical psychology in europe 2021, vol. 3(2), article e6701 https://doi.org/10.32872/cpe.6701 https://www.psychopen.eu/ dr. aaron t. beck and the dalai lama photo © 2019 beck institute for cognitive behavior therapy dr. beck (and colleagues) began to apply cognitive therapy to other disorders, such as anxiety, personality disorders, substance use, and suicidality. he developed a comprehen­ sive theory of psychopathology that provided the basis for treatment and methods to evaluate the validity of his theories and the efficacy and effectiveness of the therapy. for each new condition, he would begin by making clinical observations, identifying typical maladaptive beliefs associated with the disorder. he often developed scales and instruments to assess these beliefs. he would then develop a treatment to target the dys­ functional beliefs and associated maladaptive behavioral strategies. the therapy would be validated using a randomized controlled trial, then disseminated in the literature so that others could study, practice, and refine the treatment (beck, 2019). other researchers followed suit. in the uk, for example, a group at oxford used a similar method to devise and test cognitive therapy treatment protocols for panic disorder, social anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder (clark, 1986; clark & wells, 1995; salkovskis, 1999; ehlers et al., 2005). cognitive therapy was also successfully applied to eating disorders, couples’ problems, anger and hostility, psychosis, and other mental health problems. it was also successfully applied to children, adoles­ cents, adults, and older adults in a variety of settings, including hospitals, outpatient clinics, residential placements, schools, and prisons. beck & fleming 3 clinical psychology in europe 2021, vol. 3(2), article e6701 https://doi.org/10.32872/cpe.6701 https://www.psychopen.eu/ dr. aaron t. beck at the beck excellence summit photo © 2019 beck institute for cognitive behavior therapy additionally, researchers found that patients with medical conditions can benefit from cognitive therapy, or cognitive behavior therapy (cbt), as it is known today. in many cases, cbt can help reduce symptoms. in other cases, cbt can help patients cope better with their conditions. research has shown that patients with scores of medical problems from dementia and insomnia to irritable bowel syndrome, migraine headaches, obesity, and chronic pain have benefited from cbt. achievements in cognitive therapy cbt has become the most widely practiced (knapp et al., 2015) and heavily researched (david et al., 2018) psychotherapy in the world. much of its success can be attributed to the careful attention paid to its dissemination and implementation and to the training and credentialing of cbt therapists around the world. to this end, dr. aaron beck and his daughter, dr. judith beck, founded the nonprofit beck institute for cognitive behavior therapy (bi) in 1994. the mission of bi is to improve lives worldwide through excellence and innovation in cbt training, practice, and research. the organization has trained more than 28,000 health and mental health professionals from 130 countries through a variety of in person and virtual programs and distance supervision, including some of the leading researchers in cbt today. all of the organization’s programs operate in service of its mission. one of the largest and most successful implementations of cbt has been the improv­ ing access to psychological therapies (iapt) program. dr. david m. clark, a prominent cbt researcher, who had maintained a close working relationship with dr. aaron beck a brief history of aaron t. beck, md, and cognitive behavior therapy 4 clinical psychology in europe 2021, vol. 3(2), article e6701 https://doi.org/10.32872/cpe.6701 https://www.psychopen.eu/ since he was a doctoral student, partnered with economist lord richard layard to radi­ cally expand access to evidence-based psychological therapies throughout england via a massive overhaul of england’s national health service (nhs). through iapt, dr. clark and his colleagues have trained over 10,500 clinicians in cbt and other evidence-based therapies. as of 2019, one million people pass through the program each year, with over half a million receiving a course of treatment. the program has collected outcome data on 99% of those treated. around seven in every ten treated individuals (67%) show substantial reductions in their anxiety or depression. for five in every ten (51%) the reductions are large enough for the person to be classified as recovered (clark, 2019). by 2024, the iapt program plans to increase its reach from one million to 1.9 million individuals annually. the iapt program has shown that improving public mental health is not only possible but is also cost-effective. the program should serve as a blueprint for countries around the world who want to address the growing global mental health crisis. dr. aaron t. beck and family at his 95th birthday celebration photo © 2019 beck institute for cognitive behavior therapy dr. aaron beck has continued his research into the treatment of psychopathology even until today. he is most passionate about the work he and colleagues at the university of pennsylvania and now at the beck institute undertook two decades ago. they devel­ oped recovery-oriented cognitive therapy (ct-r), which provides concrete, actionable steps to promote recovery and resilience among individuals with serious mental health conditions. ct-r is beginning to change the way severe mental illness is conceptualized and treated. initial research has supported this approach (grant et al., 2012; grant et al., 2017). originally developed to treat schizophrenia, the principles of ct-r can be incorpo­ rated into cbt (j. beck, 2020) and may be especially useful for individuals experiencing beck & fleming 5 clinical psychology in europe 2021, vol. 3(2), article e6701 https://doi.org/10.32872/cpe.6701 https://www.psychopen.eu/ extensive behavioral, social, and physical health challenges. ct-r is highly collaborative, person-centered, and strengths-based, focusing on developing and strengthening positive beliefs of purpose, hope, efficacy, empowerment and belonging (and deemphasizing a focus on symptoms and negative beliefs). this approach has been implemented in a variety of inpatient, residential, and community settings, resulting in the reduction or elimination of controlling interventions such as seclusion, restraint, and as-needed medication, as well as reducing the length of hospital stays for individuals (beck et al., 2020). the future of cognitive therapy building on cbt’s demonstrated efficacy, one important continuing challenge for re­ searchers and clinicians is to develop ways to deliver quality cbt treatment to the indi­ viduals who need it most. this involves both adapting treatment for diverse cultures and populations and creating effective and efficient treatment delivery models, including the expansion of digital and online methods of delivery and integrating cbt into primary care settings and public health clinics. it also entails robust and effective training pro­ grams for health and mental health professionals, peer specialists, care givers, teachers, and other groups. dr. aaron beck has devoted his life to alleviating human suffering through his study and application of psychological principles. the cbt community looks forward to honoring his 70-year legacy by continuing to study and disseminate evidence-based cbt around the world. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references beck, a. t. (2019). a 60-year evolution of cognitive theory and therapy. perspectives on psychological science, 14(1), 16-20. https://doi.org/10.1177/1745691618804187 beck, a. t., grant, p., inverso, e., brinen, a., & perivoliotis, d. (2020). recovery-oriented cognitive therapy for serious mental health conditions. new york, ny, usa: guilford press. beck, j. s. (2020). cognitive behavior therapy, third edition: basics and beyond. new york, ny, usa: guilford press. blackburn, i. m., bishop, s., glen, a. i. m., whalley, l. j., & christie, j. e. (1981). the efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and a brief history of aaron t. beck, md, and cognitive behavior therapy 6 clinical psychology in europe 2021, vol. 3(2), article e6701 https://doi.org/10.32872/cpe.6701 https://doi.org/10.1177/1745691618804187 https://www.psychopen.eu/ pharmacotherapy, each alone and in combination. the british journal of psychiatry, 139(3), 181-189. https://doi.org/10.1192/bjp.139.3.181 clark, d. m. (1986). a cognitive approach to panic. behaviour research and therapy, 24(4), 461-470. https://doi.org/10.1016/0005-7967(86)90011-2 clark, d. m. (2019). iapt at 10: achievements and challenges. https://www.england.nhs.uk/blog/iapt-at-10-achievements-and-challenges clark, d. m., & wells, a. (1995). a cognitive model of social phobia. in r. g. heimberg, m. liebowitz, d. hope, & f. scheier (eds.), social phobia: diagnosis, assessment and treatment (pp. 69–93). new york, ny, usa: guilford press. david, d., cristea, i., & hofmann, s. g. (2018). why cognitive behavioral therapy is the current gold standard of psychotherapy. frontiers in psychiatry, 9, article 4. https://doi.org/10.3389/fpsyt.2018.00004 ehlers, a., clark, d. m., hackmann, a., mcmanus, f., & fennell, m. (2005). cognitive therapy for post-traumatic stress disorder: development and evaluation. behaviour research and therapy, 43(4), 413-431. https://doi.org/10.1016/j.brat.2004.03.006 grant, p. m., bredemeier, k., & beck, a. t. (2017). six-month follow-up of recovery-oriented cognitive therapy for low-functioning individuals with schizophrenia. psychiatric services, 68, 997-1002. https://doi.org/10.1176/appi.ps.201600413 grant, p. m., huh, g. a., perivoliotis, d., stolar, n. m., & beck, a. t. (2012). randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. archives of general psychiatry, 69, 121-127. https://doi.org/10.1001/archgenpsychiatry.2011.129 knapp, p., kieling, c., & beck, a. t. (2015). what do psychotherapists do? a systematic review and meta-regression of surveys. psychotherapy and psychosomatics, 84(6), 377-378. https://doi.org/10.1159/000433555 rush, a. j., beck, a. t., kovacs, m., & hollon, s. (1977). comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. cognitive therapy and research, 1, 17-37. https://doi.org/10.1007/bf01173502 salkovskis, p. m. (1999). understanding and treating obsessive—compulsive disorder. behaviour research and therapy, 37, s29-s52. https://doi.org/10.1016/s0005-7967(99)00049-2 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. beck & fleming 7 clinical psychology in europe 2021, vol. 3(2), article e6701 https://doi.org/10.32872/cpe.6701 https://doi.org/10.1192/bjp.139.3.181 https://doi.org/10.1016/0005-7967(86)90011-2 https://www.england.nhs.uk/blog/iapt-at-10-achievements-and-challenges https://doi.org/10.3389/fpsyt.2018.00004 https://doi.org/10.1016/j.brat.2004.03.006 https://doi.org/10.1176/appi.ps.201600413 https://doi.org/10.1001/archgenpsychiatry.2011.129 https://doi.org/10.1159/000433555 https://doi.org/10.1007/bf01173502 https://doi.org/10.1016/s0005-7967(99)00049-2 https://www.psychopen.eu/ a brief history of aaron t. beck, md, and cognitive behavior therapy (introduction) the development of cognitive therapy achievements in cognitive therapy the future of cognitive therapy (additional information) funding acknowledgments competing interests references acute effect of physical exercise on negative affect in borderline personality disorder: a pilot study research articles acute effect of physical exercise on negative affect in borderline personality disorder: a pilot study samuel st-amour 1,2 , lionel cailhol 2,3 , anthony c. ruocco 4 , paquito bernard 1,2 [1] department of physical activity sciences, université du québec à montréal, montreal, quebec, canada. [2] mental health university institute of montreal research center, montreal, quebec, canada. [3] department of psychiatry and addictology, medicine faculty, university of montreal, montreal, quebec, canada. [4] department of psychology (scarborough), university of toronto, toronto, ontario, canada. clinical psychology in europe, 2022, vol. 4(2), article e7495, https://doi.org/10.32872/cpe.7495 received: 2021-09-13 • accepted: 2022-02-08 • published (vor): 2022-06-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: samuel st-amour, 141 avenue du président-kennedy (sb-4290), montréal, qc, canada, h2x 1y4. phone: (+1)514-987-3000(3606). fax: (+1)514.987.6616. e-mail: st-amour.samuel.2@courrier.uqam.ca supplementary materials: data, materials [see index of supplementary materials] abstract background: physical exercise is an evidence-based treatment to reduce symptoms and negative affect in several psychiatric disorders, including depressive, anxiety, and psychotic disorders. however, the effect of physical exercise on negative affect in patients with borderline personality disorder (bpd) has not yet been investigated. in this pilot study, we tested the safety, acceptability, and potential acute effects on negative affect of a single session of aerobic physical exercise in adults with bpd. method: after completing a negative mood induction procedure, 28 adults with bpd were randomly assigned to a 20-minute single session of stationary bicycle or a control condition (emotionally neutral video). results: no adverse effects attributed to the physical exercise were reported and it was considered acceptable to patients. following the negative mood induction, both conditions decreased the level of negative affect with a medium effect size but there was no significant difference between them. conclusion: the results suggest that a single 20-minute session of physical exercise does not produce a reduction of negative affect in bpd. future research should consider the duration and intensities of physical exercise with the greatest potential to reduce negative affect both acutely and in a more prolonged manner in this patient group. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7495&domain=pdf&date_stamp=2022-06-30 https://orcid.org/0000-0002-6282-7885 https://orcid.org/0000-0002-5931-8182 https://orcid.org/0000-0002-1942-7181 https://orcid.org/0000-0003-2180-9135 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords physical activity, emotion regulation, affect, emotion dysregulation, emotion induction highlights • adults with bpd have potential to benefit physical exercise. • in this pilot study, no adverse effects were attributed to physical exercise. • physical exercise was as effective as a neutral video in decreasing negative affect. borderline personality disorder (bpd) is characterized by an instability of self-image, goals, interpersonal relationships, and affect (gunderson et al., 2018). the one-year and lifetime prevalence rates of the diagnosis in the general population are estimated at 1.6% and 5.9%, respectively (american psychiatric association, 2013). among pathogenesis models of bpd (d’agostino et al., 2018), the biosocial developmental model proposes that emotion dysregulation is the core of bpd and underlies many characteristic behaviors (crowell et al., 2009). this model is based on three main components: heightened sensi­ tivity to emotional stimuli, intense reactions to emotional stimuli, and a delayed return to an emotional baseline (crowell et al., 2009; linehan, 1993). difficulties regulating emotions in bpd are linked to maladaptive behaviors, which presumably function to reduce negative affect (daros, guevara, et al., 2018). a higher level of emotion dysregu­ lation has also been associated with lower quality of life and daily functioning (gratz et al., 2016) and a poorer therapeutic relationship (gunderson et al., 2018). emotion dysregulation has also been identified as a mechanism in other psychopathologies such as major depression and bipolar disorder, but seems to be present at a higher level in bpd than in these disorders (gratz et al., 2016). moreover, little is known regarding the specific dimensions of emotion dysregulation to bpd and its development compared to those of other disorders and psychopathology in general (gratz et al., 2016). therefore, finding diagnosis specific interventions to improve emotion regulation and help regulate negative emotions should be among the priorities for research on bpd. from this perspective, a single session of physical exercise (pe) could be useful to help individuals with bpd regulate their emotions in the short term. the effect of a single bout of pe on affect has been the subject of two meta-analyses synthesizing the results of more than 150 studies totaling 13,000 adults in the general population (ekkekakis et al., 2011; reed & ones, 2006). these meta-analyses show that a single bout of pe significantly increases positive affect with a moderate effect size (d = 0.47) and that this effect is higher for individuals with a lower initial level of positive affect (d = 0.63). additionally, self-selected exercise intensity is more effective in increasing positive affect than an imposed intensity. the effects were moderated by cardiovascular capacity, obesity, and exhaustion tolerance (ekkekakis et al., 2011). similar results but with higher effect sizes have been demonstrated in adults with generalized anxiety disorder (d = 1.01; physical exercise and affects in bpd 2 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ herring et al., 2019), major depressive disorder (d = 1.25; meyer, koltyn, et al., 2016) and obsessive-compulsive disorder (d = 0.76; abrantes et al., 2009). another study (stanton et al., 2016) also measured the effect of a 20-minute pe session on core affect (valence and arousal) in individuals with anxiety, bipolar, and depressive disorders and reported an increase in arousal for individuals with depressive and bipolar disorders, and an increase in valence (more positive affect) across all participants. when studying the impact of pe on affect (bernstein & mcnally, 2017a, 2017b, 2018), researchers often experimentally induce an emotion to produce similar levels of affect across participants before exercising, or to modify affect after exercising (barrett et al., 2007; barrett & bliss‐moreau, 2009; kuppens et al., 2013; posner et al., 2005). different strategies are used to induce negative emotions, including frustrating tasks (gratz et al., 2006; sauer & baer, 2012), electric shocks (seibert-hatalsky & wilson, 2011), videos of sexual abuse or domestic violence (chapman et al., 2010; daros, williams, et al., 2018; elices et al., 2012; jacob et al., 2011), remembering negative memories (sauer & baer, 2012), music (diedrich et al., 2016) or emotionally charged images (sloan et al., 2010). of these approaches, presenting videos that induce negative emotions has been shown to be the easiest, most acceptable, and most frequently used strategy (for a review, see gilet, 2008). to our knowledge and according to two recent reviews (hall et al., 2019; mehren et al., 2020; st-amour et al., 2021), no study has yet examined the acute effects of pe on negative affect in bpd. in the present pilot study, our goal was to assess the acceptability and safety of a single session of 20 minutes of pe and quantify the effect size of the impact of such an intervention on core affect (valence and arousal) in patients with bpd following a negative emotion induction, compared to a control condition. we hypothesized that the pe session would be well accepted by the participants and that no adverse effects would be attributed by the participants to the pe condition. based on the research conducted on participants drawn from the general population and those with psychiatric disorders, we additionally hypothesized that the pe condition would increase the valence and decrease the arousal of their core affect with a moderate effect size after the negative emotion induction procedure. method participants patients from the relational and personality disorders service from the mental health university institute of montreal gave their consent to their healthcare professionals to be contacted for research. thereafter, healthcare professionals referred patients to research­ ers based on their established bpd diagnosis. researchers then contacted patients by st-amour, cailhol, ruocco, & bernard 3 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ phone and/or email and planned an appointment after a short screening of inclusion and exclusion criteria. to be included in the study, participants were required to meet the following criteria: 18 years or older; previously diagnosed with bpd by two convergent psychological measures—borderline personality questionnaire (larivière et al., 2021) and structured clinical interview for dsm-iv axis ii disorders (bpd interview; lobbestael et al., 2011)— by a psychiatrist from the relational and personality disorders service from the mental health university institute of montreal; outpatient status at the mental health university institute of montreal; physically inactive (i.e., engaging in less than 150 minutes of physical activity weekly as measured with the simple physical activity questionnaire [simpaq]; rosenbaum et al., 2020); and have a sufficient written and oral comprehen­ sion of french for the completion of the study. participants were excluded if they had an active psychotic episode, a functional limitation preventing them from using a stationary bicycle, or a severe substance use disorder other than tobacco and cannabis. since active individuals in general population seem to better regulate their negative affects (bernstein et al., 2019), by recruiting inactive individuals only, we isolated the acute effect of pe from its chronic effect. all participants gave their informed consent by reading and signing a consent form. the research protocol was approved by the ethics board committee from the university integrated center of health and social services of montreal. participants were given $50 cad compensation at the end of the protocol. safety and acceptability at the end of the pe session, the participants reported how they felt and were asked to call or write to the research assistant to report any adverse effects that may have occurred in the following days. at the end of the session, the researcher asked each participant: “how did you feel about the physical exercise you just did?” the answer to this question was written on the participant’s results sheet. the psychiatrist from the mental health university institute of montreal (co-investigator in this study) who referred the participants was asked to report any adverse effects he noticed with his patients to the rest of the research team. baseline measures upon completion of the consent form, participants filled out questionnaires about socio­ demographic, physical activity, and mental health information. the sociodemographic questionnaire included questions on sex, age, education level, marital status, height, weight, household income, psychiatric history, and current medications. additional measures were used to assess physical activity, depression, bpd, and substance use symptoms. the simpaq is a validated five-item physical activity questionnaire for use physical exercise and affects in bpd 4 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ with adults with severe mental health disorders with good reliability, although it has not been validated in adults with bpd (rosenbaum et al., 2020). the beck depression invento­ ry-short form (bdi-sf) is a 13-item questionnaire that provides a rating of depression symptom severity (steer et al., 1997) and has been used in adults with bpd (hasler et al., 2014). for each item, answers are rated using a score from 0 to 3, producing a total score ranging from 0 to 39, with a score over 9 indicating a risk of moderate-to-severe depressive episode (furlanetto et al., 2005). this questionnaire has been thoroughly validated in adults with psychiatric illness with cronbach’s α ranging from 0.83 to 0.96; however, the measure has not been validated specifically in adults with bpd (wang & gorenstein, 2013). the short form of the borderline symptom list (bsl-23) is a self-rating scale that assesses the severity of bpd symptoms and has been validated in adults with bpd, with a cronbach’s α of 0.94 (nicastro et al., 2016). each item is answered on a 5-point likert scale ranging from 0 to 4, generating a total score ranging from 0 to 92. the questionnaire instructions were adapted in our protocol: participants self-reported their symptom severity for the day preceding the study and not the previous month (note that the validity of this form has not been tested). since there is a high prevalence of substance use disorder in adults with bpd (kienast et al., 2014) and substance use is linked to less pe (abrantes & blevins, 2019; lisano et al., 2018; martens et al., 2006; werneck et al., 2019), three questionnaires were administered to assess substance use in our sample. the cigarette dependence scale (cds) evaluates cigarette addiction with 5 items answered on a 5-point likert scale from 1 to 5. a global score of at least 16 indicates addiction. this questionnaire has been validated with individuals with bpd with a cronbach’s α of 0.89 (etter et al., 2009). the cannabis abuse screening test (cast) is a 6-item questionnaire assessing cannabis use (legleye et al., 2007). a score of at least 3 is associated with a problematic use risk. the questionnaire has good validity (cronbach’s α = 0.81) but has not been specifically validated in adults with bpd. the alcohol use disorder identification test (audit) short form (3-item) was used to assess risk for alcohol use disorder. a score of at least 3 for women and 4 for men indicates a high risk of alcohol use disorder. this questionnaire has been validated in adults with personality disorders with an estimated sensitivity of 87.1% (dawson et al., 2005). the difficulties in emotion regulation scale (ders) is a 36-item questionnaire that was used to measure different aspects of emotion regulation difficulties. each item is answered on a 5-point likert scale ranging from 1 to 5, with the total score of the questionnaire ranging from 36 to 180. the ders has been validated in individuals with bpd with a cronbach’s α of 0.94 (côté et al., 2013). we used four items from the dimensions of openness to emotions (doe-it) questionnaire, with each item representing an emotion regulation strategy regrouped into two categories: relaxation and physical activation. for these four items, participants were asked to report how frequently they engaged in the strategy, and to what extent the strategy was effective (or how effective st-amour, cailhol, ruocco, & bernard 5 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ they think it would be) on two 5-point likert scales from 0 to 4. the four items were: “1-listen to music corresponding to my affective state (e.g., that soothes me when i’m anxious or wakes me when i’m asleep); 2-let the different feelings, impressions or noises act on me without directing them; 3-let all the impressions and sensations go as they are; 4-get physically active, move, walk a few steps.” the original full questionnaire has been validated with adults with bpd with cronbach’s α ranging from 0.67 to 0.83, depending on the subscales (haymoz & reicherts, 2015). experimental procedure figure 1 describes the experimental procedure, including the administration of the ques­ tionnaires, negative emotion induction, and randomization to experimental conditions. participants attended the session individually between 4p.m. and 6p.m. participants were not instructed to refrain from using psychotropic substances (coffee, tobacco, cannabis, etc.) before the experiment. in the negative mood induction procedure, participants watched a scene lasting 3 minutes and 30 seconds from the movie silence of the lambs showing a pursuit in a dark and dirty basement. this movie clip has been shown to induce negative emotions in adults with bpd (chapman et al., 2010; kuo & linehan, 2009). after the scene, participants were randomized with a heads or tails phone app to a condition, either 20 minutes of pe or an emotionally neutral video of 20 minutes (control). fourteen participants were randomized to each condition. the pe session consisted of 20 minutes of stationary bicycle (life fitness life cycle 9500hr recumbent bicycle). participants were instructed to cycle at an intensity they can maintain with pleasure for 20 minutes (meyer, ellingson, et al., 2016). they were also suggested the target of 11-13 on the borg scale (borg, 1998), which was used to measure pe intensity, to help them find a low-moderate intensity in which they could be comfortable. the borg scale ranges from 6 to 20 and includes visual cues to help participants rate their pe intensity. participants were allowed to change the load and cycling speed at will to maintain the desired intensity. there was no practice run and the participants did not receive any encouragement through the session, but they were supervised by a member of the research team in case they needed something or had a problem. the control condition consisted of the first 20 minutes of the movie baraka, which has been validated to be emotionally neutral (liu & mcnally, 2017). this is a video documentary showing images of landscapes, people, and cultural rituals from around the world, with a soothing musical background and without dialogue or commentaries. physical exercise and affects in bpd 6 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ figure 1 research protocol schema note. negative emotion induction was presented after baseline questionnaires but before randomization to unify participants’ affects before the protocol. time of the measurements is indicated in minutes from the beginning of the protocol between the boxes representing both groups. affect measurement an experimental procedure was implemented to induce a state of negative affect, which is a common approach in affective science research (barrett et al., 2007; barrett & bliss‐moreau, 2009; kuppens et al., 2013; posner et al., 2005). consequently, core affect was selected as the main outcome of our study. core affect refers to any mental state of pleasure or displeasure with a degree of arousal (russell, 2003). the properties of core affect (i.e., pleasure/displeasure and arousal) are brain representations of changes in autonomic and hormonal systems of the body and regulation efforts (barrett, 2009; ekkekakis, 2013; kuppens et al., 2013), and are continuously changing over time. core affect was measured before and after the induction procedure, at the beginning of the experiment, at 5, 10 and 15 minutes into the experiment, and again at the end of each experimental condition, using two 11-point analog scales for a total of 7 measurements. the feeling scale (fs; hardy & rejeski, 1989) was used to measure affective valence (positive or negative). the instructions were to “estimate how good or bad you feel right st-amour, cailhol, ruocco, & bernard 7 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ now.” anchors are provided at 0 (neutral) and odd integers, ranging from -5 (very bad) to +5 (very good). the felt arousal scale (fas; svebak & murgatroyd, 1985) was used to measure arousal. it ranges from 1 to 6 with half points. the instructions were to “estimate how aroused you feel right now” (low arousal meaning calm or fatigued and high arousal meaning anxious or energized). anchors are provided at 1 (low arousal) and 6 (high arousal). the fs and fas items have been used in numerous studies, including with adults who have severe psychiatric illness (bernstein & mcnally, 2017b; edwards et al., 2018; herring et al., 2019; lebouthillier & asmundson, 2015; meyer, ellingson, et al., 2016; schuch et al., 2014), and are strongly correlated with the self-assessment manikin (unick et al., 2015). statistical analysis participants’ characteristics were compared between experimental conditions. quantita­ tive variables were compared between conditions using t-tests for gaussian variables (according to the shapiro-wilk test) and mann-whitney tests otherwise. fs scores were transformed by adding 5 to produce only positive scores for the analysis. fas scores were also transformed by multiplying them by 2 and subtracting 1 to create whole numbers only. a paired-samples t-test was used to examine the effects of the emotion induction. linear mixed effect models were fitted to examine the effects of acute pe on affective valence and arousal measures. participants were included as a random effect. all the prerequisites were met for conducting t-tests and linear mixed models. all statis­ tical analyses were carried out with r 4.0, and the nlme and ggplot2 packages (pinheiro & bates, 2006). data and analysis coding are available in open access in the open science framework account of the first author (https://osf.io/ncd6r/). post hoc achieved power analysis were carried out with g*power 3.1.9.7 (faul et al., 2007). results sample characteristics twenty-eight adults (21 women) with bpd participated in the study. they were aged 19 to 56 with a mean of 36.8 (sd = 11.5). sixteen participants were considered smokers (8 in each group) and 19 cannabis users (9 in the pe group and 10 in the control group). after randomization, our control group had a significantly lower household income, χ2(4) = 15.6, p = .004, and higher ders, t(25) = 2.42, d = 0.93, p = .023, score than the pe group. participant characteristics are reported in table 1. physical exercise and affects in bpd 8 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://osf.io/ncd6r/ https://www.psychopen.eu/ table 1 sample characteristics at baseline variables pe (n = 14) control (n = 14) age (sd) 37.29 (10.79) 36.35 (12.51) female (male) 8 (5) 13 (1) marital status single/divorced/widow 11 12 married 3 2 body mass index (sd) 32.75 (10.26) 26.37 (6.83) antidepressant user 9 6 antipsychotic user 6 9 other psychotropic user 4 4 education elementary school 3 4 high school 2 1 professional school 5 6 college 3 3 university 1 0 household income* < 20,000$ 0 7 20,000$-39,999$ 11 4 40,000$-59,999 0 3 60,000$ and over 1 0 do not know 2 0 bdi score (sd) 14.15 (6.91) 16.46 (5.11) min 1 9 max 26 26 bsl-23 score (sd) 20.69 (16.26) 25.46 (17.55) min 5 0 max 54 58 ders score (sd)* 103.08 (29.49) 122.92 (15.54) min 50 97 max 137 164 doe-it 1listen to music frequency (sd) 3.00 (1.18) 2.71 (1.44) efficiency (sd) 3.00 (1.04) 2.46 (1.13) 2let the feeling act on me frequency (sd) 1.36 (1.45) 1.86 (1.29) efficiency (sd) 1.57 (1.40) 2.23 (0.73) st-amour, cailhol, ruocco, & bernard 9 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ variables pe (n = 14) control (n = 14) 3let the feeling go frequency (sd) 1.07 (1.27) 1.50 (1.35) efficiency (sd) 1.36 (1.45) 1.62 (1.26) 4get physically active frequency (sd) 2.14 (1.23) 2.57 (1.34) efficiency (sd) 2.50 (1.29) 3.08 (0.76) cds score/smokers (sd) 16.13 (1.25) 15.63 (1.51) cast score/cannabis users (sd) 15.00 (6.61) 14.00 (6.88) audit score (sd) 6.15 (3.11) 6.00 (2.48) note. bdi = beck depression inventory; bsl-23 = borderline symptoms list short version; ders = difficulties in emotional regulation scale; doe-it = dimension of openness to emotions; cds = cigarette dependence score; cast = cannabis abuse screening test; audit = alcohol use disorder identification test. *p < .05 when comparing both groups. safety and acceptability an adverse effect was reported in two participants. both participants attributed this adverse effect to the negative emotion induction procedure, which reportedly triggered psychotic symptoms (hallucinations and distress) in one participant, leading to a need for psychiatric care immediately after completion of the protocol. however, the data col­ lected for this participant was similar to those collected for other participants. therefore, we kept these data for analyses. it also reminded another participant of an aggression that person had reportedly experienced, which produced a drastic increase in the partici­ pant’s anxiety. it forced the participant to take a break at the 10-minute mark of the pe session and led the person to increase their alcohol consumption in the following week to a point where they sought emergency psychiatric care. given that the participant interrupted the experiment, that individual was excluded from our analyses of the effect of the pe session. on the other hand, there were no reported adverse effects related to either the pe or control condition in the days following the protocol. all participants responded to the question, “how did you feel about the physical exercise you just did?” with positive answers (felt great, made them feel good, enjoyed exercising, etc.). however, three participants also expressed a slight discomfort related to pe (exhaustion, muscular fatigue, breathlessness). mood induction the valence of affect was significantly more negative (fs) after (m = -0.36, sd = 2.59) the mood induction than before (m = 1.29, sd = 2.49), t(26) = 2.41, p = .023, d = 0.46, but the clip did not impact arousal (fas), t(26) = -1.79, p = .086. however, there were individual differences in these effects: the emotion induction succeeded in increasing negative physical exercise and affects in bpd 10 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ affect in 18 participants, whereas 10 participants reported no change or a decrease in negative affect. the fs and fas data for each participant from the emotion induction are presented in figures 2 and 3, respectively. figure 2 negative emotion induction’s effect on the feeling scale by participants note. spaghetti plot with each line representing a participant. the bold blue line indicates the mean value of affect surrounded by a darker gray area representing the confidence interval. figure 3 negative emotion induction’s effect on the felt arousal scale by participants note. spaghetti plot with each line representing a participant. the bold blue line indicates the mean value of arousal surrounded by a darker gray area representing the confidence interval. st-amour, cailhol, ruocco, & bernard 11 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ effects of pe on negative affect the level of negative affect (fs) decreased in our sample during the 20 minutes of our protocol, t(106) = 2.79, b = .45, d = .54, se = .16, p = .006. the post hoc power analysis revealed a power of 0.85. however, the pe session did not decrease negative affect more than the control condition over time, t(106) = -0.40, b = -.09, se = .22, d = -.07, p = .70, as shown in figure 4. the post hoc power analysis revealed a power of 0.07. the arousal (fas) did not change over time, t(106) = -0.31, b = 0.04, se = 0.15, d = 0.05, p = .80, and the pe and control groups were not significantly different, t(106) = 0.09, b = .02, se = .21, d = .01, p = .92, as shown in figure 5. the post hoc power analysis revealed a power of .08 and .05 respectively. however, some participants were observed almost sleeping while watching the control video. each participant presented different patterns of fs and fas and reacted differently in both groups (pe and control). figure 4 protocol's effect on the feeling scale by participants note. spaghetti plots with each curve representing a participant with a smooth representation of the group effect with confidence intervals of the curve. the bold blue line indicates the mean value of affect valence surrounded by a darker gray area representing the confidence interval. preand post video marks indicate evaluation before and after emotion induction. 0min through 20min marks indicate the time from the beginning of the condition (exercise or control). physical exercise and affects in bpd 12 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ figure 5 protocol's effect on the felt arousal scale by participants note. spaghetti plots with each curve representing a participant with a smooth representation of the group effect with confidence intervals of the curve. the bold blue line indicates the mean value of arousal surrounded by a darker gray area representing the confidence interval. preand post video marks indicate evaluation before and after emotion induction. 0min through 20min marks indicate the time from the beginning of the condition (exercise or control). discussion this pilot study is the first to our knowledge to examine the acute effects of pe on nega­ tive affect in adults with bpd. we hypothesized that pe would be safe, well accepted, and more effective than an emotionally neutral film in decreasing negative affect and arousal. our findings show that pe is safe and well accepted, and participants in both conditions had a decrease in negative affect with a medium effect size, although the effect did not differ between the groups and arousal did not decrease during the protocol. however, the effects of pe on affect have been extensively studied and a meta-analysis shows its efficacy in increasing positive affect (ekkekakis et al., 2011). the absence of a difference between the groups in our study is therefore unexpected. moreover, we met many obstacles during this study that might explain the absence of group difference and therefore make it difficult to draw conclusion on our hypothesis. one of the main reasons why our results were not significant was because this pilot study was underpowered to detect group effect. indeed, the between-group analysis of affect valence difference had a power of .07 which is weak. according to the a priori analysis we made with the effect size we found, a sample size of 70 would have been st-amour, cailhol, ruocco, & bernard 13 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ sufficient to detect a significant group difference. however, because of the reasons detailed below, this effect size might be biased. despite the unanticipated findings, this experiment is useful and informative for future research investigating the acute effects of physical exercise on emotion regulation in bpd. first, no adverse effect was reported from the exercise sessions in this study, which indicates the safety of such an intervention. second, every participant declared having appreciated the pe session with few negative feelings or discomfort toward it. however, this acceptability measure might not be the most valid and might be subject to biases. third, the validated emotion induction procedure had unexpected effects. as reported by chapman et al. (2010) and kuo and linehan (2009), it increased the mean level of negative affect in our sample. however, for nearly half of our sample, it had no effect or decreased the participants’ negative affect, as they either liked the thriller kind of movie or recognized the scene as being part of a movie they liked, suggesting that other mood induction content should be considered for future research of this nature. according to rottenberg et al. (2018), non-response to mood induction is frequent and may affect the validity of a study. to avoid nonresponse, researchers might use multiple induction strategies at once, an instruction to strengthen the induction, or a longer induction. on the other hand, two participants reacted enough to the emotion induction such that they needed psychiatric care after the protocol. those incidents indicate that this strategy might not be the safest available to induce negative affect in patients with bpd or that comorbid disorders (such as psychotic disorder) or previous traumas should be considered when selecting an induction strategy. therefore, further research might attempt other induction strategies that better suit this population. for example, viewing negative emotional photos from the international affective picture set paired with negative emotionally charged music (lynn et al., 2012), reading emotionally charged sentences from the velten validated battery (velten, 1968), and/or vividly imag­ ine personal negative situations (especially those relevant to bpd, such as abandonment experiences) triggered by a verbal script (barnow et al., 2012). finally, the neutral video that served as a control had a meditative effect on participants. some participants were observed as almost sleeping while watching the video regardless of being probed every 5 minutes to rate their affect. some participants also reported they meditated or used mindfulness strategies while looking at the video. therefore, this control video might have had a meditating effect and effectively decreased the self-reported arousal level and increased the self-reported valence of affect. indeed, meditation and mindfulness have been found to reduce negative affect (goyal et al., 2014; sathyanarayanan et al., 2019) and is currently used in dialectic behavioral therapy (linehan, 2014) to help reduce negative affect. therefore, the control condition should not give participants the opportunity to use these techniques. for example, participants could be directed to do light stretching or articular warm-up for the same period as the pe session (oberste et physical exercise and affects in bpd 14 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ al., 2017). these results may be informative for researchers who are considering mood induction in experimental studies of pe in bpd. apart from the induction strategy and the control video, other factors might explain the absence of a difference between pe and the video in this study. the low physical activity level coupled with the high bmi of our sample might also be contributory. in a meta-analysis from ekkekakis and colleagues (2011), inactive obese individuals were more likely to feel negative affect at low pe intensity than active individuals during a single bout of pe. therefore, future research should investigate this effect in physically active individuals with bpd or with a bmi under 30. our findings resemble a previous investigation examining the effects of acute pe on core affect in adults with psychiatric illness (depressive disorder, bipolar disorder and anxiety disorder) using the fs and the fas (stanton et al., 2016). this study found a significant increase of valence only among participants with bipolar disorder or depres­ sive disorder but not anxiety disorder. furthermore, the pe session did not decrease the self-reported arousal level. therefore, we can conclude that pe’s impact on affect likely differs depending on the specific psychiatric disorder. emotion dysregulation is a component of all three of the disorders included in the stanton et al. study, as well as bpd, with the latter associated with more severe emotion dysregulation than the other disorders (gratz et al., 2016). therefore, we can believe that pe might influence affect in bpd as well. table 2 presents a set of potential solutions to overtake the main limitations encountered in our study to improve future studies. table 2 study limitations and potential improvements limitations suggestion heterogenous emotion induction (i.e., positive emotion following negative induction) three steps negative emotion induction (kuo et al., 2014): 1. listening to emotionally charged music while watching emotionally charged photographs; 2. reading emotionally charged sentences; 3. vividly imagine personal negative emotion triggered by verbal script previously prepared. meditative effect of control condition use of placebo exercise (ex., light stretching, articular warm-up, oberste et al., 2017) group discrepancy regarding household income and difficulties in emotion regulation recruit a larger sample to decrease group difference risk or combined with a stratified randomization technique possible missed affect change after the ending of the measurement continue affect measurement for a period after the intervention (i.e., +5, +10, + 15 minutes) st-amour, cailhol, ruocco, & bernard 15 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ limitations suggestion participants’ comorbid disorders were not reported accessing participants’ medical file to report comorbid disorders possible missed adverse effects adverse effects and safety should have been systematically assessed in the days following the investigation by calling participants directly possible invalid acceptability measure acceptability should have been measured using a validated questionnaire or a numerical scale to answer a single question to provide more information (rabin et al., 2009). sample size based on a simulation analysis, a future well-powered study should include a total of 70 participants to reach a power of > 80% (kumle et al., 2021) on the other hand, this research has many strengths. the main strength is that it is the first study to include individuals with bpd to study the effect of pe. also, the low to moderate pe intensity as self-selected by the participants optimizes pe benefits on affect (ekkekakis et al., 2011). moreover, we used core affect to assess physical activity effect on emotional feeling since it is known to be an effective way to characterize subjective feeling (ekkekakis, 2013). future studies should use better suited negative emotion induction for adults with bpd (e.g., velten validated battery). other control strategies should also be used, such as light stretching or articular warm-up (lebouthillier & asmundson, 2015) considered as placebo pe. watching a pleasant video at the end of the protocol could be used to improve participants’ affective valence before they complete the study, improving the safety of the protocol (bernstein & mcnally, 2017a, 2017b, 2018). further work may study the impact of pe on affect in adults with bpd with ecological momentary assessments, which has been shown to be an efficient way to evaluate rapidly evolving phenomena in bpd (santangelo et al., 2014). for example, the study of affect over a day after a pe session could elucidate the emotion regulation dynamics following pe. other types, durations, and intensities of pe should also be tested, as these are all possible factors that might influence the affective response to pe (ekkekakis et al., 2011). finally, future exercise studies might evaluate the blood level of brain-derived neurotropic factor to measure the potential mediating role of this biomarker on affect in this population. physical exercise and affects in bpd 16 clinical psychology in europe 2022, vol. 4(2), article e7495 https://doi.org/10.32872/cpe.7495 https://www.psychopen.eu/ funding: the funding to carry this study has been given by the fond de recherche du québec – santé, and the fondation de l'institut universitaire en santé mentale de montréal. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. twitter accounts: @sstamour23, @paquitobernard data availability: for this article, a data set is freely available (st-amour et al., 2021). supplementary materials data and analysis coding are available in open access in the open science framework account of the first author (for access see index of supplementary materials below). index of supplementary materials st-amour, s., cailhol, l., ruocco, a. c., & bernard, p. 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[2] division of clinical psychology and psychotherapy, department of psychology, university of marburg, marburg, germany. §these authors contributed equally to this work. clinical psychology in europe, 2021, vol. 3(special issue), article e4577, https://doi.org/10.32872/cpe.4577 received: 2020-10-19 • accepted: 2021-05-17 • published (vor): 2021-11-23 handling editor: eva heim, university of lausanne, lausanne, switzerland corresponding author: ricarda mewes, outpatient unit for research, teaching, and practice, faculty of psychology, university of vienna, renngasse 6-8, vienna, 1010, austria. e-mail: ricarda.nater-mewes@univie.ac.at related: this article is part of the cpe special issue “cultural adaptation of psychological interventions”, guest editors: eva heim & cornelia weise, clinical psychology in europe, 3(special issue), https://doi.org/ 10.32872/10.32872/cpe.v3.si supplementary materials: materials [see index of supplementary materials] abstract background: asylum seekers often suffer from high levels of mental distress. however, as a result of a lack of knowledge about mental health and health care, as well as cultural and language barriers, the utilization of mental health care in western host countries is often difficult for these individuals. reducing these barriers may thus be a crucial first step towards appropriate mental health care. previous research showed that psychoeducation may be helpful in this regard. method: the current manuscript describes a short, low-threshold and transdiagnostic intervention named ‘tea garden (tg)’. the tg aims to increase specific knowledge about mental health problems and available treatments, and may improve psychological resilience and self-care. in this manuscript, we specifically focus on culturally sensitive facets, following the framework proposed by heim and colleagues (2021, https://doi.org/10.32872/cpe.6351), and lessons learned from three independent pilot evaluations (ns = 31; 61; 20). results: the tg was found to be feasible and quantitative results showed that it was helpful for male and female asylum seekers from different countries of origin (e.g., afghanistan, syria, this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4577&domain=pdf&date_stamp=2021-11-23 https://orcid.org/0000-0002-4724-9597 https://orcid.org/0000-0001-5216-1031 https://orcid.org/0000-0001-9855-4658 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ pakistan, iraq) and with different educational levels. interestingly, even asylum seekers who had already been in germany or austria for three or more years benefited from the tg. conclusion: the tg specifically aims to be culture-sensitive rather than culture-specific, to be transdiagnostic rather than focused on specific mental disorders, and to be suitable for asylum seekers who are still in the insecure process of applying for asylum. it may also be helpful for distressed asylum seekers who do not fulfill the criteria for a mental disorder, and for healthy asylum seekers who could use the knowledge gained in the tg to help others. keywords asylum seekers, culture-sensitive, knowledge, mental health (care), psychoeducation, transdiagnostic highlights • there is a lack of short, low-threshold, and culture-sensitive interventions for asylum seekers. • a transdiagnostic intervention, named ‘tea garden’ (tg), is described and findings of pilot evaluations are reported. • the tg aims to increase knowledge about mental health (care), and improve resilience and self-care. • the tg was found to be helpful for refugees from different origins and with different educational levels. the prevalence of mental disorders in refugees and asylum seekers1 is high, as they have frequently experienced different kinds of hardship and traumatic situations (blackmore et al., 2020; henkelmann et al., 2020). even when asylum seekers have arrived in a safe host country, factors such as a lengthy asylum procedure, fear of deportation, or ethnic discrimination pose a risk for the aggravation or new manifestation of mental health problems (gleeson et al., 2020). despite high levels of mental distress, access to mental health treatment for asylum seekers is limited (björkenstam et al., 2020; führer et al., 2020). this is mainly a result of barriers such as a general lack of knowledge about mental disorders and mental health care, but is also caused by limited access to health care systems in host countries, cultural understanding and stigmatization of mental disorders and mental health care, and language barriers (grupp et al., 2019; mårtensson et al., 2020). systematic reviews have revealed that psychoeducation improves specific knowledge about mental disorders (e.g., about possible causes, typical symptoms of a disorder, 1) 'an asylum seeker' is defined as a person who is seeking international protection and whose claim for asylum has not yet been finalized. if protection is granted according to the 1951 refugee convention, the person is recognized as a 'refugee'. accordingly, all refugees were initially asylum seekers. many of the studies cited investigated both asylum seekers and refugees. because of the current study's focus, we primarily use the term 'asylum seekers' and speak of refugees only if they are specifically addressed. description and feasibility of the tea garden 2 clinical psychology in europe 2021, vol. 3(special issue), article e4577 https://doi.org/10.32872/cpe.4577 https://www.psychopen.eu/ factors influencing the symptoms) and psychosocial functioning, including coping with symptoms, and reduces distress for people suffering from mental disorders (barnicot et al., 2020; tursi et al., 2013). colom (2011, p. 339) defines psychoeducation “as a patient’s empowering training targeted at promoting awareness and proactivity, providing tools to manage, cope and live with a chronic condition …, and changing behaviours and attitudes related to the condition.” consequently, psychoeducation may be an effective intervention to improve the mental health knowledge and to enable an initial mental health improvement of different cultural groups of asylum seekers in western host coun­ tries. such a psychoeducation intervention should be adapted to a degree that allows its use in different cultural groups (i.e., being culture-sensitive; e.g., see the suggestions on cultural adapted cognitive behavioral therapy by hinton et al., 2012) rather than focused on one specific culture or group (i.e., culture-specific; e.g., see the examples and recommendations for specific cultural/ethnic groups by smith et al., 2011). however, this type of psychoeducation for asylum seekers is lacking. therefore, we developed a short, culture-sensitive intervention, named tea garden (tg). we chose this name because a tea garden is a familiar concept for many migrants from different regions of origin and is often associated with a positive situation. we wanted to avoid difficult names or labels (e.g. psychotherapy or psychological) that could discourage interested persons as a result of a lack of knowledge about psychotherapy and psychological interventions or a possi­ ble fear of stigmatization. our focus was on reducing distress and increasing knowledge about the development of mental disorders, resources to cope with mental distress, and interventions, that were assumed to be of particular relevance for asylum seekers. in line with betsch and colleagues, we aimed for a “deliberate and evidence-informed adaptation of health communication to the recipients’ cultural background in order to increase knowledge and improve preparation for medical decision making and to enhance the persuasiveness of messages in health promotion” (betsch et al., 2016, p. 813). we did not limit culture to the nationality or a set of habits and beliefs, but also account for the particular sociodemographic, legal, and living situation of asylum seekers (e.g., napier et al., 2014). our main aim (i) in this paper is to describe the tg with a specific focus on culturally sensitive facets, following the framework proposed by heim and colleagues (2021, this issue). additionally, we provide summarized findings (ii) from pilot evaluation studies with regard to the acceptability and feasibility of the tg, as well as lessons learned. description of the tea garden (tg) the tg was developed as part of the project ‘psychotherapeutic first aid for asylum seekers living in hesse’ funded by the european refugee fund, eff-12-775 (mewes et al., 2015). the aim of the tg is threefold: (1) to increase knowledge about mental disor­ ders most relevant for asylum seekers, psychological and psychiatric treatments, mental mewes, giesebrecht, weise, & grupp 3 clinical psychology in europe 2021, vol. 3(special issue), article e4577 https://doi.org/10.32872/cpe.4577 https://www.psychopen.eu/ health care in the resettlement country, and the special access conditions for asylum seekers in this regard; (2) to reduce stigmatization of mental disorders and mental health care, and thereby increase openness to psychotherapy and psychiatric treatments; and (3) to strengthen psychological resources and achieve first reduction of mental distress. team of developers the developing team comprised members from different countries of origin and different cultural backgrounds (e.g., persian, arabic, kurdish, turkish), some of them with a refugee background, psychotherapists working with asylum seekers, and researchers in the field of intercultural psychology. target population the target group for the tg consists of asylum seekers who have recently arrived in a host country (e.g., max. 18 months), are still in the process of applying for asylum, and may suddenly be transferred to other cities or federal states during their asylum procedure. participants may be mentally distressed or suffer from a mental disorder, but this is not mandatory for participation. the tg is transdiagnostic and may even be helpful for healthy asylum seekers who could use the knowledge gained in the tg to help others. general implementation of the tg with the aid of interpreters, the tg is provided in a group format to provide help to several asylum seekers simultaneously. the tg consists of four modules (a-d): module a) establishing trust and confidence; module b) symptoms of mental disorders; module c) resources and self-care, and module d) treatment options. these modules are inter­ actively presented in two 90-minute sessions delivered one week apart in groups of approximately six participants (detailed information can be found in the german manual, mewes et al., 2015). this schedule is considered short enough to reach many target clients, but long enough to provide the required information in a relaxing and interactive manner. a group setting is applied to enhance social support and mutual exchange, and to take into account the mainly collectivistic background of the main groups of asylum seekers (in western host countries) as well as shared pre-, peri-, and postmigration expe­ riences (kananian et al., 2017; kira et al., 2012). these benefits are assumed to outweigh possible disadvantages, such as reservations to participate in a group (e.g., worries about confidentiality and being stigmatized), the limited consideration of individual problems, and the therapists’ necessity to closely monitor not only the content but also the group process (kira et al., 2012). description and feasibility of the tea garden 4 clinical psychology in europe 2021, vol. 3(special issue), article e4577 https://doi.org/10.32872/cpe.4577 https://www.psychopen.eu/ tea and food are offered to promote a relaxing and welcoming atmosphere. in addi­ tion, the tg uses images/ illustrations, symbols (e.g., rope, flowers, stones, spinning top) and familiar metaphors in order to facilitate communication and to adapt to different educational levels. its material is free of written language or complicated figures, and operates best in genderand language-homogenous groups of five to seven participants. components and contents of the intervention based on a literature review and our own work (hinton et al., 2012; reich et al., 2015) as well as advice from experienced psychotherapists in the field, we included several treatment components in order to foster confidence and therapy motivation, and thus to increase the usefulness of the tg. with regard to specific components, i.e. components that have specific relevance for the aims of the tg, we focused on psychoeducation (e.g., explaining that traumatic events can cause symptoms, explaining the concept of psychotherapy), strengthening resources (e.g., introducing possible resources, initiating exchange about useful strategies for coping and how to implement them in the daily life), giving hope (e.g., by explaining that symptoms can improve with the right care), and reducing stigmatization (e.g., by initiating exchange about problems and by emphasizing that persons with mental problems are not ‘mad’). in addition, we included several unspecific components that should support the implementation of the tg (but do not specifically relate to the aims of the tg) such as guiding through the sessions (e.g., by outlining the structure of the sessions and monitoring the time), normalizing (e.g., by explaining that experiencing symptoms such as worries and flashbacks after traumatic events is normal), discussing advantages of and barriers to treatments (e.g., by asking for the participants’ views on psychopharmacological treatments, by explaining how to get a psychotherapy and addressing possible barriers), monitoring the distress level of participants (e.g., by working with two therapists and a limited number of participants, one therapist can watch out for signs of distress), and interrupting participants when narratives become too personal/ distress becomes too high (this is part of a set of group rules which are introduced at the first session). moreover, in-session techniques such as behavioral experiments (relaxation) and exchange between group participants were included to this end. in order to consider relevant target syndromes, needs, and concepts of distress (lewis­ fernández & kirmayer, 2019) of our target group, the following contents were included in the tg: i. explanatory models, etiological assumptions. based on a literature review (e.g., liedl et al., 2010), we used a body-mind metaphor for the description of a traumatic event and the care and healing related to this event (i.e., the mind can be wounded by traumatic events; this wound is similar to a wound on the hand after a cut; wounds mewes, giesebrecht, weise, & grupp 5 clinical psychology in europe 2021, vol. 3(special issue), article e4577 https://doi.org/10.32872/cpe.4577 https://www.psychopen.eu/ in the mind may cause symptoms; and the wound must be nursed and will then heal, leaving a scar). ii. symptom patterns and socially acceptable terms for expressing distress. the higher relevance of bodily symptoms in many groups of immigrants in western host countries and culture-specific symptoms such as 'burning liver' or 'pulling hair' was accounted for by explicitly introducing these symptoms (among others) with drawings as part of a module about symptoms (module b). this decision was based on a literature review (e.g., hinton et al., 2012; rometsch et al., 2020) and experiences from the team of developers. culturally salient resources. as many groups of asylum seekers in western host countries highly value religion and faith, and have strong ties within the ‘extended family’, these potential resources were introduced as part of the module on resources and self-care (module c). this decision was based on a literature review, our own scientific work (e.g., grupp et al., 2019), and advice from the team of developers. suggested outcome measure in line with trials offering psychoeducation interventions for persons with serious men­ tal illnesses (e.g., zhao et al., 2015), the primary outcome for evaluations of the tg should be changes in specific knowledge with regard to mental health (please see the appendix in the supplementary materials for suggestions on measures of the other aims of the tg). moreover, the feasibility and acceptability of the tg should be assessed, e.g., the atmosphere, the comprehensibility, and the communication, as well as the personal benefit, relief, and perceptions of resources. for the three pilot studies reported below, a questionnaire developed by our work group was used (demir et al., 2016). this questionnaire assessed self-reported knowledge on 1) symptoms of mental disorders, 2) resilience and coping strategies, and 3) mental health care offered in the country. to facilitate assessment in illiterate and low-educated participants, we aimed for easy language and used smileys to indicate negative to posi­ tive response or low to high agreement and a right-angled triangle symbol to indicate increase in knowledge (range 1 = not at all to 5 = very much; the higher the value the more positive the assessment), respectively. moreover, feedback on the personal benefits, and suggestions for improvement, could be given using free text. findings from first evaluations of the tea garden and lessons learned three independent pilot evaluations were conducted with a focus on acceptance, feasi­ bility, first hints of possible effectiveness, as well as lessons learned (mainly based on anecdotal reports of the researchers, and the therapists who conducted the tgs, and description and feasibility of the tea garden 6 clinical psychology in europe 2021, vol. 3(special issue), article e4577 https://doi.org/10.32872/cpe.4577 https://www.psychopen.eu/ written and verbal feedback of participants). two pilot evaluations were conducted in germany (bogdanski et al., 2019; demir et al., 2016) and one in austria. most participants came from syria, afghanistan, pakistan, or iraq. more detailed information is provided in the appendix (see supplementary materials). by reason of the low-threshold character of the tg, participants in the pilot evaluations were not screened for mental disorders. the outcome assessments were conducted after each tg session and were supported by interpreters when necessary. after the tg, participants reported increased knowledge about mental health care, psychotherapy and self-help options, relief for general distress, improved perceptions of resources, and high overall satisfaction with the program. lessons learned: i. to facilitate recruitment, potential participants needed to be educated in detail about the program, and it was necessary to establish trust, be patient, and build a network of contact persons. ii. the outcome assessment was too complex and unfamiliar for some participants, and was simplified by only using smileys. iii. some participants erroneously expected to learn about asylum procedures. therefore, flyers and invitations should be phrased very clearly and highlight the content of the tg. iv. even asylum seekers with longer durations of stay (e.g. three years and more) appreciated the tg. v. the illustrations used in the tg were complemented by new illustrations in order to enhance the variety of shown human appearances and the fit for different groups of asylum seekers. vi. the larger the size of the group the more likely conflicts between participants may emerge. we thus suggest to limit the number of participants to eight. discussion in contrast to other interventions, the tg specifically aims to be culture-sensitive rath­ er than culture-specific, to be transdiagnostic rather than focusing on specific mental disorders, and to be suitable for asylum seekers who are still in the insecure process of applying for asylum. the three independent pilot evaluations demonstrated the feasi­ bility of the tg and its acceptance with regard to different countries of origin, spoken languages, educational levels, and durations of stay in the host countries. moreover, they provided us with important lessons for the future recruitment of potential participants, appropriate designs for the outcome assessment, the materials used, and the recommen­ ded group size. in general, our findings suggest that the tg may be a useful first step to improve mental health care for asylum seekers. however, the generalizability and explanatory power of the presented results is limited by the single-group designs, and the lack of pre-post comparisons as well as follow-up assessments that would provide mewes, giesebrecht, weise, & grupp 7 clinical psychology in europe 2021, vol. 3(special issue), article e4577 https://doi.org/10.32872/cpe.4577 https://www.psychopen.eu/ information about the sustainability of possible benefits. these limitations will now be tackled by the multicenter randomized controlled trial ‘efficacy of low-threshold, culturally sensitive group psychoeducation in asylum seekers’ (lope; drks00020564), where the participants will be randomized to either the tg or a waitlist control group and changes in knowledge will be assessed preand postintervention as well as two and six months later. following the example of other projects that successfully used brief psychological interventions to reduce the treatment gap for common mental disorders in affected groups, such as the friendship bench project in zimbabwe (chibanda et al., 2016) or the self-help plus project in uganda (tol et al., 2020), the tg might best be implemented via psychologists working in asylum facilities, trained and supervised social workers or even lay facilitators, depending on the local means and structures. by being culture-sensitive and very low-threshold, the tg considers the high diversity of asylum seekers living in western host countries (e.g., with regard to their countries of origin, their ethnicity, religion, education level, asylum status, distress level, etc.) and avoids the discrimination of specific (often particularly marginalized) groups. the tg may, thus, be considered as a broadly applicable first-line mental health intervention. funding: parts of this study were funded by the european refugee fund (eff-12-775). the lope study is funded by the german ministry of education and research (01ef1804b). acknowledgments: we thank mag.a vesna maric medjugorac (caritas vienna) for supporting the pilot evaluation 3. competing interests: cornelia weise is one of the editors-in-chief of clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. twitter accounts: @corneliaweise supplementary materials the supplementary materials contain suggestions for the measures of the aims two and three of the tea garden and more detailed information about findings from the first evaluations of the tea garden and lessons learned (incl. two tables) (for access see index of supplementary materials below). index of supplementary materials mewes, r., giesebrecht, j., weise, c., & grupp, f. (2021). supplementary materials to "description of a culture-sensitive, low-threshold psychoeducation intervention for asylum seekers (tea garden)" [additional information]. psychopen gold. https://doi.org/10.23668/psycharchives.5030 description and feasibility of the tea garden 8 clinical psychology in europe 2021, vol. 3(special issue), article e4577 https://doi.org/10.32872/cpe.4577 https://twitter.com/corneliaweise https://doi.org/10.23668/psycharchives.5030 https://www.psychopen.eu/ references barnicot, k., michael, c., trione, e., lang, s., saunders, t., sharp, m., & crawford, m. j. (2020). psychological interventions for acute psychiatric inpatients with schizophrenia-spectrum disorders: a systematic review and meta-analysis. clinical psychology review, 82, article 101929. https://doi.org/10.1016/j.cpr.2020.101929 betsch, c., bohm, r., airhihenbuwa, c. o., butler, r., chapman, g. b., haase, n., . . . uskul, a. k. 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(2013). effectiveness of psychoeducation for depression: a systematic review. the australian and new zealand journal of psychiatry, 47(11), 1019-1031. https://doi.org/10.1177/0004867413491154 zhao, s., sampson, s., xia, j., & jayaram, m. b. (2015). psychoeducation (brief) for people with serious mental illness. cochrane database of systematic reviews, 4, article cd010823. https://doi.org/10.1002/14651858.cd010823.pub2 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. mewes, giesebrecht, weise, & grupp 11 clinical psychology in europe 2021, vol. 3(special issue), article e4577 https://doi.org/10.32872/cpe.4577 https://doi.org/10.1016/j.jpsychores.2020.109931 https://doi.org/10.1002/jclp.20757 https://doi.org/10.1016/s2214-109x(19)30504-2 https://doi.org/10.1177/0004867413491154 https://doi.org/10.1002/14651858.cd010823.pub2 https://www.psychopen.eu/ description and feasibility of the tea garden (introduction) description of the tea garden (tg) team of developers target population general implementation of the tg components and contents of the intervention suggested outcome measure findings from first evaluations of the tea garden and lessons learned discussion (additional information) funding acknowledgments competing interests twitter accounts supplementary materials references from formative research to cultural adaptation of a face-to-face and internet-based cognitive-behavioural intervention for arabic-speaking refugees in germany latest developments from formative research to cultural adaptation of a face-to-face and internet-based cognitive-behavioural intervention for arabic-speaking refugees in germany maria böttche 1,2, christina kampisiou 1, nadine stammel 1,2, rayan el-haj-mohamad 1, carina heeke 1, sebastian burchert 1, eva heim 3,4, birgit wagner 5, babette renneberg 6, johanna böttcher 7, heide glaesmer 8, euphrosyne gouzoulis-mayfrank 9, jürgen zielasek 9, alexander konnopka 10, laura murray 11, christine knaevelsrud 1 [1] clinical-psychological intervention, freie universität berlin, berlin, germany. [2] center überleben, berlin, germany. [3] department of psychology, university of zurich, zurich, switzerland. [4] institute of psychology, university of lausanne, lausanne, switzerland. [5] clinical psychology & psychotherapy, medical school berlin, berlin, germany. [6] clinical psychology and psychotherapy, freie universität berlin, berlin, germany. [7] clinical psychology and psychotherapy, psychologische hochschule berlin, berlin, germany. [8] medical psychology and medical sociology, university of leipzig, leipzig, germany. [9] lvr-institute for healthcare research, cologne, germany. [10] health economics and health services research, university medical center hamburg-eppendorf, hamburg, germany. [11] johns hopkins university, baltimore, md, usa. clinical psychology in europe, 2021, vol. 3(special issue), article e4623, https://doi.org/10.32872/cpe.4623 received: 2020-10-30 • accepted: 2021-06-17 • published (vor): 2021-11-23 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: maria böttche, clinical-psychological intervention, freie universität berlin, habelschwerdter allee 45, 14195 berlin, germany. tel +49 30 838 58883. e-mail: maria.boettche@fu-berlin.de related: this article is part of the cpe special issue “cultural adaptation of psychological interventions”, guest editors: eva heim & cornelia weise, clinical psychology in europe, 3(special issue), https://doi.org/ 10.32872/10.32872/cpe.v3.si supplementary materials: materials [see index of supplementary materials] abstract background: this study aims to provide a transparent and replicable documentation approach for the cultural adaptation of a cognitive-behavioural transdiagnostic intervention (common elements treatment approach, ceta) for arabic-speaking refugees with common mental disorders in germany. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4623&domain=pdf&date_stamp=2021-11-23 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ method: a mixed-methods approach was used, including literature review, interviews, expert decisions and questionnaires, in order to adapt the original ceta as well as an internet-based guided version (eceta). the process of cultural adaptation was based on a conceptual framework and was facilitated by an adaptation monitoring form as well as guidelines which facilitate the reporting of cultural adaptation in psychological trials (recapt). results: consistent with this form and the guidelines, the decision-making process of adaptation proved to be coherent and stringent. all specific ceta treatment components seem to be suitable for the treatment of arabic-speaking refugees in germany. adaptations were made to three different elements: 1) cultural concepts of distress: a culturally appropriate explanatory model of symptoms was added; socially accepted terms for expressing symptoms (for eceta only) and assessing suicidal ideation were adapted; 2) treatment components: no adaptations for theoretically/empirically based components of the intervention, two adaptations for elements used by the therapist to engage the patient or implement the intervention (nonspecific elements), seven adaptations for skills implemented during sessions (therapeutic techniques; two for eceta only) and 3) treatment delivery: 21 surface adaptations (10 for eceta only), two eceta-only adaptations regarding the format. conclusion: the conceptual framework and the recapt guidelines simplify, standardise and clarify the cultural adaptation process. keywords cultural adaptation, transdiagnostic, refugees, decision-making process highlights • the framework and the guidelines allow for a reproducible and systematic cultural adaptation. • the flexible and simple format of the original ceta manual requires mainly surface adaptations. • eceta requires additional adaptations compared to the face-to-face version. arabic-speaking refugees from the mena (middle east and north africa) region have constituted the largest group of refugees in germany in recent years (federal office for migration and refugees, 2020). epidemiological studies on the mental health of asylum seekers and refugees indicate high prevalence rates of mental disorders, especially for posttraumatic stress disorder (ptsd) and depression (nesterko et al., 2020; turrini et al., 2017). despite the need for psychological treatment among refugees, only a minority utilise specialised mental health care services. göpffarth and bauhoff (2017) reported that refu­ gees in germany have six psychotherapist contacts per 1,000 health-insured persons, compared to 20 contacts for non-refugee persons. reasons for this treatment gap lie in structural barriers (e.g. difficult to access the health system, post-migration difficulties, from formative research to cultural adaptation 2 clinical psychology in europe 2021, vol. 3(special issue), article e4623 https://doi.org/10.32872/cpe.4623 https://www.psychopen.eu/ regional lack of trained therapists, long waiting lists) and cohort-specific characteristics (e.g. language, fear of stigmatisation, comorbid disorders), but are also due to a general lack of psychotherapeutic treatments for culturally diverse groups (colucci et al., 2015; sijbrandij, 2018). transdiagnostic approaches seem to be especially promising for the treatment of a wide range of psychological symptoms, as they can be effectively applied for different and comorbid disorders (newby et al., 2015; reinholt & krogh, 2014). a prominent evidence-based transdiagnostic approach for war-torn populations is ceta (common elements treatment approach; murray et al., 2014, supplement 1: modules and content). ceta has proven to be effective in reducing common mental health problems in cultur­ ally diverse settings in lowand middle-income countries (e.g. zambia: kane et al., 2017; iraq: weiss et al., 2015). it addresses symptoms of depression, anxiety, substance use and trauma-related disorders, and follows a tailored approach, i.e. element selection, sequencing and dosage vary depending on symptom presentation. ceta might also be a promising approach to reduce the treatment gap for refugees in european countries. additionally, an internet-based format would enable a wider reach, since it does not depend on geography (e.g. lack of trauma therapists in the local area), and communi­ cation between client and counsellor can be asynchronous. an internet-based version could also overcome the fear of stigmatisation due to the visual anonymity of the online format. as many refugees in high-income countries use the internet (gillespie et al., 2016), internet-based interventions are easily accessible for refugee populations. in order to tailor mental health interventions to the context and needs of diverse cultural groups, there has been an increasing focus on culture-sensitive interventions. meta-analyses generally indicate a superiority of culturally adapted interventions for the respective target group over non-adapted interventions (hall et al., 2016; harper shehadeh et al., 2016), although it should be noted that most adaptations did not follow a systematic procedure, thus limiting the ability to compare and replicate their findings. to overcome this weakness, a conceptual framework for cultural adaptation of inter­ ventions for common mental disorders was developed (heim & kohrt, 2019). this frame­ work consists of three main elements: 1) cultural concepts of distress, including cultural explanations, cultural syndromes, idioms of distress; 2) treatment components, compris­ ing specific and unspecific elements and therapeutic techniques; and 3) treatment deliv­ ery including delivery format, surface adaptation and setting. specific elements refer to interventions that are based on theoretical assumptions, such as behavioural or cog­ nitive approaches; unspecific treatment elements are the common factors such as the therapeutic relationship or providing a meaningful treatment rationale; and therapeutic techniques refer to exercises and other interventions that are undertaken to transmit the therapeutic components, such as role plays or homework (singla et al., 2017). in addition, the framework by heim and kohrt (2019) includes “surface adaptations”, which refer to matching materials and illustrations to the target population (resnicow et al., böttche, kampisiou, stammel et al. 3 clinical psychology in europe 2021, vol. 3(special issue), article e4623 https://doi.org/10.32872/cpe.4623 https://www.psychopen.eu/ 1999). this framework has been extended and translated into a set of reporting criteria for the cultural adaptation of psychological interventions (heim et al., 2021, this issue; supplement 2). in conclusion, some of the existing barriers to psychological treatment provision for refugees in europe might be addressed by culturally adapted and transdiagnostic interventions with different delivery formats. thus, the aim of the present study was to conduct a culture-sensitive adaptation of a cognitive-behavioural transdiagnostic in­ tervention (ceta) for arabic-speaking refugees with common mental health disorders in germany in a transparent and replicable manner, based on the framework (heim & kohrt, 2019) and the guidelines of reporting cultural adaptation in psychological trials (recapt, heim et al., 2021, this issue). the study focuses on the decision-making proc­ ess, i.e., the process from assessing cultural concepts of distress to adapting treatment components. the adaptation was conducted both for the original face-to-face context and for an internet-based context (eceta). method procedures and participants the process of cultural adaptation in this study used the recapt guidelines (heim et al., 2021, this issue), and consists of six steps (details on the procedures followed and the study participants are presented in supplement 2, recapt guidelines; supplement 3, adaptation monitoring form, and supplement 4, consolidated criteria for reporting qualitative research [coreq] checklist): first, in a workshop with the ceta developers as well as in discussions of the research team, all interventional components (e.g. treatment components, therapeutic techniques, expressions) were identified in the treatment manual and included in the free list and key informant interviews in step 3. second, a literature review was conducted regarding existing cultural concepts of distress among arabic-speaking persons in the mena region (e.g. idioms of distress, cultural explanations). third, semi-structured interviews and focus groups were conducted to discuss cul­ tural concepts of distress and treatment components with arabic-speaking refugees/mi­ grants and mental health experts. participants included i) arabic-speaking potential users without a medical and/or psychosocial background (au, arabic users; n = 20); ii) arabic-speaking mental health professionals with a migration and refugee background (ap, arabic professionals; n = 11); iii) mental health experts working with refugees in different institutions in germany (he, health experts; n = 6). additionally, two focus groups of arabic-speaking mental health professionals (male and female) discussed in­ consistent results of the interviews (fg, n = 7). the structure of the interviews and focus from formative research to cultural adaptation 4 clinical psychology in europe 2021, vol. 3(special issue), article e4623 https://doi.org/10.32872/cpe.4623 https://www.psychopen.eu/ groups was based on module 1 of the established manual for design, implementation, monitoring, and evaluation of mental health and psychosocial assistance programs for trauma survivors in low resource countries (applied mental health research group, 2013). the interviews were carried out on the basis of semi-structured interviews. each type of interview contains different, non-overlapping closed and open-ended questions. in addition to the interviews, potential users (au, n = 20) and arabic-speaking profes­ sionals (ap, n = 11) also completed the “barts explanatory model inventory-checklist” (bemi-c), which assesses cultural concepts of distress (rüdell et al., 2009). fourth, all adaptations and examinations were listed and summarised in a monitoring form (supplement 3, heim et al., 2021, this issue). fifth, final agreements on the adapted version were made with the help of four independent arabic-speaking experts, who evaluated the suggested adaptations based on the aforementioned steps (supplement 3). sixth, any differences between the preliminary adapted version and the experts’ suggestions were discussed within the research team and a final decision was made (supplement 3). data collection after receiving information about the study, participants signed an informed consent form prior to participating in the interviews/focus groups. all forms were provided in arabic. the interviews (au, ap) and the fg were conducted by arabic-speaking trained interviewers. all interviews/fgs were audio-recorded, and the recordings were summar­ ised and translated into german. an interview id was assigned by the first author, who kept an encrypted digital document with the identifying keys. basic non-identifying information about the respondents was collected (age, gender). interviews were conducted in berlin and cottbus, germany, between december 2019 and may 2020. final agreements (step 6 in procedures and participants) were made between july and september 2020. all participants (table 1 for more details) received an incentive for their participation (20-40 euros). the ethics committee of the freie universität berlin (germany) gave approval for this study (008/2020). data analysis the data were analysed using content analysis, i.e. transcripts of the communication were evaluated and prepared for the adaptation process (rädiker & kuckartz, 2019) with the help of maxqda 2018 (verbi software, 2018). all responses from the au, ap and he interviews were listed and coded. no prior coding framework existed. a coding system was developed inductively for all three forms of interviews. codes represented the themes provided in responses to the open-ended questions and were summarised quantitatively (e.g. 18 out of 20 au interviewees named sport as a positive activity: sport böttche, kampisiou, stammel et al. 5 clinical psychology in europe 2021, vol. 3(special issue), article e4623 https://doi.org/10.32872/cpe.4623 https://www.psychopen.eu/ n = 18/20). the frequency of the answers can be interpreted as an indicator of their importance (applied mental health research group, 2013). each group received different questions, so the second number always indicates the interview group (n/20 = au, n/6 = he, n/11 = ap). all data were analysed at the individual level, with the exception of data from the fgs, which were analysed at the group level. findings of the fgs aimed to complement or contrast findings from au, ap and he interviews. the themes that arose from the coded framework were presented to the four arabic-speaking experts and finalised by the research team. quantitative data from bemi-c were analysed using the spss software, version 26 (ibm corporation, 2018). results decision-making and expert reviews for the decision-making process, the monitoring form (supplement 3) was used. here, all preliminary and final adaptations in the process were written down and discussed. first, two one-day workshops of the research group (see supplement 2) took place in berlin, germany, to discuss and evaluate the results of the fl and ki interviews. these results were prepared by mb (first author) and a psychology student (re). during the workshop, the prepared results and suggestions were read by all participants (written in the monitoring form). there was either agreement with the adaptation or further suggestions were made. table 1 sample description of participants of the formative research (step 3) interviews/focus group sample size age in years m (sd) age range sample size age in years m (sd) age range free list interview (arabic users) total 20 30.10 (8.86) 23-57 men 15 27.40 (3.94) 23-39 women 5 38.20 (14.46) 24-57 key informant interview (arabic professionals) key informant interview (health experts) total 11 30.78 (5.36) 23-37 6 47.83 (12.81) 32-68 men 5 31.80 (5.63) 23-37 2 45.50 (12.02) 37-54 women 6 29.50 (5.51) 24-36 4 49.00 (14.83) 32-68 focus group i focus group ii men 3 28.33 (4.73) 23-32 – – – women – – – 4 27.75 (3.50) 24-32 note. sd = standard deviation. from formative research to cultural adaptation 6 clinical psychology in europe 2021, vol. 3(special issue), article e4623 https://doi.org/10.32872/cpe.4623 https://www.psychopen.eu/ second, based on the two workshops, the content of the fgs was elaborated and the first version of the adaptations from the workshops was adapted in writing in the document. third, based on the results of the fgs, the existing adaptations were modified and written down if necessary. fourth, the four arabic-speaking experts were sent the form with all of the existing preliminary adaptations. the experts either agreed to the proposals in writing or noted changes in writing in the monitoring form. explicit linguistic comments were also made here. finally, another two-day workshop of the research group took place. this was again prepared by mb and re, who had written down the suggestions of the four experts so that the members of the research group could see the changes beforehand. during these two days, all changes in the document were discussed and voted on. cultural concepts of distress (ccd) three cultural adaptations of ceta were made with regard to the ccd. two adaptations were made regarding idioms of distress. first, based on the bemi-c (au & ap), five idioms of distress were integrated into the introduction of ceta/eceta (table 2; in bold). second, the ap interviews showed that the assessment of suicidal ideation in the component “safety” should be carried out gradually, i.e. with the topic being introduced indirectly (n = 6/11, e.g. “have you had thoughts that you would be better off dead or not waking up in the morning?”), followed by direct questions regarding suicidal thoughts and plans. the description of arabic-speaking refugees’ ccd (hassan et al., 2015), as well as the data from the he interviews, highlighted the importance of an exploratory model of psychological symptoms. therefore, the introduction of ceta/eceta was expanded with a section addressing fear of becoming crazy, the relationship between body and mind, and awareness of mental health problems (he: n = 3/6, supplement 2). treatment components (specific and unspecific elements, and therapeutic techniques) with regard to therapeutic treatment components, he stated that all specific ceta components were suitable for the treatment of arabic-speaking refugees. therefore, all components remained in the adapted manual (supplement 1). the he interviews did not result in a clear conclusion regarding the fit of the compo­ nent “problem solving”, since half of the respondents assessed the content as not feasible (e.g. too cognitive, difficult to work with). therefore, the focus groups and the research group discussed this component further during the process. ultimately, the component böttche, kampisiou, stammel et al. 7 clinical psychology in europe 2021, vol. 3(special issue), article e4623 https://doi.org/10.32872/cpe.4623 https://www.psychopen.eu/ remained in the manual, as it was considered useful to address post-migration living difficulties. regarding the unspecific treatment elements, two adaptations were carried out in the introductory part of ceta. first, the component “encouraging participation” was extended regarding the presentation of the rules of interpretation, because interpreters are of crucial importance in the face-to-face context. second, the literature and ap interviews (n = 11/11) emphasised the importance of understanding the treatment proc­ ess in order to increase compliance (e.g., patients' active role during sessions, possible destabilisation). therefore, the analogy of “walking on a mountain path” was explicitly added to this component in ceta/eceta (supplement 2). based on discussions and practical experiences of the research group, four therapeu­ tic techniques were excluded due to the difficulties in implementation and delivery in an adequate online format (supplement 1). results from the ap interviews showed that all other therapeutic techniques were suitable (supplement 1). due to the asynchronous communication of lay counsellor and patient in eceta, two role plays were adapted. this therapeutic technique, which requires simultaneous interaction, was transformed into a written "letter to a friend", in which the patient addresses an imaginary friend with the same problem. also due to the asynchronous communication, the decision was made to fix the order of the techniques in tdw-ii in ceta/eceta. table 2 typical somatic and mental symptoms of arabic-speaking refugees (selection from bemi-c) symptoms free list interview (au) key informant interview (ap) total men women total men women somatic n (%) sleep disturbances 15 (75) 11 (73.3) 4 (80) 9 (81.8) 4 (80) 5 (83.3) pain/aches 17 (85) 12 (80) 5 (100) 10 (90.9) 4 (80) 6 (100) fatigue/tiredness 20 (100) 15 (100) 5 (100) 11 (100) 5 (100) 6 (100) nerves/being agitated/restless 19 (95) 14 (93.3) 5 (100) 11 (100) 5 (100) 6 (100) bodily weakness 16 (80) 11 (73.3) 5 (100) 9 (81.8) 4 (80) 5 (83.3) nausea or feeling sick 12 (60) 7 (46.7) 5 (100) 8 (72.7) 5 (100) 3 (50) mental n (%) dysphoria (feeling down) 9 (45) 4 (26.7) 5 (100) 6 (54.5) 2 (40) 4 (66.7) feeling irritable or fed up/bored 20 (100) 15 (100) 5 (100) 7 (63.6) 3 (60) 4 (66.7) feeling nervous, anxious 17 (85) 13 (86.7) 4 (80) 9 (81.8) 5 (100) 4 (66.7) feeling frightened or fearful 17 (85) 12 (80) 5 (100) 9 (81.8) 4 (80) 5 (83.3) lack of concentration/forgetfulness 18 (90) 13 (86.7) 5 (100) 10 (90.9) 5 (100) 5 (83.3) loss of interest/ not being able to enjoy things 18 (90) 13 (86.7) 5 (100) 7 (72.7) 5 (100) 3 (50) note. bold, five most prominent symptoms included in the manual. from formative research to cultural adaptation 8 clinical psychology in europe 2021, vol. 3(special issue), article e4623 https://doi.org/10.32872/cpe.4623 https://www.psychopen.eu/ treatment delivery (format, surface) regarding the delivery format, two changes were implemented. first, ceta is also of­ fered in an internet-based context (eceta). second, the handling of self-endangering and third-party-endangering behaviour had to be adapted for eceta, which is conducted by lay counsellors. as soon as such behaviour is detected, the communication immediately changes from asynchronous to synchronous (i.e., telephone). the final category of adaptations refers to the surface, e.g. text, examples, and migration-, language-, and culture-related material. arabic-speaking individuals (au, ap) revealed that the expressions used in the manual are for the most part culturally appropriate. four specific adaptations were made (i.e. translation of the phrases “a day in the life” and “here and now”, expressions for “suicide” and “suicidal ideation and plans”). all other 17 adaptations are shown in supplement 5). discussion in this study, the transdiagnostic ceta was adapted for arabic-speaking refugees in germany. the cultural adaptation process followed an approach that enables a replicable and systematic documentation (heim et al., 2021, this issue). the results showed that ceta in its original form seems to be largely culture-sensitive for this target group. mainly surface adaptations were made, especially for eceta due to its asynchronous communication. based on our formative research, the cultural adaptation of the manual comprised three main aspects: i) cultural concepts of distress in the target population (i.e. arabic speakers from the mena region), ii) treatment components to address post-migration living conditions, and iii) treatment delivery, i.e., the provision of an additional online version to address potential treatment barriers. concerning the cultural concepts of distress, all adaptations are in line with previous findings. the qualitative interviews showed that the introduction of ceta should be expanded to include an explanatory model to address cultural explanations. thus, the relationship between physical and mental well-being is now more clearly demonstrated and explained, since the literature underlines that arabic idioms of distress do not dis­ tinguish between somatic experiences and psychological problems (hassan et al., 2015). furthermore, the “fear of going crazy” (shannon, 2014) was addressed by explaining the concept of mental disorders and psychological treatment. to assess suicidal ideation, different opinions were expressed, which tended either to assess suicidal ideation directly or indirectly. this difference was affected both by culture (e.g. suicide is a crime in some arab countries, hassan et al., 2015) and by legal aspects of the german health care system (suicidality must be clearly clarified). accordingly, the adaptation comprises the böttche, kampisiou, stammel et al. 9 clinical psychology in europe 2021, vol. 3(special issue), article e4623 https://doi.org/10.32872/cpe.4623 https://www.psychopen.eu/ gradual assessment of suicidal tendencies (i.e. starting with an indirect question, followed by a direct question). with regard to treatment components, the results indicated that the specific ceta components as well as the unspecific elements are suitable for the current context of arabic-speaking refugees in germany. this is in line with a review examining the effec­ tiveness of psychological interventions in different lowand middle-income countries (singla et al., 2017). the specific component of "problem solving" was considered to be important in the discussions of the research team and in the literature (singla et al., 2017). the difficult living conditions, in which refugees have to deal with multiple social problems (e.g. asylum process, housing), have been shown to affect refugees’ mental health (schick et al., 2018). to address these difficulties, “problem solving” will be offered to every patient in order to provide problem-solving skills to manage some of these existential problems. with regard to treatment delivery, an online version of ceta was developed. since this type of asynchronous communication requires more active patient involvement, the therapeutic tasks have to be described in more detail and include more examples. thus, some adaptations will only be applied in eceta. adaptations with regard to materials mostly referred to analogies, as well as examples and translations of words or phrases. a distinction was made between linguistic adaptations (e.g. translation of the phrase "a day in the life") and adaptations based on culture and migration (e.g. typical receptacles used for alcohol, everyday situations). this is in line with other studies in the field (e.g., shala et al., 2020). in sum, a small number of mainly surface adaptations were required. this might be a consequence of the fact that ceta was developed particularly for culturally diverse groups, already used simple language, already had an easily understandable structure, and has been used in different countries (murray et al., 2014). this very well thought-out structure of the original ceta provided an excellent basis for the current adaptation process. even though the cultural adaptation was facilitated by the existing framework, some limitations remain. first, only people from two different cities in germany were inter­ viewed, and most of them were from syria. however, the interviewees were of different ages and gender, and the four arabic-speaking experts were from different countries of origin. second, although we did not consider the entire ceta manual for adaptation, we selected an exact choice of words to explain a technique, main parts, and all interven­ tional components that corresponded to the framework (heim & kohrt, 2019). third, the decision to use the online format with an asynchronous communication was made prior to the formative research. these decisions are based on known contextual conditions (e.g. fear of stigmatisation, difficulties in accessing the health care system). all further adjustments to the format were then again part of the formative research. from formative research to cultural adaptation 10 clinical psychology in europe 2021, vol. 3(special issue), article e4623 https://doi.org/10.32872/cpe.4623 https://www.psychopen.eu/ the conceptual framework and the recapt guidelines simplify, standardise and clarify the cultural adaptation process. it can thus be summarised that adaptations do not always have to start from scratch; rather, practitioners and researchers are able to use existing material. future research needs to compare different levels of adaptation and their impact on treatment acceptance and effectiveness. such results might enable a balance between adaptation and the required time and financial effort. funding: this project has received funding from the german federal ministry of education and research (bmbf) under grant agreement no. 01ef1806a and no. 01ef1806h acknowledgments: we would like to thank dr. kristina metz for providing us with the opportunity to gain a deep insight into ceta and to adapt the existing manual. our sincerest thanks go to the interviewers a. alsaod and l. ighreiz, who did a tremendous job, as well as to the interviewees who participated and gave us constructive feedback. we would also like to thank a. hajjir, p. selmo, p. nour and j. abi ramia for giving us their expert opinions during the final steps in the decision-making process. competing interests: eva heim is one of the guest editors of this cpe special issue but played no editorial role in this particular article or intervened in any form in the peer review process. supplementary materials the supplementary materials (for access see index of supplementary materials below) include detailed information about: 1. components of ceta and decision regarding remaining, adaptation or exclusion from the adapted manual (supplement 1) 2. process of cultural adaptation based on the reporting criteria (recapt, supplement 2) 3. extract from the adaptation monitoring form (supplement 3) 4. qualitative research checklist (coreq, supplement 4) 5. surface adaptations (supplement 5) index of supplementary materials böttche, m., kampisiou, c., stammel, n., el-haj-mohamad, r., heeke, c., burchert, s., heim, e., wagner, b., renneberg, b., böttcher, j., glaesmer, h., gouzoulis-mayfrank, e., zielasek, j., konnopka, a., murray, l., & knaevelsrud, c. 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(2017). psychological treatments for the world: lessons from lowand middle-income countries. annual review of clinical psychology, 13, 149-181. https://doi.org/10.1146/annurev-clinpsy-032816-045217 turrini, g., purgato, m., ballette, f., nosè, m., ostuzzi, g., & barbui, c. (2017). common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies. international journal of mental health systems, 11(1), article 51. https://doi.org/10.1186/s13033-017-0156-0 verbi software. (2018). maxqda 2020. berlin, germany: verbi software. weiss, w. m., murray, l. k., zangana, g. a., mahmooth, z., kaysen, d., dorsey, s., lindgren, k., gross, a., murray, s. m., bass, j. k., & bolton, p. (2015). community-based mental health treatments for survivors of torture and militant attacks in southern iraq: a randomized control trial. bmc psychiatry, 15, article 249. https://doi.org/10.1186/s12888-015-0622-7 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. from formative research to cultural adaptation 14 clinical psychology in europe 2021, vol. 3(special issue), article e4623 https://doi.org/10.32872/cpe.4623 https://doi.org/10.1016/j.invent.2020.100339 https://doi.org/10.1093/fampra/cmu017 https://doi.org/10.1017/s2045796017000713 https://doi.org/10.1146/annurev-clinpsy-032816-045217 https://doi.org/10.1186/s13033-017-0156-0 https://doi.org/10.1186/s12888-015-0622-7 https://www.psychopen.eu/ from formative research to cultural adaptation (introduction) method procedures and participants data collection data analysis results decision-making and expert reviews cultural concepts of distress (ccd) treatment components (specific and unspecific elements, and therapeutic techniques) treatment delivery (format, surface) discussion (additional information) funding acknowledgments competing interests supplementary materials references prospective mental imagery in depression: impact on reward processing and reward-motivated behaviour scientific update and overview prospective mental imagery in depression: impact on reward processing and reward-motivated behaviour fritz renner 1 , jessica werthmann 1, andreas paetsch 1, hannah e. bär 1, max heise 1, sanne j. e. bruijniks 1 [1] clinical psychology and psychotherapy unit, institute of psychology, university of freiburg, freiburg, germany. clinical psychology in europe, 2021, vol. 3(2), article e3013, https://doi.org/10.32872/cpe.3013 received: 2020-03-30 • accepted: 2021-02-08 • published (vor): 2021-06-18 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: fritz renner, clinical psychology and psychotherapy unit, institute of psychology, university of freiburg, engelbergerstr. 41, 79106 freiburg, germany. e-mail: fritz.renner@psychologie.uni-freiburg.de abstract background: mental imagery has long been part of cognitive behavioural therapies. more recently, a resurgence of interest has emerged for prospective mental imagery, i.e. future-directed imagery-based thought, and its relation to reward processing, motivation and behaviour in the context of depression. method: we conducted a selective review on the role of prospective mental imagery and its impact on reward processing and reward-motivated behaviour in depression. results: based on the current literature, we propose a conceptual mechanistic model of prospective mental imagery. prospective mental imagery of engaging in positive activities can increase reward anticipation and reward motivation, which can transfer to increased engagement in reward-motivated behaviour and more experiences of reward, thereby decreasing depressive symptoms. we suggest directions for future research using multimodal assessments to measure the impact of prospective mental imagery from its basic functioning in the lab to real-world and clinical implementation. conclusion: prospective mental imagery has the potential to improve treatment for depression where the aim is to increase reward-motivated behaviours. future research should investigate how exactly and for whom prospective mental imagery works. keywords prospective mental imagery, depression, reward processing, motivation, behavioural activation this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3013&domain=pdf&date_stamp=2021-06-18 https://orcid.org/0000-0002-1692-449x https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • this review provides a selected update of the literature on prospective mental imagery. • prospective mental imagery might decrease depression via reward processing and reward-motivated behaviours. • suggestions for future research to investigate these hypotheses are provided. according to beck’s cognitive model, individuals with depression hold negative views about the self, others and the future (beck, rush, shaw, & emery, 1979). in addition to the negatively biased content of future thinking in depression, the importance of thought modality, particularly mental representations, has increasingly been recognized as a key target in psychotherapy (arntz, 2020). thinking about events or activities in the future might draw on imagery-based thought, involving a rich perceptual experience in the absence of external sensory input (pearson, naselaris, holmes, & kosslyn, 2015). prospective mental imagery, i.e. future-directed imagery-based thought, has recently gained interest in the context of depression. in this review, we provide a selected update of the recent scientific literature on prospective mental imagery and its impact on reward processing (i.e., anticipation or experience of reward) and reward-motivated behaviour (i.e., behaviour driven by the motivation to attain rewards) in depression. drawing from the wider research in this area, we present a conceptual model linking prospective mental imagery to reward processing and reward-motivated behaviour and discuss future directions for research. for a broader discussion of the nature, function and clinical applications of mental imagery in depression and other mental disorders see e.g. blackwell, 2019; holmes, blackwell, burnett heyes, renner, and raes, 2016; ji, kavanagh, holmes, macleod, and di simplicio, 2019; renner and holmes, 2018. identifying core clinical features in depression: reward processing major depressive disorder (mdd) is characterized by low mood and/or the loss of interest in previously rewarding or enjoyable activities as well as a number of other emotional, cognitive and physical symptoms (american psychiatric association, 2013). mdd is a heterogeneous disorder, meaning that two individuals with a diagnosis of mdd may have little or no symptoms in common (strunk & sasso, 2017). this presents a major challenge for research and treatment development in depression (fried, 2015, 2017; olbert, gala, & tupler, 2014). accordingly, recent initiatives have called to focus research on core clinical features rather than psychiatric syndromes in depression and other mental disorders (insel et al., 2010). alterations in reward processing are common in psychopathology (zald & treadway, 2017) and therefore one potential treatment target in this context. in depression, alterations in reward processing might manifest in a reduced prospective mental imagery in depression 2 clinical psychology in europe 2021, vol. 3(2), article e3013 https://doi.org/10.32872/cpe.3013 https://www.psychopen.eu/ sensitivity to reward, resulting in decreased approach motivation (alloy et al., 2016). def­ icits in reward processing represent a central aspect of anhedonia, defined as “diminished interest or pleasure in almost all activities” (american psychiatric association, 2013). diminished interest and diminished experienced pleasure correspond to two distinct components of reward processing: reward anticipation and reward consummation (gard, germans gard, kring, & john, 2006; treadway & zald, 2011). reward anticipation can be further divided into anticipated reward, i.e. the expectation of how rewarding/pleasant a future activity will be, and anticipatory reward, i.e. the subjective experience of how rewarding/pleasant it is to think about a future activity (baumgartner, pieters, & bagozzi, 2008). reward consummation, on the other hand, refers to rewarding/pleasant feelings experienced while engaging in enjoyable activities (gard, germans gard, kring, & john, 2006). while both components are important, research has suggested that deficits in reward-motivated behaviour are primarily driven by reduced or dysfunctional reward anticipation (bakker et al., 2017; gorka et al., 2014). given that these deficits in reward processing are not adequately addressed by current treatments of depression (treadway & zald, 2011), one way forward in treatment innovation is to develop procedures directly targeting reward anticipation and reward-motivated behaviours. targeting reward anticipation, reward motivation and reward-motivated behaviours using prospective mental imagery by drawing on shared brain structures and functions (dijkstra, bosch, & van gerven, 2019; kosslyn, ganis, & thompson, 2001; pearson et al., 2015), vivid mental imagery can give rise to an “as real” experience and evoke emotional responses at subjective, physio­ logical and neural levels (ji, burnett heyes, macleod, & holmes, 2016). these properties of prospective mental imagery allow us to simulate engagement in behavioural activities and to “pre-experience” future activities, thereby providing “a taste” of different courses of action and their potential (emotional) consequences (moulton & kosslyn, 2009). this makes prospective mental imagery an excellent candidate procedure to target reward anticipation and reward-motivated behaviours. recently, a number of studies have emerged that tested the impact of prospective mental imagery of positive events or activities on reward anticipation and reward-mo­ tivated behaviour. these studies have the common aim of investigating new ways of promoting positive experiences, in line with recent calls for treatment innovation in depression to focus on positive affect systems (dunn, 2012; dunn et al., 2019). studies presented here also fit within the broader literature that highlights the role of expectan­ cies in mental disorders (rief & glombiewski, 2017; rief et al., 2015). in depression, an absence of positive expectancies might manifest as low anticipated reward/pleasure from engaging in otherwise enjoyable activities. renner, werthmann, paetsch et al. 3 clinical psychology in europe 2021, vol. 3(2), article e3013 https://doi.org/10.32872/cpe.3013 https://www.psychopen.eu/ several studies have investigated the impact of mental imagery on reward antici­ pation. in a case-series, hallford, sharma, and austin (2020) asked participants with depression to rate anticipatory pleasure of future events over a no-treatment baseline phase. participants then switched to an intervention phase in which they completed an episodic future thinking task involving vivid imagery of engaging in enjoyable upcom­ ing activities, focussing on contextual and episodic detail of these events. the authors found large effects of the intervention on anticipatory pleasure. in two experimental studies, hallford, farrell, and lynch (2020) further tested the impact of guided episodic thinking about past or future positive events on anticipated and anticipatory pleasure in a non-clinical sample. participants were instructed to imagine past or future events from a first-person perspective emphasising positive aspects of the events. in general, the authors found support for their hypothesis that guided episodic thinking of positive events (pastand future-oriented) increases anticipated and anticipatory pleasure (com­ pared to baseline ratings). in an earlier study, pictet et al. (2016) tested the effect of an imagery cognitive bias modification (cbm) procedure on depression, anhedonia and anticipatory and consummatory pleasure in individuals with depressive symptoms. they found positive effects of the cbm intervention involving imagery of positive everyday experiences (compared to a closely matched control condition) on anhedonia and antic­ ipatory pleasure as well as a stronger increase in consummatory pleasure (compared to a waitlist control condition). this is in line with earlier findings by blackwell et al. (2015), who found positive effects of an imagery cbm intervention (compared to an active control condition) on the anhedonia item of the beck depression inventory. these studies suggest that imagery-based interventions might have merit in targeting reward-related processes in depression. other studies have focussed on the effects of mental imagery on approach motiva­ tion. for example, linke and wessa (2017) tested the effects of an online mental imagery training, compared to a waitlist control condition, on reward sensitivity and approach tendencies towards positive activities and edibles. during the imagery training, partici­ pants imagined the positive emotions, affirmative thoughts and pleasurable sensations associated with previously selected positive activities every second day over a two-week period. the authors found that the imagery training successfully increased reward sensi­ tivity and faster approach tendencies for activities (linke & wessa, 2017). another study tested the effects of a positive prospective imagery intervention for planned everyday enjoyable and routine activities in a non-clinical sample (renner, murphy, ji, manly, & holmes, 2019). participants first selected and planned activities following the procedures described in behavioural activation treatment for depression (martell, addis, & jacobson, 2001). participants in a motivational imagery condition then vividly imagined engaging in each of their planned activities. participants in a no-imagery control condition plan­ ned the activities, but did not engage in the imagery exercise. the prospective imagery intervention increased anticipated pleasure/reward and motivation to engage in the prospective mental imagery in depression 4 clinical psychology in europe 2021, vol. 3(2), article e3013 https://doi.org/10.32872/cpe.3013 https://www.psychopen.eu/ activities, compared to the control condition. in two independent experiments, boland, riggs, and anderson (2018) asked non-depressed and dysphoric participants to simulate positive events using vivid mental imagery. they found that event likelihood (i.e., how likely participants thought the event would happen to them in the future) for positive events increased following imagery simulation of the events compared to a neutral imagery control task. taken together, these studies demonstrate that engaging in positive prospective mental imagery of everyday activities has an impact on reward processing and transfers to approach motivation for engaging in the simulated activities. finally, a number of studies have investigated the transfer of the motivating effect of mental imagery interventions to self-reported activity levels outside the lab. one study conducted a secondary analysis of a randomized controlled trial (blackwell et al., 2015) to test the effects of a four-week positive mental imagery intervention on self-reported behavioural activation in individuals with major depressive disorder (renner, ji, pictet, holmes, & blackwell, 2017). participants randomized to the positive imagery condition showed a greater increase in self-reported behavioural activation over the study period, compared to participants randomized to a control condition (renner et al., 2017). in line with these findings, renner et al. (2019; reviewed above) found that positive men­ tal imagery simulations of planned activities was associated with higher completion of activities that participants had previously been putting-off doing. considering all types of activities, mental imagery led to a higher completion compared to a control group receiving activity reminder messages but not to a control group without reminder messages. thus, while these preliminary findings need replication, they provide initial evidence that the positive effects of prospective mental imagery on approach motivation for rewarding activities might transfer to reward-motivated behaviour outside the labo­ ratory. the studies reviewed here suggest that positive prospective mental imagery of activ­ ities can facilitate reward anticipation, reward motivation and reward-motivated behav­ iour. this is clinically relevant given that reward anticipation deficits are not adequately addressed in current treatments of depression (treadway & zald, 2011). drawing from this broader literature, in the following paragraph, we provide a conceptual model de­ scribing how prospective mental imagery could promote the engagement in reward-mo­ tivated behaviour and its clinical potential to impact mood and depressive symptoms. mental imagery as motivational amplifier: a conceptual model figure 1 provides a conceptual model illustrating the expected effects of prospective mental imagery on reward-motivated behaviour: positive prospective mental imagery of activities gives rise to a motivational amplifier effect by facilitating reward anticipation, reward motivation and reward-motivated behaviour. given the power of mental imagery renner, werthmann, paetsch et al. 5 clinical psychology in europe 2021, vol. 3(2), article e3013 https://doi.org/10.32872/cpe.3013 https://www.psychopen.eu/ to amplify emotions (holmes, geddes, colom, & goodwin, 2008), it has the potential to evoke the anticipation of reward-related emotions by drawing upon prior knowledge and experiences (kavanagh et al., 2005; moulton & kosslyn, 2009; schacter et al., 2008). anticipating the positive emotional consequences of future behaviour, in turn, predicts reward motivation and reward-motivated behaviour (hallford & sharma, 2019; mellers & mcgraw, 2001; sherdell, waugh, & gotlib, 2012; treadway & zald, 2011). this transfer from imagery to behaviour might be further facilitated by a boost in prospective memory for the simulated activity (schacter, benoit, & szpunar, 2017). actual engagement in simulated activities might then lead to a reward experience. the episodic memory of this experience, in turn, affects subsequent imagery simulations of similar future activities (figure 1, see table 1 for key term definitions). figure 1 conceptual model of the motivational amplifier hypothesis note. positive prospective mental imagery of engaging in (everyday) activities (e.g. running) can increase reward anticipation (anticipatory and anticipated reward) and reward motivation, which can transfer to increased engagement in reward-motivated behaviour and reward experience. note that concepts in bold boxes are part of the literature review above. prospective mental imagery in depression 6 clinical psychology in europe 2021, vol. 3(2), article e3013 https://doi.org/10.32872/cpe.3013 https://www.psychopen.eu/ table 1 definition of key terms used in the conceptual model concept definition prospective mental imagery future-directed imagery-based thought, involving a rich perceptual experience without external sensory input reward processing reward anticipation anticipated reward expectation of how rewarding/pleasant a future activity will be anticipatory reward subjective experience of how rewarding/pleasant it is to think about a future activity reward experience pleasant/rewarding feelings experienced while engaging in the activity reward motivation amount of effort an individual is prepared to expend for reward attainment reward-motivated behaviour behaviour driven by the motivation to attain rewards prospective memory remembering to carry out a planned activity in the future episodic memory memory of personal experiences the conceptual model has clinical potential insofar as it illustrates how positive prospec­ tive mental imagery could be used to promote behavioural activation in depression. the central assumption here is that reduced reward anticipation in depression contributes to a downward-spiral of reduced reward-motivated behaviours due to a loss of interest in previously rewarding activities that reduces the experience of rewards in daily life and, consequently, worsens depressive symptoms such as low mood (figure 2). based on our conceptual model, we hypothesise that positive prospective mental imagery of everyday activities can reverse this process by acting as a motivational amplifier boosting behavioural activation and thereby alleviating depressive symptoms (figure 2). renner, werthmann, paetsch et al. 7 clinical psychology in europe 2021, vol. 3(2), article e3013 https://doi.org/10.32872/cpe.3013 https://www.psychopen.eu/ figure 2 reversing the downward spiral of depression with prospective mental imagery note. key assumption: reduced reward anticipation leads to a downward spiral of reduced reward-motivated behaviour and less reward experiences, resulting in increased depressive symptoms (left side). key hypothesis: targeting reward anticipation using vivid prospective mental imagery leads to increased reward-motivated behaviour and more reward experiences, resulting in a decrease of depressive symptoms (right side). in summary, the recent literature reviewed above supports the idea that positive prospec­ tive mental imagery of activities can facilitate reward anticipation, reward motivation and reward-motivated behaviour. however, the reviewed studies primarily relied on self-report and more work is needed to investigate how the transfer of imagery to behaviour beyond the laboratory can be facilitated and how prospective mental imagery might benefit clinical practice. future directions recent literature has emphasised the importance of conducting multimodal research to understand and thereby improve clinical interventions (holmes, craske, & graybiel, 2014). a future endeavour might thus be to extend previous research on the mechanism underlying prospective mental imagery beyond self-report. neuroimaging, for instance, has provided initial evidence for a recruitment of brain regions implicated in reward pro­ cessing, such as the dorsal (caudate nucleus) and ventral striatum (nucleus accumbens), prospective mental imagery in depression 8 clinical psychology in europe 2021, vol. 3(2), article e3013 https://doi.org/10.32872/cpe.3013 https://www.psychopen.eu/ during prospective mental imagery of positive events (d’argembeau, xue, lu, van der linden, & bechara, 2008; gerlach, spreng, madore, & schacter, 2014). other measures that have been used to evaluate imagery-based manipulations and reward processing include pupil size, attention bias and approach/avoidance tendencies (anderson, laurent, & yantis, 2011; henderson, bradley, & lang, 2018; linke & wessa, 2017; schneider, leuchs, czisch, sämann, & spoormaker, 2018; werthmann, jansen, & roefs, 2016). sim­ ilar approaches could prove useful to further investigate reward processing as a work­ ing mechanism of prospective mental imagery for behavioural activation. ultimately, investigations beyond self-report will help us fine-tune imagery-based interventions and thereby guide treatment innovation for depression. another important question in experimental psychopathology research is how lab­ based findings hold up under everyday circumstances. recent research in the broader field of clinical psychology demonstrated the added value of combining laboratory ex­ periments with ecological momentary assessment (ema; e.g. bakker et al., 2019; moran, culbreth, & barch, 2017; ramirez & miranda, 2014) and of integrating experimental manipulations into daily life (huffziger et al., 2013; huffziger, ebner-priemer, koudela, reinhard, & kuehner, 2012). for example, bakker and colleagues (2019) showed that when neural activity in reward processing regions was lower, assessed in the lab, ema of reward anticipation and activity pleasantness were increasingly dissociated from one another. findings like these can be valuable to refine or develop interventions by identi­ fying treatment targets (e.g. coupling of anticipation and engagement) under well-speci­ fied circumstances (e.g. low neural activity in reward-processing brain regions). these findings are also relevant in the context of earlier findings regarding challenges with the transfer of experimental prospective mental imagery interventions from lab to the real world (renner et al., 2019). integration of ema with lab-based experiments as well as the use of ecological momentary interventions (emi; myin-germeys, klippel, steinhart, & reininghaus, 2016) or manipulations of reward processing through prospective mental imagery in daily life may offer an additional means to facilitate the transfer from lab to real-world behaviour. moreover, individuals may differ in the extent to which they benefit from prospec­ tive mental imagery interventions. studies already pointed to individual variation in processes related to prospective mental imagery, such as anticipatory pleasure (hallford, sharma, & austin, 2020) and the perception of reward (locke & braver, 2008), and sug­ gested promising potential predictors or moderators that should be investigated in future studies. potential moderators include individual differences in generating vivid mental imagery (blackwell et al., 2015; renner et al., 2017, 2019), procrastination (renner et al., 2019) and the number of depressive episodes (blackwell et al., 2015). additionally, when moving towards clinical applications, the question of how individual differences interact with the active ingredients of prospective imagery interventions becomes relevant. for example, initial evidence highlights the importance of simulating rewarding aspects of renner, werthmann, paetsch et al. 9 clinical psychology in europe 2021, vol. 3(2), article e3013 https://doi.org/10.32872/cpe.3013 https://www.psychopen.eu/ planned activities in non-clinical participants, but it has not yet been investigated if individuals who have difficulties experiencing pleasure/reward from (thinking about) activities (i.e., individuals with anhedonia) benefit from simulating rewarding aspects of planned activities. relatedly, prospective mental imagery interventions developed in the lab might need to be adjusted for clinical groups. for example, individuals with low mood and depression experience more difficulty in generating vivid prospective imagery and experience less spontaneous positive imagery (hallford, barry, et al., 2020; holmes et al., 2016; ji, holmes, macleod, & murphy, 2019; morina, deeprose, pusowski, schmid, & holmes, 2011). individuals with depression might thus benefit from additional training in generating vivid imagery for positive events. imagery based interventions have been used as stand-alone interventions as well as part of regular cbt for depression (renner & holmes, 2018). so far, we have mainly discussed the use of prospective mental imagery to target specific core clinical features in depression. another line of inquiry involves integrating prospective imagery procedures to enhance the effects of established treatments for depression. recent studies have suggested that cbt might be improved by the use of cognitive support strategies that enhance memory for the session content, and subsequently outcome (harvey et al., 2017, 2014). we suggest that prospective mental imagery could potentially work as a cognitive support strategy for cbt skill acquisition. cbt skills have been defined as the ability to re-evaluate the accuracy of one's own automatic beliefs or underlying stable cognitive patterns (a cognitive therapy skill; ct skill) and to engage proactively in pleasurable activities (a behavioral therapy skill; bt skill) (strunk, derubeis, chiu, & alvarez, 2007). in non-clinical settings, mental imagery has been linked to improved skill acquisition in health-related and sport contexts (anton, bean, hammonds, & stefanidis, 2017; dana & gozalzadeh, 2017). in a clinical setting, mental imagery has been indirectly linked to bt skill by demonstrating an impact on self-reported behavioural activation (renner et al., 2017; reviewed above). future studies should investigate how and for whom prospective mental imagery may increase the acquisition of cbt skills. further down the road, for a successful clinical implementation, training sessions in prospective mental imagery could be included as part of a regular behavioural activation treatment protocol (martell et al., 2001) to facilitate engagement in pleasant and rewarding activities. overall conclusion in this review, we provided a selected update of the recent scientific literature on pro­ spective mental imagery and its impact on reward processing and reward-motivated behaviour in depression. overall, the studies presented here suggest that prospective mental imagery simulations of activities can increase reward processing related to these activities as well as reward motivation and reward-motivated behaviors. thus, these initial studies suggest that prospective mental imagery is a promising experimental prospective mental imagery in depression 10 clinical psychology in europe 2021, vol. 3(2), article e3013 https://doi.org/10.32872/cpe.3013 https://www.psychopen.eu/ intervention in the context of depression, where the aim is to increase engagement in potentially rewarding activities. future directions for research in this area may focus on multimodal assessments of prospective mental imagery effects to gain a better under­ standing of the processes involved, from basic mechanisms to everyday situations and its clinical applications. funding: all authors are supported by a sofja kovalevskaja award from the alexander von humboldt foundation and the german federal ministry for education and research awarded to fr. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. twitter accounts: @fritz_renner, @andreaspaetsch references alloy, l. b., olino, t., freed, r. d., & nusslock, r. 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(2011). reconsidering anhedonia in depression: lessons from translational neuroscience. neuroscience and biobehavioral reviews, 35(3), 537-555. https://doi.org/10.1016/j.neubiorev.2010.06.006 werthmann, j., jansen, a., & roefs, a. (2016). make up your mind about food: a healthy mindset attenuates attention for high-calorie food in restrained eaters. appetite, 105, 53-59. https://doi.org/10.1016/j.appet.2016.05.005 zald, d. h., & treadway, m. t. (2017). reward processing, neuroeconomics, and psychopathology. annual review of clinical psychology, 13(1), 471-495. https://doi.org/10.1146/annurev-clinpsy-032816-044957 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. prospective mental imagery in depression 16 clinical psychology in europe 2021, vol. 3(2), article e3013 https://doi.org/10.32872/cpe.3013 https://doi.org/10.1016/j.neuroimage.2018.04.078 https://doi.org/10.1037/a0024945 https://doi.org/10.1037/0022-006x.75.4.523 https://doi.org/10.1016/j.neubiorev.2010.06.006 https://doi.org/10.1016/j.appet.2016.05.005 https://doi.org/10.1146/annurev-clinpsy-032816-044957 https://www.psychopen.eu/ prospective mental imagery in depression (introduction) identifying core clinical features in depression: reward processing targeting reward anticipation, reward motivation and reward-motivated behaviours using prospective mental imagery mental imagery as motivational amplifier: a conceptual model future directions overall conclusion (additional information) funding acknowledgments competing interests twitter accounts references dysfunctional cognition in individuals with an increased risk for mania research articles dysfunctional cognition in individuals with an increased risk for mania raphaela ulrich a, thomas d. meyer b, sylke andreas ac, claudia lex d [a] department of psychology, university of klagenfurt, klagenfurt, austria. [b] faillace department of psychiatry and behavioral sciences, mcgovern school of medicine, university of texas hsc, houston, tx, usa. [c] department of psychology, university witten/herdecke, witten, germany. [d] department of psychiatry, villach general hospital, villach, austria. clinical psychology in europe, 2021, vol. 3(1), article e3733, https://doi.org/10.32872/cpe.3733 received: 2020-05-19 • accepted: 2021-01-17 • published (vor): 2021-03-10 handling editor: tania lincoln, university of hamburg, hamburg, germany corresponding author: claudia lex, department of psychiatry, villach general hospital, nikolaigasse 43, 9500 villach, austria. phone: (43) 4242-208-0. e-mail: clex@iit.edu abstract background: there is still a lack of knowledge about attitudes and cognitions that are related to bipolar disorder. theoretically, it was proposed that exaggerated beliefs about the self, relationships, the need for excitement, and goal-related activities might lead to mania in vulnerable individuals, however, the few studies that examined this hypothesis provided mixed results. one of the unresolved issues is if such a cognitive style is associated with current mood symptoms or with different stages of the illness, i.e. at-risk versus diagnosed bipolar disorder. therefore, the present study aimed at evaluating depression and mania-related cognitive style in individuals at-risk for mania. method: in an online survey, we collected data of 255 students of the university of klagenfurt, austria. all participants completed the hypomanic personality scale (hps), the cognition checklist for mania – revised (ccl-m-r), the dysfunctional attitude scale (das), the beck depression inventory (bdi), and the internal state scale (iss). results: in a hierarchical regression, hps was positively related to scores of all subscales of the ccl-m-r. the hps did not significantly predict scores of the das. current manic and depressive symptoms significantly contributed to the models. conclusion: the present results suggest that a trait-like risk for mania is associated with maniarelated but not depression-related cognitions. keywords bipolar disorder, hypomania, hypomanic personality, dysfunctional attitudes, cognition, vulnerability this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3733&domain=pdf&date_stamp=2021-03-10 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • individuals at-risk for mania show mania-specific rather than depression-specific thinking patters. • current subclinical mood symptoms are related to mood-congruent attitudes and cognitions. bipolar spectrum disorders, which include bipolar i, bipolar ii, and subthreshold bipolar disorder, affect about 2.4% of the population worldwide (merikangas et al., 2011) and can be highly disabling. compared to other psychiatric illnesses, bipolar disorder (bd) is the fifth leading cause of years lived with disability (ferrari et al., 2016), it is associated with social disruption (e.g., depp et al., 2010) and an increased risk of suicide (e.g., nordentoft et al., 2011). psychological treatments for bd combined with pharmacological strategies yielded better outcomes than pharmacological treatment alone (miklowitz et al., 2007). for example, structured psychological treatments, such as cognitive behavioral therapy (cbt) seem to be effective (chiang et al., 2017), but this effect might be specific for depressive symptoms (oud et al., 2016). one reason for this result might be that cognitive behavioral interventions for bd stem from cbt that was originally developed in the context of major depression (lam et al., 2010), and usually psychotherapy does not focus on decreasing activation, changing self-confident thoughts or lowering elevated mood. in addition, there is still relatively little knowledge about cognition specifically related to bd and mania. one of the few cognitive theories specifically developed for bd was proposed by beck et al. (2006). they state that individuals possess schemata defined as underlying cognitive structures for organizing perceptions of the world. these schemata can be detected by asking people about their beliefs and attitudes. if a negatively biased schema is activated by a stressful life event, the individual might develop even more negative thoughts and subsequently experience depressive symptoms. for example, an underlying belief “i am incompetent” can be represented in the conscious thought “i can’t do it” when asked to handle a difficult situation, which then might lead to an increase in de­ pressive symptoms (beck & haigh, 2014). parallel, a different set of dysfunctional beliefs might lead to manic episodes. these mania-specific cognitions relate to exaggerated be­ liefs about self-worth, to grandiose beliefs about interpersonal relationships, to erroneous beliefs about needing excitement caused by high-risk situations, and unrealistic beliefs about having high energy levels for undertaking goal-driven activities (beck et al., 2006; newman et al., 2002). to tap into mania-related dysfunctional beliefs beck et al. (2006) developed the cognition checklist for mania – revised (ccl-m-r) that comprises four subscales, i.e. ‘myself’, ‘relationship’, ‘pleasure/excitement’, and ‘activity’. based on beck’s model, all four dimensions of the ccl-m-r should be elevated in manic states. however, the cognition and risk for mania 2 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ few studies conducted so far have yielded mixed results. beck et al. (2006) found that currently manic patients indeed reported more mania-related cognition with regards to ‘myself’, ‘relationship’, and ‘activity’ compared to patients in depressed and mixed states, whereas another study found that only the ‘pleasure/excitement’ subscore was related to manic symptoms (fulford et al., 2009). in addition, it is unclear whether this specific set of cognitions is associated exclusively with manic states or if they persist in other bipolar states as well, e.g., remission or prodromal. while two studies mentioned before concluded that certain mania-related cognitions were linked only to acute manic states (beck et al., 2006; fulford et al., 2009; ruggero et al., 2015) showed that individuals with a history or current diagnosis of bd reported elevated levels of mania-related cognitions, irrespective of current symptoms. also, mania-related cognitions might be present and prevalent in different stages of the disorder, i.e. at-risk stages or symptomatic bd (fulford et al., 2009). for example, beliefs relating to self-confidence in the ccl-m-r were increased in individuals at risk for bd but not in those diagnosed with bd. in contrast, cognitions relating to interpersonal problems were increased in individuals diagnosed with bd but not in those at high risk for bd. a few more studies examined depression-related cognition in bd. in this context, one of the most wildly used instruments is the dysfunctional attitude scale (das; weisman, 1979). however, the results of the studies that used the das were mixed. some studies found no differences in overall dysfunctional attitudes between healthy controls and in­ dividuals diagnosed with remitted bd (alatiq et al., 2010; lex et al., 2008; lex et al., 2011; mansell et al., 2011). other studies found elevated das scores in patients with remitted bd relative to healthy control groups (hollon et al., 1986; jones et al., 2005; scott et al., 2000; tosun et al., 2015). however, dysfunctional attitudes refer to different areas, for example, achievement, dependency, and goal attainment. since mania involves increased goal-directed activity (american psychiatric association, 2013) some researchers argued that it would be essential to focus on assessing beliefs relating to goal attainment. in line with this, lam et al. (2004) found evidence that dysfunctional attitudes related to goal attainment were indeed more pronounced in individuals with bd compared to unipolar depression. however, this was not found in all studies (e.g., jabben et al., 2012). despite the recent increased efforts to understand cognitive processes in bd, studies are still sparse and their results are mixed. for example, it still remains unclear whether these dysfunctional cognitions are tied to depressive or (hypo)manic states of bd or if they are part of the underlying diathesis of bd. one possibility to examine this question would be to assess these cognitions among individuals at-risk for mania. risk for bd can be defined via a genetic vulnerability (ruggero et al., 2015) or via a constitutional pre­ disposition. hyperthymic temperament represents such a constitutional predisposition for mania and can be assessed by the hypomanic personality scale (hps; eckblad & chapman, 1986) because there is evidence that people scoring high on the hps are more ulrich, meyer, andreas, & lex 3 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ likely to develop symptoms of bd over time (blechert & meyer, 2005; kwapil et al., 2000; walsh et al., 2015). therefore, the present study aimed at examining, if mania related cognition depicted by the ccl-m-r were even present in at-risk states or if they were rather tied to acute manic symptoms. also, we were interested if core beliefs related to goal attainment were associated with at-risk states for mania. therefore, we hypothesized that risk for mania predicted mania-related cognition assessed with the ccl-m-r and the das subscale ‘goal attainment’. we also expected that current manic symptoms were associated with mania-related cognition. we, however, did not expect such a relation for depression-spe­ cific cognition, i.e. das-subscales ‘dependency’ and ‘achievement’. method participants and procedure at first, we contacted all students at the university of klagenfurt, austria, via their cam­ pus e-mail addresses. the e-mail contained general information on the study and a link to “lime survey”. “lime survey” is a web application to conduct online surveys. if the students decided to participate, the provided informed consent, filled out the question­ naires, and provided demographic data. we also asked if they had been in psychotherapy before, because some psychological approaches might potentially alter cognitions related to mood symptoms. the participants remained anonymous and could leave the survey and delete their data at any time. at the end, the participants could optionally disclose their mail address to obtain course credit (n = 68). in total, we obtained data from 255 students. most participants were female (80%) and had never been in psychotherapy before (63.5%). the demographic data is displayed in table 1. measurements hypomanic personality scale (hps) the hps (eckblad & chapman, 1986) is a self-rating scale and includes 48 true-false items covering emotions (e.g., “i frequently get into moods where i feel very speeded-up and irritable”), behavior (e.g., “at social gatherings, i am usually the ‘life of the party’”), and energy level, (e.g., “there have often been times when i had such an excess of energy that i felt little need to sleep at night”) one feels at most times of his/her life. it assesses hyperthymic temperament, was used in clinical and non-clinical samples before, and is predictive of bipolar disorder and (hypo)manic symptoms (blechert & meyer, 2005; kwapil et al., 2000; walsh et al., 2015). in the present study, we used the total score to operationalize a constitutional risk to develop mania. scores can range between 0 and 48, and individuals scoring above 26 are considered at high risk for mania (meyer & baur, 2009). the german version (meyer et al., 2000) showed an internal consistency of α = .89. cognition and risk for mania 4 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ hyperthymic temperament was a stable trait over time (rtt = .87 [2 years]; hofmann & meyer, 2006). in the present sample the reliability was adequate (cronbach’s α = .87), and 34 participants were considered at high risk for mania (hps > 26). cognition checklist for mania – revised (ccl-m-r) the ccl-m-r (beck et al., 2006; goldberg et al., 2008) includes 29-items assessing beliefs associated with mania one had had during the past two days and has been used in clinical and non-clinical samples (fulford et al., 2009). the questionnaire contains four subscales. the ‘myself’ subscale contains 7 items and assesses cognition related to the self (e.g., “i am the best”), the ‘relationship’ subscale contains 7 items and assesses interpersonal issues (e.g., “i love everyone”), the ‘pleasure/excitement’ scale contains 9 items exploring excitement seeking (e.g., “it is ok to take risks”), and the ‘activity’ subscale comprises 6 items and assesses goal-driven activities (e.g., “i have got to get the job done while i can”). a ‘thwarting’ subscale can be derived from the ‘relationship’ scale by summing two items (“i could accomplish great things, if people did not get in my way” and “other people stand between me and my goals”; fulford et al., 2009). inde­ table 1 characteristics of the sample (n = 255) variable m sd minimum maximum age 28.27 9.56 18 65 hps 16.28 8.25 1 42 bdi 10.25 9.36 0 48 act 142.88 95.22 0 466 ccl-m-r myself 8.42 4.12 1 19 relation 4.05 2.92 0 14 pleasure/ excitement 9.87 4.00 0 20 activity 7.80 3.39 0 18 thwarting 0.90 1.38 0 6 total 30.14 11.12 1 60 das goal attainment 20.27 4.82 3 35 dependency 8.27 4.84 0 22 achievement 9.80 6.60 0 29 total 60.58 18.03 20 117 note. act = internal state scale activation subscore; bdi = beck depression inventory; ccl-m-r = cognition checklist mania; das-24 = dysfunctional attitude scale; hps = hypomanic personality scale. ulrich, meyer, andreas, & lex 5 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ pendent back-translation was used by two of the authors (r. u. and c. l.) and a native english speaker to obtain a german version of the ccl-m-r. internal consistencies in the present study were adequate (total ccl-m-r score: cronbach’s α = .89, ‘myself’: α = .80, ‘relationship’: α = .64, ‘pleasure/excitement’: α = .83, ‘activity’: α = .70) and comparable to the english version (beck et al., 2006; ruggero et al., 2015). dysfunctional attitude scale (das-24) the das (weisman, 1979; german version: hautzinger et al., 1985) is designed to assess depression-specific beliefs that individuals have about themselves, others, and their envi­ ronments most of the time. although the das has been widely applied in clinical sam­ ples, it is also used with analogue samples (e.g., perez & rohan, 2021). lam et al. (2004) used a 24-items das version in their study from which 3 factors could be derived: ‘goal attainment’ (6 items e.g., “i ought to be able to solve problems quickly”), ‘dependency’ (4 items, e.g., “if others dislike you, you cannot be happy”, and ‘achievement’ (5 items, e.g., “people who have good ideas are more worthy”). these subscales showed good internal consistency. in the present study, we adapted the german das in order to parallel the das-24 by lam et al. (2004). we obtained cronbach α = .83 for the total score, for ‘goal attainment’ α = .44, for ‘dependency’ α = .65, and for ‘achievement’ α = .80. beck depression inventory (bdi) the bdi (beck et al., 1961; german version: hautzinger et al., 1995) measures the severity of self-reported depression during the past 2 weeks and is used in clinical and non-clini­ cal samples (richter et al., 1998). it consists of 21 items and each item is scored on a 4-point scale, e.g. “0 i do not feel sad; 1 i feel sad; 2 i am sad all the time and i can't snap out of it, 3 i am so sad and unhappy that i can't stand it”. scores can range from 0 to 63, and higher scores indicate more severe depressive symptoms. in the present study, we used the validated german version that has comparable psychometric properties to the english version (hautzinger et al., 1995). internal state scale (iss) the iss (bauer et al., 1991, 2000; german version: meyer & hautzinger, 2004) is a self-report measure that consists of 16 items that are rated on a visual analogue scale (0 – “not at all” to 100 – “totally”) incorporating 4 subscales (activation, well being, perceived conflict, depression index). the activation subscale (act) contains 5 items. it reflects self-reports of manic symptoms within the last 24 hours by assessing behavioral and formal cognitive activation (e.g. “i feel overactive”, “my thoughts are going fast”). it correlates positively with selfand expert ratings of mania (bauer et al., 1991, 2000) and has been used in clinical and non-clinical samples (e.g., kelly et al., 2016). cognition and risk for mania 6 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ statistical analysis to examine if high risk for mania predicted depressionand mania-specific cognition we calculated hierarchical regression analyses using ibm spss statistics for macintosh, version 25.0. scores of the ccl-r-m and das-24 were used as dependent variables. all analyses controlled for age and gender in block 1, for current manic and depressive symptoms in block 2, and for a prior history of psychotherapy in block 3. scores of the hps were entered in block 4 after accounting for the other variables of interest. prior to interpreting the models, the relevant assumptions for linear regressions and potential biases were examined. first, the visual inspection of all scatter plots depicturing ‘standard residuals’ vs. ‘standard predicted value’ revealed no specific pattern, hence the assumptions of linearity and heteroscedasticity were met. second, the correlations between the predictors were low (all r < |.5|), and the multicollinearity statistics (i.e., tolerance and vif) were all within the tolerable limits (field, 2009). third, histograms and p-p plots showed that the standard residuals were normally distributed. forth, the assumption of independent errors was met because all durbin-watson results were close to 2 (between 1.83 and 2.14). finally, we identified the presence and significance of outliers by looking at the standard residuals, the mahalanobis distance and the leverage effect (i.e., cook’s distance). cases with standard residuals values below -2 and above 2 were defined as outliers. however, the proportion of identified outliers was less than 5% in all analyses and was, therefore, tolerated (field, 2009). in order to examine this issue in more detail, we also looked at the mahalanobis distance. eleven cases were defined as outliers because their values of the mahalanobis distance were above 22.59 (for the cut-off value see stevens, 1984). however, the leverage effects of these 11 cases were small (i.e., cook’s distance < 1); therefore, the cases were not deleted from the analyses (field, 2009, p. 309). results first, the final overall models including all predictors for mania-related cognitions (ccl­ m-r) are reported. the final overall model for the composite ccl-m-r score was signifi­ cant f(6, 248) = 23.96, p < .001. also, the final overall models for the specific dimensions of the ccl-m-r were significant: ‘myself’ f(6, 248) = 22.56, p < .001, ‘relationship’ f(6, 248) = 18.05, p < .001, ‘pleasure/excitement’ f(6, 248) = 14.52, p < .001, and ‘activity’ f(6, 248) = 15.40, p < .001. looking at the δr 2, it became evident that bdi, act, and hps scores significantly increased the explained variance in all five models (table 2). ulrich, meyer, andreas, & lex 7 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ ta bl e 2 fi na l m od el (s te p 4) o f t he h ie ra rc hi ca l r eg re ss io n a na ly se s fo r c og ni tio n r el at ed to m an ia pr ed ic to r c c lm -r t ot al c c lm -r m ys el f c c lm -r r el at io ns hi p c c lm -r p le as ur e/ ex ci te m en t c c lm -r a ct iv it y b se b β b se b β b se b β b se b β b se b β bl oc k 1 se x 2. 02 1. 45 0. 07 0. 45 0. 54 0. 04 0. 94 0. 40 0. 13 * 0. 06 0. 56 0. 01 0. 56 0. 47 0. 07 a ge 0. 06 0. 06 0. 05 0. 00 0. 02 0. 00 0. 02 0. 02 0. 08 -0 .0 1 0. 02 -0 .0 2 0. 04 0. 02 0. 12 * bl oc k 2 bd i -0 .1 1 0. 06 -0 .0 9 -0 .1 7 0. 02 -0 .3 9* ** 0. 12 0. 02 0. 37 ** * 0. 01 0. 02 0. 01 -0 .0 6 0. 02 -0 .1 7* * a c t 0. 03 0. 01 0. 22 ** * 0. 01 0. 00 0. 14 ** 0. 00 0. 00 0. 05 0. 01 0. 00 0. 20 ** * 0. 01 0. 00 0. 26 ** * bl oc k 3 t he ra py 0. 00 0. 00 -0 .0 1 0. 00 0. 00 0. 00 0. 00 0. 00 -0 .0 5 0. 00 0. 00 -0 .0 6 0. 00 0. 00 0. 08 bl oc k 4 h ps 0. 65 0. 08 0. 48 ** * 0. 23 0. 03 0. 46 ** * 0. 10 0. 02 0. 28 ** * 0. 18 0. 03 0. 36 ** * 0. 14 0. 03 0. 35 ** * n ot e. c c lm -r t ot al : r 2 = .0 1 fo r bl oc k 1; δ r 2 = .1 8* ** fo r bl oc k 2; δ r 2 = .0 1 fo r bl oc k 3; δ r 2 = .1 7* ** fo r bl oc k 4; c c lm -r m ys el f: r 2 = .0 1 fo r bl oc k 1; δ r 2 = .1 9* ** fo r bl oc k 2; δ r 2 = .0 0 fo r bl oc k 3; δ r 2 = .1 5* ** fo r bl oc k 4; c c lm -r r el at io ns hi p: r 2 = .0 3* fo r bl oc k 1; δ r 2 = .2 1* ** fo r bl oc k 2; δ r 2 = .0 1 fo r bl oc k 3; δ r 2 = .0 5* ** fo r bl oc k 4; c c lm -r p le as ur e/ ex ci te m en t: r 2 = .0 1 fo r bl oc k 1; δ r 2 = .1 4* ** fo r bl oc k 2; δ r 2 = .0 1 fo r bl oc k 3; δ r 2 = .1 0* ** fo r bl oc k 4; c c lm -r a ct iv ity : r 2 = .0 2 fo r bl oc k 1; δ r 2 = .1 6* ** fo r bl oc k 2; δ r 2 = .0 0 fo r bl oc k 3; δ r 2 = .0 9* ** fo r bl oc k 4. a c t = in te rn al s ta te s ca le a ct iv at io n su bs co re ; b d i = b ec k d ep re ss io n in ve nt or y; c c lm -r = c og ni tio n c he ck lis t m an ia ; h ps = h yp om an ic p er so na lit y sc al e; t he ra py = p ri or p sy ch ot he ra py . *p < .0 5. * *p < .0 1. * ** p < .0 01 . cognition and risk for mania 8 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ more specifically, act positively predicted cognition related to ‘myself’ (β = 0.14), ‘pleasure/excitement’ (β = 0.20), and ‘activity’ (β = 0.26), bdi positively predicted cogni­ tion related to ‘relationship’ (β = 0.37), and hps scores positively predicted all ccl-m-r dimensions as well as the total ccl-m-r score. an exploratory hierarchical regression model for the thwarting subscale was also significant, f(6, 248) = 10.63, p < .001 (final model). specifically, bdi (β = 0.40, p < .001) and hps scores (β = 0.16, p = .01) predicted thwarting. next, the final overall models including all predictors for depression-related cognitions (das-24) are reported. the final overall model for the composite das-24, f(6, 248) = 18.30, p < .001, as well as the final overall models for the specific dimensions of the das-24 were significant: ‘achievement’ f(6, 248) = 15.20, p < .001, ‘dependency’ f(6, 248) = 13.63, p < .001, ‘goal attainment’ f(6, 248) = 4.52, p < .001. the bdi significantly predicted attitudes related to ‘achievement’ (β = 0.45), ‘dependency’ (β = 0.46) and the total das-24 score (β = 0.49). the act (β = 0.20) and sex (β = 0.17) significantly predicted ‘goal attainment’. the hps score could not increase the explained variance in any of the regression models (table 3). table 3 final model (step 4) of the hierarchical regression analyses for cognition related to depression predictor das-24 total das-24 achievement das-24 dependency das-24 goal attainment b seb β b seb β b seb β b seb β block 1 sex 3.98 2.45 0.09 1.66 0.92 0.10 0.13 0.69 0.01 2.06 0.75 0.17** age -0.02 0.10 -0.01 0.02 0.04 0.03 0.00 0.03 -0.01 0.03 0.03 0.06 block 2 bdi 0.95 0.11 0.49*** 0.32 0.04 0.45*** 0.24 0.03 0.46*** 0.03 0.03 0.05 act 0.02 0.01 0.11 0.01 0.00 0.11 0.00 0.00 0.04 0.01 0.00 0.20** block 3 therapy 0.00 0.00 0.00 0.00 0.00 -0.03 0.00 0.00 0.04 0.00 0.00 -0.03 block 4 hps 0.13 0.13 0.06 0.06 0.05 0.07 0.05 0.04 0.08 0.04 0.04 0.06 note. das-24 total: r 2 = .02* for block 1; δr 2 = .28*** for block 2; δr 2 = .00 for block 3; δr 2 = .01 for block 4; das-24 achievement: r 2 = .02 for block 1; δr 2 = .24*** for block 2; δr 2 = .00 for block 3; δr 2 = .01 for block 4; das-24 dependency: r 2 = .01 for block 1; δr 2 = .23*** for block 2; δr 2 = .00 for block 3; δr 2 = .01 for block 4; das-24 goal attainment: r 2 = .03** for block 1; δr 2 = .06*** for block 2; δr 2 = .00 for block 3; δr 2 = .01 for block 4. *p < .05. **p < .01. ***p < .001. ulrich, meyer, andreas, & lex 9 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ discussion the present study examined the relation between an increased risk for mania, current mood symptoms and cognition specifically related to depression and mania. the risk for mania was assessed with the hps. in line with our hypotheses, risk for mania significantly predicted mania-specific but not depression-specific cognitions. however, while we had expected that risk for mania would be specifically related to one aspect of dysfunctional attitudes, i.e., ‘goal attainment’, this was not the case. current manic and depressive mood also contributed significantly to the regression models. the association between high risk for mania and elevated levels of mania-specific cognition was proposed by beck and his colleagues (2006) as a logical extension of the original theory of depression (beck et al., 1979). in line with this theory, we found that the ccl-m-r total score as well as all subscores were associated with increased vulnerability for mania. beck et al. (2006) also found evidence for their theory regarding most types of mania-specific cognition, however, they failed to find elevated scores on the ccl-m-r subscale ‘pleasure/excitement’. as they point out, they tested inpatients who had few opportunities to engage in exciting, high risk behavior while admitted to the hospital. in contrast, our sample consisted of university students who had much more chances for potentially risky behavior to fulfill their need for excitement. this is consistent with fulford et al. (2009) who also found that hps scores were related to a modified ‘pleasure/excitement’ score of the ccl-m-r in a college student sample. the ccl-m-r assesses mania-specific beliefs and although it explicitly asks to focus on the last days, it might capture more long-standing beliefs and attitudes about the self, the interaction with others, the engagement of high risk behavior to feel excitement, and the attainment of high goals. this would explain why an indicator of vulnerability for bd would be related to these beliefs, even after accounting for current symptoms. in contrast, ruggero et al. (2015) found no difference in ccl-m-r scores between indi­ viduals at-risk for mania and those with no elevated risk. there are several differences between the studies. we used continuous scaling, whereas ruggero et al. (2015) used be­ tween group differences, i.e. high-risk group vs. low risk group, which could reduce the variance in the predictor group. in addition, their sample was much smaller and might have lower power.1 finally, contrary to ruggero et al. (2015), we assessed current mood symptoms and found associations to the ccl-m-r, therefore, not differentiating between current symptoms and vulnerability could also affect the results. finally, it might be that the ccl-m-r and the hps show some construct overlap. although designed to tap into emotion, behavior, and energy levels, some items of the hps might also assess cognition, e.g. “i expect that someday i will succeed in several different professions”.2 1) we thank an anonymous reviewer for these comments. 2) see footnote 1. cognition and risk for mania 10 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ the same study found that the hypomanic attitudes and positive prediction invento­ ry (happi; mansell, 2006) differentiated between individuals at-risk and those with no elevated risk. the happi assesses hypomania-specific positive and negative appraisals relating to high and low activation internal states, e.g., an emotion one feels in a specific situation (e.g., kelly et al., 2017). given the few studies, it remains unclear whether cognition relating to internal states as measured by the happi or cognition potentially relating to more long-standing cognitive factors as measured by the ccl-m-r is more relevant for at-risk stages in bd. furthermore, the way risk for bd is defined might be essential, as well. in the present study, we focused specifically on risk for mania by assessing temperamental traits (e.g., blechert & meyer, 2005; kwapil et al., 2000), whereas ruggero et al. (2015) defined the risk for bd genetically (offspring of parents diagnosed with bd). speculatively, individuals scoring high on the hps who might never have been exposed to actual bd might be less familiar with its presentation and more likely to endorse items on the ccl-m-r than individuals whose parents have expressed such mania-related attitudes and beliefs while being (hypo)manic. internal processes, such as appraisals might be less shared with others even if they influence actual behaviors. or perhaps, offspring of parents with bd might have been exposed to challenging situations due to their parent’s disorder during their childhood and therefore be more cautious to endorse, for example, grandiose statements or behaviors that are considered risky as asked in the ccl-m-r. in the present study, risk for mania did not predict cognitions related to goal attain­ ment as measured with the das. although lam et al. (2004) found that the ‘goal attainment’ subscale of the das differentiated between patients with remitted bd and patients with remitted unipolar depression, most previous studies found little evidence for increased scores on the ‘goal attainment’ subscale of the das in remitted bd (e.g., alatiq et al., 2010; lex et al., 2008). this is interesting because there is evidence that a dysregulation of goal-directed behavior and goal striving is an important aspect in bd (alloy et al., 2012; urošević et al., 2008) and life events relating to goal attainment caused increases in manic symptoms (johnson et al., 2000, 2008; tharp et al., 2016). subsequent­ ly, it would make sense that individuals at-risk for mania endorse exaggerated believes about goal attainment. in the present study risk for mania predicted elevated scores on the ‘activity’ subscale of the ccl-m-r but not on the ‘goal attainment’ subscale of the das. one possible reason for this could be that the items of the das ‘goal attainment’ subscale are worded more generally, e.g. “i should be happy all the time”, while the items on the ccl-m-r ‘activity’ scale are targeted at more specific events, e.g., “i have new goals”. additionally, there is evidence that dysfunctional attitudes might be latent outside of acute mood episodes and must be activated before individuals endorse them (babakhani & startup, 2012) or are state-dependent (alloy et al., 1999; hollon et al., 1986; lex et al., 2008, 2011; reilly-harrington et al., 1999; scott et al., 2000). we actually found an association between current manic symptoms and the das subscale ‘goal at­ ulrich, meyer, andreas, & lex 11 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ tainment’. although one has to keep in mind that the reliability for the ‘goal attainment’ subscale was low, this result suggests that manic mood, rather than risk for mania, might be more closely related to dysfunctional attitudes related to goal attainment. we also found that current subthreshold manic symptoms predicted the mania-rela­ ted cognition, even though to a lesser degree than the risk for mania. this is consistent with previous studies (fulford et al., 2009). however, our data also revealed an unexpec­ ted association between current depressed mood and the ccl-m-r subscale ‘relation­ ship’. this is in conflict to previous evidence and to the theoretical background (beck et al., 2006; fulford et al., 2009). it might be that some of the items of the ‘relationship’ scale might relate to depressed mood, e.g., “people treat me like i am sick” and “they do not understand me”. however, even if only those two items of the ‘relationship’ scale were extracted, that focus on interpersonal behavior most relevant in bd, namely being thwarted by others in the attainment of goals (fulford et al., 2009), we still found that the level of depression was a significant predictor. the present study focused on risk and cognitions associated with mania. however, in most cases bd also includes depressive mood episodes. based on our results we cannot explain how depressive symptoms might arise, which could be a limitation of the present study. in terms of methodical limitations, first, our data was collected online. this approach bears some disadvantages, e.g., limited control regarding the test setting (wright, 2005). however, there is evidence that paper-and-pencil and internet data col­ lection methods are equivalent (weigold et al., 2013). second, our participants were not asked if they had been diagnosed with an affective or any other psychiatric illness before or if they were experiencing an acute illness episode at the time of their participation. however, in order to control for psychological problems we asked them if they had ever been in psychological therapy and found no relation to mania-specific cognition. third, we had a mainly female non-clinical sample that might not be representative of people developing bd. however, several reviews emphasize the relevance of analogous samples to understanding clinical phenomena (abramowitz et al., 2014; ehring et al., 2011). at last, we used a hierarchical regression design in a cross-sectional approach because we aimed at examining a directional association. it might be that this approach missed longitudinal developments and changes of our target variables. despite these limitations, the present study showed that risk for mania was associ­ ated with mania-specific dysfunctional cognition. this finding points toward the impor­ tance to identify mania-specific cognitions in early or at-risk states of bd in order to help individuals to question and modify these cognitions to potentially prevent more severe symptoms. future studies should assess mania-specific beliefs in different phases of bd in order to examine the relation between mania-specific cognitions and current mood, perhaps even looking at specific symptoms, such as elated versus irritable mania. also, longitudinal studies are highly awaited in order to test if dysfunctional cognitions cognition and risk for mania 12 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://www.psychopen.eu/ increase the risk of acute bipolar episodes or if they interact with life events or other factors (e.g., lex et al., 2017). funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: we would like to thank markus emperger for technical support and nikki la rosa for proofreading the final version of the manuscript. ethics approval: all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. informed consent: informed consent was obtained from all individual participants included in the studies. animal rights: this article does not contain any studies with animals performed by any of the authors. references abramowitz, j. s., fabricant, l. e., taylor, s., deacon, b. j., mckay, d., & storch, e. a. 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(2005). researching internet-based populations: advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services. journal of computer-mediated communication, 10(3), article jcmc1034. https://doi.org/10.1111/j.1083-6101.2005.tb00259.x clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. cognition and risk for mania 18 clinical psychology in europe 2021, vol.3(1), article e3733 https://doi.org/10.32872/cpe.3733 https://doi.org/10.1111/j.1083-6101.2005.tb00259.x https://www.psychopen.eu/ cognition and risk for mania (introduction) method participants and procedure measurements results discussion (additional information) funding competing interests acknowledgments ethics approval informed consent animal rights references looking on the bright side reduces worry in pregnancy: training interpretations in pregnant women research articles looking on the bright side reduces worry in pregnancy: training interpretations in pregnant women colette r. hirsch 1 § , frances meeten 2 §, jill m. newby 3,4, sophie o’halloran 1, calum gordon 1, hannah krzyzanowski 1, michelle l. moulds 3 [1] institute of psychiatry, psychology and neuroscience, king’s college london, london, united kingdom. [2] school of psychology, university of sussex, brighton, united kingdom. [3] school of psychology, university of new south wales, sydney, australia. [4] black dog institute, hospital road randwick, new south wales, sydney, australia. §these authors contributed equally to this work. clinical psychology in europe, 2021, vol. 3(2), article e3781, https://doi.org/10.32872/cpe.3781 received: 2020-05-28 • accepted: 2021-03-22 • published (vor): 2021-06-18 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: colette r. hirsch, department of psychology, institute of psychiatry, psychology and neuroscience, king’s college london, de crespigny park, london se5 8af, uk. phone: +44 207 848 0697. e-mail: colette.hirsch@kcl.ac.uk supplementary materials: materials, preregistration [see index of supplementary materials] abstract background: recent evidence suggests that anxiety is more common than depression in the perinatal period, however there are few interventions available to treat perinatal anxiety. targeting specific processes that maintain anxiety, such as worry, may be one potentially promising way to reduce anxiety in this period. given evidence that negative interpretation bias maintains worry, we tested whether interpretation bias could be modified, and whether this in turn would lead to less negative thought (i.e., worry) intrusions, in pregnant women with high levels of worry. method: participants (n = 49, at least 16 weeks gestation) were randomly assigned to either an interpretation modification condition (cbm-i) which involved training in accessing positive meanings of emotionally ambiguous scenarios, or an active control condition in which the scenarios remained ambiguous and unresolved. results: relative to the control condition, participants in the cbm-i condition generated significantly more positive interpretations and experienced significantly less negative thought intrusions. conclusions: our findings indicate that worry is a modifiable risk factor during pregnancy, and that it is possible to induce a positive interpretation bias in pregnant women experiencing high this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3781&domain=pdf&date_stamp=2021-06-18 https://orcid.org/0000-0003-3579-2418 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ levels of worry. although preliminary, our findings speak to exciting clinical possibilities for the treatment of worry and the prevention of perinatal anxiety. keywords perinatal mental health, worry, interpretation bias, cognitive bias mediation (cbm), pregnancy, anxiety highlights • modification of interpretation bias in pregnant women with high levels of worry was examined. • participants received interpretation bias training or an active control condition. • training led to less negative interpretations and fewer negative thought intrusions. • modifying negative interpretation bias in pregnant women may have clinical utility. the perinatal period, the time from conception to 12 months post birth (austin, highet, & expert working group, 2017), is a time of significant change and adjustment. it often brings new stressors which, combined with hormonal fluctuations, can leave women vulnerable to mental health problems. women are at a higher risk of developing a serious mental illness during the first month postpartum than at any other point in their lives (stewart et al., 2003), and are also at risk for relapse or recurrence of a pre-existing mental health problem. perinatal mental health problems are associated with negative outcomes for both mother and baby; for example, poor foetal development (dipietro et al., 2002), low birth weight (hedegaard et al., 1993), and greater risk of behavioural, psychological and developmental problems (o’connor et al., 2002; stein et al., 2014). until relatively recently, most research on perinatal mental health has focused on postnatal depression, with other conditions overlooked (goodman, watson, & stubbs, 2016; howard, molyneaux, et al., 2014). in particular, perinatal anxiety has tended to be ignored in favour of depression, despite evidence that anxiety disorders are more prevalent than depression in pregnancy and postpartum (fairbrother et al., 2016). this is particularly the case in the treatment outcome literature. in a systematic review, loughnan et al. (2018) identified only one randomised controlled trial evaluating a treatment for perinatal anxiety. with prevalence rates of up to 8.5% (goodman et al., 2016), and given that maternal prenatal anxiety is associated with a twofold increase in the risk of a child developing psychological disorders (o’donnell et al., 2014), there is a clear need to develop effective, evidence-based approaches to treat perinatal anxiety. one promising approach may be to target modifiable psychological processes that maintain anxiety symptoms and their consequences, such as repetitive negative thinking (rnt). rnt refers to types of thinking which are pathological, perseverative and difficult to control (samtani & moulds, 2017); for example, worry and rumination. worry is a form of rnt that is predominantly verbal, difficult to control and involves entertaining potential negative outcomes of future situations (borkovec, 1994). rumination primarily training positive interpretations in pregnant worriers 2 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://www.psychopen.eu/ involves focusing on events in the past, as well as one’s perceived personal inadequacies, current mood/symptoms and their causes and consequences (nolen-hoeksema, 1991). both these forms of rnt are experienced as unwanted negative intrusive thoughts that come to mind unbidden, and capture attention such that it is difficult to shift focus away from the thought. moulds et al. (2018) proposed that rnt could be an important factor to target in interventions to improve perinatal distress. in keeping with this, a recent study of pregnant women (hirsch, meeten, et al., 2020) demonstrated that worry and rnt more generally was associated with increased levels of perinatal anxiety and depression. the predictive role of worry in the development and maintenance of anxiety is well-established, and recent research has indicated that this may similarly apply in the perinatal context. for example, schmidt et al. (2016) reported that levels of worry in the first four months of pregnancy predicted anxiety and depression symptoms in the third trimester. one key cognitive process proposed to contribute to pathological worry is negative interpretation bias: the transdiagnostic tendency to perceive ambiguous information or events as threatening or negative (hirsch & mathews, 2012; hirsch et al., 2016). krahé et al. (2019) found that greater levels of negative interpretation were associated with increased worry. similarly, hirsch, meeten, et al. (2020) demonstrated that higher levels of both worry and anxiety in pregnant women are associated with more negative inter­ pretation bias. these findings speak to the clinically related possibility that modifying interpretation bias may reduce worry. one experimental methodology showing promise in this regard is cognitive bias modification for interpretation (cbm-i). the goal of cbm-i is to facilitate consistent generation of positive interpretations of ambiguous information (where the interpretation could be positive or threatening) via repeated computerised practice. specifically, participants listen to ambiguous scenarios, with ambiguity being resolved by the final word in a benign manner (see appendix a in the supplementary materials for an example scenario). evidence indicates that a single session of cbm-i can modify interpretation bias and in turn reduce worry in high worriers (feng et al., 2020; hirsch et al., 2009), as well as those with generalised anxiety disorder (gad) (hayes, hirsch, krebs, & mathews, 2010). in another gad sample, hirsch et al. (2018) demonstrated that multi-session positive cbm-i training resulted in a more positive interpretation bias and reduced worry and anxiety one month later compared to an active control condition. more recently, community participants with high levels of rnt (worry and/or rumination) completed an enhanced version of cbm-i where participants were instructed to generate positive resolutions to ambiguous scenarios (rather than be presented with a positive resolution) for half of the scenarios, in order to aid generalisation and engagement. participants were also instructed to generate positive images of the outcome for each scenario. this led to more positive interpretation bias, fewer negative interpretations, and lower levels of rnt, anxiety and depression, relative to a control condition in which ambiguity was unresolved (hirsch, krahé, whyte, bridge, hirsch, meeten, newby et al. 3 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://www.psychopen.eu/ et al., 2020). these findings prompt the clinically interesting possibility that cbm-i can be used as a potential intervention for anxiety. to determine whether cbm-i can help reduce worry and anxiety via a web-based platform with no face-to-face contact with researchers during assessment or training, we conducted a study with a sample of individuals with gad with or without comorbid ma­ jor depressive disorder (hirsch, krahé, whyte, krzyzanowski, et al., 2020). training was highly effective at reducing negative interpretations compared to the control condition. importantly, reductions in worry, rumination, anxiety and depression were evident at three-months follow-up. furthermore, effects were mediated by changes in interpretation bias. these findings raise the possibility of cbm-i forming a low-intensity intervention for pregnant women at risk of escalating levels of anxiety or depression due to height­ ened rnt. as an online intervention, it could be completed at a location and time convenient for pregnant women, and thus has scope to be more readily integrated into daily life. the possibility that cbm-i may have utility in facilitating a more positive interpreta­ tion bias in pregnant women who engage in high levels of worry remains untested. giv­ en that pregnant women who worry have a more negative interpretation bias (hirsch, meeten, et al., 2020), and the proposal that targeting rnt, such as worry, in pregnancy may have the potential to prevent and treat postpartum anxiety (moulds et al., 2018), testing whether cbm-i can shift interpretive bias in pregnant high worriers represents a logical first step. accordingly, we recruited pregnant women with self-reported high lev­ els of worry who were randomly allocated to either (i) cbm-i (i.e., interpretation training enhanced with positive imagery and self-generation) or (ii) control (no resolution of am­ biguity nor positive imagery) conditions. we hypothesised that participants in the cbm-i condition would generate more positive interpretations and thus demonstrate a positive interpretation bias compared to those in the control condition. we also hypothesised that participants in the cbm-i condition would experience fewer negative thought intrusions (indicative of worry) during a behavioural worry task in which they were instructed to focus on their breathing, relative to participants in the control condition. method study registration the study was registered on open science framework: https://osf.io/ye84g. see appen­ dix b in the supplementary materials for registered information. participants 49 women with high levels of self-reported worry (scoring ≥ 561 on the penn state worry questionnaire cf. hayes, hirsch, & mathews, 2010) completed the study and 47 women training positive interpretations in pregnant worriers 4 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://osf.io/ye84g https://www.psychopen.eu/ completed useable data (see table 1 for demographic information). participants were required to be 16 or more weeks pregnant, fluent in english, with normal or corrected vision and hearing, and have no history of either stillbirth or three or more miscarriages. participation involved attending a session in the lab, and participants were reimbursed £25 for taking part. table 1 mean demographic and statistics characteristics and questionnaires (standard deviation in parenthesis) characteristic cbm-i n = 23 control n = 24 t(45) p age 33.35 (4.78) 32.46 (4.65) 0.65 0.52 weeks of gestation 26.96 (7.10) 28.29 (6.62) 0.67 0.51 pswq 64.30 (5.67) 66.13 (5.66) 1.10 0.28 rtqt 39.70 (10.63) 40.67 (7.01) 0.37 0.71 pass 43.09 (15.83) 47.54 (17.87) 0.90 0.37 edps 11.87 (3.55) 14.21 (5.37) 1.76 0.09 phq-9 8.87 (3.88) 11.00 (6.09) 1.42 0.16 gad-7 8.52 (4.12) 11.42 (5.36) 2.07 0.04 rrs 54.48 (13.30) 52.63 (13.54) 0.47 0.64 note. cbm-i = cognitive bias modification for interpretation; weeks of gestation = number of weeks pregnant at time of testing; pswq = penn state worry questionnaire; rtqt = trait repetitive thinking questionnaire; pass = perinatal anxiety screening scale; epds = edinburgh postnatal depression scale; gad7 = generalised anxiety disorder questionnaire; phq9 = patient health questionnaire; rrs = ruminative response scale. individuals who expressed interest in the study were sent a screening questionnaire via qualtrics, an online data acquisition platform. 163 women completed the screening questionnaire, of whom 64 did not meet the inclusion criteria. 99 respondents were eligible to take part in the study and were invited via email to take part in the study. 63 of these responded and were offered a testing date. of these, 49 participants completed the study, while six were found to be ineligible on the day of testing due to their penn state worry questionnaire score (meyer et al., 1990) being below cut off, seven withdrew before attending and one session was cancelled due to the covid-19 pandemic. two participants’ data was not included in the study as their responses to the recognition test comprehension questions indicated they had either not understood or not engaged with the task. the final sample of 47 participants were aged between 22 and 42 years (m = 32.89, sd = 4.69), and ranged between 16 and 39 weeks pregnant (m = 27.64, sd = 1) in a sample of individuals diagnosed with gad, a pswq score of 56 was one standard deviation below the mean (molina & borkovec, 1994) and is commonly used as a cut-off in research (feng et al., 2020; hirsch, perman, et al. 2015). accordingly, we classified participants as high worriers if their pswq score was ≥ 56. hirsch, meeten, newby et al. 5 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://www.psychopen.eu/ 6.82). 12 participants had one child and two participants had two children. the other 35 participants were pregnant with their first child. sample size an a-priori power calculation with an alpha of .05 and power of .80 was computed in gpower. the effect size was determined by a study examining the effects of interpreta­ tion bias manipulation on the recognition test (feng et al., 2020). projected sample size was 26 per condition. as we did not know whether pregnancy would influence the capacity to modify interpretation bias, we elected to increase the planned number of participants recruited per condition to 30. however, due to the covid-19 pandemic in 2020, face-to-face testing was ultimately prohibited. recruitment and testing ended prematurely after testing 49 participants (two participants were excluded due to perform­ ance on the recognition test) resulting in final samples of n = 23 and n = 24 in the cbm-i and control conditions, respectively. measures and materials questionnaires penn state worry questionnaire (pswq) — the pswq (meyer, miller, metzger, & borkovec, 1990) consists of 16 statements related to worry (e.g., my worries overwhelm me) which are rated from 1 (not at all typical of me) to 5 (very typical of me). the pswq has high internal consistency (present sample cronbach’s α = .70), convergent and discriminant validity (brown, antony, & barlow, 1992), and good test-retest reliability (meyer et al., 1990). other standardised questionnaires — perinatal anxiety was assessed using the per­ inatal anxiety screening scale (pass; somerville et al., 2014; cronbach’s α = .94 in current sample). perinatal depression was assessed with the edinburgh postnatal de­ pression scale (epds; cox, holden, & sagovsky, 1987: cronbach’s α = .84). general depressed mood was assessed using the patient health questionnaire 9 (phq-9, kroenke & spitzer, 2002; cronbach’s α = .84) and anxiety symptoms using the generalized anxiety disorder 7-item scale (gad-7; spitzer et al., 2006; cronbach’s α = .87). trait rnt was assessed with the repetitive thinking questionnaire (rtq-t [trait]; mcevoy, thibodeau, & asmundson, 2014; cronbach’s α = .90). ruminative response scale (rrs; nolen-hoeksema & morrow, 1991; cronbach’s α = .93) was used to assess depressive rumination2. 2) vas mood ratings were also taken during the study, but were not available for analysis due to the university being closed because of covid-19. training positive interpretations in pregnant worriers 6 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://www.psychopen.eu/ tasks worry induction — participants identified a current worry topic (related to their preg­ nancy or other aspects of their life) and were asked a series of questions to prime salient features. they were instructed to silently worry about this topic as they normally would for five minutes. interpretation assessment task recognition test — the first phase of this task (hirsch et al., 2018; adapted from mathews & mackintosh, 2000) requires participants to read a series of ambiguous scenarios. the last word of each scenario (which leaves the ambiguity unresolved) is presented as a word fragment, and participants are instructed to fill in the first missing letter of that word. next, participants complete a comprehension question (yes/no) about the scenario (see appendix a in the supplementary materials for example). in the second phase, participants are presented with a scenario title and four statements in random order, then indicate how similar each statement is to the meaning of the original scenario. the statements include one positive target (in keeping with the positive interpretation of the original scenario), one negative target, one positive and one negative foil unrelated to the scenario meaning. participants rate each statement on a scale from 1 (very different in meaning) to 4 (very similar in meaning). interpretation bias is assessed by calculating a positivity index, which is calculated by subtracting the mean ratings for negative targets from the mean ratings for positive targets. higher scores indicate a more positive interpretation bias. breathing focus task — in the version of the task (feng et al., 2020; adapted from ruscio & borkovec, 2004) employed in this study, participants first practiced the breath­ ing focus task. next, they were instructed to engage in worry about a current worry topic for five minutes, then completed a five-minute breathing focus task. during this task, participants were instructed to focus on their breathing. they were given a series of prompts (12 computerised tones) throughout the task; at each prompt, participants were asked to indicate if they were focusing on their breathing as instructed, or if their mind had wandered to another topic (i.e., they were experiencing a thought intrusion). if the latter, participants were asked to indicate the valence of the intrusion (i.e., positive, negative or neutral). negative thought intrusions are interpreted to be indicative of worry, as per previous cbm-i studies (e.g., feng et al., 2020). cbm-i condition imagery practise task — participants in the cbm-i condition completed an online imagery practice task (adapted from holmes et al. (2006) and used in hirsch, krahé, whyte, bridge, et al., 2020; feng et al., 2020) to help them generate vivid mental images, and to instruct them on how to hold them in mind (see feng et al., 2020). hirsch, meeten, newby et al. 7 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://www.psychopen.eu/ cognitive bias modification for interpretation (cbm-i) — cbm-i is a scenar­ io-based task that requires participants to listen (over headphones) to 40 scenarios which present common worry-related situations that are initially emotionally ambiguous. par­ ticipants in the active condition were provided with a positive resolution (i.e. ending) of the ambiguous scenario for 20 trials, and instructed to generate their own positive resolution for the 20 remaining trials. participants are instructed to use mental imagery to vividly picture the resolution. after each scenario, participants are presented with a ‘yes/no’ comprehension question, designed to emphasise the desired interpretation of the scenario. they then receive feedback (‘correct/incorrect’) on these answers. par­ ticipants then rate the positivity of the scenario, on a scale of 0 (‘not at all’) to 100 (‘extremely’) (see appendix a, supplementary materials, for example). control condition filler task — the feng et al. (2019) filler task was used to match the time taken to complete the imagery training in the cbm-i condition. sham training — similar to cbm-i training, participants listened to 50 ambiguous worry-related scenarios over headphones. an increased number of trials was required to match the duration of cbm-i training. in this condition ambiguity remained unresolved, and participants were not instructed to generate particular outcomes. participants com­ pleted comprehension questions without feedback, thus allowing for either positive or negative interpretations without correction. procedure participants completed the pswq online within the 24 hours prior to the experimental testing session, to ensure that they met study eligibility criteria. before coming into the lab, participants were randomly allocated to the cbm-i or control condition on the basis of an allocation by an independent researcher. they then completed the study tasks associated with their allocated condition. see figure 1. for an overview of the study procedure. training positive interpretations in pregnant worriers 8 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://www.psychopen.eu/ figure 1 overview of study procedure hirsch, meeten, newby et al. 9 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://www.psychopen.eu/ results questionnaire measures for cbm-i and control conditions see table 1 for means of questionnaire measures and statistics for participants included in the analysis. the only significant between-condition difference to emerge was for gad-7; such that participants in the control condition reported higher anxiety. impor­ tantly, however, we note that the conditions did not differ on the pass, – i.e., a measure of perinatal anxiety specifically (rather than a measure of general anxiety developed for non-pregnant populations). assessing the impact of cbm-i on interpretation bias (hypothesis 1) to examine the effect of condition on interpretation bias, we conducted a regression analysis with mean positivity index score as the dependent variable. condition3 signifi­ cantly predicted post-training positivity index score, b = 0.54, se = .19, p = .007, 95% cis [0.16, 0.92]. the mean positivity index was higher for the cbm-i (m = 0.35, sd = 0.64) than the control (m = 0.19, sd = 0.65) condition, confirming that cbm-i was effective in facilitating a positive interpretation bias. assessing the impact of cbm-i on negative thought intrusions (hypothesis 2) to examine the effect of condition on negative thought intrusions, we conducted a bootstrapped (due to non-normality of data) regression analysis with number of negative thought intrusions from the breathing focus task as the dependent variable. condition significantly predicted post-training positivity index score, b = -1.11, se = .45, p = .02, 95% cis [-1.96, -0.28]. consistent with the hypothesis, participants in the cbm-i condition reported significantly fewer intrusions (m = 1.50, sd = 1.01) than did those in the control condition (m = 2.61, sd = 1.85). discussion in this first study of interpretation training in pregnant worriers, we successfully induced a positive interpretation bias using cbm-i. consistent with hirsch et al. (2009) and feng et al. (2019), participants in the cbm-i condition reported fewer negative thought 3) as gad7 scores were significantly different at baseline we re-ran the regression analysis with mean centred gad7 scores and an interaction variable of (mean centred) gad7 and condition. neither gad7 scores (p = .67) or the interaction term (p = .54) were significant predictors in the model. condition remained a significant predictor (p = .02). training positive interpretations in pregnant worriers 10 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://www.psychopen.eu/ intrusions relative to the control condition, supporting a causal role for interpretation bias in maintaining worry in pregnant women. as the first study to employ cbm-i to test questions about interpretation bias and worry in pregnant women, our results extend the cbm literature in important ways. first, on a methodological note, they demonstrate the applicability and effectiveness of cbm-i in the perinatal context. second, they confirm that interpretation bias maintains worry in pregnant women. whilst this relationship is well-established in the broader literature (feng et al., 2019; hirsch et al., 2009; hirsch, krahé, whyte, bridge, et al., 2020) given the unique and multi-faceted circumstances and changes (e.g., biological, cognitive) which characterise the perinatal period, our results are theoretically important in confirming this link in a perinatal sample. third, by indicating that worry is a modifiable psychological risk factor in pregnancy, our findings have clinical promise. as noted earlier, the treatment of perinatal anxiety has received limited research attention. further, the treatments that have been developed are primarily generic such that they are comprised of standard cbt techniques, includ­ ing challenging cognitions by generating alternative interpretations (e.g., forsell et al., 2017; see moulds et al., 2018). in contrast, cbm-i seeks to enhance access to positive interpretations in a more direct, automatic way. our findings suggest that developing novel approaches which draw on experimental findings and directly target factors that have been identified to maintain anxiety (e.g., worry) to potentially supplement existing treatment approaches may be a promising future clinical direction. moreover, our findings speak to the issue of prevention. given growing evidence that antenatal rnt predicts perinatal mental health problems (dejong et al., 2016; schmidt et al., 2016), the prospect of reducing worry in pregnant women by targeting interpretation bias represents an exciting possibility for preventing postpartum anxiety. topper et al. (2017) found that that a preventive intervention which targeted rnt reduced the onset of depression and anxiety 12 months later. our finding that antenatal worry is a modifiable risk factor similarly raises the possibility that an intervention targeting worry may also have utility in preventing subsequent mental health problems in the postnatal period. we acknowledge some limitations and suggest future research directions. first, while single-session cbm experiments critically advance understanding of theoretical mecha­ nisms, they do not provide sufficient evidence regarding the sustained consequences of targeting interpretation bias in this way (hirsch et al., 2018). however, we note that recent studies using multiple cbm-i sessions (e.g., 10 internet-delivered sessions) have reported encouraging preliminary evidence of the longevity of effects (i.e., reductions in rnt at one-month follow-up; hirsch et al., 2018; hirsch, krahé, whyte, bridge, et al., 2020). future research employing multiple sessions with an extended follow-up period is needed before conclusions can be drawn about potential clinical benefit and preventive utility in the perinatal context. second, we did not gather detailed information about previous numbers of miscarriages or complications in participants’ current (or any hirsch, meeten, newby et al. 11 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://www.psychopen.eu/ previous) pregnancy, leaving it unknown whether our findings generalise to pregnant women who have experienced pregnancy loss or complications in participants’ current (or any previous) pregnancy. third, we did not assess interpretation bias or the presence of negative intrusions pre-training, and thus do not know whether groups differed at the outset. however, participants were randomised to condition by a researcher outside of the study team, making these possible explanations for the results unlikely. fourth, randomisation led to differences in anxiety (gad-7) between groups. finally, due to covid-19 pandemic ruling out completion of data collection, the number of participants was slightly below that recommended in the original sample size calculation. our findings raise interesting possibilities for future research. in a recent fully web­ based study, hirsch, krahé, whyte, krzyzanowski, et al. (2020) reported that cbm-i led to reductions in depression and anxiety, as well as worry and rumination, in partici­ pants with gad with or without comorbid depression. the effects persisted to 3-month follow-up, and notably, were mediated by changes in interpretation bias. these results raise the exciting possibility that cbm-i could form a low intensity intervention to treat or prevent anxiety and worry, with potential for application in the perinatal context. further, given evidence that cbm-i may be effective in modifying interpretation bias in the context of a range of mental health conditions (e.g., depression, hirsch et al., 2018; eating disorders, turton et al., 2018; social anxiety, stevens et al., 2018), another potential research direction could be to investigate the effectiveness of cbm-i for other perinatal psychological symptoms, beyond anxiety. in sum, this study is the first to evaluate the effectiveness of single session cbm-i for reducing worry in pregnant women. our findings provide empirical support for inter­ pretive bias as a mechanism underlying antenatal worry, and thus indicate that worry is a modifiable risk factor during pregnancy. future research with a broader sample warrant investigation (where the current sample were from south london and had not experienced three or more miscarriages) to determine if findings generalise to a more heterogenous sample. furthermore, future research with pregnant women diagnosed with gad is needed to confirm that these results are generalisable to treatment-seeking, clinical samples. nonetheless, given evidence that worry early in pregnancy predicts later anxiety, these data represent an important first step in investigating whether cbm-i holds promise as a therapeutic approach to address perinatal mental health problems. funding: ch receives salary support from the national institute for health research (nihr), mental health biomedical research centre at south london and maudsley nhs foundation trust and king’s college london. acknowledgments: we are very grateful to the pregnant women who took part in the study. competing interests: the authors have declared that no competing interests exist. training positive interpretations in pregnant worriers 12 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://www.psychopen.eu/ supplementary materials the following supplementary materials are available (for access see index of supplementary materials below): • via the open science framework (osf) repository: the preregistration for the study • via the psycharchives repository: supplementary materials (appendices) – appendix a includes: further methodological details of cognitive bias modification for interpretation and the recognition task assessment of interpretation bias – appendix b includes: open science framework pre-registered study protocol index of supplementary materials hirsch, c. r., meeten, f., newby, j. m., o’halloran, s., gordon, c., krzyzanowski, h., & moulds, m. l. 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(2017). prevention of anxiety disorders and depression by targeting excessive worry and rumination in adolescents and young adults: a randomized controlled trial. behaviour research and therapy, 90, 123-136. https://doi.org/10.1016/j.brat.2016.12.015 training positive interpretations in pregnant worriers 16 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://doi.org/10.1037/0022-3514.61.1.115 https://doi.org/10.1097/00004583-200212000-00019 https://doi.org/10.1017/s0954579414000029 https://doi.org/10.1016/j.brat.2003.10.007 https://doi.org/10.1016/j.cpr.2017.01.007 https://doi.org/10.1007/s10608-016-9759-z https://doi.org/10.1007/s00737-014-0425-8 https://doi.org/10.1001/archinte.166.10.1092 https://doi.org/10.1016/s0140-6736(14)61277-0 https://doi.org/10.1016/j.beth.2018.02.004 https://www.who.int/mental_health/prevention/suicide/lit_review_postpartum_depression.pdf https://doi.org/10.1016/j.brat.2016.12.015 https://www.psychopen.eu/ turton, r., cardi, v., treasure, j., & hirsch, c. r. (2018). modifying a negative interpretation bias for ambiguous social scenarios that depict the risk of rejection in women with anorexia nervosa. journal of affective disorders, 227, 705-712. https://doi.org/10.1016/j.jad.2017.11.089 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. hirsch, meeten, newby et al. 17 clinical psychology in europe 2021, vol. 3(2), article e3781 https://doi.org/10.32872/cpe.3781 https://doi.org/10.1016/j.jad.2017.11.089 https://www.psychopen.eu/ training positive interpretations in pregnant worriers (introduction) method study registration participants sample size measures and materials procedure results questionnaire measures for cbm-i and control conditions assessing the impact of cbm-i on interpretation bias (hypothesis 1) assessing the impact of cbm-i on negative thought intrusions (hypothesis 2) discussion (additional information) funding acknowledgments competing interests supplementary materials references medication-enhanced psychotherapy for posttraumatic stress disorder: recent findings on oxytocin’s involvement in the neurobiology and treatment of posttraumatic stress disorder scientific update and overview medication-enhanced psychotherapy for posttraumatic stress disorder: recent findings on oxytocin’s involvement in the neurobiology and treatment of posttraumatic stress disorder katrin preckel 1 , sebastian trautmann 2 , philipp kanske 1,3 [1] max planck institute for human cognitive and brain sciences, leipzig, germany. [2] institute of clinical psychology and psychotherapy, department of psychology, medical school hamburg, hamburg, germany. [3] clinical psychology and behavioral neuroscience, faculty of psychology, technische universität dresden, dresden, germany. clinical psychology in europe, 2021, vol. 3(4), article e3645, https://doi.org/10.32872/cpe.3645 received: 2020-04-30 • accepted: 2021-08-25 • published (vor): 2021-12-23 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: katrin preckel, max planck institute for human cognitive and brain sciences, stephanstraße 1a, 04103 leipzig, germany. phone: +49 341 9940-2653. e-mail: preckel@cbs.mpg.de abstract background: traumatic experiences may result in posttraumatic stress disorder (ptsd), which is characterized as an exaggerated fear response that cannot be extinguished over time or in safe environments. what are beneficial psychotherapeutic treatment options for ptsd patients? can oxytocin (oxt), which is involved in the stress response, and safety learning, ameliorate ptsd symptomatology and enhance psychotherapeutic effects? here, we will review recent studies regarding oxt’s potential to enhance psychotherapeutic therapies for ptsd treatment. method: we conducted a literature review on the neurobiological underpinnings of ptsd especially focusing on oxt’s involvement in the biology and memory formation of ptsd. furthermore, we researched successful psychotherapeutic treatments for ptsd patients and discuss how oxt may facilitate observed psychotherapeutic effects. results: for a relevant proportion of ptsd patients, existing psychotherapies are not beneficial. oxt may be a promising candidate to enhance psychotherapeutic effects, because it dampens responses to stressful events and allows for a faster recovery after stress. on a neural basis, oxt modulates processes that are involved in stress, arousal and memory. oxt effectively counteracts memory impairments caused by stress and facilitates social support seeking which is a key resilience factor for ptsd and which is beneficial in psychotherapeutic settings. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3645&domain=pdf&date_stamp=2021-12-23 https://orcid.org/0000-0003-1498-3813 https://orcid.org/0000-0002-8976-3244 http://orcid.org/0000-0003-2027-8782 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: oxt has many characteristics that are promising to positively influence psychotherapy for ptsd patients. it potentially reduces intrusions, but preserves memory of the event itself. introducing oxt into psychotherapeutic settings may result in better treatment outcomes for ptsd patients. future research should directly investigate oxt’s effects on ptsd, especially in psychotherapeutic settings. keywords ptsd, oxytocin, treatment, medication-enhanced therapy, stress highlights • lower endogenous oxt levels after traumatic experiences are associated with developing ptsd. • oxt administration around the time of the traumatic event may result in fewer intrusive memories. • abnormal signaling of the hippocampus and the vmpfc to the amygdala result in hyperactivation of the amygdala in ptsd. • oxt facilitates social support seeking and safety learning while reducing personal distress. • oxt’s characteristics are promising to enhance psychotherapeutic treatment for ptsd patients. traumatic experiences may result in posttraumatic stress disorder (ptsd), which is characterized as an exaggerated fear response that cannot be extinguished over time or in safe environments. the lifetime prevalence of developing ptsd lies at about 4% (koenen et al., 2017). this number is relatively low considering that 80% of the general population experience traumatic events during their lifetime. critical factors that determine if someone develops ptsd after experiencing or witnessing traumatic events include female gender, history of mental disorder (tortella-feliu et al., 2019), childhood adversities (mclaughlin et al., 2017), but also individual emotional contagion and empathy (trautmann et al., 2018). in particular, for witnessed trauma, the ability to distinguish own feelings from that of others is crucial to avoid excessive personal distress and anxiety (preckel, kanske, & singer, 2018). also, emotion regulation abilities may be indicative of ptsd development after a traumatic experience, as prospective studies on emotion regulation and trauma symptoms show (bardeen, kumpula, & orcutt, 2013; ehring & ehlers, 2014). treatment approaches for ptsd are not yet sufficiently successful, this is shown by patient drop-out rates, for instance, which are highly variable with rates between 16% to 53.1% (hatchett & park, 2003; lewis, roberts, gibson, & bisson, 2020), depending on how the drop-out rates were defined. importantly, although trauma‐focused cognitive behav­ ior therapy is the best‐validated treatment for ptsd, it has failed to develop over the oxytocin’s role in the neurobiology and treatment of ptsd 2 clinical psychology in europe 2021, vol. 3(4), article e3645 https://doi.org/10.32872/cpe.3645 https://www.psychopen.eu/ past few decades. importantly, only two‐thirds of ptsd patients respond effectively to this therapy. besides, the majority of ptsd patients does not take part in evidence‐based treatment, this applies predominately to low‐ and middle‐income countries (bryant, 2019). this underlines the need for better therapeutic approaches and ongoing research on this topic. behavioral and medication treatment approaches for ptsd have different strengths and weaknesses (flanagan & mitchell, 2019), which makes a combination, of a medication-enhanced psychotherapy approach very promising. regarding the common symptoms of ptsd such as intrusive memories and flashbacks, avoidance behavior, (negative) changes in cognition and in arousal (american psychiatric association, 2013), as well as deficits in social cognition (e.g. empathy, compassion and theory of mind) (couette, mouchabac, bourla, nuss, & ferreri, 2020; palgi, klein, & shamay-tsoory, 2016), the neuropeptide and hormone oxytocin (oxt) may bear relevance for the treatment of ptsd (palgi, klein, & shamay-tsoory, 2016). oxt may be a relevant treatment enhancer, because it has been found to influence memory (lee et al., 2015), approach-avoidance behavior (preckel, scheele, kendrick, maier, & hurlemann, 2014), social cognition (e.g. emotion recognition) (schwaiger, heinrichs, & kumsta, 2019) and arousal (rash & campbell, 2014). due to oxt’s broad influence on human well-being, it has been introduced as a promising treatment agent for various disorders including ptsd (koch et al., 2014; misrani, tabassum, & long, 2017; preckel, kanske, singer, paulus, & krach, 2016). furthermore, oxt attenuates the development of ptsd symp­ toms after trauma exposure in patients with high acute symptomatology (van zuiden et al., 2017) and is useful as an early preventive intervention (frijling, 2017). another study found that oxt was able to reduce ptsd symptoms which were triggered by trauma-script exposure (sack et al., 2017). in this update article, we review the latest literature on the relationship of biological underpinnings of ptsd, memory formation and oxt. we investigate the question: what role can/ does oxt play in ptsd symptom development and how might it improve ptsd symptoms? we start our article by describing the stress physiology and the roles that oxt and cortisol play in it, we then continue by discussing the influence of oxt on the neural circuits of fear conditioning, ptsd and memory and, before summarizing our thoughts, we discuss the potential benefits of oxt as a treatment enhancer for ptsd psychotherapy. stress physiology and the roles of oxytocin and cortisol the stress response involves multiple levels, which include cognitive, behavioral and physiological processes. on the physiological level, highly stressful or traumatic experi­ ences, activate the hypothalamic-pituitary-adrenal (hpa) axis as well as the oxytociner­ preckel, trautmann, & kanske 3 clinical psychology in europe 2021, vol. 3(4), article e3645 https://doi.org/10.32872/cpe.3645 https://www.psychopen.eu/ gic system (donadon, martin-santos, & osório, 2018). activity of the hpa axis and its end-product cortisol facilitate adaption to the faced stressor (e.g. de kloet, joëls, & holsboer, 2005). a typical physiological stressful response involves the following steps: the hypothalamus releases the cortiocotropin-releasing-hormone (crh) to the pituitary gland, which in turn releases the adrenocorticotropic hormone (acth) into systemic circulation. acth prompts the adrenal gland to release glucocorticoids such as cortisol. when cortisol levels in the blood increase, this is perceived by brain regions (e.g. hypo­ thalamus) and the release of crh is stopped to return to homeostasis (smith & vale, 2006). in ptsd patients, the reinstating of homeostasis fails (yehuda, 2002), resulting in an indiscriminately heightened physiological stress responses (e.g. mcfarlane, atchison, rafalowicz, & papay, 1994). hypocortisolism is often reported in ptsd patients, which might at first sight be counterintuitive. yet, the downregulation of available cortisol could be an attempt of the body to compensate for exaggerated stress responses (thaller, vrkljan, hotujac, & thakore, 1999). this compensatory attempt, however, results in a sensitization to the glucocorticoid system (rohleder, wolf, & wolf, 2010), meaning that low concentrations of cortisol are sufficient to induce a fear or stress response. furthermore, the observed hypocortisolism may be dependent on the type of cortisol measure, because in the cerebrospinal fluid of patients with ptsd, a sustained increase of the corticotropin-releasing hormone was observed (sherin & nemeroff, 2011). while hair cortisol levels are commonly reported to be lower in ptsd patients when compared to those of healthy controls (steudte-schmiedgen, kirschbaum, alexander, & stalder, 2016; steudte-schmiedgen et al., 2015; van zuiden et al., 2019), but there are contradictory findings (van den heuvel et al., 2020). exogenously administered oxt promotes a faster recovery after the stress response (heinrichs, baumgartner, kirschbaum, & ehlert, 2003; kubzansky, mendes, appleton, block, & adler, 2012), and it attenuates salivary cortisol elevations after a physical stres­ sor (cardoso, ellenbogen, orlando, bacon, & joober, 2013). endogenous oxt levels are frequently measured in the periphery and lower endogenous oxt levels after traumatic experiences are associated with developing ptsd (donadon, martin-santos, & osório, 2018), even though endogenous oxt levels of individuals who suffer from ptsd and those of healthy controls did not differ (engel et al., 2019). interestingly, oxt and cortisol levels are positively correlated when participants were able to anticipate a stressor (brown, cardoso, & ellenbogen, 2016). anticipation and predictability seem to strongly influence oxt’s action, because also exogenously administered oxt has ambiguous effects on threatening responses which is partly due to the predictability or unpredicta­ bility of threatening cues. this means that oxt administration results in anxiogenic effects when threat cues are unpredictable, because defensive responses to unpredictable shocks were significantly increased by oxt (as compared to placebo and vasopression administration), while predictable shocks were not influenced by oxt administration oxytocin’s role in the neurobiology and treatment of ptsd 4 clinical psychology in europe 2021, vol. 3(4), article e3645 https://doi.org/10.32872/cpe.3645 https://www.psychopen.eu/ (grillon et al., 2013). furthermore, oxt’s effects on anxiety depend on the timing of oxt administration and threat content, because both anxiolytic and anxiogenic effects have been reported (frijling, 2017; neumann & slattery, 2016). importantly though, in people who experienced moderate emotional trauma, anxiolytic effects of oxt have been found (donadon et al., 2018). while oxt’s effects on cortisol are diverse, a recent meta-analysis reported that oxt attenuated the cortisol response to a greater extend, when the hpa-axis was strongly activated and this effect was strongest among clini­ cal populations (patients with ptsd, major depressive disorder and bipolar disorder) (cardoso, kingdon, & ellenbogen, 2014). these ambiguous findings may be due to the cross-binding ability of oxt and vasopressin, (for more detail see: preckel & kanske, 2018). moreover, oxt enables rapid and flexible adaptation to fear signals in social contexts, which can be advantageous in preventing ptsd; but simultaneously it may elevate vulnerability for interpersonal trauma (eckstein et al., 2016). thus, we assume that the dampening effect of oxt on the hpa axis (neumann, krömer, toschi, & ebner, 2000) may act on different levels and result in reduced stress responses, thereby eliciting the opposite effects of typical stress tasks such as the trier social stress test (tsst; kirschbaum, pirke, & hellhammer, 1993). this assumption is grounded in the observation that oxt is associated with faster recovery of the endocrine and the autonomic system after stressful events (engert et al., 2016), as well as on skin conductance findings which were measured directly after traumatic events and predicted subsequent chronic ptsd development (hinrichs et al., 2019). consequently, oxt’s dampening effect on the hpa axis activation may function as a stress-buffer for traumatic events and by buffering stress responses it may prevent the development of chronic ptsd after trauma exposure. the anxiolytic oxt effects may also result in fewer treatment dropouts. cortisol, like oxt, has time-sensitive effects on the hpa-axis activity. activating the hpa-axis by exposing participants to a stress task, for instance the tsst, before they participate in a trauma analogue paradigm (trauma film), results in increased numbers of intrusive memories (in participants who biologically respond to the tsst) as compared to participants who perform a control task (placebo tsst) and are not stressed prior to the trauma film paradigm (schultebraucks et al., 2019). in contrast, administering cortisol after a trauma results in fewer intrusions (de quervain, 2006). outcomes of post-trauma cortisol administration are, however, also somewhat inconclusive, because not all stud­ ies report fewer subsequent intrusions (graebener, michael, holz, & lass-hennemann, 2017; ludäscher et al., 2015). cortisol (here: hydrocortisone) as a treatment enhancer augmented psychological treatment successfully, meaning that prolonged exposure ther­ apy resulted in greater retention when participants received cortisol (yehuda et al., 2015). thus, oxt as well as cortisol are promising agents for medication-tailored treatment for ptsd patients. preckel, trautmann, & kanske 5 clinical psychology in europe 2021, vol. 3(4), article e3645 https://doi.org/10.32872/cpe.3645 https://www.psychopen.eu/ oxt’s influence on fear conditioning, and its role in ptsd and memory to investigate the mechanisms, which underlie ptsd, pavlovian fear conditioning para­ digms are helpful models. in fear conditioning experiments, an aversive stimulus is used as an unconditioned stimulus (us) in order to establish fear as soon as the conditioned stimulus (cs) is presented. in ptsd, one traumatic event is sufficient to establish a cs. the main brain structures that are involved in fear conditioning and ptsd include the amygdala, the hippocampus and the ventromedial prefrontal cortex (vmpfc) (careaga, girardi, & suchecki, 2016; koenigs & grafman, 2009). the amygdala is the core structure of fear conditioning (duvarci & pare, 2014; ehrlich et al., 2009) and extinction (maren, 2011; myers & davis, 2002). the different nuclei of the amygdala have specialized roles in the fear learning and extinction processes. the lateral nucleus of the amygdala (lan) provides the amygdala primarily with input and is important for mediating fear learning via neural plasticity, while the basolateral and basomedial nuclei converge sensory information of the conditioned stimulus and the unconditioned stimulus (herry & johansen, 2014). the hippocampus is important for encoding information, and for modulating appropriate emotional responses to potentially fearful stimuli (acheson, gresack, & risbrough, 2012; lissek & van meurs, 2015). furthermore, lower hippocampal activation has been linked to direct memory suppression in healthy participants (benoit & anderson, 2012), that can be interpreted as reduced voluntary recall. the vmpfc mediates the extinction of conditioned fear by inhibiting the amygdala (koenigs et al., 2008). in ptsd patients, these brain regions differ on a structural and functional level in comparison to healthy controls. for example, reduced hippocampal volume is associated with ptsd development (gilbertson et al., 2002; logue et al., 2018; pitman et al., 2006) as well as being a consequence of stressful experiences (admon et al., 2013). on a functional level, abnormal hippocampus activation hindered extinction learning in safe contexts (patel, spreng, shin, & girard, 2012) and reduced top-down regulation to the amygdala which results in enhanced fear conditioning (rauch, shin, & phelps, 2006). a reduction of functional and structural connectivity between the hippocampus and the vmpfc has also been reported (admon et al., 2013). the amygdala is also crucially involved in associative learning (ledoux, 1996; mcgaugh, 2000) and its dysfunction may be responsible for increased fear conditioning responses in ptsd patients, which in turn results in stronger memory formation of the traumatic event (= intrusive memories) (careaga et al., 2016). also, vmpfc activation is lower and results in decreased top-down regulation of the amygdala (rauch, shin, & phelps, 2006). the hippocampus as well as the vmpfc project to the amygdala and their failure to adequately inhibit amygdala activation causes its hyperactivity which is frequently found in ptsd patients (hayes, hayes, & mikedis, 2012; liberzon & abelson, 2016; patel, spreng, shin, & girard, 2012; pitman et al., 2012; shin & liberzon, 2010). oxytocin’s role in the neurobiology and treatment of ptsd 6 clinical psychology in europe 2021, vol. 3(4), article e3645 https://doi.org/10.32872/cpe.3645 https://www.psychopen.eu/ amygdala hyperactivation is especially pronounced when compared to non-trauma ex­ posed controls, but not necessarily when compared to trauma-exposed controls (patel et al., 2012), therefore it cannot be ruled out that this mechanism is related to trauma exposure rather than to ptsd (van wingen, geuze, vermetten, & fernandez, 2011). however, the evidence that amygdala hyperactivation might be causally related to ptsd development, could be shown by previous lesion studies in veterans with and without ptsd (koenigs & grafman, 2009). another lesion study showed that elevated amygdala activation is related to dysfunctional vmpfc activity (motzkin et al., 2015). furthermore, ptsd patients (as compared to healthy controls) display an initially increased amygdala response when confronted with trauma-related negative (vs. non-trauma related nega­ tive) stimuli (protopopescu et al., 2005). the elevated amygdala activation may explain the emotional memory quality in ptsd patients, especially, because this activation does not habituate over time (protopopescu et al., 2005). diminished structural connectivity between the amygdala and vmpfc has been found in ptsd patients (koch et al., 2017). the functional connectivity between these regions, could be increased by oxt (in men with ptsd), thereby reducing amygdala hyperactivity (koch et al., 2014). returning to fear conditioning experiments, administering intranasal oxt before fear conditioning results in faster fear conditioning, (eckstein et al., 2016) while administra­ tion after fear-conditioning and before fear extinction results in better fear extinction and inhibited amygdala activation (eckstein et al., 2015). moreover, reduced skin conductance responses to electric shocks after oxt as opposed to placebo administration in human studies support the notion of oxt’s “anti-stress-properties” (eckstein et al., 2016). thus, exogenous oxt effects are time sensitive and remain currently inconclusive. the amygdala is further suggested to mediate influences of medication on memory consolidation (mcgaugh, 2000), therefore it may also mediate oxt effects on memory and potentially change the emotional content of memories in ptsd patients. a recent study showed that the severity of childhood trauma exposure (as reported from memory) was related to oxytocin-modulated amygdala responses in patients with ptsd while this was not the case in healthy controls (flanagan et al., 2019). if oxt has the potential to change the content of memories to turn more positively, this may already result in less hyperactivity of the amygdala, which is strongly influenced by negative valence (preckel et al., 2019). this is further supported by oxt’s inhibiting effects on the activation of (para-)limbic structures, its facilitating action on cognitive performance and its inhibiting effects on arousal (lischke, herpertz, berger, domes, & gamer, 2017; misrani et al., 2017; solomon et al., 2018). animal studies report that exogenous oxt has “anti-stress proper­ ties” on hippocampal plasticity and memory (lee et al., 2015). the hippocampus plays an important role in the negative feedback loop of the hpa-axis (joseph & whirledge, 2017) and it is altered in ptsd patients (schumacher et al., 2019). preckel, trautmann, & kanske 7 clinical psychology in europe 2021, vol. 3(4), article e3645 https://doi.org/10.32872/cpe.3645 https://www.psychopen.eu/ regarding oxt’s effects on memory, earlier studies found that oxt impairs mem­ ory recall, the generation of associated target words, or explicit memory (heinrichs, meinlschmidt, wippich, ehlert, & hellhammer, 2004). recent findings, however, suggest that exogenous oxt may also have positive influences on memory. for example, oxt improves safety learning in healthy humans (eckstein et al., 2019) and animal studies show that oxt effectively counteracts memory impairments caused by stress on a cellular level, thereby preventing memory impairments (lee et al., 2015). another animal study found changes in long-term synaptic plasticity in the amygdala (medial nucleus) due to oxt’s action. these oxytocin-induced synaptic changes are strongly related to social recognition memory (rajamani, wagner, grinevich, & harony-nicolas, 2018). these findings indicate that oxt may have restoring functions on plasticity related to memory processes. furthermore, oxt improves memory performance which is accompanied by in­ creased connectivity between the dorsolateral (dl)pfc and the acc in traumatized as compared to trauma exposed individuals without ptsd (flanagan et al., 2018). this is an important finding, because decreased connectivity between the dlpfc and the acc is described as a maladaptive neural process (= reduced neural processing efficiency) in demanding cognitive tasks. furthermore, the decrease in connectivity between these brain regions is associated with the trait measure “worry” (as a dimension of anxiety) in healthy individuals (barker et al., 2018). regarding the association between worry and ptsd that has been found in previous studies (blazer, hughes, & george, 1987), it may be assumed that similar neural maladaptations take place in ptsd and which may be positively influenced by oxt administration. increased acc activation after oxt administration has also been reported elsewhere (preckel, scheele, eckstein, maier, & hurlemann, 2015). to sum up, oxt positively influences memory on a cellular, neural activation and behavioral level. moreover, exogenous oxt was able to improve social behavioral deficits in autism spectrum disorder patients (asd) via reinstating vmpfc activation, during a social-com­ munication task (aoki et al., 2015). in male ptsd patients, oxt reinstated diminished connectivity between the amygdala and the vmpfc and in female patients it reestablish­ ed increased connectivity between the amygdala and the dorsal anterior cingulate cortex (dacc), accompanied by reduced subjective anxiety and nervousness (koch et al., 2016b). a recent study showed that oxt dampened amygdala activation in ptsd patients, when they saw emotional faces (regardless of valence), while amygdala activation was increased in trauma-exposed control participants (koch et al., 2016a). assuming that oxt’s action in asd patients is the same as in ptsd patients, as the common action on brain activity suggests, oxt may also improve social and affective functioning in ptsd by restoring vmpfc activation. oxytocin’s role in the neurobiology and treatment of ptsd 8 clinical psychology in europe 2021, vol. 3(4), article e3645 https://doi.org/10.32872/cpe.3645 https://www.psychopen.eu/ oxytocin’s potential benefit in psychotherapy for ptsd apart from different comorbidities such as depression, anxiety or alcohol abuse, social support is one of the strongest predictors for successful ptsd therapy (dewar, paradis, & fortin, 2020), just like therapeutic alliance (lantz, 2004). the willingness to share thoughts and emotions is clearly related to perceived social support (kahn & cantwell, 2017). as mentioned previously, oxt increases social support seeking and the perception of received social support (cardoso, valkanas, serravalle, & ellenbogen, 2016) and it also increases the willingness to verbally share one’s emotions with someone else (lane et al., 2013). this makes it specifically promising for medication-enhanced psychother­ apeutic interventions, because it might facilitate emotional disclosure. oxt increases social support seeking and the perception of received social support (cardoso, valkanas, serravalle, & ellenbogen, 2016) as well as safety learning (eckstein et al., 2019) in healthy individuals. assuming that oxt unfolds the same characteristics in ptsd patients, it is likely that oxt can ameliorate ptsd symptoms successfully. in a study on trauma disclosure, oxt alone did not increase the tendency to disclose trauma (scheele et al., 2019). this might be due to insufficient(ly perceived) social support, because it has also been suggested that the presence of social support might be necessary to elicit prosocial oxt effects (cardoso et al., 2016), to mention one of many context-dependent oxt effects. therefore, administering oxt in a psychotherapeutic setting, where social support is available, might result in increased disclosure. concerning the therapeutic relationship which is important for successful therapy outcomes, increased sensitivity to social reward may result in increased social support seeking and may thus increase the likelihood of a positive psychotherapeutic relationship. notably, it has been found that anterior insula activation was normalized, during social reward processing, in ptsd patients after oxt administration (nawijn et al., 2017). psychotherapeutic interventions that have been successful in ameliorating ptsd symptoms include eye movement desensitization and reprocessing (shapiro, 2014) pro­ longed exposure (singh, 2019), imagery rescripting and reprocessing therapy (grunert, weis, smucker, & christianson, 2007), exposure therapy (paunovic & ost, 2001) as well as exposure-based cognitive-behavioral group therapy (cbgt) (schwartze, barkowski, strauss, knaevelsrud, & rosendahl, 2019). clinical trials which have investigated oxt’s enhancing effects on different treatment options, revealed that oxt could enhance expo­ sure-therapy in ptsd patients (flanagan et al., 2019) and patients with arachnophobia (acheson et al., 2015). a study, which focused on physiological responses to oxt, found one notable difference and that was a higher skin conductance baseline level in the oxt group (pitman et al., 1993). here, we take cbgt as an example to explain how simultaneous oxt administration can enhance psychotherapy. preckel, trautmann, & kanske 9 clinical psychology in europe 2021, vol. 3(4), article e3645 https://doi.org/10.32872/cpe.3645 https://www.psychopen.eu/ oxt improves various aspects of social cognition, for example trust (kosfeld, heinrichs, zak, fischbacher, & fehr, 2005). trust is an essential component of psycho­ therapy that needs to be established first, before the actual therapy can begin (wampold, 2015). therefore, if oxt facilitates trust, by decreasing amygdala and dorsal striatum activation as neuroimaging studies were also able to show (baumgartner, heinrichs, vonlanthen, fischbacher, & fehr, 2008), it may have beneficial effects on psychothera­ peutic outcomes. a recent study on food intake reported that oxt enhances brain activation in areas that govern cognitive control, including the vmpfc (spetter et al., 2018). should oxt have the same effects on the vmpfc in ptsd patients, oxt might be particularly beneficial for ptsd patients who take part cbgt. there is a growing literature body which investigates oxt’s potential on psychotherapies for ptsd patients (e.g. engel et al., 2021; koch et al., 2014; koch et al., 2019). though oxt appears to be a promising candidate to ameliorate ptsd symptoms, especially when combined with psy­ chotherapies, further studies are required to disentangle the exact mechanism of oxt. it is also crucial to find out which ptsd patients can benefit most from oxt-enhanced psychotherapy, because oxt has many person-specific characteristics, ranging from a person’s attachment style to oxytocin receptor gene variations which differentially influence oxt’s action in individuals (bartz, zaki, bolger, & ochsner, 2011; olff et al., 2013). thus, studies with precise designs which combine behavioral, biological, imaging and clinical aspects are required to further address these questions (giovanna et al., 2020). conclusion and outlook in this update paper, we described the mechanisms underlying ptsd by discussing the most recent studies on structural and functional brain changes associated with ptsd, including findings on structural and functional connectivity. we have discussed potential oxt mechanisms of action from the healthy population and asd patients and related these to mechanisms that are malfunctioning in ptsd patients, thereby building direct implications for oxt’s potential action mechanism. most importantly, we like to emphasize oxt’s promising characteristics as a psychotherapeutic enhancer. however, there are still uncertainties, which need further investigation. these include the critical aspects of pharmacodynamics and the ideal dosage. it became clear that therapeutic approaches are not yet sufficiently successful in treating ptsd patients, because patients drop out of therapy frequently and some symptoms remain after treatment. oxt remains a promising candidate for medication-tailored ptsd therapy and research on this topic should be continued. oxytocin’s role in the neurobiology and treatment of ptsd 10 clinical psychology in europe 2021, vol. 3(4), article e3645 https://doi.org/10.32872/cpe.3645 https://www.psychopen.eu/ funding: kp is supported by german federal ministry of education and research within the asd-net (bmbf fkz 01ee1409a). st is supported by the german research foundation (dfg r 1489/1-1) and the federal ministry of defense (e/u2ad/hd008/cf550) pk is supported by german 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(2015). cortisol augmentation of a psychological treatment for warfighters with posttraumatic stress disorder: randomized trial showing improved treatment retention and outcome. psychoneuroendocrinology, 51, 589-597. https://doi.org/10.1016/j.psyneuen.2014.08.004 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. preckel, trautmann, & kanske 21 clinical psychology in europe 2021, vol. 3(4), article e3645 https://doi.org/10.32872/cpe.3645 https://doi.org/10.1016/j.biopsych.2016.11.012 https://doi.org/10.1002/jts.22395 https://doi.org/10.1002/wps.20238 https://doi.org/10.1016/j.psyneuen.2014.08.004 https://www.psychopen.eu/ oxytocin’s role in the neurobiology and treatment of ptsd (introduction) stress physiology and the roles of oxytocin and cortisol oxt’s influence on fear conditioning, and its role in ptsd and memory oxytocin’s potential benefit in psychotherapy for ptsd conclusion and outlook (additional information) funding acknowledgments competing interests twitter accounts references sex differences in the outcome of expressive writing in parents of children with leukaemia research articles sex differences in the outcome of expressive writing in parents of children with leukaemia dorte mølgaard christiansen 1 , maria luisa martino 2 , ask elklit 1 , maria francesca freda 2 [1] national center of psychotraumatology, institute of psychology, university of southern denmark, odense, denmark. [2] department of humanistic studies, federico ii university, naples, italy. clinical psychology in europe, 2022, vol. 4(1), article e5533, https://doi.org/10.32872/cpe.5533 received: 2020-12-31 • accepted: 2021-10-03 • published (vor): 2022-03-31 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: dorte mølgaard christiansen, university of southern denmark, campusvej 55, 5230 odense m, denmark. e-mail: dochristiansen@health.sdu.dk abstract background: sex differences are widely reported in clinical psychology but are rarely examined in interventions. method: this mixed-method explorative study examined sex differences in 13 mothers and 10 fathers of children in the off-therapy phase of acute lymphoblastic leukaemia. parents underwent an expressive writing intervention using the guided written disclosure protocol (gwdp). results: mothers had more negative mood profiles than fathers but improved more during the intervention. conclusion: though preliminary, our findings highlight the importance of sex as a potential moderator of intervention and treatment outcome that could be of great clinical significance. keywords sex differences, gender differences, expressive writing therapy, mood states, childhood leukaemia, parental stress highlights • parents of children in remission from cancer can benefit from expressive writing. • expressive writing can improve mood states. • mothers may benefit more than fathers. • more research on gender differences in outcomes is needed. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5533&domain=pdf&date_stamp=2022-03-31 https://orcid.org/0000-0003-0650-3031 https://orcid.org/0000-0003-1906-9369 https://orcid.org/0000-0002-8469-7372 https://orcid.org/0000-0002-2529-2279 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ when a child falls severely ill, it affects the whole family and parental stress levels remain increased even after successful treatment (hile et al., 2014). how the parents cope with the shared trauma and burden of that illness is essential to the health of the family as a whole (morris et al., 2012). one study reported that parental stress was the strongest correlate of functional impairment in children at least 2 years following treatment for leukemia/lymphoma (hile et al., 2014). consequently, decreasing the stress and symptom levels of parents of children who have undergone treatment for serious illnesses is likely to benefit the whole family. however, parents receive little attention from hospital personnel and healthcare researchers beyond the first initial shock associated with the child’s diagnosis and treatment. inspired by the field of linguistics, pennebaker et al. (2010) theorised that words used in a written narrative reflect the writer’s state of mind and could be used to track changes in the meaning attributed to an event (pennebaker et al., 2010; tausczik & pennebaker, 2010). building on these principles, expressive writing was designed to be used as an element in therapy or as an independent intervention to promote mean­ ing-making and integrate traumatic content into a personal narrative (de luca picione et al., 2017; de luca picione et al., 2018; martino & freda, 2016; martino et al., 2013). one such expressive writing intervention, the guided written disclosure protocol (gwdp) has been used to reduce distress, anxiety, and ptsd symptoms in parents of children with cancer, whereas results for depression have been less promising (cafaro et al., 2019; dicé et al., 2018; duncan & gidron, 1999; duncan et al., 1998; gidron et al., 2002; martino et al., 2019; martino et al., 2013). this protocol is designed to help participants build an increasingly complex and coherent narrative by building on themes of meaning-making, insight, emotion-regulation, mastery and self-efficacy (baikie & wilhelm, 2005). one factor that likely affects how parents respond to different interventions is sex, but research remains scarce (christiansen, 2015, 2017; ogrodniczuk, 2006). research on sex differences in the outcomes of different interventions is often limited by small sample sizes (especially few male participants), yet effect sizes are rarely reported. furthermore, moderation effects are rarely based on a priori hypotheses. possibly as a consequence of poor statistical power, few studies have reported significant sex differences. nonetheless, there are indications that women generally benefit more from psychotherapy than men (christiansen, 2015, 2017; ogrodniczuk, 2006; wade et al., 2016), especially interventions focusing on verbal processing of traumatic content (christiansen, 2017). little focus has been given to potential sex differences in outcome of expressive writing. one meta-anal­ ysis found that percentage of male participants was positively associated with effect size across 13 studies. however, this effect was not found for psychological outcomes. furthermore, as trauma type was not controlled, it may be that women were more likely to write about more toxic exposures, such as sexual trauma, which is more common among women (christiansen, 2017). other studies have generally failed to report sex differences in the effects of expressive writing (pennebaker & chung, 2011), though this sex differences in expressive writing 2 clinical psychology in europe 2022, vol. 4(1), article e5533 https://doi.org/10.32872/cpe.5533 https://www.psychopen.eu/ may be at least partly due to low statistical power. to the best of our knowledge, no studies have examined whether references to emotion and cognition predict treatment outcome in both men and women. knowledge on sex differences in how parents respond to different interventions may help improve outcomes for both individual parents and their family, not least the children whose functioning is often very dependent on the psychological health of their parents (morris et al., 2012). in the present study we examined how a brief intervention of expressive writing affects the mood states of parents whose children were in the off­ therapy all phase (i.e. remission of malignant cells; interruption of radio/chemotherapy; ca. 2 years post diagnosis). we chose to focus on this phase because parents whose children were not in remission would likely be too focused on the current threat to their child to fully benefit from the intervention, yet this phase remains an extremely vulnerable period within which families begin to return to “normal” life, yet parents still feel vulnerable and may need help processing the trauma (martino et al., 2013). the present study was a pilot study implementing an expressive writing protocol in a group of parents in a very sensitive period following a serious threat to their children. the purpose was to examine sex as a moderator of the impact of expressive writing on mood states over time. we expected mothers to benefit more from the intervention than fathers. method participants participants included 10 fathers and 13 mothers whose children were at the beginning of the off-therapy remission phase being treated for acute lymphoblastic leukemia at one of italy’s leading facilities for children with neoplastic illness. the mean age was 41.5 years (sd = 5.01) for fathers and 38.2 years (sd = 5.6) for mothers. the children undergoing treatment were four boys (m = 4.25 years, sd = 0.5) and nine girls (m = 6.77 years, sd = 3.3). procedure the sample was consecutive with parents being identified from medical reports. recruit­ ment occurred through phone calls or at the hospital. parents were contacted one day after their child was confirmed to be in remission. exclusion criteria were ongoing thera­ py/interventions for symptoms related to dealing with their child’s illness. participation was voluntary and confidential based on informed written consent, and the study was approved by the hospital’s ethics committee. the gwdp protocol was used in the present studies because of the above mentioned positive results in parents of children with cancer. writing sessions lasted 30 minutes and christiansen, martino, elklit, & freda 3 clinical psychology in europe 2022, vol. 4(1), article e5533 https://doi.org/10.32872/cpe.5533 https://www.psychopen.eu/ were conducted individually in a quiet room of the hospital with only the psychologist researcher present. in the first session parents were asked to describe events as they occurred and developed over time. in the second session (10-15 days later) parents were invited to express the emotions accompanying these same events. in the final session (10-15 days later) parents were instructed to envision their future, compare their present and past feelings, consider the effects the experience has had on them, and describe how they expect to cope with future adversities. following the intervention parents were assessed for need of continued psychological support. one mother was offered and accepted additional meetings with a psychologist at the hospital. the study originally included a control group of 23 parents not undergoing a writing intervention who were invited to participate during the subsequent year. however, as the two groups differed significantly on the main outcome measure at t1, prior to inter­ vention, we unfortunately had to exclude the control group, as it would be impossible to conclude whether any potential differences between the groups were caused by the intervention or by other factors. out of a total of 20 couples whose children were diag­ nosed during 2007, seven couples and an additional three fathers declined participation, thus leaving us with 10 parental dyads and three mothers without participating partners. participants were assessed prior to the intervention (t1), 10-15 days post-intervention (t2) and at follow-up (40-45 days post-intervention (t3). measure the profile of mood states (poms) is a self-report questionnaire assessing specific affective states during the past week (mcnair et al., 1971). the test consists of 58 ad­ jectives belonging to six factors: tension–anxiety, depression–dejection, anger–hostility, vigor–activity, fatigue–inertia, and confusion–bewilderment. items are rated on a 5-point likert scale ranging from 0 (not at all) to 4 (extremely). the poms scale revealed accept­ able reliability across all three measurements (cronbach’s α > .96) and across five of the six subscales (cronbach’s α > .81). cronbach’s α was consistently low for the vigor-activ­ ity subscale and an inter-item correlation matrix revealed internal inconsistencies. thus, this subscale was excluded from all analyses. a measure of change in poms scores was calculated for later analyses (t3 scores – t1 scores) with negative scores indicating an improvement in mood states. data analyses the low number of participants (n = 23) limited the type and power of statistical analyses. therefore, the results must be considered preliminary. a significance level of p < .05 was used but to better guide future research, high and medium effect sizes are also reported regardless of statistical significance level. a t-test was also used to examine sex differences in changes in poms total and subscale scores between assessments. effect sex differences in expressive writing 4 clinical psychology in europe 2022, vol. 4(1), article e5533 https://doi.org/10.32872/cpe.5533 https://www.psychopen.eu/ sizes were calculated using cohen’s d with values of 0.2, 0.5, and 0.8 used as guidelines for small, medium, and large effect sizes, respectively. the main effect of time was examined along with the main effect of sex and the interaction effect between time and sex in a mixed methods within-between subjects anova. effect sizes were calculated using partial eta squared (ηp2) with values of .01, .06, and .14 used as guidelines for small, medium, and large effect sizes, respectively. due to the way in which data was collected and stored, it was not possible to conduct paired analysis based on parental dyads. thus, analyses of sex differences fail to take into account that paired parents affect each other and share both the child and the circumstances surrounding that child’s illness and treatment. results the mixed methods anova for mothers and fathers across all three measurements is shown in table 1a, 1b, and 1c. in accordance with the t-tests, significant large main effects of sex were found for poms total score, f(1, 21) = 7.77; p < .05; ηp2 = .27, and all subscale scores, ηp2 > .20; p < .05), except for depression-dejection (p = .07; ηp2 = .14; see table 1a). no significant main effect was found for time on poms total score despite a relatively large effect size (ηp2 = .17; see table 1b). there was, however, a significant main effect on tension-anxiety (wilk’s lambda = .70, f(2, 20) = 4.26, p < .05, ηp2 = .30). the main effects for time on the remaining subscales were all medium though non-significant (.08 < ηp2 < .20). all effect sizes indicated a decrease in poms levels from pre-treatment to follow-up. finally, the interaction effects between sex and time were all non-significant, though all except for the depression-dejection subscale had effect sizes that can be considered medium-to-large (.06 < ηp2 < .17; please see table 1c). table 1a anova: between-subjects effect – sex poms subscale f p pe 2 total 7.77 < .05 .270 tension-anxiety 7.52 < .05 .264 depression-dejection 3.63 .07 .147 anger-hostility 5.45 < .05 .206 fatigue-inertia 8.90 < .01 .298 confusion-bewilderment 21.10 < .001 .501 note. poms: profile of mood states. christiansen, martino, elklit, & freda 5 clinical psychology in europe 2022, vol. 4(1), article e5533 https://doi.org/10.32872/cpe.5533 https://www.psychopen.eu/ table 1b anova: multivariate tests – time poms subscale wilk’s λ f p pe 2 total .828 2.07 ns. .172 tension-anxiety .701 4.26 < .05 .299 depression-dejection .915 0.93 ns. .085 anger-hostility .900 1.12 ns. .100 fatigue-inertia .806 2.41 ns. .194 confusion-bewilderment .912 0.96 ns. .088 note. poms: profile of mood states. table 1c anova: multivariate tests – time * sex poms subscale wilk’s λ f p pe 2 total .887 1.28 ns. .113 tension-anxiety .835 1.97 ns. .165 depression-dejection .960 0.41 ns. .040 anger-hostility .898 1.14 ns. .102 fatigue-inertia .869 1.50 ns. .131 confusion-bewilderment .934 0.71 ns. .066 note. poms: profile of mood states. post-hoc t-tests examining the moderation effects (please see table 2) revealed that mothers reported a higher average decrease in poms scores (m = -20.46, sd = 54.43) compared to fathers (m = -6.20, sd = 8.04) from t1 to t3, though the effect size was small and non-significant (cohen’s d = .37). the main decrease in poms levels in mothers occurred during the intervention (m = -21.54) with little additional change occurring afterwards (m = -1.08; see table 2). this difference was much smaller in fathers (m = -4.7 vs. m = -1.5). though independent t-tests examining sex differences in the decrease in poms scores at each step were non-significant, a large effect size was found comparing the decrease in poms scores during the intervention (d = .54) but not subsequently (d = .23). these sex differences were not significant for any of the subscales and could only be considered medium for the tension-anxiety subscale (d = 0.70). most participants (78%) experienced some decrease in their poms scores over the course of writing. however, 10.0% of fathers and 30.8% of mothers reported some increase in poms scores from t1 to t3. sex differences in expressive writing 6 clinical psychology in europe 2022, vol. 4(1), article e5533 https://doi.org/10.32872/cpe.5533 https://www.psychopen.eu/ table 2 poms total and subscale scores at baseline and over time poms total score m (sd) t p dall f m poms total scores poms total t1 52.61 (39.15) 27.80 (25.02) 71.69 (37.86) 3.16 < .05 1.37 poms total t2 38.39 (34.41) 23.10 (22.43) 50.15 (38.06) 1.99 .060 0.87 poms total t3 38.35 (38.64) 21.60 (20.06) 51.23 (44.97) 2.12 < .05 0.85 change from t1 to t3 poms total -14.26 (41.17) -6.20 (8.04) -20.46 (54.43) 0.93 ns. 0.37 tension-anxiety -4.91 (8.05) -2.00 (3.56) -7.15 (9.84) 1.75 ns. 0.70 depression-dejection -3.52 (14.21) -1.90 (1.79) -4.77 (19.08) 0.54 ns. 0.21 anger-hostility -2.22 (9.26) -1.00 (2.05) -3.15 (12.32) 0.62 ns. 0.24 fatigue-inertia -2.43 (6.06) -1.40 (1.35) -3.23 (8.02) 0.81 ns. 0.32 confusion-bewilderment -1.17 (5.16) 0.10 (1.29) -2.15 (6.72) 1.18 ns. 0.47 note. f = fathers; m = mothers. t, p, and cohen’s d all relate to sex differences. poms = profile of mood state. t1: prior to therapy; t2: at the end of therapy: t3: at follow-up. discussion as the present study was a pilot study, the most relevant finding was that the implemen­ tation of the emotional writing procedure in this clinical setting was successful. that significant sex differences were found despite low statistical power highlights the impor­ tance of taking sex into account in intervention studies. several of the non-significant effects could be considered moderate or even strong, indicating that type ii error due to small sample size may have disguised further significant findings. mothers reported sig­ nificantly more negative mood states than fathers. it is possible that mothers were more negatively affected by their child’s illness, as indicated by prior research (christiansen, 2017; clarke et al., 2009). another possibility is that these findings may just reflect sex differences in everyday mood. although there was no significant main effect of time, the effect size was quite large for poms total scores, and medium-to-large effect sizes were found for all five poms subscales. without a control group, it is unknown whether the apparent improvements in mood profiles were caused by the intervention or simply by the passing of time. however, mothers showed a much steeper decline in symptom scores from t1 to t2 than from t2 to t3. this decline was larger in mothers than in fathers during the intervention, whereas there was no difference between the two sexes in changes in mood states occurring from the end of the intervention until follow-up. this may suggest that, at christiansen, martino, elklit, & freda 7 clinical psychology in europe 2022, vol. 4(1), article e5533 https://doi.org/10.32872/cpe.5533 https://www.psychopen.eu/ least in mothers, some of the changes were caused by the writing intervention. accord­ ingly, although the interaction between time and sex was statistically non-significant, the medium-to-large effect sizes found for both poms total score and all but one of the subscale scores suggests that future studies may reveal women to benefit more from expressive writing interventions than men. though preliminary, our findings highlight the importance of including sex as a moderator in treatment studies. though not shown here, analyses using the linguistic inquiry and word count software (liwc) (pennebaker et al., 2007; freitag et al., 2011; freda & martino, 2015) found that mothers focused more on affect during writing sessions than fathers, includ­ ing both positive and negative emotions (analyses may be obtained from corresponding author). this is in accordance with findings from prior studies (newman et al., 2008; thomson & murachver, 2001). ogrodniczuk (2006) suggested that women’s willingness to self-disclose and express emotion make them better patients and help them benefit more from therapy. perhaps the socialization processes that cause women to share emotional content with others more easily than men make them more prepared to benefit from interventions focusing on emotional processing. another possibility is that women’s stronger inclination to seek treatment (christiansen, 2015; ogrodniczuk, 2006) makes them generally more prepared than men to put in the effort needed for it to be successful. though the present study was not based on a treatment-seeking sample, mothers were more likely than fathers to agree to participate, so a similar phenomenon may be present in this sample. whereas it is possible that mothers’s scores simply declined more because they were higher from the beginning, thus leaving more room for improvement, this would also be the case from the end of treatment to follow-up where no additional change occurred. this may suggest that the decrease was in fact caused by the writing intervention, but due to the unfortunate exclusion of the control group, there is no way of knowing for sure. finally, it is important to note that four of the mothers and one father experienced an increase in symptoms over the course of the writing intervention. thus, whereas mothers on average benefitted more, they also appear more likely to get worse over time. as the poms measure was not directly linked to the child’s illness and only assessed mood states during the past weeks, the increased poms scores may have been caused by new chronic or temporary stressors, independently of the intervention. however, such findings does serve as a reminder that when evaluating the benefits of any intervention, we must focus both on overall gains and on potential detrimental individual effects. sex differences in intervention outcomes is of great importance to both scientists and clinicians, and implementing these into treatment and intervention designs may increase the benefits of these for both men and women presenting with a variety of symptoms, thus reducing the great societal and personal costs associated with ineffective interventions (christiansen, 2017; donner & lowry, 2013). knowledge about both sex and gender and how they influence intervention outcomes should be implemented in sex differences in expressive writing 8 clinical psychology in europe 2022, vol. 4(1), article e5533 https://doi.org/10.32872/cpe.5533 https://www.psychopen.eu/ research on different types of psychotherapy to a much greater degree than what is cur­ rently being done (bekker & van mens-verhulst, 2007; christiansen, 2015; christiansen & berke, 2020; christiansen & elklit, 2012). whereas the results of the present study are preliminary and cannot in and of themselves be used as evidence of sex differences in the therapeutic effects of expressive writing and emotional processing in general, it is our great hope that it may increase focus on the importance of considering sex differences in the impact of psychotherapy and psychological interventions. in terms of clinical implications, taking sex differences into account when designing and selecting interventions for parents of critically ill children may help reduce symptom levels for both mothers and fathers and in turn improve quality of life for the whole family. strengths and limitations beyond showing the feasibility of such an intervention in a sensible clinical environ­ ment, the primary strength of this study is the specific focus on sex as a potential moderator of intervention outcome. however, the fact that the study was not originally designed with this in mind, thus failing to ensure sufficient power for detecting signifi­ cant effects, severely limits the conclusions. the exclusion of the control group due to significant pre-treatment differences in poms scores severely limits the results, as we were not able to conclude whether the reductions in poms scores over time were in fact caused by the intervention. further, low sample size of this pilot trial only allows cautious interpretation of results. finally, the inability to match mothers and fathers into parental dyads forced us to treat the two sexes as independent groups, thereby making our results vulnerable to certain biases, 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(2001). predicting gender from electronic discourse. british journal of social psychology, 40(2), 193–208. https://doi.org/10.1348/014466601164812 christiansen, martino, elklit, & freda 11 clinical psychology in europe 2022, vol. 4(1), article e5533 https://doi.org/10.32872/cpe.5533 https://doi.org/10.1093/fampra/19.2.161 https://doi.org/10.1002/pon.3543 https://doi.org/10.6092/2282-1619/2019.7.2049 https://doi.org/10.5964/ejop.v12i4.1150 https://doi.org/10.1177/1359105312462434 https://doi.org/10.1093/jpepsy/jss091 https://doi.org/10.1080/01638530802073712 https://doi.org/10.1080/10503300600590702 https://doi.org/10.1177/0261927x09351676 https://doi.org/10.1348/014466601164812 https://www.psychopen.eu/ wade, d., varker, t., kartal, d., hetrick, s., o’donnell, m., & forbes, d. (2016). gender difference in outcomes following trauma-focused interventions for posttraumatic stress disorder: systematic review and meta-analysis. psychological trauma: theory, research, practice, and policy, 8(3), 356–364. https://doi.org/10.1037/tra0000110 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. sex differences in expressive writing 12 clinical psychology in europe 2022, vol. 4(1), article e5533 https://doi.org/10.32872/cpe.5533 https://doi.org/10.1037/tra0000110 https://www.psychopen.eu/ sex differences in expressive writing (introduction) method participants procedure measure data analyses results discussion strengths and limitations (additional information) funding acknowledgments competing interests references premature dropout from psychotherapy: prevalence, perceived reasons and consequences as rated by clinicians research articles premature dropout from psychotherapy: prevalence, perceived reasons and consequences as rated by clinicians niclas kullgard 1 , rolf holmqvist 1 , gerhard andersson 1,2,3 [1] department of behavioural sciences and learning, linköping university, linköping, sweden. [2] department of biomedical and clinical sciences, linköping university, linköping, sweden. [3] department of clinical neuroscience, karolinska institute, stockholm, sweden. clinical psychology in europe, 2022, vol. 4(2), article e6695, https://doi.org/10.32872/cpe.6695 received: 2021-05-07 • accepted: 2022-01-16 • published (vor): 2022-06-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: niclas kullgard, department of behavioural sciences and learning, linköping university, se-581 83 linköping, sweden. tel.: +46-705-789848. e-mail: niclas.kullgard@liu.se abstract background: why clients discontinue their psychotherapies has attracted more attention recently as it is a major problem for many healthcare services. studies suggest that dropout rates may be affected by the mode of therapy, low-quality therapeutic alliance, low ses, and by conditions such personality disorders or substance abuse. the aims of the study were to investigate what happens in therapies which end in a dropout, and to estimate how common dropout is as reported by practicing clinicians. method: an online questionnaire was developed and completed by 116 therapists working in clinical settings. they were recruited via social media (facebook and different online psychotherapy groups) in sweden and worked with cognitive behavioural therapy (cbt), psychodynamic therapy (pdt), interpersonal psychotherapy (ipt) and integrative psychotherapy (ip). results: psychotherapists rated the frequency of premature dropout in psychotherapy to be on average 8.89% (md = 5, sd = 8.34, range = 0-50%). the most common reasons for a dropout, as stated by the therapists, were that clients were not satisfied with the type of intervention offered, or that clients did not benefit from the treatment as they had expected. the most common feeling following a dropout was self-doubt. conclusion: in conclusion, premature dropout is common in clinical practice and has negative emotional consequences for therapists. premature dropout may lead to feelings of self-doubt and powerlessness among therapists. the therapeutic alliance was mostly rated as good in dropout this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6695&domain=pdf&date_stamp=2022-06-30 https://orcid.org/0000-0002-2445-0079 https://orcid.org/0000-0003-2093-2510 https://orcid.org/0000-0003-4753-6745 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ therapies. further research is needed to validate the findings with data on the prevalence and subjective reasons behind a dropout from point of view of clients. keywords premature dropout, psychotherapy dropout, psychotherapy, therapeutic alliance highlights • the dropout rate was estimated to 8.89% by the therapists in this study. • the psychotherapists believe that reasons as to dropout was that clients were not satisfied with interventions in therapy. • the most common feeling following a dropout was self-doubt. • the therapeutic alliance was generally rated as good in therapies resulting in dropout. dropout from psychotherapy has been defined as “termination of the treatment without fulfilment of the therapeutic goals, without attainment of the full therapeutic benefit that would have been possible with normal termination of the therapy or without completion of the full scope of the therapy” (swift & greenberg, 2012). there is a significant amount of variation on how to operationalize dropout, for example when it is meaningful to use dropout as a description of what happened in a therapy (garfield, 1994; hatchett & park, 2003; swift et al., 2009; swift & greenberg, 2012). one way to operationalize dropout is to consider anyone who do not attend a special number of sessions as a dropout. the idea is that clients need to attend a minimal number of sessions in order to improve (lambert, 2007). another operationalization is failure to complete a specific treatment protocol. in this definition anyone who fails to complete a full treatment protocol is considered a dropout. a third operationalization is based on missed sessions. this approach suggests that anyone who misses or fails to reschedule sessions is considered a dropout. another fourth approach is to let the therapist decide if the client has prematurely dropped out or not. a final approach is to define a dropout when a client terminates prior to a reliable improvement has occurred and prior to obtaining an outcome score within the normal range (hatchett & park, 2003). there are both positive and negative aspects of all these operationalizations. while number of sessions, missed sessions and failure to follow a treatment protocol are relatively easy to assess they do not say anything about actual change or improvement. it is problematic to classify a client as a dropout when attending few sessions and showing major improvement when a client who attends all scheduled sessions but do not engage in the therapy and show no improvement will not be defined as a dropout. when using therapists’ judgement there is a considerable risk that the judgment is biased or even flawed (garb, 2005; grove et al., 2000). despite numerous studies there is no consensus regarding the definition of dropout. for example, as mentioned it is possible to drop out from a therapy while still reaching the treatment goals. the term premature dropout from psychotherapy 2 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ premature suggests that the therapy is terminated before the goals of the treatment are obtained. while there are premature terminations of therapy that are agreed upon, not turning up and ending therapy without explanation or any notice can be a major problem. for example, clients may not get the treatment they need, and therapists and services are disrupted (for example when trying to locate the client). in a meta-analysis of 125 psychotherapy studies, wierzbicki and pekarik (1993) estimated that about 47% of the therapies resulted in a unilateral dropout. however, swift and greenberg (2012) reported dropout rates across methods and disorders at approximately 19.7%, and unilateral drop­ outs ranged between 0 to 74% (m = 19.7%) (swift & greenberg, 2012, 2014). most studies included in these reviews were clinical trials on adult clients who were participants in studies in which both clients and methods had been carefully selected. thus, there may be differences in reasons behind dropout in therapies conducted in clinical practice and in clinical trials depending on the definition of dropout or the context (for example interviews, questionnaires, videorecording, compliance to a specific method or manual) often present in clinical trials. psychotherapy in clinical practice more often includes patients that would not be included in clinical trials depending on multiple psychiatric diagnosis, psychosocial problems or other problems that excludes them from clinical trials. effects of premature dropouts premature dropout has been associated with a range of negative effects for both clients and therapists. in clinical trials, dropouts tend to report more dissatisfaction (björk et al., 2009; knox et al., 2011; kokotovic & tracey, 1987) and poorer treatment outcomes (cahill et al., 2003; klein et al., 2003; lampropoulos, 2010; pekarik, 1983, 1992; swift et al., 2009), compared with therapy completers. therapists are likely to experience loss of revenue (i.e., in private practice), and a sense of failure or demoralization when clients prematurely drop out (barrett et al., 2008; ogrodniczuk et al., 2005; piselli et al., 2011). factors related to premature dropout the therapeutic alliance has consistently been associated with outcome in psychotherapy (horvath et al., 2011; lambert & barley, 2002; safran et al., 2014). research commonly shows that a strong alliance is related to better outcomes (bickman et al., 2012; flückiger et al., 2018; spinhoven et al., 2007; zuroff & blatt, 2006), and that a weak alliance is related to dropout (barrett et al., 2008; sharf et al., 2010). some meta-analyses show sig­ nificant correlations between repairing ruptures in the therapeutic alliance and therapy outcome measured either as therapy completion, premature dropout or as change on symptoms measures (eubanks et al., 2018; safran et al., 2011; safran et al., 2014). more­ over, the ability to manage behavioural, cognitive, somatic, and affective reactions during psychotherapy (related to the therapist’s own unresolved emotional stressful events or kullgard, holmqvist, & andersson 3 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ themes during therapy) may also influence psychotherapy process and outcome. the ability to manage and potentially use own reactions to “what happens during psycho­ therapy” – for example if the therapist has dealt with his/her own negative experiences and are aware of them may increase the ability to effectively help the client (hayes et al., 2011; hayes et al., 2018). overall, the proportion of dropout reported in different studies is related to the definition of dropout, and since there is no consensus on the definition comparisons on rates is difficult. however, the literature suggests that dropout is common, has negative effects on clients and their therapists, and that a poor therapeutic alliance may increase the risk of a premature dropout. the aim of this study was to investigate how common premature dropout is in clinical practice, to analyse perceived reasons behind a dropout, the role of therapeutic alliance and feelings associated with dropouts. psychotherapists working with different orientations, target groups, and in different settings completed an online survey with the aim to reach a broad sample. method procedure the study was conducted online using an anonymous questionnaire during 2 months in the spring of 2020. the study was announced via social media (facebook), email to employees at two outpatient psychiatric clinics and networks for psychotherapists. in sweden, where the study was conducted, almost all practicing clinicians have regular internet access. in total 594 persons accessed the website, and, of those, 116 persons (19.5%) completed the whole questionnaire. data analysis the data from the survey were prepared with spss statistics version 26. means (m), medians (mdn), standard deviations (sd) and ranges were calculated. anovas were calculated to investigate differences between means. nominal data were compiled and descriptive measures such as percentages were calculated. participants participants were psychotherapists from different professional backgrounds. they had at least basic psychotherapy training (which in sweden is 3 years) and used psychothera­ peutic methods in their work. participation was anonymous and no data was collected that could be used to identify the participant. of the 116 psychotherapists who partici­ pated, 83 were female (70.9%). they had worked as psychotherapists for an average of 10.51 years (sd = 7.91). the professional background of the participants was: clinical premature dropout from psychotherapy 4 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ psychologists (n = 67; 57.8%), social workers (n = 28; 24.1%), nurses (n = 4; 3.4%), medical doctors (n = 1; 0.9%) and other (n = 16; 13.8%). regarding the therapists’ main methodological orientation, the following distribution was obtained (multiple answers were possible): cognitive behavioural therapy (cbt) (n = 99; 84.6%), psychodynamic psychotherapy (pdt) (n = 47; 40.2%), interpersonal psychotherapy (ipt) (n = 19; 16.2%), family therapy (ft) (n = 11; 9.4%), humanistic/existential psychotherapy (n = 7; 6%) and 20 (n = 20; 17.1%). see table 1 for further description of the participants. table 1 background data of the participating psychotherapists (n = 117) variables n (%) gender (female) 83 (70.9%) age in profession m = 10.51 years profession psychologists 67 (57.8) social workers 28 (24.1) nurses 4 (3.4) medical doctors 1 (0.9) others 16 (13.8) workplace public sector (primary care) 46 (39.6) public sector (psychiatry) 43 (37.1) private sector (psychiatry) 11 (9.4) private sector (primary care) 13 (11.2) private practice 31 (26.7) other 6 (5.2) age group children (0-13 years) 14 (12.1) youths (14-18 years) 21 (18.1) young adults (18-25 years) 35 (30.2) adults (18-65 years) 97 (83.6) older adults (65 years-) 14 (12.1) psychotherapeutic orientation cognitive behaviour therapy (cbt) 99 (84.6) psychodynamic therapy (pdt) 47 (40.2) interpersonal psychotherapy (ipt) 19 (16.2) other 21 (17.9) kullgard, holmqvist, & andersson 5 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ measures a brief questionnaire was developed for use in the present study. the questionnaire was developed in discussion with clinicians, by consulting the literature on dropout and the therapeutic relationship in psychotherapy. to increase the content validity, the questionnaire was piloted with 6 colleagues, all licensed clinical psychologists, and researchers in clinical psychology. they filled out the questionnaire individually which was followed by a discussion which resulted in some adjustments and clarifications. the final questionnaire started with this definition: the aim of this study is to explore psychotherapists’ clinically based opinion of the frequency of dropouts in psychotherapy and, also their feelings prior to and after a dropout. our definition of dropout is “when a client stops coming to an agreed and started psychother­ apy without notice.” the initial part of the questionnaire consisted of 6 items on generic information regard­ ing gender, years of working with psychotherapy, primary age group in the work, type of organization, professional background and use of psychotherapeutic methods. the scales were made as nominal variables where the most common professional back­ grounds, organizations and most used psychotherapeutic methods were specified as single response options. there was also an open-ended alternative to capture alternatives that were not specified. the participants were asked to estimate the dropout rate in their therapies, based on our definition of a premature dropout, as a percentage of their total number of psychotherapies. in the next section participants were asked why they believed a typical dropout had occurred, their own feelings during the therapy and after the dropout. further, feelings before and after the dropout were derived from a feeling checklist used in psychotherapy process research (lindqvist et al., 2017). there were 20 different feelings which were rated on a five-point likert-scale ranging from 1 (‘not very important for me’) to 5 (‘very important to me’). in the next part, the therapeutic alliance was rated with three items (task, goal, and emotional bond). these items were rated on a three-point likert-scale from 1 (‘bad’) to 3 (‘very good’). further the participants rated if they had suspected that the clients would drop out. the rating was made on a five-point likert-scale ranging from 1 (‘not very important for me’) to 5 (‘very important to me’). finally, questions regarding discussing the suspicion of a potential dropout with someone (yes/no/don’t know) and in that case with whom (e.g. supervisor, colleague, friend, partner), and lastly if they had received the support they needed in psychotherapy supervision. the time for filling out the form was approximately 15 minutes. premature dropout from psychotherapy 6 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ results the average estimated dropout-rate, defined as the percentage of the total number of psychotherapies during the last two years was 8.89% (mdn = 5, sd = 8.34, range = 0–50%). we conducted an anova-analysis to test if there were any differences regard­ ing the estimated dropout rate between cbt, pdt, ipt and eclectic therapy and no differences were found, all p-values were above p > .11. ratings in the survey done with questions on likert-scales generally generated responses in the middle of the scales, as measured by median. few therapists rated in the top end of the scales (4 or 5). the views among the therapists were primarily that dropout depended on the clients, by for example not wanting to do specific interventions or not responding to certain interventions. reasons for dropout table 2 shows the therapist’s ratings of reasons for dropout (in the order of highest rating first). table 2 therapists’ ratings of reasons for dropout variables m mdn sd the client did not want to do specific interventions related to the method. 3.08 3 1.10 the client did not “respond” to the intervention. 2.99 3 1.25 it seemed like the client did not believe that the method would help. 2.92 3 0.10 the client was in a difficult psychosocial situation. 2.79 3 1.21 the client had difficulties in the attachment with me (the therapist). 2.61 3 1.04 we had a weak emotional bond. 2.55 2 1.05 the client was discontent with me (the therapist). 2.47 2 0.90 the client had too complex psychological problems. 2.43 2 1.15 the therapy had low effect. 2.41 2 0.92 it was the wrong method for the problem. 2.38 2 0.92 we disagreed about the goals with the therapy. 2.31 2 0.97 i think we had too few sessions for our disposal. 2.28 2 1.32 i thought that the client was too difficult. 2.20 2 0.11 i (the therapist) had difficult to attach to the client. 2.08 2 0.92 it was the client’s age. 1.69 1 0.94 the client used drugs. 1.65 1 1.06 the client started another psychotherapy. 1.39 1 0.87 note. n = 107. instruction: think of a typical dropout, what do you think it was related to? (mark one or several alternatives (1 not important and 5 very important). kullgard, holmqvist, & andersson 7 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ when using mean as measure the most common reason for a dropout was that the client did not want to perform the intervention, respond to it, or did not believe in it. the lowest ratings were reasons for dropout related to clients age, clients using drugs or had started another therapy. emotions related to dropout the therapists were asked to rate their feelings during the therapy and after the dropout. table 3 shows the rating of feelings during therapy as indicated by the therapists. table 3 rating of feelings during therapy as indicated by the therapists variables m mdn sd interested 2.94 3 0.67 calm 2.52 3 0.72 energetic 2.31 2 0.76 insecure 2.28 2 0.81 sceptical 2.13 2 0.84 powerless 2.07 2 0.82 content 2.01 2 0.68 irritated 2.01 2 0.78 worried 1.97 2 0.77 tired 1.96 2 0.85 neutral 1.94 1 0.86 disappointed 1.93 2 0.73 tense 1.90 2 0.84 surprised 1.84 2 0.79 shame 1.70 2 0.78 overwhelmed 1.62 1 0.81 relieved 1.58 1 0.67 bored 1.54 1 0.72 angry 1.54 2 0.69 note. n = 107. instruction: if you think of the same therapy, which of the following emotions did you experience during therapy, as you remember it? for example “i felt…..” (1 not important and 4 very important). mark one or several feelings. feelings with the highest mean reported by the therapists during therapy were interes­ ted, calm, and energetic. feelings with the lowest mean were relieved, bored, and angry. in table 4, the therapists’ feelings following a dropout are presented. the feelings with highest mean after dropout was self-doubt, being touched and powerless. feelings with lowest mean were satisfied, overwhelmed, and bored. premature dropout from psychotherapy 8 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ table 4 therapists’ feelings following a dropout variables m mdn sd self-doubt 2.79 3 1.04 touched 2.66 3 1.01 powerless 2.61 2 1.13 disappointed 2.52 2 0.96 calm 2.38 2 1.12 surprised 2.22 2 1.08 annoyance at the client 2.13 2 0.87 doubt regarding my method 2.12 2 1.06 annoyance at myself 2.10 2 1.03 guilt 2.10 2 1.06 relieved 1.96 2 0.94 worried 1.93 2 1.00 shame 1.92 2 0.96 neutral 1.73 1 0.98 indifference 1.39 1 0.72 satisfied 1.39 1 0.66 overwhelmed 1.37 1 0.78 bored 1.28 1 0.69 note. n = 107. instruction: what did you feel after the dropout? i felt…. mark one or several options. (1 not important and 5 very important). therapeutic alliance and dropout the therapeutic alliance with the client who dropped out in mind was rated by the therapists using an ordinal scale with three response options (bad, good, very good). ratings of alliance in association with a dropout therapy are presented in table 5. table 5 ratings of alliance in association with a dropout therapy items low good very good m mdn sd the task of the therapy 32% 55% 13% 1.81 2 0.65 the goal in the therapy 26% 64% 10% 1.84 2 0.58 emotional bond in the therapy 33% 55% 12% 1.79 2 0.64 note. n = 107. instruction: afterwards, how would you rate the therapeutic alliance between you and the client who dropped out? (rate between 1-3 were 1 is low and 3 is very good). kullgard, holmqvist, & andersson 9 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ all three dimensions (task, goal, and bond) of the alliance were generally rated as good, with few (10-13%) stating that it was very good. one third rated the alliance in all three dimensions as low. there was no significant difference between the different aspects of the therapeutic alliance, f(2, 105) = .24, n.s.). support from others regarding suspicions about dropout regarding the question if the therapists had suspected the dropout during therapy, 24% did not suspect dropout while 76% had suspected dropout. about one fourth (23%) of the therapists had talked with their clients about their suspicions, 37% of the therapists did not talk to the client and 40% did not remember. about 59% of the therapists had talked to a supervisor or a colleague when they suspected that their client would drop out. only one third (30%) felt that they had received support. discussion one aim of this study was to explore the extent of premature dropout in clinical practice as rated by therapists. the estimated dropout for the last two years was 8.89%. the results indicate that in clinical practice the dropout-rate, as defined in this study, is lower than in earlier studies in which the estimated dropout-rate has been 20% or higher (swift & greenberg, 2014). as mentioned in the introduction, wierzbicki and pekarik (1993) estimated the dropout-rate to be 47% based on 125 studies, whereas swift and greenberg (2012) reported a dropout rate of 19.7% in their meta-analytic study of 669 research studies. it is important to note that these discrepancies most likely depend on the difference in definition of dropout used in studies and reviews. regarding studies on differences between psychotherapy orientations a significant difference has been reported in depression studies in which cbt was found to result in more dropouts than other therapies (cuijpers et al., 2008). swift and greenberg (2014) reported that that there may be differences between psychotherapies related to diagnosis and that depression, eating disorders and ptsd may be associated with differential dropout rates. these differences were not investigated in our study, but we cannot exclude that the sample we obtained and the groups of clients and/or psychotherapy method the therapists worked with influenced the estimated dropout rate. information about the proportion of dropout in regular clinical practice seems to be scarce. cinkaya (2016), in a study on outpatients in germany, reported that patients with personality disorder were most likely to drop out whereas patients with depression, somatoform, and anxiety disorder were less likely to drop out. although the estimation done by the therapists in this study could be biased and uncertain, our findings is relevant for the understanding of how common dropout is in clinical practice. premature dropout from psychotherapy 10 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ overall, some prior studies have reported substantially higher dropout rates than we found in this study. there are some possible explanations. first, we used a definition that leaves out agreed upon terminations that would have been regarded as dropouts in research studies. another possibility, again referring to the difference between research studies and clinical settings, it that the length of a therapy and the demands on the client may be more flexible in clinical settings than in research studies in which for example the number of therapy sessions tend to be tied to treatment manuals. however, this does not mean that the figure we found is low. if almost one out of ten client dropout without any discussion or agreement it is still a problem in clinical settings both for the client and the service provider. our study explored reasons and feelings related to a typical premature dropout and the perception of the therapeutic alliance in such therapies. based on means, the three most common emotions during therapy were interested, calm, and insecure. after the dropout the three most common emotion were self-doubt, touched and powerlessness. our results indicate that premature dropouts affect the therapists negatively. after premature dropout therapists tend to feel self-doubt and experience emotions like powerlessness. on the other hand, the most common reasons for dropout stated by the therapists were that the client did not want to perform the intervention, respond to it, or did not believe in it. it appears as if the therapists blame themselves emotionally but rationally blame the client. another explanation might be that therapists do not manage to convince their client of about the ways in which they are supposed to work in therapy and therefore feel powerless in relation to what they are supposed to do in therapy, agreement about goals in therapy, or own conviction about what is best for the client. overall, the therapists rated the therapeutic alliance as good. approximately 30% rated the alliance as low regarding agreement on tasks and the emotional bond, and 26% rated the alliance as regarding goal. the result is a bit puzzling because it would be expected that maybe a higher percentage would rate the alliance as low or weak. as mentioned in the introduction, research has consistently showed that a strong alliance is related to good outcomes (bickman et al., 2012; spinhoven et al., 2007; zuroff & blatt, 2006), and that a weak alliance is related to dropout (barrett et al., 2008; sharf et al., 2010). some meta-analysis showed a significant correlation between repairing the alliance and therapy outcome (safran et al., 2011; safran et al., 2014), which we did not study but could be important to investigate in relation to dropout in future research. another possibility would be to investigate ruptures in the alliance, which also have been associated with treatment outcome (larsson et al., 2018). in a micro-analysis of sessions before a dropout more withdrawal alliance ruptures were observed (gülüm et al., 2018). findings also suggested that both therapists and clients decreased the pace of work and engaged in less exploration during the sessions before the dropout (gülüm et al., 2018). our findings correspond with these findings as approximately 30% rated the alliance as low and suspected a dropout. the fact that they mostly did not talk to kullgard, holmqvist, & andersson 11 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ the client suggests a withdrawal pattern in the therapeutic alliance. nissen-lie et al. (2017) found that when therapists actively help clients deal with clinical problems by exercising reflexive control and problem solving, it was associated with positive change while avoiding problems was associated with less change. it seems reasonable to assume that when clients dropout, they do so because they experience that they are not getting the help they hoped for or do not have enough trust in the therapist being able to be helping them sufficiently. the therapists provided the highest ratings for the following reasons: a) the client did not want to engage in or respond to specific interventions, b) the clients did not seem to believe that the method would help them. the discrepancy between what therapists reported as reasons for the dropout and their own feelings during therapy suggests that the client and the therapist have different experiences related to therapy. one example of this would be that the therapist is interested and eager to help but the client do not want to engage in or even resists interventions. it is likely that relational strains, which may be interpreted as a rupture in the therapeutic alliance, affects therapy negatively. if the rupture is not articulated there may be a silent withdrawal rupture in the therapeutic alliance, it may also be that psychological mecha­ nisms (for example countertransference or avoidant coping) may be involved without the therapist necessarily being aware of it and still communicating these sentiments in the therapy. another possibility in terms of psychological mechanisms is when we suspect that a client will leave therapy and this suspicion triggers anxiety about being inferior, being left in other relationships, not being “good-enough”, a failure or other signs of downgrading our competence or even ourselves as persons. thoughts and emotions like this are hard to verbalize and therapists may hesitate to reveal to the client that that he/she suspect that the client will leave the therapy. our findings showed that a majority suspected premature drop out but only 23% of the therapists had communicated about their suspicions with the client. it seems like many therapists suspect a dropout, but do not communicate their suspicions. limitations and strengths the study has several limitations. first, the recruitment of therapists was done on the internet via facebook, email to psychiatric outpatient clinics and different psychotherapy networks. this narrowed down the sample to persons frequently using the internet (e.g. social media and online networks) and could be reached. even if the sample was limited by the number of persons who could answer the questionnaire, we still believe we reached a fairly broad sample and that many currently active psychotherapists use the internet and social media. using a postal survey or telephone interview could possibly lead to different estimates and findings even if we doubt there would be major discrepan­ cies. further, although we asked the therapists to think of a particular premature dropout it is difficult to know if the answers reflect a single dropout or if they rather mirror general opinions related to non-agreed premature dropouts. it can be hard to remember premature dropout from psychotherapy 12 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://www.psychopen.eu/ specific emotions or what was going on in hindsight, and we cannot exclude memory bias and selective reporting. cuijpers et al. (2015) also showed that there were differences in how dropout had been defined which makes it difficult to interpret the findings. some strengths with our study are that we measured what therapists clinically en­ counter in association with dropouts. further, the observation that clients drop out fairly often most likely reflects what occurs in a typical clinical setting and adds information to what is already known regarding research and educational settings for psychotherapy where most studies regarding estimated dropout rates have been conducted. finally, the respondents were from different organizations, used therapeutic methods and had varied work experience as therapists. future research this study indicates that there are discrepancies in the number of premature dropouts observed in clinical settings, research studies, and studies made in psychotherapy educa­ tion settings. however, the number of people in the general population who have an experience of premature dropout from psychotherapy is to our knowledge not known and could be investigated as was done long ago with regards to therapy experiences in the consumers report study (seligman, 1995). it is reasonable to assume that there are different reasons behind premature dropouts. to investigate reasons for premature dropout it will be vital to ask clients about their reasons for terminating therapy. to further investigate therapists’ views on the impact of dropout, interviews or focus groups are possible methods to obtain a deeper understanding of processes related to dropout. by analysing video clips of therapy session in which clients subsequently dropout, one could gain a deeper understanding the reasons for and the process of dropout. funding: this study was sponsored in part by linköping university. acknowledgments: we thank webmaster george vlaescu for his help with the survey. competing interests: the authors have declared that no competing interests exist. references barrett, m. s., chua, w.-j., crits-christoph, p., gibbons, m. b., casiano, d., & thompson, d. 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(2006). the therapeutic relationship in the brief treatment of depression: contributions to clinical improvement and enhanced adaptive capacities. journal of consulting and clinical psychology, 74(1), 130–140. https://doi.org/10.1037/0022-006x.74.1.130 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. premature dropout from psychotherapy 16 clinical psychology in europe 2022, vol. 4(2), article e6695 https://doi.org/10.32872/cpe.6695 https://doi.org/10.1080/00107530.2014.880318 https://doi.org/10.1037/0003-066x.50.12.965 https://doi.org/10.1037/a0021175 https://doi.org/10.1037/0022-006x.75.1.104 https://doi.org/10.1037/a0017003 https://doi.org/10.1037/a0028226 https://doi.org/10.1037/a0037512 https://doi.org/10.1037/0735-7028.24.2.190 https://doi.org/10.1037/0022-006x.74.1.130 https://www.psychopen.eu/ premature dropout from psychotherapy (introduction) effects of premature dropouts factors related to premature dropout method procedure data analysis participants measures results reasons for dropout emotions related to dropout therapeutic alliance and dropout support from others regarding suspicions about dropout discussion limitations and strengths future research (additional information) funding acknowledgments competing interests references effect of cultural adaptation of a smartphone-based self-help programme on its acceptability and efficacy: randomized controlled trial research articles [registered report] effect of cultural adaptation of a smartphone-based self-help programme on its acceptability and efficacy: randomized controlled trial eva heim 1 , sebastian burchert 2 , mirëlinda shala 3 , anna hoxha 4, marco kaufmann 5 , arlinda cerga pashoja 6,7 , naser morina 8 , michael p. schaub 9 , christine knaevelsrud 2 , andreas maercker 4 [1] institute of psychology, university of lausanne, lausanne, switzerland. [2] department of education and psychology, division of clinical psychological intervention, freie universität berlin, berlin, germany. [3] department of economics, lucerne university of applied sciences and arts, lucerne, switzerland. [4] department of psychology, university of zurich, zurich, switzerland. [5] epidemiology, biostatistics and prevention institute, university of zurich, zurich, switzerland. [6] faculty of population health, london school of hygiene and tropical medicine, london, united kingdom. [7] st marys university, twickenham, london, united kingdom. [8] department of consultation-liaison psychiatry and psychosomatic medicine, university hospital of zurich, university of zurich, zurich, switzerland. [9] swiss research institute for public health and addiction, zurich, switzerland. clinical psychology in europe, 2024, vol. 6(2), article e2743, https://doi.org/10.32872/cpe.2743 study plan received: 2020-02-06 • study plan accepted (ipa): 2020-07-17 • full paper received: 2023-09-12 • full paper accepted: 2024-03-20 • published (vor): 2024-06-28 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: eva heim, university of lausanne, institute of psychology, géopolis, bureau 4114, 1015 lausanne, switzerland. phone: +41 (0)21 692 31 75. e-mail: eva.heim@unil.ch supplementary materials: preregistration [see index of supplementary materials] abstract background: research on cultural adaptation of psychological interventions indicates that a higher level of adaptation is associated with a higher effect size of the intervention. however, direct comparisons of different levels of adaptations are scarce. aims: this study used a smartphone-based self-help programme called step-by-step (albanian: hap-pas-hapi) for the treatment of psychological distress among albanian-speaking immigrants in switzerland and germany. two levels of cultural adaptation (i.e., surface vs. deep structure adaptation) were compared. we hypothesised that the deep structure adaptation would enhance the acceptance and efficacy of the intervention. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.2743&domain=pdf&date_stamp=2024-06-28 https://orcid.org/0000-0001-7434-7451 https://orcid.org/0000-0003-3126-5485 https://orcid.org/0000-0001-6997-467x https://orcid.org/0000-0002-4810-7734 https://orcid.org/0000-0002-7029-947x https://orcid.org/0000-0002-6470-4408 https://orcid.org/0000-0002-8375-4005 https://orcid.org/0000-0003-1342-7006 https://orcid.org/0000-0001-6925-3266 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ method: we conducted a two-arm, single-blind randomised controlled trial. inclusion criteria were good command of the albanian language, age above 18, and elevated psychological distress (kessler psychological distress scale score above 15). primary outcome measures were the total score of the hopkins symptom checklist and the number of participants who completed at least three (out of five) sessions. secondary outcomes were global functioning, well-being, posttraumatic stress, and self-defined problems. results: two-hundred-twenty-two participants were included, of which 18 (8%) completed the post-assessments. the number of participants who completed the third session was equal in both conditions, with n = 5 (5%) and n = 6 (6%) respectively. discussion: drop-out rates were high in both conditions, and no group difference was found regarding the acceptance of the intervention. the high drop-out rate stands in contrast with other trials testing step-by-step. future research should examine cultural factors impacting recruitment strategies, as insights could help to reduce participant drop-out rates in clinical trials. keywords cultural adaptation, psychological interventions, mobile mental health, self-help, immigrants, online interventions, cultural concepts of distress, fatalism, working alliance highlights • an online self-help intervention was adapted to albanian’s cultural concepts of distress. • in a randomised controlled trial, two levels of cultural adaptation were compared. • recruitment was slow, and drop-out rates were high (92%). • no difference was found between the two levels of adaptation with regard to acceptance. background common mental disorders (cmds) such as depression, anxiety, and post-traumatic stress disorder (ptsd) contribute to a significant burden of disease worldwide (whiteford et al., 2013), particularly among populations affected by armed conflicts and migrant popu­ lations (charlson et al., 2016; turrini et al., 2017). negative effects of violent conflicts and migration on mental health often persist over years or decades (de jong et al., 2003), e.g., in survivors of the balkan wars (bogic et al., 2015; priebe et al., 2010). however, migrant populations often do not have access to care due to barriers such as poor command of the host country language, cultural beliefs about mental health, lack of trust towards mental health services, and mental health-related stigma (priebe et al., 2016). internet-based interventions are currently propagated as one potential measure to address the worldwide mental health treatment gap (schröder et al., 2016). meta-analytic evidence shows that these interventions are efficacious (andersson et al., 2019), and effect of cultural adaptation: randomised controlled trial 2 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ there is a growing number of studies testing them among culturally diverse groups (naslund et al., 2017). one rct in the netherlands examined the efficacy of a culturally adapted online-in­ tervention for the treatment of depression among turkish immigrants (ünlü ince et al., 2013). no significant difference was found in symptom improvement in the experimental group compared to the control group, although the same intervention had shown a medium effect size in a dutch sample (van straten et al., 2008). the drop-out rate among turkish participants was 42% at post-test and 62% at three-months follow-up, compared to 17% at postand follow-up in the dutch sample. these results indicate that the efficacy and acceptance of online mental health interventions may not be the same if they are applied in a group that is ethnically or culturally different from the one it was developed for. world health organization (who), in collaboration with the ministry of public health in lebanon, the freie universität (fu) berlin, and the university of zurich, have developed an online intervention called step-by-step for the treatment of depression among culturally diverse groups (carswell et al., 2018). step-by-step was written in english and developed in a “generic” approach, designing illustrations and narratives in a way that they can potentially speak to people from different contexts (carswell et al., 2018). thereafter, it was culturally adapted for different cultural groups living in lebanon (abi ramia et al., 2018). effectiveness and cost-effectiveness of step-by-step was tested in two parallel rcts among syrian refugees and other people residing in lebanon (n = 1,249 in total), showing intervention effects on depression and impaired functioning, among other outcomes (cuijpers et al., 2022a; cuijpers et al., 2022b). step-by-step is also currently being tested in three parallel rcts among syrian refugees in germany, swe­ den, and egypt (n = 500 per site) within the eu-funded strengths project (sijbrandij et al., 2017). there is an ongoing debate on the extent to which cultural adaptation of psycholog­ ical interventions contributes to their acceptability, efficacy, and effectiveness. culture is related to how symptoms are expressed (haroz et al., 2017; kohrt et al., 2014) and how different cultural groups explain the emergence of such symptoms, which is also known as explanatory models (bhui & bhugra, 2002; bhui et al., 2006). explanatory models reveal people’s implicit assumptions about mind-body relationships and religious or spiritual beliefs (e.g., kohrt & hruschka, 2010). in dsm-5, culturally diverse idioms of distress and explanatory models are subsumed under the term cultural concepts of distress (ccd) (american psychiatric association, 2013; kohrt et al., 2014). evidence on cultural adaptation of psychological interventions indicates a benefit of adapting psychological interventions to the target group (griner & smith, 2006; harper shehadeh et al., 2016; smith et al., 2011). however, it remains unclear what has to be adapted, and what the benefits are (heim & knaevelsrud, 2021). resnicow et al. (1999) differentiate between surface and deep structure adaptations to health interventions. heim, burchert, shala et al. 3 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ surface adaptations refer to matching materials (e.g., illustrations, language), as well as channels and settings for treatment delivery to observable characteristics of the target population. by contrast, deep structure adaptations take into account how cultural, social, environmental, or historical factors influence health behaviours. such adaptations are based on assumptions of how members of a particular cultural group perceive the cause, course, and treatment of a particular illness, thus refer to ccds (heim & kohrt, 2019). however, there is not much evidence on the effects of such adaptations. direct comparisons of adapted and non-adapted versions of the same interventions are scarce. one meta-analysis found a medium effect size (hedge’s g = .52) for such direct compari­ sons (hall et al., 2016), but this was based on a small number of studies. when adapting interventions to ccd, addressing fatalism might be one key as­ pect. an ethnopsychological study among albanian-speaking immigrants in switzerland (shala et al., 2020b) showed that participants understood their suffering as part of normal life, given by god or fate (fati), and something that cannot be cured but has to be borne with endurance (durim). lohaus and schmitt (1989) differentiate between internal beliefs about health (i.e., beliefs that one can influence health or illness), social-external beliefs (i.e., beliefs that other people, including health workers, can influence health or illness), and fatalistic-external beliefs (i.e., beliefs that health and illness depend on luck or destiny). thus, albanian-speaking immigrants in switzerland seem to hold fatalisticexternal health beliefs. a similar concept of suffering has also been described among turkish immigrants in germany (franz et al., 2007; reich et al., 2015). reich et al. (2021) developed a web-based intervention to enhance motivation for psychotherapy among turkish immigrants in germany. in a pilot study, they found that this intervention enhanced treatment motivation and reduced fatalistic-external beliefs. fatalism might therefore be a relevant aspect in cultural adaptation of psychological interventions for migrants. in the present study, we aim to compare surface vs. deep structure adaptation of the online intervention step-by-step (albanian: hap-pas-hapi) for albanian-speaking immigrants in switzerland and germany. we conducted an ethnopsychological study to examine the target group’s ccd (shala et al., 2020b). this study revealed specific idioms of distress, which were used for the deep structure adaptation. the study also showed that the target population held fatalistic-external beliefs. a modified version of the intervention developed by reich et al. (2021) will be used in the deep structure adaptation of step-by-step in the present study. effect of cultural adaptation: randomised controlled trial 4 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ method aims and design the culturally adapted, smartphone-based self-help intervention called hap-pas-hapi (albanian for step-by-step) for the treatment of depression was tested in a two-arm, single-blind rct among albanian immigrants in switzerland and germany. hap-pas-ha­ pi starts with an introduction and then offers five sessions (see below). in this study, one group had access to the albanian translation of hap-pas-hapi that only includes surface adaptations (resnicow et al., 1999), and the other group received a version of hap-pas-hapi that was adapted to the target populations’ ccd (i.e., deep structure adaptation). the deep structure adaptation was done based on an ethnopsychological study conducted in the target population (shala et al., 2020b) and is described more in detail elsewhere (shala et al., 2020a). based on current literature, we hypothesised higher efficacy (first primary outcome) and treatment adherence (second primary outcome) in the deep structure when compared to the surface adaptation version. more specifically, we hypothesised that the deep structure adaptation would decrease participants’ fatalistic-external health beliefs (reich et al., 2021) and enhance their work­ ing alliance with the programme (gómez penedo et al., 2020). we hypothesised that fatalistic-external beliefs would mediate the relationship between cultural adaptation and efficacy (first primary outcome), and working alliance would mediate the relationship between cultural adaptation and adherence (second primary outcome). a mediation effect can only be shown if the change in the mediator occurs before the change in symptoms (lemmens et al., 2016). therefore, working alliance was measured at the end of the introduction and session 1. control beliefs and severity of symptoms were measured at baseline, before starting session 3, and at the end of the programme (for assessments and time points, see heim et al., 2020s-b). finally, we aimed to test whether the required cultural adaptation of an intervention interacted with the level of acculturation among the target population. more precisely, we assumed that the less albanian-speaking immigrants adopted the receiving (i.e., swiss and german) culture and the more they retained their culture of origin, the higher the effect of cultural adaptation on treatment adherence and efficacy. participants inclusion criteria were: a) albanian-speaking, b) age 18 or above, c) a score of 15 or high­ er on the kessler psychological distress scale (k10, kessler et al., 2002), albanian version (hyseni duraku et al., 2018), and d) access to internet (smartphone or web-browser on tablet or computer). exclusion criteria were: a) living outside switzerland and germany, b) serious suicidal thoughts or plans (self-assessed with a corresponding question). we did not explicitly screen for mental disorders but assumed that people with severe heim, burchert, shala et al. 5 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ mental disorders (e.g., acute psychosis) would not be able to sign-up and go through the onboarding procedure. we did not exclude people due to severe mental disorders. intervention step-by-step is an online intervention for the treatment of depression that can be ac­ cessed through a mobile app (ios or android) or a web browser (burchert et al., 2019; carswell et al., 2018). it uses a narrative approach, in which an illustrated character tells his recovery story. an illustrated doctor narrator provides psychoeducation and interactive exercises. the therapeutic components are behavioural activation, stress man­ agement, positive self-talk, mood tracking, strengthening social support, and relapse prevention (carswell et al., 2018). step-by-step can be used as a guided or unguided mental health intervention. guid­ ance was provided in the lebanon trials (cuijpers et al., 2022a; cuijpers et al., 2022b). so-called “e-helpers”, i.e., trained non-specialists, contacted participants weekly through phone or chat and provided minimal guidance (max. 15 minutes per week). in the present study, we used a “contact on-demand” model, in which e-helpers (, i.e., albanian-speak­ ing students working in our team, and trained to communicate with participants in the study) responded to users’ questions but did not proactively reach out to participants. step-by-step was translated into albanian language and adapted through two differ­ ent approaches. the first, surface adaptation (resnicow et al., 1999) was based on a “cognitive interviewing” technique, in which users read through the intervention and provide comments on the content, illustrations, exercises, and the usability of the inter­ vention. a similar approach was used for the cultural adaptation of step-by-step in lebanon (abi ramia et al., 2018). the deep structure adaptation was done based on an ethnopsychological study conducted in the target population (shala et al., 2020b) and included three components: i) idioms of distress of the target population, ii) a new exercise in the introduction, in which the treatment rationale was adapted to the target populations’ explanatory models, and iii) a goal-setting task (added to the introduction, as well), which aimed to address participants’ socio-centric concept of the self (kirmayer, 2007). the goal-setting task focused on the potential benefits of using hap-pas-hapi for the family or community at large. thus, the main adaptations were done to the introduction (before starting session 1) with the aim of enhancing treatment motivation and adherence. the deep structure adaptation is described more in detail elsewhere (shala et al., 2020a). recruitment participants were recruited through three streams: social media (e.g., facebook, insta­ gram, linkedin, twitter, viber, and whatsapp), health services (e.g., general practition­ ers, psychiatric services), and the community (e.g., albanian associations, religious and effect of cultural adaptation: randomised controlled trial 6 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ women’s groups, and a television emission on “diaspora tv” for albanians). social media recruitment has proven to be an effective recruitment strategy in e-mental health research (kayrouz et al., 2016; whitaker et al., 2017), and was used in an rct with the arabic and english version of hap-pas-hapi, called step-by-step, in lebanon (cuijpers et al., 2022a; cuijpers et al., 2022b). for recruitment, an account in albanian language with the title “hap-pas-hapi” was created on facebook, instagram, and twitter. a minimum of three posts per week on these platforms shared study information and illustrations on the program. the social media messages were shared by the accounts of the research team, as well as on pages of albanian associations, and health institutions that have a connection to albanian clients and patients. in addition, we posted short movies in albanian language. in one of them, members of the research team invited people to participate. in another one, the study was explained with the help of animated sketches. the use of social media influencers, who serve as multipliers of health-related con­ tent, is becoming increasingly relevant in digital health communication (dusberger & pierau, 2020). a selection of trusted and popular social media influencers in the albanian community were contacted and a few of them shared information about the present study. we also compiled a list of albanian-speaking medical doctors (i.e., family doctors, psychiatrists) and psychologists. we contacted them via phone or visited them in their workplace and asked them to support our recruitment. flyers and posters were deposited in the waiting rooms at private and public outpatient clinics. a group of psychiatrists installed the app on their smartphones to show it directly to patients and help them sign up. in addition, they spread the word in their respective networks to support our recruitment. in addition, we started recruitment efforts within the albanian communities in swit­ zerland and in berlin. a team of a senior researcher, a doctoral student, and several master’s students and interns participated in this process. we organized a series of events with albanian-speaking associations, where we presented the project and the study and invited people to participate. at these events, the project received positive feedback and interest. one master’s student went to events of albanian groups and associations, and to the mosque to distribute flyers and talk to people about the project. two students at university of lausanne involved the association of albanian-speaking students in the french-speaking part of switzerland. we also hired a series of “cultural brokers” (wenger, 1998), i.e., members of the community who were offered a small reimbursement for supporting our recruitment by diffusing the information and helping people with the sign-up process. given the flood of health-related digital content and rampant misin­ formation during the covid-19 pandemic, we felt it was important to emphasize that “hap-pas-hapi” adheres to evidence-based practices and is a trustworthy intervention. to build trust in the institutions and the research team behind the intervention, we installed a weekly “meet-the-expert” session via zoom, where people could join us, talk heim, burchert, shala et al. 7 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ with us, and ask questions about the study and discuss strategies to address mental health in albanian-speaking communities. finally, we reduced the number of baseline assessments to reduce dropouts during that phase (see results section). when recruitment did not proceed after all these efforts, we sought ethical approval in austria and italy to expand the recruitment in those countries. we collaborated with albanian-speaking health professionals in these countries who promised to support our study. procedure interested people accessed the study information and informed consent procedures on­ line, all of which were presented in albanian language. applicants were reminded that they were free to decline to participate or withdraw at any time. after giving consent, participants were asked to create an account, first completed the screening question­ naires, and (if screened positive) completed the additional baseline questionnaires. appli­ cants who were excluded based on one of the exclusion criteria received an on-screen message thanking them for their interest in the study and explaining that they could not participate in this study at this point. people who answered “yes” on the question about imminent risk of suicide received a message saying that it was important that they sought help, providing a list of crisis intervention centres in switzerland and germany, along with numbers for telephone counselling in both countries. included participants could use the intervention and were invited for post-assess­ ments six weeks after baseline assessments. three months later, they were invited for follow-up assessments. all measures (pre-, postand follow-up) were completed online. as soon as the assessment was due, participants saw them as a new “session” on their home screen within the hap-pas-hapi programme. if they used the mobile version and had previously agreed to receive automated notifications, they received a pop-up mes­ sage saying that the assessments were due. e-helpers sent a maximum of three reminders for postand again for follow-up assessments. randomisation after sign-up, informed consent and screening, participants were randomly allocated to one of the two treatment conditions and invited to complete the baseline assessments. in the study information, participants learned that they would be randomised into one of two conditions, but we did not provide any further information on the differences between the two versions of hap-pas-hapi. participants were blind to the condition they were allocated to. randomisation and group allocation (1:1) were done automatically by the system. a permuted block randomisation algorithm (random block lengths of 4, 6, or 8) was used. all assessments were done online, and the study team did not have access to data or randomisation during the trial. effect of cultural adaptation: randomised controlled trial 8 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ sample size the power analysis for the current study is described in detail in the protocol paper (see heim et al., 2020s-b). according to this analysis, we needed 320 participants (completed baseline assessments) to make sure the trial was sufficiently powered. screening measure the k10 (kessler et al., 2002) was used as screening measure. it includes ten items on psychological distress, with a total score ranging from 10 to 50. in line with the strengths study, we used a score of >15 as an indication of moderate to high levels of psychological distress (de graaff et al., 2020). primary outcomes questionnaires applied at each assessment time are described in detail in the protocol pa­ per (heim et al., 2020s-b). the first primary outcome was the hopkins symptom check­ list (hscl-25), which consists of 25 items related to psychological distress (derogatis et al., 1974). the second primary outcome was treatment adherence, defined as completing at least three (out of five) sessions. the reason for this definition of treatment adherence was the fact that the main adaptations had been done in the first two sessions. thus, after session 3, we did not expect group differences with regard to adherence, because the intervention versions were identical. use of the intervention (i.e., start and completion of sessions, exercises) was automatically registered by the online platform. secondary outcomes we used the who disability assessment schedule (whodas) 2.0 for assessing func­ tioning (rehm et al., 1999). in addition, we applied the who well-being index (who-5), a 5-item questionnaire measuring current psychological wellbeing and quality of life (bech et al., 2003). ptsd symptoms were measured using the abbreviated eight-item version of the ptsd checklist for dsm-5 (pcl-5, price et al., 2016). and finally, self-de­ fined problems and symptoms were measured using the psychological outcome profiles instrument (psychlops, ashworth et al., 2004). mediators the german questionnaire «fragebogen zur erhebung von kontrollüberzeugungen zu krankheit und gesundheit» (kkg, 'questionnaire to assess control beliefs about illness and health', lohaus & schmitt, 1989) measures three dimensions, i.e., beliefs in internal, social–external, and fatalistic–external illness-related locus of control. heim, burchert, shala et al. 9 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ the illness perception questionnaire revised (ipq-r, moss-morris et al., 2002) meas­ ures different kinds of beliefs about an illness (e.g., about its course, consequences, personal control, treatment control, etc.). we only used the second part, which includes assumptions about causes (i.e., personal attributions, risk factors, immunity, accidents, or chance). furthermore, we measured working alliance with hap-pas-hapi using the working alliance inventory (wai, munder et al., 2010) for guided internet interventions (gómez penedo et al., 2020). other measures we gathered socio-demographic information, including sex, age, marital status, nationali­ ty, level of education, employment, and time lived in the host country. and we applied an adapted version of the client satisfaction questionnaire csq (larsen et al., 1979) for internet-based interventions (boß et al., 2016). statistical analysis the original data analysis plan is described in the trial’s protocol paper (heim et al., 2020s-b). due to the small sample size (n = 97 completed baseline assessments) and high dropout (81%), we only calculated the percentage of users completing at least 3 out of 5 sessions (second primary outcome). results a total of 222 participants were included in this study (see figure 1), of which n = 112 were assigned to the surface and n = 110 were assigned to the deep structure adaptation version of hap-pas-hapi. less than half of participants (n = 97, 43.7%) completed baseline assessments. we first report on the results of the different recruitment strategies. table 1 shows results of the question “where have you heard about our study”, which was responded by n = 145 participants. this table shows that the largest number was recruited through social media (59%), while other strategies such as information events and recruitment through healthcare worker, did not work at all. our social media posts reached up to 23,000 times, thus we can assume that they were seen. in the first month (i.e., june 2020), 31 people signed up and completed baseline assessments. in the following three months, only 15, 11, and 12 completed baseline assessments. from october 2020, social media posts did no longer result in an immediate increase of participants, although they were seen and shared. from there on, we had between 0 and 6 new participants per month. influencers’ posts had a short positive effect on recruitment rates. the events in albanian associations and communities did not lead to an increase in participants, effect of cultural adaptation: randomised controlled trial 10 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ although the project and the application received very positive feedback. recruitment through healthcare workers did not work at all. in july 2021, the budget for recruitment and for maintaining the platform ran out. due to very little success of our recruitment strategies, and high drop-out rates (see below), we opted for an early termination of the trial. table 1 results of the question “where have you heard about study?” (n = 145) recruitment channel n (%)a facebook, instagram, other social media 86 (59.3%) other online platforms 8 (5.5%) family member, friends 33 (22.8) healthcare worker 1 (0.7%) association 7 (4.8%) information event 1 (0.7%) other 8 (5.5%) apercentage out of those who responded to the question (n = 145). descriptive statistics are reported in table 2. a total of n = 145 responded to the socio-demographic questions at the beginning of baseline assessment. the mean age was 30.5 years, with no significant difference between groups (p = .338). no significant group differences emerged regarding the other socio-demographic variables. table 2 descriptive statistics (n = 145) characteristic surface adaptation (n = 69) n (%)a deep structure adaptation (n = 76) n (%)a total (n = 145) n (%)a p group comparison female gender 47 (68.1%) 52 (68.4%) 99 (68%) .969b age .338c 18-30 47 (68.1%) 49 (64.5%) 96 (66.2%) 31-40 13 (18.8%) 15 (19.7%) 28 (19.3%) 41-50 6 (8.7%) 6 (7.9%) 13 (9.0%) 51-60 3 (4.3%) 5 (6.6%) 8 (5.5%) 61-70 0 1 (1.3%) 1 (0.7%) nationality .106b switzerland 9 (13%) 11 (14.5%) 20 (13.8%) germany 3 (4.3%) 13 (17.1%) 16 (11%) kosovo 32 (46.4%) 31 (40.8%) 63 (43.4%) albania 18 (26.1%) 16 (21.1%) 34 (23.4%) heim, burchert, shala et al. 11 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ characteristic surface adaptation (n = 69) n (%)a deep structure adaptation (n = 76) n (%)a total (n = 145) n (%)a p group comparison macedonia 3 (4.3%) 2 (2.6%) 5 (3.4%) other 3 (4.3%) 0 3 (2.1%) no response 1 (1.4%) 3 (3.9%) 4 (2.8%) 2nd nationality .673b none 43 (62.3%) 44 (57.9%) 87 (60%) swiss 4 (5.8%) 10 (13.2%) 14 (9.7%) germany 4 (5.8%) 3 (3.9%) 7 (4.8%) kosovo 9 (13%) 7 (9.2%) 16 (11%) albania 1 (1.4%) 2 (2.6%) 3 (2.1%) macedonia 2 (2.9%) 2 (2.6%) 4 (2.8%) serbia 1 (1.4%) 3 (3.9%) 4 (2.8%) other 4 (5.8%) 2 (2.6%) 6 (4.1%) i’d rather not say 1 (1.4%) 1 (1.3%) 2 (1.4%) no response 0 2 (2.6%) 2 (1.4%) years lived in host country .818b born in switzerland / germany 16 (23.2%) 21 (27.6%) 37 (25.5%) more than 30 years 2 (2.9%) 4 (5.3%) 6 (4.1%) 21-30 years 8 (11.6%) 11 (14.5%) 19 (13.1%) 11-20 years 8 (11.6%) 7 (9.2%) 15 (10.3%) 5-10 years 16 (23.2%) 12 (15.8%) 28 (19.3%) less than 5 years 19 (27.5%) 21 (27.6%) 40 (27.6%) education .855b no education 1 (1.4%) 0 1 (0.7%) primary school 0 1 (1.3%) 1 (0.7%) elementary education 3 (4.3%) 3 (3.9%) 6 (4.1%) secondary education 15 (21.7%) 13 (17.1%) 28 (19.3%) technical secondary education 14 (20.3%) 17 (22.4%) 31 (21.4%) undergraduate or bsc degree 20 (29%) 25 (32.9%) 45 (31%) graduate or msc degree 15 (21.7%) 14 (18.4%) 29 (20%) higher university degree (phd) 1 (1.4%) 2 (2.6%) 3 (1.4%) no response 0 1 (1.3%) 1 (0.7%) marital status .525b single 39 (56.5%) 37 (48.7%) 76 (52.4%) married 27 (39.1%) 31 (40.8%) 58 (40.0%) separated 2 (2.9%) 3 (3.9%) 5 (3.4%) divorced 0 2 (2.6%) 2 (1.4%) widowed 1 (1.4%) 3 (3.9%) 4 (2.8%) work status .100b paid work 35 (50.7%) 43 (56.6%) 78 (53.8%) non-paid work 4 (5.8%) 6 (7.9%) 10 (6.9%) student 18 (26.1%) 18 (23.7%) 36 (24.8%) retired 1 (1.4%) 2 (2.6%) 3 (2.1%) unemployed (health reasons) 1 (1.4%) 5 (6.6%) 6 (4.1%) unemployed (other reasons) 10 (14.5%) 2 (2.6%) 12 (8.3%) apercentage out of those who responded to the question. bt-test for independent samples. cchi-square test. effect of cultural adaptation: randomised controlled trial 12 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ drop-out rates were high (see figure 1). a large percentage of participants (n = 125, 56%) was lost already during baseline assessments. in both groups, just nine participants (8%) completed the post-assessments respectively, with no significant group difference (chi-square test p = .968). post-assessment completion rates out of those who had com­ pleted the baseline assessments was 19% for the surface adaptation and 18% for the deep structure adaptation group (chi-square test p = .884). the follow-up assessments were completed by seven (5%) participants from the surface adaptation and four (4%) participants from the deep structure adaptation group. figure 1 flow chart assessed for eligibility (n = 286) randomized (n = 222) exclusion (n = 64) screening under cut off (n = 14) age under 18 (n = 20) serious suicidal thoughts or plans (n = 30) allocated to surface adaptation (n = 112) completed baseline assessment (n = 47) allocated to deep structure adaptation (n = 110) completed baseline assessment (n = 50) completed post-assessment (n = 9) completed intervention (n = 4) completed post-assessment (n = 9) completed intervention (n = 5) completed follow-up (n = 7) completed follow-up (n = 4) heim, burchert, shala et al. 13 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ the number of participants who completed at least three out of five sessions did not differ between the surface and deep structure adaptation group (4.5% and 5.5%, respec­ tively, see table 3). due to the large drop-out rate and thus an insufficient number of participants for the planned analyses, we did not continue with further statistical analyses of the questionnaire data. table 3 completion rates stage surface adaptation (n = 112) deep structure adaptation (n = 110) completed baseline 47 (48.5%) 50 (51.5%) completed intro 24 (21.4%) 23 (20.9%) completed s3 5 (4.5%) 6 (5.5%) completed s5 4 (3.6%) 5 (4.5%) note. intro = introduction; s3 = session 3; s5 = session 5. discussion in cultural adaptation literature, empirical evidence on different levels of adaptation is lacking, and experimental studies are scarce. the present study aimed to deliver such evidence as a starting point for future studies. for this purpose, two levels of cultural adaptation – surface vs. deep structure (resnicow et al., 1999) – of an online self-help programme for the treatment of psychological distress were compared in a randomized controlled trial. despite an extensive effort through a variety of channels, we were unable to recruit a sufficient number of participants for our trial. most participants were recruited through social media, while other strategies, such as involving health workers or organising events with albanian associations, were not successful. this is in line with previous studies (i.e., harper shehadeh et al., 2020; heim et al., 2021). however, the social media recruitment strategy was successful only during the first three months. we can only speculate about the reason for this outcome. it is possible that at start, people who were most motivated for participation enrolled, whereas the large majority could not be convinced with the posts and ads that followed. we conducted a qualitative study (heim et al., 2024, this issue), showing recruitment materials to a small sample of albanian-speaking immigrants in switzerland, to gather feedback and suggestions for future studies. upon early termination of the study, we had included a total of 222 participants, of which 204 (92%) were lost to post-assessment (see figure 1). this large drop-out rate stands in contrast with other step-by-step trials. in two rcts in lebanon, the drop-out effect of cultural adaptation: randomised controlled trial 14 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ rates (completed post-assessment) were 65% in the lebanese population (cuijpers et al., 2022a) and 46% among syrian refugees (cuijpers et al., 2022b). it is important to mention that in our study, n = 125 (56%) were already lost during baseline assessments and thus did not proceed to the intervention content. one potential explanation for this large drop-out during baseline assessments is the lack of cultural adaptation of the applied questionnaires, and the high stigmatisation of mental health problems in the albanian-speaking community (dow & woolley, 2011; shala et al., 2020b). however, we used standard measures that are widely used across a large variety of cultural and ethnic groups worldwide. thus, the questionnaires themselves do not fully explain the large drop-out rates during baseline assessments. it might also be possible that potential participants stopped baseline assessment due to the extensive number of questions, and the related workload. however, the majority (n = 80) was lost already during the first questionnaire, i.e., the hscl. there seem to be other reasons for dropout at this stage. against our hypothesis, the drop-out rates did not differ between the two conditions. our trial was not sufficiently powered to draw meaningful conclusions, but we can at least state that the deep structure adaptation did not lead to a considerable reduction of drop-out compared to the surface adaptation. it is of course also possible that the few participants who continued the intervention were highly motivated in both groups, so that the deep structure adaptation did not make a difference. taken together, the low recruitment rate and the large drop-out rate indicate that hap-pas-hapi, in its current format, did not meet the needs and expectations of the albanian-speaking community in switzerland and germany. one reason for this result might be the lack of intrinsic motivation to seek help, and a lack of self-efficacy when it comes to one’s help, which is related to fatalistic-external health beliefs (lohaus & schmitt, 1989; shala et al., 2020b). another reason might be the above-mentioned high stigmatization of mental health problems in the albanian-speaking community (dow & woolley, 2011; shala et al., 2020b). and yet another reason might be the lack of guidance. in this study, we used a guidance-on-demand model, in which e-helpers do not proactive­ ly reach out to participants. proactively contacting all participants and providing weekly minimal guidance, might have reduced drop-out rates in our study (torous et al., 2020). another important limitation might have been caused by our careful adaptation process itself. we adapted hap-pas-hapi to cultural concepts of distress in the albani­ an-speaking community (shala et al., 2020a; shala et al., 2020b), and the application was only available in albanian language. however, our ethnopsychological research showed that there are large differences between firstand second-generation immigrants (pnishi et al., 2024). second generation immigrants were born and socialized in the host country. our socio-demographic data shows that 26% of those who had completed the socio-demographic questionnaire were born in switzerland or germany. although we do not know anything about all those who saw our social media posts and did not enroll in the study, we might speculate that a german (or french, for this part of switzerland) heim, burchert, shala et al. 15 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ version would have motivated second-generation immigrants to participate in our study. as to the group of first-generation immigrants, a lack of e-health literacy (norman & skinner, 2006), and a lack of motivation to use a mobile application for mental health, might have played an important role. ethnic minorities are generally under-represented in clinical trials in high-income countries (hussain-gambles et al., 2004; wendler et al., 2006). our results show that it is not enough to have “good intentions” to include ethnic minorities in research. without a deep understanding of their concepts and beliefs about health and illness, health services, help-seeking, and research, it may result very difficult to reach them. and despite our extensive ethnopsychological study, careful adaptation, and massive recruitment effort, we seem to have missed key facts about our target population. we can only hope that our post-hoc qualitative study (heim et al., 2024, this issue) will help us understand the reasons for our difficulties, and gain a deeper understanding of what needs to be done in future studies. funding: this study is funded by the swiss national science foundation (snsf, grant number: 10001c_169780.2) and the swiss foundation for the promotion of psychiatry and psychotherapy. we also received funding by the freie universität berlin and university of zurich to build a strategic partnership. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. ethics statement: the project was approved by the ethics committee of the faculty of arts and social sciences at the university of zurich (approval number 20.2.4). in addition, the study was approved as an amendment of the strengths study by the ethics committee at the department of education and psychology, fu berlin (161_2/2017). supplementary materials the supplementary materials contain the following items: • the trial registration (heim et al., 2020s-a) • the preregistration for the study (heim et al., 2020s-b) index of supplementary materials heim, e., burchert, s., shala, m., hoxha, a., kaufmann, m., cerga pashoja, a., morina, n., schaub, m. p., knaevelsrud, c., & maercker, a. (2020s-a). supplementary materials to "effect of cultural adaptation of a smartphone-based self-help programme on its acceptability and efficacy: randomized controlled trial" [trial registration]. clinicaltrials.gov. https://www.clinicaltrials.gov/study/nct04230135 effect of cultural adaptation: randomised controlled trial 16 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.clinicaltrials.gov/study/nct04230135 https://www.psychopen.eu/ heim, e., burchert, s., shala, m., hoxha, a., kaufmann, m., cerga pashoja, a., morina, n., schaub, m. p., knaevelsrud, c., & maercker, a. (2020s-b). supplementary materials to "effect of cultural adaptation of a smartphone-based self-help programme on its acceptability and efficacy: randomized controlled trial" [preregistration]. psycharchives. https://doi.org/10.23668/psycharchives.3152 references abi ramia, j., harper shehadeh, m., kheir, w., zoghbi, e., watts, s., heim, e., & el chammay, r. 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(2013). global burden of disease attributable to mental and substance use disorders: findings from the global burden of disease study 2010. lancet, 382(9904), 1575–1586. https://doi.org/10.1016/s0140-6736(13)61611-6 effect of cultural adaptation: randomised controlled trial 22 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://doi.org/10.1007/s11013-019-09638-5 https://doi.org/10.1080/20008198.2017.1388102 https://doi.org/10.1002/jclp.20757 https://doi.org/10.1016/j.jad.2019.11.167 https://doi.org/10.1186/s13033-017-0156-0 https://doi.org/10.2196/jmir.2853 https://doi.org/10.2196/jmir.954 https://doi.org/10.1371/journal.pmed.0030019 https://doi.org/10.1017/cbo9780511803932 https://doi.org/10.2196/jmir.7071 https://doi.org/10.1016/s0140-6736(13)61611-6 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. heim, burchert, shala et al. 23 clinical psychology in europe 2024, vol. 6(2), article e2743 https://doi.org/10.32872/cpe.2743 https://www.psychopen.eu/ effect of cultural adaptation: randomised controlled trial (introduction) background method aims and design participants intervention recruitment procedure randomisation sample size screening measure primary outcomes secondary outcomes mediators other measures statistical analysis results discussion (additional information) funding acknowledgments competing interests ethics statement supplementary materials references special issue editorial: cultural adaption of psychological interventions editorial special issue editorial: cultural adaption of psychological interventions eva heim 1,2 , cornelia weise 3 [1] institute of psychology, university of lausanne, lausanne, switzerland. [2] department of psychology, university of zürich, zürich, switzerland. [3] division of clinical psychology and psychotherapy, department of psychology, philippsuniversity of marburg, marburg, germany. clinical psychology in europe, 2021, vol. 3(special issue), article e7627, https://doi.org/10.32872/cpe.7627 published (vor): 2021-11-23 corresponding author: eva heim, institute of psychology, university of lausanne, géopolis, bureau 4114, 1015 lausanne, switzerland. e-mail: eva.heim@unil.ch related: this article is part of the cpe special issue “cultural adaptation of psychological interventions”, guest editors: eva heim & cornelia weise, clinical psychology in europe, 3(special issue), https://doi.org/ 10.32872/10.32872/cpe.v3.si cultural adaptation of psychological interventions has been discussed controversially in literature. on the one hand, culturally diverse groups are underrepresented in psycholog­ ical trials, and evidence on acceptability and efficacy of interventions cannot necessarily be transferred from one cultural group to another (hussain-gambles et al., 2004; la roche & christopher, 2008; wendler et al., 2006). on the other hand, some researchers are concerned about the fidelity of treatment if culturally adapted (castro et al., 2010). there is also considerable debate about what to adapt, and the effect of such adapta­ tions. empirical evidence on substantial modifications is scarce, and cultural adaptation methods are often insufficiently reported in literature (chowdhary et al., 2014; harper shehadeh et al., 2016). this does not only include adaptations implemented before a trial starts, but also the so called “on-the-fly” adaptations that are done during an ongoing trial. in this special issue, experiences and empirical evidence on the cultural adaptation of psychological interventions for refugee populations are brought together. in 2016, the german federal ministry of education and research (fmer) launched a call for research proposals covering the ‘mental health of refugee populations’. seven research projects were funded. one exclusively focuses on diagnostics, and the other six projects test evi­ dence-based psychological interventions. each of those six projects consists of three or more sub-projects, which are testing diagnostic tools, the efficacy and cost-effectiveness this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7627&domain=pdf&date_stamp=2021-11-23 https://orcid.org/0000-0001-7434-7451 https://orcid.org/0000-0001-5216-1031 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ of interventions, and implementation methods. a total of eleven randomised controlled trials (rcts) are implemented to test different kinds of psychological interventions among a diversity of target groups, i.e., age groups, specific disorders, or unspecific psychological distress. in the context of the fmer call, a “task force for cultural adaptions of mental health interventions for refugees” was launched. it pursued two major goals: first, it aimed to develop a common understanding and methodology for documenting and monitoring cultural adaptations in clinical trials. second, it aimed to integrate the findings of the first step and compile criteria on how cultural adaptations in clinical trials could be reported. the conceptual framework for cultural adaptation by heim and kohrt (2019) was used as a basis for this work. this special issue features experiences, empirical evidence and recommendations resulting from this task force, as well as the final composition of the reporting criteria. the paper by heim and knaevelsrud (2021, this issue) provides an introduction to the methodology developed by the task force and describes how cultural adaptations across the different projects and studies were documented and monitored. a content analysis of the documented adaptations is presented in this paper. the subsequent papers highlight five examples of studies that applied the jointly developed cultural adaptation method­ ology, with different thematic foci. these papers are based on empirical evidence from formative research (e.g., focus groups or key informant interviews) and pilot studies. mewes et al. (2021, this issue) describe the development of a culture-sensitive, transdiagnostic intervention to increase knowledge about mental health problems and available treatments. this study highlights the importance of differentiating between the culture-specific adaptation of interventions (for one particular group) and the devel­ opment of culture-sensitive interventions that can be used for culturally diverse groups. kananian et al. (2021, this issue) used culturally adapted cognitive behavioural therapy (ca-cbt, hinton et al., 2012), an intervention that had already been tested among different cultural groups (i.e., cambodian, latino, and arabic-speaking popula­ tions). in this study, ca-cbt was prepared to be tested in a new, culturally different group (i.e., afghan refugees in germany). based on a pilot study and focus groups, the intervention was further adapted to be tested in an rct. böttche et al. (2021, this issue) focus on the process from formative research to adaptation. a transdiagnostic intervention, the common elements treatment approach (ceta, murray et al., 2014), was adapted for arabic-speaking refugees in germany and will be provided both face-to-face and through the internet in a non-inferiority trial. in preparation of this study, cultural concepts of distress were assessed among the target population. the main focus of the paper is on the decision-making process, and the authors provide a summary of their most salient decisions. the process of adapting an already culturally-sensitive, transdiagnostic treatment to also include substance use disorders is described in the paper by lotzin et al. (2021, editorial 2 clinical psychology in europe 2021, vol. 3(special issue), article e7627 https://doi.org/10.32872/cpe.7627 https://www.psychopen.eu/ this issue). the authors used skills-training of affect regulation – a culture-sensitive approach (starc, koch & liedl, 2019) in their study. focus group discussions were conducted to examine culture-specific assumptions about substance use. this data was used to adapt the treatment manual that will be tested in an upcoming rct. unterhitzenberger et al. (2021, this issue) tested trauma-focused cognitive behav­ ioral therapy (tf-cbt, cohen et al., 2017) in a pilot study with unaccompanied refu­ gee minors (urms). the paper highlights “on-the-fly” adaptations implemented by the therapists during the pilot study. the main adaptation concerned the so-called “crisis of the week”, i.e., participants struggles and concerns in their daily lives. this shows that post-migration stressors are a very important factor when adapting psychological interventions to refugee populations – an aspect that may sometimes be even more relevant than ethnic origin. finally, heim et al. (2021, this issue) present the reporting cultural adaptation in psychological trials (recapt) criteria. the recapt criteria were developed jointly by the above-described task force. to achieve a broader consent on the recapt criteria, an online survey was conducted among eleven international experts in the field of global mental health and psychological interventions for refugee populations. in summary, this special issue features the experience of a variety of studies in which a diversity of psychological interventions were culturally adapted and tested among refu­ gee populations in germany. the task force provided a unique opportunity for exchange and discussions, with the aim of advancing the emerging field of cultural adaptations in mental health interventions. the recapt criteria (heim et al., 2021, this issue) will hopefully contribute to a more systematised and transparent documentation of cultural adaptation in psychological research in the future. this is an important precondition to enhance the empirical evidence concerning the effect of such adaptations on the efficacy and acceptability of psychotherapy among culturally diverse groups. funding: german federal ministry of education and research (nr 01ef1806h). acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: cornelia weise is one of the editors-in-chief of clinical psychology in europe. references böttche, m., kampisiou, c., stammel, n., el-haj-mohamad, r., heeke, c., burchert, s., heim, e., wagner, b., renneberg, b., böttcher, j., glaesmer, h., gouzoulis-mayfrank, e., zielasek, j., konnopka, a., murray, l., & knaevelsrud, c. (2021). from formative research to cultural adaptation of a face-to-face and internet-based cognitive-behavioural intervention for arabicheim & weise 3 clinical psychology in europe 2021, vol. 3(special issue), article e7627 https://doi.org/10.32872/cpe.7627 https://www.psychopen.eu/ speaking refugees in germany. clinical psychology in europe, 3(special issue), article e4623. https://doi.org/10.32872/cpe.4623 castro, f. g., barrera, m., jr., & holleran steiker, l. k. (2010). issues and challenges in the design of culturally adapted evidence-based interventions. annual review of clinical psychology, 6, 213-239. https://doi.org/10.1146/annurev-clinpsy-033109-132032 chowdhary, n., jotheeswaran, a. t., nadkarni, a., hollon, s. d., king, m., jordans, m. j. d., rahman, a., verdeli, h., araya, r., & patel, v. 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(2021). starc-sud – adaptation of a transdiagnostic intervention for refugees with substance use disorders. clinical psychology in europe, 3(special issue), article e5329. https://doi.org/10.32872/cpe.5329 mewes, r., giesebrecht, j., weise, c., & grupp, f. (2021). description of a culture-sensitive, lowthreshold psychoeducation intervention for asylum seekers (tea garden). clinical psychology in europe, 3(special issue), article e4577. https://doi.org/10.32872/cpe.4577 murray, l. k., dorsey, s., haroz, e., lee, c., alsiary, m. m., haydary, a., weiss, w. m., & bolton, p. (2014). a common elements treatment approach for adult mental health problems in lowand middle-income countries. cognitive and behavioral practice, 21(2), 111-123. https://doi.org/10.1016/j.cbpra.2013.06.005 unterhitzenberger, j., haberstumpf, s., rosner, r., & pfeiffer, e. (2021). “same same or adapted?” therapists’ feedback on the implementation of trauma-focused cognitive behavioral therapy with unaccompanied young refugees. clinical psychology in europe, 3(special issue), article e5431. https://doi.org/10.32872/cpe.5431 wendler, d., kington, r., madans, j., van wye, g., christ-schmidt, h., pratt, l. a., brawley, o. w., gross, c. p., & emanuel, e. (2006). are racial and ethnic minorities less willing to participate in health research? plos medicine, 3(2), article e19. https://doi.org/10.1371/journal.pmed.0030019 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. heim & weise 5 clinical psychology in europe 2021, vol. 3(special issue), article e7627 https://doi.org/10.32872/cpe.7627 https://doi.org/10.32872/cpe.5329 https://doi.org/10.32872/cpe.4577 https://doi.org/10.1016/j.cbpra.2013.06.005 https://doi.org/10.32872/cpe.5431 https://doi.org/10.1371/journal.pmed.0030019 https://www.psychopen.eu/ intuitive judgments in depression and the role of processing fluency and positive valence: a preregistered replication study research articles intuitive judgments in depression and the role of processing fluency and positive valence: a preregistered replication study carina remmers a, johannes zimmermann b, sascha topolinski c, christoph richter d, thea zander-schellenberg e, matthias weiler a, christine knaevelsrud a [a] division of clinical psychological intervention, department of education and psychology, freie universität berlin, berlin, germany. [b] department of psychology, university of kassel, kassel, germany. [c] social and economic cognition center, university of köln, köln, germany. [d] vivantes klinikum kaulsdorf, berlin, germany. [e] division of clinical psychology and epidemiology, department of psychology, university of basel, basel, switzerland. clinical psychology in europe, 2020, vol. 2(4), article e2593, https://doi.org/10.32872/cpe.v2i4.2593 received: 2019-12-19 • accepted: 2020-10-28 • published (vor): 2020-12-23 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: carina remmers, schwendener straße 27, 14195 berlin, germany. e-mail: carina.remmers@fu-berlin.de supplementary materials: preregistration [see index of supplementary materials] abstract background: recent preliminary evidence indicates that depression is associated with impaired intuitive information processing. the current study aimed at replicating these findings and to move one step further by exploring whether factors known as triggering intuition (positivity, processing fluency) also affect intuition in patients with depression. method: we pre-registered and tested five hypotheses using data from 35 patients with depression and 35 healthy controls who performed three versions of the judgment of semantic coherence task (jsct, bowers et al., 1990). this task operationalizes intuition as the inexplicable and sudden detection of semantic coherence. results: results revealed that depressed patients and healthy controls did not differ in their general intuitive performance (hypothesis 1). we further found that fluency did not significantly affect depressed patients’ coherence judgments (h2a) and that the assumed effect of fluency on coherence judgments was not moderated by depression (h2b). finally, we found that triads positive in valence were more likely to be judged as coherent as compared to negative word triads in the depressed sample (h3a), but this influence of positive (vs. negative) valence on coherence judgments did not significantly differ between the two groups (h3b). conclusion: overall the current study did not replicate findings from previous research regarding intuitive semantic coherence detection deficits in depression. however, our findings suggest that this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i4.2593&domain=pdf&date_stamp=2020-12-23 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ enhancing positivity in depressed patients may facilitate their ability to see meaning in their environment and to take intuitive decision. keywords depression, intuition, meaning detection, positive affect, positive valence, processing fluency, replication, semantic coherence judgments highlights • the pre-registered replication study did not find intuition deficits in patients with depression. • processing fluency did not affect coherence judgments in depressed patients or healthy controls. • depressed patients and healthy controls use positive valence as cue for intuitive coherence judgments. • future studies should test whether enhancing positivity in depressed patients boosts their ability to find meaning (e.g., meaning in life). people continuously make decisions and judgments without long consideration by rely‐ ing on their gut feelings. following one’s intuition does not only feel right (thompson et al., 2011), but also leads to adaptive outcomes, especially in complex situations, during stress or when a person is experienced in the given environment (kahneman & klein, 2009). by integrating a multitude of factors such as implicit personal needs and goals (baumann & kuhl, 2002; lieberman et al., 2004), intuitions enable people to make "smart" decisions (gigerenzer, 2007), and to interact with other people (e.g., facilitating adaptive parent-child interaction; parsons et al., 2017). moreover, intuition is associated with central aspects of mental well-being, such as experiencing meaning in life (heintzelman, trent, & king, 2013; hicks & king, 2007; hicks et al., 2010; schlegel et al., 2011). intuition relies on processes that are based on experience, run quickly and uncon‐ sciously, and allow many relevant aspects to be effortlessly integrated into a coherent whole (kahneman, 2011). by this, intuition enables people to detect coherence and meaning. the judgment of semantic coherence task (jsct; bowers et al., 1990) oper‐ ationalizes this core characteristic of intuition by asking people to discriminate word triads in terms of their semantic relatedness. research using this task consistently shows that people can intuitively discriminate semantically related word triads (e.g., deep salt foam; common denominator: sea) from semantically unrelated word triads (e.g., dream ball book; no common denominator) (bolte & goschke, 2005; bowers et al., 1990) without being able to explicitly name the basis for their judgment – they just know it without knowing why (epstein, 2008). it seems reasonable to assume that people are not always able to intuitively detect meaning and coherence. one important influencing factor seems to be the affective state intuitive judgments in depression 2 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ of a person. positive mood broadens the scope of attention, facilitates associative process‐ ing (fredrickson & losada, 2005; harel, tennyson, fava, & bar, 2016) and increases the preference for thematic processing that is needed for semantic coherence detection (e.g., maldei, baumann, & koole, 2020). in line with this, people are more likely to rely on in‐ tuition (zander-schellenberg, remmers, zimmermann, thommen, & lieb, 2019) and are more accurate in discriminating meaning from meaninglessness when in a positive mood (balas et al., 2012; bolte et al., 2003). negative mood states, in contrast, are associated with narrowing attentional focus and inhibiting associative processing (sass et al., 2012). along this line, negative mood and a tendency to brood have been shown to impair intuition (baumann & kuhl, 2002; bolte et al., 2003; remmers & zander, 2018; sweklej et al., 2015). here, we assume that intuitive processing is impaired in depressed patients in particular. depression is characterized by negative mood and a brooding, rigid, style of think‐ ing. this is opposed to an intuitively integrating and holistic style of processing (see remmers & michalak, 2016). while intuitive processing is accompanied by cognitive ease, feelings of rightness and the detection of meaning and coherent structures in the environment (see fluency-affect intuition model; topolinski & strack, 2009a), depressive thinking is doubtful – as a consequence, nothing feels easy and right anymore. further‐ more, depression is associated with experiencing less meaning in life and with lower abil‐ ities to construct coherent narratives of one’s life (baerger & mcadams, 1999; mascaro & rosen, 2005). as finding meaning is mainly a product of intuitive processing (hicks & king, 2007), and intentional, analytical search for meaning can impair the intuitive detec‐ tion of meaning (topolinski & strack, 2008), it seems reasonable to assume that intuitive meaning detection is impaired in depression where a ruminative processing style is prev‐ alent (watkins & teasdale, 2004). recent research has indeed shown that patients with depression have deficits to intuitively detect semantic coherence as compared to healthy control participants (remmers & michalak, 2016; remmers, topolinski, buxton, dietrich, & michalak, 2017; remmers, topolinski, dietrich, & michalak, 2015). the current study seeks to replicate these findings and moves one step further in exploring the underlying mechanisms of assumed intuition impairments in depression. apart from the influence of people’s mood states (balas et al., 2012; bolte et al., 2003), research has investigated further cognitive-affective processes underlying intuition and semantic coherence detection. the fluency-affect model of intuition suggests that processing fluency and subtle positive affect are major factors jointly driving coherence judgments (topolinski & strack, 2009a). coherent triads are processed more fluently (i.e., faster), and fluency leads to a brief positive affective response channeling the intuitive judgment (e.g., a positive feeling of ease that is used in the following judgment or decision; reber, schwarz, & winkielman, 2004; reber, winkielman, & schwarz, 1998). moreover, it has been shown that coherent triads are liked more than incoherent triads and that the mere reading of coherent triads activates people’s smiling muscle and remmers, zimmermann, topolinski et al. 3 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ relaxes the frowning muscle (indicating decreased negative affect and mental effort; see topolinski, likowski, weyers, & strack, 2009). these results suggest that coherence is fluently processed and triggers subtle positive affect that in turn functions as an internal cue generating the intuitive coherence judgment (topolinski & strack, 2009a; see also winkielman & cacioppo, 2001, for psychophysiological evidence on the effects of processing fluency and positive affect). in addition, there is also evidence showing that manipulating both fluency and posi‐ tive affect influences whether people feel coherence. manipulating positivity on a subtle level (e.g., by subliminal affective facial priming or by manipulating the affective valence of word triads or solution words; balas et al., 2012) increases participants’ tendency to judge triads as being coherent (independent of their actual coherence). in a similar vein manipulating the fluency of word triads (e.g., by manipulating the figure-ground contrast in which triads are presented) makes it more likely that people judge these as being coherent (as compared to less fluently processed word triads presented in a low figure-ground contrast; topolinski & strack, 2009a). yet, whether manipulated fluency and positivity also influence depressed patients’ intuitive coherence judgments has not been investigated so far. the current study the aim of the current study was to replicate and extend preliminary evidence on intuition deficits in depression. we tested a sample of depressed inpatients and compared their performance in the judgment of semantic coherence task (jsct; bowers et al., 1990) to a healthy control sample. going one step further, we also aimed at investigating potential underlying mechanisms of impairments in intuitive coherence detection in patients with depression. the following main hypotheses were pre-registered and investigated (see the supple‐ mentary materials for the preregistration): the first hypothesis (h1) refers to the replica‐ bility of recently found intuition deficits in depression (remmers et al., 2015; remmers et al., 2017). we hypothesized that patients with an acute episode of major depression are less able to intuitively discriminate semantic coherence from semantic incoherence in the jsct than healthy controls. the second hypothesis (h2a) assumes that processing fluency triggers semantic co‐ herence judgments in patients with depression. building up on basic research, we expec‐ ted that in depressed patients word triads that are presented in a high figure-ground contrast – and which are therefore presumed to be processed more fluently – are more likely to be judged to be coherent than triads presented in a low contrast. given that research using self-reports (tsourtos et al., 2002; see also o’connor et al., 1990) as well as experimental tasks supports the notion that mental activity is slowed in depression (e.g., den hartog et al., 2003), we also expected that the effect of processing fluency intuitive judgments in depression 4 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ on coherence judgments would be smaller in the depressed sample as compared to the healthy sample (h2b). the third hypothesis (h3a) was that the positive valence of stimuli influences seman‐ tic coherence judgments in patients with depression. building up on basic research (topolinski & strack, 2009a; experiment 8) showing that healthy subjects are more likely to judge triads to be coherent that consist of positive as compared to negative words, we expected that this effect would also emerge for depressed patients. however, it seemed reasonable to assume that depression moderates the effect of positive valence on coherence judgments because research shows that the preference for positive stimuli usually found in healthy samples is attenuated in depressed patients (deveney & deldin, 2006; joormann & gotlib, 2007). thus, we hypothesized that the effect of positive valence on coherence judgments is smaller in the depressed sample as compared to the healthy sample (h3b). an a priori power analysis can be found in appendix a. method participants forty inpatients were recruited from the vivantes klinikum berlin-kaulsdorf, germany, a municipal psychiatry. the clinic staff informed the trained research assistant from the freie universität berlin about patients potentially fitting the inclusion criteria, who were then approached in person. in addition, patients were addressed in the weekly psychoeducation depression group therapy. the healthy control sample was recruited through advertisements in social media, local newspapers and online advertisement platforms and tested by research assistants at the freie universität berlin. in the clinical sample, the presence of a current episode of unipolar depression was required for inclu‐ sion. exclusion criteria for the clinical sample were presence of psychotic symptoms, a bipolar disorder and acute suicidal tendencies. for the control sample, the presence of any mental disorder was an exclusion criterion. for all participants inclusion in the study additionally required a minimum age of 18 years and signed written consent. the inclusion and exclusion criteria were verified by conducting the affective and psychotic disorder modules of the structured clinical interview according to dsm-iv with each participant (scid; german version: wittchen, zaudig, & fydrich, 1997). in the clinical sample, five subjects were excluded from the study. two subjects did not fulfill the criteria for a current depressive episode. one subject had to be excluded due to the presence of psychotic symptoms and in one patient a depressive diagnosis due to a medical condition could not be excluded. another subject could not credibly distance herself from suicidal tendencies during the interview, so that the hospital staff was called in and participation in the study was terminated. in the healthy sample, no subject was excluded. a total of 70 subjects took part in the study (35 in each group). remmers, zimmermann, topolinski et al. 5 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ procedure upon arrival both at the clinic and at the university laboratory, participants were wel‐ comed and received the informed consent that they were asked to sign. participants were then interviewed by a trained rater with the scid. either directly after the scid interview or at an appointment shortly afterwards, included subjects completed the intuition task consisting of three blocks (general intuition, fluency, valence; for a detailed description see appendix b). the procedure of the jsct was identical to that of previous studies (remmers et al., 2015, 2017). participants saw a set of word triads (e.g. deep salt foam; dream ball book) and were asked to indicate for each triad whether it was coherent or incoherent by pressing the respective key on the computer keyboard. each trial began with the presentation of a fixation cross (1000 ms), followed by the presentation of the triad (1500 ms). after disappearance of the triad from the screen, "coherent" and "incoherent" appeared on the left or right side of the computer screen. the key positions of "coherent" and "incoherent" were randomized for each participant; once assigned, the key positions remained the same for each participant throughout the experimental task. participants had 2000 ms to press the reaction key on the keyboard for their corresponding coherence judgment. if a participant failed to react within 2000 ms, "too slow" appeared on the screen and the next trial started. if participants managed to respond within the given reaction time window, they could type in an x or a possible solution word within 8 seconds. each word triad was only presented once, which prevented exposure and repetition effects as well as analytic insight. all participants performed three blocks that followed the procedure above but with varying stimulus material (see appendix b for a detailed description). in the general intuition block, only coherence (coherent triads vs. incoherent triads) was manipulated. in addition to manipulating coherence, we manipulated fluency (high figure-ground contrast vs. low figure-ground contrast) in the fluency block and valence (positive triads vs. negative triads) in the valence block, resulting in four conditions in the latter two blocks respectively. at the end of each block participants indicated how much they trusted their intuition in the respective task on a 7-point likert scale. all three blocks were programmed using jspsych, a javascript library for creating behavioral experiments in a web browser (de leeuw, 2015). after completion of the three intuition blocks, subjects filled out a demographic questionnaire as well as other self-report instruments, not of interest for the current paper (see supplementary materials for all measured variables) and then received an amazon voucher as study compensation. participating in the entire study lasted about 1 – 1.5 hours. the study was approved by the ethical committee of the freie universität berlin and in compliance with the helsinki declaration. intuitive judgments in depression 6 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ statistical analysis participants’ performance in the jsct was the main outcome of the study. trials were discarded in which participants did not provide their coherence judgment within the given time window of 2000 ms. these missed trials were analyzed separately and served us to explore whether patients and healthy controls differed in their ability to react within the given short time window. solved trials were also discarded from the following coherence judgment analyses because these trials were indicative of explicit insight and not intuition (see topolinski & strack, 2009a). a trial was considered as solved when a participant provided the correct solution word or a synonym after the coherence judgment, being rated by two raters independently. solved trials were thus analyzed separately and served us to explore whether depressed patients and healthy controls differed in the extent to which they had explicit insight. participants who had missed responding in the given time window were not asked to type in a solution word. missed trials and solved trials did not overlap. to test h1, we computed a discrimination index for each participant after exclusion of missed responses and solved trials. for this, we first computed hit rates (i.e., the proportion of coherent trials that were correctly judged as coherent, but which were not solved) and false alarm rates (i.e., the proportion of incoherent trials, which had incorrectly been judge as coherent). we then calculated a simple discrimination index by subtracting false alarm rates from hit rates (called pr in snodgrass & corwin, 1988; see also bolte & goschke, 2008). this index conveys participants’ ability to discriminate between coherent and incoherent trials (see bolte et al., 2003; remmers et al., 2017; topolinski & strack, 2009a). participants’ responses are defined as accurate to the extent that their hit rate exceeds their false alarm rate. we tested h1 using an independent samples t-test with depression as the independent variable and the discrimination index from the jsct general intuition block as the dependent variable. hypothesis h2a was tested using a random intercept model, which is conceptually equivalent to fitting a repeated measures anova. in this model, the four conditions of the jsct fluency block are nested within participants (i.e., each participant contributes four data points, and the random intercept accounts for the fact that the four assessments are usually positively correlated). we used coherence, fluency, and their interaction to predict the percentage of triads that have been judged as coherent (after deleting missed and solved triads). the relevant effect here was the effect of fluency. note that we only included participants with depression for testing this hypothesis. in contrast, h2b was tested in the full sample, again using a random intercept model. this time, we used coherence, fluency, depression, and their twoand three-way interactions to predict the percentage of triads that have been judged as coherent in the fluency block. the relevant effect here is the interaction effect of depression and fluency. hypotheses 3a and 3b were tested using the same approach, this time based on data from the jsct valence block and using valence instead of fluency as a predictor. remmers, zimmermann, topolinski et al. 7 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ in line with the preregistration, we corrected univariate outliers within groups (|z| > 2.5) prior to hypothesis testing using the winsoring method. this way, we corrected 19 data points in 21 variables across 70 participants (1.3%). the criterion for inferences for each hypothesis was p < .05 (two-tailed). satterthwaite’s approximations were used to derive p-values for fixed effects in random intercept models. all analyses were conducted within the statistical environment r (r core team, 2018). random intercept models were estimated using full maximum likelihood estimation implemented in the r package “lme4”. results descriptive statistics the depressive sample (m = 41.74, sd = 12.40) and the control sample (m = 44.37, sd = 16.85) did not differ significantly from each other in terms of age, t(62) = 0.74, p = .46. also, with respect to gender (depressed group: 22 females; control group: 21 females), there was no significant group difference, χ2(1) = 0.06, p = .806. however, there was a significant difference in terms of education, u(35, 35) = 445.5, p = .032, with the control sample having a higher educational degree as compared to the depressed sample. preparatory analyses of the general intuition block results suggested that depressed patients did not differ significantly from healthy con‐ trols regarding the number of missed trials (i.e., trials in which subjects did not respond within the given time window), the number of solved trials (i.e., coherent trials for which the correct solution word was typed in), and the average response time (see appendix c for details). moreover, depressed patients (m = 0.50, sd = 0.18) and healthy control participants (m = 0.47, sd = 0.21) did not differ significantly in the hit rate (i.e., proportion of triads that they correctly judged as coherent), t(68) = 0.68, p = .50, 95% ci [-0.06, 0.13]. also, with regard to the false alarm rate (i.e., proportion of triads that were incorrectly classified as coherent), there was no significant difference between the depressed sample (m = 0.32, sd = 0.17) and the healthy sample (m = 0.28, sd = 0.14), t(68) = 1.01, p = .31, 95% ci [-0.04, 0.11]. finally, on average, participants from both samples could discriminate between coherent and incoherent trials above chance level. this was indicated by one sample t-tests showing that the discrimination index differed from zero in both the depressed sample (m = 0.18, sd = 0.17, t[34] = 6.13, p < .001) and the healthy sample (m = 0.19, sd = 0.18, t[34] = 6.10, p < .001). confirmatory hypotheses testing analyses regarding h1 revealed that depressed patients and healthy control participants did not differ significantly in their ability to discriminate semantic coherence from intuitive judgments in depression 8 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ semantic incoherence in the jsct general intuition block, t(68) = 0.12, p = .90, 95% ci [-0.09, 0.08] (see figure 1). figure 1 boxplots of intuition discrimination index for patients with depression (red column) and healthy control participants (blue column) −0.2 0.0 0.2 0.4 0.6 patients with depression healthy controls groups in tu it io n d is cr im in at io n in de x with regard to h2a, results showed that fluency did not significantly predict the per‐ centage of triads that have been judged as coherent in depressed patients, f(1,105) = 0.21, p = .65. however, coherence had a significant effect on coherence judgments, with coherent trials being more likely to be judged as coherent as compared to incoherent trials, f(1,105) = 13.57, p < .001. the interaction between coherence and fluency was not significant, f(1,105) = 0.11, p = .74 (see left panel in figure 2). with regard to h2b, results revealed that the interaction effect of depression and fluency was not significant in predicting coherence judgments, f(1, 210) = 0.19, p = .66. thus, our findings do not support the hypothesis that the effect of fluency on coherence judgments was smaller in the depressed sample as compared to the healthy sample. in this model, only coherence, f(1, 210) = 60.95, p < .001, and the interaction of group and coherence, f(1, 210) = 4.75, p = .03, significantly predicted the percentage of triads that have been judged as coherent. fluency, depression, and further interaction effects were not significant (see figure 2). remmers, zimmermann, topolinski et al. 9 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ figure 2 coherence judgment rates for depressed patients and healthy controls in the high vs. low fluency and coherent vs. incoherent conditions patients with depression healthy controls low high low high 0.2 0.4 0.6 0.8 fluency c oh er en ce r at e coherence coherent incoherent note. figure 2 indicates no significant effect of the fluency manipulation on coherence judgments and no interaction effect between group and fluency on coherence rate. in line with h3a, analyses revealed that positive valence of word triads significantly predicted semantic coherence judgments in depressed patients, f(1, 105) = 38.45, p < .001. furthermore, the effect of coherence, f(1, 105) = 80.98, p < .001, and the interaction effect of valence and coherence were significant, f(1, 105) = 8.60, p < .01. the pattern of results suggested that coherent triads that were positive in valence were most likely to be judged as coherent (see left panel of figure 3). with respect to h3b, results did not confirm the hypothesis that depression moderated the effect of positive valence on coherence judgments. the effect of positive valence on coherence judgments was not smaller in the depressed sample as compared to the healthy sample, f(1, 210) = 0.02, p = .88. in this model, valence, f(1, 210) = 85.52, p < .001, coherence, f(1, 210) = 175.04, p < .001, and their interaction, f(1, 210) = 10.01, p < .01, were significant. the effect of group and its interaction with valence and coherence were not significant (see figure 3). intuitive judgments in depression 10 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ figure 3 coherence judgment rates for depressed patients and healthy controls in the positive vs. negative valence and coherent vs. incoherent conditions patients with depression healthy controls negative positive negative positive 0.2 0.4 0.6 0.8 valence c oh er en ce r at e coherence coherent incoherent note. figure 3 indicates a significant effect of the valence manipulation in both the depressed group and the control group and no interaction effect between group and valence on coherence rate. exploratory follow-up analyses for testing our main preregistered hypothesis regarding intuition deficits in depressed patients, we selected a simple discrimination index (i.e., the difference between hit and false alarm rates) that has also been used in previous studies (bolte & goschke, 2008). to check the robustness of our results, we calculated another index established in signal detection theory, namely a’. this non-parametric measure accounts for small numbers of observations per cell and corrects for hit rates of 1.0 and false-alarm rates of 0.0 (pollack, 1970; pollack & norman, 1964). a’ of .5 indicates performance on chance level, and perfect discrimination yields an a’ of 1. we repeated our analyses for h1 using a’ and found that results did not differ from results using the simple discrimination index (see appendix c). we also repeated our preparatory analyses and analyses for h1 combining the data from all blocks (i.e., including the data from the fluency and valence block). with regard to h1, again no significant differences emerged, neither for the simple discrimination index nor for a’. we also did not find significant differences in the number of solved remmers, zimmermann, topolinski et al. 11 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ trials. however, across all intuition blocks, depressed patients missed more trials and had significantly higher reaction times as compared to healthy controls (see appendix c). discussion the aim of the present study was to replicate recently demonstrated deficits in intui‐ tive semantic coherence detection and to explore the effects of processing fluency and positivity on intuition in depressed patients. one major finding was that patients with depression did not differ from healthy controls in their ability to discriminate semantic coherence from semantic incoherence (h1). even though controls were better at discrim‐ inating coherent from incoherent triads compared to depressed patients in the fluency block (indicated by a significant interaction between group and coherence), differences in discrimination indices were not significant when considering data from all blocks. these findings may query the hypothesis of impaired intuition in depression. howev‐ er, methodological issues should be considered. the true difference between the groups might be smaller than expected (based on prior research). thus, our study may have lacked the power to detect it. moreover, hit and false alarm rates were computed after exclusion of missed trials. thus, subjects who only responded when they were relatively confident in their judgment (i.e., when seeing a comparably easy triad) might have yielded a higher intuitive discrimination index as compared to subjects who missed rela‐ tively few trials. as such, the non-significant difference in intuitive performance might have resulted from depressed patients’ higher tendency to not respond within the given time window, for example when being unsure and less confident, or when confronted with more difficult trials. indeed, depressed patients missed significantly more trials as compared to healthy control participants when considering their responses across all three intuition blocks. our exploratory analyses with reaction times also showed that on average and across all blocks, depressed patients were slower than healthy controls. together with the finding on missed trials, this result points out that future research would do well in elucidating how longer response times are associated with patients’ intuitive discrimina‐ tion accuracy. researchers should hereby distinguish between simple between-subject approaches such as mean reaction time analyses and more sophisticated within-subject methodologies. using, for example, stochastic diffusion models, can provide important insights into speed-accuracy trade-offs (voss, nagler, & lerche, 2013). the latter take information from individual distributions into account and hereby help to disentangle how performance differs between conditions (or groups), and – importantly – in which way it does and how speed-accuracy interactions may reflect cognitive biases (e.g., being more accurate when responding faster may reflect intuitive capacities). although this kind of model can be applied to many experimental paradigms and provides much more intuitive judgments in depression 12 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ insight than the analysis of mean response times, it is still rarely used in cognitive psychology and in clinical psychopathology research in specific. altogether, our findings and considerations call for more replication studies to eluci‐ date the question whether depressed patients are impaired in intuitively detecting mean‐ ing and coherence in their environment and within themselves (e.g., meaning in life). regarding the latter, it seems fruitful to connect intuitive coherence detection research with research on memory coherence, i.e., the ability to construct one’s autobiography in a coherent, integrated way. as memory coherence is associated with psychological health, positive therapy outcomes and seems to buffer protectively against the impact of early life stress (adler et al., 2013; baerger & mcadams, 1999), future research should explore to what extent performance in the jsct is associated with a person’s memory coherence. hereby, upcoming research should also take the heterogeneity of depression (monroe & anderson, 2015) as well as interindividual differences into account. hicks and colleagues (2010) showed for example how interindividual differences in self-reported preference for intuitive processing influence the interplay between positive affect and intuition. with respect to our research question arises whether intuitive processes are especially impaired in patients with recurrent forms of depression, (and) or only in patients with anhedonia? in other words: it should be explored for which patients the assumption of impaired intuitive processing holds to get a better understanding of this issue. results did not reveal any effect of our fluency manipulation, and thus our hypothe‐ ses regarding fluency (h2) were not supported. as such, the current study could not replicate previous results that bolstered the fluency model proposed by topolinski and strack (2009a, 2009b). in order to explore whether processing fluency will prove as a major determinant of coherence judgments or not, future studies should use other fluen‐ cy manipulations such as priming (see topolinski & strack, 2009a). in addition, future research should take into account that fluency may not always lead to positive affective responses (gamblin, banks, & dean, 2020) and thus also not to coherent responses. given that processing fluency and affective responses may interact differently depending on characteristics of the presented stimulus or the responding individual, future studies should disentangle the differential effects of processing ease on task performance. the results further showed that positive (vs. negative) valence triggered coherence judgments (h3a) and that this effect was – in contrast to our hypothesis (h3b) – not moderated by depression. this suggests that depressed patients may be susceptible for positive affectivity conveyed by the valence of word triads and used it – when provided externally – in their judgments. this is an important finding, because even though depression is characterized by anhedonia (i.e., the inability to experience positivity), pa‐ tients seemed to be inclined to detect meaningfulness and coherence when encountering positive valence, bolstering the idea that positivity plays a major role in finding meaning. remmers, zimmermann, topolinski et al. 13 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ how can the current findings be reconciled with previous research depressed pa‐ tients’ processing of positivity? at first glance they seem to stand in contrast to research showing that – opposed to healthy people – depressed patients do not direct their attention to positivity and are less susceptible to positive stimuli (duque & vázquez, 2015; pool, brosch, delplanque, & sander, 2016; winer & salem, 2016). in their compre‐ hensive review lemoult and gotlib (2019) conclude that biases (e.g., faster reaction time in response to negative as opposed positive stimuli) are mostly found when stimuli are presented longer and when faces as opposed to words are presented. thus, it is conceivable that depression did not moderate the effect of positive valence manipulation in our study because (a) presentation of stimuli was short enough (and hereby prevented conscious processing) and (b) words (and no faces) were presented. however, these comparative conclusions should be drawn cautiously because our main outcome were binary coherence judgments and not response times. given the heterogeneity of previous research on biases in the processing of positive affect (e.g., yoon, joormann, & gotlib, 2009), future studies would do well in examining different cognitive abilities (memory, attention, intuitive decisions) along together. also, it remains open to what extent posi‐ tivity exhibited its effect on a conscious level. future work should elucidate this issue by exploring whether rather implicit or explicit induced positive affect resonates in depressed patients. our findings also revealed a significant interaction between valence and coherence in the valence block (i.e., positive word triads that were coherent were most likely to be judged as coherent in both groups). this finding indicates that positivity (con‐ veyed by positive valence in the current study) may lead to more accurate intuitive judgments and is in line with previous research showing that not only “tonic” positive affect (e.g., manipulated or freestanding positive mood; balas et al., 2012; bolte et al., 2003) but also “phasic” positive affect (induced by the activation of positively valenced memory content) can strengthen the accuracy of coherence judgments (topolinski & strack, 2009b). in a similar fashion, balas et al. (2012) demonstrated increased accuracy for triads with positive solution words as compared to triads with negative solution words. future research should test the underlying theoretical assumptions on the positive affect-intuition-interplay by implementing measures assessing positive affect in individu‐ als, because otherwise it remains speculative whether it is indeed “affect” (within the individuals) that triggers these effects (see alves et al., 2015, for potential alternative explanations on the effects of positive valence). along this line, it is of important practical relevance to test whether depressed patients can themselves produce the positive affect needed to go with their intuition in daily life. extending laboratory research, a recent daily diary study found that people are not only inclined to make decisions intuitively when they are in a good mood (as com‐ pared to a negative mood, remmers & zander, 2018) but that people also report to feel better after intuitive as compared to analytical decisions (zander-schellenberg, remmers, intuitive judgments in depression 14 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ zimmermann, thommen, & lieb, 2019). to explore whereas these decision-mood dynam‐ ics also apply to currently depressed patients outside the laboratory, is an important next step also in terms of ecological validity and clinical relevance. from a therapeutic perspective, the current findings imply that targeting positive af‐ fect in psychotherapy may be important in fostering patients’ ability to detect coherence. it would be an important next step to investigate the intuitive detection of meaning not only with regard to laboratory stimuli but also on a broader level with regard to finding coherence and meaning in life. hereby, clinical researchers may build upon recent basic psychological research on how intuitive processing, positive affect, and finding meaning in life interact (heintzelman & king, 2013). considering that finding meaning in life is rather a product of intuitive processing than a result of analytical reasoning or explicit meaning construction (heintzelman & king, 2013), research in this field may have farreaching practical and theoretical clinical implications. a number of limitations should be taken into account. first, even though the sample size was in compliance with the a-priori power analysis, it was still relatively small. thus, future studies should test our assumptions with larger samples to increase the power and reliability of findings. furthermore, a limitation of the current study was that the samples were not matched in terms of educational level. even though the relatively lower educational level of depressed patients is consistent with epidemiological studies showing that the prevalence of psychological disorders is higher in low socioeco‐ nomic groups, future studies should take care of the matching issue to avoid potential confounds. in addition, we randomized different factors such as the key position for the coherence judgments and the stimuli that were either presented in the main intuition block or the fluency bock. even though randomization is of methodological importance, this may have led to reduced comparability of responses between subjects and thus to reduced power to detect group differences. thus, future research should use larger sets of stimuli and larger sample sizes in order to ensure randomization and reduce statistical noise. furthermore, conclusions with regard to the role of positivity should be drawn cautiously because our study was lacking a neutral control condition. thus, we cannot rule out that, for example, reduced negativity (as opposed to increased positivity) drove our effects in the valence block. future studies should test whether positivity (e.g., conveyed by the valence of stimuli) alters subtle affective responses in subjects. only by this means we can conclude whether positive affect elicited in subjects triggers coherence judgments (see topolinski & strack, 2009a for a detailed description of the fluency-affect intuition chain). albeit these considerations, the current study presents an important contribution to the field. it is a preregistered replication study which follows current state-of-the-art demands to bolster the robustness of psychological research findings. in addition, we used experimental paradigms from basic psychology and hereby build the bridge from basic to clinical research. altogether one may conclude from the current study that the remmers, zimmermann, topolinski et al. 15 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ cognitive profile of depressed patients is not merely deficient. the results elucidate the importance of positivity when it comes to detecting meaning and coherence. the latter is of major clinical importance, because in a depressed state, people often experience their life as meaningless and cannot find coherence. whether promoting positivity may not only enhance how patients feel but will also help them to find meaningfulness and to follow their intuitions is a fruitful endeavor to study for future research. funding: this research was facilitated by research funds of the forschungskommission of the freie universität berlin. competing interests: the authors have declared that no competing interests exist. acknowledgments: we thank lola hermann, isabelle klausener, and leonard wegner for their help in data collection. supplementary materials the supplementary materials include the preregistration protocol for this study (for access see index of supplementary materials below). index of supplementary materials remmers, c., zimmermann, j., topolinski, s., richter, c., zander-schellenberg, t., weiler, m., & knaevelsrud, c. 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remmers et al., 2015); the within-subjects effect size of the fluency manipulation in a student sample was dz = 0.5 (similar to h2a; topolinski & strack, 2009a, experiment 1); and the within-subjects effect size of the affect induction in a student sample was dz = 1.19 (similar to h3a; topolinski & strack, 2009a, experiment 8). we did not have any prior information about the size of the proposed interaction effects (h2b and h3b), and thus we considered here a smaller effect size of d = 0.35. based on these assumptions, we conducted a series of a priori power analyses using gpower (faul, erdfelder, buchner, & lang, 2009), focusing on the difference between two independent means (h1), the within-subjects effect of a repeated measures anova (h2a and h3a, assuming a correlation of r = .5 between the repeated measurements), and the within-between-subjects interaction effect of a repeated measures anova (h2b and h3b, again assuming a correlation of r = .5 between the repeated measurements). to detect each of these effects with a probability of 80% and an alpha error probability of 5% (two-sided), the following sample sizes (per group) are required: 33 (h1), 34 (h2a) 34 (h2b), 8 (h3a), and 34 (h3b). thus, we conclude that 35 participants per group may represent an acceptable sample size given prior findings. appendix b: procedure of the judgment of the semantic coherence task introduction phase. the first computer screens introduced subjects to the intuition task and explained that the task was about intuition. participants were informed that the task was not about right or wrong decisions or about finding a solution (i.e., typing in the correct solution word) but rather about intuitive gut reactions in response to the presented stimuli. letting participants type in a solution word served us to distinguish between intuitively detected but unsolved trials (being indicative for intuition; see remmers et al., 2015 and topolinski & strack, 2009a for detailed description) and explicitly solved trials (being indicative for insight and not intuition). the intro‐ ductory phase also included the presentation of exemplary coherent and incoherent word triads (e.g., deep salt foam; coherent triad, common denominator: sea) not reappearing later in the task. next, subjects underwent a practice block in which they were asked to react within 2000 ms and to indicate whether presented exclamation marks appeared on the right or left side of the screen by pressing the respective keyboard keys. the same keys, namely s and l on the keyboard (german qwertz keyboard layout), later served as reaction keys for the coherence judgments. keyboard button assignment was randomly assigned for each participant and remained the same for each participant once assigned during the entire experimental task. hereby, it was manipulated whether the left (s) or the right (l) keyboard button indicated a coherence or incoherence judg‐ ment. general intuition block. to measure the general ability to intuitively detect semantic coher‐ ence subjects performed the jsct according to bowers et al., 1990 (see also topolinski & strack, 2009a; remmers et al., 2015, 2017). thus, in this block, all subjects performed the jsct in which only the coherence of the triads was manipulated (coherent vs. incoherent word triads). a total of 36 triads were presented in this part to test the ability to detect semantic coherence (18 coherent, 18 remmers, zimmermann, topolinski et al. 21 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ incoherent, re-randomized order for each subject, stimulus material see bolte et al. 2003; topolinski & strack, 2009a). fluency block. to investigate the effect of processing fluency on coherence judgments, an experimental manipulation established in basic research was applied. methodologically equivalent to topolinski and strack (2009a, experiment, 1), the figure-ground contrast was manipulated as a means to alter the fluency with which stimuli are processed. for this, triads were presented in blue, red or green letters. high-fluency triads had a high figure-ground contrast (against the white background) by manipulation of the rgb (red, green, blue) components. an rgb combination of r = 255, g = 0 and b = 0 results, for example, in a red triad with a strong contrast, whereas the combination of r = 255, g = 200, b = 200 yields a light red colour and hence low contrast against the white background. in line with the procedure of topolinski & strack (2009a; but see also reber, winkielman, & schwarz, 1998; unkelbach, 2007), we designed a red high-contrast (thus high-fluency) triad by assigning a random value between 100 and 120 for the b and g component, and by assigning 255 to the r component. a red low-contrast (thus low-fluency) triad was designed by assigning a random value between 200 and 220 for the b and g components. this was one for the other colours, too. deriving from the stimulus pool of bolte et al. (2003), 36 triads were presented. using a 2 (high vs. low fluency) x 2 (coherent vs. incoherent) intra-individual factorial design, 4 experimental conditions resulted: 9 coherent triads with high figure-ground contrast; 9 incoherent triads with high figure-ground contrast; 9 coherent triads with low figure-ground contrast; 9 incoherent triads with low figure-ground contrast. it should be noted that stimuli of the general intuition block and the fluency block are taken from the same stimulus pool, but are randomly selected anew for each participant ensuring that no triad is seen twice by an individual on the one hand and that whether a triad is presented in the intuition or the fluency block is a matter of randomization and not preselected by the study team. valence block. to investigate the effect of positive valence on coherence judgments, subjects are presented with positive (e.g., luck children meadow; common denominator: game) and negative (e.g., sulfur glue black; common denominator: pitch) word triads. just like in the other two blocks, subjects’ task is to decide whether a presented triad is coherent or incoherent. taken from the stimulus pool of topolinski and strack (2009a; experiment 8), 48 triads were presented to each subject. using a 2 (positive vs. negative) x 2 (coherent vs. incoherent) intra-individual factorial design, 4 experimental conditions resulted: 12 positive coherent triads; 12 positive incoherent triads, 12 negative coherent triads, 12 negative incoherent triads). intuitive judgments in depression 22 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ appendix c: preparatory analyses and exploratory follow-up analyses ta bl e c .1 pr ep ar at or y a na ly se s an d ex pl or at or y fo llo w -u p a na ly se s va ri ab le pa ti en ts (n = 3 5) c on tr ol s (n = 3 5) tte st s m sd m sd δ m t df p c i_ lo w c i_ hi gh d g en er al in tu it io n bl oc k d isc rim in at io n in de x 0.1 8 0.1 7 0.1 9 0.1 8 0.0 0 -0 .12 68 0.9 0 -0 .09 0.0 8 -0 .03 a‘ 0.6 5 0.1 3 0.6 5 0.1 4 0.0 0 -0 .02 68 0.9 8 -0 .06 0.0 6 -0 .01 n um be r o f m iss ed tr ia ls 7.1 7 4.7 3 5.1 7 4.2 3 -2 .00 1.8 6 68 0.0 7 -0 .14 4.1 4 0.4 5 n um be r o f s ol ve d tri al s 0.6 3 0.9 1 0.8 9 1.0 5 0.2 6 -1 .09 68 0.2 8 -0 .73 0.2 1 -0 .26 av er ag e re ac tio n tim e pe r t ria l ( in se co nd s) 1.1 1 0.1 5 1.0 4 0.2 0 -0 .08 1.7 9 68 0.0 8 -0 .01 0.1 6 0.4 3 c om bi ne d bl oc ks d isc rim in at io n in de x 0.1 7 0.1 1 0.2 0 0.1 0 0.0 3 -0 .98 68 0.3 3 -0 .08 0.0 3 -0 .24 a‘ 0.6 4 0.0 9 0.6 6 0.0 9 0.0 2 -1 .07 68 0.2 9 -0 .06 0.0 2 -0 .26 n um be r o f m iss ed tr ia ls 15 .90 10 .76 10 .85 8.7 9 -5 .05 2.1 5 68 0.0 4 0.3 6 9.7 4 0.5 2 n um be r o f s ol ve d tri al s 1.8 7 2.4 7 2.1 9 2.2 6 0.3 1 -0 .55 68 0.5 8 -1 .45 0.8 2 -0 .13 av er ag e re ac tio n tim e pe r t ria l ( in se co nd s) 1.0 2 0.2 0 0.9 3 0.1 9 -0 .10 2.1 1 68 0.0 4 0.0 1 0.1 9 0.5 1 remmers, zimmermann, topolinski et al. 23 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. intuitive judgments in depression 24 clinical psychology in europe 2020, vol.2(4), article e2593 https://doi.org/10.32872/cpe.v2i4.2593 https://www.psychopen.eu/ intuitive judgments in depression (introduction) the current study method participants procedure statistical analysis results descriptive statistics preparatory analyses of the general intuition block confirmatory hypotheses testing exploratory follow-up analyses discussion (additional information) funding competing interests acknowledgments supplementary materials references appendices appendix a: power analysis appendix b: procedure of the judgment of the semantic coherence task appendix c: preparatory analyses and exploratory follow-up analyses lifetime trauma history and cognitive functioning in major depression and their role for cognitive-behavioral therapy outcome research articles lifetime trauma history and cognitive functioning in major depression and their role for cognitivebehavioral therapy outcome lena schindler 1 , tobias stalder 2 , clemens kirschbaum 1, franziska plessow 3 , sabine schönfeld 1,4, jürgen hoyer 5 , sebastian trautmann 5,6 , kerstin weidner 7, susann steudte-schmiedgen 1,7 [1] faculty of psychology, technische universität dresden, dresden, germany. [2] department erziehungswissenschaften und psychologie, universität siegen, siegen, germany. [3] neuroendocrine unit, department of medicine, massachusetts general hospital and harvard medical school, boston, ma, usa. [4] department of psychology, lund university, lund, sweden. [5] institute of clinical psychology and psychotherapy, technische universität dresden, dresden, germany. [6] department of psychology, medical school hamburg, hamburg, germany. [7] department of psychotherapy and psychosomatic medicine, medical faculty carl gustav carus, technische universität dresden, dresden, germany. clinical psychology in europe, 2021, vol. 3(3), article e4105, https://doi.org/10.32872/cpe.4105 received: 2020-07-27 • accepted: 2021-06-03 • published (vor): 2021-09-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: susann steudte-schmiedgen, department of psychotherapy and psychosomatic medicine, medical faculty carl gustav carus, technische universität dresden, fetscherstraße 74, 01307 dresden, germany. tel.: +49 351 458 3634. e-mail: susann.schmiedgen@tu-dresden.de supplementary materials: materials [see index of supplementary materials] abstract background: while cognitive-behavioral therapy (cbt) is the gold-standard psychological treatment for major depression (md), non-response and lacking stability of treatment gains are persistent issues. potential factors influencing treatment outcome might be lifetime trauma history and possibly associated primarily prefrontal-cortexand hippocampus-dependent cognitive alterations. method: we investigated md and healthy control participants with (md+t+, n = 37; md-t+, n = 39) and without lifetime trauma history (md+t-, n = 26; md-t-, n = 45) regarding working memory, interference susceptibility, conflict adaptation, and autobiographical memory specificity. further, md+t+ (n = 21) and md+tgroups (n = 16) were re-examined after 25 cbt sessions, with md-tindividuals (n = 34) invited in parallel in order to explore the stability of cognitive this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4105&domain=pdf&date_stamp=2021-09-30 https://orcid.org/0000-0002-8355-1603 https://orcid.org/0000-0001-7558-1274 https://orcid.org/0000-0002-9721-7817 https://orcid.org/0000-0002-1697-6732 https://orcid.org/0000-0002-8976-3244 https://orcid.org/0000-0002-1171-7133 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ alterations and the predictive value of lifetime trauma history, cognitive functioning, and their interaction for treatment outcome. results: on a cross-sectional level, md+t+ showed the highest conflict adaptation, but md+tthe lowest autobiographical memory specificity, while no group differences emerged for working memory and interference susceptibility. clinical improvement did not differ between groups and cognitive functioning remained stable over cbt. further, only a singular predictive association of forward digit span, but no other facets of baseline cognitive functioning, lifetime trauma history, or their interaction with treatment outcome emerged. discussion: these results indicate differential roles of lifetime trauma history and psychopathology for cognitive functioning in md, and add to the emerging literature on considering cognitive, next to clinical remission as a relevant treatment outcome. keywords major depression, lifetime trauma history, working memory, interference susceptibility, conflict adaptation, autobiographical memory, cognitive-behavioral therapy highlights • conflict adaptation was highest in md with lifetime trauma history. • autobiographical memory specificity was lowest in md without lifetime trauma history. • no differential treatment response was found in md with and without lifetime trauma history. • there were no changes of cognitive functioning over cbt, irrespective of lifetime trauma history. • only singular predictive value of cognitive functioning for cbt success emerged. meta-analyses suggest cognitive-behavioral therapy (cbt) as the gold-standard psycho­ logical treatment for major depression (md; e.g., barth et al., 2013; cuijpers et al., 2014), a condition characterized by depressed mood and loss of motivation together with behav­ ioral alterations such as reduced activity and disturbed sleep (diagnostic and statistical manual of disorders – fifth edition; american psychiatric association, 2013). however, a substantial patient subgroup fails to achieve clinically significant symptom improvement, with non-response and dropout rates of approximately 34% and 25%, respectively (for meta-analytic data, see cuijpers et al., 2014; hans & hiller, 2013). this highlights the need to enhance our understanding of factors associated with psychopathology and treatment outcome, allowing an optimization of cbt effects and reduction of dropout rates. here, trauma history is frequently discussed, defined as exposure to actual or threatened death, serious injury, or sexual violence (american psychiatric association, 2013). particularly for childhood trauma in md, associations with poorer therapy re­ sponse, longer remission time, and greater need for additional medication are relatively well-researched (for review and meta-analytic data, see nanni et al., 2012; nemeroff, lifetime trauma and cognitive functioning in md 2 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ 2016; teicher & samson, 2013). notably, lifetime trauma, including childhood, adulthood, or both types of trauma, has been far less well studied, except for one study suggesting negative associations of both childhood and adulthood adversity with therapy outcome in md (miniati et al., 2010). importantly, lifetime trauma history is assumed to co-occur with neurobiological (e.g., kolassa & elbert, 2007; sherin & nemeroff, 2011) and cognitive alterations (e.g., vasterling & arditte hall, 2018). however, data on this and its influence on therapy success in the context of md and trauma is sparse. in particular, primarily prefrontal-cor­ texand hippocampus-dependent functioning have received attention (mcintyre et al., 2013; rock et al., 2014; snyder, 2013; snyder & hankin, 2019). regarding the former, of importance might be working memory (wm) as a facet of executive functioning (ef) rel­ evant for temporal maintenance (usually assessed by the repetition of a list of numbers) and manipulation (usually assessed by the repetition of a list of numbers in a backward fashion) of content necessary for current tasks (diamond, 2013). accumulating evidence suggests impaired wm in patients with md (for reviews, see snyder, 2013; snyder & hankin, 2019). further, one study reported childhood trauma to predict performance in a compound wm score of information maintenance and manipulation in both patients with md and healthy controls (saleh et al., 2017), but another found no wm differences with respect to information maintenance or manipulation in patients with md with or without childhood trauma (dannehl et al., 2017). an ef domain considered to be even more impaired in md (e.g., snyder, 2013; snyder & hankin, 2019) is the ability to suppress irrelevant and/or interfering response tendencies while pursuing mentally represented goals (i.e., inhibitory control, diamond, 2013). typically, this is studied via the well-known simon task (simon, 1990), where the inhibition of a response following a task-irrelevant visual stimulus is necessary as a different response is required. the resulting additional performance costs (i.e., slower reaction times [rts] and/or increased percentages of error [pes]) compared to trials with matching automatic and required tendencies comprise the so-called simon effect as a measure of interference susceptibility (simon, 1990). after response conflicts, inhibitory control is typically increased, leading to a decreased impact of task-irrelevant informa­ tion compared to trials not following conflicts. the resulting difference in the simon effect is termed conflict adaptation (botvinick et al., 2001). in md, particularly this con­ flict adaptation according to task demands is suggested to be increased (van steenbergen et al., 2012). notably, previous work from our group revealed similar findings for patients with posttraumatic stress disorder (ptsd) and, albeit less clearly, trauma-exposed con­ trols (schindler et al., 2020; steudte-schmiedgen et al., 2014), encouraging research on the interaction of trauma and md. of note, there is an abundance of studies suggesting not only ef, but also mainly hippocampally-driven overgeneral memory retrieval (ogm) to be a central correlate of md (for meta-analytic data, see, e.g., sumner et al., 2010). this increased recall of over­ schindler, stalder, kirschbaum et al. 3 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ general (e.g., “i am happy when meeting friends”) instead of specific autobiographical memories (e.g., “i was happy on july 8 when i met friends”; williams et al., 2007) is also prevalent in ptsd, with trauma history a potential shared mechanism (moore & zoellner, 2007; ono et al., 2016; sumner et al., 2010; williams et al., 2007). however, previous contrasting of trauma-exposed and non-exposed individuals with md (notably, again only focusing on childhood trauma) provided mixed results, with one study finding ogm only in trauma-exposed (aglan et al., 2010) and another only in non-exposed individuals (kuyken et al., 2006). next to these cross-sectional findings of certain alterations of ef and autobiographi­ cal memory domains, and the possible mediating role of trauma history in md, it is plausible to assume that such alterations show significant change over psychotherapy. however, the vast majority of studies could not detect any changes of the cognitive alter­ ations described above over psychotherapy/combined psychoand pharmacotherapy (for wm, see, e.g., beblo et al., 1999; lahr et al., 2007; for inhibitory control, see, e.g., schmid & hammar, 2013; but ajilchi et al., 2016; for ogm, see, e.g., peeters et al., 2002). thus, a current meta-analysis (bernhardt et al., 2019) rather support the suggestions from previous reviews (e.g., bernhardt et al., 2019; köhler et al., 2015; moore & zoellner, 2007; snyder & hankin, 2019) of high stability of such alterations even after clinical remission, with improvements not exceeding task-specific practice effects. while previous data on cognitive markers as predictors for clinical outcome in the context of pharmacotherapy is promising (groves et al., 2018), research on cbt is outstanding, except for initial studies suggesting a predictive value of enhanced autobiographical memory specificity (sumner et al., 2010), but not interference susceptibility (goodkind et al., 2016). however, while lifetime trauma history is assumed to be associated with both therapy outcome (e.g., nemeroff, 2016; teicher & samson, 2013) and cognitive alterations (e.g., vasterling & arditte hall, 2018) in md, a combined investigation is still pending. hence, the aim of the current study was to examine (i) lifetime trauma history and (ii) facets of cognitive functioning (i.e., wm, interference susceptibility, conflict adaptation, and ogm) as well as (iii) their interaction in the context of md symptomatology and therapy success. due to the inconclusive literature on the interplay of lifetime trauma history and md for cognitive functioning, our first step was to study respective baseline alterations in md and healthy control participants with (md+t+, n = 37; md-t+, n = 39)1 and without lifetime trauma history (md+t-, n = 26; md-t-, n = 45). specifically, we aimed to (1) investigate whether the previously found effect of lifetime trauma history on conflict adaptation (schindler et al., 2020; steudte-schmiedgen et al., 2014) is also visible in md and (2) shed light on the conflicting evidence regarding ogm (aglan 1) md+t+ = patients with md with lifetime trauma history; md+t= patients with md without lifetime trauma history; md-t+ = patients without md with lifetime trauma history; md-t= patients without md and without lifetime trauma history. lifetime trauma and cognitive functioning in md 4 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ et al., 2010; kuyken et al., 2006). further, we assessed clinical and cognitive treatment outcome under consideration of lifetime trauma history by re-examining patients with md with (md+t+, n = 21) and without lifetime trauma history (md+t-, n = 16) after 25 cbt sessions. in order to account for practice effects, non-traumatized healthy con­ trol individuals (md-t-, n = 34) were re-invited in parallel. here, we hypothesized (3) poorer treatment outcome for md+t+ than for md+tindividuals. based on recent meta-analytic evidence (bernhardt et al., 2019), we aimed to examine whether we could confirm the finding of (4) no changes of cognitive functioning over cbt, irrespective of lifetime trauma history, also for the tasks studied here. on a last note, we aimed to (5) exploratorily study the predictive value of cognitive functioning for cbt outcome. method participants and procedures recruitment was conducted within the outpatient unit of the institute of clinical psy­ chology and psychotherapy of the technische universität dresden, as well as via flyers and local advertisements. individuals were included in the study if they were aged between 18 and 65 years, not pregnant (women), and did not report any severe physical diseases (e.g., cancer, encephalopathy) over the past five years. further exclusion criteria concerned hair-related and endocrine factors due to biomarker analyses reported else­ where (e.g., glucocorticoid medication; steudte et al., 2013; steudte-schmiedgen et al., 2014). the presence of md and any other dsm-iv (american psychiatric association, 2007) mental disorders was assessed using the standardized munich composite inter­ national diagnostic interview (dia-x/m-cidi; wittchen & pfister, 1997) conducted by therapists of the outpatient unit or trained research team members and confirmed by an experienced clinical psychologist. twenty-eight participants from the md groups showed psychiatric comorbidities within the last 12 months (one: n = 15, two: n = 8, three or more: n = 5). those encompassed specific (n = 12) or social phobia (n = 13), somatoform disorders (n = 6), panic disorder with or without agoraphobia (n = 8), generalized anxiety (n = 3), obsessive-compulsive (n = 2), adjustment (n = 2), or eating disorders (n = 1). an assignment to the md groups was based on a current primary 12-month md diagnosis and no 12-month diagnosis of substance abuse or dependence (except for nicotine) or any lifetime diagnoses of psychosis, severe depressive disorder with psychot­ ic symptoms, or bipolar disorder. notably, individuals meeting the lifetime diagnostic criteria for ptsd were also excluded from the study, in order to allow insights into the role of lifetime trauma exposure per se for cognitive functioning in md. participants were included in the control group if they did not report any lifetime mental disorders accord­ ing to the dia-x/m-cidi stem questions and the mini international neuropsychiatric interview (m.i.n.i.; sheehan et al., 1998). participants were further classified as exposed or schindler, stalder, kirschbaum et al. 5 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ non-exposed to lifetime trauma based on the posttraumatic stress diagnostic scale (pds; ehlers, steil, winter, & foa, 1996). for an allocation to the t+ groups, both the “objective” a1 (“actual or threatened death or serious injury or a threat to the physical integrity of oneself or others”) and the “subjective” a2 criterion (“intense fear, helplessness or horror”) had to be met, following the dsm-iv requirements that qualify life events as traumatic (american psychiatric association, 2007). the control groups are the same as in the parallel study on patients with ptsd (schindler et al., 2020). for further participant characteristics, see table 1 and supplementary materials (type of lifetime trauma history). cbt for md groups was conducted within the outpatient unit based on established manuals (hautzinger, 1998, 2008) and supervised by experienced therapists. after 25 sessions, md+t+ and md+tpatients were re-invited for clinical and cognitive testing, with md-tparticipants being contacted in a parallel fashion (no difference regarding months between assessments: m = 13.5, sd = 3.86; m = 11.56, sd = 4.03; and m = 14.76, sd = 6.97, respectively; f(2, 68) = 1.78, p = .177, ηp2 = .05). among the 63 patients with md examined at baseline, 6 (9.5%) were only interested in the cross-sectional study, 16 (25.4%) dropped out of cbt, and 41 (65.1%) completed therapy. between those who dropped out of cbt and those who did not, no differences emerged regarding pre-treatment clinical variables (all ps ≥ .219). all participants had provided written informed consent before study inclusion. the study protocol was approved by the ethics committee of the technische universität dresden (ek 65022010) and conducted in accordance with the declaration of helsinki. clinical and psychological measures self-developed questionnaires were applied for socio-demographic (age, sex, education status) and health-related variables (smoking, chronic physical diseases, regular medica­ tion intake). depressive symptoms over the previous two weeks were assessed via the beck depression inventory-ii (bdi-ii, hautzinger et al., 2006). the pds (ehlers et al., 1996) provided insights into the presence or absence of lifetime trauma history and the severity of symptoms associated with posttraumatic stress according to dsm-iv criteria. the trauma history questionnaire (thq, maercker, 2002) provided an overview over number and frequency of potentially traumatic events fulfilling the dsm-iv a1, but not a2 criterion (hooper et al., 2011). furthermore, to obtain information on the severity of childhood maltreatment (irrespective of fulfilling dsm-iv a criteria), the childhood trauma questionnaire (ctq, gast et al., 2001) was used. at follow-up, patients with md additionally received the revised version of the questionnaire of changes in experi­ ence and behavior (veränderungsfragebogen des erlebens und verhaltens vev-r; zielke & kopf-mehnert, 2001). this allowed a classification of patient-evaluated therapy effects via 42 items of opposite polarity (e.g., “compared with the time prior to initiation of lifetime trauma and cognitive functioning in md 6 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ ta bl e 1 b as el in e d em og ra ph ic , h ea lth -r el at ed , a nd c lin ic al c ha ra ct er is tic s of p at ie nt s w ith m aj or d ep re ss io n w ith (m d +t +) a nd w ith ou t ( m d +t -) a s w el l a s c on tr ol s w ith (m d -t +) a nd w ith ou t ( m d -t -) l if et im e tr au m a h is to ry pa rt ic ip an ts ’ c ha ra ct er is ti cs m d +t + (n = 3 7) m d +t (n = 2 6) m d -t + (n = 3 9) m d -t (n = 4 5) te st s ta ti st ic p d em og ra ph ic s a ge (m , s d ) 37 .5 9 (1 1. 91 ) 39 .2 7 (1 1. 8) 41 .4 6 (1 2. 82 ) 35 .3 1 (1 3. 8) f( 3, 1 43 ) = 1 .7 1 .1 67 fe m al e se x (% ) 27 (7 3) 17 (6 5. 4) 32 (8 2. 1) 38 (8 4. 4) χ 32 = 4 .3 4 .2 27 h ig he st e du ca tio na l s ta tu s χ 1 22 = 2 2. 26 .0 35 a ca de m ic d eg re e (% ) 7 (1 8. 9) 2 (8 )a 16 (4 1) 11 (2 4. 4) pr of es si on al tr ai ni ng /c ol le ge d eg re e (% ) 10 (2 7) 12 (4 8) a 13 (3 3. 3) 15 (3 3. 3) a le ve l ( % ) 13 (3 5. 1) 5 (2 0) a 7 (1 7. 9) 16 (3 5. 6) h ig h sc ho ol d ip lo m a/ lo w er (% ) 7 (1 8. 9) 6 (2 4) a 3 (7 .7 ) 3 (6 .7 ) sm ok in g (% ) 8 (2 1. 6) 11 (4 2. 3) 4 (1 0. 3) 10 (2 2. 2) χ 32 = 9 .2 4 .0 26 ph ys ic al d is ea se (% ) 19 (5 1. 4) 11 (4 2. 3) 17 (4 3. 6) 12 (2 6. 7) χ 32 = 5 .5 8 .1 34 re gu la r m ed ic at io n (% ) 21 (5 6. 8) 16 (6 1. 5) 11 (2 8. 2) 8 (1 7. 8) χ 32 = 2 1. 02 < .0 01 ps yc hi at ri c (% )b 16 (4 3. 2) 12 (4 6. 2) 0 0 n on -p sy ch ia tr ic (% ) 10 (2 7) 8 (3 0. 8) 11 (2 8. 2) 8 (1 7. 8) pd s sc or e (m , s d ) 12 .4 (1 1. 45 ) n. a. 4. 56 (6 .1 8) n. a. t 5 4. 72 = 3 .6 8 .0 01 th q n um be r of a 1 tr au m at ic e ve nt s (m , s d ) 4. 3 (2 .5 ) 2. 81 (2 .0 8) 4. 21 (3 .1 7) 1. 33 (1 .2 1) f( 3, 1 43 ) = 1 4. 87 < .0 01 i th q fr eq ue nc y of a 1 tr au m at ic e ve nt s (m , s d ) 7. 33 (6 .7 1) c 6. 12 (5 .1 ) 7. 26 (8 .4 2) 2. 64 (3 .7 9) f( 3, 1 43 ) = 5 .2 5 .0 02 ii ct q s co re (m , s d ) 39 .5 9 (1 0. 48 ) 37 .4 5 (1 0. 83 ) 37 .9 4 (1 3) 29 .0 2 (4 .8 7) f( 3, 1 43 ) = 9 .4 3 < .0 01 ii i bd i-i i s co re (m , s d ) 20 .7 8 (9 .1 1) 22 .1 5 (8 .7 5) 5. 1 (6 .8 ) 4. 52 (0 .6 7) f( 3, 1 43 ) = 6 6. 66 < .0 01 iv n ot e. pd s = po st tr au m at ic s tr es s d ia gn os tic s ca le ; t h q = t ra um a h is to ry q ue st io nn ai re ; c tq = c hi ld ho od t ra um a q ue st io nn ai re ; b d iii = b ec k d ep re ss io n in ve nt or yii . a re fe rs to n = 2 5. b in cl ud ed a nt id ep re ss an ts (n = 2 7) , a nt ic on vu ls iv es (n = 3 ), ne ur ol ep tic s (n = 2 ), se da tiv es (n = 2 ). c re fe rs to n = 3 6. i m d +t + = m d -t + > m d -t ( ps < .0 01 ), w ith m d +t i n be tw ee n. ii m d +t + = m d -t + > m d -t ( ps ≤ .0 06 ), w ith m d +t i n be tw ee n. ii i m d +t + = m d -t + = m d -t + > m d -t ( ps ≤ .0 05 ). iv m d +t + = m d +t -> m d -t + = m d -t ( ps ≤ .0 01 ). schindler, stalder, kirschbaum et al. 7 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ therapy, i feel more relaxed/no change/more tense.”) into three categories (i.e., symptom improvement, no change, and worsening). cognitive tasks wm was examined using the wechsler memory scale digit span task (wechsler, 1997). participants repeated a series of numbers read out loud by the experimenter in a forward (information maintenance) or backward fashion (information manipulation). interference susceptibility and conflict adaptation were assessed by a number version of the simon task (fischer et al., 2008). in brief, participants categorized the numbers 1 to 9, except 5, as smaller or larger than five by pressing a left (alt) or right (alt gr) key on a qwertz keyboard with their left or right index finger, respectively. although task-irrelevant, stimulus location automatically facilitates the pressing of the corresponding response button, either in accordance, or in conflict with the required action, resulting in compati­ ble and incompatible trials, respectively. the resulting difference in rts and pes compri­ ses the simon, and the typical reduction of interference susceptibility after conflict trials the conflict adaptation effect (botvinick et al., 2004; simon, 1990). participants completed a 16-trial practice, followed by three 64-trial test blocks, resulting in 192 test trials (for further details, see schindler et al., 2020; steudte-schmiedgen et al., 2014). indices for interference susceptibility (i – c) and conflict adaptation [(ci – cc) – (ii – ic)] (lowercase letters: compatibility of the previous, uppercase letters: compatibility of the current trial, larger values indicating more pronounced effects) were calculated (van steenbergen et al., 2010). autobiographical memory specificity was assessed via the standardized autobio­ graphical memory test (williams & broadbent, 1986). participants were instructed to read words out loud (practice phase: three neutral words, testing phase: five positive and five negative words in a pseudo-randomized order, starting with a positive word and alternating valence) and briefly describe a related specific autobiographical memory. the words were randomly chosen from a word pool from a previous study (schönfeld & ehlers, 2006) matched for word frequency, emotionality, imagery, and pleasantness (apart from positive words rated as more pleasant than negative ones; hager & hasselhorn, 1994), with different sets used at baseline and follow-up. answers were tape-recorded, transcribed and coded by trained research assistants. as an outcome variable, the number of specific memories was used, defined as having happened at a particular place and time more than one week ago and having lasted for one day or less. if no answer was provided within 30 seconds, the trial was considered an omission. for assessing inter-rater-reliability, a second, independent rater re-assessed a random sample (10%) of the tape-recorded sequences, resulting in κ = .76 for the baseline and κ = .82 for the follow-up assessment. lifetime trauma and cognitive functioning in md 8 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ statistical analyses analyses were conducted via spss for windows, version 25 (ibm, armonk, ny), r (r core team, 2017), and stata 15.1 (statacorp llc, 2017). cross-sectional group comparisons were carried out via univariate analyses of variance (anovas; continuous variables) and χ2 contingency tables (dichotomous variables). for the simon task, the first trial of each block (1.6%), posterror trials (3%), target repetitions (11.3%), and, for rt analyses, error trials (3%) were excluded. amt data from one md+tand one md-t participant were missing. for longitudinal analyses, as a first step, participants from the md+t+, md+t-, and md-tgroups with available longitudinal data were re-examined regarding baseline demographic and clinical differences. simon task data from one md+t+ and three md-t participants, and amt data from one md+tand two md-tparticipants were missing. again, the first trial of each block (1.6%), posterror trials (baseline: 2.8%, follow-up: 2.7%), target repetitions (baseline: 11.5%, follow-up: 10.9%) and, for rt analyses, error trials (baseline: 2.8%, follow-up: 2.7%) were excluded. repeated-measures anovas with time [2, baseline vs. follow-up] as within-subject and group [3, md+t+ vs. md+tvs. md-t-] as between-subject factor were applied to assess clinical and cognitive changes over cbt. exploratory linear/logistic regression analyses were conducted for examining the pre­ dictive value of lifetime trauma history (pds; yes/no) for changes of depressive symptom severity (bdi-ii) and dropout from care as core outcome measures, respectively. due to the small sample size for the longitudinal analyses, and the high correlations between depressiveness (bdi-ii) and the subjectively evaluated therapy effects (vev-r, r = -.66, p < .001) at the follow-up assessment, we decided to omit the vev-r from the predictive analyses. for the bdi-ii, a change score was computed by subtracting baseline from follow-up values, and baseline values were included as a covariate to the regression analyses. as a second step, baseline cognitive performance (centered around the mean to avoid multicollinearity issues), and, as a third, the interaction of lifetime trauma history (yes/no) and baseline cognitive performance were added to the model. whenever hypothesis testing referred to one major cognitive domain (i.e., ef and learning/memory) and were not exploratory in nature, holm-bonferroni correction (holm, 1979) for family-wise error (fwer) per respective domain was applied. as the assumptions of conventional glms (anova, linear regression) are frequently violated in psychological data possibly leading to poor power and inaccurate effect sizes (field & wilcox, 2017), we repeated hypothesis testing using robust regressions. these drop glm assumptions by using a robust sandwich estimation of standard errors, down-weight­ ing observations with large residuals, and omitting outlying residuals (royall, 1986). predictive analyses were repeated using mixed-effects regressions with random intercept parameter addressing regression to the mean, which can otherwise yield biased results (oberg & mahoney, 2007). however, due to the higher prevalence and familiarity of schindler, stalder, kirschbaum et al. 9 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ conventional glms in the field, whenever both analyses yielded the same results, con­ ventional glms were reported. results sample characteristics, clinical symptomatology, and baseline cognitive functioning the groups were well-matched regarding age, sex, and physical diseases (all ps ≥ .134, see table 1). however, group differences emerged for educational status (χ12 2 = 22.26, p = .035) and smoking (χ3 2 = 9.24, p = .026). furthermore, both clinical groups reported higher medication intake than the non-clinical ones (χ3 2 = 21.02, p < .001), mainly driven by psychiatric medication. however, including these variables as covariates did not change the cross-sectional results. for depressive symptom severity (bdi-ii), both md+t and md+t+ individuals reported higher levels than the control groups (all ps ≤ .001), with post-hoc analyses indicating no difference between them. for number and frequen­ cy of dsm-iv a1 traumatic events, both md+t+ and md-t+ scored higher than md-t individuals, with md+tindividuals in between (thq, all ps ≤ .006). for the severity of childhood maltreatment, both md+ groups as well as the md-t+ participants scored higher than the md-tgroup (ctq, all ps ≤ .005). no group differences emerged for forward, backward, and overall digit span (all ps ≥ .283, see table 2). for the simon task, groups differed regarding conflict adaptation of median rts with a medium effect size, f(3, 143) = 3.23, p = .024, ηp2 = .063, 90% ci [0, .12], see figure 1), with higher levels in md+t+ compared to md-tindividuals (p = .017) and no other differences (all ps ≥ .43). neither for conflict adaptation of mean pes, nor for interference susceptibility did group differences emerge (all ps ≥ .424). regarding ogm, for positive and negative words and the overall score, md+tparticipants scored lower than both md-t+ and md-tones with, again, medium effect sizes (all ps ≤ .002), and no other differences (all ps ≥ .118). while ogm results remained stable after holm-bonferroni correction for fwer, the group difference for conflict adaptation of median rts lost statistical significance (p = .168). applying robust regressions did not considerably change the results, except for the difference between md-t+ and md-tparticipants regarding conflict adaptation of median rts and the interference effect of median rts emerging as non-significant trends, β = -15.2, 95% ci [-30.7, 0.2], p = .053 and β = -11.5, 95% ci [-24.2, 1.2], p = .076). lifetime trauma and cognitive functioning in md 10 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ ta bl e 2 b as el in e w or ki ng m em or y in th e d ig it sp an t as k, in te rf er en ce a nd c on fl ic t a da pt at io n ef fe ct s of m ea ns o f m ed ia n r ea ct io n ti m es (r ts ) a nd p er ce nt ag e of e rr or s (p e) in th e si m on t as k, a nd a ut ob io gr ap hi ca l m em or y sp ec if ic ity in th e a ut ob io gr ap hi ca l m em or y te st (a m t) o f p at ie nt s w ith m aj or d ep re ss io n w ith (m d +t +) a nd w ith ou t (m d +t -) a s w el l a s c on tr ol s w ith (m d -t +) a nd w ith ou t ( m d -t -) l if et im e tr au m a h is to ry fa ce t o f c og ni ti ve fu nc ti on in g m d +t + (n = 3 7) m d +t (n = 2 6) m d -t + (n = 3 9) m d -t (n = 4 5) te st s ta ti st ic p η p2 90 % c i [l l, ul ] a dj us te d p (h ol m bo nf er ro ni co rr ec ti on ) d ig it s pa n to ta l 17 .5 7 (3 .5 2) 17 .7 7 (3 .8 2) 17 .3 3 (3 .7 4) 18 .6 2 (3 .0 3) f( 3, 1 43 ) = 1 .1 .3 51 .0 23 [ 0, .0 6] 1 fo rw ar d 9. 84 (1 .9 4) 9. 81 (1 .9 8) 9. 72 (1 .7 5) 10 .1 3 (1 .7 ) f( 3, 1 43 ) = 0 .4 1 .7 46 .0 09 [ 0, .0 3] 1 ba ck w ar d 7. 73 (2 .0 6) 7. 96 (2 .3 6) 7. 62 (2 .4 ) 8. 49 (2 .1 4) f( 3, 1 43 ) = 1 .2 8 .2 83 .0 26 [ 0, .0 7] 1 si m on ta sk : r t in te rf er en ce e ff ec t 27 .3 2 (2 9. 05 ) 24 .8 8 (2 8. 2) 31 .8 7 (2 8. 54 ) 21 .9 9 (2 4. 81 ) f( 3, 1 43 ) = 0 .9 4 .4 24 .0 19 [ 0, .0 5] 1 c on fli ct a da pt at io n ef fe ct 68 .9 3 (4 2. 42 ) 51 .1 5 (4 4. 22 ) 57 .7 4 (3 9. 49 ) 43 .1 4 (2 8. 83 ) f( 3, 1 43 ) = 3 .2 3 .0 24 i .0 63 [ 0, .1 2] .1 68 si m on ta sk : p e in te rf er en ce e ff ec t 1. 83 (3 .3 9) 1. 73 (3 .5 7) 2. 05 (4 .4 8) 1. 32 (3 .5 7) f( 3, 1 43 ) = 0 .2 7 .8 46 .0 06 [ 0, .0 2] 1 c on fli ct a da pt at io n ef fe ct 5. 23 (5 .8 8) 5 (5 .7 9) 5. 26 (7 .1 2) 4. 6 (6 .4 2) f( 3, 1 43 ) = 0 .1 .9 62 .0 02 [ 0, 0 ] 1 a m t nu m be r of s pe ci fi c m em or ie s to ta l 5. 68 (2 .7 2) 4. 36 (2 .4 6) a 6. 69 (2 .1 8) 6. 73 (1 .8 6) b f( 3, 1 41 ) = 7 .1 6 < .0 01 ii .1 32 [ .0 5, .2 1] < .0 01 po si tiv e cu es 2. 92 (1 .4 4) 2. 4 (1 .3 5) a 3. 49 (1 .3 6) 3. 57 (1 .2 3) b f( 3, 1 41 ) = 5 .2 .0 02 ii i .1 [ .0 2, .1 7] .0 02 n eg at iv e cu es 2. 76 (1 .5 4) 1. 96 (1 .3 4) a 3. 21 (1 .2 ) 3. 16 (1 .1 6) b f( 3, 1 41 ) = 5 .7 2 .0 01 iv .1 1 [.0 3, .1 8] .0 02 n ot e. d at a ar e pr es en te d as m (s d ). c i = c on fi de nc e in te rv al ; l l = lo w er le ve l; u l = up pe r le ve l; rt = m ed ia n re ac tio n tim es ; p e = pe rc en ta ge s of e rr or . a re fe rs to n = 2 5. b re fe rs to n = 4 4. i m d +t + > m d -t ( p = .0 17 ). ii m d +t < m d -t + = m d -t ( ps ≤ .0 01 ). ii i m d +t < m d -t + = m d -t ( ps ≤ .0 11 ). iv m d +t < m d -t + = m d -t ( ps ≤ .0 02 ). schindler, stalder, kirschbaum et al. 11 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ figure 1 mean (± sem) (a) conflict adaptation of median rts (simon task) and (b) specificity of autobiographical memory (autobiographical memory test) of patients with major depression with (md+t+) and without (md+t-) as well as controls with (md-t+) and without (md-t-) lifetime trauma history at baseline note. *p < .05, †p < .10, dotted lines indicate differentiating results between general linear and robust models. clinical and cognitive treatment outcome under consideration of lifetime trauma history md+t+ (n = 21), md+t(n = 16), and md-tparticipants (n = 34) available for longitudi­ nal analyses did not differ regarding baseline demographic/health-related characteristics (all ps ≥ .136, see supplementary materials), except for higher medication intake in both md groups (χ2 2 = 13.9, p = .001). however, including it as a covariate did not affect the longitudinal results. md+t+ individuals reported a higher number of dsm-iv a1 traumatic events (thq) than md+tones, which, in turn, reported more than md-t individuals (all ps ≤ .036). with respect to their frequency (thq), as well as for childhood maltreatment severity (ctq), both md+ groups scored higher than the md-tone (all ps ≤ .035 and all ps ≤ .002, respectively). notably, while cbt led to substantial clinical improvements, md+t+ and md+t individuals did not differ regarding depressive symptom changes (bdi-ii), subjectively evaluated therapy effects (vev-r), and percentage of dropouts (all ps ≥ .605, see table 3). furthermore, no cognitive improvements over cbt in the clinical groups emerged (all ps ≥ .272, see table 3). however, for digit span, medium-to-large time effects indicated better performance at follow-up over all groups (all ps ≤ .009). robust regressions yielded similar results. regression analyses on the predictive value of lifetime trauma history (yes/no) for therapy outcome (bdi-ii changes of depressive symptom severity and dropout status, lifetime trauma and cognitive functioning in md 12 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ ta bl e 3 c lin ic al im pr ov em en t a nd c ha ng es in w or ki ng m em or y in th e d ig it sp an t as k, in te rf er en ce a nd c on fl ic t a da pt at io n ef fe ct s of m ea ns o f m ed ia n r ea ct io n ti m es (r ts ) an d pe rc en ta ge o f e rr or s (p e) in th e si m on t as k, a nd a ut ob io gr ap hi ca l m em or y sp ec if ic ity in th e a ut ob io gr ap hi ca l m em or y te st (a m t) b et w ee n b as el in e an d fo llo w -u p a ss es sm en t i n pa tie nt s w ith m aj or d ep re ss io n w ith (m d +t +) a nd w ith ou t ( m d +t -) a s w el l a s c on tr ol s w ith ou t ( m d -t -) l if et im e tr au m a h is to ry pa rt ic ip an ts ’ c ha ra ct er is ti cs m d +t + (n = 2 1) m d +t (n = 1 6) m d -t (n = 3 4) te st s ta ti st ic p η p2 90 % c i [l l, ul ] a dj us te d p (h ol m -b on fe rr on i c or re ct io n) t1 t2 t1 t2 t1 t2 bd i-i i s co re (m , s d ) 21 .6 7 (7 .7 2) 12 .1 4 (9 .5 2) 23 .1 2 (8 .8 3) 11 .2 5 (8 .1 9) 3. 97 (4 .7 6) 4. 59 (5 .3 ) f 2 , 6 8 = 2 3. 54 a, b < .0 01 i .4 09 [ .2 5, .5 2] bd i-i i c ha ng e sc or e (m , s d ) -9 .5 2 (8 .4 8) -1 1. 88 (7 .6 9) 0. 62 (5 .3 2) ve vr sy m pt om im pr ov em en t ( % ) 16 (7 6. 2) 13 (8 6. 7) n. a. χ 22 = 1 .0 1 .6 05 n. a. d ro po ut s (% ) 9 (2 9) 7 (2 6. 9) n. a. χ 22 = 0 .3 1 1. 00 n. a. d ig it s pa n to ta l 18 .5 7 (3 .1 6) 19 .8 1 (4 .0 9) 18 .1 3 (3 .5 7) 18 .9 4 (3 .0 9) 18 .5 9 (3 .2 ) 20 .3 8 (3 .5 4) f 2 , 6 8 = 0 .7 7a .4 7 .0 22 [ 0, .0 9] 1 fo rw ar d 10 .1 (1 .7 3) 10 .8 1 (2 .2 1) 9. 81 (1 .8 ) 9. 94 (1 .3 9) 10 (1 .6 7) 10 .9 4 (1 .9 8) f 2 , 6 8 = 1 .1 7a .3 18 .0 33 [ 0, .1 1] 1 ba ck w ar d 8. 48 (1 .9 4) 9 (2 .1 5) 8. 31 (2 .3 ) 9 (2 .0 3) 8. 59 (2 .2 9) 9. 44 (2 .2 1) f 2 , 6 8 = 0 .1 8a .8 33 .0 05 [ 0, .0 4] 1 si m on ta sk : r t in te rf er en ce e ff ec t 26 .4 8 (2 9. 66 )b 20 .0 5 (2 6. 93 )b 20 .3 8 (2 7. 09 ) 15 .7 8 (2 3. 59 ) 20 .7 1 (2 5. 65 )c 24 .4 8 (2 4. 12 )c f 2 , 6 4 = 1 .3 3a .2 72 .0 4 [0 , . 12 ] 1 c on fli ct a da pt at io n ef fe ct 66 .6 (2 9. 95 )b 60 .1 (3 1. 4) b 54 .8 8 (5 0. 85 ) 65 .8 4 (3 5. 65 ) 41 .0 2 (2 3. 4) c 50 .3 2 (3 7. 03 )c f 2 , 6 4 = 0 .9 6a .3 87 .0 29 [ 0, .1 ] 1 si m on ta sk : p e in te rf er en ce e ff ec t 2. 24 (1 .8 4) b 1. 55 (3 .2 7) b 1 (3 .3 5) 1. 45 (2 .5 8) 1. 31 (4 .0 5) c 2. 41 (2 .7 6) c f 2 , 6 4 = 1 .2 3a .2 99 .0 37 [ 0, .1 2] 1 c on fli ct a da pt at io n ef fe ct 4. 76 (5 .4 9) b 4. 22 (6 .1 6) b 4. 4 (5 .7 5) 4. 24 (5 .1 2) 5 (6 .2 6) c 3. 32 (6 .2 )c f 2 , 6 4 = 0 .2 5a .7 8 .0 08 [ 0, .0 5] 1 a m t nu m be r of s pe ci fi c m em or ie s to ta l 6. 05 (2 .7 1) 6. 67 (2 .3 1) 4. 47 (2 .1 3) d 4. 53 (2 .2 3) d 6. 75 (2 )e 6. 25 (2 .2 4) e f 2 , 6 5 = 1 .2 1a .3 05 .0 36 [ 0, .1 1] po si tiv e cu es 3. 1 (1 .3 8) 3. 29 (1 .3 1) 2. 47 (1 .3 )d 2. 4 (1 .3 )d 3. 63 (1 .2 9) e 3. 19 (1 .4 2) e f 2 , 6 5 = 1 .2 a .3 08 .0 36 [ 0, .1 1] n eg at iv e cu es 2. 95 (1 .4 7) 3. 38 (1 .3 2) 2 (1 .1 3) d 2. 13 (1 .1 3) d 3. 12 (1 .2 4) e 3. 06 (1 .1 6) e f 2 , 6 5 = 0 .6 4a .5 29 .0 19 [ 0, .0 8] n ot e. d at a is p re se nt ed a s m (s d ). ci = c on fi de nc e in te rv al ; l l = lo w er le ve l; u l = up pe r le ve l; bd iii = b ec k d ep re ss io n in ve nt or yii ; r t = m ed ia n re ac tio n tim es ; pe = p er ce nt ag es o f e rr or . a g ro up x ti m e in te ra ct io n. b re fe rs to n = 2 0. c re fe rs to n = 3 1. d re fe rs to n = 1 5. e re fe rs to n = 3 2. i m d +t + = m d +t > m d -t ( p < .0 01 ). schindler, stalder, kirschbaum et al. 13 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ respectively) yielded no associations (all ps ≥ .391). when, in a second step, adding respective facets of baseline cognitive functioning, more pronounced reductions of de­ pressive symptom severity (bdi-ii) emerged with smaller forward digit span, b = 1.48, 95% ci [0.07; 2.90], p = .041), while for all other measures of cognitive functioning, no predictive value emerged (all ps ≥ .059). adding, in a third step, interaction terms of lifetime trauma history (yes/no) and baseline cognitive functioning did not predict cbt outcome regarding bdi-ii and dropout status (all ps ≥ .058). notably, robust regressions led to similar results. discussion the aim of the study was to assess associations of (i) lifetime trauma history according to the dsm-iv (american psychiatric association, 2007) and (ii) facets of cognitive func­ tioning (i.e., wm, interference susceptibility, conflict adaptation, and ogm) as well as (iii) their interaction with cbt outcome among patients with md. at baseline, more pronounced conflict adaptation emerged in individuals with md and lifetime trauma history in contrast to non-exposed healthy controls, while autobiographical memory was found to be primarily affected in md without lifetime trauma history compared to both control groups. notably, individuals with md with and without lifetime trauma history did not differ regarding treatment outcome, and the cognitive parameters proved stable over cbt. exploratory analyses suggested no direct or interacting association of lifetime trauma history, and only a tentative one of forward digit span, but no other aspects of cognitive functioning with treatment outcome. baseline cognitive functioning on a cross-sectional level, the results support the role of lifetime trauma history for cognitive functioning in md. while no differences emerged for interference susceptibil­ ity and wm, md+t+ patients showed higher conflict adaptation of median rts than md-tparticipants, with md+tand md-t+ in between. this corresponds with previous findings from our group of more pronounced conflict adaptation in traumatized individ­ uals with and possibly also without ptsd (schindler et al., 2020; steudte-schmiedgen et al., 2014). however, as there also are suggested associations of conflict adaptation and depressive symptom severity (van steenbergen et al., 2012), albeit without considering trauma history, further studies are desirable. interestingly, autobiographical memory yielded contrasting findings: md+tpatients showed more pronounced ogm compared to the healthy control groups, corresponding with our previous findings of ogm in ptsd, but not trauma exposure per se (schindler et al., 2020), and suggestions from reviews and meta-analyses (moore & zoellner, 2007; ono et al., 2016; sumner et al., 2010; williams et al., 2007). further, it supports the findings of lifetime trauma and cognitive functioning in md 14 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ kuyken, howell, and dalgleish (2006) of ogm only in md without (childhood) trauma history, but not those of aglan et al. (2010) of ogm in md with history of csa. in sum, neither the results for conflict adaptation, nor those for ogm speak for a mere additive effect of trauma and md on cognitive functioning, but rather for complex patterns with different impacts on different processes, and, potentially, different implications for clinical practice. clinical and cognitive treatment outcome under consideration of lifetime trauma history in contrast to several previous studies particularly on childhood trauma (reviewed in nemeroff, 2016; teicher & samson, 2013), our data suggest cbt to be equally effective in individuals with md with and without the history of at least one traumatic event according to the dsm-iv. several aspects may contribute to this divergence. firstly, it is plausible that lifetime trauma, as examined in this study, does exert different effects than childhood trauma. importantly, in our study, md+t+ and md+tgroups reported equal ctq childhood maltreatment severity, and it is conceivable that this may have contributed to lacking group differences with respect to cbt effectiveness. notably, also with respect to the thq, the md+t+ and the md+tgroups did only differ on a descriptive level. however, it is important to consider that this instrument refers to the number and frequency of potentially traumatic events, for which the presence of the complete dsm-iv criteria are not checked. in order to better understand the role of childhood and adulthood trauma for cbt effectiveness, studies explicitly contrasting individuals with md (i) without lifetime trauma, (ii) with exclusively childhood, and (iii) with exclusively adulthood trauma as defined by the current diagnostic criteria are necessary. furthermore, treatment differences might have played a role. most prominent­ ly, the majority of studies reporting similar therapy outcome for md with and without (particularly childhood) trauma history had applied combined psychotherapy and antide­ pressant medication (lewis et al., 2010; miniati et al., 2010; nemeroff et al., 2003; but asarnow et al., 2009), as was the case for approximately half of our sample. further, we cannot rule out whether, in our study, trauma status had led to slight individual treatment adaptations by the responsible therapists. this might, for instance, have led to combined modifications of trauma-related and -unrelated automatic thought patterns, or the encouraging of restarting activities avoided after the trauma during behavioral interventions within the context of the utilized cbt manuals (hautzinger, 1998, 2008). thus, future studies applying more strictly manualized cbt and investigating larger md groups with and without medication intake are required. additionally, the results corroborate previous findings of cognitive alterations in md being highly stable over cbt (reviewed in köhler et al., 2015; moore & zoellner, 2007; snyder & hankin, 2019), and of this to be irrespective of trauma history. while wm im­ proved from baseline to follow-up, this is presumably attributable to practice/habituation schindler, stalder, kirschbaum et al. 15 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ effects, as it also concerned md-tindividuals. as cognitive impairments are assumed to be associated with worse psychosocial functioning and increased relapse risk in md (rock et al., 2014), the continuous finding of this to not be adequately addressed by cbt shows the necessity to strive for “cognitive”, next to clinical remission in md (bernhardt et al., 2019; bortolato et al., 2016). for example, this might be achieved by directly targeting cognitive functioning during md-centered cbt. while research on ef training in md is still in its infancy (for a meta-analysis, see, e.g., motter et al., 2016), there are promising results that ogm, as well as md symptomatology itself may be influenced by interventions directly focusing on autobiographical recall, albeit with long-term stability still questionable (for a meta-analysis, see barry, sze, & raes, 2019). the exploratory predictive analyses on lifetime trauma history and cognitive func­ tioning for cbt do not provide clear results from which robust next steps could be derived. what can be clearly stated as of now is that there, again, was no evidence for a relevant role of lifetime trauma history. further, only a singular association with cognitive parameters emerged, suggesting smaller wm to be associated with more pro­ nounced depressiveness-related cbt effects. in sum, this pattern, albeit stemming from a very small sample size, supports the findings of goodkind et al. (2016) on interference susceptibility, but stands at variance with those of sumner et al. (2010) suggesting a predictive role of autobiographical memory specificity in md. future studies are needed to follow up on autobiographical memory in this context, or investigate whether other cognitive markers might be more suitable to predict clinical outcome after standardized psychotherapeutic/pharmacological treatment (e.g., groves et al., 2018) with or without taking trauma history into account. strengths, limitations, and outlook one central strength of the study is the naturalistic, highly ecologically valid study design. while the inclusion of a waiting control group of md+t+/md+tpatients not receiving cbt was impossible for ethical reasons, the fact that a healthy control group was studied longitudinally alongside the md individuals is a further major strength, as it allowed the separation of cbt-associated and mere practice effects on cognitive functioning. however, limitations resulting from the naturalistic design are the heteroge­ neous manifestations of psychopathology and medication and the group differences in educational status and smoking. further limitations include the lack of an objective, ob­ server-rated outcome of depressiveness (e.g., the hamilton rating scale for depression; hamilton, 1960), as well as the small sample sizes and the thus reduced statistical power for detecting especially interactive relationships. however, the fact that the vast major­ ity of associations were confirmed in robust analyses corroborates the validity of the findings. finally, behavioral tasks established in cognitive psychology, such as the ones used in our study, are characterized by task impurity, which describes the impossibility of assessing “pure” cognitive processes without simultaneously eliciting others (miyake lifetime trauma and cognitive functioning in md 16 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ et al., 2000; e.g., scott et al., 2015). in order to maximize transparency in data reporting, we chose to report subscale scores of the cognitive tasks for which different properties are discussed (botvinick et al., 2004; wechsler, 1997; williams & broadbent, 1986). in ad­ dition, we acknowledge that for any of the assessed tasks, additional cognitive processes such as processing speed, attention, and motivation – while not directly studied – are inevitably involved. conclusions in conclusion, the study is the first to examine lifetime trauma history, cognitive func­ tioning, and their interaction in the context of cbt in patients with md. on a cross-sec­ tional level, conflict adaptation and autobiographical memory specificity emerged to be differentially affected in md with and without lifetime trauma history. contrary to previous research on childhood trauma, we found no evidence for a differential treatment response in patients with md with and without lifetime trauma history as defined by the dsm-iv. further, the cognitive parameters were stable over cbt, and only a singular predictive association of forward digit span, but no other facets of baseline cognitive functioning, lifetime trauma history, or their interaction with treatment out­ come emerged. these insights into the interaction between lifetime trauma history and cognitive functioning provide unique extensions for research on md psychopathology and treatment and underline the relevance of “cognitive” remission (bernhardt et al., 2019; bortolato et al., 2016). for achieving this aim, further research is required to allow more profound, neuroscience-informed diagnostic processes and personalized, multi-mo­ dal treatment approaches depending on patients’ individual manifestation of cognitive functioning (de raedt, 2020). schindler, stalder, kirschbaum et al. 17 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://www.psychopen.eu/ funding: this work was supported by the german research foundation (dfg; grant nos. sta 1213/5-1 to t.s. and j.h. and sfb 940/1 project no. b5 to f.p. and c.k). l.s. was supported by the german academic scholarship foundation. s.s.-s. was funded by a habilitation fellowship for women from the faculty of medicine carl gustav carus, technische universität dresden. acknowledgments: the authors would like to thank elisabeth cohors-fresenborg, fanny weber, anna-katharina richter, juliane kant, inger-sophie hellerhoff, kristin werzner, the staff of the outpatient unit, and the members of the endocrinology laboratory of the department of psychology at the technische universität dresden for their great help in conducting this research. competing interests: all authors have no conflicts of interest to disclose. author contributions: lena schindler: formal analysis, data curation, writingoriginal draft preparation, visualization. tobias stalder: conceptualization, writingreview & editing, funding acquisition. clemens kirschbaum: resources, writingreview & editing. franziska plessow: conceptualization, methodology, writing review & editing. sabine schönfeld: conceptualization, methodology, writingreview & editing. jürgen hoyer: resources, writingreview & editing, funding acquisition. sebastian trautmann: formal analysis, writingreview & editing. kerstin weidner: writingreview & editing. susann steudte-schmiedgen: conceptualization, methodology, investigation, formal analysis, writingreview & editing, supervision supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • supplement 1 (lifetime trauma history and mental disorder comorbidities) • supplement 2 (baseline demographic, health-related, and clinical characteristics of patients with major depression with (md+t+) and without (md+t-) as well as controls without (md-t-) lifetime trauma history available for longitudinal analyses) index of supplementary materials schindler, l., stalder, t., kirschbaum, c., plessow, f., schönfeld, s., hoyer, j., trautmann, s., weidner, k., & steudte-schmiedgen, s. (2021). supplementary materials to "lifetime trauma history and cognitive functioning in major depression and their role for cognitive-behavioral therapy outcome" [additional information]. psychopen gold. https://doi.org/10.23668/psycharchives.5073 lifetime trauma and cognitive functioning in md 18 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://doi.org/10.23668/psycharchives.5073 https://www.psychopen.eu/ references aglan, a., williams, j. m. g., pickles, a., & hill, j. (2010). overgeneral autobiographical memory in women: association with childhood abuse and history of depression in a community sample. british journal of clinical psychology, 49(3), 359-372. https://doi.org/10.1348/014466509x467413 ajilchi, b., nejati, v., town, j. m., wilson, r., & abbass, a. 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(2001). der vev-r-2001: entwicklung und testtheoretische reanalyse der revidierten form des veränderungsfragebogens des erlebens und verhaltens (vev). praxis klinische verhaltensmedizin und rehabilitation, 53, 7-19. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. lifetime trauma and cognitive functioning in md 24 clinical psychology in europe 2021, vol. 3(3), article e4105 https://doi.org/10.32872/cpe.4105 https://doi.org/10.1176/appi.ajp.2013.12070957 https://doi.org/10.1177/0956797610385951 https://doi.org/10.3758/s13415-011-0078-2 https://doi.org/10.1007/s11920-018-0964-1 https://doi.org/10.1037/0033-2909.133.1.122 https://doi.org/10.1037/0021-843x.95.2.144 https://www.psychopen.eu/ lifetime trauma and cognitive functioning in md (introduction) method participants and procedures clinical and psychological measures cognitive tasks statistical analyses results sample characteristics, clinical symptomatology, and baseline cognitive functioning clinical and cognitive treatment outcome under consideration of lifetime trauma history discussion baseline cognitive functioning clinical and cognitive treatment outcome under consideration of lifetime trauma history strengths, limitations, and outlook conclusions (additional information) funding acknowledgments competing interests author contributions supplementary materials references psychotherapy under lockdown: the use and experience of teleconsultation by psychotherapists during the first wave of the covid-19 pandemic research articles psychotherapy under lockdown: the use and experience of teleconsultation by psychotherapists during the first wave of the covid-19 pandemic jessica notermans 1,2 , pierre philippot 1,2 [1] consultations psychologiques spécialisées, université catholique de louvain, louvain-la-neuve, belgium. [2] laboratory for experimental psychopathology, université catholique de louvain, louvain-la-neuve, belgium. clinical psychology in europe, 2022, vol. 4(3), article e6821, https://doi.org/10.32872/cpe.6821 received: 2021-05-27 • accepted: 2022-05-31 • published (vor): 2022-09-30 handling editor: anton-rupert laireiter, university of vienna, vienna, austria corresponding author: jessica notermans, institut de recherche en sciences psychologiques, université catholique de louvain, place du cardinal mercier, 10, b-1348 louvain-la-neuve, belgium. phone: +32489195018. email: jessicanotermans@gmail.com supplementary materials: materials [see index of supplementary materials] abstract background: facing the covid-19 pandemic, some psychotherapists had to propose remote consultations, i.e., teleconsultation. while some evidence suggests positive outcomes from teleconsultation, professionals still hold negative beliefs towards it. additionally, no rigorous and integrative practice framework for teleconsultation has yet been developed. this article aims to explore the use and experience of teleconsultation by 1) investigating differences between psychotherapists proposing and not proposing it; 2) evaluating the impact of negative attitudes towards teleconsultation on various variables; 3) determining the perceived detrimental effect of teleconsultation, as opposed to in-person, on the therapeutic relationship and personal experience; and 4) providing insights for the development of a teleconsultation practice framework. method: an online survey was distributed via different professional organisations across several countries to 246 (195 women) french-speaking psychotherapists. results: psychotherapists who did not propose teleconsultation believed it to be more technically challenging than psychotherapists who proposed it, but felt less constrained to propose it, and had less colleagues offering it. attitudes towards teleconsultation showed no significant associations with therapeutic relationship, personal experience, and percentage of teleconsultation. as compared to in-person, empathy, congruence, and therapeutic alliance were perceived to significantly deteriorate online, whereas work organisation was perceived to be significantly this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6821&domain=pdf&date_stamp=2022-09-30 https://orcid.org/0000-0002-0602-560x https://orcid.org/0000-0003-0207-2430 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ better. while most psychotherapists proposed remote consultations, they did not provide adaptations to such setting (e.g., ascertaining a neutral video background); nor used videoconferencing platforms meeting privacy and confidentiality criteria. conclusion: training and evidenced-based information should be urgently provided to practitioners to develop rigorous guidelines and an ethically and legally safe practice framework. keywords teleconsultation, covid-19, attitudes, online psychotherapy, ethics, therapeutic relationship highlights • psychotherapists differ in their perceptions of teleconsultation as whether they propose it or not. • attitudes towards teleconsultation are not related to its use nor to the therapeutic relationship. • teleconsultation worsens perceived therapeutic relationship, but improves work organisation. • training is needed to improve an ethically and legally safe practice of teleconsultation. following the first wave of the covid-19 pandemic, many countries imposed a lock­ down, which resulted in the suspension of various healthcare practices, including faceto-face psychotherapy. consequently, many psychotherapists had to rapidly adapt their services and propose consultations at a distance, i.e., teleconsultation. teleconsultation refers to “interactions that happen between a clinician and a client for the purpose of providing diagnostic or therapeutic advice through electronic means” (pan american health organization, 2021). this drastic change in the provision of mental health serv­ ices was largely improvised as most psychotherapists and professional organisations were unprepared for this challenge. some evidence suggests positive outcomes from teleconsultation for the treatment of specific conditions (acierno et al., 2016; poletti et al., 2021; wright & caudill, 2020). moreover, recent evidence from the covid-19 pandemic also shows that most psycho­ therapists experience remote psychotherapy rather positively (feijt et al., 2020; humer et al., 2020; mcbeath et al., 2020). these attitudes towards teleconsultation are influenced by a set of factors (connolly et al., 2020), such as previous online experience, clinical experi­ ence (békés & aafjes-van doorn, 2020), perceived ability to develop a strong therapeutic relationship (aafjes-van doorn et al., 2021; roesler, 2017), and perceived therapeutic efficacy (aafjes-van doorn et al., 2021). in contrast, other evidence reports that mental health practitioners hold negative attitudes towards teleconsultation (mendes-santos et al., 2020; perle et al., 2013; varker et al., 2019). beliefs regarding poor efficacy (schulze et al., 2019) and ethical limitations (stoll et al., 2020) of such practices may hamper its psychotherapy under lockdown 2 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ use and implementation, as well as reduce clients’ adhesion. questions regarding the strengths and limitations of online therapy are known topics of discussion among mental health professionals (rochlen et al., 2004). therefore, it is important to further investigate current attitudes towards teleconsultation and evaluate their potential impact. last but not least, with the drastic transition from in-person to remote consultation, several authors underlined the importance to develop an integrative and balanced prac­ tice framework with specific guidelines to inform psychotherapists about the use of teleconsultation (smith et al., 2020). boldrini and colleagues (2020) provided a set of recommendations to help professionals support the implementation and use of telecon­ sultation. moreover, another team of researchers listed useful evidence-based guidelines for clinicians using telepsychiatry (smith et al., 2020). however, these recommendations are gathered from country-specific sources (italy and england respectively), and thus do not allow for a global perspective on the matter. finally, while a set of valuable recom­ mendations regarding the policy and practice of telepsychotherapy was also developed in field studies (shore et al., 2018; van daele et al., 2020), and suggested by professional organisations (british association for behavioral & cognitive psychotherapies, 2021), they are largely based on clinical consensus. further empirical data are thus required to provide a rigorous, ethical, and safe framework to support the provision of remote mental healthcare in times of crisis (ohannessian et al., 2020). in this perspective, the present survey aims to explore the use and experience of teleconsultation among french-speaking psychotherapists in order to provide insights regarding its challenges and benefits. first, we hypothesise that there will be significant differences between psychotherapists proposing teleconsultation and those who do not, specifically in terms of attitudes towards it, previous online experience, feelings of con­ straint, perceived support, and colleagues’ usage. second, attitudes towards teleconsulta­ tion will have significant and negative associations with the therapeutic relationship, the personal experience of teleconsultation, and the percentage of teleconsultation proposed. third, the therapeutic relationship and personal experience of teleconsultation will be perceived as significantly worse than in-person. lastly, this study will explore how various elements of teleconsultations (e.g., legal and ethical questions, adaptations, etc.) may contribute to the elaboration of a practice framework. altogether, it investigates the information, skills, and knowledge that would help psychotherapists improve their prac­ tice of teleconsultation, in terms of effectiveness, ethics, and well-being at work. thus, it may serve as a basis for establishing psychotherapists’ potential needs for training in teleconsultation, as suggested by recent studies (van daele et al., 2020; wijesooriya et al., 2020). notermans & philippot 3 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ method recruitment and procedure the survey was developed online (on the qualtrics platform), and distributed via dif­ ferent professional organisations (e.g. uppcf, aemtc) to 246 french-speaking psycho­ therapists between september 15th and october 31st of 2020 in belgium, france, morocco, switzerland, and tunisia. the study was approved by the ipsy ethics committee of uclouvain (project 2020-30; approved on june 10th, 2020). survey questionnaire the questionnaire (appendix 1, supplementary materials) comprises four sections. sec­ tion 1 presents the aim of the study and provides informed consent details. if consent was given, participants were asked whether they proposed teleconsultations from the first lockdown (march 16th, 2020) onwards. those who answered positively were directed to section 2; others were directed to section 3. section 2 includes questions pertaining to the use and experience of teleconsultation for psychotherapists proposing it. section 3 examines the attitudes towards teleconsulta­ tion of psychotherapists not proposing it, as well as other variables that may shed light on the motives behind their non-adhesion to teleconsultation. section 4, was given to all participants, and covers demographics, namely gender, level of education, level of psychotherapy training, psychotherapeutic orientation, work status, years of experience, percentage of teleconsultations proposed since june 2020, living situation, number of dependent children and their age, if any, the extent to which the charge of dependent children living at home impacted their psychotherapy activities during the lockdown, age, and country of residence. measures to the authors’ knowledge, no valid and reliable measures evaluating their questions of interest were found in the literature. therefore, the survey’s validity and reliability are limited. survey’s questions are detailed below (see appendix 1 in the supplementary materials for the full survey). section 2 contains 20 questions inquiring on: 1) whether the number of consulta­ tions in 2020 decreased or increased (ranging from -100 to +100%) between march and june, and 2) between july and september, as compared to the same period in 2019; 3) attitudes (i.e., negative beliefs) towards teleconsultation, evaluated on a 5-point likert scale ranging from 0 “strongly disagree” to 4 “strongly agree”, from an 11-item ad hoc questionnaire; 4) what remote mediums were utilised (telephone, chat messaging, e-mails, and/or videoconferencing); 5) the type of platforms used (e.g., zoom, whatsapp, whereby, etc.); 6) whether they had prior experience with teleconsultation (no experi­ psychotherapy under lockdown 4 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ ence; experience as a supervisee/or as a patient; experience as a supervisor; and/or experience as a psychotherapist); 7) whether they felt constrained to use it (not at all, slightly, moderately, or strongly); 8) whether their colleagues used it (none; a few, some, most, or all); 9) whether they had specific concerns regarding data protection and confidentiality (no; “yes, i found satisfactory answers”; or “yes, but i still have ques­ tions (specify)”); 10) whether they received support to set up teleconsultation (no, mild, moderate, or complete support); 11) whether (yes or no), and 12) how they encouraged clients to engage in teleconsultation (selecting from a 10-item ad hoc questionnaire items such as “providing information regarding the efficacy of teleconsultation”, “providing a short free trial on the media used”, etc.); 13) whether they provided adaptations to the teleconsultation setting (“generally, i did not have to adapt the teleconsultation setting” or “i had to do minor changes”), and 14) how they adapted their online interventions, based on the population (e.g., children, adolescents, adults, etc.), and 15) disorder (e.g., mood disorder(s), anxiety disorder(s), eating disorder(s), etc.). question 16 investigated the percentage of clients for whom their issue was directly linked to the pandemic, aggravated by it, or independent from it. question 17 evaluated, on a 5-point likert scale (from 0 “highly degraded” to 4 “highly improved”), psychotherapists’ experience of teleconsultation as compared to in-person for the therapeutic relationship (empathy, con­ gruence, positive regard, and therapeutic alliance). question 18 asked whether psycho­ therapists will continue to propose teleconsultation after the pandemic (“yes, based on the patient/client demand, teleconsultation will be an option”; “yes, teleconsultation will become major in my clinical practice”; or no). question 19, evaluated on a 5-point likert scale (from 0 “much worse” to 4 “much better”), psychotherapists’ personal experience of teleconsultation (therapeutic efficacy, professional satisfaction, fatigue/exhaustion, work organisation, and ease of payment) as opposed to in-person. a final open-ended question asked about additional comments/remarks regarding teleconsultation. section 3 includes seven questions. first, a 7-item ad hoc questionnaire evaluates on a 5-point likert scale (from 0 “not at all important” to 4 “very important) psychothera­ pists’ motives for not providing teleconsultation (e.g., “this mode of communication does not seem appropriate for a psychotherapy”, or “people did not wish to start/continue via teleconsultation”). then, participants were asked whether they could have received support if they proposed teleconsultation (no, mild, moderate, or complete support); whether they felt constrained to offer it (not at all, slightly, moderately, or strongly); whether they had previous experience with it (no experience; experience as a supervi­ see/or as a patient; experience as a supervisor; and/or experience as a psychotherapist); whether their colleagues were offering it (none, a few, some, most, or all); and whether they intended to propose it in the future (no; “yes, if the pandemic persists”; or “yes, no matter what”). finally, the same ad-hoc questionnaire from section 2 investigated their attitudes towards teleconsultation. notermans & philippot 5 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ data analysis for hypothesis 1, an exploratory factor analysis (efa) explored the internal structure of attitudes. the kaiser–meyer–olkin index and the bartlett sphericity test were computed to assess the robustness of the results. then, independent t-tests evaluated the significant differences in attitudes between psychotherapists who did and did not propose telecon­ sultation, as well as for previous experiences, feelings of constraint, perceived support, and colleagues’ usage. levene's corrections were used for cases in which variances differed between groups. for hypothesis 2, pearson’s correlations were calculated be­ tween attitudes towards teleconsultation, therapeutic relationship, personal experience, and percentage of teleconsultation. for hypothesis 3, single sample t-tests determined whether teleconsultations were perceived as worse than in-person, for the therapeutic relationship and personal experience. finally, for hypothesis 4, single sample t-tests and descriptive statistics explored variables related to the use and experience of teleconsulta­ tion, and participants’ demographics. qualitative data complemented quantitative results. ibm spss statistics for windows, version 21.0, was used for all analyses. results participants characteristics a total of 246 individuals (195 women; 35 men) participated in the study. 16 participants did not fill the entire survey, mainly on demographic questions. they were aged between 25 and 70 years (m = 42.4). out of 230 participants, all were psychotherapists and most of them (186) had at least 3 years of postgraduate training in psychotherapy. they were mostly from belgium (133), switzerland (45), and france (37). the majority were self-em­ ployed (114) or part-time self-employed (59), while 94 were employees. most participants identified themselves as cbt (156) or integrative (58) psychotherapists. the majority (158) lived as a couple and 115 had children living at home (average 1.90 children). dependent children living at home were aged between 0 and 29 years of age (m = 11.32). out of the total sample (n = 246), 222 psychotherapists proposed teleconsultation (173 females; 33 males; 16 did not answer), and 24 (22 females; 2 males) did not. hypothesis 1 the factorability of the 11 attitudes towards teleconsultation was examined for the total sample. a three-factor solution explained 58.2% of the variance for the entire set of variables, with eigenvalues greater than 1 and a minimum of 10% of variance explained by each factor. the kaiser–meyer–olkin index for sampling quality was good: 0.191, and the bartlett sphericity test was correct, χ2(55) = 75.84, p > .04. the scree plot also suggests a three-factor solution. the factor solution, after oblimin rotation, is displayed in table psychotherapy under lockdown 6 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ 1. the first factor, “attention”, pertains to the belief that teleconsultation entails attention difficulties in both the client/patient and therapist. the second factor, “technical issues”, covers beliefs that teleconsultation requires significant technical skills and infrastructure. the last factor, “interpersonal communication”, reflects the belief that teleconsultation is detrimental to the communication quality between client/patient and therapist. table 1 factor loadings, after oblimin rotation, for the 11 items of attitudes towards teleconsultation for psychotherapists proposing and not proposing it items of attitudes towards teleconsultation factors (1) attention (2) technical issues (3) interpersonal communication (reversed) i will be too distracted .883 i will not be engaged/present enough .851 the client/patient will not be engaged/present enough .647 there will be too many distractions in the individual .572 my personal infrastructure will not be adequate for teleconsultation (e.g., limited infrastructure, isolated room for the session, etc.) .387 .328 teleconsultation requires a good handling of informatics tools .838 technical issues will have too big of an impact on communication .729 the lack of non-verbal information will be too important -.854 teleconsultation will limit the development of a good therapeutic relationship -.778 it will be difficult to set up some interventions .433 -.505 teleconsultation will increase dropout number in certain individuals (e.g., addictions) -.357 t-tests were run to determine whether attitudes differed between psychotherapists as a function of whether they proposed teleconsultations. a significant difference was ob­ served only for factor 2, “technical issues”, indicating that psychotherapists who did not propose teleconsultations believed they entailed more technical issues, t(32.247) = -3.159, notermans & philippot 7 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ p = .003, than those who proposed them. mean differences for each attitude towards tel­ econsultation between psychotherapists proposing and not proposing teleconsultations are found in appendix 2, supplementary materials. most psychotherapists had no experience with teleconsultation before the pandemic, whether they proposed it (n = 188) or not (n = 19), with no difference between these two groups, χ2(1, n = 243) = 0.764, p = .382. most psychotherapists who proposed teleconsul­ tation felt significantly more constrained (i.e., strongly constrained; m = 2.78, sd = 1.17) to do so than those who did not (i.e., slightly constrained; m = 1.79, sd = .66), t(41.249) = 6.340, p < .001. in addition, psychotherapists reported having received little support to set up teleconsultation, whether they offered it (m = 1.69, sd = .88) or not (m = 1.75, sd = 1.07), t(240)= -.321, p = .749. qualitative data indicate that support mainly came from colleagues (n = 55), it services (n = 22), supervisors (n = 13), friends and family (n = 15), and professional associations (n = 11). finally, the majority of psychotherapists (n = 116) expressed that some colleagues used teleconsultation. yet, psychotherapists proposing teleconsultation reported that most of their colleagues used it (m = 3.24, sd = .87) as opposed to colleagues of psychotherapists not offering it (m = 2.38, sd = .77), t(241) = 4.677, p < .001. hypothesis 2 no significant correlations above the coefficient .30 were found. however, for explorato­ ry purposes, significant (p < .001) and positive associations were found between thera­ peutic relationship, personal experience, and percentage of teleconsultation (appendix 3, supplementary materials). regarding the therapeutic relationship, empathy is correlated with congruence (r = .389), unconditional positive regard (r = .411), therapeutic alliance (r = .417), therapeutic efficacy (r = .378), and professional satisfaction (r = .303). thus, the more psychothera­ pists perceived empathy as better online than in-person, the more the above variables were perceived similarly, and vice versa. comparably, congruence is correlated with therapeutic alliance (r = .394), and therapeutic efficacy (r = .413), while unconditional positive regard is only correlated with therapeutic alliance (r = .309). finally, therapeutic alliance is correlated with therapeutic efficacy (r = .472), and professional satisfaction (r = .382). regarding therapeutic experience, therapeutic efficacy is correlated with professional satisfaction (r = .592), such that the more psychotherapists perceived therapeutic efficacy as better online than in-person, the more they perceived professional satisfaction as better online than in-person, and vice versa. therapeutic efficacy is also correlated with percentage of consultation (r = .343), meaning that the more psychotherapists perceived therapeutic efficacy as better online than in-person, the more their percentage of teleconsultation increased from june 2020, and vice versa. similarly, professional satisfaction is correlated with strain (r = .438), efficiency in work organisation (r = .352), psychotherapy under lockdown 8 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ and percentage of consultation (r = .356). finally, strain is also correlated with efficiency in work organisation (r = .403). hypothesis 3 single sample t-tests against 3 (neutral “no change” point) showed significant changes in three aspects of the therapeutic relationship: empathy, congruence, and therapeutic alliance. specifically, participants perceived that these significantly degraded online as compared to in-person (table 2). table 2 perceived effect of teleconsultation on therapeutic relationship as compared to face-to-face (n = 207) (1: highly degraded, 3: no change, 5: highly improved) aspects of therapeutic relationship m sd p empathy 2.81 0.59 < .001 congruence 2.76 0.67 < .001 unconditional positive regard 2.96 0.51 .206 therapeutic alliance 2.86 0.70 .006 similarly, single sample t-tests against 3 showed that all variables of personal experience of teleconsultation were perceived as significantly worse online, as compared to in-per­ son, except ‘organisation, time and task management, etc.’ which was perceived as significantly better (table 3). table 3 experience of teleconsultation as compared to face-to-face (n = 206) (1: much worse; 3: no difference, 5: much better) variables of personal experience of teleconsultation m sd p organisation, time and task management, etc. 3.24 1.17 .004 ease/rapidity to receive payments 2.49 0.91 < .001 therapeutic efficacy 2.39 0.77 < .001 professional satisfaction 2.24 0.96 < .001 strain, fatigue 2.24 1.12 < .001 notermans & philippot 9 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ hypothesis 4 data from psychotherapists proposing teleconsultation during the first lockdown (from march to june 2020), consultations significantly dropped by almost 24% (sd = 46.03), t(221) = -7.759, p < .001 (single sample t-test against 0). this decrease was observed for all job status: self-employed (n = 110, m = -24.81, sd = 58.46); employees (n = 83, m = -20.34, sd = 42.31); and part-time self-employed (n = 47; m = -40.28, sd = 44.71). however, from june to september 2020, consultations appeared to have slightly but significantly increased by 6.3%, (sd = 31.68), t(220) = 2.945, p = .004, as compared to the same period in 2019. such increase is also observed in all status: self-employed (n = 109, m = 2.95, sd = 30.09); employees (n = 83, m = 10.72, sd = 30.39); and part-time self-employed (n = 47, m = 11.57, sd = 39.56). then, from june to september 2020, 19.1% of consultations, on average, occurred remotely. out of 115 participants with dependent children at home, 53.9% did not report a decrease in their professional activities. however, 20.0% slightly reduced (10.0% to 30.0%) their professional activities, 14.8% moderately reduced (31.0 to 60.0%), 6.1% strongly reduced (61.0 to 80.0%), and 5.2% extremely reduced them (81.0 to 100.0%). no significant gender difference was found; such that dependent children did not present more difficul­ ties in professional activities for men, and vice versa. participants reported that the majority of their clients (n = 207, m = 64.9%, sd = 24.40) consulted for reasons independent of the covid-19 crisis. 12.8% (n = 207, sd = 15.56) consulted for issues mainly related to covid-19, and 29.5% (n = 207, sd = 21.23) consulted for issues significantly aggravated by covid-19. out of 222 participants, 94.1% used videoconference for teleconsultations; 67.1% used the telephone; 12.6% used e-mails; and 4.5% used chat messaging. regarding videoconfer­ encing platforms, 63.6% of psychotherapists reported using skype, 42.6% used zoom, 29.2% used whatsapp, and 26.3% used whereby (appendix 4, supplementary materials). more than half of the participants (n = 116, 52.3%) found satisfactory answers regard­ ing data protection and deontology issues, whereas a third (n = 61, 27.5%) did not have questions regarding these issues. still, a fifth (n = 41, 18.9%) found answers but had remaining questions, mainly concerning the confidentiality of videoconferencing platforms (n = 32). the majority of practitioners (n = 119, 54.6%) set up actions to encourage clients’ adhesion (table 4). most participants (n = 128, 57.7%) did not adapt their practice to the teleconsultation setting, while 27% (n = 60) provided minor changes. some (n = 19, 8.6%) adapted their therapeutic procedures (e.g., screen sharing to show schemas or other visuals; printing materials to present before the camera; emailing questionnaires and other documents); others (n = 18, 8.1%) adapted their room, desk, and/or video back­ ground; and 12 participants (5.4%) adapted their schedules and/or consultation timing and frequency. a small portion of respondents, 12.6% (n = 28), adapted significantly their consultation based on the type of population (see appendix 5, supplementary materials), psychotherapy under lockdown 10 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ while 10.4% (n = 23) adapted significantly their consultation based on the type of disorder (see appendix 5, supplementary materials). changes pertained mainly to therapeutic procedures and interventions (e.g., shortened session, flexible schedule, adaptation of interventions, etc.). table 4 actions set up to encourage adherence to teleconsultation actions to encourage adherence to teleconsultation n = 222 % communicating with the patient/client to assess the situation (via email, telephone, or other) 97 43.7 giving general advice to ensure optimal conditions for teleconsultations (e.g., be in a quiet space to avoid distractions and increase privacy, ensure a good internet connection, have charged devices, etc.) 79 35.6 underlining the importance of psychotherapy continuity for the well-being of the patient/client 75 33.8 giving information on the use of virtual platform (or other used media) 69 31.1 being flexible regarding schedule 67 30.2 giving information on the privacy of personal data (confidentiality regarding the session and the used media) 51 23 doing a trial test on the used media 45 20.3 giving information on the efficacy of teleconsultations 41 18.5 being flexible regarding payments 29 13.1 finally, out of 207 respondents, 65.8% (n = 146) intend to keep teleconsultation as an option, after the lockdown, if requested by their client. only, 6.8% (n = 15) intend to rely mainly on teleconsultation in their clinical practice. in contrast, 20.7% (n = 46) intend to not use teleconsultation anymore after the lockdown. qualitative results from participants’ comments (n = 74) provided additional useful information. some participants (n = 12) underlined numerous advantages (e.g., facility to consult regardless of geographical distance, schedule flexibility), while others (n = 17) enumerated disadvantages and difficulties (e.g., increased fatigue, lack of warmth, difficulty to set up specific intervention and/or share therapeutic information). few (n = 5) underlined that there was no important difference between teleconsultation and in-person. some (n = 4) were agreeably surprised by teleconsultation and saw their attitudes improved after using it. finally, 12 participants explained that the majority of clients refused to pursue via teleconsultation. notermans & philippot 11 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ data from psychotherapists not proposing teleconsultation only 24 participants did not propose teleconsultation during the lockdown. the two main reasons behind this decision concerned personal issues, and the belief that this type of communication was not appropriate for psychotherapy (table 5). open answers showed that personal reasons (n = 8) pertained mainly to limited infrastructure (n = 6), such as having access to adequate it material or a private room. more than half (n = 14; 58.3%) do not have the intention to use teleconsultation in the near future; over a third (n = 9; 37.5%) will use it if the pandemic persists; and one participant definitely intends to use it in a near future. table 5 reasons for not proposing teleconsultation (from 1: not at all important to 5: very important) reasons for not proposing teleconsultation m sd personal reasons (e.g., limited infrastructure, childcare, etc.) 3.75 1.62 this type of communication does not seem appropriate for psychotherapy 3.54 1.10 individuals did not want to start or pursue via teleconsultation 3.54 1.38 lack of it support 3.46 1.44 i have doubts regarding the therapeutic efficacy in teleconsultation 3.13 1.23 the (mental) state of individuals did not require the continuity of therapy 2.42 1.21 financial reasons (e.g., to receive governmental or other financial aid) 1.75 1.11 discussion this survey shows that most psychotherapists rapidly responded to the sanitary crisis by proposing teleconsultations. they did so with little support and no previous experience with teleconsultation. the important drop (24%) in consultations observed during the first lockdown might have fostered for some the rapid transition to teleconsultation. regarding the first hypothesis, while psychotherapists who did not propose telecon­ sultation believed it to be more technically challenging, received less support, and had less colleagues using it, than those proposing it, attitudes towards teleconsultation did not appear to significantly influence its use. similar findings from a recent systematic review (connolly et al., 2020) suggest that, overall, practitioners tend to have positive attitudes towards telemental health regardless of its disadvantages. moreover, they sug­ gest that previous experience as well as repetitive use of telemental health is related to positive attitudes and acceptance of such method. comparably, our qualitative data sug­ gest that most therapists felt reassured about these issues after gaining some experience with teleconsultation, and surprisingly pleased; a finding also expressed in elford et al.’s study (2000). additionally, qualitative data suggest that the main determinant for not proposing teleconsultation lied in contextual factors, rather than being a personal choice. psychotherapy under lockdown 12 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ for example, working in an institution (e.g., hospital, prison) or at home made it difficult to set up teleconsultations due to the lack of appropriate infrastructure (e.g., it material, stable internet connection, private room). connolly et al. (2020) describe similar negative attitudes regarding the disadvantages of telepsychiatry but underline that the benefits of such methods often outweigh its costs. nevertheless, it is important to note that the sample of psychotherapists not proposing teleconsultation in the present survey is rather small, which calls for caution in interpreting the findings. rejecting our second hypothesis, no significant correlations were evidenced between attitudes and teleconsultation’s use and experience. a similar finding was reported by monthuy-blanc and colleagues (2013), such that intention to use telepsychotherapy was not determined by providers’ attitudes towards it, neither by how difficult they expected it to be, but merely by how useful they thought it to be to first nations clients in australia. nevertheless, a recent study also reported that therapists’ concerns about online connectedness predicted negative attitudes towards teleconsultation and decreased perceived efficacy (békés et al., 2021). therefore, it would be of interest to pursue researching the impact of attitudes on the experience of teleconsultation. in accordance to our third hypothesis, most aspects of the therapeutic relationship (empathy, congruence, and therapeutic alliance) were perceived as significantly deterio­ rated online, as compared to in-person, with the exception of unconditional positive regard. moreover, participants also reported that their personal experience with tele­ consultation in terms of ease of payment, work exhaustion, therapeutic efficacy, and professional satisfaction was also perceived as significantly worse online. unexpectedly, however, work organisation was perceived as significantly better online. regarding our fourth hypothesis, a plethora of findings could be used to help in the development of a practice framework. first, privacy and confidentiality information and trainings should be urgently provided to professionals. in fact, in our survey, the major­ ity of platforms used (e.g., skype, whatsapp, messenger) does not reach the minimal legal criteria for privacy and confidentiality (e.g., some platforms record and sell commu­ nication data) as requested by psychotherapy. moreover, ethical concerns are raised by the fact that many respondents (27.5%) did not seem concerned about deontology and data protection issues with respect to teleconsultation. however, current guidelines and recommendations from different countries strongly underline the importance of ensuring the privacy and confidentiality of videoconferencing platforms (american psychological association, 2020; british association for behavioral & cognitive psychotherapies, 2021; commission des psychologues, 2020; shore et al., 2018; smith et al., 2020; van daele et al., 2020). as lustgarten et al. (2020) explain, even if some platforms (e.g., skype, facetime) may be familiar for most providers and clients, other platforms may be more secure and legally compliant. these authors also provide further recommendations regarding safe practice. evidently, guidelines and recommendations must be made more accessible to all psychotherapists, and professional organisations should work actively notermans & philippot 13 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ in providing recommendations and safe-to-use platforms and apps protecting clients’ personal information (ohannessian et al., 2020). second, psychotherapists should keep encouraging clients’ adhesion to teleconsulta­ tion. in the survey, half of the psychotherapists proposing teleconsultation actively sought to motivate their clients to accept teleconsultation. they mostly kept in touch with them and provided information regarding its use, safety, and efficacy. in fact, showing informational videos discussing the benefits of internet-based mental health services increases clients’ acceptance (ebert et al., 2015). surprisingly, however, only 20% proposed a trial on the chosen media, while theory and anecdotal evidence suggest this action to be very effective (sasangohar et al., 2020; smith et al., 2020). third, information and training should be provided regarding contextual and thera­ peutic adaptions to the teleconsultation setting. in the survey, most therapists did not significantly adapt their way of delivering psychotherapy beyond the switch towards teleconsultation. however, it is important to have a proper and professional setting for teleconsultation (british association for behavioral & cognitive psychotherapies, 2021; de witte et al., 2021; sasangohar et al., 2020; smith et al., 2020), such as ensuring that their video background conveys a feeling of safety and intimacy, and ensuring that clients are benefiting from a quiet, secure, and undisrupted space for the therapy session. more importantly, therapists should be aware of their clients’ location in order to contact them in case of communication failure (e.g., having a contact cell phone number) or emo­ tional breakdown (e.g., having a backup person in the client’s immediate surrounding who could be reached and intervene). regarding interventions, only slight adaptations were provided. our qualitative data and anecdotal evidence suggest that many therapists avoid interventions entailing the activation of intense or aversive emotions, such as exposure. however, recent evidence suggests that such interventions can be successfully and safely provided online (wells et al., 2020). furthermore, few adaptations were repor­ ted as a function of clients’ age or disorder, although some authors (smith et al., 2020; van daele et al., 2020) emphasise that teleconsultation be adapted to the population, its context, and the conditions they are facing. other authors and clinicians provide recommendations on how to adapt therapeutic interventions to the teleconsultation setting for groups (banbury et al., 2018), children (american academy of children and adolescent psychiatry, 2021; american psychiatric association, 2020; becqueriaux, 2020; landrum, 2020), as well as for people suffering from eating disorders (waller et al., 2020) and post-traumatic stress (kaltenbach et al., 2021; moring et al., 2020). nevertheless, such works are still in their infancy and more empirical evidence is needed to optimise the provision of teleconsultation. the present survey suffers from some limitations. first, it has been conducted online and among french-speaking psychotherapists, thus reducing its reach to participants from other countries, and with minimal internet literacy and/or accessibility. second, from a lack of valid measurements in the literature, no psychometrically sound measures psychotherapy under lockdown 14 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ could be used to evaluate our hypotheses. third, a memory bias may have impacted our findings, as psychotherapists were asked retrospectively about their use and experience of teleconsultation. finally, it should also be noted that while this survey addressed the first lockdown, the situation kept evolving. further surveys, targeting the following phases of the pandemic should examine these evolutions in terms of increase in the provision of teleconsultation and professionals’ exhaustion. conclusion while some findings enlightened the use and experience of teleconsultation by psycho­ therapists during the first lockdown, many questions remain in all discussed domains: the impact of attitudes towards the use and experience of teleconsultation; the legal and ethical aspects of videoconferencing platforms; and ways to develop contextual and therapeutic adaptations to the teleconsultation setting. it is the authors’ opinion that basic psychotherapy training should address these questions, and that professional organisations should provide detailed information and instructions about the use of ethically and legally safe teleconsultation platforms. funding: the authors have no funding to report. acknowledgments: we would like to thank the team of the consultations psychologiques spécialisées for their support during the development of this survey, as well as the numerous professional associations (e.g., uppcf, aemtc, afforthec, aspco) of psychotherapists who helped us distributing the survey. competing interests: the authors have declared that no competing interests exist. twitter accounts: @philippotp_ucl supplementary materials the supplementary materials include the entire survey questionnaire and additional tables related to some results (e.g., mean differences, correlations, etc.). for access see index of supplementary materials below. index of supplementary materials notermans, j., & philippot, p. (2022). supplementary materials to "psychotherapy under lockdown: the use and experience of teleconsultation by psychotherapists during the first wave of the covid-19 pandemic" [survey questionnaire, and additional tables]. psychopen gold. https://doi.org/10.23668/psycharchives.8181 notermans & philippot 15 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://twitter.com/philippotp_ucl https://doi.org/10.23668/psycharchives.8181 https://www.psychopen.eu/ references aafjes-van doorn, k., békés, v., & prout, t. a. (2021). grappling with our therapeutic relationship and professional self-doubt during covid-19: will we use video therapy again? counselling psychology quarterly, 34(3-4), 473–484. https://doi.org/10.1080/09515070.2020.1773404 acierno, r., gros, d. f., ruggiero, k. j., hernandez‐tejada, m. a., knapp, r. g., lejuez, c. w., muzy, w., frueh, c. b., egede, l. e., & tuerk, p. w. 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(2020). remote treatment delivery in response to the covid-19 pandemic. psychotherapy and psychosomatics, 89(3), 130–132. https://doi.org/10.1159/000507376 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. notermans & philippot 19 clinical psychology in europe 2022, vol. 4(3), article e6821 https://doi.org/10.32872/cpe.6821 https://doi.org/10.3389/fpsyt.2019.00993 https://doi.org/10.1037/int0000218 https://doi.org/10.1037/ser0000239 https://doi.org/10.1002/eat.23289 https://doi.org/10.1002/jts.22573 https://doi.org/10.1016/j.prrv.2020.06.009 https://doi.org/10.1159/000507376 https://www.psychopen.eu/ psychotherapy under lockdown (introduction) method recruitment and procedure survey questionnaire measures data analysis results participants characteristics hypothesis 1 hypothesis 2 hypothesis 3 hypothesis 4 discussion conclusion (additional information) funding acknowledgments competing interests twitter accounts supplementary materials references early adverse effects of behavioural preventive strategies during the covid-19 pandemic in germany: an online general population survey research articles early adverse effects of behavioural preventive strategies during the covid-19 pandemic in germany: an online general population survey michael witthöft 1 , stefanie m. jungmann 1 , sylvan germer 1 , anne-kathrin bräscher 1 [1] department of clinical psychology, psychotherapy, and experimental psychopathology, johannes gutenberg university of mainz, mainz, germany. clinical psychology in europe, 2022, vol. 4(3), article e7205, https://doi.org/10.32872/cpe.7205 received: 2021-07-23 • accepted: 2022-04-13 • published (vor): 2022-09-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: michael witthöft, department of clinical psychology, psychotherapy, and experimental psychopathology, johannes gutenberg university of mainz, wallstrasse 3, d-55099 mainz, germany. tel.: +496131-3939202. e-mail: witthoef@uni-mainz.de abstract background: quarantine and physical distancing represent the two most important nonpharmaceutical actions to contain the covid-19 pandemic. comparatively little is known about possible adverse consequences of these behavioural measures in germany. this study aimed at investigating potential early adverse effects associated with quarantine and physical distancing at the beginning of the countrywide lockdown in germany in march 2020. method: using a cross-sectional online survey (n = 4,268), adverse consequences attributed to physical distancing, symptoms of psychopathology, and sociodemographic variables were explored in the total sample as well as in high-risk groups (i.e., people with a physical or mental condition). results: the most frequently reported adverse effects were impairment of spare time activities, job-related impairment, and adverse emotional effects (e.g., worries, sadness). participants with a mental disorder reported the highest levels of adverse consequences (across all domains) compared to participants with a physical disease or participants without any mental or physical condition. no significant association between the duration of the behavioural protective measures and the severity of adverse mental health effects was observed. conclusion: results showed that non-pharmaceutical actions were associated with adverse effects, particularly in people with mental disorders. the findings are of relevance for tailoring support to special at-risk groups in times of behavioural preventive strategies. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7205&domain=pdf&date_stamp=2022-09-30 https://orcid.org/0000-0002-4928-4222 https://orcid.org/0000-0003-0201-9517 https://orcid.org/0000-0002-8134-976x https://orcid.org/0000-0002-2621-5689 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords quarantine, social, physical distancing, anxiety, depression, somatic symptoms highlights • physical distancing and quarantine were associated with negative psychological effects. • the most frequently affected areas were spare time activities, job, and emotional condition. • participants with a mental disorder reported the highest levels of adverse consequences. • no significant relation between duration of the protective measures and severity of adverse effects. background behavioural non-pharmaceutical interventions and preventive strategies (i.e., isolation, quarantine, and physical distancing) represent the most important first-line interventions to counteract novel pandemics such as covid-19. despite its effectiveness, already findings from earlier pandemics suggest that behavioural preventive strategies have psychological costs (e.g., brooks et al., 2020; henssler et al., 2021). similar findings were observed in meta-analyses related to covid-19 which found small positive associ­ ations between the implementation, duration, and stringency of behavioural measures and symptoms of mental disorders (e.g. jin et al., 2021; o’hara et al., 2020; wang et al., 2021). however, another meta-analysis using longitudinal data suggests that the psychological impact of behavioural measures (e.g. lockdown) is weak and heterogenous at best (prati & mancini, 2021), and one meta-analysis comparing countrywide point prevalences of depression and stringency levels regarding early interventions (e.g. coun­ trywide lockdowns) found less severe adverse mental health consequences associated with more stringent early interventions (lee et al., 2021). due to the heterogeneity of existing findings, this study aimed at investigating possible adverse effects associated with different behavioural preventive strategies (quarantine and physical distancing), particularly during the early stage of the covid-19 pandemic in germany in march and april 2020. shortly after covid-19 was declared a pandemic by the who on march 11th 2020, preventive actions were taken by the german government and the federal states. since march 16th, federal states decided to close kindergartens and schools and the federal government restricted cross-border traffic from a number of neighboring countries. on 23rd of march, a nationwide assembly ban was established, prohibiting assemblies of more than two persons (except people and families living in the same household). additionally, restaurants and businesses concerned with body care were immediately psychological effects of physical distancing 2 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ closed (robert koch institut [rki], 2020a), resulting in a partial nationwide lockdown. despite their effectiveness, comparatively little is known about possible psychological side effects of these preventive actions. studies from germany (benke et al., 2020), italy (fornili et al., 2021), the uk (fancourt et al., 2021), u.s. (daly & robinson, 2021), and china (gan et al., 2022) suggest that government restrictions on daily life (e.g., lockdown and stay-at-home orders) result in significantly elevated levels of psychological distress (mainly increased symptoms of anxiety, depression, and higher levels of loneliness) at the beginning of the pandemic in march 2020. longitudinal population-based studies in the uk (fancourt et al., 2021) and u.s. (daly & robinson, 2021) suggest that after an initial increase in mental distress during the first wave of the pandemic in march 2020, distress levels significantly declined on the population level, despite continued behavioural restrictions and lockdown measures. it therefore remains unclear, to what extend the observed higher levels of mental distress are directly (i.e., causally) attributa­ ble to behavioural preventive strategies. interestingly and rather unexpectedly, no direct evidence of a dose-response relationship between the intensity (i.e., duration) of the behavioural preventive strategies and levels of psychological distress could be observed, neither in a study from china (gan et al., 2022) nor an early german study (benke et al., 2020). moreover, observed associations between behavioural restrictions and mental distress appear small in terms of effect sizes (benke et al., 2020; prati & mancini, 2021). gan et al. (2022) interpret this observation as a “psychological typhoon eye effect”, i.e., during an immediate threat, the negative emotional response to a disaster might appear atypically weak at first glance. alternatively, these findings might suggest that the threat by the disease itself, rather than behavioural precautions might be responsible for the observed adverse mental health effects. when considering adverse effects of behavioural precautions, three types of strat­ egies have to be conceptually distinguished: (a) isolation (i.e., separation of already infected and thus potentially contagious individuals); (b) quarantine (i.e., separation of individuals with contact to potentially contagious individuals); and (c) social distanc­ ing/physical distancing (i.e., restricting social physical contacts as a primary preventive strategy to reduce the number of new infections in the population). early reviews and meta-analyses suggest adverse mental health effects associated with isolation and quar­ antine in terms of increased levels of anxiety, depression, and stress (jin et al., 2021; wang et al., 2021) and those findings appear similar to results from earlier pandemics as e.g. sars-cov or mers-cov (e.g., brooks et al., 2020; henssler et al., 2021). still, empirical evidence directly related to different behavioural measures in the covid-19 pandemic is comparatively sparse. moreover, earlier reviews and meta-analyses mainly focus on the effects of isolation and quarantine, rather than more general social and physical restrictions that are characteristic of the global response to the covid-19 pandemic. witthöft, jungmann, germer, & bräscher 3 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ the primary aim of this study was to explore the early psychological effects of the most important behavioural non-pharmacological interventions (i.e., physical distancing and quarantine) initiated against the covid-19 pandemic in germany in march 2020. furthermore, this study aimed at examining whether potential high-risk groups within the general population (i.e., people with a current mental disorder or physical disease) were more negatively affected by these actions compared to healthy people without a current mental or physical condition. finally, it was hypothesized that significant positive dose-response relationships would exist between the duration of the respective behavioural actions (i.e., lockdown, physical distancing, and quarantine) and individual levels of psychological distress or adversities, suggesting first evidence of a causal rela­ tionship between the duration of preventive actions and psychological distress levels. method sample and procedure the online survey took place between 25th of march and 13th of april 2020, at an early stage of the virus outbreak in germany, and was presented in german language. the first cases of sars-cov-2 infection in germany became known at the end of january 2020. on march 25th, about 31,554 cases of sars-cov-2 infection, including 149 deaths (worldwide: 413,467 infections), and on april 13th about 123,016 cases, including 2,799 deaths (worldwide: 1,773,084 infections) were registered (rki, 2020a, 2020b; who, 2020a, 2020b). participants were recruited via social media (e.g., twitter), e-mail distribution lists of student councils at universities, and our department's website. in addition to information on the study (type, content, duration, lottery of gift vouchers as compensation for partic­ ipation), the study announcements included a link to the online study. inclusion criteria were a minimum age of 16 and informed consent. the study protocol was approved by the local ethics committee. altogether, 4288 persons completed the survey. twenty persons were excluded due to the following reasons: implausible indication of age (n = 2), very fast completion of the questionnaire (n = 3), long quarantine (> 33 days) for reasons other than sars-cov-2 (n = 6), long period (> 50 days) of social distancing (n = 9) possibly for reasons other than sars-cov-2. the final sample consisted of n = 4268 persons (table 1). of the participants, 10.5% (n = 449) reported to be in quarantine themselves (for m = 9.86 days, sd = 3.83 [range: 2-30]), 27.1% (n = 1156) reported to know someone in their close social environment (family/friends) and 34.0% (n = 1451) in their wider social environment (e.g., acquaintances or at the same residence) who had been in quarantine. concerning physical distancing, participants reported to practice it for an average of 11.85 days (sd = 5.18, range [0, 50]). while 0.6% (n = 25) reported not reducing their physical contacts psychological effects of physical distancing 4 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ at all, 1.7% (n = 71) reported to reduce their physical contacts a little, 3.8% (n = 161) a medium amount, 23.5% (n = 1005) considerably, and 70.4% (n = 3,006) very strongly. table 1 sample characteristics (n = 4268) variable m sd age 32.89 12.07 n % sex female 3389 78.9 male 886 20.8 diverse 13 0.3 born in germany 4015 94.1 professional status employed 1698 39.8 students 1286 30.1 in school/vocational training 209 4.9 public servants 209 4.9 self-employed 204 4.8 unemployed 145 3.4 retired 134 3.1 on parental leave 132 3.1 housewife/househusband 96 2.2 other 158 3.7 education college/university degree 1866 43.7 general qualification for university entrance 1662 39.0 general certificate of secondary education 529 12.4 basic school education 117 2.7 still in school/dropped out of school 74 1.7 health status healthy 2877 67.4 physical disease 817 19.1 psychological disorder 331 7.8 physical disease and psychological disorder 243 5.7 witthöft, jungmann, germer, & bräscher 5 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ measures somatic symptom reporting the patient health questionnaire somatic symptom scale (phq-15; kroenke et al., 2002) is a self-administered instrument that assesses the severity of fifteen common somatic symptoms on a scale from 0 (not bothered at all) to 2 (bothered a lot) covering the preceding four weeks. the phq-15 has shown good reliability and validity in previous studies (gräfe et al., 2004; kroenke et al., 2002; van ravesteijn et al., 2009). in the current study, the internal consistency was cronbach’s α = 0.80. psychosocial stress the stress module of the patient health questionnaire (phq-stress; gräfe et al., 2004) assesses psychosocial stressors (including health, work/financial, social, and traumatic stress) that provide indications of potentially causing or maintaining factors of mental disorders. it is a self-report questionnaire and consists of ten questions referring to the last month, which can be answered on a scale ranging from 0 (not bothered at all) to 2 (bothered a lot). a limited number of studies suggest adequate reliability and validity of the questionnaire (beutel et al., 2018; klapow et al., 2002). internal consistency in the present study was cronbach’s α = 0.69. anxiety and depression the patient health questionnaire depression and anxiety screener (phq-4; kroenke et al., 2009) is an ultra-brief screener for anxiety and depression. it is a composite instrument that consists of two items assessing the core criteria for depression and two items assessing core aspects of general anxiety disorder. the scale ranges from 0 (not at all) to 3 (almost every day) and refers to the last two weeks. adequate reliability and validity have been demonstrated (kroenke et al., 2009; löwe et al., 2010). the internal consistency in this study was cronbach’s α = 0.84. loneliness the three-item loneliness scale (ucla-ls-3; hughes et al., 2004) is the short version of the ucla-loneliness scale (russell et al., 1980) and assesses subjective isolation. items can be answered on a scale from 1 (hardly ever) to 3 (often). some evidence confirms sufficient reliability and adequate validity of the questionnaire (hughes et al., 2004). for the current study, the authors translated the three items to german. internal consistency in the current study was cronbach’s α = 0.74. strains/changes due to social/physical isolation in order to assess changes and strains due to the pandemic in more detail, participants were asked whether they experienced the following due to social/physical isolation: psychological effects of physical distancing 6 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ more socially isolated/lonely, being separated from important people, lack of leisure activities (e.g., sport), occupational restrictions/job loss, increased computer/internet use, increased tv consumption, more conflicts at home, worsened mood/sadness, worries, anger, boredom, or other. participants were also asked to indicate how much they felt distressed by the applicable changes/strains on a scale from 1 (not distressing at all) to 101 (extremely distressing). quantifying the duration of quarantine and physical distancing first, the duration of current quarantine and the reduction of social (physical) contacts were assessed via two questions (i.e., with an open-ended response format: for how many days have you been in quarantine? for how many days have you been limiting your social contacts?). as an additional, objective criterion for the duration of physical distancing, we computed the number of days since the official lockdown in germany (23rd of march 2020). statistical analyses analyses were conducted using spss 23 (ibm corp., 2015) and jasp 0.13 (jasp team, 2022). for all tests, the alpha level was set to 5%. eta-squared (η2) was calculated as effect size for anovas (η2 ≥ 0.01 small effect; η2 ≥ 0.06 medium effect; η2 ≥ 0.14 large effect) and cohen’s d for (post-hoc) t-tests (d ≥ 0.30 small, d ≥ 0.50 medium, d ≥ 0.80 large). for correlation analyses, effect size conventions are r ≥ |.10| small; r ≥ |.30| medium, r ≥ |.50| large (cohen, 1992). for the corresponding bayes analyses, bayes factors (bf) were used to quantify the evidence for h1 and h0, respectively (e.g. jarosz & wiley, 2014; nuzzo, 2017). results psychological effects of behavioural actions (i.e., lockdown, social/physical distancing, quarantine) strains/changes due to social/physical distancing of the participants, 1.4% (n = 59) did not report any change or distress due to social/phys­ ical distancing, 67.4% (n = 2875) observed increased computer and/or internet use, 61.7% (n = 2632) reported a lack of leisure activities (e.g., sport), 61.5% (n = 2624) felt separated from important people, 48.1% (n = 2055) reported worries, 44.8% (n = 1914) observed increased tv consumption, 42.5% (n = 1814) reported occupational restrictions or job loss, 44.2% (n = 1886) perceived boredom, 40.7% (n = 1735) perceived decreased mood or sadness, 36.9% (n = 1574) felt socially isolated or lonely, 17% (n = 726) reported to have more conflicts at home, 13.5% (n = 578) felt anger, and 12.7% (n = 544) noticed other witthöft, jungmann, germer, & bräscher 7 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ changes or strains. on average, participants experienced 4.91 changes/strains (sd = 2.20, range [0, 12]) and they reported an average level of distress of m = 54.70 (sd = 25.29, range [1, 101]). high-risk groups with mental disorder and/or physical disease perception of changes/strains due to social distancing the four subgroups (i.e., persons with a physical disease, persons with a mental disorder, persons with both a physical disease and a mental disorder, and persons without any reported physical or mental condition) differed significantly in the number of perceived changes/strains and perceived distress due to the changes/strains (table 2). according to bonferroni-corrected post-hoc tests, healthy individuals reported as much changes/ strains as individuals with a physical disease (t = -0.35, p > .999, d = -0.01) and were similarly distressed (t = 1.01, p > .999, d = 0.04) but reported less changes/strains and were less distressed than individuals with a mental disorder (t = -7.31, p < .001, d = -0.42; t = -8.45, p < .001, d = -0.50) or both a physical disease and a mental disorder (t = -5.30, p < .001, d = -0.35; t = -5.34, p < .001, d = -0.36). individuals with a physical disorder reported less changes/strains and were less distressed than persons with a mental disorder (t = -6.30, p < .001, d = -0.41; t = -8.14, p < .001, d = -0.53) and persons with both (t = -4.66, p < .001, d = -0.34; t = -5.42 p < .001, d = -0.39). individuals with a mental disorder did not differ from individuals who had both a physical disease and a mental disorder (t = -0.83, p > .999, d = 0.07; t = 1.59, p = .675, d = -0.14). phq-15 the subgroups differed concerning their reporting of somatic symptoms, f(3, 680.65) = 161.49, p < .001, η2 = 0.12. post-hoc tests indicated that all subgroups differed from each other; healthy individuals had lower scores than persons with a physical disease (t = -11.83, p < .001, d = -0.48), individuals with a mental disorder (t = -15.44, p < .001, d = -0.92), and individuals with both (t = -17.50, p < .001, d = -1.22). further, individuals with a physical disease showed lower scores than individuals with a mental disorder (t = -6.55, p < .001, d = -0.39) and individuals with both (t = -9.58, p > .001, d = -0.65). individuals with a mental disorder reported less somatic symptoms than individuals with both a physical disease and a mental disorder (t = -3.23, p = .007, d = -0.24). psychological effects of physical distancing 8 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ ta bl e 2 m ea ns s ta nd ar d d ev ia tio ns , a nd a n o va r es ul ts (f re qu en tis t a nd b ay es ) o f t he n um be r of c ha ng es /s tr ai ns p er ce iv ed d ue to s oc ia l/ ph ys ic al d is ta nc in g an d ps yc ho m et ri c in st ru m en ts a ss es se d fo r th e w ho le s am pl e an d d if fe re nt s ub gr ou ps m ea su re s of p sy ch ol og ic al d is tr es s to ta l s am pl e m (sd ) su bg ro up s f t es t ( p); bf in clu sio n po st -h oc te st s 1 2 3 4 n o m en ta l o r ph ys ic al d is ea se m (sd ) ph ys ic al d is ea se m (sd ) m en ta l d is or de r m (sd ) ph ys ic al d is ea se a nd m en ta l d is or de r m (sd ) n um be r of c ha ng es /s tr ai ns 4. 91 (2 .2 0) 4. 79 (2 .1 8) 4. 92 (2 .1 3) 5. 71 (2 .2 5) 5. 56 (2 .2 7) 25 .6 4, (< .0 01 ); 1. 41 *1 013 1, 2 < 3 , 4 d is tr es s du e to c ha ng es /s tr ai ns 54 .7 0 (2 5. 29 ) 53 .4 3 (2 4. 98 ) 52 .4 3 (2 6. 02 ) 65 .7 0 (2 2. 92 ) 62 .3 4 (2 4. 49 ) 37 .6 6, (< .0 01 ); ∞ 1, 2 < 3 , 4 ph q -1 5 6. 97 (4 .7 1) 5. 97 (4 .1 9) 8. 05 (4 .7 8) 9. 95 (5 .1 6) 11 .1 6 (4 .8 6) 16 1. 49 , ( < .0 01 ); ∞ 1 < 2 < 3 < 4 ph q -s tr es s 5. 75 (3 .6 0) 5. 17 (3 .3 7) 6. 18 (3 .5 4) 7. 93 (3 .9 2) 8. 20 (3 .7 0) 10 0. 73 , ( < .0 01 ); ∞ 1 < 2 < 3, 4 ph q -4 3. 66 (2 .8 8) 3. 21 (2 .6 4) 3. 59 (2 .6 2) 6. 12 (3 .2 8) 5. 84 (3 .1 9) 12 5. 15 , ( < .0 01 ); ∞ 1 < 2 < 3, 4 u c la -l s3 6. 08 (1 .7 5) 5. 93 (1 .7 1) 5. 98 (1 .7 4) 7. 09 (1 .6 6) 6. 81 (1 .8 2) 60 .6 1, (< .0 01 ); ∞ 1, 2 < 3 , 4 n ot e. ph q -1 5, p at ie nt h ea lth q ue st io nn ai re s om at ic s ym pt om s ca le ; p h q -s tr es s, p at ie nt h ea lth q ue st io nn ai re s tr es s m od ul e; p h q -4 , p at ie nt h ea lth q ue st io nn ai re d ep re ss io n an d a nx ie ty s cr ee ne r; u c la -l s3, 3 -i te m s ho rt v er si on o f t he u c la lo ne lin es s sc al e. witthöft, jungmann, germer, & bräscher 9 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ phq-stress the subgroups differed with regards to their level of psychosocial stress, f(3, 688.77) = 100.73, p < .001, η2 = 0.08. according to post-hoc tests, healthy individuals had lower stress levels compared to individuals with a physical disease (t = -7.34, p < .001, d = -0.30), a mental disorder (t = -13.69, p < .001, d = -0.80), and both (t = -13.06, p < .001, d = -0.89). individuals with a physical disease were less stressed than individuals with a mental disorder (t = -7.73, p < .001, d = -0.48) and both (t = -7.96, p < .001, d = -0.56). there was no difference between individuals with a mental disorder and both a physical disease and a mental disorder regarding psychosocial stress level (t = -0.92, p = .793, d = -0.07). phq-4 the subgroups significantly differed in the screening for depression and anxiety, f(3, 681.77) = 125.15, p < .001, η2 = 0.11. healthy individuals had lower scores compared to individuals with a physical disease (t = -3.52, p = .003, d = -0.14), a mental disorder (t = -18.40, p < .001, d = -1.07), and both (t = -14.46, p < .001, d = -0.98). individuals with a physical disorder scored lower than individuals with a mental disorder (t = -14.25, p < .001, d = -0.90) and both (t = -11.31, p < .001, d = -0.82). individuals with a mental disorder did not differ significantly from individuals with both a physical disease and a mental disorder (t = 1.21, p = .621, d = 0.09). ucla-ls-3 the subgroups significantly differed in their perception of loneliness, f(3, 4264) = 60.61, p < .001, η2 = 0.04. post-hoc tests indicated that healthy individuals did not differ significantly from individuals with a physical disease (t = -0.71, p = .895, d = -0.03), but had lower scores compared to individuals with a mental disorder (t = -11.59, p < .001, d = -0.68) and both a physical disease and a mental disorder (t = -7.65, p < .001, d = -0.51). individuals with a physical disease had lower scores than persons with a mental disorder (t = -9.89, p < .001, d = -0.64) and individuals with both (t = -6.61, p < .001, d = -0.47). no significant difference occurred between individuals with a mental disorder and both a physical disease and a mental disorder (t = 1.91, p = .224, d = 0.16). associations between sociodemographic factors and perceived changes/strains (number of strains and perceived distress) due to physical distancing the results of (frequentist and bayesian) multiple regression analyses (table 3) suggest that the number of strains attributed to physical distancing was significantly (and inde­ pendently) associated with lower age, being female, lower educated, living alone, having a current mental disorder, and having a current physical disease. similarly, perceived psychological effects of physical distancing 10 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ distress of physical distancing was significantly (and independently) associated with the same factors, except for the presence of a current physical disease (table 3). table 3 associations (multiple regression) between sociodemographic factors and perceived changes/strains (number of strains and perceived distress) due to physical distancing (n = 4171) predictor variables dependent variables number of physical distancing strains (0 – 12) perceived distress of physical distancing (0 – 100) b se(b) β p b se(b) β p age < -0.04 < 0.01 -0.21b < .01 -0.24 0.04 -0.11b < .01 sex (1 = female; 2 = male) 0.37 0.08 -0.07b < .01 -4.41 0.94 -0.07b < .01 education (1 = low; 2 = medium; 3 = high) -0.24 0.06 -0.06b < .01 -4.61 0.68 -0.10b < .01 currently unemployed (1 = yes; 0 = no) 0.12 0.19 0.01e .53 0.56 2.17 < 0.01e .80 living alone (1 = yes; 2 = no) -0.21 0.09 -0.04e .02 -3.57 1.01 -0.06b < .01 children (1 = yes; 0 = no) 0.09 0.08 0.02e .27 4.22 0.91 0.08b < .01 current mental disorder (1 = yes; 0 = no) 0.72 0.10 0.11b < .01 9.74 1.15 0.13b < .01 current physical disease (1 = yes; 0 = no) 0.22 0.08 0.04a .01 -0.26 0.92 < 0.01e .78 r2 .07 (p < .01)b .05 (p < .01)b note. results of independent bayesian regression analyses: abfinclusion / bf10 = 3 10 (moderate evidence for h1), bbfinclusion / bf10 > 10 (strong evidence for h1), cbfinclusion / bf10 = 1/10 1/3 (moderate evidence for h0); dbfinclusion 7 bf10 = 1/30 – 1/10 (strong evidence for h0); eweak/inconclusive evidence. associations between behavioural actions (quarantine and physical distancing) and levels of psychological distress correlation analyses (table 4) suggest that current behavioural actions (quarantine and physical distancing) are weakly positively associated with symptoms of stress, anxiety, and depression (phq) as well as somatic symptoms (phq-15) and loneliness (uclals-3). the corresponding bayes factors (bf) suggest moderate to strong evidence for a witthöft, jungmann, germer, & bräscher 11 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ positive relationship in all but one of the associations (in case of stress and physical distancing; bf10 = 0.55 indicating inconclusive evidence for a relationship). further correlational analyses focusing on possible associations between the duration of behavioural actions and levels of psychological distress (table 4) suggest that the duration (in days) since the start of the lockdown is largely unrelated to symptoms of stress, anxiety and depression, somatic symptoms, and loneliness (with correlation coefficients ranging from -.04 to .001). the evidence in favour of h0 (i.e., no association between the respective variables) is thereby moderate (somatic symptoms) to strong (anxiety and depression, loneliness), and inconclusive regarding symptoms of stress (phq). using the self-reported number of days regarding physical distancing resulted in almost equivalent findings: correlation coefficients were very small in size (range: -.03 .04) with moderate (anxiety and depression, somatic symptoms, loneliness) to strong (stress symptoms) evidence in favour of h0 (i.e., no association between the respective variables). table 4 associations between behavioral actions and measures of psychological distress measures of psychological distress quarantine, currently at the day of assessment (1 = no; 2 = yes) strength of physical distancing, currently (1 = no to 5 = extremely) days since official lockdown in germany (23.03.2020) self-reported duration physical distancing (days) self-reported duration quarantine (days)‡ stress (phq) .06*b (.06*) .04e (.03) -.04*c (-.04*) .01d (.02) -.09e (-.09) anxiety/ depression (phq-4) .06*b (.04*) .06*b (.06*) <.01d (.02) .04c (.06*) -.04d (-.02) somatic symptoms (phq-15) .09*b (.08*) .05*a (.04*) -.03c (-.02) .04c (.05*) -.08c (-.05) loneliness (ucla-ls3) .07*b (.05*) .09*b (.10*) <-.01d (.01) -.03c (-.02) -.02d (-.01) note. coefficients represent pearson’s rho; corresponding partial correlation coefficients conditioned on age, sex and education in parentheses (npartial corr = 4171); results of independent bayesian regression analyses: abf10 = 3 10 (moderate evidence for h1). bbf10 > 10 (strong evidence for h1). cbf10 = 1/10 1/3 (moderate evidence for h0). dbf10 = 1/30 – 1/10 (strong evidence for h0). einconclusive evidence. phq = patient health questionnaire; phq-4 = patient health questionnaire-4 (brief screening for anxiety and depression). phq-15 = 15-item somatic symptom subscale of the patient health questionnaire; ucla-ls3 = 3-item short version of the ucla loneliness scale; ‡subsample of participants reporting at least 1 day of quarantine (n = 449; npartial corr = 431). *p < .01. psychological effects of physical distancing 12 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ similarly, the self-reported number of days in quarantine (for the subsample of partici­ pants n = 449 reporting at least 1 day of quarantine) showed consistently small negative associations (range: -.09 .02) with symptoms of stress, loneliness, and psychopathology. bayes factors were indicative of mostly moderate to strong support for h0 (i.e., no association exists between the respective variables). in sum, support for a dose-response relationship as evidence of causality between symptom severity and behavioural meas­ ures was observed neither for the duration of physical distancing nor the duration of quarantine. since the day-wise subsamples differ in terms of sociodemographic variables, we additionally computed partial correlations (with statistically controlling for age, sex, and education) as a robustness check (table 4). the pattern of correlations remained largely unchanged. only two of the reported associations reached statistical significance (the association between self-reported days of physical distancing and symptoms of anxiety and depression in the phq-4: rpartial = .06, p < .01; the association between self-reported days of physical distancing and somatic symptoms in the phq-15: rpartial = .05, p < .01). the changes in the strength of associations are generally small and not indicative of qualitatively meaningful differences, though. associations between covid-19 anxiety, strength of physical distancing, symptoms of stress and psychopathology, and perceived changes/strains of physical distancing associations between covid-19 anxiety, strength of physical distancing, number of covid-19 cases and subjective measures of distress and psychopathology are detailed in table 5. covid-19 anxiety shows significant medium sized associations with symptoms of stress, anxiety, depression, and somatic symptom distress in the phq. self-reported strength of physical distancing showed only small associations with loneliness, the number of strains of physical distancing and associated distress but not with any of the phq measures. neither the number of days since lockdown nor the daily number of covid-19 cases were significantly associated with symptoms of stress, psychopathology, or loneliness. discussion the primary aim of this study was to investigate potential early adverse effects associ­ ated with behavioural non-pharmacological preventive strategies (i.e., quarantine and so­ cial/physical distancing) initiated at the onset of the covid-19 pandemic in germany in march 2020. the majority of the studied sample (98.6%) reported significant changes and adverse effects of physical distancing, with restricted spare time activities, job-related difficulties, and negative emotional consequences as the most frequent topics. regarding witthöft, jungmann, germer, & bräscher 13 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ potential high-risk groups, people with a mental disorder (regardless of an additional physical health condition) reported significantly higher levels of adverse effects associ­ ated with the social restrictions resulting from physical distancing. early reviews on potential adverse effects of quarantine and social distancing (e.g., brooks et al., 2020) suggest a dose-response relationship between the duration of quar­ antine and social distancing and the burden of adverse psychological effects. in our study, no such evidence for a dose-response relationship emerged, i.e., no meaningful association was observed between the duration of physical distancing (both at the level of self-report and objective assessment) or duration of quarantine and symptoms of psychopathology. the findings suggest that the (causal) association between the duration of behavioural preventive strategies (i.e., quarantine and social/physical distancing) and symptoms of psychopathology might be smaller than expected, although caution must be taken that these observations might be specific to the situation (and particularly the restrictiveness of the measures) in germany between march, 25th and april, 14th. conse­ quently, increased levels of psychopathology observed in early stages of the pandemic (e.g., benke et al., 2020) might be stronger related and attributable to the perceived threat table 5 associations between covid-19 anxiety, strength of physical distancing, symptoms of stress and psychopathology, and perceived changes/strains due to physical distancing predictor variables dependent variables stress (phq) anxiety/ depression (phq-4) somatic symptoms (phq-15) loneliness (ucla-ls3) physical distancing strains (0 12) distress physical distancing (0 – 100) covid-19 anxiety .34*b (.31*b) .30*b (.28*b) .33*b (.30*b) .19*b (.17*b) .14*b (.14*b) .23*b (.22*b) strength of physical distancing (1 = no to 5 = extremely) -.01d (-.02c) .02d (.02e) < -.01d (<-.01c) .07*b (.07*b) .09*b (.09*b) .09*b (.08*b) days since official lockdown in germany (23.03.2020) .15c (.19c) .24d (.19e) .13d (.13c) .24c (.22e) .04e (< -.01e) .19e (.18e) daily covid-19 cases (per million) -.18c (-.21e) -.22d (-.16e) -.15d (.-.14c) -.23c (-.19e) -.07e (.01e) -.23e (-.19e) note. table contains beta coefficients of multiple regression analyses; corresponding values after adjusting for sex, age, and education in parentheses (n = 4171); results of independent bayesian regression analyses: abfinclusion / bf10 = 3 10 (moderate evidence for h1). bbf inclusion / bf10 > 10 (strong evidence for h1). cbf inclusion / bf10 = 1/10 1/3 (moderate evidence for h0). dbf inclusion / bf10 = 1/30 – 1/10 (strong evidence for h0). eweak/inconclusive evidence. *p < .01. psychological effects of physical distancing 14 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ by covid-19, rather than to the behavioural measures imposed to contain the pandem­ ic. in line with this hypothesis, covid-19 anxiety appears to be stronger related to measures of negative affect and psychopathology compared to the strength of behavioral measures (table 5). overall, our results are in line with a recent meta-analysis focusing on longitudinal and natural-experimental data across europe, north america, and asia suggesting that “the psychological impact of covid-19 lockdowns is small in magnitude and highly heterogeneous, suggesting that lockdowns do not have uniformly detrimental effects on mental health and that most people are psychologically resilient to their effects” (prati & mancini, 2021, p. 201). additionally, the implementation of stringent behavioral measures might not exclusively be associated with more adverse negative mental health consequences but might also serve as a protective factor, not only in terms of physical but also for mental health (lee et al., 2021). it appears noteworthy that our study focused primarily on physical distancing compared to quarantine. since the restrictions associated with quarantine appear more stringent and severe, it might be possible that quarantine could have more stable adverse mental health effects compared to physical distancing (e.g. jin et al., 2021; wang et al., 2021). strengths and limitations the generalization of findings is restricted by the nature of the sample: the current sample represents an online convenience sample and therefore consists of a higher percentage of women, younger people, and people with higher education and socio-eco­ nomic status compared to strictly population-representative samples. therefore, two opposing biases might be existent in the data: women and younger people have been found to report higher levels of mental distress (bräscher et al., 2021), i.e., these groups might increase the distress levels observed in our study. on the other hand, the underre­ presentation of people with lower education and socio-economic status might lower the observed distress levels in our study. it is difficult to determine, which of the two trends is stronger in size, but representative samples are needed to confirm the current results. because this study relied on self-reported questionnaire data only, the formation of subgroups regarding the presence of a mental disorders or a physical disorder should be interpreted cautiously, and further studies using clinical interviews are necessary to confirm our findings and to quantify the amount of additional distress associated with different kinds of mental and physical disorders. finally, the examination of possible dose-response associations between distress lev­ els and the duration of the respective behavioural intervention is limited by the crosssectional nature of our study, the comparatively short period of data assessment (over the period of 20 days), and early point in time in the pandemic situation. more extended, longitudinal studies are needed to rigorously test the question of possible dose-response witthöft, jungmann, germer, & bräscher 15 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://www.psychopen.eu/ relationships that would be indicative of a causal relation between duration of non-phar­ macological interventions and adverse mental health effects. conclusion this study aimed at evaluating possible adverse effects associated with non-pharmaco­ logical preventive measures imposed to contain the covid-19 pandemic in germany. the findings suggest that most of the participants were negatively affected by the be­ havioural interventions with restrictions in spare time activities, occupational problems, and negative emotional reactions (e.g., worries, sadness, and loneliness). the adverse effects were highest in people with a mental disorder, suggesting that this group should receive particular attention and support in order to prevent exacerbations of mental distress levels. significant positive association (as possible evidence of a dose-response relationship) with mental distress could neither be observed for the duration of physical distancing nor for the duration of quarantine, leaving open the question whether higher levels of mental distress observed during early stages of the first wave of covid-19 are causally related to the behavioural interventions. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. twitter accounts: @witthoef, @steffi_jungmann, @sylvangermer, @annekbraescher references benke, c., autenrieth, l. k., asselmann, e., & pané-farré, c. a. 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(2021). the impact of quarantine on mental health status among general population in china during the covid-19 pandemic. molecular psychiatry, 26(9), 4813–4822. https://doi.org/10.1038/s41380-021-01019-y world health organization. (2020a, march 25). coronavirus disease 2019 (covid-19) situation report – 65. retrieved from https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200325-sitrep-65covid-19.pdf?sfvrsn=ce13061b_2 world health organization. (2020b, april 13). coronavirus disease 2019 (covid-19) situation report – 84. retrieved from https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200413-sitrep-84covid-19.pdf?sfvrsn=44f511ab_2 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. witthöft, jungmann, germer, & bräscher 19 clinical psychology in europe 2022, vol. 4(3), article e7205 https://doi.org/10.32872/cpe.7205 https://doi.org/10.1038/s41380-021-01019-y https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200325-sitrep-65-covid-19.pdf?sfvrsn=ce13061b_2 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200325-sitrep-65-covid-19.pdf?sfvrsn=ce13061b_2 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200413-sitrep-84-covid-19.pdf?sfvrsn=44f511ab_2 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200413-sitrep-84-covid-19.pdf?sfvrsn=44f511ab_2 https://www.psychopen.eu/ psychological effects of physical distancing background method sample and procedure measures quantifying the duration of quarantine and physical distancing statistical analyses results psychological effects of behavioural actions (i.e., lockdown, social/physical distancing, quarantine) high-risk groups with mental disorder and/or physical disease associations between sociodemographic factors and perceived changes/strains (number of strains and perceived distress) due to physical distancing associations between behavioural actions (quarantine and physical distancing) and levels of psychological distress associations between covid-19 anxiety, strength of physical distancing, symptoms of stress and psychopathology, and perceived changes/strains of physical distancing discussion strengths and limitations conclusion (additional information) funding acknowledgments competing interests twitter accounts references repetitive negative thinking about suicide: associations with lifetime suicide attempts research articles repetitive negative thinking about suicide: associations with lifetime suicide attempts tobias teismann 1, thomas forkmann 2, johannes michalak 3, julia brailovskaia 1 [1] mental health research and treatment center, ruhr-universität bochum, bochum, germany. [2] department of clinical psychology, university of duisburg-essen, essen, germany. [3] department of clinical psychology and psychotherapy, universität witten-herdecke, witten, germany. clinical psychology in europe, 2021, vol. 3(3), article e5579, https://doi.org/10.32872/cpe.5579 received: 2021-01-08 • accepted: 2021-06-28 • published (vor): 2021-09-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: tobias teismann, mental health research and treatment center, ruhr-universität bochum, germany, massenbergstraße 9-13, 44787 bochum. phone: 0049-234-3227787. e-mail: tobias.teismann@rub.de supplementary materials: materials [see index of supplementary materials] abstract background: repetitive negative thinking has been identified as an important predictor of suicide ideation and suicidal behavior. yet, only few studies have investigated the effect of suicide-specific rumination, i.e., repetitive thinking about death and/or suicide on suicide attempt history. on this background, the present study investigated, whether suicide-specific rumination differentiates between suicide attempters and suicide ideators, is predictive of suicide attempt history and mediates the association between suicide ideation and suicide attempts. method: a total of 257 participants with a history of suicide ideation (55.6% female; age m = 30.56, age sd = 11.23, range: 18–73 years) completed online measures on suicidality, general and suicide-specific rumination. results: suicide-specific rumination differentiated suicide attempters from suicide ideators, predicted suicide attempt status (above age, gender, suicide ideation, general rumination) and fully mediated the association between suicide ideation and lifetime suicide attempts. conclusion: overall, though limited by the use of a non-clinical sample and a cross-sectional study design, the present results suggest that suicide-specific rumination might be a factor of central relevance in understanding transitions to suicidal behavior. keywords repetitive negative thinking, rumination, suicide ideation, suicide attempts this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5579&domain=pdf&date_stamp=2021-09-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • suicide-specific rumination was investigated in participants with a history of suicide ideation. • suicide-specific rumination differentiated suicide attempters from suicide ideators. • suicide-specific rumination predicted suicide attempt status. • suicide-specific rumination mediated the association between suicide ideation and lifetime suicide attempts. • suicide-specific rumination might be a factor of central relevance in understanding transitions to suicidal behavior. repetitive negative thinking (rnt) is defined as a style of thinking about one’s problems or negative experiences with three key characteristics: the thinking is repetitive, it is at least partly intrusive, and it is difficult to disengage from. two additional features of rnt are that individuals perceive it as unproductive and it captures mental capacity (ehring et al., 2011). the two most intensively studied types of rnt are worry and depressive rumination. rnt – in the form of rumination and worry – has been identified as a critical factor in the development and maintenance of psychiatric symptoms and dis­ orders (ehring & watkins, 2008; teismann & ehring, 2019; watkins, 2008). in prospective studies, rumination was found to predict the future onset of a major depressive episode (nolen-hoeksema, 2000; nolen-hoeksema et al., 2007; robinson & alloy, 2003; wilkinson et al., 2013) and to mediate the effect of various risk factors on the onset of depression (spasojević & alloy, 2001). additional studies have shown that rumination prospectively predicts the onset of post-traumatic stress disorder (moulds et al., 2020; szabo et al., 2017) and is linked to the maintenance of social anxiety disorder (penney & abbott, 2014), insomnia (takano et al., 2014) and eating disorder psychopathology (smith, mason, & lavender, 2018). moreover, a close association between rnt, suicide ideation and suicide attempts has been shown in cross-sectional and longitudinal studies (rogers & joiner, 2017) – even when different types of rnt as well as different methodologies, samples (clinical and non-clinical) and measures of suicidality were used (kerkhof & van spijker, 2011; law & tucker, 2018). as such, rumination significantly predicted suicide ideation in prospective studies using student and community samples (miranda & nolen-hoeksema, 2007; smith, alloy, & abramson, 2006). furthermore, rumination was found to be more common in suicide attempters than in non-attempters (e.g., horwitz et al., 2019). galynker (2017) understands intensive, persistent and uncontrollable brooding (ruminative flooding) as a core feature of an acute suicidal state, the so-called suicide crisis syndrome. taken together, there is strong empirical evidence for the importance of rnt with respect to understanding suicide ideation and behavior. in the vast majority of these studies, the relationship between general rnt and suicidal ideation and suicide attempts was investigated. however, rogers and joiner (2018a, 2018b) have recently started to study the effect of suicide-specific rumination, repetitive thinking and suicide 2 clinical psychology in europe 2021, vol. 3(3), article e5579 https://doi.org/10.32872/cpe.5579 https://www.psychopen.eu/ that is, rnt about death and/or suicide. they found that suicide-specific rumination is associated with lifetime suicide attempts over and above a large array of known risk factors, including suicide ideation, general rumination, depression and anxiety (rogers & joiner, 2018a). furthermore, they could show that the association between suicide-specif­ ic rumination and lifetime suicide attempts is mediated by an acute suicidal state, called acute suicidal affective disturbance (asad; rogers & joiner, 2018b). in both of these studies, suicide-specific rumination was assessed using either a 5-item (rogers & joiner, 2018b) or an 8-item (rogers & joiner, 2018a) version of the suicide rumination scale (srs). this scale assesses the tendency to ruminate or fixate on one’s suicidal thoughts, intention and plans. however, it cannot be excluded that some items of the srs may confound general preparation behavior (“when i have thoughts of suicide, i think about how i want to kill myself”; “… i wonder what the fastest and easiest way to die is”) or so called flash forwards (“when i have thoughts of suicide, i imagine the process of how i want to kill myself”), with generic features of rnt (“when i have thoughts of suicide, i have trouble getting the suicidal thoughts out of my mind”). it is therefore unclear whether the significant association between suicide-specific rumination – as assessed with the srs – and lifetime suicide attempts are in fact due to rnt or rather a consequence of increased preparation and planning behavior. on this background, the current study aims at investigating the association between suicide-specific rumination and suicidal behavior with a suicide-specific version of the perseverative thinking questionnaire (ptq; ehring et al., 2011), a self-report measure designed to assess core characteristics of rnt (repetitiveness, intrusiveness, difficulties with disengagement, perceived unproductiveness). the study had three aims: 1. to inves­ tigate whether suicide-specific rumination – as assessed with an unconfounded measure – differentiates between lifetime suicide attempters and non-attempters; 2. to investi­ gate, whether suicide specific rumination is associated with lifetime suicide attempts – above and beyond age, gender, current suicide ideation and general rumination; 3. to investigate whether suicide-specific rumination mediates the association between current suicide ideation and lifetime suicide attempts. since most suicide ideators do not show suicidal behavior, the necessity to understand what differentiates attempters from ideators has recently been highlighted (may & klonsky, 2016). method and materials participants and procedure between march and may 2019, n = 300 (58% female; mage= 32.25, sdage = 13.68, range: 18–77 years) and again between february and june 2020, n = 276 (67% female; mage = 32.08, sdage = 10.73, range: 18–64 years) participants took part in a single assessment using an online survey. the assessments took part within the context of two other teismann, forkmann, michalak, & brailovskaia 3 clinical psychology in europe 2021, vol. 3(3), article e5579 https://doi.org/10.32872/cpe.5579 https://www.psychopen.eu/ studies (teismann & brailovskaia, 2020; teismann et al., 2020), that were advertised as investigating the association between well-being and psychological strain. it was assured that no participant took part in both of these studies. of the two samples, n = 257 (55.6% female; mage = 30.56, sdage = 11.23, range: 18–73 years) reported lifetime suicide ideation and were included in the present study. one-hundred and twenty-nine participants (50.2%) reported some suicide ideation in the last four weeks (ssevscore ≥1); fifty-two participants (20.2%) indicated that they had attempted suicide at least once in their lifetime (range: 1–6). all participants – except for one asian participant – were caucasian. participants were recruited through postings at local university as well as social media postings on facebook and twitter. data was collected through an anonymous online survey using the sosci-server (https://www.soscisurvey.de/). participation in the study was not compensated; yet, participating students were eligible to receive course credits. in order to take part in the study, participants had to be at least 18 years old and to give their consent to participation at the beginning of the study. prior to assessments, all participants were informed about the purpose of the study, the voluntary nature of their participation, data storage and security. the study was approved by the responsible ethics committee. measures suicide ideation and behavior scale (ssev) the ssev (teismann et al., 2021) assesses with six items the frequency of suicide ideation in the past four weeks (e.g., “during the past four weeks, … i thought it would be better if i wasn't alive, … i've been thinking about killing myself, … i have seriously considered killing myself”). all items are answered on a 6-point likert scale ranging from “1=never” to “5=many times every day”, with higher scores indicating greater severity of suicidal ideation. occurrence (“in the course of my life i have tried to kill myself and i really wanted to die”) and number of lifetime suicide attempts (“how many times have you tried to kill yourself?”) are assessed with two further ssev-items. the scale has been shown to have a good internal consistency (cronbach’s α ≥ .92; teismann et al., 2021). accordingly, internal consistency was good in the current sample, (α = .84). perseverative thinking questionnaire (ptq) the ptq (ehring et al., 2011) is a 15-item self-report measure designed to assess process characteristics of perseverative thinking (“the same thoughts keep going through my mind again and again”; “i keep asking myself questions without finding an answer”; “thoughts intrude into my mind”; “my thoughts take up all my attention”). all items are to be answered on a 5-point scale ranging from 0 (“never”) to 4 (“almost always”). the scale has been shown to have good internal consistencies (cronbach`s α ≥ .93; ehring repetitive thinking and suicide 4 clinical psychology in europe 2021, vol. 3(3), article e5579 https://doi.org/10.32872/cpe.5579 https://www.soscisurvey.de/ https://www.psychopen.eu/ et al., 2011). accordingly, internal consistencies were excellent in the current sample, α = .95. perseverative thinking about suicide questionnaire (ptsq) the ptsq (teismann, 2018) is modeled after the ptq and assesses with nine items suicide specific rumination (“i can´t stop dwelling about suicide”; “i am thinking about suicide the whole time”; “thoughts about suicide intrude into my mind”; “my thoughts about suicide repeat themselves”). in the adaption process the word “thoughts” from the original ptq was replaced by the term “suicidal thoughts” in the ptsq: for example the ptq-item “the same thoughts keep going through my mind again and again” became the ptsq-item “the same thoughts about suicide keep going through my mind again and again”. items from the ptq that were not adjustable in the described manner (i.e., “i think about many problems without solving any of them”) were not included in the ptsq. the adaptation was conducted by the first author and consented with all co-au­ thors. all items are to be answered on a 5-point scale ranging from 0 (“never”) to 4 (“al­ most always”). participants are only asked to answer all these items, if they affirm a first screening item (“in my lifetime i have thought about suicide”). the scale has been shown to have high internal consistency (cronbach`s α = .94; höller et al., in preparation). accordingly, an exploratory factor analysis (efa) using principal component analysis (pca; rotation method: varimax) revealed a unidimensional factor structure within the present sample as well as excellent internal consistency, α =.95. statistical analyses statistical analyses were conducted with spss 26 and the process macro version 3.5 (www.processmacro.org/index.html; rockwood & hayes, 2020). descriptive statistics and zero-order bivariate correlations between the investigated variables were calculated. differences between groups (lifetime suicide ideators: n = 205 vs. lifetime attempters: n = 52) were analyzed using one-way anovas. considering the different sizes of both groups, hedges’g was included as effect size (see hedges, 1981). notably, the current data fit the assumptions for the calculation of multivariate analyses (no significant outliners > 3 and < -3, number of significant outliners > 2 and < -2 below 5%; no violation of multicollinearity assumption as all values of tolerance > 0.25, and all variance inflation factor values < 5; interaction between the independent variables and their logarithmic transformations is not significant) (see field, 2013; tabachnick & fidell, 2014; urban & mayerl, 2006). next, a three-step multiple logistic regression analysis was calculated to examine the relative contribution of current suicide ideation (ssev), general rumina­ tion (ptq) and suicide-specific rumination (ptsq) to the prediction of lifetime suicide attempt status (coded: 0 = no attempts, 1 = attempts). the variable age was significantly correlated with current suicide ideation (r = -.163, p < .01), general rumination (r = -.189, p < .05), and suicide-specific rumination (r = -.161, p < .05). the variable gender (coded: 0 teismann, forkmann, michalak, & brailovskaia 5 clinical psychology in europe 2021, vol. 3(3), article e5579 https://doi.org/10.32872/cpe.5579 http://www.processmacro.org/index.html https://www.psychopen.eu/ = woman, 1 = man) was negatively correlated with general rumination (r = -.147, p < .05), and lifetime suicide attempt status (r = -.129, p < .05). considering the relationships of age and gender with the potential predictors and the outcome of the regression model, both were included as control variables. thus, age and gender were included in step 1 of the regression model, current suicide ideation and general rumination were included in step 2, and suicide-specific rumination was included in step 3. finally, a mediation analysis was conducted that included current suicide ideation (predictor), suicide-specific rumination (mediator), and number of lifetime suicide attempts (outcome). the basic association between current suicide ideation and lifetime suicide attempts was denoted by c (the total effect). the path of current suicide ideation to suicide specific rumination was denoted by a, and the path of suicide specific rumination to lifetime suicide attempts was denoted by b. the combined effect of path a and path b presented the indirect effect. the direct effect of current suicide ideation on lifetime suicide attempts after inclusion of suicide specific rumination in the model was denoted by c’. the mediation effect was assessed by the bootstrapping procedure (10.000 samples) that provides percentile bootstrap confidence intervals (95% ci). results descriptive statistics, correlations and group differences descriptive statistics for each measure and correlations are presented in table 1. cor­ relation analyses indicated that all study variables correlated significantly with each other (see table 1). the correlations ranged between r = .354 and r = .806 (all: p < .01), indicating medium to large effects (see cohen, 1988). table 1 means, standard deviations and correlations of study variables measure m (sd) min–max skewness kurtosis 2 3 4 1. ssev 8.00 (3.35) 6–23 2.130 4.449 .354** .806** .406** 2. ssev-sa 0.32 (0.84) 0–6 3.932 18.382 – .463** .265** 3. ptsq 15.07 (7.32) 9–44 1.509 1.813 – .490** 4. ptq 47.04 (13.07) 16–75 -.043 -.448 – note. n = 257; m = mean; sd = standard deviation; min = minimum; max = maximum; ssev = suicide ideation and behavior scale; ssev-sa = suicide ideation and behavior scale – lifetime number of suicide attempts; ptsq = perseverative thinking about suicide questionnaire; ptq = perseverative thinking questionnaire. ssev-sa was dichotomized (0 = no attempts, 1 = attempts) for the correlation analyses. **p < .01. repetitive thinking and suicide 6 clinical psychology in europe 2021, vol. 3(3), article e5579 https://doi.org/10.32872/cpe.5579 https://www.psychopen.eu/ lifetime suicide ideators (assessed with the ptsq-screening item) and lifetime suicide attempters differed significantly in ptsq-scores (suicide ideators: n = 205; m = 13.50, sd = 5.88, range: 9–36; suicide attempters: n = 52; m = 21.29, sd = 9.02, range: 9–44), f(1,255) = 57.52, p < .001, effect size: hedges’g = 1.17 (large effect). furthermore, lifetime suicide ideators (m = 45.36, sd = 12.61, range: 16–75) and lifetime suicide attempters (m = 53.67, sd = 12.89, range: 23–75) differed significantly in ptq-scores, f(1,255) = 17.89, p < .001, effect size: hedges’g = 0.65 (medium effect); with suicide attempters reporting more rnt than suicide ideators. prediction of lifetime suicide attempts associations between study variables and lifetime suicide attempts are shown in table 2. in the multiple logistic regression model, current suicide ideation (or: 1.19; small effect, see chen, cohen, & chen, 2010) and general rumination (or: 1.03; small effect, see chen et al., 2010) served as a significant predictor of lifetime suicide attempts in step 2. however, in step 3, only the new included variable suicide-specific rumination emerged as a significant predictor of lifetime suicide attempts (or: 1.14; small effect, see chen et al., 2010). table 2 results from a three-step multiple logistic regression analysis predicting lifetime suicide attempts (dichotomized: 0 = no attempts, 1 = attempts) step or (95% ci) p step 1 age 0.98 [0.95-1.01] .163 gender 0.47 [0.25-0.90] .023 step 2 age 0.99 [0.96-1.03] .720 gender 0.56 [0.28-1.14] .110 ssev 1.19 [1.09-1.31] < .001 ptsq 1.03 [1.00-1.06] .047 step 3 age 1.00 [0.96-1.03] .796 gender 0.50 [0.24-1.04] .065 ssev 0.97 [0.85-1.12] .719 ptq 1.01 [0.98-1.04] .461 ptsq 1.14 [1.06-1.23] < .001 note. n = 257; ssev-si = suicide ideation and behavior scale; ptq = perseverative thinking questionnaire; ptsq = perseverative thinking about suicide question­ naire; or = odds ratio from logistic regression; ci = confidence interval. teismann, forkmann, michalak, & brailovskaia 7 clinical psychology in europe 2021, vol. 3(3), article e5579 https://doi.org/10.32872/cpe.5579 https://www.psychopen.eu/ mediation analysis figure 1 shows results of the bootstrapped mediation analysis. the basic relationship between current suicide ideation (predictor) and lifetime suicide attempts (outcome) was significant (total effect, c: p < .001). the association between current suicide ideation and suicide-specific rumination (mediator) (a: p < .001), as well as the link between suicide-specific rumination and lifetime suicide attempts (b: p < .001) were also signifi­ cant. in contrast, the relationship between current suicide ideation and lifetime suicide attempts was no longer significant after the inclusion of suicide-specific rumination in the model (direct effect, c’: p = .445). the indirect effect (ab) was significant, b = .10, se = .03, 95% ci [.04, .17]. thus, suicide-specific rumination significantly mediated the relationship between current suicide ideation and lifetime suicide attempts. figure 1 mediation model with suicide ideation (predictor), suicide-specific rumination (mediator), and lifetime suicide attempts (outcome). note. c = total effect; c’ = direct effect; b = standardized regression coefficient; se = standard error; ci = confidence interval. discussion the present study investigated the association between rnt – that is, suicide-specific rumination and general rumination – and (lifetime) suicide attempts. the main findings were as follows: (1.) general rumination and suicide-specific rumination differentiated between lifetime suicide attempters and suicide ideators; (2.) suicide-specific rumination was predictive of lifetime suicide attempt status – controlling for age, gender, current suicide ideation and general rumination; (3.) the association between current suicide ideation and lifetime suicide attempts was fully mediated by suicide-specific rumination. these results complement previous research showing an association between general rumination and suicide ideation/behavior (rogers & joiner, 2017) as well as between sui­ cide-specific rumination and lifetime suicide attempts (rogers & joiner, 2018a, 2018b). in accordance with findings by rogers and joiner (2018a) it was shown that suicide-specific repetitive thinking and suicide 8 clinical psychology in europe 2021, vol. 3(3), article e5579 https://doi.org/10.32872/cpe.5579 https://www.psychopen.eu/ rumination outperformed other suicide risk factors – including current suicide ideation – in the prediction of lifetime suicide attempt status. of note, findings could be replica­ ted with a new – potentially unconfounded – measure of suicide-specific rumination. though further study results have to be awaited, these findings suggest a rather robust effect of suicide-specific rumination. accordingly, it seems as if rnt about suicide may be more pernicious in increasing the risk for suicidal behavior than ruminative thoughts about one’s distress more generally. nonetheless, both general rumination and suicide-specific rumination differentiated between (lifetime) suicide attempters and (lifetime) suicide ideators (cf., horwitz et al., 2019). klonsky and may (2015) recently emphasized that it is crucial to understand factors that differentiate those who consider suicide from those who make suicide attempts. yet, in a comprehensive meta-analysis may and klonsky (2016) found only few studies that directly compared suicide ideators and suicide attempters and only few variables that differentiated the two groups. though the importance of single factors in differentiating suicide attempters and suicide ideators has recently been disputed (huang et al., 2020), these findings point to the potential potency of (suicide-specific) rnt in understanding transitions to suicidal behavior. a further analysis showed that the association between current suicide ideation and (lifetime) suicide attempts is completely mediated by suicide-specific rumination, that is, the risk of suicidal behaviour only increases when suicide is considered in a repeti­ tive way. within the metacognitive theory of emotional disorders, wells and matthews (2015) state that a psychological disorder results from an unhelpful thinking style called the cognitive attentional syndrome (cas). the cas incorporates worry/rumination, threat monitoring and unhelpful thought control strategies. according to the theory, not single thoughts, assumptions or beliefs create emotional turmoil, but the way a person deals with these thoughts: only if respective thoughts activate the cas, emotional and behavioral problems will follow. on this background one may assume that thoughts of suicide per se do not pose a great risk for suicidal behaviour (cf., mchugh et al., 2019), unless individuals engage in such thoughts in a repetitive manner. in future studies, the association between suicide-specific rumination and other variables of the metacognitive model should be investigated more closely. the results of the current study should be interpreted with consideration of the fol­ lowing limitations. first, the ptsq was developed for the current study and has only re­ cently been subjected to stringent psychometric evaluation (höller et al., in preparation). however, no direct comparison between the ptsq and the suicide rumination scale (srs; rogers & joiner, 2018a) was made. therefore, no conclusions with respect to the relationship between the two measures can be drawn, or determined whether one of the two measures is more valid in assessing suicide-specific rumination. second, rogers and joiner (2018a) included a large number of control variables (e.g., depression, anxiety, insomnia, agitation, emotion regulation, general rnt) in their study on suicide specific teismann, forkmann, michalak, & brailovskaia 9 clinical psychology in europe 2021, vol. 3(3), article e5579 https://doi.org/10.32872/cpe.5579 https://www.psychopen.eu/ rnt, whereas in the present study only age, gender, general rnt and current suicide ideation were included as control variables. future studies should therefore strive to in­ vestigate, whether suicide specific rnt – as assessed with the ptsq – also outperforms such a great number of suicide risk factors in predicting the presence of a lifetime suicide attempt. third, general rnt is understood as a trait (watkins & nolen-hoeksema, 2014) and both the ptsq and the srs capture suicide specific rnt in a trait-like manner. nev­ ertheless, it is unclear whether suicide specific rnt is indeed stable over time and across suicidal crises and/or whether it is (only) associated with more intense suicidal crises (cf., galynker, 2017). prospective studies with repeated measurements are needed. fourth, all of the constructs included in this study were measured exclusively via selfreport assessments. although it may be difficult to gather information regarding the frequency of particular thought patterns, participants may be prone to inaccuracy and uncertainty when responding to self-report items. finally, the use of a cross-sectional research design and a sample comprised of predominantly caucasians, limits the generalizability of the results and the discussion of temporal/causal relationships between study variables. this limitation is of specific importance considering the interpretation of the results of the mediation analysis: as all data were collected at a single measurement time-point and the outcome measure (i.e., lifetime suicide attempts) is retrospective, it might be more appropriate to frame the findings as indirect effects rather than as mediation effects. a replication of this study in treatment-seeking samples with prospective research designs would help to indicate whether the study results remain consistent in more at-risk populations. still, it is important to emphasize that all participants within the current study reported lifetime suicidal ideation, and in this sense are a group of clinical interest. not least therefore, the current study does exhibit potential clinical implications: first of all, it might be important to account for the presence of suicide-specific rumi­ nation in addition to other risk factors, when assessing individuals for suicide risk. fur­ thermore, suicide-specific rumination may be a potential target in treatment to reduce one’s suicidality. as such, (general) rumination has been shown to be malleable through treatments such as cognitive behavioral therapy (teismann & ehring, 2019) or mindful­ ness-based cognitive therapy (gu et al., 2015). therefore, it should be tested, whether suicide-specific rumination might be modifiable by similar interventions and techniques than general rumination. on the background of findings regarding the relevance of (suicide-specific) rnt in understanding suicidal behavior, respective studies seem highly warranted. should the current findings be confirmed in further studies, it also seems reasonable to integrate suicide-specific rumination as a relevant factor with respect to the transition from suicide ideation to suicidal behavior within the current models of suicide ideation/behavior (cf., o’connor & kirtley, 2018). repetitive thinking and suicide 10 clinical psychology in europe 2021, vol. 3(3), article e5579 https://doi.org/10.32872/cpe.5579 https://www.psychopen.eu/ funding: no funding was received. acknowledgments: the authors would like to thank pierre schumacher and mandy funke for their support in the data collection. competing interests: the dataset reported here is not part of any published or currently in-press works. the authors have no conflict of interests to declare. supplementary materials perseverative thinking about suicide questionnaire (ptsq). the ptsq is modeled after the perseverative thinking questionnaire (ehring et al., 2011) and assesses with nine items suicide specific rumination (for access see index of supplementary materials below). index of supplementary materials teismann, t., forkmann, t., michalak, j., & brailovskaia, j. 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(2013). rumination, anxiety, depressive symptoms and subsequent depression in adolescents at risk for psychopathology: a longitudinal cohort study. bmc psychiatry, 13, article 250. https://doi.org/10.1186/1471-244x-13-250 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. repetitive thinking and suicide 14 clinical psychology in europe 2021, vol. 3(3), article e5579 https://doi.org/10.32872/cpe.5579 https://doi.org/10.1186/s12888-020-02875-8 https://doi.org/10.1026/0012-1924/a000269 https://doi.org/10.1037/0033-2909.134.2.163 https://doi.org/10.1037/a0035540 https://doi.org/10.1186/1471-244x-13-250 https://www.psychopen.eu/ repetitive thinking and suicide (introduction) method and materials participants and procedure measures statistical analyses results descriptive statistics, correlations and group differences prediction of lifetime suicide attempts mediation analysis discussion (additional information) funding acknowledgments competing interests supplementary materials references reporting cultural adaptation in psychological trials – the recapt criteria latest developments reporting cultural adaptation in psychological trials – the recapt criteria eva heim 1,2 , ricarda mewes 3, jinane abi ramia 4,5, heide glaesmer 6, brian hall 7, melissa harper shehadeh 7, burçin ünlü 8, schahryar kananian 9, brandon a. kohrt 10, franziska lechner-meichsner 9, annett lotzin 11, marie rose moro 12, rahmeth radjack 12, alicia salamanca-sanabria 13, daisy r. singla 14,15,16, annabelle starck 9, gesine sturm 17, wietse tol 18, cornelia weise 19, christine knaevelsrud 20 [1] institute of psychology, university of lausanne, lausanne, switzerland. [2] department of psychology, university of zürich, zürich, switzerland. [3] outpatient unit for research, teaching and practice, faculty of psychology, university of vienna, vienna, austria. [4] national mental health programme – ministry of public health, beirut, lebanon. [5] department of clinical, neuroand developmental psychology, amsterdam public health research institute, vrije universiteit amsterdam, amsterdam, the netherlands. [6] department of medical psychology and medical sociology, university of leipzig, leipzig, germany. [7] global public health, new york university shanghai, shanghai, china. [8] psyq, parnassia psychiatric institute, the hague, the netherlands. [9] department of clinical psychology and psychotherapy, goethe university frankfurt, frankfurt, germany. [10] department of psychiatry and behavioral sciences, george washington university, washington, dc, usa. [11] department of psychiatry and psychotherapy, university medical center hamburg-eppendorf, hamburg, germany. [12] inserm, hôpital cochin, ap-hp, paris university, paris, france. [13] future health technologies, singapore-eth centre, campus for research excellence and technological enterprise (create), singapore, singapore. [14] campbell family mental health research institute, toronto, canada. [15] department of psychiatry, temerty faculty of medicine, university of toronto, toronto, canada. [16] lunenfeld tanenbaum research institute, toronto, canada. [17] laboratoire cliniques psychopathologique et interculturelle lcpi ea 4591, université toulouse ii jean jaurès, toulouse, france. [18] section for global health, department of public health, university of copenhagen, copenhagen, denmark. [19] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. [20] department of education and psychology, freie universität berlin, berlin, germany. clinical psychology in europe, 2021, vol. 3(special issue), article e6351, https://doi.org/10.32872/cpe.6351 received: 2021-03-18 • accepted: 2021-08-18 • published (vor): 2021-11-23 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: eva heim, university of lausanne, institute of psychology, géopolis, bureau 4114, 1015 lausanne, switzerland. e-mail: eva.heim@unil.ch this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6351&domain=pdf&date_stamp=2021-11-23 https://orcid.org/0000-0001-7434-7451 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ related: this article is part of the cpe special issue “cultural adaptation of psychological interventions”, guest editors: eva heim & cornelia weise, clinical psychology in europe, 3(special issue), https://doi.org/ 10.32872/10.32872/cpe.v3.si supplementary materials: materials [see index of supplementary materials] abstract background: there is a lack of empirical evidence on the level of cultural adaptation required for psychological interventions developed in western, educated, industrialized, rich, and democratic (weird) societies to be effective for the treatment of common mental disorders among culturally and ethnically diverse groups. this lack of evidence is partly due to insufficient documentation of cultural adaptation in psychological trials. standardised documentation is needed in order to enhance empirical and meta-analytic evidence. process: a “task force for cultural adaptation of mental health interventions for refugees” was established to harmonise and document the cultural adaptation process across several randomised controlled trials testing psychological interventions for mental health among refugee populations in germany. based on the collected experiences, a sub-group of the task force developed the reporting criteria presented in this paper. thereafter, an online survey with international experts in cultural adaptation of psychological interventions was conducted, including two rounds of feedback. results: the consolidation process resulted in eleven reporting criteria to guide and document the process of cultural adaptation of psychological interventions in clinical trials. a template for documenting this process is provided. the eleven criteria are structured along a) set-up; b) formative research methods; c) intervention adaptation; d) measuring outcomes and implementation. conclusions: reporting on cultural adaptation more consistently in future psychological trials will hopefully improve the quality of evidence and contribute to examining the effect of cultural adaptation on treatment efficacy, feasibility, and acceptability. keywords cultural adaptation, reporting criteria, randomised controlled trials, common mental disorders, psychological interventions reporting cultural adaptation in psychological trials (recapt-criteria) 2 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ highlights • adaptation starts with defining the target population along cultural and sociodemographic criteria. • literature review and formative research are used to define target symptoms, syndromes, needs, and context. • using a standardized documentation system to structure the adaptation process is recommended. • documentation includes results of formative research and adaptation of treatment elements. psychotherapies developed in western, educated, industrialized, rich, and democratic (weird; henrich et al., 2010) societies may not or only partly be relevant to cultural groups or ethnic minorities who differ from the former in terms of cultural values, norms, or illness concepts. evidence indicates that cultural adaptation of psychological interventions for the treatment of common mental disorders increases their acceptabili­ ty and efficacy (benish et al., 2011; chowdhary et al., 2014; hall et al., 2016; harper shehadeh et al., 2016). there is a large variety of target populations, psychological interventions and settings where cultural adaptation is applied, from low-intensity inter­ ventions in humanitarian settings (perera et al., 2020) to higher-intensity interventions through the internet (knaevelsrud et al., 2015) or face-to-face (hinton et al., 2012), to mention only a few. most cultural adaptation studies use a top-down approach, in which existing psychological interventions developed for one cultural group are adapted for another one. few studies use a bottom-up approach to develop new interventions based on culturally specific symptoms or syndromes (hall et al., 2016; hwang, 2006). so far, there are no standard criteria for documenting bottom-up and top-down cultural adaptations in clinical trials testing psychological interventions (in short: psy­ chological trials). a more detailed standard documentation is key to obtain more reliable information regarding the effect of cultural adaptation on treatment efficacy, feasibility, and acceptability. in this paper, we suggest a set of reporting criteria for this purpose. first, we outline the theoretical and empirical background. thereafter, the reporting criteria are introduced. more detailed information on the background, the development of the reporting criteria, and the use of these criteria, can be found in appendix a (see supplementary materials). background in the lancet commission on culture and health, culture is defined as follows: “culture, then, can be thought of as a set of practices and behaviours defined by customs, habits, language, and geography that groups of individuals share” (napier et al., 2014, p. 1609). heim, mewes, abi ramia et al. 3 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ in appendix a (supplementary materials), we provide additional definitions of culture. these definitions highlight that culture refers to shared systems of understanding and engaging with the world, which extends beyond language and ethnicity to include polit­ ical, economic, environmental, and other contexts that shape these patterns of shared experience. for instance, this means that translation from english into spanish is unlikely to be sufficient to address the needs of residents of barcelona, venezuelan refugees in co­ lombia, and first generation salvadoreans immigrated to the united states. conversely, because culture is strongly tied to context, many of the adaptations done for syrian refugees in urban host communities in jordan may be helpful for venezuelan refugees in urban host communities in colombia, despite the language of adaptation being entirely different. cultural adaptation, therefore, refers to enabling an intervention to produce its desired psychological effect with a particular group in a specific context. several frameworks for cultural adaptation of evidence-based interventions exist (e.g., applied mental health research [amhr] group at johns hopkins university, 2013; gonzález castro et al., 2010; perera et al., 2020), all of which have been developed mainly for clinical practice. these frameworks have in common that they use stage models which include assessment, selection of the intervention (components), adaptation, pilot­ ing, and implementation. such stage models provide guidance on the process of cultural adaptation (i.e., how to adapt). with regard to content of cultural adaptation (i.e., what to adapt), several frameworks exist, which are described more in detail in appendix a (supplementary materials). empirical evidence from experimental studies is needed to show differential effects of different kinds of adaptations (heim et al., 2020). using a standardised documentation system, such as proposed in this paper, is key to meta-analytic evidence that is based on high quality of research. to achieve this aim, it is vital to structure reports on cultural adaptations, and to enhance transparency on what was culturally adapted in psychological trials. theoretical framework heim and kohrt (2019) propose a new framework of cultural adaptation that is based on evidence from cultural clinical psychology and psychotherapy research (see the sec­ tion on cultural adaptation frameworks in appendix a, supplementary materials). the authors suggest using cultural concepts of distress (ccd) as the starting point for cultural adaptation. the term ccd has been introduced into the diagnostic and statistical man­ ual of mental disorders, fifth edition (dsm-5, american psychiatric association, 2013) to describe culturally shaped mental health-related phenomena. ccd encompass idioms of distress (nichter, 1981, 2010), cultural explanations (bhui & bhugra, 2002), and cultural reporting cultural adaptation in psychological trials (recapt-criteria) 4 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ syndromes (kaiser & jo weaver, 2019). evidence shows that ccd differ from diagnostic categories in dsm and the international classification of diseases (kohrt et al., 2014). heim and kohrt (2019) further suggest using a taxonomy of treatment components proposed by singla et al. (2017) to structure the cultural adaptation and reporting proc­ ess. different taxonomies to dismantle components of psychological interventions have been proposed in literature, e.g., for behaviour change interventions (michie et al., 2013) or for interventions for children and adolescents (chorpita & daleiden, 2009). based on such blueprints, singla et al. (2017) proposed a taxonomy to distil the components of psy­ chological interventions for the treatment of common mental disorders (i.e., depression, anxiety, and stress-related mental health issues) in lowand middle-income countries. this taxonomy consists of specific and nonspecific elements, and therapeutic techniques. elements are therapeutic activities or strategies (e.g., problem solving), whereas techni­ ques are skills that the therapist implements during a session (e.g., role-playing). specific elements are grounded in specific psychological mechanisms (i.e., behavioural, cognitive, emotional, and interpersonal elements), and nonspecific elements are routed in common factors of psychological interventions (cuijpers et al., 2019; wampold, 2007). aside from elements and techniques, which refer to what is provided in treatment, singla et al. (2017) describe the how (e.g., delivery format), who (e.g., non-specialists), and where (i.e., setting) of psychological interventions. in cultural adaptation, treatment aspects that are related to how content is transmitted, include, e.g., the consideration of different dialects in translation or culture-specific aspects in illustrations that are not directly related to therapeutic elements (e.g., abi ramia et al., 2018). in accordance with resnicow et al. (1999), these are considered as adaptations of the surface (heim & kohrt, 2019). process for developing the reporting criteria the reporting cultural adaptation in psychological trials (recapt) criteria were devel­ oped by a “task force for cultural adaptation of mental health interventions for refugees” in germany. the aim of this task force was to harmonise and document the cultural adaptation process across eleven randomised controlled trials testing psychological in­ terventions among refugees in germany (heim & knaevelsrud, 2021, this issue). the task force developed a first set of criteria. thereafter, an expert survey was conducted to seek consensus among international experts in the field of cultural adaptation and global mental health. twenty-four international experts were invited, of which eleven responded to our survey and provided feedback on the reporting criteria. a second round of feedback was implemented, where the experts provided their comments on the revised criteria. for more details, please refer to appendix a (supplementary materials). the expert survey is provided in appendix b (supplementary materials). heim, mewes, abi ramia et al. 5 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ reporting criteria in the following, we propose eleven reporting criteria for future psychological trials with different cultural and ethnic groups. based on the theoretical and empirical consid­ erations outlined above, the reporting criteria for bottom-up and top-down cultural adap­ tation in psychological trials are structured along the following categories: a) set-up; b) formative research methods; c) intervention adaptation; d) measuring outcomes and implementation. an overview of the eleven criteria is shown in box 1. the last category, measuring outcomes, is kept short, as this is addressed in specific literature (e.g., leong et al., 2019). however, because measuring outcomes is an integral part of randomised controlled trials, we decided to include it as part of the reporting criteria. box 1 reporting cultural adaptation in psychological trials (recapt): overview of criteria a. set-up criterion 1: definition of the target population criterion 2: team and roles criterion 3: documentation and monitoring system criterion 4: documentation of adaptations during trial (“on the fly”) b. formative research criterion 5: formative research methods criterion 6: target symptoms, syndromes, needs, and context c. intervention adaptation criterion 7: specific treatment elements criterion 8: nonspecific elements and therapeutic techniques criterion 9: surface adaptations d. measuring outcomes and implementation criterion 10: questionnaires and clinical interviews criterion 11: implementation measures we recommend reporting on these criteria, regardless of whether they were implemen­ ted or not. these reporting criteria can also be used as a guideline for planning the process of cultural adaptation of an existing intervention (top-down), or the considera­ tion of cultural aspects in the development of new interventions (bottom-up) to be tested in psychological trials. the sequence of the reporting criteria is not fixed, as the process is often iterative; however, we put the sequence in what we considered to be a helpful order (e.g., establishing a documentation system early in the process). for reasons of reporting cultural adaptation in psychological trials (recapt-criteria) 6 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ word count, the description of each criterion is kept short. more detailed information can be found in the appendix a (supplementary materials). if possible, we recommend publishing a separate paper on formative research and cultural adaptation alongside the regular papers of a psychological trial (i.e., protocol and outcome paper), as it has been done in several studies (e.g., abi ramia et al., 2018). a separate paper allows researchers to provide detailed information on the decision-mak­ ing process and the different adaptations that were implemented. if it is not possible to publish a separate paper on the formative research and cultural adaptation, it is still recommendable to report on the most important aspects in the protocol or results paper. a reporting form that can be used for future trials is presented in the supplementary materials). for reasons of transparency and replicability, we recommend adding the documentation and monitoring sheet as supplementary material to published papers. the template is structured along the reporting criteria. a) set-up cultural adaptation of psychological interventions is a complex process which most often includes several stages. once a psychological trial is completed and results are about to be published, it may be difficult or impossible to reconstruct all the decisions that were made during the cultural adaptation process. for this reason, it is advisable to continuously document this process, and to be explicit about the people involved in decision-making. criterion 1: definition of the target population as described above, culture is a complex construct that cannot be reduced to ethnic groups or race. many different socio-demographic factors may contribute to one’s “cul­ ture”, such as language, religion, age, migration background, refugee status, gender identity, sexual orientation, and socio-economic status, among others (gonzález castro et al., 2010; sue & sue, 2015). there is large variety with regard to values and norms within geographically or demographically defined groups (e.g., fischer & schwartz, 2011; resnicow et al., 1999), and people may adopt different “cultural identities” in different contexts (lehman et al., 2004). therefore, the first step in cultural adaptation is to clearly define the “unit of analysis”, i.e., the target population in the psychological trial (gonzález castro et al., 2010). the definition and operationalisation of this unit of analysis should be done along the most important criteria that may have an impact on participants’ cultural identity and their psychopathology (betancourt & lópez, 1993). the unit of analysis may not always be limited to one particular ethnic, language, or even cultural group, i.e., psychological interventions can be culture-sensitive rather than culture-specific. culture-sensitive interventions may target diverse groups, e.g., migrant populations in high-income countries, and be sensitive to cultural aspects in general rather than adapted heim, mewes, abi ramia et al. 7 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ to specific features of one particular group (e.g., lotzin et al., 2021, this issue; mewes et al., 2021, this issue). criterion 2: team and roles several guidelines for qualitative research (e.g., malterud, 2001; tong et al., 2007) consis­ tently recommend providing information on the personal characteristics of the research­ ers involved in qualitative studies (e.g., occupation, gender, training and qualifications), as well as information about preconceptions, which represent previous experiences, pre-study beliefs, and motivation. in this sense, we recommend shortly describing the team that was involved in the cultural adaptation process, as well as their roles during the formative research phase and in the decision-making process. criterion 3: documentation and monitoring system documentation is key for transparency and replicability of clinical trials in general, and therefore also for the cultural adaptation process. when documenting the process of cultural adaptation, we suggest providing as much information as possible on ccd, on other relevant aspects in the target population (e.g., specific needs), on the foundations for decisions that were made (e.g., data gathered through focus group discussions), and on the strength of evidence to support such decisions. cultural adaptation most often starts with formative research (see below). in forma­ tive research, relevant information on the target population is gathered, and representa­ tives of the target population are asked about the relevance and acceptability of the intervention. during this process, many suggestions for changing and adapting parts of the intervention may be made. some of these suggestions may be absolutely essential, for instance because of ethical considerations, because not doing them may cause harm (e.g., stigmatization, hurting feelings of subgroups), or foster higher attrition rates. moreover, a strong evidence-base might be a good indicator for the need of an adaptation. on the other hand, there may be changes that are “nice-to-have”, or even controversial, especially if they are based on personal preferences or taste (e.g., shala et al., 2020). criterion 4: documentation of adaptations during trials (“on the fly”) in most running trials, some level of adaptation may happen “on the fly”, especially when working with diverse ethnic and cultural groups, for whom we have less empiri­ cal evidence on psychological interventions (unterhitzenberger et al., 2021, this issue). as an example, if a misunderstanding in psychoeducation is discovered, it might be necessary to adapt the wording and, if needed, provide standard translations of such psychoeducation to interpreters for the rest of the trial. one may argue that ideally, such difficulties are discovered in pilot trials that are done exactly for this purpose. however, it is still possible that important information is revealed in the course of running trials, reporting cultural adaptation in psychological trials (recapt-criteria) 8 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ and documentation and transparency with regard to such “on-the-fly” adaptations may be relevant for a better understanding of trial results and implementation. in this line of thinking, chambers and norton (2016) challenge the assumption of a linear, static process from intervention development (and adaptation) to pilot testing, randomised controlled trial, and implementation. in this linear view that is still prevail­ ing in literature, deviances from manuals are considered to be problematic, as they may threaten treatment fidelity and thus, effectiveness of the intervention. in their publication entitled “the adaptome advancing the science of intervention adaptation”, chambers and norton (2016) aim to capture “positive deviance (e.g., where adaptation leads to better outcomes compared to the original trials) as well as circumstances in which program drift was deleterious to intervention effectiveness” (p. 127). thus, cham­ bers and colleagues make a case for documenting deviances from originally defined protocols: “by augmenting trial data with practice-based evidence, we can understand much more about what works for whom” (chambers et al., 2013, p. 6). using a stand­ ard documentation system (recapt template, supplementary materials) will enhance transparency on adaptations that were made during trials. b) formative research formative research includes the iterative process of gathering relevant information be­ fore starting a trial. the process of formative research is ideally reported in a consistent and transparent manner, to ensure replicability and valid interpretation of results. the recapt criteria include the methods of formative research on the one hand, and the results of this process on the other hand. criterion 5: formative research methods formative research is an iterative process using multiple qualitative and quantitative methods. in the following, we provide suggestions on how to implement this process, thus, on how to adapt. in the supplementary materials, we provide a template for documenting the cultural adaptation process. formative research methods (i.e., literature review, qualitative, quantitative, and mixed methods) can be flexibly used until a level of saturation is reached. results of this process should highlight the description of the target population’s main characteristics, their most salient symptoms or syndromes and needs, and the feedback gathered on the intervention during the process of cultural adap­ tation. although there is no “standard procedure” for top-down or bottom-up cultural adaptation, we suggest reporting on these different stages of formative research. formative research normally starts with a literature review. thereafter, researchers may conclude that available evidence on their target population is insufficient for cul­ tural adaptation. qualitative and/or quantitative information on the target population (i.e., main characteristics, symptoms, syndromes, needs) should be gathered where no or insufficient evidence is available, including mixed methods approaches (shala et al., heim, mewes, abi ramia et al. 9 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ 2020; singla et al., 2014). quantitative methods include symptoms scales, surveys, or other questionnaires used to describe the target population. qualitative methods include in-depth interviews with key informants, focus groups, free-list interviews, pile sorting, among others (cork et al., 2019; keys et al., 2012). we recommend using the consolidated criteria for reporting qualitative research (coreq, tong et al., 2007), a 32-items checklist for explicit and comprehensive reporting of qualitative studies. it includes participant selection (i.e., selection, method of approach, sample size, reasons for refusing); the setting for data collection (e.g., home, clinic); the method of data collection (i.e., interview guide, recording, duration), and the analysis methods (i.e., how themes were derived from the data). once data on the target population is gathered and compiled, interventions are adapted in a bottom-up or top-down approach. this process is accompanied by formative research, as well. and iterative process of adaptation, validation, and piloting is recom­ mended (e.g., shala et al., 2020). regardless of the methods chosen in the process of cultural adaptation, documentation is key. criterion 6: target symptoms, syndromes, needs, and context this criterion describes the most relevant aspects to consider in cultural adaptation. as outlined above, heim and kohrt (2019) suggest using ccd as the pivotal point for cultural adaptation. ccd are distinct from diagnostic categories such as depression, or post-traumatic stress, but in many cases share symptoms with these disorders (e.g., haroz et al., 2017; rasmussen et al., 2014). examples of ccd in literature are spirit possession in uganda and zimbabwe (ertl et al., 2011; patel et al., 1995), dhat in india (i.e., semen loss in urine; gautham et al., 2008), hwa-byung in korea (i.e., fire/projection of [accumulated] anger into the body; min & suh, 2010), or khyâl attacks (i.e., wind attacks) in cambodia (hinton et al., 2010). evidence shows that ccd are often associated with symptoms of psychological distress and mental disorders in general. however, it would be erroneous to conclude that ccd are just variations of the same (universal) underlying constructs across cultural groups. in their systematic review on ccd, kohrt et al. (2014) argue that higher methodological rigour is needed to better understand potential associations and distinctions between ccd and diagnostic categories developed in western countries. we recommend using an ethnopsychological model to frame the understanding and use of ccds (keys et al., 2012; kohrt & hruschka, 2010). other relevant topics for cultural adaptation may include specific needs in the target population, mental health related stigma, as well as contextual variables such as differen­ tial exposure to social determinants of mental health, and access to health systems, and mental health resources (hook et al., 2021). an example of such a contextual variable is ongoing armed conflict, which requires specific contextual adaptation of psychological interventions (castro-camacho et al., 2019). reporting cultural adaptation in psychological trials (recapt-criteria) 10 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ c) intervention in clinical and empirical literature, cultural adaptation of psychological interventions most often implicitly refers to the top-down approach, in which existing psychological interventions developed for one cultural group are adapted for another one (hall et al., 2016; hwang, 2006). there is little evidence on psychological interventions adapted in a bottom-up approach to address culture-specific symptoms and syndromes. one might argue that the development of new interventions does not fall under “adaptation”. we counter this argument by stating that psychological interventions for the treatment of distress and mental disorders are a “western” concept by themselves, as is the empirical evaluation of such interventions through randomised controlled trials. therefore, the present reporting criteria are applicable not only for trials testing cultur­ ally adapted versions of existing interventions, but also newly developed interventions and intervention components that aim to target specific factors among culturally diverse groups. psychological interventions and trials to evaluate them share a common set of fea­ tures, which have been classified by singla et al. (2017) into four categories: who (i.e., provider); what (i.e., treatment components); where (i.e., treatment setting); and how (i.e., training, supervision, treatment delivery). treatment components can be distilled into i) specific elements that are based on theoretical psychological models; ii) nonspe­ cific elements that are commonly shared by interventions of different theoretical back­ grounds; and iii) therapeutic techniques that aim to transmit specific and nonspecific elements (see theoretical framework above). this taxonomy provides a helpful grid to support the cultural adaptation of intervention, as it specifies the different levels of an intervention. other frameworks (e.g., bernal et al., 1995; bernal & sáez-santiago, 2006) have listed elements for cultural adaptation without putting them into a functional relationship. accordingly, we structured our reporting criteria along the taxonomy by singla et al. (2017). the template provided in the supplementary materials can be used for documenting cultural and contextual adaptations, evidence to support each decision, and suggestions from the research team. criterion 7: specific treatment elements most psychological trials have used manuals or protocols as unit of analysis (chorpita & daleiden, 2009). manuals most often focus on one particular diagnosis and use a series of elements for the treatment of this disorder (e.g., psychoeducation, exposition, cognitive restructuring, relapse prevention) for their treatment. transdiagnostic inter­ ventions combine treatment elements to address a broader symptom spectrum instead of one particular diagnosis, with promising effect sizes (newby et al., 2013). as an example, the common elements treatment approach (ceta, murray et al., 2014), ap­ plies evidence-based treatment elements depending on the specific symptomatology of heim, mewes, abi ramia et al. 11 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ the patient. other examples are problem management plus (pm+, dawson et al., 2015) developed by world health organization (who), or the unified protocol for emotional disorders (barlow et al., 2004). as mentioned in the theoretical framework (see above), single treatment components can be distilled from such manuals, and several authors advocate reporting on treatment components (rather than manuals) in randomised controlled trials. in the process of cultural adaptation, this distillation may be even more relevant. in psychological trials with diverse ethnic and cultural groups, it may be important to provide some empirically or theoretically based rationale for the selection, omission or adaptation of each of the specific treatment elements. in addition, explicit decisions to leave specific elements unchanged should be reported, as well (böttche et al., 2021, this issue). the mental health cultural adaptation and contextualization for implementation (mhcaci) procedure begins with identification of the mechanisms of action as the first step in order to inform the literature review, formative work, and other steps (sangraula et al., 2021). the literature review and formative work can be used to determine which specific treatment elements and other mechanisms of action will best fit with the culture and context. alternatively, the literature review and formative work can be used to select which type of intervention will fit best and is mostly likely to undergo successful adap­ tation. if the ccd, community needs, and context are clearly defined, this will inform which interventions would not require heavy adaptation for implementation, which is especially important when rapid deployment is needed such as during humanitarian emergencies. criterion 8: nonspecific elements and therapeutic techniques nonspecific elements refer to components that are universal to all treatments, also known as “common factors” (cuijpers et al., 2019; wampold, 2007). one important common factor is the provision of a convincing treatment rationale. psychological inter­ ventions ideally provide explanations that differ from the patient’s views, but that are not too discrepant from the patient’s intuitive assumptions as to be rejected (wampold, 2007). this suggests trying to find common ground between the treatment’s hypothe­ sized mechanism of action (including both specific and nonspecific elements) and the patient’s explanatory model. for treatment adherence and compliance, it is vital that patients understand and to some point share the rationale behind the treatment. the treatment rationale is ideally dovetailed with cultural explanations and idioms of distress that are part of ccd (hwang, 2006; rathod et al., 2019). ccd may include beliefs and assumptions that require to be challenged when providing the treatment rationale. in addition, it may be relevant to consider culture-specific notions of stigma, and the way how mental health-related stigma threatens the life domains that “matter most” (yang et al., 2014) to members of a specific cultural group (e.g., marriage, employment, social networks). intervention adaptation should include consideration of "what matters reporting cultural adaptation in psychological trials (recapt-criteria) 12 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ most" because this will influence stigma and motivation of those delivering the inter­ vention (kohrt, turner, et al., 2020). documentation of how adaptations address what matters most further demonstrates the rigor of the approach. we also recommend to report on the reflections that have guided the choice, omis­ sion, or adaptation of therapeutic techniques, such as role-playing, goal setting, or home­ work (singla et al., 2017). criterion 9: surface adaptations surface structure adaptations aim to enhance acceptability of an intervention through matching materials, channels and settings to the target population (resnicow et al., 1999). such surface adaptations correspond to the how and where in the taxonomy suggested by singla et al. (2017). there is much evidence on such surface adaptations of psychological interventions (chowdhary et al., 2014; chu & leino, 2017; harper shehadeh et al., 2016). cultural and contextual factors may determine the channels through which the treat­ ment components are provided, e.g. group-based as opposed to individual treatment (epping‐jordan et al., 2016; sangraula et al., 2018; verdeli et al., 2003), or internet-based interventions (naslund et al., 2017) that are increasingly tested and applied among diverse ethnic and cultural groups. reporting should include considerations that have been made with regard to such different modes of delivery. interventions (both self-help and face-to-face) may include materials such as texts, illustrations, case examples, flyers, audio files, videos, etc. standards exist for the transla­ tion of assessments and materials (e.g., van ommeren et al., 1999). several studies report that it is often difficult to draw the line between translation and adaptation, as these two are closely intertwined (ramaiya et al., 2017; shala et al., 2020). for pragmatic reasons, it is often not possible to document all the decisions that were made during the process of translation and language editing, especially if the decisions are merely questions of style or grammar. however, some decisions might be relevant to be documented in the cultural adaptation monitoring sheet. as an example, metaphors are often culture-specific and cannot be translated literally (rechsteiner et al., 2020). it might therefore make sense to report on how specific metaphors in the intervention were translated or adapted. d) measuring outcomes and implementation as outlined above, there is considerable cultural variation in symptom expression. in clinical trials testing psychological interventions among diverse ethnic and cultural groups, it is important to account for this cultural validation by using validated instru­ ments. heim, mewes, abi ramia et al. 13 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ criterion 10: questionnaires and clinical interviews when conducting clinical trials with culturally diverse populations, it is vital to provide information on the extent to which outcome measures (i.e., questionnaires and clinical interviews) were translated, (culturally) adapted, and validated. there are standard criteria for the translation, adaptation, and validation of ques­ tionnaires. as an example, wild et al. (2005) and van ommeren et al. (1999) provided principles of good practice for the translation and cultural adaptation process for pa­ tient-reported outcomes. in addition, standard psychometric methods for the cross-cul­ tural validation of questionnaires and measurement invariance have been developed (e.g., byrne et al., 1989; chen, 2008; milfont & fischer, 2010; vandenberg & lance, 2000). several standard questionnaires have been used for application among diverse cultural and ethnic groups, e.g., the patient health questionnaire (kroenke & spitzer, 2002), the generalised anxiety disorder scale (spitzer et al., 2006), the posttraumatic diagnostic scale (foa et al., 1997), the general health questionnaire (goldberg, 1972), or the who disability assessment scale (ustun et al., 2010), to mention only a few. the validity of questionnaires can be enhanced by incorporating ccd, and par­ ticularly idioms of distress. another option is the use of client-generated outcome measures, such as the psychological outcome profiles instrument (psychlops, ashworth et al., 2004), which has been validated in several countries (e.g., czachowski et al., 2011; héðinsson et al., 2013). another client-generated outcome measure is the personal questionnaire (elliott et al., 2016). most trials use self-report questionnaires as their primary outcome measure. clinical interviews are of course more labour-intensive, but the diagnostic accuracy might be higher (ferrari et al., 2013), especially among diverse cultural and ethnic groups. if the planned outcome measure for the psychological trial is a clinical interview (e.g., the structured clinical interview for dsm-5, scid-5-cv; first et al., 2016), it is rec­ ommended to integrate a culture-sensitive interview, such as the cultural formulation interview in dsm-5 (american psychiatric association, 2013). training interviewers in culture-sensitive assessments is important, in order to avoid misdiagnosis. and it is relevant to report on interviewer training and interrater reliability with regard to cultural competence. criteria 11: implementation measures in addition to measuring outcomes, the implementation process should be documented, as well. without documenting implementation, it is difficult to determine if an unsuc­ cessful intervention is due to the intervention not being effective or lack of fidelity when delivering the intervention (jordans & kohrt, 2020; kohrt, el chammay, et al., 2020). moreover, assessing implementation is vital to determine that the cultural adaptations were actually enacted in delivery of the intervention. criterion 11 refers to the who and how criteria in the taxonomy by singla et al. (2017). reporting cultural adaptation in psychological trials (recapt-criteria) 14 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ in addition to fidelity, competency of providers is important to evaluate. competency tools now exist that can be modified based by the culture and context for a psychological intervention (kohrt, schafer, et al., 2020); these address both competency in nonspecific treatment factors (kohrt et al., 2015) and culturally adapted competencies in treatment specific factors, such as for pm+ (pedersen et al., in press). quality rating currently there are no standards for ranking of cultural adaptation quality. we propose for preliminary use that cultural adaptation studies that only report on 4 or fewer of the criteria be consider ‘low quality’ of reporting. studies that are 5-8 criteria be identified as ‘moderate quality’ of reporting. finally, studies that clearly document 9-11 criteria be considered ‘high quality’. these rankings are subject to change as more documentation occurs on adaptation and further research is conducted about what aspects of adaptation matter most for successfully alleviating suffering across cultures and context around the world. concluding remarks in this paper, we propose a set of reporting criteria for cultural adaptation in clinical trials which test psychological interventions among diverse cultural and ethnic groups. although these reporting criteria were primarily developed for treatments of common mental disorders, they may be used also for other kinds of interventions, such as preven­ tion or mental health promotion. the suggested set of criteria was compiled based on the authors’ experiences and cur­ rent literature. although not exhaustive, the criteria are comprehensive and may be used for top-down and bottom-up cultural adaptation (hall et al., 2016; hwang, 2006). they can be used to guide the process of cultural adaptation, as well as for documentation. that said, it is likely that not all of these criteria are relevant for all trials conducted in this field of research. in this sense, the use and the sequence can be adapted flexibly to the needs of researchers. a template for documenting the process and results of cultural adaptation can be found in the supplementary materials. reporting on cultural adaptation more consistently in future psychological trials will hopefully improve the quality of evidence and contribute to examining the effect of cultural adaptation on treatment efficacy, feasibility, and acceptability. heim, mewes, abi ramia et al. 15 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://www.psychopen.eu/ funding: the project that led to the development of the reporting criteria and the paper was funded by the german federal ministry of education and research (nr 01ef1806h). acknowledgments: we would like to thank dr. kenneth carswell for his valuable contributions to the manuscript. competing interests: eva heim and cornelia weise are both guest editors of this special issue of clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • appendices – appendix a provides additional information on definitions of culture, cultural adaptation literature, the process for developing the recapt criteria, and detailed information on each criterion. – appendix b shows the expert survey used for developing the recapt criteria. • recapt template a template for documenting the cultural adaptation process that was developed by the “task force for cultural adaptation of mental health interventions for refugees”. a documented version for better understanding is provided, along with an empty template in word format that can be used for future studies. index of supplementary materials heim, e., mewes, r., abi ramia, j., glaesmer, h., hall, b., harper shehadeh, m., ünlü, b., kananian, s., kohrt, b. a., lechner-meichsner, f., lotzin, a., moro, m. r., radjack, r., salamanca-sanabria, a., singla, d. r., starck, a., sturm, g., tol, w., weise, c., & knaevelsrud, c. (2021a). supplementary materials to "reporting cultural adaptation in psychological trials – the recapt criteria" [appendices]. psychopen gold. https://doi.org/10.23668/psycharchives.5201 heim, e., mewes, r., abi ramia, j., glaesmer, h., hall, b., harper shehadeh, m., ünlü, b., kananian, s., kohrt, b. a., lechner-meichsner, f., lotzin, a., moro, m. r., radjack, r., salamanca-sanabria, a., singla, d. r., starck, a., sturm, g., tol, w., weise, c., & knaevelsrud, c. (2021b). supplementary materials to "reporting cultural adaptation in psychological trials – the recapt criteria" [recapt template]. psychopen gold. https://doi.org/10.23668/psycharchives.5192 reporting cultural adaptation in psychological trials (recapt-criteria) 16 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://doi.org/10.23668/psycharchives.5201 https://doi.org/10.23668/psycharchives.5192 https://www.psychopen.eu/ references abi ramia, j., harper shehadeh, m., kheir, w., zoghbi, e., watts, s., heim, e., & el chammay, r. (2018). community cognitive interviewing to inform local adaptations of an e-mental health intervention in lebanon. global mental health, 5, article e39. https://doi.org/10.1017/gmh.2018.29 american psychiatric association. (2013). diagnostic and statistical manual of mental disorders (5th ed.). american psychiatric publishing. applied mental health research (amhr) group at johns hopkins university. 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(2014). recent advances in crosscultural measurement in psychiatric epidemiology: utilizing ‘what matters most’ to identify reporting cultural adaptation in psychological trials (recapt-criteria) 24 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://doi.org/10.1146/annurev-clinpsy-032816-045217 https://doi.org/10.1016/j.jad.2014.07.017 https://doi.org/10.1001/archinte.166.10.1092 https://doi.org/10.1093/intqhc/mzm042 https://doi.org/10.32872/cpe.5431 https://apps.who.int/iris/handle/10665/43974 https://doi.org/10.1177/109442810031002 https://doi.org/10.1177/136346159903600304 https://doi.org/10.1037/0003-066x.62.8.857 https://doi.org/10.1111/j.1524-4733.2005.04054.x https://www.psychopen.eu/ culture-specific aspects of stigma. international journal of epidemiology, 43(2), 494-510. https://doi.org/10.1093/ije/dyu039 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. heim, mewes, abi ramia et al. 25 clinical psychology in europe 2021, vol. 3(special issue), article e6351 https://doi.org/10.32872/cpe.6351 https://doi.org/10.1093/ije/dyu039 https://www.psychopen.eu/ reporting cultural adaptation in psychological trials (recapt-criteria) (introduction) background theoretical framework process for developing the reporting criteria reporting criteria a) set-up b) formative research c) intervention d) measuring outcomes and implementation quality rating concluding remarks (additional information) funding acknowledgments competing interests supplementary materials references item response model validation of the german icd-11 international trauma questionnaire for ptsd and cptsd research articles item response model validation of the german icd-11 international trauma questionnaire for ptsd and cptsd daniel christen 1, clare killikelly 1 , andreas maercker 1 , mareike augsburger 1 [1] division of psychopathology, department of psychology, university of zurich, zurich, switzerland. clinical psychology in europe, 2021, vol. 3(4), article e5501, https://doi.org/10.32872/cpe.5501 received: 2020-12-23 • accepted: 2021-08-30 • published (vor): 2021-12-23 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: daniel christen, binzmuehlestrasse 14, ch-8050 zurich, switzerland. tel.: +41 79 572 88 01. e-mail: dc_christen@gmx.ch supplementary materials: materials [see index of supplementary materials] abstract background: in the 11th revision of the international classification of diseases (icd-11) posttraumatic stress disorder (ptsd) and the complex variant (cptsd) were newly conceptualised. the international trauma questionnaire (itq) was developed as a brief self-report measure to screen for both disorders. the english original version has been rigorously tested and presents convincing psychometric properties. the aim of the current study was to validate the german version by means of item response theory (irt). method: this is a secondary analysis of a representative, trauma-exposed adult sample from the german general population (n = 500). 1and 2-parameter logistic irt models (i.e. examination on an item level), diagnostic rates and confirmatory factor analyses were calculated. results: all items showed good model fit and acceptable to good performance aligning with the items of the english original except for item c1 (long time to calm down) which had a high endorsement rate and a low discriminatory power yielding low information gain. cptsd diagnostic rate of 3.2% was lower than in comparable literature. confirmatory factor analysis deemed the six first-order, two second-order factors model superior. conclusion: measurement and factorial validity of the german version of the itq was confirmed. the german translation matches the english original in most psychometric properties and can thus be used for research and clinical practice. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5501&domain=pdf&date_stamp=2021-12-23 https://orcid.org/0000-0003-2661-4521 https://orcid.org/0000-0001-6925-3266 https://orcid.org/0000-0002-6564-0717 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords international trauma questionnaire, itq, icd-11, validation, ptsd, cptsd, item response theory, german translation highlights • the itq is a short self-report questionnaire measuring icd-11 ptsd and cptsd symptoms. there is a lack of evidence regarding the validity of the german translation. • 1and 2-parameter logistic item response theory models were calculated and are comparable to the english original. • evidence for the measurement and factorial validity of the german translation was found. • confirmation of these results and further examination of the german itq are desirable. icd-11 ptsd and cptsd in 2018, the world health organization (who) released the icd-11 in which the two diagnoses posttraumatic stress disorder (ptsd) and the complex “sibling” diagnosis (cptsd) were redefined and newly conceptualised (who, 2018). this reorganization aimed at improving clinical applicability and intercultural adaptation of the diagnoses for example by including a limited number of symptoms and clear delineation from other disorders (keeley, reed, roberts, evans, medina-mora, et al., 2016; reed, 2010). the diagnosis of ptsd consists of three symptom clusters (re-experiencing in the present, avoidance, and perception of current threat) in response to a traumatic event. symptoms must persist for several weeks and cause significant impairment. regarding cptsd, three more symptom clusters called disturbances in self-organization (dso), must be clinically endorsed in addition to the presence of ptsd symptoms: problems in affect regulation, negative self-concept, and difficulties in relationships. the two diagnoses are mutually exclusive (who, 2018). a growing body of evidence has confirmed the usefulness of these icd-11 conceptu­ alizations of ptsd and cptsd. for instance, regarding the factorial structure of ptsd the three-factor structure has been demonstrated in various studies (e.g. hansen, hyland, armour, shevlin, & elklit, 2015; hyland, brewin, & maercker, 2017). for cptsd two superordinate factors (ptsd and dso) with six subordinate factors (symptom clusters) were the best-fitting models (hyland, shevlin, elklit, et al., 2017; nickerson et al., 2016; shevlin et al., 2017). several studies found clearly distinctive symptom profiles for indi­ viduals with ptsd and cptsd by means of latent class and profile analyses (e.g. knefel, garvert, cloitre, & lueger-schuster, 2015; sachser, keller, & goldbeck, 2017). for cptsd, divergent validity was found regarding borderline personality disorder by means of latent class analyses (cloitre, garvert, weiss, carlson, & bryant, 2014) and by means validation of the german international trauma questionnaire 2 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ of a network analysis (knefel, tran, & lueger-schuster, 2016). a vignette-based study with international mental health experts found that the diagnostic guidelines for icd-11 c/ptsd provide substantial clarifications in the diagnostic framework in comparison to icd-10 (keeley, reed, roberts, evans, robles, et al., 2016). nevertheless, the icd-11 concept for c/ptsd is not without controversies. for instance, in a network analysis with israeli men, gilbar (2020) found no clear boundaries between icd-11 c/ptsd, depression, and anxiety symptoms. finally, møller, augsburger, elklit, søgaard, and simonsen (2020) compared measured icd-11 c/ptsd and active icd-10 diagnoses in danish psychiatric outpatients and found an overlap between icd-11 cptsd and icd-10 affective, personality, anxiety, behavioural, and emotional disorders. development of the international trauma questionnaire new diagnoses require accurate measuring instruments that are well conceptualized and validated. the international trauma questionnaire (itq) was developed to serve this purpose for icd-11 ptsd and cptsd (cloitre, roberts, bisson, & brewin, 2015; cloitre et al., 2018). items were developed in an iterative process based on criteria formulation from the diagnostic and statistical manual of mental disorders (dsm) 5 ptsd (brewin et al., 2009), the results of the dsm-iv field trials which assessed the most frequently reported cptsd symptoms (van der kolk et al., 2005), and a consensus survey among expert clinicians (cloitre et al., 2011). the initial english itq resulted in a preliminary version with 28 items (cloitre et al., 2015). studies provided support for this version's fac­ torial, discriminant, and convergent (karatzias et al., 2016) as well as predictive validity (hyland, shevlin, brewin, et al., 2017). in a last step, the number of items was reduced to 12 to conform to the organizing principle of icd-11 that disorders should focus on a limited but central set of symptoms. this was done by assessing the psychometric properties of the items using item response theory (irt) models (cloitre et al., 2018). in the validation study of the english itq, cloitre et al. (2018) applied confirmatory factor analyses and irt to data from both a community and a clinical sample with trauma exposure. for both, the ptsd and dso cluster groups, a 1and a 2-parameter lo­ gistic irt model were compared. the 1-parameter model had a superior fit regarding all clusters except for the dso items in the community sample. differential item functioning was tested with multigroup irt models comparing the two samples and showed adequa­ cy of the itq for both of them. rates of indicated diagnosis (diagnostic rates) of 5.3% ptsd and 12.9% cptsd in the community sample and 14.6% ptsd and 61.1% cptsd in the clinical sample were found mirroring outcomes from previous versions of the itq and pre-existing literature. regarding the latent structure, redican et al. (2021) conducted a systematic review of studies using factor analysis and mixture modelling. they found that the two-factor second-order model (the six symptom clusters as subordinate factors, christen, killikelly, maercker, & augsburger 3 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ ptsd and dso cluster groups as superordinate factors) was consistently deemed the optimal model in clinical samples whereas in most community samples the six-factor model (the six symptom clusters each measured by two items) was preferred. both models as well as the results of mixture modelling indicate that the itq can distinguish between ptsd and cptsd. in summary the studies investigated by redican et al. (2021) suggest that the itq is a valid measure of icd-11 c/ptsd. up to now, the itq has been frequently applied (cloitre et al., 2019; hyland, shevlin, fyvie, cloitre, & karatzias, 2020; karatzias et al., 2019; redican et al., 2021) and recently examined the impact of covid-19 (tsur & abu-raiya, 2020). the itq has been trans­ lated into different languages and is publicly available (https://www.traumameasuresglo­ bal.com/itq). the german translation was done by lueger-schuster, knefel, and maercker (2015/2018) but has not yet been validated. aim of the study in order to be used in clinical practice and research regarding all related areas of c/ptsd the german translation of the itq needs to be clinically validated (delahaye et al., 2015). so far, such a validation is still missing. furthermore, additional investigations of the itq on the item level as well as data about the constructs of c/ptsd would support the understanding of these disorders and thus promote this field of research and its benefits. therefore, this study aimed to validate the german translation of the itq by estimating 1and 2-parameter logistic irt models to examine item characteristics. method participants and procedures this is a secondary analysis of the data presented in maercker, hecker, augsburger, and kliem (2018). with the assistance of a scientific demographic consulting company (usu­ ma, berlin, germany) a representative sample for the german general population was selected. participants were visited by a study assistant (trained layperson) and informed about the study. all participants or caregivers for minors provided written informed consent. measurements were self-rating questionnaires except for the sociodemographic data. overall, 2524 persons between the age of 14 and 99 years completed the assessment between january and march 2016. since there is a version of the itq designed for chil­ dren and adolescents from 7 to 17 years (haselgruber, sölva, & lueger-schuster, 2020), participants under the age of 18 (n = 84) were excluded. further, participants with no traumatic event (n = 1774) and with missing values on all items of the itq (n = 166) were excluded. this resulted in a sample of n = 500 for the current study. ethical approval for the study was granted (452-15-21122015, university of leipzig, medical school). details validation of the german international trauma questionnaire 4 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.traumameasuresglobal.com/itq https://www.traumameasuresglobal.com/itq https://www.psychopen.eu/ are reported in maercker et al. (2018). the mean age of participants was 52.41 years (sd 17.46, range 18-93). measures only variables relevant for the current study are reported here. for further information, see maercker et al. (2018). sociodemographic data sex, age, family and partnership status, educational background, and employment status were assessed. the data is shown in table 1. traumatic events the trauma list of the munich version of the composite international diagnostic inter­ view ptsd module (perkonigg, kessler, storz, & wittchen, 2000; wittchen & pfister, 1997) was applied. it assesses exposure to eight traumatic events (war, physical violence, rape, natural disaster, sexual abuse in the childhood, severe accident, kidnaping, life threatening illness) in addition to the category "other severe events and catastrophes" and witnessed events. “other events” were counted if they met the definition of a traumatic event. of the participants 14.6% (n = 73) reported having experienced war, 26.2% (n = 131) physical violence, 10.2% (n = 51) rape, 8.6% (n = 43) natural disaster, 9.8% (n = 49) sexual abuse in the childhood, 29.6% (n = 148) severe accident, 1.8% (n = 9) kidnapping, 18.0% (n = 90) life threatening illness, 41.6% (n = 208) witnessed an event and 3.8% (n = 19) other kinds of traumatic events. 59.2% (n = 296) of participants reported having experienced one traumatic event. 40.8% (n = 204) reported two or more traumatic events (mean number of experienced traumatic events = 1.66, sd = 1.01). international trauma questionnaire (itq) the german version of the itq was used (lueger-schuster et al., 2015/2018). this version has already been used in several studies, e.g. with survivors of institutional abuse (lueger-schuster et al., 2018) and in international network analyses (knefel et al., 2019; knefel et al., 2020). the itq assesses each of the three clusters of ptsd (p1-p6) and dso (c1-c6) by two items as well as three additional items for functional impairment for ptsd (p7-p9) and dso (c7-c9) each. items are answered on a five-point likert scale ranging from "0 = not at all" to "4 = extremely". a symptom cluster/the functional impairment is considered fulfilled if at least one of the items is clinically endorsed (score ≥ 2, “moderately”). a diagnosis of ptsd is indicated if every symptom cluster and the functional impairment item of the ptsd cluster group are fulfilled. if all symptom clusters and both functional impairments (across both ptsd and dso cluster groups) are fulfilled, a diagnosis of cptsd is indicated. in the current study the first christen, killikelly, maercker, & augsburger 5 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ item for functional impairment of the dso cluster was not measured due to survey item restrictions. statistical analysis statistical analyses were conducted using the software r (version 3.6.2) with the package ltm (rizopoulos, 2018). table 1 sociodemographic data variable / category response % n sex female 53.0 265 male 47.0 235 family status married/living together 36.4 182 married/living separated 3.4 17 single 30.0 150 divorced 16.2 81 widowed 13.8 69 no answer 0.2 1 living with a partner yes 12.0 60 no 49.8 249 no answer 38.2 191 educational background no or basic school leaving certificate 36.4 182 intermediate school leaving certificate 37.2 186 advanced school leaving certificate (university entrance level) or university degree 26.2 131 other 0.2 1 employment status employed (fullor part-time) 47.8 239 currently not working/unemployed 12.6 63 studying 5.0 25 retired 32.6 163 no answer 2.0 10 validation of the german international trauma questionnaire 6 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ data preparation missing values in the itq (present in n = 38, max. of 5 missing values) was imputed by multiple (five) imputation. analyses with imputed values were compared with complete cases. no significant differences were found. analysis of dimensionality to choose appropriate irt models, an analysis of dimensionality of the symptom items for ptsd, dso and both together (itq) was conducted (mair, 2018). dimensionality was explored with categorial principal component analyses, item factor analysis models and exploratory factor analyses as no assumption about the factor structure of the translation was made. however, since there are a lot of studies about the factor structure of the itq in other languages (redican et al., 2021) a confirmatory factor analysis was done in addition. more detailed information is reported in appendix a (see supplementary materials). irt models irt focusses explicitly on which conclusions can be drawn from measured values/man­ ifest variables (e.g. answer to an item) on underlying constructs/traits (θ) (e.g. ptsd) which are assumed to have a probabilistic relationship that can be modelled with differ­ ent grades of complexity. one of the simplest models is the 1-parameter logistic model (rasch, 1993). it models the dichotomous answer to an item in dependence of θ with a difficulty parameter which indicates at which level of θ the probability of endorsing that item is .5. the more complex model is the 2-parameter logistic model (birnbaum, 1968) with an additional discrimination parameter, which indicates the discriminatory power of an item (moosbrugger & kelava, 2007). using the marginal maximum likelihood method, unidimensional 1-parameter logistic and 2-parameter logistic irt models were calculated for the ptsd and dso cluster groups with dichotomized items. model fit was assessed via the z-statistics to investigate whether item parameters were significantly different from zero (z > 1.65) and models were re-run with randomly generated data and compared to the real dataset. here, a p-value < .05 indicated that an item did not fit the model. 1-parameter and 2-parameter model within each cluster were compared using the akaike information criterion (aic) (akaike, 1974) and bayesian information criterion (bic) (schwarz, 1978) with lower values indicating the better model. a difference in those values of ≥ 10 was considered "significant" (raftery, 1995) and on the basis of parsimony, the 1-parameter model was chosen unless the criteria indicated the 2-parame­ ter model is superior. finally, item information curves were calculated to visualize item parameters and compare the information richness gained (wood & molenaar, 2017). estimated item difficulty and discrimination parameters along with endorsement rates were compared to the results for the community sample of the analysis by cloitre et christen, killikelly, maercker, & augsburger 7 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ al. (2018), as they used a similar method to validate the english version. additionally, diagnostic rates for ptsd and cptsd were compared to previous literature. results analysis of dimensionality overall, the categorial principal component analysis as well as the criteria very simple structure and minimum average partial supported unidimensionality of ptsd and dso cluster groups. exploratory factor analysis models with different numbers of factors all showed insufficient fit and all criteria values of the item factor analysis models laid very close to each other. confirmatory factor analysis found the six first-order, two second-or­ der factors model to be superior. more detailed results of the analysis of dimensionality are reported in appendix b (see supplementary materials). irt models model fit was good for all four estimated models (1-parameter logistic and 2-parameter logistic models for each the ptsd and dso cluster groups): none of the z-statistic values were ≤ 1.65 and thus item parameters were significantly different from zero. item fit within models yielded p-values of > .05 for all items, confirming their fit. aic and bic of the 1-parameter and 2-parameter models within each cluster group are shown in table 2. for ptsd, no model was favoured according to the aic (difference < 10) and according to the bic the 1-parameter model was superior. for the dso cluster group both criteria indicated the 2-parameter model was better. table 2 comparison of the 1and 2-parameter logistic models model aic bic ptsd 1pl 2700.48 2729.98 2pl 2700.39 2750.97 dso 1pl 2169.03 2198.54 2pl 2114.77 2165.34 note. aic = akaike information criterion; bic = bayesian information criterion; dso = disturbances in self-organization; ptsd = posttraumatic stress disorder; 1pl = 1-parameter logistic; 2pl = 2-parameter logistic. validation of the german international trauma questionnaire 8 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ item information curves of the 1-parameter model for the ptsd cluster group are visual­ ized in figure 1. item difficulty (left-right shift) showed a narrow, even distribution except for items p1 (upsetting dreams) and p2 (powerful images or memories) whose item information curves practically overlapped. figure 1 item information curves of the 1-parameter logistic model for the ptsd cluster group item information curves of the 2-parameter model for the dso cluster group are visual­ ized in figure 2. item difficulty showed a narrow distribution as well, except for item c1 (long time to calm down) whose item information curve was an outlier on the lower end of dso trait. discriminatory power varied largely with item c4 (i feel worthless) on the upper end with a tall narrow curve and item c1 on the lower end showing a flat wide curve. item parameters of the models and the endorsement rates from the current study as well as the community sample of the study by cloitre et al. (2018) are shown in table 3. for ptsd, endorsement rates of the two studies spread over similarly sized ranges. the ranges overlapped with the highest two endorsement rates of the present study within the range of the study by cloitre et al. (2018) and their three lowest rates within the range of the present study. discrimination parameters were the same for all items of the german itq and for the items of each cluster in the english itq which is due christen, killikelly, maercker, & augsburger 9 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ to the use of slightly different 1-parameter logistic models. discrimination parameters of the german version were lower. in contrast, item difficulty parameters of this study were higher than those reported by cloitre et al. (2018). still, difficulty parameters within the two studies scattered over similarly sized areas. item information curves of the non-favoured models are reported in appendix c (supplementary materials). for dso, endorsement rates found in this study were generally lower than the ones reported by cloitre et al. (2018). endorsement rate of item c1 (long time to calm down) constitutes an anomaly within the dso cluster group of the german version as it is more than double the size of the next highest endorsement rate. this was not the case for any other endorsement rate including the same item in the english version. discrimination parameters of the german version were descriptively lower and difficulty parameters higher. in the german version the parameters of item c1 again did not align with the other items. 5.0% (n = 25) in the current sample exceeded the threshold for an indication of ptsd diagnosis and 3.2% (n = 16) indicated cptsd diagnosis. figure 2 item information curves of the 2-parameter logistic model for the dso cluster group validation of the german international trauma questionnaire 10 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ table 3 endorsement rates and item parameters of the present study and cloitre et al. (2018) item endorsement (%) discrimination (se) difficulty (se) present study cloitre et al. present study cloitre et al. present study cloitre et al. ptsd p1 22.8 26.8 2.50 (0.17) 3.89 (0.17) 0.91 (0.08) 0.67 (0.05) p2 22.0 31.8 2.50 (0.17) 3.89 (0.17) 0.94 (0.08) 0.51 (0.04) p3 25.9 37.7 2.50 (0.17) 6.32 (0.58) 0.79 (0.08) 0.32 (0.04) p4 28.9 34.6 2.50 (0.17) 6.32 (0.58) 0.69 (0.07) 0.40 (0.04) p5 32.5 36.0 2.50 (0.17) 6.53 (0.62) 0.56 (0.07) 0.36 (0.04) p6 19.2 29.5 2.50 (0.17) 6.53 (0.62) 1.06 (0.08) 0.55 (0.04) dso c1 40.9 42.8 1.34 (0.21) 2.78 (0.21) 0.36 (0.10) 0.22 (0.05) c2 15.2 36.1 2.09 (0.32) 3.79 (0.33) 1.32 (0.13) 0.41 (0.04) c3 9.8 36.3 5.48 (1.32) 6.64 (0.91) 1.34 (0.08) 0.37 (0.04) c4 11.0 34.5 7.05 (2.22) 8.41 (1.43) 1.27 (0.07) 0.42 (0.04) c5 13.4 40.3 3.64 (0.61) 5.69 (0.74) 1.21 (0.09) 0.27 (0.04) c6 20.2 39.6 2.03 (0.29) 4.54 (0.48) 1.08 (0.11) 0.30 (0.04) note. c1 = long time to calm down; c2 = feeling numb; c3 = feeling like a failure; c4 = feeling worthless; c5 = feeling cut off from people; c6 = finding it hard to stay emotionally close to people; dso = disturbances in self-organization; ptsd = posttraumatic stress disorder; p1 = upsetting dreams; p2 = powerful images or memories; p3 = avoiding internal reminders; p4 = avoiding external reminders; p5 = being “super-alert”; p6 = feeling jumpy; se = standard error. discussion this study aimed to validate the german translation of the itq. this is essential for the scale to be clinically valid (delahaye et al., 2015) and enhances the understanding of the c/ptsd disorder structure. previously this was done successfully for the english version by cloitre et al. (2018) with a similar analysis. due to the strong empirical support, unidimensional irt models were calculated. for ptsd, the 1-parameter and for dso, the 2-parameter logistic models were deemed superior. this suggests that the items of the ptsd cluster group do not vary enough in discriminatory power for having to consider this parameter in modelling, whereas in the dso cluster group discriminatory power seems to vary too much to be omitted as a parameter. ptsd items showed no excessive high or low endorsement rates and no outlier. cloitre et al. (2018) found similar values but with higher overall average. this difference could be due to the translation however endorsement rates of all ptsd items were lower indicating that sample differences seem more likely. such a difference could arise from christen, killikelly, maercker, & augsburger 11 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ the number of traumatic experiences in each sample since this is associated with higher probability of c/ptsd (karatzias et al., 2016; kolassa, kolassa, ertl, papassotiropoulos, & de quervain, 2010). in the community sample of cloitre et al. (2018) the average number of traumatic experiences was 3.36 while in the current study it was 1.66 with the majority (59.2%) having experienced just a single traumatic event. this could explain higher ptsd traits and thus higher endorsement rates in the sample of cloitre et al. (2018). within the dso cluster group item c1 (long time to calm down) was an outlier in terms of endorsement rate and had the lowest discrimination parameter. this resulted in relatively little information gained from this item. in the english version, item c1 had a similar endorsement rate however it did not constitute an outlier and had a higher discrimination parameter. a possible reason for this difference could lie in the broader meaning of the german translation. while upset ("when i am upset, it takes me a long time to calm down.") represents feelings of worry, unhappiness, or anger, the german equivalent word aufgeregt additionally represents the feeling of pleasant anticipation as well as a physiological arousal or agitation. this could lead to higher endorsement of this item in the german translation. all other dso items had quite low endorsement rates compared to the ptsd cluster group as well as to the results of cloitre et al. (2018). since low endorsement rates were consistent over five items sample differences in cptsd trait seem a more probable reason than the translation process itself. differences in the average number in traumatic events could explain these different rates. to better understand the performance of item c1 and the low endorsement rates of items c2 to c6 it would be desirable to have future studies investigate this, for example, using polytomous irt modelling with a community and a clinical sample. combined diagnostic rate of ptsd (5.0%) and cptsd (3.2%) was 8.2% and thus lower than in comparable studies like ben-ezra et al. (2018) (9% ptsd and 2.6% cptsd), knefel et al. (2019) (12.9% ptsd and 20.6% cptsd), and hyland et al. (2020) (5.0% ptsd and 7.7% cptsd). in the latter study with a nationally representative sample form ireland the difference in diagnostic rates was mainly due to the difference in cptsd rate. the cptsd rate in the current study was most probably underestimated by omission of item c7 (concern about social life) due to survey item restrictions. diagnostic rates can thus be considered in accordance with pre-existing literature. the prevalence ratio of ptsd and cptsd in different samples is subject to an ongo­ ing scientific debate (cloitre et al., 2018). there is a dominant hypothesis that community rates of ptsd should be higher than cptsd while the reverse is true for trauma clinics (brewin et al., 2009). however, this view is challenged by studies showing that multiple traumatic experiences are associated with higher rates of cptsd than ptsd (elklit & shevlin, 2007) and that in community samples multiple experiences of traumatisation is more common than a single experience (scott et al., 2013). in the present study the ptsd rate was higher than cptsd. this is in line with the proposed hypothesis that validation of the german international trauma questionnaire 12 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ in a community sample ptsd is higher. on the other hand, it contradicts the findings that multiple experiences of traumatisation may be more likely in community samples. in comparison to the diagnostic rates of cloitre et al. (2018) (5.3% ptsd and 12.9% cptsd) the 5.0% ptsd rate in the present study was similar whereas the 3.2% cptsd rate was lower. again, this difference is likely due to the omission of item c7 as well as a higher mean number of traumatic experiences in the sample of cloitre et al. (2018). confirmatory factor analysis showed the six-factors and the six first-order, two sec­ ond-order factors model to be of good fit and the latter to be superior. this coincides with other studies on community samples e.g. with the italian (somma, maffei, borroni, gialdi, & fossati, 2019) or the korean translation (choi, kim, & lee, 2021) and speaks for the validity of the german translation of the itq (redican et al., 2021). using irt methods, the german translation of the itq was investigated with a special focus on the item level. the results support the validity of all items except for item c1 (long time to calm down). additionally, confirmatory factor analysis too, pointed to the validity of the investigated questionnaire. since the present study used data of a community sample the itq could not be tested for differential item functioning, i.e. different performance in a community than in a clinical sample. differential item functioning, potential changes in diagnostic rates and applicability in clinical samples would be interesting to investigate in the future. finally, this validation approach should be complemented with classical test theory (e.g., investigating convergent and divergent validity) in other studies. limitations almost half of the individuals contacted refused to participate in the study. although this is common in surveys of this kind, a potential selection bias cannot be excluded (maercker et al., 2018). individuals who experienced strong avoidance symptoms might have been overlooked due to the inclusion criteria of a subjectively most burdensome event. further, not all cptsd impairment items could be included in the study due to survey item restrictions. this did not impact irt model estimation but might have influenced cptsd diagnostic rate. conclusion the german translation of the itq can be considered a valid measure for icd-11 c/ ptsd. an exceptional case was the item c1 ("when i am upset, it takes me a long time to calm down."), which showed mismatched item parameters in comparison to other items of the same cluster group. as this is the first study to specifically examine the validity of the german version of the itq its findings are important in many regards. having a vali­ dated measurement for icd-11 c/ptsd in german supports future research and its ben­ efits concerning the german speaking population worldwide as well as global research christen, killikelly, maercker, & augsburger 13 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://www.psychopen.eu/ by providing data from this population. research and benefits for the population apply to all related areas of c/ptsd, from the disorders themselves, over disorders specifically associated with stress, to anything including c/ptsd as a precursory, accompanying or resulting condition and be it about prevalence, prevention, intervention, rehabilitation, or others. some studies already used the german translation of the itq prior to this valida­ tion (knefel et al., 2019; knefel et al., 2020; lueger-schuster et al., 2018). results gained this way receive backup through the validation of the instrument. besides research this study provides an important contribution to the clinical applicability of the itq and thus the health care of the german speaking population. as a validated instrument it can be used in practice to screen for icd-11 c/ptsd, support the diagnostic process, accompany a (therapeutic) process and more. further, the information gained about the performance of the translated items also furthers the understanding of the appropriate wording and combination of items to measure the c/ptsd constructs in german as well as opens the possibility to improve the itq. for the german itq, consider renaming the previous translation of "upset", e.g., using the german verb "aufgewühlt" or "aufgebracht". future studies should try to confirm the present findings including a clinical sample to test for differential item functioning and changes in diagnostic rates and include item c7. also of interest would be the investigation of different kinds of validity of the german itq to consolidate the findings here. funding: we thank jörg fegert, md, and cedric sachser, phd, university of ulm, for financial support of sample recruitment. acknowledgments: we thank elmar brähler, phd, for logistical organization of the basic study. competing interests: the authors have declared that no competing interests exist. supplementary materials the supplementary materials contain the detailed method and results of the analysis of dimen­ sionality and item information curves of the non-favoured irt-models (for access see index of supplementary materials below). index of supplementary materials christen, d., killikelly, c., maercker, a., & augsburger, m. 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(1997). dia-x-interviews: manual für screening-verfahren und interview [interview]. frankfurt, germany: swets & zeitlinger. wood, j., & molenaar, p. c. m. (2017). logistic irt models. retrieved from https://quantdev.ssri.psu.edu/sites/qdev/files/irt_tutorial_fa17_2.html world health organization. (2018). international classification of diseases for mortality and morbidity statistics (11th revision). geneva, switzerland: world health organization. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. christen, killikelly, maercker, & augsburger 19 clinical psychology in europe 2021, vol. 3(4), article e5501 https://doi.org/10.32872/cpe.5501 https://quantdev.ssri.psu.edu/sites/qdev/files/irt_tutorial_fa17_2.html https://www.psychopen.eu/ validation of the german international trauma questionnaire icd-11 ptsd and cptsd development of the international trauma questionnaire aim of the study method participants and procedures measures statistical analysis results analysis of dimensionality irt models discussion limitations conclusion (additional information) funding acknowledgments competing interests supplementary materials references announcement of the registered report "effect of cultural adaptation of a smartphone-based self-help programme on its acceptability and efficacy" announcements announcement of the registered report "effect of cultural adaptation of a smartphone-based self-help programme on its acceptability and efficacy" eva heim a, sebastian burchert b, mirëlinda shala a, marco kaufmann c, arlinda cerga pashoja de, naser morina f, michael p. schaub f, christine knaevelsrud b, andreas maercker a [a] department of psychology, university of zurich, zurich, switzerland. [b] department of education and psychology, freie universität berlin, berlin, germany. [c] epidemiology, biostatistics and prevention institute, university of zurich, zurich, switzerland. [d] faculty of population health, london school of hygiene and tropical medicine, london, united kingdom. [e] public health england, london, united kingdom. [f] swiss research institute for public health and addiction, zurich, switzerland. clinical psychology in europe, 2020, vol. 2(3), article e4281, https://doi.org/10.32872/cpe.v2i3.4281 published (vor): 2020-09-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: eva heim, university of zurich, department of psychology, binzmuehlestrasse 14/17, 8050 zurich, switzerland. phone: +41 (0)44 635 7326. e-mail: e.heim@psychologie.uzh.ch editor's note: this is an announcement of a registered report which received in-princi‐ pal-acceptance (ipa) to be published in "clinical psychology in europe". the study protocol is publicly accessible at https://doi.org/10.23668/psycharchives.3152. in this announcement, a brief summary of the study protocol is presented. in order to narrow the world-wide treatment gap, innovative interventions are needed that can be used among culturally diverse groups, e.g., immigrant populations in high-in‐ come countries. research on cultural adaptation of psychological interventions indicates that a higher level of adaptation is associated with a higher effect size of the intervention. however, direct comparisons of different levels of adaptations are scarce and have not been done with self-help interventions. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i3.4281&domain=pdf&date_stamp=2020-09-30 https://doi.org/10.23668/psycharchives.3152 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ aims the registered study will use a smartphone-based self-help programme called step-bystep (albanian: hap-pas-hapi) for the treatment of psychological distress among albani‐ an-speaking immigrants in switzerland and germany. two levels of cultural adaptation (i.e., surface vs. deep structure adaptation) will be compared. we hypothesise that the deep structure adaptation will enhance the acceptance and effect size of the intervention. the deep structure adaptation was done based on an ethnopsychological study to exam‐ ine the target population’s cultural concepts of distress. method in the registered study, we will conduct a two-arm, single-blind randomised controlled trial. participants will be randomly assigned to the surface vs. deep structure adaptation version of hap-pas-hapi (1:1 allocation using permuted block randomization). inclusion criteria are good command of the albanian language, age above 18, and elevated psycho‐ logical distress (kessler psychological distress scale score above 15). primary outcome measures are the total score of the hopkins symptom checklist and the number of participants who completed at least three (out of five) sessions. secondary outcomes are global functioning, well-being, symptoms of post-traumatic stress, and self-defined problems. in addition, we will test a mediation model, hypothesizing that the deep structure adaptation will address fatalistic beliefs and enhance alliance with the self-help programme, which in turn increases the acceptance and effect size of the intervention. and finally, we will measure acculturation and hypothesise, that with higher levels of acculturation, the effect of the deep structure adaptation will diminish. discussion the registered study is the first study to directly compare two different levels of cultural adaptation of an online self-help programme for the treatment of psychological distress among immigrants in high-income countries. we aim to deliver theory-driven and meth‐ odologically rigorous empirical evidence regarding the effect of cultural adaptation on the acceptance and effect size of this self-help programme. funding: the project described in the registered report is supported by the swiss national science foundation (grant 10001c_169780) and the swiss foundation for psychiatry and psychotherapy. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. registered report announcement 2 clinical psychology in europe 2020, vol.2(3), article e4281 https://doi.org/10.32872/cpe.v2i3.4281 https://www.psychopen.eu/ supplementary materials the study protocol for this registered report is publicly accessible via psycharchives.org (see index of supplementary materials below). index of supplementary materials heim, e., burchert, s., shala, m., kaufmann, m., cerga pashoja, a., morina, n., . . . maercker, a. (2020). effect of cultural adaptation of a smartphone-based self-help programme on its acceptability and efficacy: study protocol for a randomized controlled trial. psycharchives. https://doi.org/10.23668/psycharchives.3152 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. heim, burchert, shala et al. 3 clinical psychology in europe 2020, vol.2(3), article e4281 https://doi.org/10.32872/cpe.v2i3.4281 https://doi.org/10.23668/psycharchives.3152 https://www.psychopen.eu/ (how) can clinical psychology contribute to increasing vaccination rates in europe? editorial (how) can clinical psychology contribute to increasing vaccination rates in europe? tania m. lincoln 1, winfried rief 2 [1] clinical psychology and psychotherapy, institute of psychology, university of hamburg, hamburg, germany. [2] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2021, vol. 3(3), article e7525, https://doi.org/10.32872/cpe.7525 published (vor): 2021-09-30 corresponding author: tania m. lincoln, universität hamburg, institut für psychologie, klinische psychologie und psychotherapie, von-melle-park 5, 20146 hamburg, germany. e-mail: tania.lincoln@uni-hamburg.de the speed in which several vaccines for covid-19 were developed, approved and rolled out in europe is amazing. unfortunately, though, what started out as a story of success is presently being spoilt by the high rate of vaccine hesitancy and refusal. in those european countries that have already offered a vaccine to all adults the rate of vaccine uptake is levelling off well below 70%. while this seemed sufficient at the beginning of the pandemic, the newer virus variants with higher infectiousness require much higher participation rates for vaccination campaigns, and experts now estimate the necessary threshold to be about 90%. to better understand vaccine hesitancy, numerous researchers have diligently been studying its putative predictors. sociodemographic variables they found to be consistent­ ly associated with hesitancy or refusal were younger age, female gender, lower income, lower education, unemployment, and migrant status (freeman et al., 2020; neumann­ böhme et al., 2020; sallam, 2021; wake, 2021). also, people with more extreme political views (peretti-watel et al., 2020), higher social media consumption (allington et al., 2021; ebrahimi et al., 2021; murphy et al., 2021), and more frequent use of messenger services and online video platforms (holzmann-littig et al., 2021) seem to be less likely to accept a covid-19 vaccine. in general, the decision to participate mainly depends on three factors: “benefit” (what kind of benefit do i expect if i participate?), “harm” (i.e. are these vaccines producing negative effects on my body?), and feasibility (how difficult is it to partici­ pate?). in regard to harm expectations, research has identified attitudes indicative of a general mistrust of the government and its institutions (ebrahimi et al., 2021; freeman this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7525&domain=pdf&date_stamp=2021-09-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ et al., 2020; lincoln et al., 2021; murphy et al., 2021), conspiracy beliefs (allington et al., 2021; freeman et al., 2020; murphy et al., 2021), and specific concerns related to vaccine safety and efficacy (freeman et al., 2020; neumann-böhme et al., 2020) to predict vaccine willingness. related to benefit expectations, it has been shown that the lower people perceive the risk of getting covid-19, the less willing they are to get vaccinated (allington et al., 2021; bono et al., 2021; ebrahimi et al., 2021). interventions to combat vaccine hesitancy have included increasing the incentives (e.g. paying people for vaccination or reducing the options of social participation for re­ fusers), using role models, combatting misinformation in social media, providing patient choice, and providing low-threshold vaccination in socially deprived areas. although some of these interventions align with the known socio-demographic predictors, sur­ prisingly, none of them seem to focus directly at changing the beliefs driving vaccine hesitancy or refusal. is this, perhaps, because changing peoples’ beliefs is seen as partic­ ularly difficult? maybe. but not for clinical psychologists! changing beliefs to motivate adaptive behavior is what we do every day. we do not intend to imply that vaccine hesitancy is indicative of a mental health problem. we do think, however, that the beliefs driving vaccine hesitancy are maladaptive, both from an empirical perspective, as they are not well backed up by evidence, and from a functional perspective, as they are putting people at risk. classifying these attitudes as maladaptive provides us with a unique opportunity to bring in our expertise to the aim of finally moving out of this pandemic. to make this a bit more concrete, what do you think about the following five-step basic cognitive-behavioral intervention for dealing with vaccine hesitant fellow citizens? 1. specifying the problem in order to set a realistic aim according to the german cosmo study (cosmo-konsortium, 2021), only about half of those not yet vaccinated report to be definite refusers, the other half are either merely unsure or even basically willing. a clear understanding of where someone stands is key to setting a realistic goal and finding the most appropriate intervention. is it a problem of attitude (e.g. not wanting to get a vaccine) or of behavior (being willing in principle, but not having put this willingness into practice yet)? and if it is a problem of attitude, how pronounced is it? is someone an absolute refuser and is actively spreading misinformation? in this case, a realistic next step could be to sow some seeds of doubt. or has someone merely got a couple of specific concerns that are preventing him or her from getting a vaccine? in this case, the aim could be to overcome these doubts and develop a principle vaccination willingness. finally, for those who are already willing in principle, the aim should be to overcome the practical barriers and actually get the vaccine. prochaska and di clemente’s (1986) motivational model for change provides a helpful framework for defining what the problem is, where the patient is, and what would be a reasonable next step in this case. (how) can clinical psychology contribute to increasing vaccination rates in europe? 2 clinical psychology in europe 2021, vol. 3(3), article e7525 https://doi.org/10.32872/cpe.7525 https://www.psychopen.eu/ 2. assessing the reasons and delineating the appropriate intervention if the problem is one of attitude, the main concerns need to be explored. are they related to a profound and generalized mistrust of the government and its institutions or even to conspiracy beliefs or does someone have very specific vaccine safetyconcerns? are we dealing with a fear of sideor long-term effects or with phobic concerns related to the prick of the needle? is someone clearly underestimating the risk of the pandemic or have they perhaps not understood the differences in probabilities between developing serious side effects, versus getting infected with serious consequences? in addition, we need to understand how these attitudes are maintained even if contradicting information is provided. do people use “cognitive immunization” (rief & joormann, 2019) strategies to block any effects of corrective information? in this case, it will not be sufficient to provide new information, but also to challenge or circumvent these cognitive immunization strategies. if the problem is one of behaviour, we need to find out what the specific barriers are (is it, for example, a lack of time? a lack of knowledge about where to go? or is someone worried about not having the documents that may be required?). once we have understood the reasons, it will be clearer which type of intervention is the most promising. 3. building rapport to motivate behaviour change as any therapist will know, simply telling someone that their beliefs are wrong or unfounded is unlikely to be helpful. it tends to motivate people to defend their beliefs, or even to leave the conversation, never to come back. people have reasons for their beliefs and, in any case, no one can be 100% certain of what is right and wrong. staying open minded oneself and also expressing authentic understanding for the other persons’ beliefs will create an open space in which a change of perspective is more likely to occur. even in the case of extreme mistrust or conspiracy beliefs, which may be more difficult to empathize with, it can help to express understanding for the frustration with political decisions and the restrictions. 4. challenging beliefs if we are dealing with maladaptive beliefs, we can now follow the basic pattern of cognitive therapy. we begin by narrowing down the beliefs to one core statement. we then assess how certain the person is of the truth of this belief (maybe using a scale from 1 to 100 percent). we can now move on to the empirical dispute by creating a list of evidence for and against the belief. mind to use guided discovery and let the other person come up with the pros and cons herself. but if you can’t stop yourself from adding to the list, then be sure to add to both sides of evidence. you might also want to discuss the quality of each piece of evidence to help the other person decide which weight to give it. for example, while severe adverse lincoln & rief 3 clinical psychology in europe 2021, vol. 3(3), article e7525 https://doi.org/10.32872/cpe.7525 https://www.psychopen.eu/ effects are indeed a matter of concern, mild side effects are generally fleeting in nature and easy to cope with. depending on the type of belief, it may also make sense to use functional dispute. this is done by looking at the pros and cons of sticking with the belief versus changing it. knowing your stats will come in helpful here as this process may well involve weighing up the risk of severe side effects with the risk of a serious covid-19 infection (rief, 2021). established and powerful “cognitive immunization” strategies, need to be addressed specifically. these strategies can be categorized into two types: devaluating the source of information (e.g. you cannot believe those people who are in favor of vaccination anyway), and devaluating the content of expectationviolating information (e.g. information violating my beliefs is only based on accidental events). they are also evident on a behavioral level by avoidance of any conflicting information and continuing to live in an information bubble. again, we need to validate cognitive immunization strategies, because they provide stability in our lives, but they are also the basis of continuous misjudgments, and therefore, searching for alternative information channels is crucial to prevent tunnel perspectives. this process can be concluded by re-assessing the conviction in the belief to see where you stand now. don’t worry if it hasn’t changed much, after all its not about winning an argument, but about helping someone to take different aspects into account. according to prochaska and di clemente’s (1986) model, it’s just about moving to the next level of change, not about completely convincing a person in one blow. 5. overcoming behavioral barriers if the willingness to get a vaccine is there, in principle, but the problem is one of getting organized, we can use a simplified version of the good old problem-solving scheme. starting out by repeating the aim (i.e. to “get a vaccine as soon as possible”) and defining the barriers (“haven’t found the time yet” or “can’t find vaccine booklet” etc.), continue with a brainstorming of different options of where, when and how the aim can be achieved, motivate the person to think about the disadvantages and advantages of each option, then encourage to select an option and outline a concrete plan that includes the specific steps involved along with a time and place. if possible, support the person practically (e.g. find the closest doctor offering vaccines) and don’t forget to follow up by asking whether the plan was put into practice. if not, elucidate the reasons, select a new option and take it from there. does this sound straightforward enough to give it a go? if so, we are curious to hear whether it worked and are awaiting your “case-reports” in the next issue. (how) can clinical psychology contribute to increasing vaccination rates in europe? 4 clinical psychology in europe 2021, vol. 3(3), article e7525 https://doi.org/10.32872/cpe.7525 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references allington, d., duffy, b., wessely, s., dhavan, n., & rubin, j. (2021). health-protective behaviour, social media usage and conspiracy belief during the covid-19 public health emergency. psychological medicine, 51(10), 1763-1769. https://doi.org/10.1017/s003329172000224x bono, s. a., faria de moura villela, e., siau, c. s., chen, w. s., pengpid, s., hasan, m. t., sessou, p., ditekemena, j. d., amodan, b. o., hosseinipour, m. c., dolo, h., siewe fodjo, j. n., low, w. y., & colebunders, r. 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(2021). psychological characteristics associated with covid-19 vaccine hesitancy and resistance in ireland and the united kingdom. nature communications, 12(1), article 29. https://doi.org/10.1038/s41467-020-20226-9 lincoln & rief 5 clinical psychology in europe 2021, vol. 3(3), article e7525 https://doi.org/10.32872/cpe.7525 https://doi.org/10.1017/s003329172000224x https://doi.org/10.3390/vaccines9050515 https://projekte.uni-erfurt.de/cosmo2020/web/summary/48-51/ https://doi.org/10.3389/fpubh.2021.700213 https://doi.org/10.1017/s0033291720005188 https://doi.org/10.3390/vaccines9070777 https://doi.org/10.21203/rs.3.rs-787170/v1 https://doi.org/10.1038/s41467-020-20226-9 https://www.psychopen.eu/ neumann-böhme, s., varghese, n. e., sabat, i., barros, p. p., brouwer, w., van exel, j., schreyögg, j., & stargardt, t. (2020). once we have it, will we use it? a european survey on willingness to be vaccinated against covid-19. the european journal of health economics, 21(7), 977-982. https://doi.org/10.1007/s10198-020-01208-6 peretti-watel, p., seror, v., cortaredona, s., launay, o., raude, j., verger, p., fressard, l., beck, f., legleye, s., l’haridon, o., léger, d., & ward, j. k. (2020). a future vaccination campaign against covid-19 at risk of vaccine hesitancy and politicisation. the lancet infectious diseases, 20(7), 769-770. https://doi.org/10.1016/s1473-3099(20)30426-6 prochaska, j. o., & diclemente, c. c. (1986). toward a comprehensive model of change. in w. r. miller & n. heather (eds.), treating addictive behaviors: processes of change (pp. 3–27). springer us. https://doi.org/10.1007/978-1-4613-2191-0_1 rief, w. (2021). fear of adverse effects and covid-19 vaccine hesitancy: recommendations of the treatment expectation expert group. jama health forum, 2(4), article e210804. https://doi.org/10.1001/jamahealthforum.2021.0804 rief, w., & joormann, j. (2019). revisiting the cognitive model of depression: the role of expectations. clinical psychology in europe, 1(1), article e32605. https://doi.org/10.32872/cpe.v1i1.32605 sallam, m. (2021). covid-19 vaccine hesitancy worldwide: a concise systematic review of vaccine acceptance rates. vaccines, 9(2), article 160. https://doi.org/10.3390/vaccines9020160 wake, a. d. (2021). the willingness to receive covid-19 vaccine and its associated factors: “vaccination refusal could prolong the war of this pandemic” – a systematic review. risk management and healthcare policy, 14, 2609-2623. https://doi.org/10.2147/rmhp.s311074 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. (how) can clinical psychology contribute to increasing vaccination rates in europe? 6 clinical psychology in europe 2021, vol. 3(3), article e7525 https://doi.org/10.32872/cpe.7525 https://doi.org/10.1007/s10198-020-01208-6 https://doi.org/10.1016/s1473-3099(20)30426-6 https://doi.org/10.1007/978-1-4613-2191-0_1 https://doi.org/10.1001/jamahealthforum.2021.0804 https://doi.org/10.32872/cpe.v1i1.32605 https://doi.org/10.3390/vaccines9020160 https://doi.org/10.2147/rmhp.s311074 https://www.psychopen.eu/ monetary valuation of a quality-adjusted life year (qaly) for depressive disorders among patients and non-patient respondents: a matched willingness to pay study research articles monetary valuation of a quality-adjusted life year (qaly) for depressive disorders among patients and non-patient respondents: a matched willingness to pay study laura ulbrich 1 , christoph kröger 1 [1] department of psychology, university of hildesheim, hildesheim, germany. clinical psychology in europe, 2021, vol. 3(4), article e3855, https://doi.org/10.32872/cpe.3855 received: 2020-06-15 • accepted: 2021-05-23 • published (vor): 2021-12-23 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: laura ulbrich, universitätsplatz 1, 31141 hildesheim, germany. e-mail: christoph.kroeger@uni-hildesheim.de supplementary materials: materials [see index of supplementary materials] abstract background: as estimated by the world health organization, depressive disorders will be the leading contributor to the global burden of disease by 2030. in light of this fact, we designed a study whose aim was to investigate whether the value placed on health-related quality of life (hrqol) for a depressive disorder is higher in patients diagnosed with a major depressive disorder (mdd) compared to non-patients in a matched sample. method: we collected data on willingness to pay (wtp) for a total of four health-gain scenarios, which were presented to 18 outpatients diagnosed with a mdd versus 18 matched non-patient respondents with no symptoms of depression. matching characteristics included age, income, level of education, and type of health insurance. respondents were presented with different hrqol scenarios in which they could choose to pay money to regain their initial health state through various treatment options (e.g., inpatient treatment, electroconvulsive therapy). to test whether the probability of stating a positive wtp differed significantly between the two samples, fisher’s exact test was used. differences regarding stated wtp between the samples were investigated using the mann-whitney u-test. results: for most of the health scenarios, the probability of stating a positive wtp did not differ between the two samples. however, patient respondents declared wtp values up to 7.4 times higher than those stated by matched non-patient respondents. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3855&domain=pdf&date_stamp=2021-12-23 https://orcid.org/0000-0002-5434-7355 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: although the perceived necessity to pay for mental-hrqol gains did not differ between respondents with mdd and respondents with no symptoms of depression, patient respondents stated higher values. keywords depressive disorders, quality-adjusted life years, willingness to pay, quality of life, electroconvulsive therapy highlights • the probability of stating a positive wtp did not differ between samples. • however, patient respondents stated wtp values as much as 7.4 times higher than non-patients. the global burden of disease is shifting from premature death to years lived with disabili­ ty (gbd 2017 dalys and hale collaborators, 2018; licher et al., 2019; vigo et al., 2019). for this reason, the promotion of mental health has become a priority for health policies and action plans around the world (e.g., world health organization, 2013). over the past several decades, the disease burden attributed to depressive disorders has increased tre­ mendously, ranking them among the three leading causes of years lost due to disability (yld; gbd 2016 dalys and hale collaborators, 2017), as well as disability-adjusted life years (dalys; murray et al., 2012). by 2030, unipolar depression is estimated to be the leading factor within the global burden of disease (world health organization, 2008). cost-effectiveness analyses due to limited resources in the health-care sector, cost-effectiveness analyses are used as guidelines in priority setting, resource allocation, and reimbursement decisions. the preferred metric of health benefits in cost-effectiveness analyses is commonly the meas­ urement of quality-adjusted life years (qalys), combining the impact of health benefits on both health-related quality of life and quantity of life years (sund & svensson, 2018). additionally, this measurement facilitates the comparison of different interventions with­ in a disease or in comparison with other diseases (pennington et al., 2015). from a health–economic perspective, the preference for and value of health-care interventions can be assessed by estimating a person’s willingness to pay (wtp) for health gains (sund & svensson, 2018). the elicitation of preferences usually follows a two-stage process: 1) if the respondent indicates whether he or she is willing to pay money (yes/no); and 2) if the respondent indicates ‘yes’, that he or she is willing to pay money, the amount of money the respondent is willing to pay is further assessed. value of quality-adjusted life year for depression 2 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ willingness to pay for a quality-adjusted life year various studies have tried to estimate the value of a qaly through the wtp method (e.g., ahlert et al., 2013; donaldson et al., 2011; igarashi et al., 2019; pennington et al., 2015). a systematic review including 24 studies on wtp per qaly found that wtp estimates range from €1,000 to €4,800,000, with mean wtp estimates of €118,839 and median estimates of €24,226 (ryen & svensson, 2015). currently, preferences for health treatments are commonly elicited from the general public due to the recommendations of the washington panel on cost-effectiveness in health and medicine (gold et al., 1996) and the united kingdom’s national institute for health and care excellence (national institute for health and care excellence, 2013). recently, however, arguments for elicit­ ing the preferences based on appraisals of persons suffering from the health condition in question have been discussed (for a systematic overview on these arguments, see helgesson et al., 2020). effects of contextual and individual characteristics on wtp per qaly wtp per qaly seems to be related to several contextual factors, such as duration (e.g., 0.1 qalys over 10 years vs. 0.25 qalys over 4 years), timing (i.e., qaly gain at the end of life vs. in the near future), and type of qaly gain valued (i.e., life extension vs. quality-of-life improvements), as well as the type and severity of the illness presented (igarashi et al., 2019; ryen & svensson, 2015). additionally, several individual characteris­ tics seem to influence the stated values for health gains. the most common predictor effect was found for income: a higher household income significantly increased the probability to state a positive wtp (ahlert et al., 2013), as well as increasing the amount of money respondents were willing to pay (igarashi et al., 2019; pennington et al., 2015). also, individuals with a higher level of education stated greater amounts than individuals with fewer years of schooling (ahlert et al., 2013; pennington et al., 2015). the effect of age on wtp was significant in two large samples, but results showed inconsistent findings: while one study found that younger respondents stated higher amounts (ahlert et al., 2013), pennington and colleagues (2015) found a contrary effect. a study of the german general population investigated the effects of the german health care system1 on wtp per qaly and found that respondents with private health insurance were willing to pay higher amounts for a qaly, even when controlling for income effects (ahlert et al., 2013). 1) unlike other european countries, germany has a universal health-care system with two types of health insurance: germans can choose between public (statutory) insurance and private health insurance, which is co-financed by employer and employee. ulbrich & kröger 3 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ to the best of our knowledge, no study has ever investigated the effects of the individual relevance of the presented health-gain scenario on the respondent’s wtp per qaly. additionally, several studies argued that the plurality of different perspectives should be acknowledged, and that values for health benefits (i.e., qalys) should be based on preferences from both patients and the general public (dolan, 2009; ogorevc et al., 2019; versteegh & brouwer, 2016). a meta-analysis assessed whether values for qalys differed between patients and the general public, comparing different valuation methods (time trade-off, visual analogue scale and standard gamble; peeters & stiggelbout, 2010). however, preferences from patients and the general public using the wtp method have yet to be investigated. study aims with an eye toward this need for more specific information on patient and non-patient preferences, the aim of our study was to assess whether wtp preferences for mental health gains differ between outpatients with a diagnosed major depressive disorder (the patient sample) and respondents from the general public with no symptoms of depression (the non-patient sample). to control for the effects of the above-mentioned individual characteristics on wtp, we matched respondents from the patient sample with respondents from the non-patient sample based on income, level of education, age, and type of health insurance (see section ‘participants and procedures’). the above-men­ tioned meta-analytical comparison of patient and non-patient health-state assessments found that patients give higher valuations than non-patients (peeters & stiggelbout, 2010). therefore, we aim to investigate the following hypotheses: 1. the probability of indicating a positive wtp (wtp > 0) is higher throughout all the scenarios in the patient sample compared to its likelihood among respondents with no self-reported symptoms of depression (the non-patient sample). 2. respondents from the patient sample are willing to pay significantly higher amounts for the health gains presented than respondents with no self-reported symptoms of depression (the non-patient sample). method ethics approval this study was performed in accordance with the principles of the declaration of helsin­ ki. the ethical review committee of the university of hildesheim, germany, approved the study (application number: 107). value of quality-adjusted life year for depression 4 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ participants and procedure patient sample individuals with a suspected depressive disorder were screened at a german university outpatient clinic between may 2019 and march 2020. possible participants were informed as to the objective of the study both verbally and in writing, and were required to provide their written consent. participants were eligible for inclusion if they were more than 18 years of age and met the dsm-5 criteria of a major depressive disorder, using the german version of the structured clinical interview for the diagnostic and statistical manual of mental disorders, fifth edition (dsm-5), clinical version (scid-5-cv; beesdo– baum et al., 2019). one master-level psychologist and three bachelor-level research-assis­ tants conducted the interviews. all four interviewers had been trained in the adminis­ tration and scoring of the scid-5-cv in a workshop conducted by the second author, who is a licensed interviewer. the ratings of the diagnoses in question were discussed with the attending psychotherapist. we excluded patients who showed indications of mental retardation or dementia, substance-dependence disorders, bipolar disorder, or schizophrenia. patients with other co-occurring mental disorders were not excluded. after the scid-5-cv interview, patients who met the inclusion criteria and consented to participating in the study were asked to answer the questions of the online survey (further described in section ‘online questionnaire’) on a laptop that we provided. after completing the survey, patients were thanked for their participation in the study. non-patient sample for each respondent in the patient sample, we compared one matched respondent from the german general population who reported no symptoms of depression. comput­ er-based matching was conducted using the following characteristics: age at index rate (± 8 years), income category (see table 2), highest level of education (basic, secondary, or advanced), and type of health insurance (statutory vs. private). respondents from the german general population were recruited from an internet panel run by an independent research institute (usuma gmbh; http://www.usuma.com/) between march 6, 2019 and march 25, 2019. the research institute we selected complied with the esomar interna­ tional code on market, opinion, and social research and data analytics. internet-panel participants were informed about the online survey via email. after completing the survey, participants received survey ‘reward’ points from the internet-panel company, which they could exchange for an online gift certificate or merchandise. online questionnaire on the first page of the online questionnaire, respondents were informed about the objective of the study and were asked to give their consent. the hypothetical scenario that was introduced assumed that no sickness funds exist in germany, and therefore, ulbrich & kröger 5 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 http://www.usuma.com/ https://www.psychopen.eu/ respondents would not have to pay premiums or contributions toward health insurance, increasing their monthly net income by that amount. respondents were asked to imagine that instead, they would need to pay for every medical service out of their own pocket. the concept of measuring health on a visual analog scale was introduced: based on the european quality of life 5-dimensions 3-level version (eq-5d-3l; szende et al., 2007), three health states and numerical valuations derived from survey values (dolan et al., 1999) were used to indicate different levels of health on the scale. demographical questions (e.g., age, income, health insurance, pre-existing diseases, region of residence) were presented. respondents were then asked to estimate their life expectancy, and to rate the current state of their health on the european quality of life visual analogue scale (eq-vas; szende et al., 2007), with values between 0 and 100. using items of the patient-health questionnaire (phq-2; kroenke et al., 2003) and eq-5d-3l (szende et al., 2007), respondents were asked to briefly assess their symptoms of depression and current health-related quality of life. the phq-2 is a two-item, self-administered depression module that scores the two main criteria from the dsm-5. answer categories range from 0 (“not at all”) to 3 (“nearly every day”), and the total severity score ranges from 0 to 6. regarding the total value of the phq-2 in the patient sample, the internal consistency was good (α = .82). a cut-off score of ≥ 3 (see kroenke et al., 2007) proved to be most suitable regarding sensitivity and specificity for the diagnosis of a major depressive disorder. next, a description of typical symptoms of depressive disorders and their impact on everyday life, including mortality rates by suicide, was presented (see online resource 1 in the supplementary materials). the respondents were given four different scenarios of health loss of either one qaly (scenarios a and b) or a fraction of a qaly (scenarios c and d), due to a depressive episode. these scenarios, which are further described in table 1, were presented in random order. the order of the questions and the wording of one sample scenario are displayed in online resource 2 (see supplementary materials). the respondents were asked if they were willing to pay money for each of the presented health-gain scenarios. if the respondents answered “yes,” that they would be willing to pay money for treatment, a table with three columns was presented, with a series of values in euros ranging from €10 to €300,000 in accordance with previous studies (ahlert et al., 2013; donaldson et al., 2011; pennington et al., 2015). to facilitate decision-making, the respondents were asked to sort the euro values into one of three columns, indicating which amounts they would be willing to pay, the amounts they would not be willing to pay, and the amounts that left them unsure about whether or not they would pay. in order to summarize the maximum amount that the respondent was willing to pay and the minimum that he or she was not willing to pay, the respondent was asked to state his or her maximum wtp as an open-ended response. if the respondent answered that he or she would not be willing to pay money for the presented health-gain scenario, several pre-coded responses (translated from the eurovaq study) and a free text option value of quality-adjusted life year for depression 6 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ were presented. lastly, respondents were asked to rate how much they currently knew about electroconvulsive therapy (ect), which was offered as a treatment method in one of the scenarios2. if they indicated that they knew at least “a little” about ect, they were asked to state whether they thought this method was adequate. respondents were given the chance to view and change their answers in the recapitulation section on the last page. the feasibility and validity of the questions were examined by pilot respondents who provided detailed feedback prior to the development of the survey. table 1 health gains valued scenario health gain duration time initial health state achieved? treatment a 25 points 4 years in 1 year 100% pain-free treatment b 10 points 10 years in 1 year 100% pain-free treatment c 25 points 4 years in 1 year 90% 8-week inpatient treatment d 25 points 4 years in 1 year 90% 8-week inpatient treatment plus electroconvulsive therapy exclusion criteria to ensure that the questions were relevant to the individual respondents, and in accord­ ance with the eurovaq report (donaldson et al., 2011), the following exclusion criteria were applied: general exclusion criteria respondents who indicated that “the government should pay” from the set of pre-coded responses as the reason for zero wtp (so-called “protest respondents”), were excluded due to their not having understood the hypothetical nature of the scenario (as is standard for wtp studies; see olsen & donaldson, 1998; pennington et al., 2015). scenario-specific exclusion criteria additionally, respondents were excluded from data analysis regarding scenarios a, c, and d if they rated their health state at less than 35 points (indicating poor health), and 2) this treatment method was used because its efficacy is recognized by the german association for psychiatry, psychotherapy, and psychosomatics (dgppn), and because it is a highly standardized procedure with rapid response rates (dgppn et al., 2015). ulbrich & kröger 7 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ if they expected to live for less than 6 years as of that day. respondents were excluded from data analysis regarding scenario b if they rated their health state at less than 20 points, and if their life expectancy was assumed to be below 12 years. the intention was to ensure that no health loss reduced the respondent’s health to below 10 points, and that all health gains were complete at least one year before the respondent expected to die. data analysis all analysis was undertaken with ibm spss statistics 26. the collection of open-ended responses allowed us to determine the mean and median values reported for each scenar­ io, which were collected in euros. the current study does not report trimmed means because ahlert and colleagues (2013) found that trimming the top 1% or 5% of wtp val­ ues may lead to the exclusion of potentially reasonable cases (e.g., younger respondents with a higher income). the kolmogorov–smirnoff test and q-q plots indicated that the assumption of normal distribution was violated: distribution of wtp scores for scenario a (d(20) = 0.385, p < .001), scenario b (d(20) = 0.416, p < .001), scenario c (d(20) = 0.363, p < .001), and scenario d (d(20) = 0.270, p < .001) all differed significantly from normal. to test hypothesis 1 — whether the likelihood of expressing a positive wtp differed across both samples — wtp responses were dichotomized as zero and non-zero values. because of the small sample size, fisher’s exact test and odds ratios were calculated. to assess hypothesis 2 — whether wtp values for the described health gains differed between the patient and the non-patient sample — the nonparametric mann–whitney u-test was applied, due to the skewed distribution of the wtp scores. effect size r was calculated by dividing the z-scores for the test statistic by the square root of the sample size (field, 2018; rosenthal, 1991). bias-corrected accelerated 95% confidence intervals around means were estimated. results sociodemographic characteristics of the samples figure 1 depicts the flowchart. a total of n = 36 participants were included in the study, with n = 18 participants in each sample. most of the total sample (75%) was female, with a mean age of 48 years (sd = 14.88). value of quality-adjusted life year for depression 8 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ figure 1 flowchart patient sample from an initial sample of 20 screened outpatients, n = 18 patients met the dsm-5 criteria of a major depressive disorder. no co-occurring mental disorders were diagnosed. the cut-off score of the phq-2 was exceeded by 16 patients (88.9%), while the mean score was 4.33 (sd = 1.57). the mean overall health state of the patient sample was indicated as poor (m = 61.67; sd = 18.31). matched non-patient sample the matching process based on income, level of education, type of health insurance, and age resulted in a sample of n = 18 matched respondents from the german general population. we ensured that respondents of the matched non-patient sample reported no symptoms of depression (phq-2 sum score = 0). the mean overall health state of the non-patient sample was indicated as rather good (m = 89.94, sd = 9.17). ulbrich & kröger 9 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ table 2 displays the sociodemographic characteristics of the two samples. no be­ tween-group differences were found in terms of the sociodemographic data. none of our subjects had to be excluded as protest respondents. table 2 sociodemographic characteristics of both samples characteristic patient sample n = 18 non-patient sample n = 18 m (sd) min/max m (sd) min/max age (in years) 48.33 (15.22) 22/77 47.89 (14.97) 22/70 life expectancy (age) 82.28 (9.49) 65/99 83.78 (8.45) 70/110 health status (0-100) 61.67 (18.31) 20/95 89.94 (9.17) 70/100 n % n % 20 to 69 (poor) 11 61.1 0 0.0 70 to 79 (rather poor) 2 11.1 2 11.1 80 to 89 (rather good) 4 22.2 2 11.1 90 to 100 (very good) 1 5.6 14 77.8 low remaining lifetime (< 16 years) 4 22.2 1 5.6 females (rather than males) 16 88.9 11 61.1 educational level basic (nine years) 0 0.0 0 0.0 secondary (ten years) 8 44.4 7 38.9 tertiary (> ten years) 10 55.6 11 61.1 monthly household income no answer 1 5.6 1 5.6 below 500 € 0 0.0 0 0.0 500 to below 1.000 € 1 5.6 1 5.6 1.000 € to below 1.500€ 1 5.6 1 5.6 1.500€ to below 2.000€ 4 22.2 4 22.2 2.000€ to below 3.000€ 4 22.2 4 22.2 3.000€ to below 4.000€ 6 33.3 6 33.3 4.000€ and more 1 5.6 1 5.6 health insurance social insurance 17 94.4 17 94.4 private insurance 1 5.6 1 5.6 icd-10 diagnosis depressive episode 8 44.4 recurrent mdd 10 55.6 note. m = mean; sd = standard deviation; min/max = minimum/maximum; n = sample size; mdd = major depressive disorder. value of quality-adjusted life year for depression 10 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ results regarding hypothesis 1: probability of indicating a positive wtp results from fisher’s exact test indicate no association between the sample (patient vs. non-patient sample) and the probability of stating a positive wtp (wtp > 0) in three of four scenarios (scenarios b, c, and d). only in scenario a was the probability of expressing a positive wtp higher in the patient sample compared to the non-patient sample (χ2 = 6.84, p < .05). odds ratios could not be calculated, as 100% of the patient sample indicated a positive wtp. in the patient sample, the number-one reason for being unwilling to pay for the presented health gains across all scenarios was: “the effects of treatment are too small.” in the non-patient sample, the number-one reason stated was: “it would not be so bad/i could live with it.” table 3 shows the frequency of reasons stated for zero wtp. table 3 frequencies of reasons for zero wtp scenario n zero wtp it would not be so bad/ i could live with it effects of treatment are too small i want my family to have the money i would get better without treatment i value the treatment but cannot afford it other reasons patient sample a 0 0 0 0 0 0 0 b 1 0 1 (6.3) 0 0 0 0 c 2 0 0 0 0 0 2 (11.8) d 8 0 2 (11.8) 0 0 0 6 (35.4) non-patient sample a 6 1 (5.6) 0 1 (5.6) 1 (5.6) 1 (5.6) 2 (11.2) b 7 4 (22.2) 0 1 (5.6) 0 1 (5.6) 1 (5.6) c 6 1 (5.6) 0 0 2 (11.2) 2 (11.2) 1 (5.6) d 8 2 (11.2) 0 0 2 (11.2) 2 (11.2) 2 (11.2) note. percentages are in parentheses. n = sample size; wtp = willingness to pay. results regarding hypothesis 2: wtp differences between patient and non-patient respondents mean, median, and maximum wtp values, as well as bias-corrected accelerated 95% confidence intervals around means, are displayed in table 4. in the patient sample, mean wtp values ranged from €15,778 (scenario d) to €54,794 (scenario a). in the matched non-patient sample, mean values ranged from €2,277 (scenario b) to €4,650 (scenario a). results from the mann–whitney u-test indicated that patient respondents stated significantly higher wtp values than non-patients in all scenarios: scenario a (u = 33.50, z = –3.05, p < .01, r = –.56), scenario b (u = 25.50, z = –2.97, p < .01, r = –.58), scenario ulbrich & kröger 11 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ c (u = 22.50, z = –3.31, p < .001, r = –.64) and scenario d (u = 10.50, z = –2.83, p < .01, r = .65). for all scenarios, differences between samples represented a medium effect in accordance with cohen (1988). table 4 mean, median and maximum values in euros (€) for both samples after applying general and scenario-specific exclusion criteria scenario na n wtp > 0 m bootstrapped 95% ci mdn maximum wtp patient sample a 17 17 54,794 14,646-116,424 15,000 350,000 b 16 15 52,667 6,956-121,249 10,000 350,000 c 17 15 23,867 10,714-45,548 10,000 150,000 d 17 9 15,778 7,667-25,762 13,000 50,000 non-patient sample a 18 12 4,650 2,322-7,686 2,500 15,000 b 18 11 2,277 1,000-4,126 1,500 10,000 c 18 12 3,433 2,245-4,737 2,750 10,000 d 18 10 2,415 1,183-3,567 1,750 5,000 note. na= sample size after applying scenario-specific exclusion criteria; n = sample size; ci = confidence interval. discussion a vital assessment of patient preferences as currently discussed (e.g., dolan, 2009; ogorevc et al., 2019; versteegh & brouwer, 2016), the present study is one of the first attempts to directly compare experience-based preferences from patients to ‘hypothetical’ preferences of the general population using the wtp method. results indicate that the probability of stating a positive wtp does not differ between patients and non-patient respondents. however, when assessing the number-one reasons indicated for zero wtp (patient sample: “effects of treatment are too small,” vs. non-pa­ tient sample: “it would not be too bad/i could live with it”), it seems that respondents with no prior experience of depression underestimate the burden of depressive symp­ toms. as discussed by dolan (2007), “hypothetical” preferences of the general public, as elicited through assessing wtp values, may not be a reliable basis for judgment because the “general public are not good at assessing what it would be like to experience different states of health” (dolan, 2007, p. 6). however, contrary to the assumption that “hypothet­ ical” preferences by the public tend to overestimate the severity of a loss of health value of quality-adjusted life year for depression 12 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ (dolan, 2007, p. 6), patients stated significantly higher wtp values than non-patients. these findings are in accordance with previous studies (ogorevc et al., 2019; versteegh & brouwer, 2016) and emphasize the need to consider both the perspectives of the general public and those of patients when assessing values or preferences for health benefits. in this study, we assessed respondents’ wtp for one specified treatment (electrocon­ vulsive therapy) in detail due to its high standardization when compared to other psy­ chotherapeutic interventions. thus, when assessing results for this specified scenario, it seems unexpected that only 53% of the patient sample and 55% of the non-patient sample were willing to pay money for ect. one possible explanation might be that 83% of the patient sample stated that they knew nothing or little about ect, compared to 72% of the non-patient sample. the present findings accord with the conclusion of a recent study, which found that ect is still largely underutilized due to persisting stigma and lack of knowledge about modern ect techniques (kellner et al., 2020). in particular, considering recent discussions of advocating for patients in the decision-making process regarding treatment options (e.g., barry, 2011; couët et al., 2015), the present findings underline the importance of an informed patient. so-called patient-decision aids — tools designed to help patients make an informed choice, which include explanations about treatment options based on scientific evidence — can be used to improve patients’ knowledge of which treatment route to choose, as well as the risks and benefits of various treatments (for an overview, see perestelo‐perez et al., 2017). the cost-effectiveness of primary care for depressive disorders has been investigated by, for example, chisholm et al. (2004) and pyne et al. (2003). low-cost, non-medical interventions for relief from depression, such as exercise, relaxation, and bibliotherapy, are also readily available (for a systematic review, readers are referred to morgan & jorm, 2008). their (cost-)effectiveness in reducing symptoms of depression is, however, yet to be assessed in randomized controlled trials in a clinical population (bellón et al., 2021; lawlor & hopker, 2001; philippot et al., 2019) strengths and limitations matching the respondents from the patient sample to respondents from the non-patient sample allowed us to control for the effects of individual characteristics (e.g., income, level of education) on wtp. presenting the scenarios in a randomized order let us control for ordering effects. however, some limitations should be also mentioned. first, the size of both samples (n = 18 in each sample) was quite small, and the post-hoc power analysis indicated medium power (1– β = 0.89), assuming a medium effect size (|d| = 0.5, according to the convention of cohen (1988)). second, the broad majority (88.9%) of the recruited patient sample was female. results from the eurovaq study indicate that men stated a higher wtp (donaldson et al., 2011, p. 76). still, ahlert and colleagues (2013) investigated the effect of gender in more detail, and found that although women were significantly more likely than men to state a ulbrich & kröger 13 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ positive wtp, males were willing to pay significantly higher amounts than females. therefore, generalization of results may be limited, and a more representative patient sample should be recruited in subsequent studies. additionally, presenting scenarios that emphasize the certainty of successful treat­ ment — which may be especially unlikely with respect to mental health — may have led to the overestimation of estimated wtp values. more scenarios with uncertainty charac­ teristics should be evaluated in further research, as well as other specified treatment options, such as psychotherapeutic treatment approaches or antidepressant medication (dgppn et al., 2015). fourth, the assessment of the variable “knowledge about ect” consisted of one item only, and did not objectively specify how much respondents know or how and where they became informed (e.g., movies, media, medical services). during administration of the present survey, a measure to assess perceptions and knowledge of ect was published (tsai et al., 2020), and we believe that it should be used in future studies to guarantee an objective, more detailed measurement of the respondents’ attitudes toward and knowledge of ect. additionally, we only recruited people who were being seen at an outpatient clinic. it is possible that patients of an inpatient clinic with more severe depressive symptoms would place higher values on mental-health-related quality of life, and might also be bet­ ter informed about their treatment options — ect in particular. generalization of results may therefore be limited to patients from an outpatient setting with no co-occurring mental disorders. finally, the health-care system (including psychiatric and psychological care) in ger­ many is unique compared to that of other european systems (see melcop et al., 2019, for an overview). in germany, health insurance is mandatory, and germans can choose between public or private health insurance. access to mental health care is free of additional charges in germany, which is uncommon among the other european union member states (strauß, 2009). additionally, the mental-health-care spending proportion­ ate to the gross domestic product is higher in germany (4.8%) than the european average (4.1%), and is only exceeded by that of denmark (5.4%; oecd, 2018). therefore, external validity may be limited to countries with similar health services for mental disorders. conclusion this study investigated the effect of the personal relevance of a presented health-gain scenario on the respondent’s wtp per qaly, and produced findings that add valuable information toward estimating the effects that individual characteristics have on the value that respondents place on a qaly. additionally, our findings emphasize the need to assess hypothetical population preferences alongside actual patients’ preferences for health benefits. value of quality-adjusted life year for depression 14 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: we would like to thank lars paternoster and robert szczepanski for their help in implementing the questionnaire versions online. in addition, we would like to thank sina haider, marieke hansmann, laura lefarth and kira schamke, who conducted the screening interviews together with one of the authors. competing interests: the authors have declared that no competing interests exist. supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): supplementary material 1: translation of the health state description supplementary material 2: sample scenario index of supplementary materials ulbrich, l., & kröger, c. 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(2013). mental health action plan 2013-2020. https://apps.who.int/iris/bitstream/handle/10665/89966/9789241506021_eng.pdf clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. ulbrich & kröger 19 clinical psychology in europe 2021, vol. 3(4), article e3855 https://doi.org/10.32872/cpe.3855 https://doi.org/10.1097/yct.0000000000000609 https://doi.org/10.1016/j.socscimed.2016.07.043 https://doi.org/10.1016/s2468-2667(18)30203-2 https://www.who.int/healthinfo/global_burden_disease/gbd_report_2004update_full.pdf?ua=1 https://apps.who.int/iris/bitstream/handle/10665/89966/9789241506021_eng.pdf https://www.psychopen.eu/ value of quality-adjusted life year for depression (introduction) cost-effectiveness analyses willingness to pay for a quality-adjusted life year effects of contextual and individual characteristics on wtp per qaly study aims method ethics approval participants and procedure online questionnaire exclusion criteria data analysis results sociodemographic characteristics of the samples results regarding hypothesis 1: probability of indicating a positive wtp results regarding hypothesis 2: wtp differences between patient and non-patient respondents discussion a vital assessment of patient preferences strengths and limitations conclusion (additional information) funding acknowledgments competing interests supplementary materials references this is not a christmas editorial! editorial this is not a christmas editorial! cornelia weise a, winfried rief a [a] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2020, vol. 2(4), article e5433, https://doi.org/10.32872/cpe.v2i4.5433 published (vor): 2020-12-23 corresponding author: cornelia weise, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, gutenbergstrasse 18, 35032 marburg, germany. e-mail: weise@unimarburg.de when the two editors-in-chief of this journal met to discuss whether we should strive for a christmas editorial this year, it was a moment of desperation. we began brainstorming potential topics over zoom. it had been the fourth video conference on a friday after‐ noon for both of us, and we were starting to experience headaches, fatigue, vision and concentration problems, as well as annoying noises in the ear. and we also felt that we are tired of speaking and writing about all the events that characterized this very special year. last but not least we considered: is a christmas editorial still contemporary and fresh, especially if we want to express our openness to the diversity of people, cultures, and religions? we started by investigating the background of christmas, and we did it empirically (what else would you expect?). a word search in the bible with typical, christmas-asso‐ ciated items seemed a good way to start to evaluate religious chauvinism. however, neither “rudolph, the red nosed reindeer” nor “christmas tree” led to any hits. wikipedia informed us that the christmas tree goes back to the days of nordic tribes, and many rituals of the end-of-the-year season have their roots in profane rites of celebrating the longest night. after a period of searching, even the origin of santa claus became more and more blurred. the white-bearded male with a bmi of >35 does not resemble any head of most popular religions in europe. eventually we decided that writing a christmas editorial is not cultural chauvinism, but rather that it is more of a chance to reflect before the year ends on what has happened in 2020. but to be on the safe side: this is not a christmas editorial. so what should we write about? many themes came to mind that we were tired to talk or write about. a virus posed a threat to all of us, but are our readers really keen to hear even more about the c-word at the very end of the year? although some aspects this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i4.5433&domain=pdf&date_stamp=2020-12-23 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ are still worth mentioning, even in a not-a-christmas-editorial. this year we learned so much about zooming, break-out rooms, and personal background preferences. what, for example, is the clinical implication of people preferring a spiderman-virtual-background vs. a fake office background, or how relevant are the number of kids and cats appearing in the speaker's background? is it really true that nations differed in terms of the choice of goods hoarded during lockdowns? are these preferences really related to the people's mental health status in the respective countries, e.g. weed in the netherlands, feta cheese in greece, toilet paper in germany, or wine and condoms in france? with a clear preference to migrate to france, we ended this discussion. now is the time to stand together and solve problems. stop, no. we have to respect physical distancing. but why is there a country in europe who really exaggerates social distancing? shall we dedicate a special paper to this topic in our “politics and education” section? how do we maintain the illusion of independent countries in the 21st century? but no, as with the c-word, we do not want to talk about the b-word either; we express our sympathies to all european and non-european countries, even if they are on islands drifting around in the north sea. you are always very welcome to join us under the umbrella of our journal. finally, in our discussion we turned to the us elections. although we are not a politi‐ cal journal, this topic offers many possible starting points for an editorial. for example, it would have provided perfect examples for psychological treatment (e.g. behaviour analy‐ sis, reality neglect, cognitive reframing and working with infantile schema modes). since classification of mental disorders started more than 100 years ago, the starting point of classifying mental disorders was always the neglect of reality: medium in neuroses, even more serious in psychosis. however, while ruminating about these topics, we became more and more worried that we would end up writing a comprehensive overview of personality disorders, which is too big a topic, and beyond our expertise. therefore, we decided to write just a brief editorial with two major points. first, we want to express our thanks to all people involved in cpe's second volume. we wish to acknowledge our authors, reviewers, section editors, guest editors, and the whole publishing team. when we started with this journal more than two years ago, we were worried how the new publication would be accepted by the scientific community? it is risky to start a new scientific journal, in an era when scientists receive daily announce‐ ments and requests to submit to obscure and unknown journals. but we did it. and it has been a really successful year for cpe. not only have we published the first two volumes, but there are also a number of exciting manuscripts in the pipeline, and further manuscripts are waiting for consideration. we are grateful for all the support we have received – particularly in this tough and challenging year – and we are extremely pleased to see cpe becoming a more and more impactful journal. second, we want to wish you a happy holiday season and a peaceful and prosperous new year. we hope it will soon be possible to meet up with family and friends, to editorial 2 clinical psychology in europe 2020, vol.2(4), article e5433 https://doi.org/10.32872/cpe.v2i4.5433 https://www.psychopen.eu/ pursue hobbies, and to do all the things that belong to our previous regular life. we all know about the challenges of the current times, and should therefore use our knowledge and expertise in clinical psychology to get through this challenging time together and support those needing help. we are looking forward to receiving your submissions in 2021 despite all the chal‐ lenges that we are all facing. thank you for your support of the journal. cornelia weise & winfried rief pandemic-compliant greetings to all of you funding: the authors have no funding to report. competing interests: cornelia weise and winfried rief are editors-in-chief of clinical psychology in europe. acknowledgments: the authors wish to thank keith petrie for language editing. weise & rief 3 clinical psychology in europe 2020, vol.2(4), article e5433 https://doi.org/10.32872/cpe.v2i4.5433 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. editorial 4 clinical psychology in europe 2020, vol.2(4), article e5433 https://doi.org/10.32872/cpe.v2i4.5433 https://www.psychopen.eu/ engaging turkish immigrants in psychotherapy: development and proof-of-concept study of a culture-tailored, web-based intervention research articles engaging turkish immigrants in psychotherapy: development and proof-of-concept study of a culturetailored, web-based intervention hanna reich 1,2 , daniela zürn 1, ricarda mewes 1,3 [1] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. [2] depression research centre of the german depression foundation, department for psychiatry, psychosomatics and psychotherapy, goethe university, frankfurt, germany. [3] outpatient unit for research, teaching and practice, faculty of psychology, university of vienna, vienna, austria. clinical psychology in europe, 2021, vol. 3(4), article e5583, https://doi.org/10.32872/cpe.5583 received: 2021-01-26 • accepted: 2021-08-25 • published (vor): 2021-12-23 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: hanna reich, forschungszentrum depression der stiftung deutsche depressionshilfe c/o universitätsklinikum frankfurt am main, klinik für psychiatrie, psychosomatik und psychotherapie, heinrichhoffmann-str. 10, 60528 frankfurt am main, germany. tel.: +49-69-6301-86341. e-mail: hanna.reich_de_paredes@deutsche-depressionshilfe.de supplementary materials: data, materials [see index of supplementary materials] abstract background: culturally tailored interventions can increase the engagement and the success rate of psychotherapy in immigrant and ethnic minority patients. in this regard, the integration of the patients’ illness beliefs is a key element. applying principles of motivational and ethnographic interviewing, we developed a culture-tailored, web-based intervention to facilitate engagement of turkish immigrant inpatients in psychotherapy. method: the different aspects of the engagement intervention development are described and its acceptance and usefulness were tested in a proof-of-concept trial with an experimental control group design (active control condition: progressive muscle relaxation) in a sample of turkish immigrant inpatients in germany (n = 26). illness perception, illness-related locus of control, and self-efficacy were assessed pre and post intervention. results: the engagement intervention was rated better than the control condition (p = .002) and in particular, participants felt better prepared for therapy after working with it (p = .013). by working with the engagement intervention, self-efficacy increased (p = .034) and external-fatalistic control beliefs diminished (p = .021). however, half of the participants needed assistance in using the computer and web-based interventions. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5583&domain=pdf&date_stamp=2021-12-23 https://orcid.org/0000-0002-9577-1144 https://orcid.org/0000-0002-4724-9597 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: the developed intervention provides a first step towards feasible culture-tailored psychotherapeutic elements that can be integrated into routine clinical care. the first results regarding acceptance and usefulness are promising. keywords engagement, motivational interviewing, psycho-education, web intervention, cultural tailoring highlights • culturally tailored psychotherapeutic interventions are more effective than generic ones. • we explored the use of native language, web-based interventions for ethnic minority patients. • an engagement intervention facilitated feeling ready for psychotherapy in turkish immigrants. • web-based interventions can address complex themes such as motivational factors and illness beliefs. prevalence rates of psychological distress and disorders are higher in many ethnic minor­ ity populations than in the general population (aichberger et al., 2010; de wit et al., 2008; sariaslan et al., 2014). psychotherapy is a well-established and effective treatment for many mental disorders, but its interventions are based in european tradition and may be difficult to embrace for ethnic minorities (priebe et al., 2011). reasons for less favorable outcomes might be that socioeconomic stressors that have been reported to negatively impact mental health treatment (e.g. lower education, unemployment) are common among immigrant populations in europe (mösko et al., 2008; priebe et al., 2011). meta-analytical evidence on premature discontinuation of psychotherapy showed that low education, but not ‘race’ (i.e., the proportion of white patients) was a predictor of dropout (swift & greenberg, 2012). moreover, conventional psychotherapy may not be sufficiently specific and can be incongruent with the cultural values and worldviews of ethnic minorities (mösko et al., 2008; priebe et al., 2011). unfavorable treatment expecta­ tions, different expectations about the roles of doctors/ psychotherapists and patients, and a different understanding of illness and treatment have been shown to reduce patient motivation to seek for or engage in psychotherapy (drieschner et al., 2004; priebe et al., 2011; reich et al., 2015). last but not least, even if language, per se, is not crucial for the successful delivery of culturally appropriate psychotherapy (benish et al., 2011), the patient must at least have some understanding of what is being said within an intervention. limited access to interpreting services has been shown to curtail immigrant health care throughout europe (priebe et al., 2011). fortunately, some of these factors can be addressed: preparatory interventions in advance of inpatient treatment have been shown to improve knowledge and reduce engaging turkish immigrants in psychotherapy 2 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ tension among patients (best et al., 2009). meta-analytic evidence showed that culturally adapted psychotherapy is more effective than unadapted therapy (hall et al., 2016) and that the extent of cultural adaptation of minimally guided mental health interventions had an effect on intervention efficacy (harper shehadeh et al., 2016). the adaptation of the ‘illness myth’ (i.e., the subjective concepts of illness) in particular was the key moderator for a superior outcome (benish et al., 2011). patients’ ‘illness myths’ include, among others, treatment expectations and self-efficacy beliefs that influence the moti­ vation for psychotherapy and treatment outcome (drieschner et al., 2004; hagger & orbell, 2003). both, subjective illness concepts and self-efficacy, can be influenced by psychological interventions such as motivational interviewing (miller & rollnick, 1991; petrie & weinman, 2012). an integration of techniques from motivational interviewing (mi) and ethnographic interviewing (ei) has been proposed to engage patients from ethnic minorities in psychotherapy (swartz et al., 2007). mi is a ‘directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence’ (miller & rollnick, 1991). it is effective in a broad range of behavioral prob­ lems and diseases (rubak et al., 2005), and is particularly helpful in clients from ethnic minority groups (lundahl et al., 2010). complementing mi, ei focuses on the patient’s cultural background, including perceptions of the world and its nature, values, and faith (westby, 1990). in this regard, it encourages patients to share their own ‘narrative’, the adaptation of which benish and colleagues (2011) found to be the key to a superior outcome in culturally adapted psychotherapy. however, there is a lack of culturally adapted, standardized interventions for immi­ grant patients (mösko et al., 2008; priebe et al., 2011). osilla and colleagues (2012) dem­ onstrated how to develop and deliver a culturally relevant mi intervention successfully on the web. the use of technological platforms is considered as a strategy with great potential to address major barriers to mental healthcare (rebello et al., 2014). given the background outlined above, we aimed to design a web-based intervention providing in­ patients with information and ideas on how they could benefit from the therapies offered in inpatient treatment. the primary goal was to encourage patients to accept psychother­ apy as a culturally appropriate healing practice and thereby increase motivation for psy­ chotherapy. the present study focused on turkish immigrant inpatients who are among the largest immigrant populations in european countries (european commission, 2011). turkish immigrants reported about language problems and difficulties obtaining medical information when hospitalized (giese et al., 2013) and inpatient treatment for common mental disorders was less successful in turkish immigrants than in non-migrants (mösko et al., 2008). the aims of our study were twofold: a) to develop a culture-tailored, web-based intervention to facilitate treatment engagement that can be integrated into routine clinical care without major expense, and b) to conduct a proof-of-concept study, testing the acceptance and feasibility of the intervention and its effect on motivation, control beliefs, and illness representations in a randomized controlled pilot trial. reich, zürn, & mewes 3 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ materials and method a) development of the engagement intervention the engagement intervention was based on mi and ei techniques and developed as a web-based tool in german and turkish language versions for the use as one session (approx. 50 minutes) within the first two weeks of inpatient treatment for common mental disorders. we chose a bi-lingual, web-based approach to bridge the gap between patients of turkish origin with poor knowledge of german and the german healthcare system with very scant resources of turkish-speaking therapists. the engagement and the active control intervention were drafted in german and then fully developed in both languages simultaneously through expert discussion, pilot testing and feedback with the help of five turkish native speakers (psychotherapists, medical doctors, professional interpreters, and university students of psychology). summary of the contents the intervention was named sağlığa doğru (turkish for ‘path to health’) and was organized into five sections following the structure of the engagement session developed by swartz and colleagues (2007). at the beginning, a short introduction to the structure and elements of the intervention was given. the first section of sağlığa doğru addressed individual symptoms, illness beliefs, and social consequences of the illness. the aim for the patients was to feel accepted, understood, taken seriously regarding their individual history, and to achieve a positive general orientation about the inpatient treatment. the second section dealt with the patients’ previous treatment experiences, allowing them to specify wishes for the current treatment. the professional help offered in the hospital was introduced as support in addition to the patients’ own resources, such as the family. the patients’ own resources were thereby validated while the integration of professional mental health care into the patients’ support system was facilitated. educational material about the concept, process, and efficacy of psychotherapy was provided in the next section. positive outcome expectancies regarding treatment success were encouraged by providing automated feedback using previous information entered by the patients. section four gave the patients scope to express concerns about their treatment. in addition to practical obstacles (e.g. worries about being away from family during inpatient treatment), psychological and cultural barriers that may hamper partici­ pation in the therapy were addressed (e.g. being ashamed of symptoms, being seen as ‘crazy’). feedback was given that such concerns are quite common, and the patients were encouraged to talk about their concerns with their therapist. the aim of the final section was to strengthen the patients’ commitment to engage in treatment. after a brief summary of the previous contents, the patients were asked to write down their individual goals for the inpatient treatment as concretely as possible, and what they engaging turkish immigrants in psychotherapy 4 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ could do to achieve them. a structured overview of sağlığa doğru is given in table 1; the script of the engagement intervention is available as supplementary materials. table 1 overview of the engagement intervention sağlığa doğru topic of the section aims central message culture-tailored web-mi elements 1. my story reflect upon symptoms and their social consequences; learn that therapist is validating and interested in individual story your personal view of your illness counts, each disease history is different. • turkish sample patient and therapist talk about symptoms and social consequences in a video. therapist behaves in a validating and encouraging manner. • patient is asked about his/her most impairing symptom and to check areas of life in which he/she is impaired. written feedback corresponding to the chosen areas is provided. • patient is asked to write down his/her ‘good reason’ for therapy (‘what do you want to do again after treatment?’). examples and hints are given. 2. treatment – what do i already know? reflect upon previous treatment experiences and draw conclusions for your current treatment you can shape your therapy – say what you like and what you don’t like! • previous treatment experiences are queried in adapted stages. • questions about personal do’s and don’ts for the current treatment based on prior experiences (personal, hearsay, positive or negative nature of experience, personal opinion about psychotherapy). • invitation to express a wish for the treatment. examples are given; patients are encouraged to tell their practitioners about their wish. 3. psychotherapy can help learn about the efficiency and effectiveness of psychotherapy; see how a psychological model can integrate mixed causal illness attributions psychotherapy is an efficient and effective treatment for your disease. • written and graphic material about process and effectiveness of psychotherapy. • video sequence in which the sample patient and the therapist develop a rationale for psychotherapeutic treatment and integrate mixed causal illness attributions (genetic predisposition, family stress, punishment from god, problems dealing with emotions) into a working model for psychotherapeutic interventions. • rating of the personal relevance of causal illness attributions addressed in the video sequence. reich, zürn, & mewes 5 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ topic of the section aims central message culture-tailored web-mi elements 4. possible obstacles clarify and handle (expected) treatment difficulties it is normal to have concerns about treatment – talk about them! • rating of the importance of different practical problems associated with inpatient treatment (e.g. unfamiliar food, difficulties to comply with religious requirements in the inpatient setting). • video in which the sample therapist asks about the sample patient’s concerns regarding treatment. • rating of the importance of psychological and cultural problems associated with psychotherapy. • feedback acknowledging the concerns and stimulating courage to talk about them openly with the therapist. 5. next steps commit to engage in treatment and work for individual goals you can influence the achievement of your goals and improve your health and life. • open-ended questions about individual goals and actions planned. • examples from the sample patient. motivational interviewing (mi) and ethnographic interviewing (ei) elements sağlığa doğru was informed by principles of mi and ei. using open-ended questions and empathic feedback, the patients were asked about their motivation for treatment, their motivation for change, and about their own health history (cf. table 1, sections 1, ‘my story’, and 5, ‘next steps’). natural resistance to change was integrated into the intervention by actively addressing possible barriers and concerns of the patient without judgment (see section 4, ‘possible obstacles’). instead, the patients’ concerns were validated by written feedback and they were encouraged to actively talk about these concerns with their therapist. this should facilitate redirection of resistance into an active client behavior in actual therapy sessions. a further goal informed by principles of mi was patient empowerment that constituted a particular aim of sections 2 and 3 of the intervention. knowledge about the treatment offered and an evaluation of previous treatment experiences were stimulated, as those formed the basis for informed decision making. principles of ei helped us to focus on the cultural background of turkish immigrants living in germany, especially their values and faith. we addressed typical values with video sequences of a male turkish sample patient who talked openly about some issues prevalent in turkish immigrants (e.g. high relevance of religious beliefs and ‘punishment from god’ as a causal illness attribution). after watching the video, the participants were asked to rate how relevant the respective attributions or concerns were to them (see sections 3 and 4, table 1). encouragement to tell one’s own individual story and to actively talk about one’s own illness beliefs was given at various points throughout the intervention. engaging turkish immigrants in psychotherapy 6 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ culturally adapted elements in order to plan and evaluate the cultural adaptations, we used the parameters suggested by hinton and jalal (2014) to create culturally sensitive cbt interventions, i.e., identify­ ing the cultural group, culturally appropriate framing of cbt techniques, identifying and addressing key stressors, and incorporating key local sources of recovery and resilience. sağlığa doğru was culturally adapted in terms of its surface structure, e.g., the use of the native language and an ethnically matched therapist, as well as its deep structure, involving the incorporation of cultural ideas, beliefs, and values (heim & kohrt, 2019). surface structure adaptations included the turkish name sağlığa doğru that was used in all presentations and materials (also the german ones). moreover, we provided a complete turkish language version, for which idiomatic expressions and german stand­ ard terms were carefully translated. in addition, names and identities of sample patient and therapist were informed by turkish immigrants living in germany. for instance, a high relevance of the family and religion were taken into account. comprehensibility for persons with low literacy was also an important goal, as many turkish immigrants in germany had a poor educational background. therefore, as much information as possible was delivered using video, audio, or graphics, and sentences were kept short and grammatically simple. deep structure adaptations were made regarding the ingredients of psychotherapy that make it a culturally accepted ‘healing practice’: a trusting relationship between patient and therapist was modeled in video sequences by a female therapist and a male sample patient both originating from turkey, aimed to help the patient to identify with the intervention and its contents. the therapist embedded in the program gave meaningful feedback and comprehensive information in order to foster the image of a capable ‘healer’. a common rationale for illness was developed by way of example in a video session, in which we integrated a broad variety of causal illness attributions that have been shown to be culturally relevant (minas et al., 2007; reich et al., 2015). to strengthen confidence in the effectiveness of psychotherapy, general information was provided in conjunction with a case vignette as an example of a patient with a turkish migration background who got better following psychotherapy. active control condition the active control intervention consisted of an applied progressive muscle relaxation (pmr) with a duration of approx. half an hour (see table 3). the structure of the pmr was harmonized with sağlığa doğru and offered through a web-based platform with the same content management system. the design was interactive and patients were addressed directly. in videos, the same sample patient as in sağlığa doğru gave illustrative information and examples and reported on his experience with the relaxation process. after introducing the content and structure of the intervention, the purpose and principles of the muscle and breathing relaxation were explained in the first section. in reich, zürn, & mewes 7 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ addition, the participant could select answers to related questions regarding the relaxa­ tion technique. in section two, ‘my muscle and breathing relaxation’, the participant was given the opportunity to participate in a 15-minute pmr audio relaxation session with specific instructions. then, the participants were asked about their positive and negative experiences with the relaxation, with the sample patient providing example answers. the program concluded with further information and suggestions on how to transfer the relaxation exercise to everyday life. b) proof-of-concept study participants and setting the institutional review board of the department of psychology, marburg university, germany, gave ethics approval to the study protocol. all participants provided written informed consent. the study was based on an experimental control group design (see figure 1) to test the feasibility and usefulness of the culture-tailored, web-based engagement intervention described above. participants were recruited between august 2013 and march 2014 in two psychiatric hospitals in the federal state of hessen, germany. we included adult inpatients with a turkish migration background and an icd-10 f3 or f4 principal diag­ nosis (depressive, somatoform, anxiety, or adjustment disorder) in their first or second week of treatment. migration background was categorized as present when one or both parents were not born in germany (schenk et al., 2006). patients with bipolar disorders, acute psychosis, substance abuse disorders, neurodegenerative diseases, and a primary diagnosis of eating disorders were excluded. during the study period, nearly all eligible patients were contacted (about 95%; see figure 1). about 60% of the contacted patients participated in the study. self-reported reasons for non-participation included shame, the current mental state, the duration of the study, lack of reading ability or lack of schooling, little experience in using comput­ ers, and the planned storage of study data. during the first half of the study period, participants were randomly assigned to the experimental conditions (engagement inter­ vention or active control intervention). in the second half, groups were gender-matched to prevent a bias in the results due to an unequal gender distribution and increase internal validity of the study. three patients dropped out shortly after the initiation of the trial. reasons for discontinuation were exhaustion, as well as language difficulties and problems with the contents of the questions. the final total study sample comprised n = 26 inpatients. we hypothesized that patients working with sağlığa doğru were going to feel better prepared for therapy and be more strongly motivated to engage in therapy than those working with the pmr, and that personal and treatment control beliefs as well as self-ef­ ficacy would be stronger after using the engagement intervention than before, while engaging turkish immigrants in psychotherapy 8 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ external-fatalistic control beliefs and threatening illness perceptions would diminish after using sağlığa doğru. figure 1 study design and flow chart process of the study trial participants could choose their preferred language, as all instruments and both interven­ tions were provided in german and turkish. they completed all questionnaires and the intervention on a computer in the presence of a bilingual research assistant (d.z.). the research assistant was ready to provide help at any time, while paying attention to ensure standardized test conditions. written instructions were given for the individual parts of the study. the participants could take a break or discontinue assessments at any time without any consequences. to make participation less taxing, all questionnaires (see below) were completed in a morning session. in the afternoon, participants worked with the intervention, provided feasibility feedback, and completed the questionnaires for the post-assessment. measures clinical diagnoses were reported by the treating physician or psychologist after receiv­ ing written consent. socio-demographics, migration-related characteristics, and dimen­ reich, zürn, & mewes 9 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ sional psychopathology (see supplementary materials) were assessed at the beginning. questionnaires about illness concept and self-efficacy (brief ipq, ipq-r personal and treatment control scales, kkg external-fatalistic control scale, and swe) were applied before and after the interventions. questions regarding acceptance and feasibility were completed at the end of the interventions. all self-rating questionnaires were provided on a computer in german or turkish according to the participants’ choice. the brief illness perception questionnaire (brief ipq) — the brief ipq (nine items) assesses the cognitive and emotional representations of illness (broadbent et al., 2006). response options range from 0 to 10 with labeled endpoints. item 9 (illness causes) has an open response format and was not used in this study. sum scores range from 0 to 80, with higher scores indicating a more pessimistic and threatening illness representation. broadbent and colleagues (2006) demonstrated its validity and reliability. turkish and german versions of the brief ipq were available (weinman et al., 2012). the revised illness perception questionnaire (ipq-r) — the ipq-r scales ‘personal control’ (six items) and ‘treatment control’ (five items) (moss-morris et al., 2002) were used to assess the individual’s assumed self-efficacy and efficacy of treatments, respec­ tively, for controlling the disorder. response options range from 1 (‘strongly disagree’) to 5 (‘fully agree’). high values indicate high controllability of the disorder by the respective domain. reliability and validity of the ipq-r have been confirmed repeatedly (e.g. moss-morris et al., 2002). german and turkish versions of the ipq-r were available online (weinman et al., 2012). locus of control inventory for illness and health (kkg) — the kkg scale ‘exter­ nal-fatalistic control’ (lohaus & schmitt, 1989) captured the extent to which a patient is convinced that his/her complaints depend on chance, fate, or luck. its seven items are answered from 1 (‘not at all’) to 6 (‘fully agree’); sum scores range from 7 to 42. higher values indicate a higher conviction of external-fatalistic control of the illness. acceptable reliability and validity has been shown (lohaus & schmitt, 1989). as no turkish version was available, it was translated following the forward-backward-translation method (brislin, 1970). generalized self-efficacy scale (swe) — based on ten items, the swe (schwarzer & jerusalem, 1995) measures an optimistic anticipation of one’s competence to cope with a situation successfully. it shows convincing evidence of validity and good psychometric properties (luszczynska et al., 2005). response options range from 1 (‘not at all true’) to 4 (‘exactly true’) and sum scores range from 10 to 40. the reliability of the german (jerusalem & schwarzer, 1999) and turkish version (yeşilay et al., n.d.) was satisfactory (luszczynska et al., 2005). engaging turkish immigrants in psychotherapy 10 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ acceptance and feasibility — at the end of the interventions, patients provided their global evaluation of the interventions by rating them on a scale from 0 to 10, with higher values indicating a better rating. subsequently, they answered to four items (‘are you motivated to engage in therapy?’, ‘after using the tool, do you feel better prepared for therapy?’, ‘would you recommend this tool to other patients?’, and ‘was the tool easy to handle?’) on a rating scale ranging from 0 ‘no, not at all’ to 10 ‘yes, absolutely’. the research assistant noted whether participants used the computer and the interventions without assistance and how much time participants spent using the interventions. statistical analyses the distribution of continuous variables was assessed for normality using q-q plots. one univariate outlier was detected: one participant reported 17 years of education because of his university degree. since all other participants had reported 2-12 years of schooling, his value was replaced with the maximum schooling duration (i.e. 12 years). univariate normality was assessed with shapiro-wilk tests and confirmed for all variables except for ‘german language proficiency’, most feasibility variables (see table 3), and self-effica­ cy (swe pre and post). homoscedasticity was inspected visually via box-plots and tested statistically with bartlett’s test for normally distributed variables or fligner-killeen test for non-parametric variables. for all variables, homoscedasticity was confirmed (all p > .05), with the exception of treatment control pre (p = .049). first, the experimental groups were compared regarding socio-demographic, clinical, and feasibility variables. discrete variables were coded dichotomously and their distribu­ tion was checked with 2x2 cross tables. group differences were assessed using a χ2 test or fischer’s exact test in the case of cells with a count less than 5. for sample compari­ sons in continuous variables (see table 2 and table 3), t-tests for normally distributed variables and mann-whitney-wilcoxon u tests for nonparametric variables were applied. then, the effectivity of the engagement intervention in comparison to the active control intervention with regard to treatment-related variables was analyzed using analyses of variance (anovas) for repeated measures with time (pre vs. post) as within-subjects-fac­ tor and experimental group (engagement intervention vs. active control intervention) as between-subjects-factor for each variable. since self-efficacy (swe) was not normally distributed, an equivalent nonparametric analysis was conducted additionally using the package nparld in r (noguchi et al., 2012). for the group that had worked with the engagement intervention, contrast analyses (one-sided t-tests for dependent samples: pre vs. post / wilcoxon signed rank test with continuity correction) were carried out to differentiate whether the observed effects originated from an improvement through the use of the engagement intervention, and were not merely due to variations in the active control condition. reich, zürn, & mewes 11 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ table 2 study sample characteristics variable active control intervention (n = 12) engagement intervention (n = 14) test statistic socio-demographic characteristics age in years 36-59, 48.6 (7.3) 38-58, 47.8 (5.5) t(20) = -0.31, p = .76 female sex 6 (50) 7 (50) χ2(1) = 0, p = 1 education in years 2-11, 6.8 (2.7) 4-12, 7.4 (2.7) t(23) = 0.71, p = .48 being employeda 6 (50) 10 (71.4) or = 2.4 [0.4;17.2], p = .42 migration-related characteristics years since immigrationb 9-40, 30.8 (9.6) 17-43, 28.1 (7.4) t(16) = -0.75, p = .46 german language proficiencyc 1-4, 3.1 (0.9) 2-5, 3.4 (0.8) u = 98.5, p = .43 clinical characteristics (categorical) depressive disorder 9 (75.0) 11 (78.6) or = 1.2 [0.1;11.4], p = 1 somatoform disorder 2 (16.7) 2 (14.3) or = 0.8 [0.1;13.4], p = 1 stress or adjustment disorder 1 (8.3) 1 (7.1) or = 0.9 [0.1;72.3], p = 1 comorbid disorders 10 (83.3) 8 (57.1) or = 0.3 [0.02;2.2], p = .22 note. for continuous variables, minimum to maximum, mean and standard deviation are given. for discrete variables, the frequency and percentage rates are given. aworking part-time or full-time. bn = 2 participants in the active control group were born in germany and are not included here. cself-reported german language proficiency (1 = very good, 5 = none). effect sizes and 95% confidence intervals (as far as available) are reported for all feasibili­ ty variables and treatment-related measures. for normally distributed variables, cohen’s d was calculated; a value of .2 was considered a small effect, .5 a medium effect, and .8 a large effect. cliff’s d was used for non-parametric continuous variables. cliff’s d ranges between -1 and 1, with 0 indicating no effect; |d| < 0.147 was considered a negligible effect, |d| < 0.33 small, |d| < 0.474 medium, and otherwise a large effect. generalized eta squared (ηg2 ) was given as a measure of effect size for the anovas described above; an ηg2 of .02 was considered a small effect, .13 a medium effect, and one of .26 as large. phi was calculated as a measure of effect size for discrete feasibility variables. a value of phi = .1 was considered a small effect, .3 a medium effect, and .5 a large effect. the significance level was set at α = .05; a p-value < .10 was considered a statistical trend and also reported in the results section. with respect to anovas with repeated measures, only statistically significant effects were reported in the results section; all fand p-values can be obtained as supplementary materials. statistical analyses were conducted using r version 3.5.0 (r development core team, 2008). engaging turkish immigrants in psychotherapy 12 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ results participants the sample consisted of n = 26 turkish immigrant inpatients (see table 2). the mean age was 48 ± 6 years, and 50% of the participants were female. on average, participants had received 7 ± 3 years of schooling and approximately 60% were employed in a part-time or full-time job. self-reported german language proficiency was moderate, even though 29 ± 8 years had passed since immigration and two participants were born in germany. the most frequent main diagnosis was depression (77%), followed by somatoform disorder (15%), and stress or adjustment disorder (8%). about 70% of participants had one or more comorbid diagnoses. there were no statistically significant differences between the experimental groups in terms of socio-demographic and clinical characteristics. acceptance and feasibility the overall rating for sağlığa doğru was better than that for the pmr and participants working with sağlığa doğru felt better prepared for therapy (see table 3). participants in both groups showed statistically similar levels of motivation to engage in therapy and willingness to recommend their tool to other patients. table 3 acceptance and feasibility of the interventions variable active control interventionb engagement interventionc test statistic effect size [95% ci] overall rating 5.3 (2.5) 8.4 (1.6) t(18) = 3.63, p = .002 cohen’s d = 1.48 [0.55; 2.41] ‘are you motivated to engage in therapy?’ 8.1 (2.5) 8.7 (1.7) u = 86.5, p = .65 cliff’s d = .11 [-.34; .51] ‘after using the tool, do you feel better prepared for therapy?’ 3.6 (3.1) 7.0 (2.6) u = 115, p = .013 cliff’s d = .60 [.10; .86] ‘would you recommend this tool to other patients?’ 7.2 (2.8) 7.9 (2.1) u = 94, p = .62 cliff’s d = .12 [-.33; .53] ‘was the tool easy to handle?a 8.0 (2.7) 9.4 (1.1) u = 21.5, p = .50 cliff’s d = .23 [-.45; .74] use of the intervention without assistance [n (%)] 5 (45.5) 7 (50) χ2(1) = 0.0009, p = .98 phi = 0.08 time working with the intervention (minutes) 31.7 (6.8) 49.6 (6.9) t(23) = 6.34, p < .001 cohen’s d = 2.61 [1.51; 3.71] note. unless otherwise indicated, m (sd) are presented. rating scales ranged from 0 ‘no, not at all’ to 10 ‘yes, absolutely’. aonly participants that used the intervention without assistance. bn = 12. cn = 14. reich, zürn, & mewes 13 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ only half of the participants were able to use the interventions without assistance, regardless of the experimental condition. however, those who used the interventions by themselves indicated that they were very easy to handle. participants worked approxi­ mately 28 minutes longer with sağlığa doğru than with the pmr. illness perception and self-efficacy brief ipq threatening illness perceptions decreased on a descriptive level after using sağlığa doğru as expected, while there was no change in the pmr-condition. the contrast analysis confirmed a statistical trend in the expected direction (cohen’s d = -0.43, see table 4). after using sağlığa doğru, beliefs in personal (cohen’s d = 0.34) and treatment control (cohen’s d = 0.20) increased, and beliefs in external-fatalistic control decreased significantly (cohen’s d = -0.60). self-efficacy increased after working with sağlığa doğru, while it decreased after working with the pmr with a small and statisti­ cally significant effect for the group*time interaction (ηg2 = 0.024) that was confirmed by the nonparametric approach (wald-type and anova-type test statistic = 7.432, df = 1, p = .006). the contrast analyses confirmed a small effect and a statistically significant increase in self-efficacy after using sağlığa doğru (cliff’s d = 0.22). table 4 usefulness of the engagement intervention regarding treatment-related variables variable active control interventiona engagement interventionb anova (group*time interaction)c contrast analysesd pre post pre post test statistic ηg2 test statistic d [95% ci]e illness concept (brief-ipq) 58.7 (8.5) 58.6 (7.6) 60.3 (6.0) 57.0 (7.5) f(1, 24) = 1.18, p = .288 0.012 t(13) = 1.62, p = .065 -0.43 [-1.22; 0.35] personal control (ipq-r) 17.3 (2.1) 16.7 (3.9) 17.4 (3.9) 18.8 (4.1) f(1, 24) = 2.27, p = .145 0.020 t(13) = -1.36, p = .111 0.34 [-0.44; 1.13] treatment control (ipq-r) 14.7 (2.8) 14.9 (3.6) 15.8 (5.1) 16.7 (4.9) f(1, 24) = 0.17, p = .683 0.001 t(13) = -0.74, p = .236 0.20 [-0.58; 0.98] external-fatalistic control (kkg) 17.0 (6.3) 18.8 (7.1) 16.8 (6.4) 15.0 (6.9) f(1, 24) = 3.94, p = .059 0.019 t(13) = 2.26, p = .021 -0.60 [-1.40; 0.19] self-efficacy (swe) 15.7 (4.1) 14.6 (3.8) 17.4 (6.4) 19.9 (8.2) f(1, 24) = 6.81, p = .015 0.024 v = 15.5, p = .034 0.22 [-0.24; 0.60] note. m (sd) are presented. an = 12. bn = 14. call main effects for group and time were statistically not significant in anova and are not shown. dpre-post comparison for the engagement intervention group only (see statistics section). ecohen’s d for normally distributed data, cliff’s d for swe (not normally distributed). engaging turkish immigrants in psychotherapy 14 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ discussion our work aimed at developing and piloting a culture-tailored intervention assisting turkish immigrant inpatients to engage in psychotherapeutic treatment. in a proof-of­ concept study, this intervention was rated better than an active control intervention, in particular concerning a better preparedness for psychotherapy. self-efficacy and personal and treatment control beliefs improved through working with sağlığa doğru, while threatening illness perceptions and external-fatalistic control beliefs diminished. multicultural, web-based mi interventions have received positive feedback before, particularly regarding less shame, embarrassment, and discomfort compared to face-to­ face group interventions (osilla et al., 2012). our study demonstrated that a web-based intervention is applicable even in a group of relatively low-educated immigrants, but the pilot trial showed that half of the sample was unable to use the computer and the web-based interventions on their own. we assume that the recruitment strategy of the current study (i.e., approaching potential participants in-person during specialized inpatient treatment for turkish migrants) resulted in a sample that was potentially older and less digitally literate than participants who are typically included into randomized controlled trials, particularly into trials on web-based and app-based interventions with inclusion criteria such as having access to the internet (e.g., heim et al., 2020). under­ standing this barrier to implementation could be addressed by an even more rigorous emphasis on user-centered design for the target population (burchert et al., 2019) or through task-sharing with turkish-speaking non-therapists (e.g. nursing staff) assisting patients with low technical or digital literacy (rebello et al., 2014). the improvements in self-efficacy and personal control beliefs indicate the engage­ ment intervention’s capability to strengthen the belief in one’s own coping abilities. the beliefs that health depends on chance, fate, or luck diminished after working with sağlığa doğru. however, even though the illness perception was less threatening, it remained in the range of a rather pessimistic and threatening concept of disease. it has been shown previously that a threatening illness perception was associated with poor psychological health and low motivation for psychotherapy (petrie & weinman, 2012). while this highlights the relevance of sağlığa doğru, it also suggests that continuous work is needed to achieve longer lasting changes in illness perception (petrie et al., 2012). limitations this proof-of-concept study comprised a small sample, limiting the generalizability of the present findings. only 60% of patients were willing to participate in the study, imply­ ing that participant burden due to study duration and concerns about data storage were relevant barriers towards participation. german and turkish language versions of ques­ tionnaires and interventions were provided to the participants ad libitum, including the options to switch between language versions and use both versions. this approach was reich, zürn, & mewes 15 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ well received and facilitated participation but tracking of the use of language versions was not possible within the system and hence, no further analysis could be undertaken regarding language use. for most turkish-language versions of the questionnaires, psy­ chometric properties, cultural validity, and measurement equivalence with the german versions have not been established to a satisfactory degree, which might compromise reliability and validity of the findings regarding treatment-related variables. contrast analyses were carried out to give a first impression of the effect of the engagement intervention on treatment-related variables, but effects need to be replicated in larger trials since statistical power was, at best, acceptable due to the small sample size. wide confidence intervals containing zero point out that the estimates are imprecise and cannot be readily transferred to a population level. the intervention material included no female sample patient. therefore, the identification with the (male) sample patient might have differed between male and female participants. conclusions the present proof-of-concept study gave an example of how to adapt psychoeducational information and foster treatment engagement in turkish immigrant inpatients in a one­ session, web-based intervention. while we found promising first results, the effect of the engagement intervention on actual treatment engagement and treatment outcome is still to be evaluated. further evaluation is also needed regarding whether a one-session inter­ vention is sufficient, or whether more sessions are necessary to create a reliable effect regarding treatment engagement. the evident limitations notwithstanding, this study provided a novel approach to fostering the engagement of an immigrant population in psychotherapy. it might encourage the further development and application of culturally tailored, web-based treatment elements which facilitate the delivery of psychotherapy or single techniques (e.g., pmr as a relaxation technique). treatment enhancement by web-based interventions can add language and cultural resources in a scalable way and bridge gaps in the field of immigrant and minority psychotherapy. clinical applications may be realized for immigrant and minority patients undergoing professional treatment to increase readiness for and thereby effectiveness of psychotherapy. further applications can be envisioned to facilitate the uptake of professional treatment by using culturally tailored, web-based interventions to bridge gaps in mental health literacy and foster openness for psychotherapy in the most vulnerable populations (e.g. asylum seekers and refugees (böttche et al., 2021), as well as other socio-economic disadvantaged groups, or adolescents and young adults). engaging turkish immigrants in psychotherapy 16 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: we would like to thank the cooperating clinic sites, namely: vitos clinic for psychiatry and psychotherapy marburg (medical director: prof. dr. dr. matthias j. müller), and parkland clinic bad wildungen (medical director: dr. hartmut imgart). we also express our thanks to dr. david daniel ebert and dipl. psych. christian rosenau for technical support and feedback during the development of the web-based interventions. competing interests: the authors have declared that no competing interests exist. data availability: all data, analytic methods, and study materials are available to other researchers and can be obtained from psycharchives as supplementary materials to this article (reich, zürn, & mewes, 2021a, 2021b). supplementary materials the supplementary materials include the turkish and german versions of the sağlığa doğru intervention script, additional analyses of the sample characteristics using self-report measures for dimensional psychopathology, test statistics for main effects (table 4), and the full dataset including a codebook (for access see index of supplementary materials below). index of supplementary materials reich, h., zürn, d., & mewes, r. (2021a). supplementary materials to "engaging turkish immigrants in psychotherapy: development and proof-of-concept study of a culture-tailored, web-based intervention" [research data]. psychopen gold. https://doi.org/10.23668/psycharchives.5156 reich, h., zürn, d., & mewes, r. (2021b). supplementary materials to "engaging turkish immigrants in psychotherapy: development and proof-of-concept study of a culture-tailored, web-based intervention" [additional information]. psychopen gold. https://doi.org/10.23668/psycharchives.5155 references aichberger, m. c., schouler-ocak, m., mundt, a., busch, m. a., nickels, e., heimann, h. m., ströhle, a., reischies, f. m., heinz, a., & rapp, m. a. (2010). depression in middle-aged and older first generation migrants in europe: results from the survey of health, ageing and retirement in europe (share). european psychiatry, 25(8), 468-475. https://doi.org/10.1016/j.eurpsy.2009.11.009 benish, s. g., quintana, s., & wampold, b. e. 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(n.d.). turkish adaptation of the general perceived selfefficacy scale. genelleştirilmiş özyetki beklentisi. http://userpage.fu-berlin.de/~health/turk.htm clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. reich, zürn, & mewes 21 clinical psychology in europe 2021, vol. 3(4), article e5583 https://doi.org/10.32872/cpe.5583 https://doi.org/10.1037/0735-7028.38.4.430 https://doi.org/10.1037/a0028226 http://www.uib.no/ipq/ https://doi.org/10.1177/152574019001300111 http://userpage.fu-berlin.de/~health/turk.htm https://www.psychopen.eu/ engaging turkish immigrants in psychotherapy (introduction) materials and method a) development of the engagement intervention b) proof-of-concept study process of the study trial results participants acceptance and feasibility illness perception and self-efficacy discussion limitations conclusions (additional information) funding acknowledgments competing interests data availability supplementary materials references “same same or adapted?” therapists’ feedback on the implementation of trauma-focused cognitive behavioral therapy with unaccompanied young refugees latest developments “same same or adapted?” therapists’ feedback on the implementation of trauma-focused cognitive behavioral therapy with unaccompanied young refugees johanna unterhitzenberger 1 , sophia haberstumpf 2, rita rosner 1, elisa pfeiffer 3 [1] department of psychology, catholic university eichstätt-ingolstadt, eichstätt, germany. [2] center for mental health, department of psychiatry, psychosomatics and psychotherapy, university hospital würzburg, würzburg, germany. [3] clinic for child and adolescent psychiatry/psychotherapy, ulm university, ulm, germany. clinical psychology in europe, 2021, vol. 3(special issue), article e5431, https://doi.org/10.32872/cpe.5431 received: 2020-12-11 • accepted: 2021-06-29 • published (vor): 2021-11-23 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: johanna unterhitzenberger, catholic university eichstätt-ingolstadt, department of psychology, ostenstr. 26, d-85072 eichstätt, germany. phone: +49 8421 9321733. e-mail: johanna.unterhitzenberger@ku.de related: this article is part of the cpe special issue “cultural adaptation of psychological interventions”, guest editors: eva heim & cornelia weise, clinical psychology in europe, 3(special issue), https://doi.org/ 10.32872/10.32872/cpe.v3.si supplementary materials: materials [see index of supplementary materials] abstract background: rates of trauma exposure and posttraumatic stress disorder (ptsd) are high among refugee youth. although there is a vast evidence base on effective trauma-focused interventions for children and adolescents, there is only limited understanding of how to adapt these interventions for oftentimes severely traumatized young refugees. this study aims to investigate adaptations undertaken during trauma-focused cognitive behavioral therapy (tf-cbt) in a pilot study with unaccompanied refugee minors (urms). method: written answers on five questions given by n = 9 therapists on n = 16 tf-cbt cases were analysed qualitatively using mayring’s content analysis. the questions were on (1) additional techniques used in the sessions, (2) obstacles to tf-cbt treatment, (3) cultural factors considered and most helpful components for (4) patient and (5) therapist. the categories were built inductively and analysed descriptively. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5431&domain=pdf&date_stamp=2021-11-23 https://orcid.org/0000-0002-7417-8747 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ results: in addition to the regular tf-cbt components, added content mostly concerned the socalled “crisis of the week”, meaning a more lengthy discussion of struggles and concerns in their daily lives. few obstacles in treatment were reported, and little cultural factors had to be considered. the implementation of a trauma narrative and the agenda provided by the manual were frequently reported as helpful. conclusion: the results of this study indicate that the manualized evidence-based treatment tfcbt can be used in the culturally heterogeneous population of urms with minor adaptations. these findings can contribute to future research as well as clinical practice with urms. keywords tf-cbt, cultural adaptation, refugee, therapist, adolescent highlights • tf-cbt is a promising treatment for ptsd in traumatized refugee minors. • necessary adaptations for this target group have not been analysed so far. • therapists reported only a few “on the fly” adaptations during a pilot study on tfcbt. unaccompanied refugee minors (urms) constitute a vulnerable population, firstly due to their various traumatic experiences before, during and after their flight (reed et al., 2012; steel et al., 2017), and secondly in terms of severe post-migration stressors (keles et al., 2018) on their arrival in the host country. it comes as no surprise that the prevalence rates of traumaand stress-related mental health conditions are higher among urms compared to youth without a migration background, immigrant samples (betancourt et al., 2017) or accompanied refugee minors (bean et al., 2007). a recent meta-analysis on mental illness among refugee minors revealed that 23% report posttraumatic stress disorder (ptsd) (blackmore et al., 2020). current treatment guidelines for treating trauma-related disorders, especially ptsd, recommend trauma-focused cognitive behavioral approaches (international society for traumatic stress studies [istss], 2019; rosner et al., 2019) for traumatized children and adolescents. in this context, trauma-focused cognitive behavioral therapy (tf-cbt, e.g. the specific manual by cohen et al., 2017) has been identified as a gold standard treatment for children and adolescents with ptsd across guidelines and meta-analyses (gutermann et al., 2016). experts claim, however, that yet child trauma guidelines focus too little on children’s cultural background and possible adaptations (alisic et al., 2020). most evidence-based treatments for ptsd were developed in western societies. they were then increasingly widely implemented and found to be effective in samples with cultures outside of western societies (ennis et al., 2020). only a very small number of interventions have been specifically developed and tailored to the needs of urms, for example the trauma-focused group intervention “mein weg” (english “my way”) therapists’ feedback on tf-cbt with refugees 2 clinical psychology in europe 2021, vol. 3(special issue), article e5431 https://doi.org/10.32872/cpe.5431 https://www.psychopen.eu/ (pfeiffer et al., 2018), which is based on tf-cbt but re-modeled into a group-based low-level intervention for refugees in child welfare programs. the development of this intervention adopted a theory-driven approach for cultural adaptation (heim & kohrt, 2019). the theory-driven changes focused mostly on delivery in a group format (e.g. additional group discussions), the language barrier (e.g. changes in materials) and the inclusion of flight and migration specific content (flight route as part of narrative). more commonly, evidence-based trauma-focused treatments are adapted to cultural char­ acteristics of study populations in a data-driven, so-called “bottom-up” approach. these approaches are especially favorable if the question is whether there is a good fit between the evidence-based treatment itself and the new target group, and whether cultural adaptations are necessary to some or all aspects of that specific therapy. a recent review (ennis et al., 2020) systematically reviewed research articles on cultural adaptations in trauma-focused cbt approaches with children and adults. the results highlight the complexity of cross-cultural adaptations of psychotherapy due to several reasons such as heterogeneous sources of information (e.g. stakeholders, thera­ pists or patients), the usage of different frameworks for cultural adaptations (if used at all) and different levels of efficacy evaluation. seven out of the 17 included studies were on cultural adaptations in tf-cbt. they either implemented the treatment with immigrant samples in western countries (e.g. schottelkorb et al., 2012) or delivered the treatment abroad in the cultural context of the country itself (drc: mcmullen et al., 2013; jordan: damra et al., 2014; zambia: murray et al., 2013; tanzania: o’donnell et al., 2014). one study involved local therapists (murray et al., 2013) as main source of information for assessing potentially necessary changes to the treatment protocol during treatment delivery, while others used focus groups, surveys, or expert panels ahead of treatment implementation. the most often used source in the studies described in the review by ennis et al. (2020), which focused on data-driven approaches, were (local) therapists as they might function as a direct mediator between high adherence in the implementation of the manual on the one hand and the individual needs of their patients on the other hand. there are only two studies on cultural adaptations to the tf-cbt protocol delivered to refugee minors (schottelkorb et al., 2012; unterhitzenberger et al., 2019). the refugee population might throw up specific challenges as it represents a heterogeneous popula­ tion that originates from different countries and cultures. consequently, this makes an oftentimes preferred “one size fits all” approach even more challenging. the authors of both studies gave only a brief description of marginal changes to the protocol (e.g. translation when needed, tailored psychoeducation, more sessions on trauma narrative). this leaves a gap in the literature on the need for cultural adaptations in tf-cbt for this vulnerable cohort. especially so-called “on the fly” adaptations of experienced therapists (heim & kohrt, 2019) might be crucial to increasing understanding of necessary adapta­ tions to evidence-based trauma-focused treatments such as tf-cbt for urms. unterhitzenberger, haberstumpf, rosner, & pfeiffer 3 clinical psychology in europe 2021, vol. 3(special issue), article e5431 https://doi.org/10.32872/cpe.5431 https://www.psychopen.eu/ in our recent pilot study (unterhitzenberger et al., 2019) on tf-cbt with urms, we implemented the tf-cbt protocol without prior theory-driven adaptations. the aim was to evaluate the feasibility of tf-cbt for this specific target group. therapists were instructed to provide the treatment according to the manual, however, also to implement and document any “on the fly” adaptations they made in order to successfully treat the refugee patient. the present study, which was part this pilot study (unterhitzenberger et al., 2019), aims to increase knowledge on how to adapt tf-cbt to the specific needs of urms by examining therapists’ self-reported cultural adaptations in implementing tf-cbt with urms in a qualitative study design. method this study is part of a recently published pilot study conducted in germany between march 2015 and july 2017. for details on the procedure please refer to the main publica­ tion (unterhitzenberger et al., 2019). the participants treated in this pilot study were 26 male urms (mage = 17.1; sd = 1.0; range 15-19) who had been in germany for an average of 9.8 months (sd = 3.9) and who originated from eight different countries in the middle east and africa. 22 of them completed treatment. uncontrolled effect sizes were high for ptsd symptoms at post (d = 1.08) and follow-up assessments (d = 1.23). participants a total of 9 therapists were taken into account for this analysis. please see table 1 for the description of participants’ characteristics. therapists responded to the survey for a total of 16 treatment cases. unfortunately, we do not have therapist feedback on all the cases treated, as the questionnaire was put together during the ongoing pilot study. all therapists participated in a tf-cbt training by a certified trainer and received biweekly supervision. in addition, one of the manual developers offered case consultation calls once a month. during the project, an expert in psychotherapy with refugees and torture survivors ran a half-day training session attended by all therapists. therapists’ feedback on tf-cbt with refugees 4 clinical psychology in europe 2021, vol. 3(special issue), article e5431 https://doi.org/10.32872/cpe.5431 https://www.psychopen.eu/ table 1 sociodemographic characteristics of the participating therapists (n = 9) characteristic age m (sd) 35 (9.5) range 29 – 60 gender n (%) female 8 (88.9) cbt therapist n (%) 9 (100) licensed 6 (66.7) in training 3 (33.3) child and adolescent therapist 1 (11.1) adult therapist with additional training for children 8 (88.9) clinical experience n (%) 1 to 5 treated cases 2 (25.0) 11 to 20 treated cases 1 (12.5) 21 to 50 treated cases 1 (12.5) > 50 treated cases 4 (50.0) tf-cbt cases treated m (sd) 5.5 (2.99) range 0 – 20 note. cbt = cognitive behavioral therapy; tf-cbt = trauma-focused cognitive behavioral therapy; m = mean; sd = standard deviation. intervention the tf-cbt treatment protocol followed the manual by cohen et al. (2017). it consists of nine treatment modules on psychoeducation and parenting skills, relaxation, affec­ tive modulation, cognitive processing, trauma narrative and cognitive processing ii, in vivo exposure, conjoint child/caregiver session, and enhancing safety and future skills. standard tf-cbt involves twelve 90-minute sessions with the child and the caregiver. usually, the caregiver is a parent, however, for children and adolescents housed in child welfare facilities (like urms) these are professionals, for instance, social workers. the amount of caregiver involvement depends on the child’s age. according to the manual developers, tf-cbt is flexible and culturally sensitive (cohen et al., 2017). in this pilot study, treatment fidelity was relatively high (62-82%) (unterhitzenberger et al., 2019). the mean treatment dose was 15 sessions. an interpreter was present in 55% of treatment cases. data collection after each session, therapists filled out a session checklist for the tf-cbt module addressed in the respective session to report on treatment adherence. after the respon­ unterhitzenberger, haberstumpf, rosner, & pfeiffer 5 clinical psychology in europe 2021, vol. 3(special issue), article e5431 https://doi.org/10.32872/cpe.5431 https://www.psychopen.eu/ ses to the components (yes/no), one item “additional content or techniques” was to be answered openly that was analyzed for this article (question 1). furthermore, we conducted a survey among therapists. they were given a questionnaire for each study case at the same day they had completed it. the questionnaire consisted of four lik­ ert-scaled questions and eleven questions on each treatment case. it included questions on the complexity of the disorder, therapeutic relationship, therapist’s satisfaction, help­ ful components and obstacles as well as cultural considerations. for the purpose of this study, we present responses from the following four questions that we deemed to be helpful regarding (cultural) adaptations: “which component(s) constituted an obstacle in treatment?” (question 2), “did you consider cultural factors in this treatment case? if so, which ones?” (question 3); “which tf-cbt component(s) helped the patient most?” (question 4); “which tf-cbt component(s) was/were especially helpful for you in treat­ ment?” (question 5). data analysis the answers were analyzed according to mayring’s qualitative content analysis (mayring, 2000). we conducted categories in a structured manner. a key component of this process is the coding manual (for an overview see supplementary material). the coding manual is developed in three steps: the definition of categories, the derivation of examples from the text, and the addition of rules for coding when necessary. categories were built inductively, meaning they were derived from the material rather than from a theoretical concept. the coding was done by sh, any uncertainties regarding the coding and coding manual were discussed with ju. the categories were then analyzed quantitatively by percentage of naming. this approach seemed suitable, as many answers were very short or only bullet points. categories were built separately for each question so there is a coding manual for each question. for question 1, 242 session checklists were analyzed. for questions 2 to 5, we analyzed 16 questionnaires from 16 treatment cases. percentages represent how often one category was named by the answers analyzed for the respective question. percentages represent data from one question and all categories for the respective question are reported except for question 1, where we report only categories with percentages ≥ 4. results additional content or techniques in 150 out of the 242 checklists, the therapists named 172 additional contents or techni­ ques. we coded them in 21 subcategories. the categories named most often were “crisis of the week” (12.2%), psychoeducation (11.3%), cognitive processing and trauma narrative therapists’ feedback on tf-cbt with refugees 6 clinical psychology in europe 2021, vol. 3(special issue), article e5431 https://doi.org/10.32872/cpe.5431 https://www.psychopen.eu/ (each 11.1%). these were followed by relaxation (4.7%), treatment course, grief, and affective modulation (4.1% respectively). obstacles in treatment five therapists named obstacles regarding tf-cbt for six cases. eleven responses cate­ gorized in six categories showed the following challenges in implementing tf-cbt: relaxation (36.4%), cognitive processing i and tf-cbt components ahead of trauma narrative (each 18.2%), affective modulation, work sheets and linguistic problems (each 9.1%). cultural factors in treatment nine therapists gave 14 responses that indicate consideration of cultural factors that were assigned to eleven categories: using pride, religion, and metaphors (each 14.3%), simplify language, using strength and respect, culture-specific grief rituals, combination of psychological and somatic complaints, information on the culture-specific image of women, handling of aggressive behavior, culture-specific adaptation of treatment rela­ tionship and handling of general cultural controversies (each 7.1%). for six cases, thera­ pists did not describe any cultural considerations. three of the participants indicated that they possibly did but were not aware of it or did not explicitly do so. most helpful for patient twenty-six responses for 15 treatment cases were given regarding the most helpful tf­ cbt components for the patient: trauma narrative (53.9%), cognitive processing (19.2%), psychoeducation, relaxation, conjoint session with patient and caregiver (each 7.7%) and affective modulation (3.9%). most helpful for therapist eight therapists responded to the question about what was most helpful for their work derived from tf-cbt in 22 responses for 13 treatment cases: having an agenda (22.7%), trauma narrative and psychoeducation (each 18.2%), cognitive processing (13.6%), intervi­ sion with other tf-cbt therapists (9.1%) and affective modulation, conjoint session, grief modules, and expectation of treatment success (each 4.6%). discussion this is the first study to investigate “on the fly” adaptations by practitioners implement­ ing tf-cbt with an especially vulnerable and diverse population. as one of the first studies, we present qualitative findings from therapists’ adaptations during tf-cbt, unterhitzenberger, haberstumpf, rosner, & pfeiffer 7 clinical psychology in europe 2021, vol. 3(special issue), article e5431 https://doi.org/10.32872/cpe.5431 https://www.psychopen.eu/ which is a valuable addition to the research field. the overall results suggest that the implementation of tf-cbt is feasible without a tremendous amount of adaptation. in line with other studies on cultural adaptations to trauma-focused treatments, therapists also made changes in the conceptualization of the trauma’s effects such as spiritual approaches (ennis et al., 2020), and tailored materials and language (e.g. usage of meta­ phors) to the target group. the additional content or techniques described were mostly tf-cbt components. consequently, therapists had to repeat some components in later sessions (like psycho­ education before starting the trauma narrative) or brought components forward that were supposed to be carried out later (like affective modulation in the first session to enable some self-efficacy in dealing with ptsd symptoms). this is an approach that is typical for tf-cbt, which is meant to be flexible in the use of its components (cohen et al., 2017). it is not surprising that dealing with the ‘crisis of the week’ was the content added most often. in addition to their trauma history, urms have to deal with daily stressors and post-migration stressors (keles et al., 2018) such as an unsecure asylum status, discrimination, or language and cultural barriers in the acculturation process. therefore, we recommend that enhanced problem management related to post-migration stressors should be added as an additional component in tf-cbt (‘crisis of the week’) for this population. there were reports of obstacles related to tf-cbt in only one third of cases. lan­ guage was named as the only problem in treatment, the other responses referred to components of little help for the respective treatment case. relaxation was named most often. we recommend, however, to retain this content as part of the treatment as it is considered to be an important part of stabilization ahead of the trauma confrontation and suitable for use across different cultures. the cultural adaptations named by the therapists were rather diverse. looking at the data, we can see that most adaptations named were techniques that we would use irregularly throughout treatment, like the meaning of pride, strength or respect that can be included in the cognitive work, trauma narrative or future safety. the use of pride or respect and culture-specific grief rituals could be discussed in the tf-cbt training in order to enable therapists to deliver culturally sensitive treatment for urms. this specific content might not be necessary for all urms in treatment though, which means that therapists need to evaluate the inclusion of such culture-specific rituals and concepts for each individual patient independently. therapists need to be trained to maintain a balance between cultural considerations and an overestimation of cultural aspects as this might lower manual adherence. in addition, suitable metaphors should be provided for different modules. even though trauma confrontation with asylum seekers is discussed in a controver­ sial manner in the literature (ter heide et al., 2016), the therapists named the trauma narrative as the most helpful component for their patients. the factor named most therapists’ feedback on tf-cbt with refugees 8 clinical psychology in europe 2021, vol. 3(special issue), article e5431 https://doi.org/10.32872/cpe.5431 https://www.psychopen.eu/ helpful for therapists was “having an agenda” which is not a tf-cbt component, but a characteristic of manualized cbt approaches. the agenda for every session seems especially helpful when the “crisis of the week” is a very dominant part of the treatment sessions. there are several limitations which might limit the generalizability of the findings. unfortunately, question 3 about cultural adaptations was phrased as a closed, two-step­ ped question (“did you consider cultural factors in this treatment case? if so, which ones?”). this might have forced a “yes” or “no” answer and might therefore have biased the results. furthermore, we were not able to calculate interrater reliability scores for the coding of categories. in addition, there was a lack of objective ratings (e.g. independent raters of videos from treatment sessions). lastly, we did not assess the therapists’ cultural competence or prior experience in transcultural work. therefore, we cannot rule out that the level of cultural knowledge influenced the actual cultural adaptations. conclusion the present study enhances our knowledge about the implementation of tf-cbt for a culturally diverse sample such as urms in germany. nonetheless, urms face numerous individual and structural barriers to receiving mental health care interventions tailored to their needs. within the project “better care – improving mental health care for unaccompanied young refugees through a stepped-care approach” (rosner et al., 2020) we will implement tf-cbt according to the knowledge gained from the present study. furthermore, the recommendations discussed can contribute to the implementation of tf-cbt in culturally diverse groups in future research and clinical practice and might help practitioners to overcome barriers in treating young refugees. funding: participant incentives in the pilot study were financed by profor+, a funding programme run by the catholic university of eichstätt-ingolstadt. the better care trial is funded by the german ministry of education and research (01ef1802a-b). acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. supplementary materials the supplementary material contains examples from the coding manual for the questions regard­ ing additional techniques, obstacles to treatment and cultural adaptations (for access see index of supplementary materials below). unterhitzenberger, haberstumpf, rosner, & pfeiffer 9 clinical psychology in europe 2021, vol. 3(special issue), article e5431 https://doi.org/10.32872/cpe.5431 https://www.psychopen.eu/ index of supplementary materials unterhitzenberger, j., haberstumpf, s., rosner, r., & pfeiffer, e. 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(2012). treatment for childhood refugee trauma: a randomized, controlled trial. international journal of play therapy, 21(2), 57-73. https://doi.org/10.1037/a0027430 unterhitzenberger, haberstumpf, rosner, & pfeiffer 11 clinical psychology in europe 2021, vol. 3(special issue), article e5431 https://doi.org/10.32872/cpe.5431 https://istss.org/getattachment/treating-trauma/new-istss-prevention-and-treatment-guidelines/istss_preventiontreatmentguidelines_fnl-march-19-2019.pdf.aspx https://istss.org/getattachment/treating-trauma/new-istss-prevention-and-treatment-guidelines/istss_preventiontreatmentguidelines_fnl-march-19-2019.pdf.aspx https://doi.org/10.1177/0165025416658136 https://doi.org/10.17169/fqs-1.2.1089 https://doi.org/10.1111/jcpp.12094 https://doi.org/10.1016/j.chiabu.2013.04.017 https://doi.org/10.1002/jts.21970 https://doi.org/10.1111/jcpp.12908 https://doi.org/10.1016/s0140-6736(11)60050-0 https://doi.org/10.1186/s13063-020-04922-x https://doi.org/10.1037/a0027430 https://www.psychopen.eu/ steel, j. l., dunlavy, a. c., harding, c. e., & theorell, t. (2017). the psychological consequences of pre-emigration trauma and post-migration stress in refugees and immigrants from africa. journal of immigrant and minority health, 19(3), 523-532. https://doi.org/10.1007/s10903-016-0478-z ter heide, f. j. j., mooren, t. m., & kleber, r. j. (2016). complex ptsd and phased treatment in refugees: a debate piece. european journal of psychotraumatology, 7(1), article 28687. https://doi.org/10.3402/ejpt.v7.28687 unterhitzenberger, j., wintersohl, s., lang, m., könig, j., & rosner, r. (2019). providing manualized individual trauma-focused cbt to unaccompanied refugee minors with uncertain residence status: a pilot study. child and adolescent psychiatry and mental health, 13, article 22. https://doi.org/10.1186/s13034-019-0282-3 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. therapists’ feedback on tf-cbt with refugees 12 clinical psychology in europe 2021, vol. 3(special issue), article e5431 https://doi.org/10.32872/cpe.5431 https://doi.org/10.1007/s10903-016-0478-z https://doi.org/10.3402/ejpt.v7.28687 https://doi.org/10.1186/s13034-019-0282-3 https://www.psychopen.eu/ therapists’ feedback on tf-cbt with refugees (introduction) method participants intervention data collection data analysis results additional content or techniques obstacles in treatment cultural factors in treatment most helpful for patient most helpful for therapist discussion conclusion (additional information) funding acknowledgments competing interests supplementary materials references multidimensional assessment of strengths and their association with mental health in psychotherapy patients at the beginning of treatment research articles multidimensional assessment of strengths and their association with mental health in psychotherapy patients at the beginning of treatment jan schürmann-vengels 1 , stefan troche 2 , philipp pascal victor 1, tobias teismann 3 , ulrike willutzki 1 [1] department of psychology and psychotherapy, witten/herdecke university, witten, germany. [2] department of psychology, university of bern, bern, switzerland. [3] mental health research and treatment center, ruhr-universität bochum, bochum, germany. clinical psychology in europe, 2023, vol. 5(2), article e8041, https://doi.org/10.32872/cpe.8041 received: 2021-12-28 • accepted: 2023-05-07 • published (vor): 2023-06-29 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: jan schürmann-vengels, department of psychology and psychotherapy, universität witten/herdecke, alfred-herrhausen-straße 50, 58448 witten, germany. e-mail: jan.schuermann-vengels@uniwh.de abstract background: modern concepts assume that mental health is not just the absence of mental illness but is also characterized by positive well-being. recent findings indicated a less pronounced distinction of positive and negative mental health dimensions in clinical samples. self-perceived strengths were associated with markers of mental health in healthy individuals. however, analyses of strengths and their association with different mental health variables in clinical populations are scarce. method: a cross-sectional design was conducted at a german outpatient training and research center. 274 patients before treatment (female: 66.4%, mean age = 42.53, sd = 13.34, range = 18-79) filled out the witten strengths and resource form (wirf), a multidimensional self-report of strengths, as well as other instruments assessing positive and negative mental health variables. data was analyzed with structural equation modeling and latent regression analyses. results: confirmatory factor analysis of the wirf showed good model fit for the assumed threesubscale solution. regarding mental health, a one-factor model with positive and negative variables as opposite poles showed acceptable fit. a correlated dual-factor model was not appropriate for the data. all wirf subscales significantly predicted unique parts of variance of the latent mental illness factor (p = .035 – p < .001). this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.8041&domain=pdf&date_stamp=2023-06-29 https://orcid.org/0000-0002-8963-1129 https://orcid.org/0000-0002-0961-1081 https://orcid.org/0000-0002-6498-7356 https://orcid.org/0000-0002-0149-4554 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: the context-specific assessment of patients’ strengths was confirmed and led to an information gain in the prediction of mental health. results suggest that positive and negative facets of mental health are highly entwined in people with pronounced symptoms. the scientific and practical implications of these findings are discussed. keywords strengths, resources, resilience, mental health, dual-factor model, structural equation model highlights • the witten strengths and resource form (wirf) captures strengths in three situational contexts. • a confirmatory factor analysis supported the context-structure of the wirf in a clinical sample. • positive and negative mental health variables were highly correlated in patients before treatment. • wirf subscales provided incremental information in the prediction of patients’ mental health. traditionally mental health has been understood as the absence of psychopathology. this view suggests that people are either mentally ill or mentally healthy at a given point in time. in contrast, modern dual-factor models emphasize a two-dimensional structure of mental health (keyes, 2002; who, 2005). according to such models, a dimension of negative mental health (nmh) is defined by the absence or presence of mental illness and burden, whereas a positive mental health (pmh) dimension is characterized by high or low emotional, psychological, and social well-being. in contrast to the unidimensional view of mental health, two-factor models assume that these two dimensions are nega­ tively related but still distinct from each other (iasiello et al., 2020; keyes, 2005). on the one hand, this means that individuals with mental disorders can still have moderate to high levels of well-being. on the other hand, a person with low well-being may not necessarily develop psychopathology. these assumptions were examined using various statistical approaches in healthy samples (iasiello et al., 2020). in most studies, both di­ mensions were assessed with specific instruments and then examined with confirmatory factor analysis or structural equation models (sem). these procedures are used when created theoretical models are to be tested with empirical data (schreiber et al., 2006). latent factors, such as mental health, that cannot be measured directly are extracted from the observed data. this allows a way to determine whether the study participants' data are more consistent with a one-dimensional or a two-factor understanding of mental health. findings with healthy samples consistently showed that a model with two corre­ lated factors (nmh and pmh) best reflects mental health (kim et al., 2014; magalhães & calheiros, 2017). this result means that psychopathology is only on average and not strengths and mental health 2 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ necessarily associated with lower well-being. if nmh and pmh are at least partially distinct factors, it may be useful to examine specific correlates and predictors of these two dimensions (schotanus-dijkstra et al., 2017). findings from clinical samples showed mixed results for the dual-factor hypothesis. most studies also found evidence for a correlated two-dimensional model of mental health (alterman et al., 2010; de vos et al., 2018; díaz et al., 2018; franken et al., 2018; teismann et al., 2018; tomba et al., 2014). on the other hand, van erp taalman kip and hutschemaekers (2018) showed that only a one-factor model of mental health fitted the data in an outpatient sample (n = 1069). the authors stated that psychopathology and well-being were more entwined in people with pronounced symptoms than in healthy subjects. this would imply that high psychopathology is almost always connected with low well-being (van erp taalman kip & hutschemaekers, 2018). one possible reason for this may be that people with mental disorders experience high levels of negative affect, meaning they often feel bad in everyday life (stanton & watson, 2014). this, in turn, could make it more difficult to feel good about potentially pleasant experiences or situations (carl et al., 2013). such limited positive reactivity might prevent individuals with marked psychopathology from also feeling well (at least temporarily). statistically, such a global perception by patients of either feeling bad or good is expressed in a high negative correlation between psychopathology and well-being. various studies, including the ones that found evidence for a dual-factor structure of mental health, found large correlations of nmh and pmh measures in clinical samples, r = -.67 – -.72 (bos et al., 2016; franken et al., 2018; lukat et al., 2016; van erp taalman kip & hutschemaekers 2018). these correlations are significantly higher than in healthy individuals, suggesting that patients may have less access to or less acknowledge positive experiences and situations at the beginning of psychotherapy because these are overshadowed by high symptom burden (iasiello et al., 2020). in turn, this makes it difficult for clinicians to utilize the positive experience of patients in psychotherapy. psychological strengths (also named resources; munder et al., 2019) are discussed as promotive factors of mental health for both healthy and clinical samples (grawe & grawe-gerber, 1999; taylor & broffman, 2011). strengths are defined as already existing intraand interpersonal potentials and abilities of a person (grawe, 1997; willutzki, 2008). several authors argued that an aspect is defined as a strength by the following criteria: (1) subjective positive evaluation, and/or (2) functionality to reach personal goals (grawe 1997; willutzki, 2008). the literature often distinguishes personal and social strengths (taylor & broffman, 2011). examples of personal strengths are the optimistic handling of difficulties and the implementation of individually positive activities, while social strengths are characteristics that help to form good relationships or perceive contacts. current concepts of strengths point to the importance of situational context in judging whether an aspect is positive and/or helpful (flückiger, 2009; taylor & broffman, 2011; willutzki, 2008). for example, a supporting family member or friend can be a high­ schürmann-vengels, troche, victor et al. 3 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ ly important resource to cope with everyday problems. however, a supporting person may also be part of the avoidance system of an anxiety disorder, making approach coping more difficult in this specific situation. research findings further indicated that aspects, rated as strengths by the person him-/herself (self-perceived strengths), are stronger related to good mental health outcomes compared to observer rated factors (melrose et al., 2015; prati & pietrantoni, 2010). various studies showed that self-perceived strengths were strongly associated with higher pmh and predicted participants’ long-term wellbeing in healthy samples (gloria & steinhardt, 2016; mc elroy & hevey, 2014; niemeyer et al., 2019; siedlecki et al., 2014). strengths and their relationship to mental health are less researched in clinical populations, although the activation of strengths is a widely supported mechanism in psychotherapy (munder et al., 2019). it is assumed that people with mental disorders often do not perceive possible strengths in themselves as strengths, although these are recognized as such by outsiders (for example, the therapist values the patient's creativity as helpful, while the patient perceives it as trivial for coping with the problem). high levels of psychopathology appear to be associated with negativity biases, which may be one reason why patients have less access to their own strengths that are present despite their distress (stanton & watson, 2014; trompetter et al., 2017). with respect to this, two studies showed that both psychiatric inpatients and psychotherapy outpatients report significantly lower levels of self-perceived strengths compared to healthy individuals with large effect sizes for this difference (goldbach et al., 2020; victor et al., 2019). most available instruments assess strengths over all situations a person experiences (trans-situational). such global measures can be problematic in clinical samples because they only reflect that patients have a strong focus on their problems and, in turn, a low perception of their strengths (iasiello et al., 2022; joseph & wood, 2010). thus, such instruments do not provide additional information compared to problem measurements in the clinical context. therefore, victor et al. (2019) developed the witten strengths and resource form (wirf), an assessment tool designed to capture strengths in three situational contexts: (1) strengths in everyday life (evdays), (2) strengths used to successfully cope with previous crises (crisess), and (3) strengths in connection with current problems (probs). the multidimensional structure was transferred from an existing diagnostic interview and obtained for the questionnaire by means of an exploratory factor analysis using data from a sample of 144 psychotherapy patients (victor et al., 2019; willutzki et al., 2005). to determine construct validity, the subscales were correlated with relevant instruments: all subscales showed significant positive correlations with an established strengths instrument (tagay et al., 2014; victor et al., 2019). the instrument is designed to capture how patients rate their strengths in dealing with different situations. a person may indeed have different thoughts about how pronounced and helpful one's strengths are in different circumstances, so that diverse aspects of patients' perceptions could be strengths and mental health 4 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ represented by the subscales of the wirf. for example, people who are currently under a lot of stress, but at the same time know what strengths have helped them in the past, may feel more able to manage the difficulty. the inclusion of different subscales of the wirf would amount to incremental prediction of, for example, mental health, because the subscales contain different information of patients’ experience. however, whether the subscales of the wirf capture different aspects of strengths perception is still unclear and needs to be confirmed confirmatory in a larger sample. objectives to the best of our knowledge, no study has yet analyzed the association of strengths with different mental health variables in the clinical context. the first aim of this study was to confirm the three-subscale structure of the wirf in a sample of psychotherapy outpatients. furthermore, to extend research on the dual-factor model, the second aim was to analyze the latent factor structure of mental health in psychotherapy outpatients with different positive and negative measures. the third aim of this study was to explore whether the strengths subscales of the wirf may predict unique parts of patients’ mental health/mental illness. h1: it is expected that the structure of the wirf with (1) strengths in everyday life (evdays), (2) strengths used to successfully cope with previous crises (crisess), and (3) strengths in connection with current problems (probs) as separate subscales will show a good model fit in a clinical sample. h2: it is expected that a dual-factor model of mental health – with pmh and nmh as correlated, but distinct factors – will be a more appropriate description of mental health related data in a clinical sample compared to a one-factor model with pmh and nmh as op­ posite poles of the same dimension. to address this hypothesis, two latent factor models will be created based on actual measurements and tested against each other in terms of model fit. h3: it is further hypothesized that all wirf subscales will signifi­ cantly predict unique variance in the latent factors of mental health/ mental illness. for the evdays scale, small to moderate positive cor­ relations are expected only with measures of pmh. for the crisess scale, small to moderate correlations are expected with measures of pmh (positively directed) and nmh (negatively directed). probs is expected to correlate strongly positive with pmh measures and strongly negative with nmh measures. schürmann-vengels, troche, victor et al. 5 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ method design and sample description participants were recruited between 2016 and 2019 at the center of mental health and psychotherapy (cmhp), an outpatient training and research center for cognitive behav­ ioral therapy (cbt) at witten/herdecke university, germany. a cross-sectional design was applied where patients filled out all instruments at one point in time before the first psychotherapy session. general inclusion criteria were as follows: (1) at least one mental disorder according to dsm-iv criteria, (2) at least 16 years of age, (3) sufficient german language skills. patients that fulfilled inclusion criteria were informed about the study procedures and signed the informed consent. after study inclusion, patients’ diagnoses were determined with the structured clinical interview for dsm-iv (scid; wittchen et al., 1997) within the first treatment sessions. diagnostic interviews were performed by licensed cbt therapists or trainee therapists in advanced cbt training. all therapists were trained in the use of diagnostic interviews in prior workshops as a part of their training schedules. the total sample consisted of 274 adult psychotherapy outpatients (female: 66.4%, mage = 42.53, sd = 13.34, range = 18-79). most common primary diagnoses were affective disorders (33.58%), anxiety disorders (17.88%), and adjustment disorders (12.04%). 33 pa­ tients (12.04%) had at least two disorders. on average, patients had 1.14 diagnoses (sd = 0.40, range: 1-3). more than half the patients (52.55%) had prior psychological treatment. table 1 shows demographic data of the clinical sample. instruments self-perceived strengths patients’ strengths were assessed with the wirf (victor et al., 2019). the instrument conceptualized strengths as individually usable abilities that help to cope with specific situations (munder et al., 2019; taylor & broffman, 2011). the wirf is a multidimension­ al self-report with 36 items (likert scale from 0 “completely disagree” to 5 “completely agree”), assessing a person’s strengths with three subscales: strengths in everyday life (evdays), strengths in previous successful crises management (crisess), and strengths in connection with current problems (probs). participants are presented with various strengths and asked to what extent they were able to use them in the specific context. in each subscale, the same 12 items are presented in a different order to compare a person's perception of strengths across contexts. each subscale starts with a short introduction referring to the context (e.g., for crisess: in the next step we would like to ask you to think back to rather difficult times of your life. everybody goes through such times. please now think of a situation that was difficult for you to handle, but which you never­ theless tackled successfully, i.e., a situation about which you would say today: “i handled strengths and mental health 6 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ that pretty well”, or “i’m quite happy with myself about how i did that”. the following statements suggest some possible actions people can take in difficult situations). a mean score was calculated for each subscale, which represents a patient’s global perception of whether he/she experiences his or her existing strengths as sufficient and helpful in the respective context. items can be further grouped into three themes: action regulation (planning and performing activities), relaxation (taking time to relax and enjoy life), and social strengths (helpful interaction patterns). the wirf was developed based on a multidimensional concept from an existing diagnostic interview (willutzki et al., 2005). a survey of psychotherapy experts, identify­ ing relevant strengths, was conducted to create an item pool. after this, a preliminary strengths questionnaire was developed and tested in a sample of psychotherapy outpa­ table 1 description of the clinical sample characteristic m sd age 42.53 13.34 n % gender female 182 66.42 male 86 31.39 missing 6 2.19 relationship statusᵃ single 80 29.20 in a relationship 146 53.28 level of educationᵃ no graduation 4 1.46 secondary education 56 20.44 a levels 46 16.79 academic degree 36 13.14 completed apprenticeship 122 44.53 employmentᵃ employed 164 60.00 self-employed 7 2.55 unemployed 49 17.88 training/studies 3 1.09 retired 29 10.58 aoptional answer. schürmann-vengels, troche, victor et al. 7 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ tients different from the one in this study (n = 144), yielding to the wirf. item indices as well as psychometric properties were analyzed in both a clinical sample and healthy con­ trols (victor et al., 2019). all subscales showed good internal consistency (α = .84 – .88). moreover, the subscales showed hypothesis-consistent correlations with other strengths and social support assessments, indicating convergent validity (victor et al., 2019). pmh constructs the who-5 well-being index — the who-5 (bech et al., 2003; who, 1998) is an internationally used five item self-report to assess the general subjective well-being of a person in the last two weeks (likert scale from 0 “at no time” to 5 “all the time”). subjective well-being is characterized by the frequency of positive feelings and one’s satisfaction with life (topp et al., 2015). a mean score of the five items was used to represent a person’s general well-being in this study. the german version showed excel­ lent internal consistency, α = .92 (brähler et al., 2007). moreover, a systematic review indicated good construct and predictive validity of the instrument in healthy and clinical samples (topp et al., 2015). internal consistency in our sample was α = .88. the sense of coherence scale – short form — the soc-l9 (schumacher et al., 2000) assesses a person’s sense of coherence as conceptualized in the salutogenic model of health (antonovsky, 1987). sense of coherence is operationalized by three components (comprehensibility, manageability, meaningfulness) and describes the global orientation of an individual that he/she has the resources to cope with stress and life in general (antonovsky, 1987). the instrument contains nine items (likert scale from 1 “very often” to 7 “rarely/never”), from which a mean score is formed that reflects the global sense of coherence. the german version showed good internal consistency, α = .87 (singer & brähler, 2007). another study showed evidence for construct validity of the soc-l9 with significant correlations with established pmh scales, r = .60 – .64 (lin et al., 2020). internal consistency in our sample was α = .85. nmh constructs the brief symptom inventory – short version — the bsi-18 (spitzer et al., 2011) is a self-report measure to assess psychopathology in the last week. it contains 18 items (likert scale from 0 “not at all” to 4 “nearly every day”), measuring symptoms of somatization, anxiety, and depression. the global severity index (gsi) of the instrument was used to represent a person’s level of general psychopathology in this study. internal consistency of the gsi was good to excellent in several clinical samples, α = .88 – .93 (franke et al., 2017; spitzer et al., 2011). internal consistency in our sample was α = .89. the perceived stress questionnaire — the psq-20 (fliege et al., 2001) is an inter­ nationally used self-report measure to assess stress experience in the last four weeks. strengths and mental health 8 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ stress is operationalized by four components (tension, worries, overload, lack of joy) and represents the global level of current burden. the instrument contains 20 items (likert scale from 1 “almost never” to 5 “usually”), that were averaged to a mean score in this study. the german version showed good internal consistency, α = .80 – .86 (fliege et al., 2001). moreover, evidence of construct validity was indicated with negative associations with quality of life and social support measures (fliege et al., 2001). internal consistency in our sample was α = .92. the incongruence questionnaire – short version — the k-ink (grosse holtforth & grawe, 2003) is a self-report assessing psychological incongruence resulting from an insufficient realization of motivational goals. a high level of incongruence occurs when a person’s real-world experiences do not match with their desired goal states. the au­ thors stated that incongruence is closely related to the experience of psychopathological symptoms (grosse holtforth & grawe, 2003). it consists of 23 items (likert scale from 1 “far too little” to 5 “perfectly good”) measuring incongruence in the context of both approximation and avoidance. a mean score was formed from the 23 items representing global incongruence. the german version showed good to excellent internal consistency in clinical samples, α = .87 – .91 (grosse holtforth & grawe, 2003). internal consistency in our sample was α = .89. statistical analyses all analyses were conducted using r, version 3.6.3, packages: lavaan (rosseel, 2012). descriptive statistics of sample characteristics and analyzed variables were determined. normality of analyzed variables was tested with separate shapiro-wilk’s tests. bivariate correlations between analyzed variables were determined and tested with a significance level of α = .05. in order to examine the main hypotheses, sem using maximum likelihood estimation with robust standard errors (huber-white) and scaled test-statistics were conducted (mlr; rosseel, 2012). this procedure allows constructs that are not directly observable to be derived from the data (latent factors) and placed in relation to one another (schreiber et al., 2006). goodness of fit for all models was evaluated with a combination of well-es­ tablished fit indices: comparative fit index (cfi), root mean square of approximation (rmsea), standardized root mean square residual (srmr). hu and bentler (1999) recom­ mended the following criteria: cfi ≥ .95, rmsea ≤ .06, srmr ≤ .08 (good fit); cfi ≥ .90, rmsea ≤ .08 (acceptable fit). moreover, chi-square statistics for each sem were determined. several studies found that results of chi-square tests in sem were highly related to sample size, therefore, it was not used for an interpretation of model fit in this study (hu & bentler, 1999; peugh & feldon, 2020). to examine the first hypothesis, whether the subscales of the strengths instrument capture different facets, a sem with the latent variables wirf-evdays, wirf-crisess, schürmann-vengels, troche, victor et al. 9 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ and wirf-probs was arranged. latent variables are usually defined with the single items of the respective measure. however, based on assumptions from prior studies, it was as­ sumed that such a model would have included too many parameters and would have led to estimation problems with respect to the sample size (little et al., 2002). therefore, item parceling was used to reduce the number of parameters in this sem. parceling describes that a subset of items is bundled to packages. in this case, the single items were averaged to scores of the three strengths themes found by victor et al. (2019): action regulation (5 items) relaxation (4 items) social strengths (3 items). latent variables were defined with the item bundles in each context (see figure 1). all latent variables were allowed to covary. furthermore, residual covariances were allowed between corresponding manifest variables in the three subscales (e.g., relaxation in wirf-evdays and wirf-crisess). figure 1 structural equation model of the three-subscale solution of the wirf crisess action1 relax1 social1 action2 relax3 social3 action3 social2 relax2 evdays probs .46 .62 .24 .68 .74 .48 .61 .80 .48 .76 .75 .52 note. evdays = witten strengths and resource form, strengths in everyday life; crisess = witten strengths and resource form, strengths used in prior crises; probs = witten strengths and resource form, in connection with current problems; action/relax/social = items of wirf parceled to action regulation, relaxation, and social support. to examine the second hypothesis, two measurement models for mental health were compared. the first model assumed a dual-factor structure with who-5 and soc-l9 being indicators of a latent variable representing pmh and bsi-18, psq-20 and k-ink being indicators of a latent variable representing nmh. latent variables were allowed strengths and mental health 10 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ to covary. the second model assumed a one-factor structure with all manifest variables loading on one latent variable. models were compared with akaike information criterion (aic) to determine which model better fit the data. the aic is used to compare nested models, with lower values indicating a better model fit (boedeker, 2017). to examine the third hypothesis, a sem combining the better fitting model of men­ tal health from hypothesis 2 with the wirf model from hypothesis 1 was arranged. stepwise regression analyses with the latent variables wirf-evdays, wirf-crisess, and wirf-probs as predictors of the latent mental health/illness factor were conducted and tested with a significance level of α = .05. results preliminary analyses total missing data was 4.93%. all analyzed variables but wirf-probs showed deviations from the normal distribution, p = .028 – p < .001. therefore, non-parametric correlations (spearman) were determined for these relationships: wirf subscales as manifest varia­ bles were significantly correlated with moderate to large coefficients, r = .35 .60, ps < .001. all pmh and nmh variables were strongly correlated to each other. wirf-evdays and wirf-crisess showed modest correlation coefficients in their association with pmh and nmh variables. wirf-probs was moderately to strongly correlated to pmh and nmh measures. table 2 shows descriptive statistics and correlations of analyzed varia­ bles. measurement models the first step was to review the context structure of the wirf. although the chi-square test statistic was statistically significant, the other fit indices suggested that the threesubscale solution for the wirf could be confirmed by means of confirmatory factor analysis, χ2 mlr(15) = 28.43, p = .019, cfi = .98, rmsea = .06, srmr = .06. although all wirf subscales consist of the same items, three delineable factors could be filtered from the data. thus, it seems warranted to assess strengths in the different contexts separately, since the subscales overlap only partially. in a next step, the dualand the one-factor model of mental health were computed and compared against each other. the model fit for the dual-factor model was good regarding cfi (.99) and srmr (.02). however, χ2 mlr-test statistic was significant, χ2(4) = 12.29, p = .015, and the rmsea of .09 was too large. the aic was 2275.38. moreover, the covariance matrix of the latent variables in the dual-factor model was not positive definite due to a high estimated correlation between nmh and pmh suggesting virtual identity of the two latent variables. schürmann-vengels, troche, victor et al. 11 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ table 2 descriptive statistics and correlations of analyzed variables measure 1 2 3 4 5 6 7 8 1. wirf-evdays – 2. wirf-crisess .60*** – 3. wirf-probs .43*** .35*** – 4. who-5 .19** .18** .55*** – 5. soc-l9 .16** .24*** .42*** .50*** – 6. bsi-18 -.12 -.14* -.44*** -.56*** -.67*** – 7. psq-20 -.11 -.13* -.44*** -.58*** .67*** .61*** – 8. k-ink -.19** -.17** -.50*** -.53*** .75*** .59*** .68*** – m 3.39a 3.00a 2.87a 1.62b 3.80c 1.13d 2.89e 3.05f sd 0.82 0.91 0.94 1.00 1.13 0.72 0.56 0.66 note. spearman ρ coefficients are displayed; wirf-evdays = witten strengths and resource form, strengths in everyday life; wirf-crisess = witten strengths and resource form, strengths used in prior crises; wirfprobs = witten strengths and resource form, strengths in connection with current problems; who-5 = who-5 well-being index; soc-l9 = sense of coherence scale – short form; bsi-18 = brief symptom inventory – short version; psq-20 = perceived stress questionnaire; k-ink = incongruence questionnaire – short version. an = 274. bn = 257. cn = 258. dn = 245. en = 243. fn = 259. *p < .05. **p < .01. ***p < .001. the fit of the one-factor model, however, was worse compared to the dual-factor model, χ2 mlr(5) = 25.54, p < .001, cfi = .97, rmsea = .13, srmr = .03, aic = 2287.22. in sum, the dual-factor model led to estimation problems, but the one-factor model did not describe the data adequately. therefore, we sought to improve the data description of the one-factor model, which could be achieved by allowing a residual correlation between the two indicators of pmh (i.e., who-5 and soc). this led to a trending acceptable data fit of the one-factor model, χ2 mlr(4) = 12.29, p = .015, cfi = .99, rmsea = .09, srmr = .02, aic = 2275.38. thus, confirmatory factor analysis revealed that a dual-factor structure for mental health with a differentiation between positive and negative aspects was not appropriate in our sample. the closest fit was a bipolar model (one factor) in which high mental illness was almost always associated with low mental health. the further analyses were conducted based on the adjusted one-factor model. the latent factor of this model will be named mental illness in the following, because nmh constructs loaded positively, while pmh constructs loaded negatively on that factor (see figure 2). strengths and mental health 12 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ figure 2 structural equation model of the one-factor model of mental illness .37 bsi-18 psq-20 k-ink who-5 soc-l9 mi .83 .74 .82 .74 .89 note. mi = latent mental illness factor; bsi-18 = brief symptom inventory – short version; psq-20 = perceived stress questionnaire; k-ink = incongruence questionnaire – short version; who-5 = who-5 well-being index; soc-l9 = sense of coherence scale – short form. latent regression analyses after having established measurement models of strengths and mental health, we inves­ tigated the relationship between the wirf subscales and general mental illness by means of a latent regression analysis (see figure 3). figure 3 core of the structural equation model for the regression of the wirf subscales on mental illness probs .41 bsi-18 psq-20 k-ink who-5 soc-l9 mi .83 .74 .82 .76 .88 crisess evdays .47 .62 .24* -.27** -.73*** .24 note. evdays = witten strengths and resource form, strengths in everyday life; crisess = witten strengths and resource form, strengths used in prior crises; probs = witten strengths and resource form, in connection with current problems; mi = latent mental illness factor; bsi-18 = brief symptom inventory – short version; psq-20 = perceived stress questionnaire; k-ink = incongruence questionnaire – short version; who-5 = who-5 well-being index; soc-l9 = sense of coherence scale – short form. schürmann-vengels, troche, victor et al. 13 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ when mental illness was regressed on the three subscales of the wirf separately, all three regression coefficients were statistically significant with β = -0.36, p = .007, for wirf-evdays, β = -0.29, p = .007, for wirf-crisess, and β = -0.67, p < .001, for wirf-probs. the model resulting from the multiple regression of mental illness on all three wirf subscales fitted the data well, χ2 mlr(61) = 126.12, p < .001, cfi = .96, rmsea = .06, srmr = .05. wirf-crisess and wirf-probs were almost unchanged when compared to the single regression analyses. more self-perceived strengths in these contexts were asso­ ciated with less mental illness. the two scales are incrementally significant and predict independent proportions of mental illness. however, the link between mental health and wirf-evdays changed its sign from negative to positive. this may be interpreted as a negative suppression effect resulting from the inclusion of other predictors (beckstead, 2012). in a post-hoc analysis, it was found that the inclusion of wirf-probs affected this suppression effect on wirf-evdays, suggesting that these two subscales share a high common intersection with the criterion (mental illness). wirf-evdays can, therefore, not be considered an independent predictor. table 3 shows results of the latent regression analysis. table 3 results of the latent regression analysis with all wirf subscales included as predictors variables b se z p std.lv criterion: mental illnessa wirf-evdays 0.20 0.10 2.11 .035 0.24 wirf-crisess -0.21 0.08 -2.62 .009 -0.27 wirf-probs -0.44 0.05 -8.69 < .001 -0.73 note. wirf-evdays = witten strengths and resource form, strengths in everyday life; wirf-crisess = witten strengths and resource form, strengths used in prior crises; wirf-probs = witten strengths and resource form, in connection with current problems; b = estimate of predictor in the sem; se = standard error; std.lv = standardized estimate of the continuous latent variable. alatent factor of the one-factor model (positive and negative mental health as two opposite poles). discussion one aim of this study was to analyze a multidimensional assessment of strengths devel­ oped for the application in clinical samples. many patients experience a lot of negative feelings and low self-efficacy in dealing with current problems at the beginning of psy­ chotherapy (tecuta et al., 2015). as studies suggest, the perception of one's own strengths also seems to be limited by this negative perspective. strengths that are present despite the problems and symptoms (e.g., taking up a hobby) are not necessarily experienced by patients as helpful, although outsiders would name these aspects as strengths. only strengths and mental health 14 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ measuring strengths to deal with current problems seems to provide little information gain in the clinical context, as such measures tend to inversely express problem burden. the assessment tool used in this study (i.e., the wirf) measured strengths with three subscales: (1) strengths in everyday life (evdays), (2) strengths used to successfully cope with previous crises (crisess), and (3) strengths in connection with current problems (probs). it was intended to examine whether the subscales are indeed distinguishable and whether they provide a better prediction of mental health. another aim of this study was to test the assumptions of the dual-factor model of mental health on another clinical sample. for this purpose, we investigated whether patients' data at therapy start point to an independence of well-being and distress, or whether only one of these states was experienced at a time. results showed that the wirf subscales were significantly interrelated with moder­ ate to large coefficients. probs showed moderate correlation coefficients in relation to pmh and nmh measures, while evdays and crisess were only slightly associated with these variables. although each subscale was comprised of the identical 12 items, the three-subscale solution of the wirf was confirmed. the subscales were filtered out as partially independent factors, suggesting that strengths can be captured in separate contexts by using explicit instructions. only a one-factor model of mental health/illness was appropriate for data of the clinical sample. nmh measures were positively related, and pmh measures negatively related to the latent factor. this result means that patients with high symptom burden hardly experienced well-being at the same time. all wirf subscales were significant predictors of the mental illness factor in the latent regression analysis. the coefficients of wirf-crisess and wirf-probs remained stable in the multi­ ple regression analysis. these two subscales were significant and incremental predictors of lower mental illness. interpretation of results our first hypothesis was confirmed as findings support the multidimensional structure of the wirf. although all subscales query the same 12 items and the same strengths in terms of content, they could be statistically distinguished. the questionnaire uses in­ structions to focus patients' perceptions on the particular context. in contrast, established instruments only capture positive trait characteristics or strengths that are currently ex­ perienced (peterson & park, 2009; tagay et al., 2014). a unique feature of the instrument in this study is that the wirf also captures strengths that have been used successfully in the past and in good times. this differential assessment of strengths seems to be relevant in clinical samples, as studies indicate a high problem focus and negative affect in patients (stanton & watson, 2014). willutzki (2008) states that the high level of suffering of individuals at the beginning of therapy leads to the fact that they hardly perceive existing strengths in themselves or evaluate them as helpful. in other words, patients’ perception of their strengths is strongly related to current distress and can hardly be schürmann-vengels, troche, victor et al. 15 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ assessed independently of problems (cf. iasiello et al., 2022). the statistically independent subscales of the wirf may make existing strengths more visible to patients themselves and their therapists. this might have scientific implications: as shown in the testing of the third hypothesis, the wirf subscales were independent predictors of mental illness. wirf-probs accounted for the largest proportion of variance, which means that a person with many self-perceived strengths for coping with current problems had fewer symptoms and more well-being. this result was to be expected since successful problem management usually leads to less stress. beyond this effect, wirf-crisess incrementally predicted mental illness. this indicates that patients who are currently under a lot of stress, but at the same time know what strengths have helped them in the past, have better mental health in comparison to persons with less good strengths awareness. the awareness of strengths in coping with previous crises may be associated to a stable sense of mastery, which was positively related to resilience and mental health in prior studies (burns et al., 2011). wirf-crisess may be relevant to research that focuses on the description and etiology of mental health in clinical populations, as it seems to be less entwined with psychopathology and, therefore, may contribute to an increase in information (bos et al., 2016). moreover, in the context of psychotherapy research, wirf-crisess was found to be a significant predictor of treatment outcome beyond problem-associated measures (schürmann-vengels et al., 2022). the independence of wirf subscales also provide practical implications: although recent studies indicated that patients perceive fewer current strengths than healthy individuals, this does not mean that strengths to cope with their problems do not exist (goldbach et al., 2020; victor et al., 2019). the results of this study highlight that it makes sense for therapists to actively address existing strengths to further foster mental health. it may be helpful to draw the patient’s attention to helpful abilities, pleasant activities, or positive relationships. for example, interventions from the solution-focused brief therapy are recommended because these target situations in which patients have already been able to use their strengths successfully (similar to wirf-crisess; franklin et al., 2017). the diagnostic of strengths during treatment with the wirf can have the advantage that patients on the one hand recognize which strengths have helped them in the past (via crisess) and on the other hand experience how strengths develop during psychotherapy (via probs). patients answered the subscales differently in this study, which suggests that a comparison between the contexts may provide therapists with additional information. this could facilitate working with patients’ strengths in sessions. the dual-factor model of mental health was not supported in this clinical sample. a high association of positive and negative variables was found, similar to prior studies in this framework (franken et al., 2018; lukat et al., 2016; van erp taalman kip & hutschemaekers, 2018). this finding suggests that positive and negative facets of mental health are more entwined in people with pronounced symptoms than in healthy subjects. one possible explanation for this finding could be that patients focus strongly on bur­ strengths and mental health 16 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ densome factors at the beginning of psychotherapy. from a clinical perspective, such negativity bias may contribute to patients' poorer ability to perceive positive aspects in their lives or to judge them as relevant (carl et al., 2013; gollan et al., 2016). this, in turn, might lead to patients frequently talking about problems and little about positive experi­ ence in the therapy session. a recent study also showed that instruments assessing pmh are answered differently by individuals with severe distress than by healthy subjects (iasiello et al., 2022). patients may tend to condition their well-being on the presence of psychopathological symptoms and automatically fill out positive questionnaires low. these explanatory attempts should be considered as hypotheses and tested in future research. almost all studies on the dual-factor model find degree of independence of positive and negative facets of mental health even in clinical samples (de vos et al., 2018; díaz et al., 2018; franken et al., 2018; teismann et al., 2018). in addition, a study using ecological momentary assessment in individuals with generalized anxiety disorder showed that these people self-reported several positive phases in their daily lives, despite severe worry (vîslă et al., 2021). these results suggest that patients can, in principle, also report well-being and positive moments. however, a problem focus often dominates in patients themselves and in therapy. therefore, it is recommended to provide space for positive reports from patients (even if they are rare or seem small). therapists should also ask specifically about patients’ strengths, exceptions, and positive changes. limitations and future directions this study has several limitations. the size of the clinical sample was small for sem, according to established thumb rules of 5-10 observations per parameter, so that repli­ cation studies are needed. on the other hand, simulation studies indicated that even smaller sample sizes could be sufficient for particular sem analyses (e.g. wolf et al., 2013). no comparisons to other clinical samples or healthy controls were included, which limits generalizability of the results. moreover, the cross-sectional design restricted the predictive value assumed in the regression analysis. longitudinal designs should analyze the predictive relevance of the strengths subscales for pmh and nmh. furthermore, moderation analyses should differentiate how resources act on mental health in clinical samples. our results suggest the assessment of strengths in psychotherapy studies. re­ peated assessment of strengths during treatment should trace potential increases of pmh and related process factors. conclusion the wirf is a promising complementary instrument of strengths in clinical psychology and psychotherapy. its multidimensional structure reaching beyond current problems is a unique feature of the instrument and may be relevant for etiology and intervention schürmann-vengels, troche, victor et al. 17 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://www.psychopen.eu/ studies. the results of this study suggest that pmh is not easily detected in the presence of simultaneous marked psychopathology. this underlines the relevance of differential assessments of patients’ positive facets. funding: this research did not receive any special grant from funding agencies in the public, commercial or nonprofit sectors. primary sponsor of this study is witten/herdecke university. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors declare that they have no competing interests. author contributions: jsv, st, ppv, tt, and uw contributed to the study design. ppv and uw implemented the study at the treatment center. jsv and ppv contributed to the data collection. jsv and st conducted all statistical analyses. jsv wrote the initial draft of the manuscript. all authors read and approved the final version of the manuscript. ethics statement: ethics approval for the study was provided by the ethics committee of witten/herdecke university (germany) in april 2015, approval no. 40/2015. all participants provided written informed consent. twitter accounts: @clinicalsherman references alterman, a. i., cacciola, j. s., ivey, m. a., coviello, d. m., lynch, k. g., dugosh, k. l., & habing, b. 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(2005). promoting mental health: concepts, emerging evidence, practice. world health organization. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. schürmann-vengels, troche, victor et al. 23 clinical psychology in europe 2023, vol. 5(2), article e8041 https://doi.org/10.32872/cpe.8041 https://doi.org/10.1002/jclp.22621 https://doi.org/10.1024/1661-4747/a000388 https://doi.org/10.3389/fpsyg.2021.722881 https://doi.org/10.1177/0013164413495237 https://www.psychopen.eu/ strengths and mental health (introduction) objectives method design and sample description instruments statistical analyses results preliminary analyses measurement models latent regression analyses discussion interpretation of results limitations and future directions conclusion (additional information) funding acknowledgments competing interests author contributions ethics statement twitter accounts references qualitative approximations to causality: non-randomizable factors in clinical psychology scientific update and overview qualitative approximations to causality: nonrandomizable factors in clinical psychology michael höfler 1, sebastian trautmann 2, philipp kanske 1,3 [1] clinical psychology and behavioural neuroscience, institute of clinical psychology and psychotherapy, technische universität dresden, dresden, germany. [2] department of psychology, medical school, hamburg, germany. [3] max planck institute for human cognitive and brain sciences, leipzig, germany. clinical psychology in europe, 2021, vol. 3(2), article e3873, https://doi.org/10.32872/cpe.3873 received: 2020-06-14 • accepted: 2021-01-14 • published (vor): 2021-06-18 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: michael höfler, clinical psychology and behavioural neuroscience, institute of clinical psychology and psychotherapy, technische universität dresden, chemnitzer straße 46, 01187 dresden, germany. tel: +49 351 463 36921. e-mail: michael.hoefler@tu-dresden.de supplementary materials: materials [see index of supplementary materials] abstract background: causal quests in non-randomized studies are unavoidable just because research questions are beyond doubt causal (e.g., aetiology). large progress during the last decades has enriched the methodical toolbox. aims: summary papers mainly focus on quantitative and highly formal methods. with examples from clinical psychology, we show how qualitative approaches can inform on the necessity and feasibility of quantitative analysis and may yet sometimes approximate causal answers. results: qualitative use is hidden in some quantitative methods. for instance, it may yet suffice to know the direction of bias for a tentative causal conclusion. counterfactuals clarify what causal effects of changeable factors are, unravel what is required for a causal answer, but do not cover immutable causes like gender. directed acyclic graphs (dags) address causal effects in a broader sense, may give rise to quantitative estimation or indicate that this is premature. conclusion: no method is generally sufficient or necessary. any causal analysis must ground on qualification and should balance the harms of a false positive and a false negative conclusion in a specific context. keywords causality, causal considerations, counterfactuals, directed acyclic graphs this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3873&domain=pdf&date_stamp=2021-06-18 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • causal inference outside randomized, controlled experiments and trials is rare in clinical psychology, regardless of the rich methodology that has evolved in the last decades. • the attractiveness of these new formal tools distracts from their limits and expenditure, but considerable benefit is hidden in their qualitative use. • qualitative considerations may suffice to approximate causal answers. causal questions drive most scientific reasoning. this should entail plenty of causal analyses, but clinical psychology often avoids causality because the established gold standard, a randomized controlled experiment or trial (rct), is in many cases infeasible. although we cannot or should not manipulate variables such as gender, traumatic events, personality traits and other constructs, their effects on clinical outcomes must be investi­ gated to inform prevention, intervention, policies, theories and further research. the specific problem of causality in observational studies the methodological toolbox has been greatly expanded. it now offers approaches to causal answers in non-randomized studies (greenland, 2017). these new tools mainly address the specific problem of causality: without randomization, a binary factor x (group comparison, e.g., with and without a bipolar disorder diagnosis) and outcome y (e.g., amount of substance use) often have shared causes, z (e.g., parental mental health), that are out of experimental control and cause bias in an estimate of the average effect of x on y. in linear models and for just a single z, this bias is the product of the effect of z on x and y, meaning that it equals α1 * α2, where α1 denotes the effect of z on x, and α2 the effect of z on y (e.g., gelman & hill, 2007, chapter 9). this simple formula implies that a. bias occurs only if α1 ≠ 0 and α2 ≠ 0 b. the direction of bias just depends on the signs of α1 and α2. if they are equal, bias is upward, otherwise downward. c. bias is small if either is small these properties generalize to non-linear relations and any distributions of y and z and to multiple z that are independent or positively inter-related (groenwold, shofty, miočević, van smeden, & klugkist, 2018; pearl’s “adjustment formula” is the most general expression; pearl, 2009). we refer to the above as the basic confounding relation. experimental control and randomization together disconnect all confounders z from x and thus eliminate confounding bias. otherwise, x is just observed, and in life-sciences qualitative approximations to causality 2 clinical psychology in europe 2021, vol. 3(2), article e3873 https://doi.org/10.32872/cpe.3873 https://www.psychopen.eu/ like clinical psychology the number of natural causes of an x might be vast. the new methodical tools try to unravel the x-y relation in an imaginary world in which x (or y) was independent of z and thus simulate what changing (rather than observing) x would do with y (“do(x),” pearl, 2009). the new methods mimic what might be observed if x were changed, but unlike real-world change experiments where x is isolated, their use requires an explicit understanding of the relationships between variables z and x. likewise, during their elaboration it has been stressed that one must consider how an x is to be changed because this may make a large difference (greenland, 2005a). for example, just stopping drug use might even worsen an outcome if an intervention does not address factors like stress coping, a putative cause of drug use. in this sense, the new methods complement randomized experiments and rcts through the more explicit need to go beyond a single x, thus to move from “causal description” to “causal explanation” (johnson, russo, & schoonenboom, 2019). for other (non-specific) sources of bias like selection and measurement error that also effect the results of randomized studies, see the supplementary materials. instead of making use of the new methodological toolbox to approach causal answers in observational studies, clinical psychology was dominated by the “mantra” that “corre­ lation is not causation” (pearl & mackenzie, 2018, back of the book). for a historical account on how this stance has emerged through the statistical pioneer karl pearson, who had considered causality to equal perfect (deterministic) correlation, see pearl and mackenzie (2018). aim of this paper some papers have already introduced tools from the new methodical box in (clinical) psychology and summarized the meanwhile vast literature on them (dablander, 2020; marinescu, lawlor, & kording, 2018). however, these have mainly focussed on quanti­ tative approaches in a discipline where methodical causal thinking is new and, thus, requires qualitative guidance beforehand. one such instance is that psychology needs not only to overcome “retreating into the associational haven” (hernán, 2005), but also im­ munization against overconfidence (greenland, 2012) in novel methods. overconfidence mainly concerns the quantitative and highly formal methods, because the mathematical sophistication in these easily obstructs the sight for hidden assumptions and over-sim­ plification through translation into mathematics (greenland, 2012, 2017; vanderweele, 2016). costs of using these methods also include learning and conducting them (which is error-prone) and the further degrees of freedom in analysis through their use which promotes p-hacking. we argue that qualitative approaches as exemplified in this article are easier to access and invite more debate and refinement on them and should at least inform the decision of using a particular quantitative method. we focus on a few causal conceptions that we believe are most illustrative for causal quests: the above basic höfler, trautmann, & kanske 3 clinical psychology in europe 2021, vol. 3(2), article e3873 https://doi.org/10.32872/cpe.3873 https://www.psychopen.eu/ confounding relation (1), counterfactuals (2), popular qualitative considerations (3) and directed acyclic graphs (dags) (4). the following figure illustrates the scheme by which we describe how qualitative approaches may guide a causal quest. figure 1 scheme of qualitative approaches guiding causal quests note. these might be sufficient for overall causal answers, give rise to designing a new study and/or quantitative analysis, or suggest that such analysis is premature. the basic bias relation, counterfactuals and dags belong to the new toolbox of causal methods. qualitative approaches gender effects and the basic bias relation the effects of gender (biological sex) may play an important role for the development and maintenance of mental disorders. if they exist to considerable extent, they contribute to explaining the different aetiology of disorders that are more prevalent in females (e.g., internalizing disorders such as depression) and males (e.g., externalizing disorders such as substance use disorders). this is because gender may also affect many putative aetiological factors (e.g., response styles such as rumination; johnson & whisman, 2013; which, in turn, may influence the onset of disorders; emsley & dunn, 2012). qualitative approximations to causality 4 clinical psychology in europe 2021, vol. 3(2), article e3873 https://doi.org/10.32872/cpe.3873 https://www.psychopen.eu/ but is the causal wording “effect” warranted here? with the basic bias relation, we are equipped to ask: are there shared causes of gender and a disorder y? if it holds true that gender is largely random in the sense that it depends only on factors that do not also affect the disorder (scarpa, 2016, and references therein), then no confounding bias is expected. if such factors exist (e.g., environmental pollution; astolfi & zonta, 1999) but affect y only weakly, they may be neglected since the bias through them should be small. if bias from other sources is also negligible like selection and measurement, a causal conclusion seems informed. upward bias through confounders that affect x and y with the same sign in the presence of reliable associational results, the basic bias relation can be applied well beyond gender effects. if there is at most a weak association between an x and a y, and assuming that the common causes of x and y affect both positively or both negatively (and are unrelated or positively inter-related), bias should be upward. hence, the effect of x on y should be smaller than the association and, thus, be absolutely small (and probably negligible). for example, the relatively weak and often inconsistently reported association between anxiety and alcohol use might be explained by genetic and personality factors increasing the risk for both (schmidt, buckner, & keough, 2007). such risk increasing may frequently apply: psychopathology in parents, genetic factors, stable personality traits, stressful life events and prior mental disorders are factors that might all affect disorders positively and be positively inter-related (uher & zwicker, 2017). however, with a larger number of shared factors, the probability rises that some have negative relations, but if these are few and unlikely to dominate bias (because their effects on x and y are not very large as compared to those of the other factors), a researcher may still use the consideration. counterfactuals and a defendable assumption on them the above gender example brings up an important limitation yet in the standard “coun­ terfactual” definition of a causal effect. biological sex cannot be entirely changed (beyond transsexual transformation) or imagined to be changed, but social aspects of gender can (glymour & glymour, 2014). imagining a person under an alternative x condition is called counterfactual and defines an effect as the amount of change in y if x is changed from one value to another (if this equals zero, there is no effect). consider the putative effect of childhood trauma (ct) on depression (de). yet the idea of counterfactuals points out that “the effect” is imprecise since there are actually two counterfactuals and associated effects: a) trauma experience in individuals who actually do not experience trauma and b) trauma recovery in those who actually had experienced a trauma (but do not recover). just referring to höfler, trautmann, & kanske 5 clinical psychology in europe 2021, vol. 3(2), article e3873 https://doi.org/10.32872/cpe.3873 https://www.psychopen.eu/ “the effect” denotes the total effect, which means that we imagine both changes at once (pearl, 2009). such a summary appears pointless in clinical psychology, at least if one aims to keep aetiology and persistence/maintenance apart which seems important since in many cases, different factors seem to be involved in the onset versus the persistence of mental disorders (mclaughlin et al., 2011). the effect of experiencing a ct is, in principle, subject to a prevention rct, but such studies would be highly ineffective. this is because ct prevention will never succeed among all individuals and is unethical if the control group is deliberately exposed to ct although exposure (and associated harm) could have been prevented. the effect of recovery from a trauma on the other hand; i.e., of successful intervention, can in principle be investigated in an rct, but only with regard to specific consequences of ct. this not only heavily depends on what is meant with “consequences” (e.g., distress, symptom onset, incidence of a diagnosis) and the mode of intervention, it is confounded with the aim of investigating the recovery effect (greenland, 2005a). at least for onset, “target trials” (here prevention trials) may be an effective further tool to clarify what a counterfactual specifically means (vanderweele, 2016). a target trial is an ideal trial (or experiment) the data of which would provide the desired causal answer. it clarifies qualitatively what we would require, what we cannot do, but what we can anyway imagine (lewis, 1973; pearl, 2013), including the target population to infer on. for a conclusion on the existence of either effect, crude estimates of counterfactual depression rates (generally mean outcomes) among those with and without ct, respec­ tively, are necessary. if we know empirically that, say, 5% of those without ct develop depression later in life, and we assume that the experience of ct in all the observed individuals would have increased this rate (i.e., the counterfactual rate is >5%; probably few clinical psychologists would doubt this), the conclusion that ct experience increases the risk for depression is valid. likewise if, say, 10% of those with ct have depression later on, we may conclude that an intervention decreases the rate provided that we are willing to assume that the intervention would achieve a rate below 10%. this line of qualitative argument determines the “target quantity” (petersen & van der laan, 2014) one wishes to estimate. it may also trigger other considerations like substituting unknown counterfactual depression rates from other, “analogous” (hill, 1965) studies. for trauma experience, a sample of children traumatized by war may be used and for recovery, a sample of traumatized, untreated but resilient children. granger causality imagining counterfactual states of brains in neuroscience and neuroimaging research seems meaningful, but in associated longitudinal studies there is a shortcut to the specif­ ic causal problem of common causes hidden in the term “granger causality” (friston, moran, & seth, 2013). originally, the term states that, given “all the information in the qualitative approximations to causality 6 clinical psychology in europe 2021, vol. 3(2), article e3873 https://doi.org/10.32872/cpe.3873 https://www.psychopen.eu/ universe up to time t” (eichler & didelez, 2010), and provided that the prediction of y at time t + 1 is worse if an x at any time up to t is disregarded, then this prior x is a cause of y (granger, 1969). although equivalent with the counterfactual definition, granger causality has been frequently mistaken as only referring to observed x variables (eichler, 2012; eichler & didelez, 2010) or even just a time-series of a single x (marinescu et al., 2018). this downgrades the conception into a heuristic for practical use with the easily wrong qualitative suggestion that adjustment for common causes has been sufficient. researchers who use it must be aware of the basic bias relation indicating that they play into their own hands if they ignore unobserved common causes that effect x and y with the same sign. these may include variables that have occurred before study onset. generally, collecting big data like thousands of voxels in a brain scan is no substitute for thoughtful reflections on the processes beyond the data that any defendable causal analysis relies on (pearl & mackenzie, 2018). in the supplementary materials we briefly discuss other popular and, mostly long­ used approaches: multimethod evidence, mixed methods research and ruling out alterna­ tives. directed acyclic graphs so far, we have only addressed direction of bias but not when and how bias can be removed. in the supplementary materials, we revisit the example of the effect of ct on de to outline the qualitative answers that the qualitative method of dags provides, including the subsequent study design and analysis that a particular dag model may give rise to. the example uses a model with four common causes and causal relations among them. it reveals that adjustment for them is possible in subsequent quantitative analysis (whereby one shared cause does not require adjustment). importantly, dags may include effects of unchangeable factors like “socio-econom­ ical family status” in the example where the counterfactual conception of an effect does not apply. the conception, however, may be extended to include other actors than humans who could change an x (bollen & pearl, 2013). sometimes such an actor is difficult to name let alone to translate into a mathematical model, wherefore instances like “socio-economical family status” are more suited “to describe something as a cause” than to “reasonably define a quantitative causal effect estimand” (vanderweele, 2016). qualitative assumptions may make quantitative approaches seem premature in contrary to the above instance, a dag might reveal that bias can not be fully elim­ inated, or leave open whether an adjustment decreases or increases bias (morgan & winship, 2014, chapter 3). the practical utility of dags for quantitative analysis rises with fewer variables in them and the number of causal relations that can be assumed höfler, trautmann, & kanske 7 clinical psychology in europe 2021, vol. 3(2), article e3873 https://doi.org/10.32872/cpe.3873 https://www.psychopen.eu/ not to exist (greenland, 2017). however, setting up a dag model should reveal this. per se, a dag renders all associated assumptions transparent and invites for debate and refinement on them (the reader might ask herself if this happens with the figure in the supplementary materials). anyway, controversy on a model might be so large that grounding a study and quantitative analysis on it appears unwarranted (petersen & van der laan, 2014). also, if the number of potential common causes is large and there is no way to prioritize them for reducing bias, quantitative analysis seems premature. instead, more research is required beforehand to set up a defendable dag. an example is the effect of inter­ nalizing symptoms on substance use where common causes may include a variety of genetic, parental, childhood, personality and environmental factors, as well as all sorts of individual variables related to neurobiological, cognitive and emotional processes (pasche, 2012). conclusions no method can fully cover all aspects of causality across research fields and specific applications, especially in a life science as complex as clinical psychology (greenland, 2017), and “there is no universal method of scientific inference” (gigerenzer & marewski, 2014). likewise, a causal query can never be fully objective, because it always involves assumptions beyond the data (greenland, 2005b). in sharp contrast, researchers tend to “mechanizing scientists’ inferences” (gigerenzer & marewski, 2014) and downgrade methods from tools for thoughtful cooperation between methodologists and substantive experts (höfler, venz, trautmann, & miller, 2018) into empty rituals (gigerenzer, 2018). in this article, we have outlined some qualitative approaches through which one may approach a crude causal answer on an average effect, plan a quantitative analysis or unravel that any analysis is currently infeasible. in fact, any causal quest must start with qualification because otherwise it would be just a mechanical exercise. the qualitative conceptions outlined here are meant as provisory heuristics that must not be ritualized but should be taken as invitations for refinement and adjustment to any particular application. above all, the two possible errors in causal conclusions should guide causal quests and the decision on whether the use of a highly formal method pays off (greenland, 2012): false positive and false negative. statistical decision theory provides the frame­ work to formalize the balance between false positive and false negative causal conclu­ sions. it states that the better decision is the one with the lower expected costs (dawid, 2012). thoughtful causal quests are essential for explaining why phenomena occur the way they do and in providing levers through which things could be changed, for instance, in preventing disorders and improving life. assessing causality is complex, demanding and qualitative approximations to causality 8 clinical psychology in europe 2021, vol. 3(2), article e3873 https://doi.org/10.32872/cpe.3873 https://www.psychopen.eu/ ambivalent, but so is science. however, it makes use of the natural capacity of causal modelling which is deeply grounded in us human beings and structures how we view the world (pearl & mackenzie, 2018). funding: the authors have no funding to report. acknowledgments: we wish to thank konrad lehmann for the layout of the figure. competing interests: the authors have declared that no competing interests exist. supplementary materials the supplement provides additions to the paper, namely other sources of bias than confounding, and futher popular approaches to causality besides those from the new toolbox and granger causality. besides, it addresses the example of the effect of childhood trauma (factor x = ct) on depression (outcome y = de) using a dag (directed acyclic graph) model on common causes and subsequent study design and data analysis the model gives rise to (for access see index of supplementary materials below). index of supplementary materials höfler, m., trautmann, s., & kanske, p. 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(2016). commentary: on causes, causal inference, and potential outcomes. international journal of epidemiology, 45(6), 1809-1816. https://doi.org/10.1093/ije/dyw230 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. qualitative approximations to causality 12 clinical psychology in europe 2021, vol. 3(2), article e3873 https://doi.org/10.32872/cpe.3873 https://doi.org/10.1093/ije/dyw230 https://www.psychopen.eu/ qualitative approximations to causality (introduction) the specific problem of causality in observational studies aim of this paper qualitative approaches gender effects and the basic bias relation upward bias through confounders that affect x and y with the same sign counterfactuals and a defendable assumption on them granger causality directed acyclic graphs qualitative assumptions may make quantitative approaches seem premature conclusions (additional information) funding acknowledgments competing interests supplementary materials references laudatio for distinguished scholar dr. aaron t. beck editorial laudatio for distinguished scholar dr. aaron t. beck claudi l. h. bockting 1 [1] amsterdam umc, university of amsterdam, amsterdam, the netherlands. clinical psychology in europe, 2021, vol. 3(2), article e6871, https://doi.org/10.32872/cpe.6871 published (vor): 2021-06-18 corresponding author: claudi l. h. bockting, department of psychiatry, amsterdam university medical center, university of amsterdam, meibergdreef 5, 1105 az amsterdam, the netherlands. e-mail: c.l.bockting@amsterdamumc.nl on behalf of the european association of clinical psychology and psychological treat­ ment (eaclipt), i am honored to have the opportunity to award dr. aaron t. beck (md) with the european ‘diamond distinguished contributor to psychological interventions award’. on july 18, 2021, dr. beck will celebrate his 100th birthday. as a psychiatrist and scientist, he spent almost his entire career on reducing human suffering. with a medical and academic career spanning more than 70 years, 600 published articles, 25 books, and numerous awards, it is without doubt that dr. beck has greatly influenced and shaped our current thinking on psychopathology and clinical practice beyond the measurable. albeit, measurability was of utmost concern to him during his career. originally starting out as a neurologist after his medical training at yale, particularly liking the precision of this field, he soon found himself becoming absorbed in psychoanalysis. carrying over his interest in empirical work, he later widely explored and rigorously tested the psychoanalytic model of depression as a psychiatrist at the university of pennsylvania. other than expected he did not find evidence for the psychoanalytic concept, but rather unraveled the core assumptions of cognitive therapy. due to his unremitting work, psychological interventions became more evidence-based, client-focused, and accessible to a wide variety of people with different conditions across the globe. today, cognitive behavior therapy (cbt) is the most studied psychotherapy (>2000 studies on cbt) for most mental health problems globally. even more so, his cognitive behavioral theoretical model has led to groundbreaking insights on the etiology, maintenance, and recurrence of psychopathology. dr. beck is not only the founding father of cbt, he also played a crucial role in demonstrating time and time again that research and clinical practice go hand in hand. that is, already in the early years of dr. beck, the concept scientist practitioner was this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6871&domain=pdf&date_stamp=2021-06-18 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ ‘a given’. most people who had the pleasure to see dr. beck on stage will recall his onstage role-plays. without hesitation, until recent times he was always prepared to do a role-play in public at a conference or at events of the beck institute. in each role-play, dr. beck managed to give the audience the impression it was a piece of cake to conduct cbt. we all know better: it requires a lot of training. nevertheless, it is indeed doable with the right amount of practice, which dr. beck was always aware of. one of the greatest achievements of dr. beck together with the beck institute, and probably one of the ingredients of the therapy’s success, is that cbt is highly transferable by training. the worldwide dissemination of cbt demonstrates clearly that cbt is highly transferable, even across different cultures. dr. aaron t. beck received the diamond distinguished contributor psychological interventions award by the eaclipt on a personal note, i vividly remember my first introduction to dr. beck when he received an honorary membership at the dutch association for cbt. i was invited to join for dinner with dr. beck and a small group, and i was shocked to find out i was seated next to him. as a classical dutch person (usually too direct), i had to actively inhibit my urge to immediately confront him with my slightly provocative questions that challenge laudatio for distinguished scholar dr. aaron t. beck 2 clinical psychology in europe 2021, vol. 3(2), article e6871 https://doi.org/10.32872/cpe.6871 https://www.psychopen.eu/ the cbt model. given all the research on inhibition, you will most likely know how hard it can be to inhibit these questions once they are on top of your mind. they can almost become intrusive, and even rebounce once you attempt to suppress them. so, well aware that pure suppression was not an option, i had to choose a more problem-focused approach. therefore, i decided to discuss something completely different with dr. beck to distract my own mind. and what could be more impartial, universal and pleasing, than talking about music? obviously, having my mental set of beck associations activated, i couldn’t think of any other artist than the famous american musician beck. so, my opening line was: “do you know the very popular song loser, in which beck sings ‘i am a loser baby (so why don’t you kill me)’?”. we discussed that the song might indeed be inspired by cbt. could it be that this song could even lead to cognitive restructuring in listeners? taken together, it includes the identification of rigid negative beliefs, evaluat­ ing the evidence, as well as the formulation of alternative beliefs! after this small talk, of course, my suppressed thoughts rebounced – how could they not? fortunately, dr. beck was happy to discuss all my burning questions, as he has always been after. for instance, why not intervene immediately on beliefs/schema level, instead of starting working on thought level before going there? he gave the only right answer: ‘that is an empirical question. you should study it’. this is, most certainly, another way in which dr. beck influenced science and clinicians: transfer curiosity to an empirical question and study it. i indeed did study this, later on in several trials. i can only imagine the large number of people he inspired throughout his life, and continues to do. dr. beck’s lifework is living and still developing. by the way, dr. beck asked me to send him a disk of the song, and i did. he later told me that he didn’t know the song, but liked the idea of using music or other means to evaluate beliefs on a large scale. he was and is more than willing to provide feedback on articles and research. hereby, he teaches us all an important lesson: curiosity should never stop. after all this time, he still serves as an inspiration to the scientific commun­ ity, numerous scientist practitioners, clinicians all over the world. more importantly he contributed and still contributes significantly to reduce human suffering of many individuals all over the world that suffer from mental health problems and mental health conditions. the eaclipt is proud that dr. beck accepts our european ‘diamond distinguished contributor to psychological interventions award’. claudi bockting professor of clinical psychology in psychiatry amsterdam umc/university of amsterdam president of eaclipt bockting 3 clinical psychology in europe 2021, vol. 3(2), article e6871 https://doi.org/10.32872/cpe.6871 https://www.psychopen.eu/ funding: the author has no funding to report. acknowledgments: the author has no additional (i.e., non-financial) support to report. competing interests: the author has declared that no competing interests exist. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. laudatio for distinguished scholar dr. aaron t. beck 4 clinical psychology in europe 2021, vol. 3(2), article e6871 https://doi.org/10.32872/cpe.6871 https://www.psychopen.eu/ examination of the new icd-11 prolonged grief disorder guidelines across five international samples latest developments examination of the new icd-11 prolonged grief disorder guidelines across five international samples clare killikelly a § , mariia merzhvynska a § , ningning zhou ab , eva-maria stelzer ac , philip hyland d , jose rocha e , menachem ben-ezra f , andreas maercker a [a] department of psychology, university of zurich, zurich, switzerland. [b] department of psychology and cognitive science, east china normal university, shanghai, china. [c] department of psychology, university of arizona, tucson, az, usa. [d] department of psychology, maynooth university, maynooth, ireland. [e] instituto universitário de ciências da saúde, gandra, portugal. [f] school of social work, ariel university, ariel, israel. §these authors contributed equally to this work. clinical psychology in europe, 2021, vol. 3(1), article e4159, https://doi.org/10.32872/cpe.4159 received: 2020-08-03 • accepted: 2020-12-30 • published (vor): 2021-03-10 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: clare killikelly, department of psychology, university of zurich, binzmuehlestrasse 14/17, ch-8050 zurich, switzerland. e-mail: c.killikelly@psychologie.uzh.ch supplementary materials: materials [see index of supplementary materials] abstract background: prolonged grief disorder (pgd) is a new disorder included in the 11th edition of the international classification of diseases (icd-11). an important remit of the new icd-11 is the global applicability of the mental health disorder guidelines or definitions. although previous definitions and descriptions of disordered grief have been assessed worldwide, this new definition has not yet been systematically validated. method: here we assess the validity and applicability of core items of the icd-11 pgd across five international samples of bereaved persons from switzerland (n = 214), china (n = 325); israel (n = 544), portugal (n = 218) and ireland (n = 830). results: the results confirm that variation in the diagnostic algorithm for pgd can greatly impact the rates of disorder within and between international samples. different predictors of pgd severity may be related to sample differences. finally, a threshold for diagnosis of clinically relevant pgd symptoms using a new scale, the international prolonged grief disorder scale (ipgds), in three samples was confirmed. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4159&domain=pdf&date_stamp=2021-03-10 https://orcid.org/0000-0003-2661-4521 https://orcid.org/0000-0002-8871-2875 https://orcid.org/0000-0002-5680-2446 https://orcid.org/0000-0002-3589-8602 https://orcid.org/0000-0002-9574-7128 https://orcid.org/0000-0003-0955-810x https://orcid.org/0000-0002-7890-2069 https://orcid.org/0000-0001-6925-3266 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusions: although this study was limited by lack of questionnaire data points across all five samples, the findings for the diagnostic threshold and algorithm iterations have implications for clinical use of the new icd-11 pgd criteria worldwide. keywords prolonged grief disorder, icd-11, psychometric validity, global applicability highlights • the first study to explore core items of the icd-11 pgd definition in five large international samples • comparison of three different diagnostic algorithms • preliminary analysis of different thresholds for diagnosis in different groups • preliminary estimates of pgd prevalence in 2019 prolonged grief disorder (pgd) was included in the international classification of diseases (icd-11) for the first time. the diagnostic criteria for a disorder of grief have a long history and there are several previous definitions and iterations (prigerson et al., 2009; shear, 2015; wagner & maercker, 2010). the current definition represents a new focus of the world health organization (who) on the clinical utility and global applica­ bility of the disorder (maercker et al., 2013). the rationale for the updated iteration in the new icd-11 definition was to standardize this diagnosis internationally, however, the validity of the diagnostic criteria across different international samples has yet to be established. in this brief report, we test, for the first time, the core items of the pgd icd-11 criteria in five international datasets. the who working groups for the icd-11 adopted a two-phase strategy to update disorder definitions. the first phase involved developing the structure of the definition based on a large international survey of psychologists and psychiatrists (evans et al., 2013; reed, correia, esparza, saxena, & maj, 2011). they called for flexible diagnostic guidelines, recognition of cultural factors, and fewer disorder categories with no sub­ types. the resulting pgd definition included two core symptoms (intense yearning or preoccupation with the deceased), examples of emotional pain (i.e anger, sadness, guilt), at least 6 months duration since loss, and an impairment criterion. for a full description see killikelly and maercker (2017). importantly, the working group also included a cultural caveat whereby symptoms of grief must exceed expected socio-cultural norms. the second phase in the who’s research approach was to evaluate the usability (clinical utility) of these guidelines in diagnostic decision making. recent field studies have been conducted to explore the clinical utility and validity of pgd through clinicians’ assessments of vignettes (keeley et al., 2016; reed et al., 2018) and proposals for further evaluation (gureje, lewis-fernandez, hall, & reed, 2019). these studies confirmed that, icd-11 prolonged grief disorder guidelines across five international samples 2 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ when compared with the icd-10, the current icd-11 including pgd improved the diag­ nostic sensitivity of grief related psychopathology, especially once the duration since loss criteria was included. however, until now this evaluative phase is limited and there are large scientific gaps in establishing the validity of the new icd-11 pgd, particularly in a global context (boelen, spuij, & lenferink, 2019; eisma & lenferink, 2018). previous research has confirmed that pgd may have different prevalence rates in different samples. for example, worldwide rates of a disorder of grief may range from 1% to 10% (kristensen, weisæth, & heir, 2012; lundorff, holmgren, zachariae, farver­ vestergaard, & o’connor, 2017). in a recent scoping review we found that the rates of disordered grief appear to be much higher in asian countries compared to countries in europe and north america (stelzer, zhou, maercker, o’connor, & killikelly, 2020). this may depend on different factors including heterogeneity in the diagnostic criteria used, the sample characteristics, and, perhaps, specific cultural factors that may influence the assessment and reporting of grief symptoms. in this study, we sought to eliminate the methodological variability of previous studies by directly comparing some of the same diagnostic criteria items across multiple national samples, as well as exploring the sample characteristics and their influence on pgd symptoms. this paper explores core items of the new icd-11 pgd disorder criteria along with some of the supplementary items indicating emotional distress, across five international samples. the aims include: firstly, the examination of rates of possible pgd caseness using the same core items and diagnostic formulations in each country. secondly, exami­ nation of criterion validity through the identification of predictors of pgd across and between countries. thirdly, to find provisional cut-off scores and assess the thresholds for the best sensitivity and specificity in each country using the receiver operating characteristic analysis (roc). method participants data from participants who experienced the loss of a loved one were analyzed. data sets were obtained from five different countries: switzerland (n = 214), china (n = 325), israel (n = 544), portugal (n = 218), and ireland (n = 830). for demographic information see table 1.1. for additional demographic characteristics for each sample please see tables 1-4 in the supplementary materials. recruitment and sampling across all of the studies participants were recruited using online survey methods. in addition, the portuguese data also includes a clinical outpatient sample. switzerland: data was collected using an online survey (qualtrics). participants were recruited through killikelly, merzhvynska, zhou et al. 3 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ online and in person fliers posted at german speaking grief and bereavement support groups, online forums and community services (i.e. churches, townhalls, libraries). china: participants were recruited to participate in an online survey (qualtrics) using social media (wechat) and online bereavement forums. israel: participants were recruited as part of a large national online survey using stratified and random sampling methods. ireland: a nationally representative sample were recruited using the company qualtrics. stratified sampling methods were used to select participants based on sex, age and geographical location. portugal: the ‘general’ group were recruited using limesurvey anonymous online survey protocol using the snowball method. the ‘clinical group’ is based on participants from a hospital setting (centro hospitalar tâmega e sousa) where participants received outpatient support for grief difficulties. participants in this group were referred to the grief consultation service part of the clinical psychology unit and had completed informed consent procedures. this service is focused on supporting parental and perinatal losses and data was collected in face-to-face interviews with self-evaluation questionnaires. measures to assess prolonged grief disorder, the international prolonged grief disorder scale with 15 items (killikelly et al., 2020) and the inventory of complicated grief-revised with 8 items (icg-r; prigerson et al., 2009; prigerson & jacobs, 2001) were used. both instruments include two core pgd symptoms (i.e. yearning for the deceased and preoc­ cupation), emotional distress symptoms as well as a measure of functional impairment, and time since loss. for the items of the ipgds please see killikelly et al. (2020). the following 8-items of the icg-r were assessed: core items 1) ‘i think about him/her so much that it can be hard for me to do the things i normally do’ 2) ‘i feel myself longing and yearning for him/her’; accessory symptoms or examples of emotional distress, 3) ‘i feel as if a part of me died’ 4) ‘i feel disbelief over his/her death’ 5) ‘ever since he/she died, i find it difficult to move on with my life’ 6) ‘i am bitter over his/her death’ 7) ‘i feel that it is unfair that i should live when he/she died’ and functional impairment criterion, 8) ‘i believe that my grief has resulted in impairment in my social, occupational or other areas of functioning. unlike the icg-r, the ipgds includes one cultural item (i.e. my grief would be considered worse, e.g., more intense, severe and/or of longer duration, than for others from my community or culture). participants were asked to rate their grief symptoms on a five-point scale (i.e. “not at all” on ipgds or “almost never” on icg-r (1), “rarely” (2), “sometimes” (3), “often” (4), “always” (5)). when filling out the ipgds, participants were asked to mark the answer that best describes their feelings, thoughts and behaviour during the last week. in case of icg-r, they were requested to select an answer that best describes how they felt during the last month. pgd was assessed using the ipgds in switzerland, china, and portugal, and the icg-r in all five countries. recently the ipgds was confirmed to be psychometrically reliable and icd-11 prolonged grief disorder guidelines across five international samples 4 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ valid with strong internal consistency (cronbach's α = .92), high concurrent and criterion validity (see killikelly et al., 2020). previously the 8-item icg-r was shown to have good reliability (cronbach's α = .94) (killikelly et al., 2019). predictors life events checklist (lec) (gray, litz, hsu, & lombardo, 2004) and international trauma exposure measure (item) (hyland et al., 2020) items were measured on a binary scale (0 = no; 1 = yes). for the lec response options 1-2 (happened to me, witnessed it) were merged into ‘yes’ while all other response options were merged into ‘no’. information about traumatic events was not collected for the portuguese sample. furthermore, in the portuguese sample, the duration since loss was not assessed and the data set revealed a high quantity of missing values (100 out of 218 participants) on the icg-r scale. therefore, the portuguese sample was excluded from the data analysis when the association between predictors and pgd was investigated. the cultural item was collected only in switzerland, china, and portugal. the following variables were included in the data analysis as predictors of pgd: 1. gender (measured in all 5 samples) 2. age (measured in all 5 samples) 3. cultural criteria (measured in swiss, chinese, portuguese samples) 4. severe human suffering (measured in swiss, chinese, israeli samples with lec, and in irish sample with item) 5. sudden, violent or accidental death (measured in swiss, chinese, israeli samples with lec and in irish sample with item) 6. serious injury, harm or death you caused to someone (measured in swiss, chinese, israeli samples with lec and in irish sample with item) statistical analysis to estimate possible pgd rates, three different diagnostic algorithms were applied; pgd strict criteria set, pgd moderate criteria set, and the criteria set according to maciejewski et al. (2016). pgd strict criteria set requires the endorsement of at least one core item, at least one item of emotional distress symptoms, and functional impairment; all of which are rated as 4 (often) or higher. pgd moderate criteria set has almost the same require­ ments except all items are rated 3 (sometimes) or higher (killikelly et al., 2020). criteria according to maciejewski et al. includes at least one of two core items, three or more emotional distress items (all rated 4 (often) or above), and no functional impairment. in all three diagnostic algorithms the same time criterion was applied (i.e., loss occurred 6 months ago or longer). the estimated rates of possible pgd were calculated across the five samples with 95% confidence interval (ci). however, it is important to note that some key items were missing in the datasets. in the portuguese and the israeli samples killikelly, merzhvynska, zhou et al. 5 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ the time criteria was not applied due to the absence of the data about time since loss and in the portuguese dataset the functional impairment criterion was not evaluated. therefore we can only examine estimates of possible pgd caseness not prevalence. logistic regression was used to examine the associations between pgd (strict criteria) and some items representing traumatic life events, gender (male/female), age, and cultur­ al caveat item using odds ratio (or) and 95% ci. the outcome was the endorsement of pgd strict criteria; coded as binary variable “yes, possible pgd caseness” (1) or “no” (2). of note, due to the use of heterogeneous questionnaires across the samples, we could only include a few traumatic life event items. in terms of missing values, the default settings of spss were used whereby cases were deleted in a list wise manner. third, re­ ceiver operating characteristic analysis (roc) was used to examine cut-off scores for the ipgds and icg-r, i.e. the threshold for the best fit in terms of sensitivity (high > .80) and specificity (.80). this analysis is presented as an initial exploration and may be highly dependent upon the samples used. roc curves and logistic regression were calculated only for pgd strict criteria (i.e. 12 symptom items plus functional impairment). statistical analyses were performed using spss version 23. results rates of pgd the proportion of people in each sample who met the criteria for possible pgd caseness differed within the country depending on (1) whether strict, moderate or maciejewski et al. (2016) diagnostic criteria were applied and (2) whether ipgds or icg-r were used to assess it. furthermore, there was a difference in rates between the countries, even if assessed with the same diagnostic algorithm and the same measure instrument. for example using the strict criteria of the ipgds the rates ranged from 6.9% to 12.6%, whereas for the icg-r rates ranged from 2.0% to 21.1%. for detailed rates and confidence intervals (ci) see table 1.1 and table 1.2. table 1.1 basic sociodemographic characteristics and predictors in five samples variable swiss (n = 214) (mage = 38.7) chinese (n = 325) (mage = 33.3) israel (n = 544) (mage = 41.4) portuguese (n = 218) (mage = 32.8) irish (n = 830) (mage = 45.4) n % n % n % n % n % gender male 33 15.4 104 32 246 45.2 43 17.5 411 49.5 female 178 83.2 212 65.2 298 54.8 203 82.5 419 50.5 other 3 2 0 0 0 icd-11 prolonged grief disorder guidelines across five international samples 6 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ variable swiss (n = 214) (mage = 38.7) chinese (n = 325) (mage = 33.3) israel (n = 544) (mage = 41.4) portuguese (n = 218) (mage = 32.8) irish (n = 830) (mage = 45.4) n % n % n % n % n % item severe human suffering (lec item 13) 83 38.8 65 20.0 39 7.1 – – – – sudden, violent death (lec item 14)a 62 29.0 53 16.3 71 13.0 – – – – accidental death (lec item 15) 57 26.6 99 30.5 173 31.8 – – – – serious injury, harm or death you caused (lec item 16) 6 2.8 49 15.1 11 2.0 – – – – serious injury, harm or death you caused (item item 12) – – – – – – – – 35 4.2 sudden, violent or accidental death (item item 13) – – – – – – – – 224 27.0 alec items 14 and 15 were merged in the logistic regression. data was not collected for the portuguese sample. table 1.2 estimates of possible pgd using different diagnostic rules across five countries scale swiss (n = 214) china (n = 325) israela (n = 544) portugueseb (n = 218) irish (n = 830) % 95% ci % 95% ci % 95% ci % 95% ci % 95% ci ll ul ll ul ll ul ll ul ll ul ipgds strict criteria 7.0 4.0 11.3 12.6 9.2 16.7 – – – 6.9 3.9 11.1 – – – moderate criteria 21.5 16.2 27.6 37.5 32.3 43.1 – – – 27.5 21.7 34.0 – – – maciejewski criteria 15.9 11.3 21.5 33.5 28.4 39.0 – – – 23.4 17.9 29.6 – – – icg-r (n = 118) estimate only strict criteria 5.1 2.6 9.0 7.1 4.5 10.4 2.0 1.0 3.6 21.1 14.2 29.7 4.1 2.9 5.7 moderate criteria 18.2 13.3 24.1 29.2 24.3 34.5 8.5 6.3 11.1 48.3 39.0 57.7 13.9 11.6 16.4 maciejewski criteria 6.1 3.3 10.2 10.5 7.4 14.3 4.2 2.7 6.3 7.6 3.5 14.0 4.7 3.4 6.4 ain israel dataset for icg-r – no time criteria applied. bin portuguese dataset for icg-r – no time criteria applied, no functional criteria (item 8) applied; for ipgds no time criteria applied, pooled across the general and clinical groups. logistic regression results from the logistic regression analyses showed that pgd assessed with ipgds was significantly associated with the cultural caveat criteria in switzerland, or = 2.463, 95% ci [1.707, 3.554], and in china, or = 3.152, 95% ci [2.361, 4.209]; with serious injury, harm or death to someone else, or = 14.016, 95% ci [1.856, 105.854], in switzerland, and killikelly, merzhvynska, zhou et al. 7 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ with gender (higher risk for women), or = 0.508, 95% ci [0.259, 0.998] in china (see table 2.1). table 2.1 logistic regressions for a set of predictor variables associated with pgd measured with ipgds variable swiss (n = 201) china (n = 302) or 95% ci or 95% ci ll ul ll ul ipgds gendera 1.240 0.331 4.646 0.508* 0.259 0.998 age 1.018 0.989 1.049 1.022 0.996 1.048 cultural criteria 2.463*** 1.707 3.554 3.152*** 2.361 4.209 severe human suffering 2.321 0.898 6.000 1.256 0.507 3.111 sudden, violent or accidental death 1.821 0.734 4.517 0.703 0.342 1.448 serious injury, harm or death you caused 14.016* 1.856 105.854 1.471 0.534 4.055 afemale compared to male. *p < .05. **p < .01. ***p < .001. when pgd was assessed with icg-r, the logistic regression analyses revealed significant associations with the cultural caveat criteria within switzerland, or = 8.148, 95% ci [2.629, 24.782], and china, or = 4.501, 95% ci [2.671, 7.586]; with serious injury, harm or death person caused to someone in china, or = 5.494, 95% ci [1.309, 23.050]; with age, or = 0.964, 95% ci [0.933, 0.966], severe human suffering, or = 5.095, 95% ci 1.670, 15.547], and with sudden, violent or accidental death, or = 3.271, 95% ci [1.178, 9.086], in israel, and finally with gender, or = 0.993, 95% ci [0.967, 1.020], and sudden, violent or accidental death, or = 0.297, 95% ci [0.127, 0.694], in ireland (see table 2.2). examination of provisional cut-off scores the roc analysis was used to determine a cut-off score for those participants meeting the strict criteria for the ipgds and icg-r. the results can be found in table 3. the chinese sample required a slightly higher cut-off score (42.5) for the ipgds when compared to the swiss (37.5) and portuguese (36.5) samples. additionally, for the icg-r the portuguese sample had a lower cut-off (16.5) when compared with the swiss (24.5), chinese (25.5), israeli (24.5) and irish (22.5) samples. icd-11 prolonged grief disorder guidelines across five international samples 8 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ ta bl e 2. 2 lo gi st ic r eg re ss io ns fo r a se t o f p re di ct or v ar ia bl es a ss oc ia te d w ith p g d a s m ea su re d by ic g -r va ri ab le sw is s (n = 2 01 ) c hi na (n = 3 02 ) is ra el (n = 5 44 ) ir is h (n = 8 30 ) or 95 % c i 95 % c i or 95 % c i or 95 % c i ll ul or ll ul ll ul ll ul ic g -r g en de ra 1. 31 9 0. 10 9 15 .9 84 0. 40 7 0. 13 9 1. 19 2 0. 84 7 0. 34 7 2. 06 8 0. 30 3* * 0. 96 7 1. 02 0 a ge 1. 06 0 1. 00 0 1. 12 4 1. 02 3 0. 98 4 1. 06 3 0. 96 4* 0. 93 3 0. 96 6 0. 99 3 0. 13 3 0. 69 2 c ul tu ra l c ri te ri a 8. 14 8* ** 2. 62 9 24 .7 82 4. 50 1* ** 2. 67 1 7. 58 6 – – – – – – se ve re h um an s uf fe ri ng 1. 49 5 0. 29 0 7. 70 8 0. 28 6 0. 05 7 1. 42 8 5. 09 5* * 1. 67 0 15 .5 47 0. 53 5 0. 24 9 1. 14 9 su dd en , v io le nt o r ac ci de nt al d ea th 0. 77 9 0. 14 7 4. 11 7 0. 80 9 0. 24 7 2. 64 8 3. 27 1* 1. 17 8 9. 08 6 0. 29 7* * 0. 12 7 0. 69 4 se ri ou s in ju ry , h ar m o r de at h yo u ca us ed 19 .5 36 0. 26 6 14 33 .8 30 5. 49 4* 1. 30 9 23 .0 50 0. 96 4 0. 07 9 11 .7 48 0. 33 9 0. 10 2 1. 13 1 a fe m al e co m pa re d to m al e. *p < .0 5. * *p < .0 1. * ** p < .0 01 . ta bl e 3 r ec ei ve r o pe ra tin g c ha ra ct er is tic a na ly si s (r o c ) sc al e sw is s (n = 2 14 ) c hi na (n = 3 25 ) is ra el (n = 5 44 ) po rt ug ue se (n = 2 18 ) ir is h (n = 8 30 ) cu tof f [m in ; m ax ] se ns it iv it y/ sp ec if ic it y cu tof f [m in ; m ax ] se ns it iv it y/ sp ec if ic it y cu tof f [m in ; m ax ] se ns it iv it y/ sp ec if ic it y cu tof f [m in ; m ax ] se ns it iv it y/ sp ec if ic it y cu tof f [m in ; m ax ] se ns it iv it y/ sp ec if ic it y ip g d s 37 .5 [1 3; 6 3] 0. 93 3/ 0. 81 4 42 .5 [1 3; 6 5] 0. 90 2/ 0. 81 0 n /a n /a 36 .5 [1 3; 5 6] 0. 93 3/ 0. 81 8 n /a n /a ic g -r 24 .5 [8 ; 4 0] 0. 81 8/ 0. 85 7 25 .5 [8 ; 4 0] 0. 95 7/ 0. 85 4 24 .5 [8 ; 4 0] 1. 00 0/ 0. 94 7 16 .5 [7 ; 3 5] 0. 92 0/ 0. 87 1 22 .5 [8 ; 4 0] 0. 94 1/ 0. 89 6 killikelly, merzhvynska, zhou et al. 9 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ discussion this paper provides the first systematic exploration of core items of the new icd-11 pgd criteria across five international samples. the results confirm large differences in the rates between and within samples depending on the diagnostic algorithm used; predictors of pgd severity may vary across samples due to the type of loss (violent or nonviolent) and the cultural caveat item of the ipgds may be an important risk screening item; finally, a threshold for a clinically relevant diagnosis may be different depending on cultural group. core items of the new icd-11 pgd criteria, as tested by the ipgds (in swiss, chinese and portuguese samples) and the icg-r (in irish and israeli samples), revealed substantially different rates depending on the diagnostic algorithm used. overall, the strict criteria for both the ipgds and the icg-r seems to capture the expected rates across the five samples, which ranged from 2-21.2%. however, substantially higher rates were found in the chinese and portuguese samples. there could be several explanations for these higher rates including sample differences and lack of cultural sensitivity of assessment measures (stelzer, zhou, & maercker, et al., 2020). when the strict criteria of the ipgds were applied, the swiss (7.0%) and portuguese (6.9%) samples had similar rates on the ipgds, whereas the chinese sample had a higher rate (12.6%) on the ipgds. a higher rate in the chinese sample is consistently found across all iterations of the ipgds but also for most of the icg-r comparisons. conversely, when assessing the icg-r the swiss, chinese, israeli and irish samples had similar rates, whereas the portuguese sample was much higher (21.1%). the portuguese sample also had high rates on the icg-r for the strict and moderate criteria, perhaps due to the exclusion of the impairment criteria in this particular sample. therefore, the results for the portuguese sample must be interpreted with caution and it points to the importance of including the functional impairment item and ensuring consistency in the use of time criterion in the assessment measure. additionally, the portuguese sample included pooled data from the general and clinical sample. the inclusion of the clinical sample could increase the prevalence rates in the portuguese data compared to the non-clinical samples obtained from the other countries. the portuguese sample consisted of a large proportion of bereaved people who expe­ rienced an unexpected loss (10%). although not explicitly recorded, this would mostly include the unexpected loss of a child as participants were from the outpatient perinatal loss clinic. loss of a child is known to predict high levels of pgd (zetumer et al., 2015) lack of culturally sensitive assessment measures or items could explain differences in the symptom ratings and severity levels across the samples. for example, our previ­ ous study confirmed that chinese bereaved may present with slightly different symp­ toms than those assessed by the icd-11 (killikelly & maercker, 2017; stelzer, zhou, merzhvynska, et al., 2020). the ipgds standard scale does not explore somatic symptoms or culturally specific symptoms such as ‘a loss of a part of oneself’ (stelzer, zhou, icd-11 prolonged grief disorder guidelines across five international samples 10 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ merzhvynska, et al., 2020). additionally, there could be a cultural bias in responding to these questionnaires which may lead to overreporting and overestimation of symptoms. chentsova-dutton et al. (2007) found that chinese participants may overreport certain symptoms in order to ensure that they receive health care and support. in terms of predictors of pgd severity we assessed a limited selection of predictors available across the datasets. interestingly, when the cultural caveat item was included (e.g. endorsement of item 14 of the ipgds), violating the cultural norms for grief was found to significantly predict more severe grief scores on the ipgds and the icg-r. al­ though we only had the data for the swiss and chinese participants, further examination of this item might indicate its importance as a screening item for grief severity. in both the israeli and irish sample grief severity was predicted by sudden violent or accidental death whereas this was not found for the swiss and chinese samples. this may be due to differences in sampling. the israeli and irish data are from large nationally representa­ tive samples that may include more instances of sudden violent or accidental death. the chinese and swiss samples are mostly student populations who experienced the loss of older relatives. the larger israeli and irish datasets contain participants who experienced a high level of violent loss (more than 25%) and this could explain the differences in predictors. previous research has confirmed that violent loss is a strong predictor of pgd severity and chronicity (lobb et al., 2010; schaal, jacob, dusingizemungu, & elbert, 2010). additionally, israel and ireland have recently experienced acts of terrorism that may preclude an added cultural vulnerability to trauma and loss (duffy, gillespie, & clark, 2007; silverman, johnson, & prigerson, 2001). the final research question was to determine a possible threshold for establishing a clinically significant severity score on the ipgds. all five datasets could not be com­ pared with the ipgds however across the swiss, chinese and portuguese data, a score above 36.5 will most likely represent clinically significant pgd symptoms. as a control, the icg-r was also examined and a score above 22 for all datasets was consistently found, except for the portuguese sample (16.5). this attests to the variation that can occur across different samples, even with gold standard clinical assessments (boelen & lenferink, 2020). limitations due to inconsistencies in data collection across the five international samples it was not possible to directly compare the ipgds or the icg-r across all data sets. the full icd-11 pgd criteria could therefore not be assessed. in particular the time criterion was not assessed consistently across the datasets for example not in the portuguese or israeli datasets. therefore, a diagnosis of pgd is not possible. however, the core items of the pgd (yearning and preoccupation) as well as some supplementary items of emotional distress could be evaluated and indications of possible caseness implied. it is important to include the time criterion for disorder as individuals may experience severe killikelly, merzhvynska, zhou et al. 11 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ distress in the first weeks and months after a loss and this should not be pathologized. importantly the estimates of prevalence rates for the portuguese data must be interpreted with caution as there was a high amount of missing data. furthermore, the portuguese sample included a clinical subgroup. this may explain why the estimates of prevalence are significantly higher. across the german, portuguese and chinese samples there is a high proportion of female responses. in the future it would be important to provide an analysis of a more representative sample. additionally, there were only a limited number of similar predictors across all datasets. the data in each country was collected separately at different times, so only a cross sectional comparison is possible on some questionnaire items. of note, the confidence intervals are very wide for some of the items in the logistic regression, particularly for the cultural criteria. this is perhaps due to a small number of values in some of the cells (response options). in the future a larger sample size should reveal more precise confidence intervals. finally, in the future and with a more complete dataset the roc analysis should also be conducted on the moderate and maciejewski et al. (2016) criteria to provide a full estimate of possible thresholds for sensitivity and specificity. conclusion this paper confirms the importance of establishing international guidance on the consis­ tent use of a diagnostic algorithm for pgd in order to ensure reliability across heteroge­ neous samples. currently, we recommend the use of the strict criteria as an indicator of pgd caseness, however this must be confirmed in a clinical sample. future studies should examine the different pgd algorithms (moderate vs strict) in clinical and cultural samples and include important items that are missing in some of the current data (i.e. the impairment and time criteria as well as the cultural caveat). additionally, clinicians should be aware of specific risk factors such as violent, sudden loss or screening ‘yes’ on the cultural caveat ipgds item as these may predict clinically severe grief. in the future it may be important for clinicians to note that different cultural groups may need different cut-off thresholds for a clinical diagnosis on the ipgds or other scales. funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: we would like to acknowledge the dedication of the participants who completed the questionnaires, the efforts of the grief and bereavement organizations that supported our recruitment, and the many student interns that assisted with data collection, input and coding. icd-11 prolonged grief disorder guidelines across five international samples 12 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ supplementary materials the supplementary information contains tables of additional demographic characteristics for each of the five samples (for access see index of supplementary materials below). index of supplementary materials killikelly, c., merzhvynska, m., zhou, n., stelzer, e.-m., hyland, p., rocha, j., . . . maercker, a. 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(2010). the diagnosis of complicated grief as a mental disorder: a critical appraisal. psychologica belgica, 50(1–2), 27-48. https://doi.org/10.5334/pb-50-1-2-27 zetumer, s., young, i., shear, m. k., skritskaya, n., lebowitz, b., simon, n., . . . zisook, s. (2015). the impact of losing a child on the clinical presentation of complicated grief. journal of affective disorders, 170, 15-21. https://doi.org/10.1016/j.jad.2014.08.021 killikelly, merzhvynska, zhou et al. 15 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://doi.org/10.1371/journal.pmed.1000121 https://doi.org/10.1002/j.2051-5545.2011.tb00034.x https://doi.org/10.1002/wps.20524 https://doi.org/10.1186/1471-244x-10-55 https://doi.org/10.1056/nejmcp1315618 http://www.ncbi.nlm.nih.gov/pubmed/11725418 https://doi.org/10.3389/fpsyg.2019.02982 https://doi.org/10.1159/000505074 https://doi.org/10.5334/pb-50-1-2-27 https://doi.org/10.1016/j.jad.2014.08.021 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. icd-11 prolonged grief disorder guidelines across five international samples 16 clinical psychology in europe 2021, vol.3(1), article e4159 https://doi.org/10.32872/cpe.4159 https://www.psychopen.eu/ icd-11 prolonged grief disorder guidelines across five international samples (introduction) method participants recruitment and sampling measures predictors statistical analysis results rates of pgd logistic regression examination of provisional cut-off scores discussion limitations conclusion (additional information) funding competing interests acknowledgments supplementary materials references a hot-cold cognitive model of depression: integrating the neuropsychological approach into the cognitive theory framework research article a hot-cold cognitive model of depression: integrating the neuropsychological approach into the cognitive theory framework elayne ahern ab, claudi l. h. bockting c, maria semkovska ab [a] department of psychology, university of limerick, castletroy, limerick, ireland. [b] health research institute, university of limerick, castletroy, limerick, ireland. [c] department of psychiatry, amsterdam umc, university of amsterdam, amsterdam, the netherlands. clinical psychology in europe, 2019, vol. 1(3), article e34396, https://doi.org/10.32872/cpe.v1i3.34396 received: 2019-03-08 • accepted: 2019-07-08 • published (vor): 2019-09-20 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: elayne ahern, department of psychology, university of limerick, castletroy, limerick, v94 t9px, ireland. e-mail: elayne.ahern@ul.ie abstract background: in the 50 years following beck’s cognitive theory, empirical research has consistently supported the role of dysfunctional, ‘hot’ cognition in the onset and maintenance of major depressive disorder. compromised ‘cold’ cognition in attention, memory, and executive control abilities, independent of the affective state, has attracted much clinical interest for its role throughout the course of illness and into remission. we propose integrating cold cognition into beck’s cognitive theory framework to account for the complementary roles of both hot and cold cognition in depression onset and maintenance. method: a critical review of cognitive research was conducted to inform an integrated hot-cold cognitive model of depression. results: cold cognitive deficits likely act as a gateway to facilitate the activation and expression of the hot cognitive biases through a weakened ability to attend, retrieve, and critically assess information. cold deficits become exacerbated by the negative mood state, essentially ‘becoming hot’, lending to maladaptive emotion regulation through ruminative processes. depleted cognitive resources contribute to the manifestation of further deficit in problem-solving ability in everyday life, which in itself, may act as a stressor for the onset of recurrent episodes, perpetuating the depressive cycle. conclusion: we discuss the interaction between hot and cold cognition within the cognitive theory framework and the potential of complementary hot-cold pathways to elucidate novel means of prevention and treatment for depression. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i3.34396&domain=pdf&date_stamp=2019-09-20 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords cognition, cognitive behavioural therapy, cognitive control, cognitive dysfunction, cognitive training, depression, emotion regulation highlights • dysfunction in hot (emotion-dependent) and cold (emotion-independent) cognition has been demonstrated in depression, but psychological treatment has largely focused on hot cognition only. • hot and cold cognition are complementary processes throughout the activation and maintenance of depressive schemas and biases, necessitating the consideration of both hot and cold cognitive aspects to disrupt the depressive cycle. • the proposed hot-cold cognitive model shows promise to stimulate new research avenues for the prevention and treatment of depression. major depressive disorder (mdd) is debilitating, usually chronic in nature, and widely prevalent, affecting approximately 300 million individuals at any given time (world health organization [who], 2018). as the likelihood of recurrence and relapse remain high (boland & keller, 2009), the need to consider novel treatment strategies and adapt current treatments for mdd is mounting. an examination of the potential mechanisms underlying the central features of mdd may help inform initiatives to optimise treat‐ ment outcomes. cognitive dysfunction is an important diagnostic feature of mdd. it is best concep‐ tualised as two interacting systems of cold and hot cognition (roiser & sahakian, 2013). cold cognition refers to information processing that occurs independent of any emotion‐ al influence. such cold cognitive functions are typically assessed using neuropsychologi‐ cal test batteries and include measures of the ability to memorise and retain new infor‐ mation, divide/shift attention between tasks, and make/follow an organised plan in the context of non-affective, neutral stimuli (i.e. no intentional positively or negatively valenced material is provided during the test). cold cognitive dysfunction has been dem‐ onstrated throughout the course of mdd, with broad deficits observed across attention, memory, and executive function measures (rock, roiser, riedel, & blackwell, 2014; snyder, 2013). meta-analytical evidence show such deficits to be present from the first episode (ahern & semkovska, 2017), while research also suggests a degree of persistence in some cognitive domains beyond the restoration of mood (semkovska et al., 2019). on the other hand, hot cognition is reactional to the presence of emotional stimuli (e.g. facial expression, affective words, music), or may be a response to feedback that produces an emotional state (e.g. disappointment). for example, individuals with mdd have demon‐ strated better memory recall for negative stimuli in comparison to healthy controls, sug‐ hot-cold cognitive model of depression 2 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ gesting that mdd has a distinct hot cognitive profile characterised by mood-congruent biases in information processing and memory (gaddy & ingram, 2014). a particular style of perseverative, negative thinking, referred to as rumination (nolen-hoeksema, 1991), also largely contributes to the hot cognitive profile characteristic of mdd. this is consid‐ ered a maladaptive emotion regulation strategy that serves to maintain the negative mood state. cold cognitive dysfunction is an area of increased clinical research focus, not only be‐ cause it can be considered a biomarker for vulnerability (allott, fisher, amminger, goodall, & hetrick, 2016), but also because it has been shown to predict poor treatment response (groves, douglas, & porter, 2018), and impede functional recovery from mdd (bortolato et al., 2016). accumulating literature suggests that the cold cognitive dysfunc‐ tion associated with mdd drives the negative consequences for everyday life and eco‐ nomic costs, over and above the influence of mood symptoms (buist-bouwman et al., 2008). cold cognitive abilities have also been identified as the single best longitudinal predictor of socio-occupational functioning among young psychiatric outpatients (lee et al., 2013). consequently, cold cognition has been increasingly recommended by clinical research as an essential therapeutic target to ensure functional recovery following a de‐ pressive episode (e.g. bortolato et al., 2016). antidepressant treatment for mdd has dem‐ onstrated efficacy on both the affective (mood state) as well as the cold cognitive aspects of depression, most notably among executive functions (e.g. baune & renger, 2014). while improvements have been observed in certain cold cognitive abilities, not all im‐ prove at a similar rate; persistent deficits have been noted across attention, verbal memo‐ ry, response inhibition, decision speed, and information processing in up to 95% of indi‐ vidual cases (shilyansky et al., 2016). although the pro-cognitive effect of antidepressants may not be consistently demonstrated, cold cognition at the very least has been recog‐ nised as a potential therapeutic target within the biological approach to mdd treatment. the psychological approach has largely been informed by beck’s cognitive model, thus establishing a focus on hot cognition. beck conceptualised cognition during mdd as rig‐ id negative schemas and dysfunctional attitudes about the self, the world, and the future. such problematic schemas and attitudes were theorised to contribute to negative auto‐ matic thoughts and biases in attention, information processing, and memory (beck, 2008). these hot cognitive features interacted, steering the onset and maintenance of mdd. beck’s cognitive model has been central to our understanding and treatment of mdd for the past 50 years. nevertheless, it has also contributed to an under-emphasis of the role of cold cognitive abilities (knight, aboustate, & baune, 2018), some of which have been outlined in the dsm diagnostic criteria for mdd, e.g. diminished ability to think or concentrate, and indecisiveness (american psychiatric association, 2013). cog‐ nitive behavioural therapy (cbt), which is informed by beck’s cognitive model, is con‐ sidered the gold standard approach for the psychological treatment of mdd. interesting‐ ly, the effect of psychotherapies such as cbt on cold cognition is not well explored (e.g. ahern, bockting, & semkovska 3 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ porter et al., 2016) as their recognised efficacy is based on the successful treatment of the hot dysfunctional cognitions. considering patient preference for psychotherapy relative to pharmacological treatment is over threefold (mchugh, whitton, peckham, welge, & otto, 2013), novel treatment adjuncts should be explored so that they can guide and ulti‐ mately help integrate cognitive remediation strategies into existing psychological treat‐ ment. contemporary theoretical approaches have brought focus to cognitive control dys‐ function during the characteristic depressive biases to account for symptom onset and maintenance (de raedt & koster, 2010; gotlib & joormann, 2010; joormann & vanderlind, 2014). such approaches propose that mdd is accounted for by an attenuated ability to inhibit the processing of negative material in working memory along with defi‐ cits in removing negative material and updating the contents of working memory. never‐ theless, the role of cognitive dysfunction, in both hot and cold forms, has not been for‐ mally integrated into the classical cognitive model of mdd proposed by beck. typically, hot and cold cognition have been investigated separately within the mdd literature, but we propose integrating hot and cold cognition considering their close alignment and po‐ tential complimentary processes as a cognitive mechanism by which negative schemas and cognitive biases contribute to depressive symptoms. the pivotal role that cold cogni‐ tive abilities may play in onset, throughout the depressive mood state, and into remission require attention in psychological, theoretical models to account for the dynamic inter‐ play between cognition and emotion. this advancement is necessary to inform treatment strategies that can potentially optimise functional recovery from mdd. hence, the aim of this paper is to propose a reframing of beck’s cognitive model to integrate a narrative on the role of cold cognition in the development, maintenance, and recovery from mdd. in subsequent sections, we will critically discuss the interaction between hot and cold cog‐ nition, followed by a review of the relevance of cold cognition for the cognitive model. thereafter, we will address the dynamic, interactive processes of hot and cold cognition with reference to each of the cognitive biases in attention, information processing, and memory recall, as outlined by beck. finally, we will present our integrated hot-cold cog‐ nitive model of depression. hot and cold cognition mdd is often conceptualised within an emotion dysregulation framework; the individual regulates emotion less effectively as a result of a compromised interaction between emo‐ tional and cognitive processes, outlining an emotion-cognition link in mdd (gotlib & joormann, 2010). specifically, cognition has been proposed as the means by which emo‐ tion is regulated (joormann & vanderlind, 2014). cognitive biases affect emotion regula‐ tion by drawing attention to emotion-eliciting details or appraisals that are congruent with the negative mood. in turn, deficits in executive functions increase the likelihood of hot-cold cognitive model of depression 4 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ using maladaptive regulatory strategies such as rumination, which only serve to intensi‐ fy and prolong the experience of negative mood (joormann, 2010; koster, de lissnyder, derakshan, & de raedt, 2011). executive functions, also referred to as cognitive control within the cognitive neurosciences, regulate information processing and behaviour to align with current goals when faced with interference from task-irrelevant stimuli or au‐ tomatic responses (friedman & miyake, 2017). the processes involved in cognitive con‐ trol are typically operationalised into shifting (switching between tasks, i.e. cognitive flexibility), inhibition (overriding a prepotent response), and updating (monitoring the contents of working memory; miyake et al., 2000). an accumulating body of research over the past decade has supported the role of cognitive control dysfunction in mdd for symptom onset and maintenance, but this has largely been investigated in relation to the emotional state. as hot cognition accounts for information processing and reasoning that is influenced by emotional state, weakened cognitive control during mdd is probably best conceptualised as a dysfunctional hot cognition within current theoretical accounts (de raedt & koster, 2010; joormann, 2010; joormann & vanderlind, 2014). consistent with this, gotlib and joormann (2010) have acknowledged that cognitive control deficits appear to manifest following affective interference and are particularly salient during the processing of negative material, rather than representing a more generalised deficit in cognitive functioning. the complexities of the emotion-cognition link could, neverthe‐ less, benefit from consideration outside of the emotional context by incorporating cold cognition into the explanatory framework. in accordance with this, recent empirical re‐ search has suggested that non-affective cognitive control training (paced auditory serial addition task, pasat; gronwall, 1977) can successfully alleviate residual depressive symptoms among a remitted mdd sample, demonstrating that cold cognitive control abilities may have preventative potential for recurrent mdd episodes (hoorelbeke & koster, 2017). this could result from a disruption to the dynamic interaction between hot and cold cognition following the cognitive training, an interaction which may be neces‐ sary for episode onset. importantly, cold cognitive control deficits are observed during the acute depressive state, with meta-analytical findings from 113 studies providing ro‐ bust support for deficits in shifting, inhibition, and updating of a moderate effect size among individuals with mdd, relative to healthy controls (snyder, 2013). consideration of cold cognition, and particularly the interaction between hot and cold cognitive pro‐ cesses, may be integral to elucidating the mechanisms by which cognition helps regulate emotion. in a critical review of cognitive control theory and research, grahek, everaert, krebs, and koster (2018) reinforced the importance of considering interactive processes in dysfunctional cognition during depression, with particular acknowledgement of the potential role that hot components (via motivation) may play in cognitive control abili‐ ties. although hot and cold cognition have been presented as somewhat separate process‐ es, their interaction is central to the maintenance of the depressive cycle. indeed, per‐ ahern, bockting, & semkovska 5 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ formances on cold cognitive tasks are thought to be partially explained in terms of an altered hot cognition generated by task feedback. as such, beats, sahakian, and levy (1996) demonstrated that negative feedback on a non-affective, neutral task can stimulate a ruminative thinking style on performance or a ‘catastrophic response to perceived fail‐ ure’ that, in turn, impairs subsequent performance; intrusion effects generated by nega‐ tive feedback can slow performance or lead to attention/distraction errors. furthermore, such feedback can lessen motivation to proceed. in this way, cold cognition can ‘become hot’, a hypothesis that has been supported by several studies (murphy, michael, robbins, & sahakian, 2003; pizzagalli, peccoralo, davidson, & cohen, 2006), although such results are not always consistently replicated. as a notable exception to the above hypothesis, douglas and porter (2009) showed that individuals with mdd can also improve their per‐ formance after perceived failure, albeit to a lesser extent relative to healthy controls. ad‐ ditionally, aker, bø, harmer, stiles, and landrø (2016) demonstrated that remitted mdd individuals did not differ from healthy controls in post-error speed of adjustment on two cold cognition tasks assessing inhibition abilities, despite a slower performance by mdd individuals on one of these tasks. this suggests that the error-feedback provided during task performance did not exacerbate cold deficits by means of hot interference via rumi‐ native processes or depleted motivation. throughout the literature, deficits in cold cogni‐ tion are demonstrated even when no feedback on performance is available, suggesting that a negative, hot feedback loop is not necessarily generated during cold cognitive tasks that can explain subsequent performance (roiser & sahakian, 2013). the distinction between hot and cold cognition is somewhat arbitrary as both mutu‐ ally influence each other, but it does direct attention to the fact that mdd is associated with compromised function in emotion-dependent (hot) and emotion-independent (cold) cognitive processes. the association between mood and cognitive deficits during mdd has stimulated much critical debate in an attempt to determine whether cognitive deficits (a) are a vulnerability trait that precede and contribute to the onset of a depressive epi‐ sode, remaining stable throughout into periods of symptomatic remission (b) represent a state by-product of depressive mood, alleviating with mood restoration or (c) develop during the depressive episode and persist as a residual scar (for further detail on trait, state, and scar patterns of cognitive deficit, see ahern & semkovska, 2017). it is likely that each of the above is relevant during the course of mdd from acute phases through to remission and relapse. although research interest on the role of cold cognition in the course of mdd is relatively recent, it represents an area ripe for further inquiry consider‐ ing the complimentary processes of cold cognition with the well-recognised hot cogni‐ tive processes. a better understanding of the role of these cold cognitive abilities within the cognitive theory framework may elucidate novel means of preventative and treat‐ ment strategies. hot-cold cognitive model of depression 6 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ relevance of cold cognition for the cognitive model beck’s cognitive model has outlined the central role of hot cognitive biases to the onset, maintenance, and remission of mdd. such biases are proposed to result from negative schemas that remain latent until activated by a stressful life event resulting in a change in information processing in a schema-congruent manner (beck, 2008). however, not all cases of mdd onset are preceded by a stressful life event (hammen, 2005), suggesting that hot cognitive biases may indeed be a correlate of depressive symptoms rather than an initiating event for onset. ample cross-sectional research confirms the interaction be‐ tween seemingly cold cognitive deficits and mood throughout the course of mdd (e.g. rock et al., 2014; snyder, 2013), albeit not explicitly measuring the potential explanatory role of hot cognition such as cognitive biases. nevertheless, it has been suggested that cold deficits precede, and therefore may facilitate, the cascade of hot cognitive biases that occur with mdd onset by compromising the ability to attend, remember, and critically assess information (knight et al., 2018). consequently, the individual becomes susceptible to negative information processing. de raedt and koster (2010) proposed that weakened cognitive processes, particularly in attention, act as a gateway for negative thoughts and biases. as such, deficits in inhibition contribute to a repetitive cycle of negative thoughts, while deficits in shifting exacerbate the ability to move away from or disengage attention from these thoughts, resulting in a maintenance of depressive mood. deficient cognitive control of negative information is considered central to the maintenance of hot cogni‐ tions and depressive mood, but this does not explain why individuals with mdd often continue to demonstrate compromised functioning when mood has alleviated. cold cog‐ nitive deficits may be an important consideration to explain the continued compromised functioning during remission, but also may help elucidate a better understanding of how the cognitive and affective components of mdd interact to initiate and sustain depres‐ sive symptoms. the conceptual framework proposed by de raedt and koster (2010) inte‐ grated biological and cognitive factors to outline the potential working mechanisms in‐ volved in vulnerability for recurrent mdd episodes. hot attentional deficit, where atten‐ tion is diverted to and maintained on negative material, was a central component of the framework to account for sustained negative affect through interaction with the activa‐ ted schemas. although de raedt and koster (2010) acknowledged cold deficits in atten‐ tion, the hot attentional component was considered of particular interest due to its de‐ pression-specificity and that it could be explained from a biological perspective (i.e. as a consequence of reduced cognitive control exerted by the dorsolateral prefrontal cortex [due to deficient signals from the anterior cingulate cortex] on the emotional processing conducted by the amygdala). thus, the framework proposed by de raedt and koster (2010) mainly accounted for the role of hot attentional deficits in the vulnerability for re‐ currence. ahern, bockting, & semkovska 7 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ it is plausible that cold deficits represent the vulnerability that interacts with the schema to generate the characteristic hot cognitive bias during mdd. weak inhibitory and shifting processes have been shown to be associated with the development of depres‐ sive symptoms up to 7.5 years later among youth, while controlling for other key predic‐ tors such as gender and iq (kertz, belden, tillman, & luby, 2016). these findings suggest that cold cognitive control deficits likely precede and represent a vulnerability factor for onset. further corroborating this, deficits in cognitive control measures such as working memory, shifting, and inhibition have been noted at initial mdd onset, with broader def‐ icits demonstrated across processing speed, attention (visual and auditory), learning and memory (visual and verbal), reasoning, verbal fluency, motor skills, and intelligence, with the magnitude of deficit varying from small to large across these cognitive domains (ahern & semkovska, 2017). as these deficits cannot be accounted for by the additive ef‐ fect of scarring from recurrent episodes, it is reasonable to assume that cold cognitive dysfunction can precede onset. furthermore, executive function deficits have even shown stable, trait-like qualities from the first depressive episode (ahern & semkovska, 2017). snyder and hankin (2016) suggested that cold executive control deficits are linked to in‐ ternalising psychopathologies through stress generation and subsequent rumination. cold deficits contribute to self-generated stressors (e.g. difficulties at work due to poor planning of time/approach to workload), and while stressors are widely acknowledged as risk factors for the development of psychopathology (e.g. grant et al., 2014), this initiat‐ ing mechanism represents a novel means to better understand the mdd cycle. perhaps it could even be postulated that the cold cognitive deficits themselves represent a self-gen‐ erated stressor when the individual is made self-aware of deficient functioning in day-today tasks. beck’s cognitive model proposed that dysfunctional schemas remained dormant until activated by a stressor (beck, 2008). along these lines, cold cognitive deficits across a broad range of cognitive domains may serve as internal, self-generated stressors that off‐ set the cascade of hot dysfunctional cognitions and biases during mdd. this assumes the affective interference hypothesis in that affective information becomes salient and im‐ pedes on the subsequent processing of information (siegle, ingram, & matt, 2002). in this way, seemingly cold cognitive deficits ‘become hot’ (e.g. in response to feedback) as the mdd cycle is initiated. it has been suggested that cognitive deficits are superimposed as a result of a ‘catastrophic response to perceived failure’ when the activated negative schema biases processing of the feedback which, in turn, impedes on subsequent per‐ formance (elliott et al., 1996). beats et al. (1996) demonstrated using the tower of london task that mdd individuals solved as many problems in the minimum specified moves as did controls, but once a mistake was made, subsequent performance deteriorated rapidly. further to this, elliott, sahakian, herrod, robbins, and paykel (1997) showed that mdd individuals underwent more errors on a series of cantab tasks (delayed matching to sample and 1-touch tower of london) in response to feedback, relative to controls and hot-cold cognitive model of depression 8 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ other clinical groups (e.g. schizophrenia). findings by beats et al. (1996) and elliott et al. (1997) suggest that cognitive deficit on neutral, non-affective tasks are largely just a man‐ ifestation of hot cognition, likely due to a ruminative response style centred around the negative feedback. once initiated, the hot dysfunctional schemas and cognitive biases place demands on cognitive resources as they commence a sequence of automatic, mood-congruent pro‐ cessing, relying on executive function, memory, and attention abilities to maintain the depressive mood state. the resource allocation hypothesis postulates that the depletion of available cognitive resources has a detrimental effect on day-to-day cognitive func‐ tioning as limited resources are available to direct to other non-affective, cold cognitive functions (ellis & ashbrook, 1988), overall exacerbating the cognitive profile of mdd. similarly, as limited cognitive resources are available to engage in effortful, controlled processing to override the automatic biases, maladaptive regulation strategies such as ru‐ mination ensue as subsequent hot cognition. consequently, hot and cold dysfunction ini‐ tiate a mutually reinforcing cycle. we propose that the dynamic interaction between hot and cold cognitive processes is central to mdd and necessitates consideration of both to stimulate theoretical advances and integrated research efforts. in the above section, we have outlined the basic tenet of our integrated hot-cold cog‐ nitive model of mdd. in the following sections, we discuss the interaction between hot and cold in the context of the cognitive model with particular reference to the character‐ istic biases in attention, information processing, and memory recall during mdd (gotlib & joormann, 2010). these hot-cold interactions are illustrated through figure 1, 2, and 3, respectively. although it is acknowledged that the cognitive biases likely influence each other and interact to exert influence on other factors (sanchez, duque, romero, & vazquez, 2017), we will discuss each of the cognitive biases separately. this is consistent with the approach of disner, beevers, haigh, and beck (2011) in their work on the neural mechanisms underpinning beck’s cognitive model. the authors demonstrated that al‐ though cognitive biases are characterised by increased bottom-up emotional processing and attenuated top-down cognitive control, the underlying mechanisms of each cognitive bias somewhat differ. thus, modelling each cognitive bias separately will allow us to best account for the interactive role of hot and cold cognitions and essentially advance our understanding of the maintenance and treatment of mdd. biased attention for negative material a compromised ability to direct attention to relevant information is central to the cogni‐ tive model of mdd. this is driven by an apparent attention bias towards negative stimu‐ li, although its existence is not robustly supported throughout the literature (mathews & macleod, 2005). williams, watts, macleod, and mathews (1988) even suggested that mdd is characterised by biases in elaboration and recall but not an attention bias, which is more so characteristic of anxiety disorders. attention biases in mdd have been exam‐ ahern, bockting, & semkovska 9 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ ined in the early and later stages of attentional processing in an attempt to better deter‐ mine whether, and under what conditions, attentional dysfunction is observed. the ini‐ tial orienting of attention has been investigated using subliminal or rapid presentation of affective material. for example, using an emotional stroop task in which valenced-words were presented against a background colour for approximately 1ms and followed by a mask, mogg, bradley, williams, and mathews (1993) showed that preattentive bias for negative information occurred in the anxiety group only, while the mdd group were comparable to controls. the absence of attention bias in the early stages of processing has been replicated throughout the literature (for review, see mogg & bradley, 2005). nevertheless, research on attention bias at later stages of conscious processing provides more robust evidence for the presence of a mood-congruent bias (e.g. gotlib, krasnoperova, yue, & joormann, 2004), and once attention is directed to the negative ma‐ terial, mdd individuals typically spend longer periods of time engaged with it (e.g. kellough, beevers, ellis, & wells, 2008). this suggests that mdd is not characterised by an automatic attention bias, as proposed by the cognitive model, but instead is associated with difficulty disengaging from negative material once attended to. as a result, a posi‐ tive feedback loop is initiated in which depressive symptoms are maintained by the inter‐ action between hot attentional control deficits and rumination. impaired disengagement from negative, self-relevant thoughts maintains an inward focus that strengthens rumi‐ native processes, overall serving to worsen the depressive mood (koster et al., 2011). findings by yaroslavsky, allard, and sanchez-lopez (2019) supported the mediational role of rumination between hot attentional disengagement deficits (slow disengagement from sad faces, fast disengagement from happy faces) and depressive symptoms. this suggests that hot cognitive deficits manifest in subsequent forms of hot cognition, name‐ ly rumination, to maintain depressive symptoms. in addition, experimental research us‐ ing attention bias modification strategies has corroborated the mediational role of rumi‐ nation in the link between attention bias and depressive symptoms (yang, ding, dai, peng, & zhang, 2015). attention bias modification strategies typically involve training the individual to direct attention away from a negative stimulus towards a neutral stimu‐ lus. this is often achieved using a dot-probe paradigm where the target probe is located more frequently behind the neutral stimulus when presented simultaneously with a neg‐ ative stimulus; after repetition, this training gradually helps to facilitate a more positive attention bias. following eight sessions of attention bias modification (90% of targets ap‐ peared in the neutral word position, relative to the sad word position) over a 2-week pe‐ riod, yang et al. (2015) demonstrated that depressive symptoms significantly improved and were maintained at 3-month follow-up; no improvements were shown for the con‐ trol attention training (50% of targets appeared in the neutral/sad word position) or as‐ sessment-only conditions. in addition, more participants remained asymptomatic at 7month follow-up subsequent to attention bias modification, relative to the comparison conditions. findings showed that this effect was fully mediated by rumination and, there‐ hot-cold cognitive model of depression 10 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ fore, change in attention bias could not directly account for improved depressive symp‐ toms. hence, it is suggested that deficient hot cognitive control abilities consequently manifest as a ruminative response style as a result of impaired disengagement from nega‐ tive material. this process overall sustains the negative affect and associated attention bias. nevertheless, findings have not unequivocally converged to demonstrate that target‐ ing hot cognition alone can account for depressive symptom improvement. considering control attention training has often shown similar efficacy to attention bias modification strategies, cold cognitive abilities may also play a potential role in symptom improve‐ ment. beevers, clasen, enock, and schnyer (2015) found that symptom improvement was not significantly different for control attention training (50% of targets appeared in neu‐ tral/negative location) relative to a homework supplemented, 4-week attention bias mod‐ ification training consisting of eight sessions (80% of targets appeared in the neutral loca‐ tion, relative to the negative location); across the training groups, an overall 40% symp‐ tom improvement was observed. such findings suggest different mechanisms of symp‐ tom improvement via hot and cold processes, although this warrants further investiga‐ tion to better understand the driving mechanism. in the attention bias modification con‐ dition, symptom change may be somewhat accounted for by change in attention bias, yet for the control attention training, benefits may have been a result of engaging in an ac‐ tivity that promoted focused and sustained attention. this allows us to postulate that cold attention abilities are involved in symptom improvement but also that their dysfunc‐ tion may represent the potential mechanism by which hot attention biases materialise following affective interference. additionally, jonassen et al. (2019) showed that attention bias modification training (87% of targets appeared in the positive location, relative to the negative location), when completed twice daily over a 2-week period, did not significant‐ ly differ from control attention training (50% of targets appeared in the positive/negative location), with both contributing to significant self-reported depressive symptom im‐ provement. notably, significant, albeit smaller, improvements on clinician-rated depres‐ sive symptoms were found for the attention bias modification group only, with such symptom improvement closely associated with a more positive attention bias. overall, changes in attention bias did not significantly differ between the training groups, sug‐ gesting that attention bias modification may exert its effect by means of another mecha‐ nism, potentially by training general attention ability. typically, the only difference be‐ tween attention bias modification training and the control training condition is the fre‐ quency of target presentation in the negative location. consequently, session duration or frequency of training cannot account for the lack of differential findings between the ac‐ tive and control intervention conditions, although these factors may become relevant for comparisons between experimental studies. inclusion of an assessment-only comparison will help to elucidate whether training attention ability, irrespective of an attention bias focus, is the underlying driving mechanism of symptom improvement. ahern, bockting, & semkovska 11 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ figure 1. model of the interaction between cold cognitive deficits and the hot cognitive attention bias during depression. note. when triggered by a perceived stressful life event, weaknesses in cognitive flexibility and inhibitory processes interact with the schema (negative core belief, e.g. ‘i am useless’) leading to a failure in disengaging attention from negative stimuli, i.e. attention bias. subsequent hot ruminative processes magnify the accessibility of negative material and represent a means by which the bias affects depressive symptoms. there is a consequent reduction in available cognitive resources while hot cognition is activated. this contributes to broader cognitive deficits, including a general attention deficit, which likely lends itself to the expression of the attention bias for negative stimuli. such deficits impact day-to-day functioning, potentially triggering subsequent hot cognition. the interaction between hot and cold pathways serves to perpetuate the activated schema and attention bias, overall worsening depressive symptoms. components of the model are informed by beck’s cognitive model of depression. hot-cold cognitive model of depression 12 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ in summary, biased attention is understood to be central to the maintenance of mdd. impaired cognitive control reduces the ability to disengage from negative information, thus contributing to exacerbated hot cognitive processes, such as rumination, which rein‐ force the attention/disengagement bias to overall maintain depressive symptoms. cold cognitive deficits appear to equally be relevant as general attention training has been shown to improve depressive symptoms, independent of change in attention bias. this suggests differentiated, but likely complimentary hot and cold cognitive processes. biased information processing in preference of negative material according to the cognitive model, mdd is associated with a pattern of interpretation in which stimuli tend to be interpreted negatively (gotlib & joormann, 2010). resultantly, a positive blockade is experienced as reduced processing abilities contribute to poorer pro‐ cessing of positive stimuli alongside a decreased salience of positive stimuli (nutt et al., 2007). the mdd interpretation bias is considered central to symptom maintenance. liter‐ ature has supported that individuals with mdd tend to employ negative interpretations of ambiguous information, relative to healthy controls, using a variety of methods (for review, see everaert, podina, & koster, 2017). for example, butler and mathews (1983) showed that when asked to interpret an ambiguous sentence from a given list of options, mdd individuals selected the negative option more frequently than controls. however, such findings in the literature have been critiqued for over-reliance on self-report meas‐ ures, which likely better capture a response bias as opposed to a negative interpretation bias. a response bias could facilitate a pattern of responding that presents as an interpre‐ tation bias as individuals with mdd tend to choose negatively-valenced responses when presented as an option, irrespective of their own interpretation of the scenario. in sup‐ port of this, lawson and macleod (1999) demonstrated that when response time was used as an indicator of interpretation bias, dysphoric individuals did not differ to controls in terms of their reaction time to target negative words following an ambiguous sen‐ tence. if an interpretation bias was evident, it could be expected that dysphoric individu‐ als would show faster reaction times to negative words than neutral words as the nega‐ tive processing bias would prime a negative interpretation. these findings have been re‐ plicated (e.g. bisson & sears, 2007), albeit not consistently throughout the literature (e.g. hindash & amir, 2012). lack of equivocal support throughout the literature could be ex‐ plained by the severity of depressive symptoms; negative interpretation biases are possi‐ bly more pronounced for those with more severe symptoms as a result of exacerbated hot cognition. consistent with this, lawson, macleod, and hammond (2002) showed that the magnitude of eye-blink reflex to negative stimuli was larger for those with more severe depressive symptoms, relative to those with less severe symptoms, indicative of greater negative processing. it is understood that mdd is not driven by the depressive mood nor the depressive thoughts per se, but rather the way in which the individual processes their depressive ahern, bockting, & semkovska 13 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ mood. during mdd, this is usually maladaptive processing that involves rumination or repetitive thinking around the causes and consequences of one’s mood (nolenhoeksema, 1991). wisco, gilbert, and marroquín (2014) demonstrated that the associa‐ tion between interpretation biases and depressive symptoms was conferred through ru‐ mination of negative thoughts as well as dampening of positive thoughts, although the effects through rumination were stronger, comparatively. in addition, reverse mediational analyses provided further evidence of the directionality of effects as the indirect effect of rumination on depressive symptoms through interpretation bias was not significant. as these findings are grounded in correlational research, it is not possible to draw causal conclusions. nevertheless, such findings suggest that the hot cognitive interpretation bias prompts the hot regulatory process of rumination to promote the maintenance of de‐ pressive symptoms. consideration of longitudinal research by hirsch et al. (2018), exam‐ ining the effect of multi-session cognitive bias modification strategies to target interpre‐ tation biases, further corroborates this mechanism. this training involved participants listening to scenarios that were emotionally ambiguous but were resolved positively (76% of trials), negatively (12%), or remained unresolved (12%). in the control, all ambiguous scenarios remained unresolved. at 1-month follow-up, findings suggested that change in interpretation bias following cognitive bias modification partially mediated the interven‐ tional effects on rumination but also on depressive symptoms among patients with mdd. this supports the idea that the mechanism by which negative interpretation biases im‐ pact depressive symptoms is through further hot ruminative processes. however, active control conditions have previously reduced negative interpretation biases when no train‐ ing effects were expected (blackwell et al., 2015; williams et al., 2015). for example, blackwell et al. (2015) did not show superior effects on depressive symptoms following multi-session cognitive bias modification, relative to the attention control condition which resolved ambiguous information either positively (50% of trials) or negatively (50%). by drawing attention to the fact that outcomes can be resolved positively, and therefore, by training general attention ability, albeit inadvertently, the attention control training still showed benefits for depressive symptoms. although further research is re‐ quired to confirm this, it could be argued that the interpretation bias is a manifestation of cold attention deficit that has been ‘made hot’ by the activated negative schema. one aspect of biased processing that has drawn interest throughout the cold cognitive deficit literature is feedback sensitivity. as mentioned, seemingly cold cognitive deficits may in fact be hot as a result of a ‘catastrophic response to perceived failure’ (elliott et al., 1996), or in other words, affective interference from an activated, negative schema when processing feedback. individuals with mdd can perform just as well as healthy controls on several measures of cold cognitive abilities, but once feedback on an error is received, performance thereafter is likely reduced (e.g. beats et al., 1996). cold cognitive deficits may manifest owing to a repetitive, ruminative response on the feedback that serves to confirm an underlying core belief (e.g. ‘i am useless’ or ‘i am a failure’), thus hot-cold cognitive model of depression 14 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ interfering with performance on the task at hand. elliott et al. (1997) supported this by demonstrating that when mdd individuals were re-assessed upon remission, general cognitive performance on the 1-touch tower of london cantab task was comparable to healthy controls, but an abnormal response to negative feedback persisted. thus, the response could not merely be due to an overall higher failure rate. this suggests that hot cognition exerts influence on cold cognitive ability and contributes to deficient perform‐ ance. however, it is important to note that this finding was exclusive to the 1-touch tow‐ er of london measure in a sample of 28 mdd patients and was not replicated in the de‐ layed matching to sample test. in a direct comparison between a feedback condition and a no feedback (paired associates) condition, mörkl, blesl, jahanshahi, painold, and holl (2016) demonstrated that performance in probabilistic classification learning was im‐ paired during the feedback condition but not for the no feedback condition, relative to controls. feedback-learning involved receiving a ‘thumbs up’ or ‘thumbs down’ in re‐ sponse to the classification of each card to a certain type of weather (rainy/fine). this corroborates that hot information processing biases can manifest as cold cognitive defi‐ cits in various domains of learning and attention during seemingly neutral cognitive tasks. whether this deficit is initiated as an epiphenomenon of the processing bias/feed‐ back sensitivity or is merely exacerbated during the acute depressive state (i.e. ‘becomes hot’) still warrants further research considering the low-effortful task employed by mörkl et al. (2016). the consideration of task demands is important when assessing the extent of cognitive control deficits in mdd. indeed, when tasks are considered more effortful and require more complex processing, the inefficient allocation of cognitive resources to the task at hand means that deficits in cold cognitive functioning become more pronounced (hammar, lund, & hugdahl, 2003; hartlage, alloy, vázquez, & dykman, 1993). deficits in various cognitive measures including attention, learning and memory, and executive function have been documented in mdd without feedback and therefore cannot merely be a manifestation of feedback sensitivity (e.g. rock et al., 2014). nevertheless, a direct comparison of mdd cognitive performance in the presence or absence of feedback would better help to elucidate whether the hot and cold elements involved in the activation and maintenance of the processing bias are mutually reinforcing (i.e. underlying cold deficit is exacerbated by hot ruminative processes following feedback, in turn manifesting as further cold cognitive deficit). thus, a differential magnitude of deficit may be observed, contingent on the catastrophic response to feedback. interestingly, literature has not consistently supported the explanation of a cata‐ strophic response, but rather it is proposed that error post-feedback represents a failure to internalise the feedback through learning and, as a result, performance is not adjusted. the findings of steele, kumar, and ebmeier (2007) align with this interpretation as mdd individuals showed a blunted response following error-feedback in a gambling task sug‐ gesting that they did not learn from their past performance. typically, a ‘post-error slow‐ ing’ is demonstrated where the individual considers the feedback to avoid a repetition of ahern, bockting, & semkovska 15 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ error and to adjust performance accordingly. this process manifests as an increase in re‐ action time. nevertheless, mdd individuals did not show increased reaction time posterror, suggesting that not even a ruminative response style was employed to process the feedback. thus, a basic deficit in cold cognitive ability likely accounted for poor perform‐ ance, not hot ruminative processes. further to this, using a non-affective flanker task with switch or no-switch blocks (no performance feedback offered), schroder, moran, infantolino, and moser (2013) demonstrated that anhedonic depressive symptoms were not associated with post-error slowing but were associated with poorer post-error accu‐ racy. as the association between anhedonic depressive symptoms and post-error accura‐ cy was only shown in the more cognitively-demanding switch block condition, the avail‐ ability of cognitive resources appears to be an important factor for cognitive control abil‐ ity. these findings allow for the consideration that deficits in attention and the ability to update the contents of working memory during an effortful task account for subsequent poor performance as post-error slowing and deficient post-error accuracy were observed independent of feedback. although the explanatory potential of deficient motivation in anhedonic depression cannot be overlooked to account for these findings (but see grahek et al., 2018), the premise that cold cognitive deficits are not merely a manifestation of biased processing is of empirical and theoretical interest. in summary, the processing bias proposed by the cognitive model appears to be large‐ ly maintained by the interaction between hot and cold cognitions. for the most part, ru‐ minative processes carry the effect of this bias on depressive symptoms by stimulating accessible, negative, self-relevant information to reinforce a negative interpretation. ar‐ guably, cold cognitive deficit, in seemingly non-affective contexts, may be a manifesta‐ tion of hot cognition through a catastrophic response to feedback, and subsequent rumi‐ nation on this feedback. nevertheless, cold deficits have reliably be shown in the absence of feedback and symptom improvement has been achieved following control, non-affec‐ tive attention training, suggesting that there is a complex interaction that likely incorpo‐ rates both hot and cold cognition as mutually reinforcing, overall serving to maintain de‐ pressive symptoms. hot-cold cognitive model of depression 16 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ figure 2. model of the interaction between cold cognitive deficits and the hot cognitive processing bias during depression. note. when triggered by a perceived stressful life event, weaknesses in cognitive flexibility, working memory, and inhibitory processes interact with the depressive schema resulting in a bias towards processing information negatively, congruent with the activated schema. there is a consequent reduction in available cognitive resources when the schema and associated bias is activated. as a result, broader cognitive deficits are observed during the acute depressive state. specifically, the inability to update the contents of working memory with a shift to positive information (cognitive flexibility) and expel irrelevant, negative information from working memory (inhibition) contribute to rumination, i.e. repetitive, negative thinking style, which further serves to maintain the processing bias and worsen depressive symptoms. yet, ruminative processes do not always account for cold cognitive deficits in post-error adjustment, suggesting some degree of independence between the hot and cold pathways for biased information processing. components of the model are informed by beck’s cognitive model of depression. ahern, bockting, & semkovska 17 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ biased memory for negative material biased memory recall during mdd is perhaps one of the most consistent and well-sup‐ ported cognitive biases (gotlib & joormann, 2010). this is best understood as an instance of memory in which mood-congruent information (i.e. negative information consistent with negative mood state) is better encoded and recalled than mood-incongruent infor‐ mation (matt, vázquez, & campbell, 1992). due to the negative mood state that is charac‐ teristic of mdd, symptomatic individuals tend to recall negative information more readi‐ ly as prompted by the accessibility of active, negative schemas, thus serving to maintain the negative mood. this negative recall is likely facilitated by biases at encoding as a re‐ sult of preferential attention to negative experiences as well as the maladaptive interpre‐ tation of ambiguous personal experiences to resolve as negative encounters (dalgleish & werner-seidler, 2014). of note, a recall bias in non-affective, cold cognitive tasks has even been observed during mdd, presenting as a serial position effect in list-learning that is characterised by impoverished recall of items from the middle region, relative to healthy controls (foldi, brickman, schaefer, & knutelska, 2003). it is postulated that the active, negative schema (e.g. ‘i am a failure’) interferes with subsequent learning and recall by means of affective interference, drawing focus to task irrelevant information (e.g. ‘i will never finish this list’). consequently, recall has been enhanced for mood-congruent nega‐ tive information and compromised for incongruent, positive or neutral information, as demonstrated across both explicit (for review, see matt et al., 1992) and implicit (for re‐ view, see gaddy & ingram, 2014) memory tasks. a meta-analysis (matt et al., 1992) on recall performance among mdd patients demonstrated, on average, that individuals re‐ call 10% more negative information than positive information on explicit memory recall tasks. a type of explicit memory known as autobiographical memory (am) is character‐ ised by a particular recall bias during mdd which takes the form of an overgeneralisa‐ tion, or a lack of specifics in the content recalled, usually in response to negative cues (e.g. dalgleish & werner-seidler, 2014; semkovska, noone, carton, & mcloughlin, 2012). research has demonstrated that overgeneral am is likely state-dependent, with improve‐ ment in specificity shown upon remission (e.g. semkovska et al., 2012), however, over‐ general am has also received support as a trait vulnerability for subsequent depressive symptoms, particularly in interaction with stressful life events (e.g. gibbs & rude, 2004). overgeneral am represents a hot cognitive profile that is specific to mdd. this hot cognition has been relatively well-explored in the literature in relation to ruminative pro‐ cesses, which tend to centre around the general themes made accessible by schema acti‐ vation at recall (e.g. incidences of failure). rumination then consolidates these themes, which further contribute to overgeneral am recall (watkins & teasdale, 2001). on the other hand, the seminal work by raes, hermans, williams, geypen, and eelen (2006) demonstrated that overgeneral am can causally influence rumination, following experi‐ mental manipulation to prime either a specific or overgeneral recall style. findings showed that among high-ruminators and subsequent to an overgeneral (vs. specific) re‐ hot-cold cognitive model of depression 18 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ call style, sentences tended to be unscrambled into sentences with a ruminative meaning. among nonor low-ruminators, this effect was not shown. thus, it is better to consider the recall bias-rumination link as mutually reinforcing, in that hot cognition stimulates further hot cognition. as such, it could be conceptualised that the effect of memory recall bias on depressive symptoms is carried by a ruminative thinking style. in corroboration of this, liu et al. (2017) demonstrated that ruminative responses, particularly the malad‐ aptive brooding subtype, partially mediated the relationship between overgeneral am and depressive symptoms. albeit, the cross-sectional design cannot infer causality so it is possible that rumination is merely a covariate as opposed to the mediator of effect. the reverse mediational models conducted by the authors, however, did not support overgen‐ eral am as a potential mediator of the rumination-depressive symptom link. likely these two hot cognitions are closely intertwined, making it difficult to discern the effect of one on another. consideration of the role of executive cognitive abilities may better help elu‐ cidate the means by which this reciprocal interaction arises. ruminative processes that occur during the recall bias use up cognitive resources that otherwise would have been directed towards accessing the specifics of am (van vreeswijk & de wilde, 2004). to demonstrate this, cheung, sin, lam, and lee (2018) as‐ sessed the specificity of am in mdd patients following negative and positive rumination induction. results showed that mdd patients, relative to controls, produced fewer specif‐ ic ams following negative rumination compared to positive rumination. the authors suggested that an inhibitory deficit in mdd compromised the ability to filter out taskirrelevant negative information from working memory, thus impairing the ability to re‐ call specific memories, stimulating a negative ruminative process. although general in‐ hibitory ability was not assessed by the authors, it could be the case that an underlying cold inhibitory deficit became hot in the presence of affective content. building on this, hitchcock, golden, werner-seidler, kuyken, and dalgleish (2018) examined the central role of executive control in negative am recall following positive and negative contextual cues among mdd patients. results showed that following positive contextual cues, those with more severe depressive symptoms rated their negative memories more positively, relative to less severely depressed patients. as such, this suggests that the executive con‐ trol deficits are somewhat state-dependent as differential effects were noted based on the magnitude of depressive symptoms. this can be explained by fewer executive resources available in those more severely depressed to override the priming generated by the posi‐ tive contextual cue. in a second study by the authors using a community sample, poorer performance on a non-affective working memory task was associated with less negative ratings of ams recalled and with the recall of a greater number of overtly positive ams. thus, compromised cold executive control appears to be the driving mechanism of this effect and not a negative recall memory bias, which beck’s cognitive model would hy‐ pothesise to occur independent of context. the influence of contextual priming, as shown in these findings, has important implications for mood maintenance. for example, ahern, bockting, & semkovska 19 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ if intrinsic contextual cues (i.e. negative thoughts, rumination) override one’s ability to derive benefit from the recall of positive or neutral memories necessary for cognitive re‐ structuring, a core aspect of cbt, then outcomes may be less favourable. in this regard, cold executive deficits may play a central role in the maintenance of depressive mood state, over and above those accounted for by hot cognitions. overgeneral am has also been conceptualised as a facet of a wider difficulty in mem‐ ory processes such as the ability to make correct attributions about the origin of informa‐ tion, known as source memory. raes, hermans, williams, demyttenaere, et al., 2006) demonstrated that among 26 acute mdd patients, reduced am episodic-specificity was associated with poorer source memory and working memory, but not verbal fluency or verbal learning and delayed recall. these associations were shown independent of cur‐ rent depressive symptoms. semkovska et al. (2012) elaborated on these findings among a sample of 30 mdd patients with severe depression, corroborating that reduced am epi‐ sodic-specificity was associated with poorer working memory, but that verbal or visual learning and delayed recall were specifically associated with am semantic-specificity for personal information (e.g. details regarding a family member). among a remitted mdd sample of 122 individuals, the findings of spinhoven et al. (2006) strengthen the argu‐ ment that aspects of reduced am specificity likely represent a facet of a more general memory deficit independent of the hot affective state, as am specificity was shown to be associated with immediate and delayed memory recall, even when controlling for residu‐ al depressive symptoms. yet, at 24-month follow-up, neither am specificity nor other cognitive measures were predictive of relapse or recurrence. this brings to question whether it is the interaction between hot and cold components that may be necessary to trigger subsequent mdd events. similarly, gibbs and rude (2004) suggested that over‐ general am, when in conjunction with stressful life events, predicted the development of subsequent depressive symptoms 4-6 weeks later in a non-clinical sample. thus, it could be the case that cold deficits condition, or likewise transfer, the effects of the hot memory recall bias. the recall of specific memories is a core component of everyday functioning and has relevance for day-to-day tasks that rely on problem-solving, the generation of future plans, and social interactions that are built upon shared experiences (dalgleish & werner-seidler, 2014). consequently, cold cognitive abilities are compromised without the script of past ams to direct and guide behaviour, contributing to subsequent negative experiences in the everyday functioning of the individual. raes et al. (2005) showed that reduced am specificity fully mediated the association between rumination and social problem-solving (e.g. handing a situation at work), while partial correlations demonstra‐ ted that this association could not be better accounted for by depressive symptoms. cor‐ roborating this, hitchcock et al. (2016) documented that an am intervention (memflex) showed far-transfer of effects by significantly improving problem-solving ability. al‐ though the authors acknowledged that problem-solving was an intermediate outcome hot-cold cognitive model of depression 20 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ that likely conferred the effect of overgeneral am on depressive symptoms, they did not formally test the mediational process. in addition, planning ability has been observed as a cold cognitive deficit following the induction of a generic retrieval style (williams et al., 1996). in a recent meta-analysis by hallford, austin, takano, and raes (2018), psychiatric diagnosis was associated with large deficits in episodic future thinking specificity. mod‐ eration by cue valence (positive, negative, neutral) was non-significant, suggesting that the deficit is more general and not wholly contingent on valence, as would be suggested by beck’s cognitive model. it is important to note, however, that moderation by valence was across all studies (k = 19), so it is possible that mdd (k = 7) shows differential effects to other psychopathologies such as bipolar disorder or schizophrenia. a subsequent meta-analysis conducted solely including depressive samples resulted in 37 studies and suggested that depressive symptoms contributed to reduced specificity for future events, more so for positive future thinking relative to negative or neutral future thinking (gamble, moreau, tippett, & addis, 2018). considering the ability to detail future scenar‐ ios is necessary to plan and pursue goals, it can be argued that the hot cognitive profile of mdd manifests as a broader spectrum of cold cognitive deficits including planning and problem-solving abilities. such deficits are likely responsible for the negative experi‐ ences of everyday functioning and may serve as a source of reference to confirm and per‐ petuate the activation of negative schemas (e.g. ‘i am a failure’), overall contributing to a maintenance of the mdd cycle. in summary, the interaction between hot and cold cognitions in the memory recall bias is difficult to disentangle but lends support to the idea that both are mutually rein‐ forcing for the activated bias as well as associated depressive symptoms. rumination has been identified as the primary hot cognition that carries the effect of the negative recall bias by stimulating negative thoughts around the negative memory that was generated. a cold deficit in non-affective memory potentially facilitates the expression of the afore‐ mentioned recall bias, but likely this is determined by the strength of executive control, characterised by the individual’s ability to flexibly disengage from mood-congruent neg‐ ative information, inhibit further irrelevant negative information, and subsequently up‐ date the contents of working memory. without the specifics in am to provide a script to guide behaviour, a broader range of cold deficit is experienced, which impacts on effi‐ cient day-to-day functioning. collectively, this may serve as self-referent negative infor‐ mation to maintain the activation of the relevant schema and recall bias. ahern, bockting, & semkovska 21 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ figure 3. model of the interaction between cold cognitive deficits and the hot cognitive memory bias during depression. note. when triggered by a perceived stressful life event, weaknesses in cognitive flexibility, memory, and inhibitory processes interact with the depressive schema resulting in a memory bias characterised by poor encoding of positive memories, over-retrieval of negative memories, and lack of specificity for autobiographical memories. there is a consequent reduction in available cognitive resources when the schema and associated bias is activated. as a result, deficits in hot and cold executive control perpetuate the activation of the memory bias due to a compromised ability to inhibit, shift away from, and update the contents of working memory, feeding into ruminative thinking centred on negative, non-specific events. impaired memory processes contribute to broader cognitive deficits during the acute depressive state affecting day-to-day planning and problem solving, potentially triggering subsequent maladaptive mood-congruent recall of past events. the interaction between hot and cold pathways serves to perpetuate the negative memory cycle and worsen depressive symptoms. components of the model are informed by beck’s cognitive model of depression. hot-cold cognitive model of depression 22 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ an integrated hot-cold cognitive model as demonstrated above, the cold cognitive processes that underlie the negative schemas and cognitive biases proposed by beck’s cognitive model seem to largely be accounted for by two, complementary processes: (i) weakened executive control (cognitive flexibili‐ ty, inhibition, working memory), which facilitates the activation and maintenance of a hot cognitive profile by means of affective interference, and (ii) further exacerbation of cold cognitive dysfunction by means of diminished cognitive resources which, in turn, likely represent internal stressors maintaining the depressive state. the former process corroborates previous literature that cognitive biases are main‐ tained by impoverished abilities to effectively disengage from negative material (gotlib & joormann, 2010). as such, the material present in working memory tends to be of moodcongruent, negative valence due to a poor ability to inhibit the generation of subsequent negative material or flexibly shift to potentially-relevant, positive material. for the most part, literature has examined the role of weakened executive control during mdd using affective tasks in which the ability to inhibit or shift from negative material is assessed (koster, hoorelbeke, onraedt, owens, & derakshan, 2017). resultantly, findings have cre‐ ated a narrative around various components of affective, hot cognitive processes. our model provides a novel narrative as it includes non-affective, cold cognitive deficits in the mdd cycle to suggest that, in some circumstances, it is a general deficit that facili‐ tates the expression of hot executive deficits towards the processing of negative material. consistent with this, an accumulating body of literature demonstrates that cognitive def‐ icits persist into remission (semkovska et al., 2019), and therefore cannot merely be an epiphenomenon of mood state. instead, these deficits are conceptualised as the means by which affective, hot deficits in cognitive domains such as attention and executive func‐ tion manifest. collectively, these factors work to initiate and maintain the depressive schemas and cognitive biases by making negative material readily accessible. the latter process takes the form of exacerbated cold cognitive deficits, which likely act as internal stressors triggering the repeated activation of dysfunctional hot cogni‐ tions. in this way, the stressors become apparent in day-to-day functioning when defi‐ cient ability to attend, memorise, plan, and problem-solve provide a source of self-refer‐ ent feedback to confirm negative schemas about the self. this sets up a self-perpetuating cycle as deficient cold cognition activates the influence of hot processing biases and a ru‐ minative response style that collectively place large demands on cognitive resources, and in turn, deprive the allocation of resources to cold cognitions required in everyday func‐ tion across work, home, and social environments. again, cold cognitive deficits appear somewhat independent of hot schemas and biases as deficient functioning is observed even in the state of mood restoration (evans, iverson, yatham, & lam, 2014). in the con‐ text of beck’s cognitive model, cold cognitive deficits reinforce hot cognition by provid‐ ing accessible schema-congruent material (e.g. ‘i am a failure’, ‘i am not as good as oth‐ ers’) and likely serve as a source of maintenance for the mdd cycle. ahern, bockting, & semkovska 23 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ our proposed model (figure 4) postulates an interaction between cold and hot cogni‐ tion in the onset and maintenance of mdd and is consistent with current neuropsycho‐ logical models of mdd such as that by roiser and sahakian (2013). in their model, roiser and sahakian (2013) integrated the traditional cognitive framework with recent pharma‐ cological findings to conceptualise mdd as the interaction between maladaptive topdown and bottom-up processes, with consideration of hot and cold components. the au‐ thors applied their findings to inform adjunctive treatment options that could address the hot/cold top-down cognition that contributes to negative expectations (e.g. cbt) or weakened executive control (e.g. transcranial magnetic stimulation), alongside the hot bottom-up cognition that accounts for negative perceptions (e.g. antidepressant medica‐ tion). our model further elaborates on this by providing a thorough, integrated account of cold cognitive abilities within the dominant cognitive framework of mdd. the proposed model lends itself to identifying novel initiatives to help interrupt the mdd cycle and best inform refined, psychological treatment options. this incorporates the consideration of hot and cold maladaptive cognitions. to date, cbt is well-establish‐ ed as an effective treatment for mdd by addressing the hot cognitive components that serve to maintain the depressive schemas. several studies have shown that cbt has ben‐ eficial effects on cognitive biases of attention (e.g. tobon, ouimet, & dozois, 2011), inter‐ pretation (e.g. williams et al., 2015), memory (e.g. mcbride, segal, kennedy, & gemar, 2007), as well as maladaptive, ruminative emotion regulation strategies (for review, see spinhoven et al., 2018). however, cbt has shown little, if any, influence on cold cogni‐ tive abilities (groves et al., 2015; porter et al., 2016). this possibly explains the relapse rates subsequent to treatment considering the cold cognitive aspects of the mdd cycle were not addressed. attention training and improving control over thinking may facili‐ tate the ability to flexibly shift attention and disengage from the negative schemas or as‐ sociated biases. in support of this, cognitive remediation strategies, which explicitly tar‐ get cognitive abilities shown to be deficient during mdd through repetitive and adaptive training, have shown much promise in strengthening such cold cognitive abilities (motter, grinberg, lieberman, iqnaibi, & sneed, 2019; motter et al., 2016; semkovska & ahern, 2017; trapp, engel, hajak, lautenbacher, & gallhofer, 2016). a comprehensive re‐ view by koster et al. (2017) provides a compelling discussion on the potential means by which cognitive training affects depressive symptoms. hot-cold cognitive model of depression 24 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ fi gu re 4 . m od el o f t he in te ra ct io n be tw ee n co ld co gn iti ve d ef ic its a nd h ot co gn iti on d ur in g de pr es sio n (m od el a da pt ed fr om a llo tt, f ish er , a m m in ge r, go od al l, & h et ric k, 2 01 6) . t he in te ra ct io n pr oc es s i s e xp la in ed th ro ug h pa rts i – iv . ahern, bockting, & semkovska 25 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ in summary, cognitive training may exert benefit by altering mediational hot cogni‐ tive factors (e.g. rumination), by targeting the underlying neurocircuitry known to be compromised during depression (for review, see drevets, price, & furey, 2008), or finally by influencing vulnerability to the activation of cognitive biases. the consideration of cognitive training as an adjunct to cbt may best complement outcomes for depressive symptoms by fully accounting for the interaction between hot and cold cognitions in the onset and maintenance of mdd. patient preference largely favours psychological treat‐ ment over medication (mchugh et al., 2013) and this gives prominence to the need for integrated treatment options that are embedded within the cognitive theory framework. significant developments have been made in understanding the role of cognition in mdd, but further integrative research with the aim of refining cognitive models of mdd will be necessary to improve approaches towards prevention and treatment. no single form of cognition solely drives the depressive cycle, thus modelling the interplay be‐ tween various facets of hot and cold cognition is a promising avenue to stimulate re‐ search. researchers should endeavour to identify the relative contribution of hot and cold cognitions in interventional research to best account for the mechanisms by which symp‐ tom improvement can be achieved. this is a crucial step in transitioning from the symp‐ tom-based to the mechanism-based view of mdd (grahek et al., 2018). in addition, con‐ sideration of hot and cold cognitive processes in longitudinal research may help to ac‐ count for the directionality of effects. cold deficits may serve as the initiating mechanism for hot cognitions, as suggested in the literature (e.g. allott et al., 2016), but once a major depressive episode is initiated, the extent to which cold deficits are necessary for the maintenance of negative schemas and associated biases is not well understood. an im‐ portant aim of our integrated model is to encourage hypothesis-driven research efforts to examine the potential of hot and cold cognitive mechanisms in novel treatment initia‐ tives. in conclusion, our integrated hot-cold cognitive model of mdd provides a prelimina‐ ry framework to identify the central role that cold cognitive abilities play in conjunction with the more widely recognised hot cognitive processes that underpin beck’s conceptu‐ alisation of mdd onset and maintenance. the growing body of research on deficits in non-affective, cold cognitive abilities during remission confirms that cold cognition is not merely an epiphenomenon of the acute state. here, we have proposed a re-framing of the cognitive model to account for the complex interaction between cognition and emotion during mdd. by doing so, this stimulates further opportunity to develop innovative treatment strategies that can effectively address a full functional recovery from this high‐ ly recurrent and debilitating disorder. hot-cold cognitive model of depression 26 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://www.psychopen.eu/ funding: this work was supported by the irish research council under the government of ireland postgraduate scholarship programme awarded to elayne ahern, under the supervision of principal investigator maria semkovska (goipg/2018/1729). competing interests: the authors declare no conflicts of interest. acknowledgments: the authors have no support to report. references ahern, e., & semkovska, m. 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(2019). can't look away: attention control deficits predict rumination, depression symptoms and depressive affect in daily life. journal of affective disorders, 245, 1061-1069. https://doi.org/10.1016/j.jad.2018.11.036 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. ahern, bockting, & semkovska 35 clinical psychology in europe 2019, vol.1(3), article e34396 https://doi.org/10.32872/cpe.v1i3.34396 https://doi.org/10.5127/jep.038213 http://www.who.int/news-room/fact-sheets/detail/depression https://doi.org/10.1016/j.jbtep.2014.08.005 https://doi.org/10.1016/j.jad.2018.11.036 https://www.psychopen.eu/ hot-cold cognitive model of depression (introduction) hot and cold cognition relevance of cold cognition for the cognitive model biased attention for negative material biased information processing in preference of negative material biased memory for negative material an integrated hot-cold cognitive model (additional information) funding competing interests acknowledgments references a mental imagery micro-intervention to increase positive affect in outpatient cbt sessions (pacific): study protocol of a randomized controlled implementation trial research articles a mental imagery micro-intervention to increase positive affect in outpatient cbt sessions (pacific): study protocol of a randomized controlled implementation trial jan schürmann-vengels 1 , philipp pascal victor 1, patrizia odyniec 1 , christoph flückiger 2 , tobias teismann 3 , ulrike willutzki 1 [1] department of psychology and psychotherapy, universität witten/herdecke, witten, germany. [2] department of clinical psychology and psychotherapy, university of zurich, zurich, switzerland. [3] mental health research and treatment center, ruhr-universität bochum, bochum, germany. clinical psychology in europe, 2022, vol. 4(2), article e7043, https://doi.org/10.32872/cpe.7043 received: 2021-06-30 • accepted: 2022-03-17 • published (vor): 2022-06-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: jan schürmann-vengels, department of psychology and psychotherapy, universität witten/herdecke, alfred-herrhausen-straße 50, 58448 witten, germany; phone: +49 2302 926 781; e-mail: jan.schuermann-vengels@uni-wh.de supplementary materials: materials [see index of supplementary materials] abstract background: recent findings indicated that mental disorders are associated with both an upregulation of negative affect and a down-regulation of positive affect (pa) as distinct processes. established treatment approaches focus on the modification of problems and negative affect only. experimental paradigms in healthy samples and research on strengths-based approaches showed that fostering pa may improve psychotherapy process and outcome. specific and easily implementable interventions targeting pa in treatment sessions are scarce. mental imagery was shown to be a promising strategy for boosting positive emotional experiences. method: the pacific-study is planned as a longitudinal randomized-controlled trial in the context of cognitive behavioral therapy, implemented at a german outpatient training and research center. in the process analysis, trajectories of pa over the first twelve treatment sessions will be examined with weekly questionnaires. in the intervention analysis, a six-minute positive mental imagery intervention to enhance pa will be developed and tested. the intervention is implemented with loudspeakers at the beginning of each session for a standardized induction of pa. the this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7043&domain=pdf&date_stamp=2022-06-30 https://orcid.org/0000-0002-8963-1129 https://orcid.org/0000-0002-9444-7473 https://orcid.org/0000-0003-3058-5815 https://orcid.org/0000-0002-6498-7356 https://orcid.org/0000-0002-0149-4554 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ experimental group will be compared to an active control group (neutral mental imagery) and treatment as usual. procedures in all treatment arms are parallelized. main outcomes after twelve sessions of psychotherapy will be psychosocial resources, resilience and self-esteem (theorydriven), as well as psychopathology and working alliance (secondary outcome). multilevel modeling will be conducted to address the nested data structure. conclusion: study results may have implications on the consideration of positive constructs in mental disorders and the implementation of strengths-based interventions in psychotherapy. keywords positive affect, mental imagery, psychotherapy process, cognitive behavioral therapy, randomized controlled trial, multilevel models highlights • this planned study will examine the trajectories of positive and negative affect during early cbt. • development and pilot-test of a six-minute positive mental imagery intervention are described. • possible effects of the positive mental imagery implementation of treatment outcome are discussed. treatments like cognitive behavioral therapy (cbt) have shown effectiveness for various mental disorders (e.g. hofmann et al., 2012). however, there is a lack of knowledge about basic processes in mental disorders and psychotherapy. affect dysregulation is recently discussed as a factor for the maintenance of psychopathology. affect is defined as the subjective experience of an emotional state and is differentiated by its valence (hofmann, 2016). positive and negative affect are assumed to be correlated, but separate constructs (larsen et al., 2017; watson et al., 1999). dysfunctional up-regulation of negative affect (na) is a common feature in mental disorders (aldao et al., 2010) and is successfully modified by cbt (boumparis et al., 2016; sauer-zavala et al., 2012). in contrast, the impact of positive affect (pa) in psychopathology and psychotherapy is not well estab­ lished. regarding this research gap, we designed the positive affect and mental imagery in the process of cognitive behavioral therapy (pacific)-study. pa and psychological processes pa is characterized by various emotions and moods with a subjective pleasant valence. according to the broaden-and-build theory of positive emotions, pa initiates a multi­ stage upward spiral process (fredrickson, 2001; garland et al., 2010). in particular, re­ search findings from healthy samples showed that pa leads to a broadening of attention as well as thought and action repertoires. positive mood inductions in experimental paradigms increased visuospatial attention as well as information processing (phaf, 2015; pacific: study protocol 2 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ pourtois et al., 2017; vanlessen et al., 2016). high pa was related to better performance in category building and creativity tasks (baas et al., 2008; nadler et al., 2010). observatio­ nal and experimental studies showed that such broadening, in turn, was associated with a reciprocal increase of psychosocial resources, resilience and mental health (garland et al., 2010; griffith et al., 2021). the broaden-and-build theory, therefore, hypothesized that an increase in pa will lead to higher levels in these specific variables. hence they may help to evaluate interventions that target an increase of pa. brief descriptions of these constructs are presented in the following: psychosocial resources were defined as positive and functional aspects of a person or his/her environment (e.g. optimism, social support; taylor & broffman, 2011). previous findings indicated moderate to high correla­ tions between different constructs and the possibility to assess a generic perception of inherent resources (goldbach et al., 2020; taylor & broffman, 2011; victor et al., 2019). psychological resilience was defined as the potential to successfully adapt to adversities and stressors (davydov et al., 2010). previous studies found that resilience is a dynamic trait, which is both influenced by internal and external experiences and changeable by purposeful interventions (connor & davidson, 2003; mealer et al., 2014). self-esteem is an important part of mental health and was defined as the degree, a person positively consider his/her characteristics or abilities (brown, 2007). baseline parameters and trajec­ tories of self-esteem and pa were strongly related in observational and intervention studies (garland et al., 2010; wood et al., 2003). most concepts have focused on a global evaluation of self-esteem rather on specific facets (rosenberg et al., 1995). pa in psychopathology and psychotherapy carl et al. (2013) pointed out that the down-regulation or dampening of pa is an independent process in mental disorders. in a prospective paradigm, baseline anxiety and depressive symptoms were related to lower rates of daily positive emotional reac­ tivity and decreased levels of pa in the subsequent 14-day period (carl et al., 2014). specific analyses found decreased levels of pa for various mental disorders (cohen et al., 2017; eisner et al., 2009; thompson et al., 2016). these findings support the idea to consider and foster pa by psychotherapeutic interventions. concurrently, classical cbt treatments had only small effects on pa in patients with major depression, g = 0.41, p = .001, and anxiety disorders, g = 0.37, p = .001 (boumparis et al., 2016; wilner tirpak et al., 2019). an established approach to foster positive constructs in psychological treatments is resource activation. the activation of patients’ strengths and resources is regarded as a change mechanism in psychotherapy and was significantly associated with patients’ pa and treatment outcome in cbt sessions (flückiger et al., 2009; mander et al., 2013). observer ratings showed that successful cbt sessions were characterized by higher levels of resource activation and pa, particularly at the beginning of treatment sessions (gassmann & grawe, 2006; smith & grawe, 2003). moreover, chui et al. (2016) found that schürmann-vengels, victor, odyniec et al. 3 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ higher initial pa of patients in psychotherapy sessions lead to both more pa of therapists and better rated post-session collaboration. although these studies indicate the feasibility to increase pa in psychotherapeutic settings and its promotive influences on symptom improvement and working alliance, economical strategies that directly targeting pa are lacking. mental imagery as a strategy to increase pa mental imagery is defined as “representations and the accompanying experience of sen­ sory information without a direct external stimulus” (pearson et al., 2015, p. 590). com­ pared to other interventions, mental imagery was found to be more effective in evoking emotions (holmes et al., 2009; holmes & matthews, 2010; schubert et al., 2020). recent research approaches compared the imagination of positive versus neutral contents to differentiate its affective impact (grol et al., 2017). in clinical settings, most studies of positive mental imagery were conducted as single interventions to promote pa in patients with major depression: these trainings were associated with reduced depressive symptoms and anhedonia, as well as increased optimism, positive self-referent cognitions and behavioral activation in clinical samples (blackwell et al., 2015; dainer-best et al., 2018; ji et al., 2017; renner et al., 2017). alternatively, positive mental imagery has also been discussed to enhance anxiety (wallace & alden, 1997) and trigger dissociation (brewin et al., 2010). another analysis by o’donnell et al. (2017) showed that positive mental imagery training in individuals with high hypomanic experiences led to a dys­ functional amplification of positive mood. thus, while there is substantial evidence that fostering pa may be a promising intervention strategy also in psychotherapy, we do not know whether the systematic implementation of positive mental imagery has a beneficial impact on psychotherapy process and outcome. specific analyses found important factors influencing the promotion of pa in mental imagery: practicing mental imagery repeatedly (blackwell et al., 2015; o’donnell et al., 2017), including various sensory modalities (holmes et al., 2008), imaging personally relevant situations, aspects or perspectives (quoidbach et al., 2009) and employing a field perspective (grol et al., 2017). current study the dysregulation of pa is a prominent and distinct factor in psychopathology and should be focused in cbt. higher experience of pa may broaden patients’ receptivity in treatment sessions and may enable goal-related approaching behaviors. however, there is a massive lack of knowledge about pa in the therapeutic process. to the best of our knowledge, no study has attempted to activate pa via an economical intervention in cbt sessions. pacific: study protocol 4 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ within the pacific-study, both a process and an intervention analysis will be conduc­ ted. in the process analysis, we will examine the course of pa and na in the first twelve sessions of cbt treatments. therefore, primary outcome in the process analysis will be the slope of pa and na. further measures of resource activation, working alliance and psychopathology after each of the twelve sessions will be included in the process analysis to analyze their relation to pa (within and between sessions). in the intervention analysis, we will examine the effects of a six-minute positive mental imagery intervention during an early phase of psychotherapy. the aim of this micro-intervention is to foster patients’ in-session pa, which may lead to increased levels of subjective resources, resilience, and self-esteem (theory-driven outcome) as well as improvements in psychopathology and working alliance (secondary outcome). changes in the theory-driven outcome variables are expected due to the specific effects of in­ creased pa according to the broaden-and-build theory of positive emotions (fredrickson, 2001). changes in the secondary outcome variables are expected due to found effects of resource activation and shared positive emotions in treatment (chui et al., 2016; flückiger et al., 2009). patients will be randomized into one of three parallel treatment arms with a 1:1:1 allocation: cbt + positive mental imagery micro-intervention (pmi), cbt + neutral mental micro-intervention (nmi), or treatment as usual (tau). two active mental imagery micro-interventions are planned to differentiate the specific effect of a pa induction within treatment sessions. the study serves the following objectives: 1. to explore the trajectories of pa and na in an early phase of cbt treatment. 2. to develop and test the feasibility of a brief intervention to promote pa in psychotherapy sessions. 3. to analyze the impact of this intervention on the therapeutic process between and within cbt sessions and intermediate outcomes. we hypothesize that pa will increase, while na will decrease during the first 12 sessions of therapy. according to the specific effects postulated by the broaden-and-build theory of positive emotions, we further hypothesize that patients in the pmi will show higher in-session pa and higher levels of subjective resources, resilience, and self-esteem com­ pared to the other conditions. method design figure 1 displays a spirit chart of the planned study design. the study is a randomized controlled implementation trial with three parallel treatment arms using a 1:1:1 alloca­ tion ratio. a blocked randomization with blocks of variable length conducted by a ran­ dom-number generator (random.org) will be performed. block length will be determined schürmann-vengels, victor, odyniec et al. 5 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ randomly (9, 12 or 15 units), before conditions will be randomized within all blocks separately. an independent research assistant will develop the block list and conduct the randomization. patients will be randomized to one of the following arms: cbt + positive mental imagery induction (pmi), cbt + neutral mental imagery induction (nmi) and tau. all arms include an individual cbt treatment. a cross-therapist design in which any therapist can deliver all three conditions is applied. randomization will be focused on patients only, so that therapists will not see a fixed number of patients per condition. however, we expect that the block randomization will enable an approximately equal number of patients in all conditions per therapist. all participants are blind to the con­ ditions and specific hypotheses. according to the consort statement concerning the criteria of a pragmatic randomized trial (zwarenstein et al., 2008) therapists and study coworkers conducting the information meetings are not blind to allocation. researchers involved in data collection and evaluation will be blind to condition labels. an independ­ ent researcher will analyze study data with non-identifying codes of the conditions. the study includes a longitudinal design with an initial diagnostic phase (four to five sessions) and the following twelve psychotherapy sessions. outcome for the process analysis will be gathered directly after each treatment sessions. in the intervention analysis, assessments will be made every forth session: at the start of treatment (pre), after fourth (mid-4), after eighth (mid-8) and after twelfth treatment session (post-12). in addition, videotapes of treatment sessions 2, 5 and 8 will be analyzed with an observer rating. participants patients a total of 120 patients will be recruited at the center of mental health and psychother­ apy (cmhp), an outpatient training and research center for cbt at witten/herdecke university, germany. general inclusion criteria will be as follows: (1) psychotherapy outpatient, (2) at least one mental disorder according to dsm-5 criteria, (3) at least 18 years of age. general exclusion criteria will be as follows: (1) current diagnosis of a severe episode of major depressive disorder, (2) suffering from a psychotic disorder, (3) suffering from substance use disorder, (4) current episode of (hypo)mania, (5) current suicidal risk, (6) extensive experiences with guided mental imagery interventions (two or more interventions in prior treatment settings), (7) insufficient german language skills, (8) currently receiving another psychological treatment. prescribed medications for anxiety or depressive disorders do not lead to exclusion from the study. the presence of comorbidities does not result in exclusion from the study. pacific: study protocol 6 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ figure 1 flowchart of study design note. a = session questionnaires: positive and negative affect schedule (panas), single-item mood scaling, multiperspective assessment of change mechanisms in psychotherapy (sacip-ra), working alliance inventory – short revised (wai-sr), short version of derogatis symptom checklist (scl-k-9); bsi = brief symptom inventory; cd-risc = connor-davidson resilience scale; cmhp = center of mental health and psychotherapy; gse = general self-efficacy scale; rses = rosenberg self-esteem scale; scid = structured clinical interview according to dsm-5 criteria; suis = spontaneous use of imagery scale; wai-sr = working alliance inventory – short revised; wirf = witten strengths and resource form. a power analysis with g*power (faul et al., 2007) based on effect sizes from relevant studies (flückiger et al., 2016; willutzki et al., 2004) was conducted to determine sample size. the detection of a small to moderate effect (cohen’s f = 0.15) for the interaction schürmann-vengels, victor, odyniec et al. 7 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ between time (pre, mid-4, mid-8, post-12) and treatment condition (pmi vs. nmi vs. tau) [mixed model analysis of variance (anova), within-between-interaction, α = .05, power = .80, number of groups = 3, number of measurements = 4, pre-post correlation = .50, non-sphericity correction = 1] resulted in a sample size of 78 patients. considering possible dropouts, we will recruit up to 120 patients. power analysis of a repeated measurement anova is comparable to multilevel models (mlm; baldwin et al., 2014). therapists 20-25 therapists will be recruited at the cmhp. all therapists have at least a master’s degree in psychology. both, licensed cbt therapists and therapists in advanced cbt training will take part in the study. trainee therapists have at least one year of clinical experience before they start treatments in the cmhp. parallel to the study, trainee therapists take part in 600 hours of practice-based workshops as a part of cbt training protocols in germany. therapists participate in 90-minute supervision in small groups on a weekly basis (general clinical supervision, not study-specific). every therapist in the cmhp will be informed about study procedures in small group meetings of approx. 30 minutes conducted by jsv. standard procedure at cmhp adult patients with various types of mental disorders receive treatment by approximate­ ly 20 licensed cbt therapists resp. trainee therapists. the cmhp has eight rooms for providing psychotherapy. all rooms are fully equipped with video and audio recording. computer-assisted psychometric assessments during therapy are standard procedures at the cmhp and regularly reviewed by staff members. personal and treatment-specific data is managed with a software called ambos. to promote data quality, fixed schedules of assessments for patients and therapists were included. patients interested in a cbt treatment have a first phone contact and a one-session consultation with a licensed therapist. they are then listed on an internal waiting list (with currently on average six months waiting time). patients are contacted by a therapist and invited to a standardized diagnostic phase. the diagnostic phase includes four to five sessions with the following order: exploration and treatment consent, structured clinical interview for dsm-5 dis­ orders (scid; beesdo-baum et al., 2019), biographic work, situation analysis. after the diagnostic phase, a cbt treatment according to the german health system is offered. development of the micro-interventions a systematic literature search of interventions to foster pa was conducted, indicating positive mental imagery as a promising strategy. important aspects to boost emotional experiences in imagery interventions were identified based on relevant studies (e.g. grol et al., 2017; holmes et al., 2008). procedures of positive and neutral interventions used pacific: study protocol 8 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ in these studies are screened in detail. based on this information, we developed a first version of the pmi in a six-minute format. next, eleven therapists piloted-tested the intervention with 25 different patients regarding its practical implication. therapists conducted the intervention within treatment sessions. an anonymous survey was con­ ducted, in which patients and therapists described positive and critical aspects of the intervention independently. we reformulated the intervention script, based on this fea­ sibility information, to its final version. the nmi script was parallelized. scripts for both interventions can be found in the appendix (see supplementary materials). we decided to record the interventions on audiotapes that will be played at the start of each treatment session to increase standardization (inspired by the promet-study by mander et al., 2019). both interventions are spoken and recorded by uw. the audiotapes will be played on bluetooth speakers (anker soundcore mini). two loudspeakers (grey: pmi; black: nmi) are installed in every therapy room. conditions and experimental session all three conditions will be parallelized and include a cbt treatment based on an individual case conception. every session will start with an initial greeting of patients and the start of video recording. experimental sessions will be conducted from session one to eight in the active conditions. in each experimental session of the pmi condition, a grey loudspeaker will be placed on a table in front of patient and therapist with on average one-meter distance. the therapist will carry out the mood scaling by asking the patient to rate his/her mood in the present moment from one (very bad mood) to ten (very good mood). after that, therapists will start the record of the pmi (duration about six minutes). patients are guided to imagine a positive situation from the last week. directly after the micro-intervention, the same mood scaling will be conducted again. at the end of the intervention, patients are instructed to communicate the content of their imagination with their therapist for about one minute. after completion, the regular cbt session will begin. after each session patients will complete session questionnaires. procedures of the experimental sessions in the nmi condition will be parallelized to the description above. at session start, the micro-intervention will be performed with a black speaker with the instruction to imagine a non-emotional situation within the last week. in the control condition, standard cbt will be conducted without additional micro-intervention. study course from patients’ perspective figure 2 shows the study course from patients’ perspective. patients will get a short-in­ formation about the studies objectives and procedures within in the first session of the diagnostic phase. if interested, a study coworker will contact them for an additional meeting. patients will receive written and verbal study information in this meeting and schürmann-vengels, victor, odyniec et al. 9 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ will sign informed consent. it will be emphasized that study participation is voluntary with the option to revoke study participation at any time without reasons and/or disad­ vantages. patients in both active conditions will receive an introduction to the respective mental imagery intervention, including cooperative exploration of specific contents (sit­ uation imagery as detailed as possible, sensory modalities, field perspective), examples of positive/neutral situation in the their life, and a practice of the respective intervention. furthermore, possible difficulties with the interventions will be discussed. the study coworkers will educate patients how to handle it if they fall out of their imagination during the intervention. after the diagnostic phase, all patients will run through twelve cbt sessions. patients will receive session questionnaires directly after each session. additional measurements after every forth session will be included in the study. figure 2 study course from patients’ perspective measures table 1 provides an overview of all measures and their application in the study. pacific: study protocol 10 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ table 1 application plan of measures measures pre session by session measurement waves mid-4 mid-8 post-12 session questionnaires mood scaling 1-12 positive and negative affect schedule (panas) x 1-12 resource activation (sacip-ra) x 1-12 working-alliance-inventory (wai-sr) x 1-12 short version of symptom-checklist (scl-9-k) x 1-12 clinical assessment witten strengths and resource form (wirf) x x x x connor-davidson resilience scale (cd-risc) x x x x rosenberg self-esteem scale (rses) x x x x brief symptom inventory (bsi) x x x x general self-efficacy scale (gse) x spontaneous use of imagery scale (suis) x observer rating resource-oriented micro-process analysis (roma) 2nd, 5th, 8th session note. pre = baseline scores; mid-4 = assessment after fourth sessions; mid-8 = assessment after eighth session; post-12 = final assessment after twelfth session. process analysis – primary outcome session questionnaire i — to assess pa and na of patients, we will apply the pos­ itive and negative affect schedule (panas; krohne et al., 1996). the panas is an internationally used 20 item self-report. as described, affect is defined as the subjective experience of an emotional state and is mostly differentiated by positive versus negative valence (hofmann, 2016). participants will be asked to rate the items according to how they feel "in the current moment". two subscales of global pa (ten items, range: 1-5) and global na (10 items, range: 1-5) will be used. item examples are shown in the following: “indicate the extent you feel this way in the current moment proud (global pa); nervous (global na). both scales have shown good internal consistency (pa: α = .85, na: α = .86) and are widely validated (krohne et al., 1996). process analysis – further measures session questionnaire ii — mood scaling – a single-item mood scaling (“how do you feel in the present moment?”) will be used as an economical assessment of affect. pa­ schürmann-vengels, victor, odyniec et al. 11 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ tients will be asked to rate their mood on a scale from one (very bad mood) to ten (very good mood). various short measures of mood were applied in previous studies: these instruments showed practicability and content validity (high correlation with measures of depressive mood) in clinical samples, especially for visual mood scales (ahearn, 1997; luria, 1975). moreover, van rijsbergen et al. (2014) showed the transferability of these re­ sults for a verbal single-item mood rating. the mood scaling will be used: (1) as a session questionnaire directly after each of the twelve sessions; (2) as an evaluation instrument of the mental imagery micro-interventions in the active conditions (mood scaling before and after the micro-intervention, see conditions and experimental sessions). we decided to include a further affect measure, additionally to the panas, because of the simple use of the single item mood scaling in therapy sessions. it is also included as a session questionnaire to analyze the post-hoc correlation between the mood scaling and the panas to check construct validity of the single-item measure. session questionnaire iii — to assess levels of resource activation from patients’ perspective, we will apply the subscale resource activation of the scale for the multi­ perspective assessment of change mechanisms in psychotherapy (sacip-ra; mander et al., 2013). resource activation refers to transdiagnostic change processes in therapy where strengths or potentials of the patient become perceptible and are used in treat­ ment sessions (grawe & grawe-gerber, 1999). the instrument was included based on prior findings, indicating the association of pa and in-session resource activation (e.g. flückiger et al., 2009). the subscale consists of three items (range: 0-4). items of the sacip-ra were developed based on the bern post session questionnaire, an established therapy process measure (flückiger et al., 2010). item example: “in today’s session, i felt where my strengths lie.” the subscale has displayed good internal consistency (α = .71) and significant associations with treatment outcome (mander et al., 2013). session questionnaire iv — to assess quality of the therapeutic alliance, we will apply the working alliance inventory – short revised (wai-sr; wilmers et al., 2008). we deci­ ded to include the wai-sr as a process measure to analyze its association with pa within and between sessions. based on prior studies, we expect that patients report better alliance directly after sessions with high levels of pa (chui et al., 2016). furthermore, we want to analyze whether pa and the working alliance will develop parallel in the process of treatment. the wai-sr is an internationally used 12 items self-report of therapeutic alliance measuring bond, goals and tasks in psychotherapy based on feedback of patients concerning the current therapy session. items are answered on a likert scale from one to five. item example: “my therapist and i respect each other.” the wai-sr is considered the gold standard in alliance assessment with excellent psychometric properties and outcome prediction (horvath et al., 2011). pacific: study protocol 12 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ session questionnaire v — to assess general psychopathology, we will apply the short version of derogatis symptom checklist (scl-k-9; klaghofer & brähler, 2001). we decided to include the scl-k-9 as a process measure to analyze its association with pa within and between sessions (e.g. parallel development of increase of pa and improvement in symptoms). the short version with nine items (range: 0-4) is an interna­ tionally used self-report. item example: “during the last past seven days, how much were you distressed by: finding it difficult to start something.” the short version has shown good internal consistency (α = .87) as well as high correlations to the original version (petrowski et al., 2019). intervention analysis – primary outcome subjective resources of patients — witten strengths and resource form (wirf; victor et al., 2019). as described, psychosocial resources were defined as positive and functional aspects of a person or his/her environment (taylor & broffman, 2011). the instrument assesses a generic perception of resources rather than separate positive as­ pects. therefore, it measures the internal evaluation of a person’s inherent resources. this subjective perception should be differentiated to the therapeutic process of resource activation. the wirf is a self-report with 37 items (range 0-5). in our study we will use a total score of resources in the context of current problems (12 items). item example: “i am dealing with my current difficulties and problems by – actively tackling tasks.” the scale has displayed good internal consistency (α = .88), evidence for convergent and divergent validity as well as evidence of change sensitivity in the course of psychothera­ py (schürmann-vengels et al., 2022; victor et al., 2019). resilience of patients — connor-davidson resilience scale (cd-risc; 10 item version, german adaption by sarubin et al., 2015). as described, psychological resilience is a dy­ namic and multidimensional trait that enables a successful adaptation to adversities and stressors (connor & davidson, 2003). the cd-risc is an internationally used self-report (range 1-7) to access general resilience. item example: “i am able to adapt when some things change”. the german adaptation with 10 items has shown good internal consis­ tency (α = .84), good retest-reliability (rtt = .81, p < .001) and evidence for convergent validity (sarubin et al., 2015). general self-esteem — rosenberg self-esteem scale (rses; von collani & herzberg, 2003). as described, self-esteem is defined as the degree, a person positively consider his/her characteristics or abilities (brown, 2007). the rses is an internationally used self-report with 10 items (range 0-3) to assess a sum score of general self-esteem. item example: “i am able to do things as well as most other people.” the german version shows good internal consistency (α = .83-.88) as well as evidence of criterion and con­ struct validity (von collani & herzberg, 2003). schürmann-vengels, victor, odyniec et al. 13 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ intervention analysis – secondary outcome general psychopathology — brief symptom inventory (bsi; franke, 2000). the bsi is an internationally used self-report with 53 items (range 0-4). the bsi was chosen as an outcome measure of the intervention analysis to analyze the effects between conditions on symptom improvement. we decided to include this version in addition to the economical process measure of psychopathology (scl-k-9), because its subscales delivers specific information on the improvement of different mental disorders and it is more comparable to outcome measures in other intervention studies. item example: “during the last past seven days, how much were you distressed by: feeling lonely.” the german version has shown excellent psychometric properties in clinical samples and is one of the most used instruments in psychotherapy research (geisheim et al., 2002). working alliance — wai-sr (wilmers et al., 2008). description of the instrument, see process analysis – further measures. we further included the wai-sr as a secondary outcome to analyze whether the conditions have specific influence on general alliance. further measures self-efficacy — general self-efficacy scale (ges; schwarzer & jerusalem, 1999). selfefficacy refers to the subjective belief that a person is confident that his/her actions lead to successful/targeted outcomes (bandura, 1977). several studies have suggested the beneficial effects of self-efficacy on mental health (e.g. schönfeld et al., 2016). the ges was, therefore, included as a possible predictor of the slope of pa and na in the process analysis. the ges is an internationally used self-report with ten items (range 0-3). item example: “i can always manage to solve difficult problems if i try hard enough.” the instrument has shown excellent internal consistency (α = .80-.90) as well as good predictive quality in psychotherapeutic contexts (schwarzer & jerusalem, 1999). general mental imagery ability — spontaneous use of imagery scale (suis; german adaptation by görgen et al., 2016). the suis is an internationally used self-report. the german adaptation consists of 17 items (range 1-5) and showed good internal consisten­ cy (α = .85), evidence for convergent validity as well as high correlations to the original scale (görgen et al., 2016). item example: “when i think about visiting a relative, i almost always have a clear mental picture of him/her.” observer rating to assess relevant aspects on a minute-by-minute basis within treatment sessions, the resource-oriented microprocess analysis will be applied (roma; flückiger & grosse holtforth, 2008). the instrument is a coding system of different aspects of resource activation (personal resources, motivational resources, reframing of problems, global resource activation) and pa from video recordings of treatment sessions. the coding pacific: study protocol 14 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ system has shown good to excellent interrater reliability for patients and therapists (κ = .82 .99). independent research assistants will analyze the videotapes. the specific application of the observer rating will be applied in a prior workshop conducted by cf. statistical analysis for the main hypotheses, measures will display a nested data structure (sessions at level 1 are nested with patients at level 2, nested with therapists at level 3). therefore, we will use mlm as recommended by baldwin et al. (2014). separate mlm analyses will be conducted for session questionnaires of the process analysis with twelve measurements, and change questionnaires of the intervention analysis with four measurements. time will be a within-subject factor and treatment condition a between-subject factor in both procedures. main effects and time*condition interactions will be analyzed. we hypothe­ size that the slope in the pmi will increase significantly stronger compared to the nmi and tau conditions. possible level-2-predictors, especially for the slope of pa, will be considered. both per-protocol and intention-to-treat analyses will be conducted. discussion the effects of pa on broadening attention and flexibility, as well as building resources and mental health, are well researched. various findings showed a down-regulation of pa in persons with mental disorders. despite its relevance for psychotherapy patients, there is a dearth of knowledge about the course and systematic implementation of pa in cbt. no study so far has attempted to activate pa at the start of cbt sessions to explore possible effects on process and outcome. to fill this research gap, we developed the pacific-study. innovations the present study includes various innovative aspects: first, in line with other studies (e.g., mander et al., 2019; flückiger et al., 2018) a new perspective of standardized strategies to introduce psychotherapy sessions is taken up. second, our study will have an explicit focus on pa and its impact on cbt. third, to the best of our knowledge, this study is the first one implementing an economical in-session intervention to enhance pa in psychotherapeutic treatment. forth, this implementation trial uses a cross-therapist design to systematize on therapist effects (e.g., flückiger et al., 2018; schiefele et al., 2017). schürmann-vengels, victor, odyniec et al. 15 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ bias minimization an independent research assistant will randomize patients to treatment arms. patients, therapists and researchers involved in the data collection and evaluation will be blind to the randomization. in addition, patients will be blind to the specific hypotheses. patient characteristics will be compared between conditions to check for possible confounding variables. a cross-therapist design is applied to minimize therapist effects. the applica­ tion of standardized audiotape records will additionally reduce possible therapists effects. the mlm will decrease an overestimation of effects emerging from the nested data structure and is robust in handling possible missing data. adherence strategies all study coworkers will use standardized materials to enhance adherence. patients in both active conditions will be trained in the respective mental imagery intervention during the diagnostic phase. patients will get email address and phone number of the study coworker who conducted the training to be reachable if any problems or questions occur. each therapist involved in the study will be informed about study procedures and technical handling. further, a list with the most important study aspects will be handed out to therapists before enrollment. this list will also be placed in every therapist-office. a study coworker will regularly contact each therapist in person to enhance study com­ pliance. furthermore, data collection will regularly be checked to discuss irregularities. identification of risks previous studies indicated that potential risks of the mental imagery interventions are low (blackwell et al., 2015; dainer-best et al., 2018; ji et al., 2017; renner et al., 2017). however, possible risks of the interventions lie in the intensification of specific symp­ toms (psychopathology) or emotional states. affect and psychopathology measures in the process analysis will be used for a post-hoc check of unwanted effects/trajectories of involved patients. furthermore, possible negative effects will be documented from patients’ (conclusion survey) and therapists’ perspective (regularly exchange with study coworkers). conclusion our study will examine patients’ pa in an early phase of cbt treatment. it will further test a brief mental imagery intervention to foster pa in an outpatient sample. our results may identify pa as a complementary factor in psychopathology and how it is affected by psychotherapy. our results could furthermore implement the idea for strengths-based interventions as a transdiagnostic strategy to improve treatment outcome. pacific: study protocol 16 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://www.psychopen.eu/ funding: this research did not receive any special grant from funding agencies in the public, commercial or nonprofit sectors. primary sponsor of this trial is witten/herdecke university. acknowledgments: we like to thank all patients and therapists at the cmhp, witten/herdecke university, who were involved in the pilot-testing of our intervention. special thanks to natalie fromme-schwarzhöfer, maud grol, and alexandra monstadt for their support on the realization and implementation of our ideas. competing interests: the authors declare that they have no competing interests. author contributions: jsv, ppv, po, cf, tt, and uw contributed to the study design. jsv and uw discussed and developed both mental imagery interventions. jsv, ppv, po, and uw implemented the study at the cmhp. jsv wrote the initial draft of the manuscript. all authors read and approved the final version of the manuscript. ethics statement: ethics approval for the study was provided by the ethics committee of the universität witten/ herdecke (germany) in october 2018, approval no. 128/2018. all participants provided a written informed consent. trial registration: trial registered at clinicaltrials.gov, identifier: nct03767101 (registered december 6, 2018), https://clinicaltrials.gov/ct2/show/nct03767101 supplementary materials the supplementary materials contain standardized scripts of the positive mental imagery induc­ tion (pmi) and neutral mental imagery induction (nmi): • appendix a – positive mental imagery induction (pmi) • appendix b – neutral mental imagery induction (nmi) for access see index of supplementary materials below. index of supplementary materials schürmann-vengels, j., victor, p. p., odyniec, p., flückiger, c., teismann, t., & willutzki, u. 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(2008). improving the reporting of pragmatic trials: an extension of the consort statement. bmj, 337, article a2390. https://doi.org/10.1136/bmj.a2390 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. pacific: study protocol 24 clinical psychology in europe 2022, vol. 4(2), article e7043 https://doi.org/10.32872/cpe.7043 https://doi.org/10.1037/0022-3514.76.5.820 https://doi.org/10.1026/0084-5345.33.1.42 https://doi.org/10.1016/j.genhosppsych.2019.06.008 https://doi.org/10.1037/0022-3514.85.3.566 https://doi.org/10.1136/bmj.a2390 https://www.psychopen.eu/ pacific: study protocol (introduction) pa and psychological processes pa in psychopathology and psychotherapy mental imagery as a strategy to increase pa current study method design participants standard procedure at cmhp development of the micro-interventions conditions and experimental session study course from patients’ perspective measures statistical analysis discussion innovations bias minimization adherence strategies identification of risks conclusion (additional information) funding acknowledgments competing interests author contributions ethics statement trial registration supplementary materials references the phenomenon of treatment dropout, reasons and moderators in acceptance and commitment therapy and other active treatments: a meta-analytic review research article the phenomenon of treatment dropout, reasons and moderators in acceptance and commitment therapy and other active treatments: a meta-analytic review maria karekla a, pinelopi konstantinou a, myria ioannou a, ioannis kareklas b, andrew t. gloster c [a] university of cyprus, nicosia, cyprus. [b] university at albany, new york, ny, usa. [c] university of basel, basel, switzerland. clinical psychology in europe, 2019, vol. 1(3), article e33058, https://doi.org/10.32872/cpe.v1i3.33058 received: 2019-01-13 • accepted: 2019-05-09 • published (vor): 2019-09-20 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: maria karekla, department of psychology, university of cyprus, p.o. box 20537, nicosia 1678, cyprus. tel: 357 22 892100; fax: 357 22 892071. e-mail: mkarekla@ucy.ac.cy abstract background: treatment dropout is one of the most crucial issues that a therapist has to face on a daily basis. the negative effects of premature termination impact the client who is usually found to demonstrate poorer treatment outcomes. this meta-analysis reviewed and systematically examined dropout effects of acceptance and commitment therapy (act) as compared to other active treatments. the goals of this study were to compare treatment dropout rates and dropout reasons, examine the influence of demographic variables and identify possible therapy moderators associated with dropout. method: the current meta-analysis reviewed 76 studies of act reporting dropout rates for various psychological and health-related conditions. results: across reviewed studies (n = 76), the overall weighted mean dropout rate was 17.95% (act = 17.35% vs. comparison conditions = 18.62%). type of disorder, recruitment setting and therapists’ experience level were significant moderators of dropout. the most frequently reported reasons for dropout from act were lost contact, personal and transportation difficulties, whereas for comparative treatments they were lost contact, therapy factors and time demands. conclusion: given that most moderators of influence are not amenable to direct changes by clinicians, mediation variables should also be explored. overall, results suggest that act appears to present some benefits in dropout rates for specific disorders, settings and therapists. keywords acceptance and commitment therapy, dropout, attrition, meta-analysis, premature termination this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i3.33058&domain=pdf&date_stamp=2019-09-20 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • there was no difference in dropout rate between act and control conditions (17.35% vs.18.62%). significant moderators were client disorder, therapists’ experience level and recruitment and setting. • comparison condition frequently reported therapy related dropout factors, suggesting that act may be a more acceptable option. acceptance and commitment therapy (act), is a so-called third wave cognitive behav‐ ior therapy (cbt) and has been applied successfully to treat numerous problems and dis‐ orders (hayes, luoma, bond, masuda, & lillis, 2006; ruiz, 2012). act helps clients choose to do what takes them closer to their goals (especially when dealing with prob‐ lematic thoughts and emotions) rather than aiming to reduce symptoms directly (hayes, hayes, strosahl, & wilson, 2012). the focus is placed on the experience of the person and the function of any behavior rather than on actions being carried out based on the literal content of a belief (hayes et al., 2006). the overall aim of treatment is to increase psycho‐ logical flexibility or the ability to fully contact the present moment, choosing to act gui‐ ded by the person’s values in the context at hand (fletcher & hayes, 2005). most existing reviews and meta-analyses of act support that it is at least as equally effective as tradi‐ tional cognitive behavioral therapy (tcbt) on indices of symptom reduction and more effective than other comparison conditions (a-tjak et al., 2015; powers, vörding, & emmelkamp, 2009; ruiz, 2012). treatment outcomes and effectiveness, however, are affected not only by the specific treatment provided but also by other factors such as premature termination/dropout or non-completion of the specified interventions (barrett, chua, crits-christoph, gibbons, & thompson, 2008). premature therapy termination or treatment dropout is a significant problem or obstacle limiting the effectiveness of any therapeutic approach and results in detrimental outcomes in patients (barrett et al., 2008; wierzbicki & pekarik, 1993). un‐ fortunately, there is no consensus definition about what constitutes treatment dropout. general definitions of dropout include: termination of the intervention prior to the pa‐ tient recovering from the problem(s) for which treatment was initially sought (hatchett & park, 2003; swift, callahan, & levine, 2009), or treatment termination without the agreement of the therapist and before the scheduled end point (stone & rutan, 1984). however, in research protocols premature termination may be considered as missing a number of pre-arranged sessions (e.g., four consecutive weeks in dbt; linehan, 1993) ir‐ respective of the patient’s recovery status. reviews and meta-analyses of this phenomenon focus on examining first the rates of dropout and, secondly, variables associated with its occurrence. swift and greenberg (2012) examined dropout definition as a moderator of dropout rates and found higher rates when the therapist judged dropout status, compared to other definitions. this was treatment dropout in act 2 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ one of the first comprehensive reviews of the dropout phenomenon encompassing vari‐ ous forms of psychotherapy and concluded that 1 in 5 clients drop out prematurely, a rate somewhat lower than previous reviews (e.g., wierzbicki & pekarik, 1993). client diagno‐ sis, age, education, gender, marital status, time-limitations of treatment, use of manual or protocol, treatment setting, providers’ level of experience, dropout definition, study type and search strategy were found to be significant moderators of dropout. however, this meta-analysis did not include studies of third wave psychological treatments, like act. moreover, it focused only on adult populations and did not include substance or alcohol abuse disorders, health-related problems (e.g., weight management, emotional burnout), and self-help interventions. finally, it focused on providing a broad analysis of premature discontinuation in psychological treatments and not on reasons for dropout. this study aims to examine the dropout phenomenon in act (compared to other ac‐ tive interventions) because of act’s emphasis on connecting clients with their deeply held values and through this process to motivate them towards behavior change. if act is successful in mobilizing individuals via the treatment process, we expect that this would prevent premature termination and thus act would result in lower dropout rates compared to other interventions. to date, only one meta-analysis on dropout has inclu‐ ded act (ong, lee, & twohig, 2018). this study found that only therapist experience sig‐ nificantly predicted dropout, specifically that when act was provided by master’s level therapists higher dropout rates were observed, compared to other levels of therapists’ ex‐ perience (e.g., phd level psychologist, md physician, graduate student). however, under‐ standing dropout in act can be further facilitated in four important ways. first, inclu‐ sion of variables found to predict dropout in previous meta-analyses (e.g., gender, race, marital status, employment and years of education) will allow for comparison across studies and methods (e.g., swift & greenberg, 2012). second, inclusion of variables that assess how the therapy and study were implemented (e.g., length of intervention, hours of intervention, setting, definition of dropout, study type, year of publication and region) can reveal clues as to how interventions can actively minimize dropout. third, testing the reasons and timing of dropouts provides hypotheses for researchers and therapists to ac‐ tively intervene to prevent this phenomenon of paramount clinical significance. finally, some methodological details regarding comparison groups are worthy of reexamination. for example, we believe that including waitlist control conditions in the comparisons may bias the dropout findings in favor of waitlist control. this is because people on the waitlist are fundamentally different to patients in a control condition. in the waitlist, pa‐ tients usually maintain hope that things will get better once the treatment begins and are not motivated to actively change during the waiting period. when clients do drop out during this period, by definition it has nothing to do with the active treatment. thus a cleaner comparison of treatment dropout should be carried out between different active treatments (including active controls). towards this goal, comparative conditions should be other active interventions. karekla, konstantinou, ioannou et al. 3 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ a minority of patients may drop out because they improved or met their goals; how‐ ever numerous individuals drop out because of a problem with the treatment or thera‐ pists or for other unforeseen circumstances. specifically, proposed problems or reasons associated with increased dropout rates include: client demographic characteristics (e.g., younger age, female gender, low socioeconomic status; wierzbicki & pekarik, 1993); type of psychopathological difficulties (e.g., eating or personality disorders); therapist charac‐ teristics (e.g., provider in training); therapy setting (e.g., university-based clinics); and specific factors (e.g., non-time limited therapy), and environmental variables or acute problems that take greater priority (bados, balaguer, & saldaña, 2007; roe, dekel, harel, & fennig, 2006; swift & greenberg, 2012). researching these reasons is difficult as variables and methods vary widely depend‐ ing on the study and its focus, the population studied, the treatment setting or the treat‐ ment offered (roe et al., 2006; todd, deane, & bragdon, 2003). however, there is an agreement that certain common reasons account for dropout. these include: lack of im‐ provement or accomplishment of goals, dissatisfaction with the treatment, and environ‐ mental obstacles and constraints (hunsley, aubry, verstervelt, & vito, 1999; pekarik, 1992; roe et al., 2006; todd et al., 2003). in addition to common factors, clients report spe‐ cific reasons for discontinuation, including: external circumstantial problems and difficul‐ ties (e.g., transportation problems, moving away, timetables), illness and new responsibil‐ ities, improvement due to therapy, satisfactory achievement of treatment goals, high treatment costs, dissatisfaction with the therapist and psychotherapy, no need for serv‐ ices and need for independence and trying to solve problems without therapy (bados et al., 2007; roe et al., 2006; todd et al., 2003). interestingly, very little attention has been given to the timing during treatment when premature termination occurs and most studies do not even report this information. some have proposed that the first two sessions are critical for premature termination, given that most dropouts (70%) occur at this point, making it a critical period to success‐ fully engage the client in treatment (olfson, mojtabai, sampson, hwang, & kessler, 2009). karekla (2004) observed that in a comparison trial of cbt vs. act for panic disorder, though dropout rates between the two approaches were similar, most individuals who dropped out in the cbt condition did so immediately after the introduction of exposure. such a pattern was not evident for the act group, where individuals dropped out at var‐ ious times during treatment unrelated to specific treatment components. it was conclu‐ ded that act might present an advantage over cbt not in terms of symptom reduction but that it may better prepare individuals to engage in exposure of previously avoided internal and external events and in dealing with the dropout problem. to date, none of the reported reviews or meta-analyses of act have examined in depth dropout, dropout reasons, extensive list of moderators, and compared to active treatments. treatment dropout in act 4 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ current study the purpose of this study is to examine dropout rates, dropout reasons’ associated fac‐ tors, and potential moderators of dropout, in act compared to active comparison condi‐ tions. the goals of this study were to: (i) compare treatment dropout rate and timing be‐ tween act and other active treatments; (ii) examine the influence of demographic varia‐ bles such as age, gender, treatment setting, race, education, duration of treatment, ethnic‐ ity and diagnosis on dropout; (iii) identify possible therapy-associated moderators of dropout; and (iv) examine timing and possible reasons for dropout. method this review was registered in the international prospective register of systematic re‐ views (see supplementary materials). literature search the literature search was conducted using the computerized literature databases google scholar, ebscohost (academic search ultimate, medline, psychology and behavioral sci‐ ences collection, psycarticles, psychinfo, opendissertations) and science direct (until june 2018) with the following keywords based on title: “acceptance and commitment training”, “acceptance-based behavior therapy”, “act-based”, “experiential avoidance”, “psychological flexibility”, “rft-based”, “cbs-based”, “third wave cbt therapies” “ac‐ ceptance and commitment therapy”, and “act”; alone first and then also combined with the terms “drop out” or “dropout” or “discontinuation” or “outcome” or “premature termi‐ nation” or “termination”. the reference lists of all identified articles were examined for additional potentially eligible studies, as well as existing meta-analyses and reviews. a request for unpublished studies was sent to the acceptance and commitment therapy (act) listserv (https://contextualscience.org/emailing_lists), as well as to the primary or secondary authors of identified articles, via email. eligibility criteria identification and selection of the included studies was performed by the second author, a clinical psychology doctoral student, who was first trained and instructed in the proce‐ dure of conducting meta-analysis by the first and last authors. everything was checked by the first author. the last three authors all have experience in meta-analysis and served to check all steps taken in the process of this study. this study includes all published and unpublished (e.g., dissertation) acceptance and commitment therapy studies that included dropout information and met the following criteria. studies were included if they: (1) were in english, (2) reported dropout rates after beginning psychotherapy or reported no dropouts (i.e., all participants completed treat‐ karekla, konstantinou, ioannou et al. 5 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://contextualscience.org/emailing_lists https://www.psychopen.eu/ ment), and (3) used an active comparison condition. studies were excluded if: (a) data ori‐ ginated from the same sample as another included study (so as to avoid violating the meta-analytic assumption of data independence); (b) information to calculate effect sizes was lacking and contact with authors was not possible; and (c) case studies. the literature search resulted in 4399 articles in total. after screening the titles and abstracts, and following the examination of the full papers, 76 studies met all aforemen‐ tioned inclusion criteria and were retained for analysis (see figure 1 for procedure de‐ tails). based on the rosenthal’s suggestions for computing the fail-safe n, it was found that the total z value was -1.181 and the number of missing studies we would need to retrieve and incorporate to result in a non-significant p-value was 147 studies (see also borenstein, hedges, higgins, & rothstein, 2009). coding procedures treatment dropout was defined as the percentage of patients who began treatment, but according to the author(s) dropped out prematurely, thus utilizing the author(s)’ defini‐ tion. for reliability and validity purposes we included only studies that reported dropout rates during treatment and not prior to treatment initiation. participant, therapist, treatment and study characteristics were coded (see table 1 for details about coding of each of the variables). eight participant characteristics included: client disorder, gender, age, race, marital status, employment, years of education and pop‐ ulation. eight treatment variables were comparison condition, treatment status, length of intervention, length of intervention in sessions, hours of intervention, format of treat‐ ment, treatment setting and description of treatment setting (as per swift & greenberg, 2012). two treatment provider variables regarding experience level: 1) experience level of act therapists, and 2) experience level of therapists in comparison groups. finally, four study variables included: definition of dropout, study type, year of publication and re‐ gion. the second and third authors coded all variables separately and these were checked for accuracy by the first authors. there was a 95% agreement rate between coders with disa‐ greements resolved via a consensus among the authors (for further coding details contact the authors). treatment dropout in act 6 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ figure 1. flow chart of information from identification to inclusion of studies in this review. karekla, konstantinou, ioannou et al. 7 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ table 1 details regarding the coding of each of the variables participant characteristics client disorder anxiety disorder (including social phobia, public speaking anxiety, generalized anxiety disorder and obsessive compulsive disorder), depression, substance abuse or dependence, chronic pain (including fibromyalgia, osteoarthritis and headaches), eating pathology/disorder (including diabetes, obesity, weight problems and eating disorders), health conditions and chronic illnesses (i.e. parkinson’s disease, multiple sclerosis, brain injury, cancer and hiv), smoking, other health problems (stress, distress, physical activity, tinnitus, procrastination and sickness absence) and severe psychopathology (including borderline personality disorder, treatment resistant and psychosis) gender percentage of female participants in each study age average age in years of participants in each sample race percentage of white (including caucasian, australian and european), black (including african american) and other (hispanic, latino, asian american/ pacific islander, native american, alaskan american and american indian/ alaskan native) marital status percentage of participants who were single (non-married, never married, divorced, separated or widowed) vs. married (cohabiting, living with partner/spouse/family or in a relationship) employment percentage of participants who were working, either full-time or part-time years of education participants’ average number of completed education years in each study. in cases where the mean number of education in years was not provided, we calculated this based on the data reported. population adults or children and adolescents treatment variables comparison condition cbt, treatment as usual (tau; studies in which tau consisted of only administrating medication were coded as medication only), medication only (i.e., medication treatment as usual plus enhanced assessment and monitoring, recommended pharmacological treatment, specialty medical management, methadone maintenance, selective serotonin reuptake inhibitors, medical treatment as usual, nicotine replacement treatment and bupropion regimen), other active treatment (i.e., narcotics anonymous, applied behavior analysis, smokefree.gov, online discussion forum, usual care, counseling services, workplace dialogue intervention, presentcentered therapy, physical exercise, drug counseling, tinnitus retraining therapy and expressive writing), component of cbt (including progressive relaxation training, systematic desensitization, applied relaxation, cognitive therapy, stress inoculation training, relaxation training) and education only (education, befriending, pedometer-based walking program) treatment status providing any treatment/training to the comparison condition or not length of intervention total length of treatment in weeks (in cases where months were reported, each month was calculated to equal 4 weeks) length of intervention in sessions total number of treatment sessions hours of intervention the overall duration of intervention in hours format of treatment individual, self-help (including web-based and online format), group, or combination (group & individual) treatment setting outpatient, inpatient or self-help (including web-based and online format) description of treatment setting university affiliated clinic (psychology department training clinic and university counseling center), outpatient clinic affiliated with a hospital or medical school, public/community outpatient clinic, research/specialty clinic, private outpatient clinic/practice, therapy took place at participant’s home (i.e., web-based/online intervention or self-help) and inpatient or residential treatment treatment dropout in act 8 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ treatment provider variables experience level of act therapists master level therapists or doctoral students/interns/residents, doctoral level or licensed therapists, mix of doctoral level, student trainees, and others (e.g., licensed clinicians, psychiatrists, social workers, psychiatric nurses), no therapists (i.e., for online/web-based or self-help formats), mix of different psychologist levels and non-psychologists (e.g. drug staff, alcohol counselor, physician, psycho-pharmacologist) experience level of therapists in comparison groups. master level therapists or doctoral students/interns/residents, doctoral level or licensed therapists, mix of doctoral level, student trainees, and others (e.g., licensed clinicians, psychiatrists, social workers, psychiatric nurses), no therapists (i.e. it was applicable for online/web-based or self-help formats), mix of different psychologist levels, psychiatrists and non-psychologists (e.g. drug staff, alcohol counselor, physician, psycho-pharmacologist). study variables definition of dropout failed to complete treatment/discontinued treatment/left before treatment end, or refused to return to treatment, failed to attend all sessions, failed to submit pre and post treatment data and attended less than or equal to either: 25-40%, 50-75% or 76-90% of total sessions study type efficacy (i.e., studies that emphasize internal validity) or effectiveness (i.e., emphasize external validity of the experimental design). if the study type was not specifically reported, efficacy was coded as studies utilizing: (a) strict exclusion criteria, (b) careful pre-selection of clients, (c) treatment following a strict protocol and was more controlled than effectiveness studies, (d) randomization of participants to treatments, and/or (e) therapists receiving training before and supervision during the study year of publication region in which each study was conducted data analysis first, the dropout rate for each study condition (act vs. comparison group) was calcula‐ ted (i.e., the total number of patients who dropped out of each treatment group, out of the total number of patients included in each group). then, the weighted average drop‐ out rate (i.e., weighted dropout rate for each study condition based on the total number of patients included in the study) was computed for each of the 76 included studies. the number of participants dropped from each group was included in the comprehensive meta-analysis software (cma; version 2.0, biostat, englewood, nj), along with the sam‐ ple size of each group (treatment and comparison). odds ratio was then computed. odds ratios higher than 1 suggest that dropout rates are higher in the intervention versus the comparison condition (i.e., comparison group is better). random-effects models were used to estimate the effect size of rate ratio in the inclu‐ ded studies, as the assumptions of random-effect models suggests that study characteris‐ tics influence the true effect of treatments, and that sampling error varies between stud‐ ies (dersimonian & kacker, 2007). the q statistic and the i2 statistic were calculated. ran‐ dom-effects models are considered appropriate when there is significant heterogeneity (p < .05) according to the q index, and when heterogeneity is high (>75%) based on the i 2 index. first, an unconditioned model without having any predictors or moderators was cal‐ culated using cma, in order to detect the general rate ratio of dropouts between treat‐ karekla, konstantinou, ioannou et al. 9 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ ment and comparison conditions. in order to examine if the results of the general model were subject to biases related to the publication of studies with favorable outcomes, pub‐ lication bias was investigated by assessing the asymmetries evident in a funnel plot, with the egger’s regression test (egger, smith, schneider, & minder, 1997) and the begg and mazumdar test (kendall’s statistic). a stratified subgroup analyses was then run in order to test the moderating role of categorical study characteristics and meta-regression anal‐ yses to test the moderating role of continuous study characteristics. q statistic was calcu‐ lated for the subgroup analyses, in order to examine if the differences detected between the mean effect sizes of the groups of studies with a particular characteristic were signifi‐ cant. the meta-regression analyses were computed using a general mixed-effects meth‐ od-of-moments (kacker, 2004) estimate for the inter-study variance τ2 (dersimonian & kacker, 2007). results characteristics of reviewed studies all identified studies were included in the meta-analysis; no structured qualitative assess‐ ment of the reviewed articles was performed. the large majority of included studies em‐ ployed a randomized controlled trial design, or at least a controlled trial design. this sug‐ gests that all studies are at least of a moderate methodological quality (petrisor & bhandari, 2007), and attempted to compare act to an active treatment comparison con‐ dition. see table 2 for characteristics of included studies. most studies dealt with the treat‐ ment of anxiety (n = 14, 18.4%) and chronic pain (n = 14, 18.4%); and targeted adults (n = 73, 96.1%) using a group treatment format (n = 34, 44.7%). act was compared mostly with tau (n = 17, 22.4%) and cbt (n = 17, 22.4%). most studies were delivered in an out‐ patient setting (n = 60, 78.9%) and participants were most frequently recruited via com‐ munity advertisements (n = 21, 27.6%). treatment in act groups was delivered mostly by psychologists of various training levels (n = 19, 25%) and licensed or doctoral level psy‐ chologists (n = 15, 19.7%). in comparison group treatment was provided mostly by a mix of doctoral level, student trainees and others (n = 15, 19.7%) and a mix of psychologists with different training levels (n = 13, 17.1%). the most frequent definition of dropout was “failed to complete treatment, left treatment prior to its end, or refused to return to treat‐ ment” (n = 53, 69.7%). finally, efficacy-type studies (n = 42, 55.3%) were more than effec‐ tiveness-type studies (n = 34, 44.7%). treatment dropout in act 10 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ ta bl e 2 c ha ra ct er is tic s of s tu di es in cl ud ed in th e m et aa na ly si s (n = 7 6) st ud y & r eg io n d is or de r n c on tr ol g ro up (s ) % dr op ou t a c t % dr op ou t co nt ro l gr ou p( s) m ea n a ge % fe m al e se tt in g fo rm at tx w ee ks a ba d et a l. (2 01 6) ; a sia ca nc er 36 cb t 0.0 0 16 .66 n i 10 0 ο g n i a lo ns ofe rn án de z e t a l. (2 01 6) ; eu ro pe cp 10 1 m s 43 .40 29 .17 83 78 o g 9 a rc h et a l. (2 01 2) ; u s a nx ie ty 12 8 cb t 35 .09 32 .39 38 52 o in d 12 av da gi c, m or ris se y, & b os ch en (2 01 4) ; au st ra lia ga d 51 cb t 12 .00 23 .08 36 67 o g 6 a zk ho sh e t a l. (2 01 6) ; a sia su bs ta nc e a bu se 60 n ar co tic s a no ny m ou s 20 .00 15 .00 27 n i o i 12 be th ay e t a l. (2 01 3) ; u s in te lle ct ua l d isa bi lit y 34 a ba 10 .00 11 .11 38 77 o g 3 br ic ke r e t a l. (2 01 3) ; u s sm ok in g 22 2 sm ok ef re e.g ov 45 .95 46 .85 45 62 s s 3 bu hr m an e t a l. (2 01 3) ; e ur op e cp 76 o nl in e d isc us sio n fo ru m 15 .79 15 .79 49 59 s s 7 bu tr yn e t a l. (2 01 1) ; u s ph ys ic al a ct iv ity 54 ed uc at io n 20 .00 5.2 6 23 10 0 o g 3 cl ar ke e t a l. (2 01 4) ; e ur op e tr ea tm en t r es ist an t 61 ta ucb t 13 .33 22 .58 43 67 o g 16 cl ar ke e t a l. (2 01 7) ; e ur op e o st eo ar th rit is 31 us ua l c ar e 31 .25 0.0 0 67 71 o g 6 cr as ke e t a l. (2 01 4) ; u s sp 87 cb t 20 .69 36 .36 28 46 o in d 12 d av ou di e t a l. (2 01 7) ; a sia sm ok in g 70 o th er a ct iv e tre at m en t 2.8 6 5.7 1 30 0 o in d 8 d jo rd je vi c & f rö gé li (2 01 2) ; e ur op e st re ss 11 3 ta u 28 .99 29 .55 25 79 o g 6 en gl an d et a l. (2 01 2) ; u s a nx ie ty 45 h a b 23 .81 20 .83 32 80 o g 6 fi nn es e t a l. (2 01 7) ; e ur op e si ck ne ss a bs en ce 35 2 w d i 7.3 2 12 .90 46 78 o in d 10 karekla, konstantinou, ioannou et al. 11 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ st ud y & r eg io n d is or de r n c on tr ol g ro up (s ) % dr op ou t a c t % dr op ou t co nt ro l gr ou p( s) m ea n a ge % fe m al e se tt in g fo rm at tx w ee ks fl ax m an & b on d (2 01 0) ; e ur op e d ist re ss 10 7 si t 13 .51 10 .81 39 72 o g 3 fo rm an e t a l. (2 00 7) ; u s a nx ie ty 10 1 ct 33 .90 42 .20 28 80 o in d m = 1 5.2 7 fo rm an e t a l. (2 01 3) ; u s o be sit y 12 8 sb t 9.4 6 20 .37 46 10 0 o g 40 ga ud ia no & h er be rt (2 00 6) ; u s ps yc ho sis 40 ta u 5.2 6 4.7 6 40 36 in p in d 3 ga ud ia no e t a l. (2 01 5) ; u s d ep re ss io n 13 m ta u 16 .66 42 .86 50 54 o in d 16 gh ie le n et a l. (2 01 7) ; e ur op e pa rk in so n 46 ta u 13 .04 8.7 0 63 39 o g 6 gi ffo rd e t a l. (2 00 4) ; u s sm ok in g 76 n rt 36 .40 38 .10 43 59 o g & in d 7 gi ffo rd e t a l. (2 01 1) ; u s sm ok in g 30 3 bp 33 .08 46 .82 46 59 o g & in d 10 gl as sm an (2 01 4) ; u s a nx ie ty 25 tc bt 0.0 0 8.3 3 24 73 o in d 1 go nz ál ez -f er ná nd ez e t a l. (2 01 8) ; eu ro pe ca nc er 66 ba 29 .41 22 .73 52 92 o g 12 gr eg g, c al la gh an , h ay es , & g le nn la w so n (2 00 7) ; u s ty pe 2 d ia be te s 81 ed uc at io n 0.0 0 0.0 0 51 47 o g 1 h an co ck e t a l. (2 01 8) ; a us tra lia a nx ie ty 19 3 cb t 20 .59 9.5 2 11 58 o g 10 h ay es e t a l. (2 00 4) ; u s po ly su bs ta nc ea bu sin g o pi at e ad di ct s 12 4 m m , i ts f 45 .24 24 .00 42 51 o g & in d 16 h ay es , b oy d, & s ew el l ( 20 11 ); au st ra lia d ep re ss io n 38 ta u 13 .63 31 .25 15 71 o in d n i h ay es -s ke lto n, r oe m er , & o rs ill o (2 01 3) ; u s a nx ie ty 81 a r 25 .00 21 .95 65 33 o in d 16 h er ná nd ez -l óp ez e t a l. (2 00 9) ; e ur op e sm ok in g 81 cb t 37 .21 23 .68 42 64 o g 7 h es se r e t a l. (2 01 2) ; e ur op e ti nn itu s 99 cb t 2.8 6 6.2 5 49 43 s s 8 ju ar as ci o et a l. (2 01 3) ; u s ed 14 0 ta u 15 .15 8.1 1 27 10 0 in p g m = 3 .91 treatment dropout in act 12 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ st ud y & r eg io n d is or de r n c on tr ol g ro up (s ) % dr op ou t a c t % dr op ou t co nt ro l gr ou p( s) m ea n a ge % fe m al e se tt in g fo rm at tx w ee ks ke m an i e t a l. (2 01 6) ; e ur op e pa in 60 a r 0.0 0 16 .66 40 73 o g 12 ki ng st on (2 00 8) ; e ur op e tr ea tm en t r es ist an t 40 cb t 15 .00 40 .00 44 60 o g 16 ko co vs ki , f le m in g, h aw le y, h ut a, & a nt on y (2 01 3) ; u s sa d 13 7 cb t 30 .19 39 .62 35 54 o g 12 la ng e t a l. (2 01 7) ; u s d ist re ss 16 0 pc t 33 .75 30 .00 34 20 o in d 12 la nz a, ga rc ia , l am el as , & g on zá le zm en én de z ( 20 14 ); eu ro pe su bs ta nc e us e 50 cb t 0.0 0 0.0 0 33 10 0 n i g 16 la ss en (2 01 0) ; u s ps yc ho sis 28 ta u 14 .29 42 .86 42 39 o g 2 li lli s e t a l. (2 01 6) ; u s w ei gh t l os s 16 2 cb t 16 .05 13 .58 50 85 o g 52 lu ci an o et a l. (2 01 4) ; e ur op e fi br om ya lg ia 15 6 rp t 9.8 0 11 .54 48 96 ο g n i lu om a, ko hl en be rg , h ay es , & fl et ch er (2 01 2) ; u s su bs ta nc e us e 13 3 ta u 10 .29 0.0 0 34 46 in p g 1 m cc ra ck en e t a l. (2 01 4) ; e ur op e cp 73 ta u 18 .92 2.7 8 58 68 o g 5 m cm ill an e t a l. (2 00 2) ; e ur op e tb i 14 5 pe 12 .00 19 .15 34 22 s s 4 m of fit t & m oh r ( 20 15 ); au st ra lia ph ys ic al a ct iv ity 76 pw p 0.0 0 5.4 0 44 83 s s 12 m oi tra e t a l. (2 01 7) ; u s h iv 34 ta u 11 .77 5.8 8 34 21 o in d 3 m or to n, s no w do n, g op ol d, & g uy m er (2 01 2) ; a us tra lia bp d 41 ta u 23 .81 30 .00 35 93 o g 12 m os he r e t a l. (2 01 8) ; e ur op e br ea st c an ce r 47 ed uc at io n 21 .74 12 .50 56 10 0 o ι 6 m o't am ed i, re za ie m ar am , & t av al la ie (2 01 2) ; a sia ch ro ni c h ea da ch e 30 m ta u 26 .67 0.0 0 36 10 0 o g 8 n or di n & r or sm an (2 01 2) ; e ur op e m ul tip le sc le ro sis 21 rt 9.0 9 0.0 0 46 76 o g 15 pa lm ei ra e t a l. (2 01 7) ; e ur op e o be sit y 73 ta u 8.3 3 10 .81 42 10 0 o g pa rli ng e t a l. (2 01 6) ; e ur op e ea tin g d iso rd er s 43 ta u 25 .00 15 .80 26 98 o in d 19 karekla, konstantinou, ioannou et al. 13 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ st ud y & r eg io n d is or de r n c on tr ol g ro up (s ) % dr op ou t a c t % dr op ou t co nt ro l gr ou p( s) m ea n a ge % fe m al e se tt in g fo rm at tx w ee ks pe te rs en & z et tle (2 00 9) ; u s co m or bi d de pr es sio n an d al co ho l u se 24 ta u 20 .00 7.6 9 38 50 in p in d m = 3 .2 sc ot t e t a l. (2 01 8) ; e ur op e cp 63 sp m 25 .81 21 .88 46 64 s in d 12 sh aw ye r e t a l. (2 01 2) ; a us tra lia ps yc ho sis 44 be fri en di ng 4.7 6 9.0 9 39 44 o in d 15 sh aw ye r e t a l. (2 01 7) ; a us tra lia ps yc ho sis 96 be fri en di ng 6.1 2 8.5 1 36 39 o in d 8 sh ay eg hi an e t a l. (2 01 6) ; a sia d ia be te s 10 6 ed uc at io n 5.6 6 0.0 0 55 60 o g 10 si m ist er e t a l. (2 01 8) ; u s fi br om ya lg ia 67 ta u 9.0 9 0.0 0 40 95 s s 8 sm ou t e t a l. (2 01 0) ; a us tra lia m ud 10 4 cb t 56 .86 56 .60 31 40 o in d 12 st ei ne r e t a l. (2 01 3) ; u s fi br om ya lg ia 28 ed uc at io n 0.0 0 0.0 0 49 10 0 o in d 8 st ot ts e t a l. (2 01 2) ; u s m et ha do ne d et ox ifi ca tio n 56 ta u 40 .00 53 .85 40 37 o in d 24 th or se ll et a l. (2 01 1) ; e ur op e cp 90 a r 36 .54 18 .42 46 64 s s 7 tr om pe tte r, bo hl m ei je r, ve eh of , & sc hr eu rs (2 01 5) ; e ur op e cp 23 8 ew 28 .05 36 .71 53 76 s s 12 tw oh ig e t a l. (2 01 0) ; u s o cd 79 pr t 9.8 0 13 .20 37 61 o in d 8 ty rb er g, c ar lb rin g, & l un dg re n (2 01 7) ; e ur op e ps yc ho sis 21 ta u 4.5 5 0.0 0 41 38 i in d 1 va ki li et a l. (2 01 3) ; a sia o cd 27 ss ri s 10 .00 27 .27 27 44 o g n i w an g et a l ( 20 17 ); as ia pr oc ra st in at io n 79 cb t 11 .54 7.6 9 21 47 ο g 8 w ei ne la nd e t a l. (2 01 2) ; e ur op e bs 39 ta u 21 .05 10 .00 43 90 s s 6 w es tin e t a l. (2 01 1) ; e ur op e ti nn itu s 64 tr t 0.0 0 10 .00 51 47 o in d 10 w et he re ll et a l. (2 01 1a ); us a nx ie ty 21 cb t 0.0 0 44 .44 71 48 o in d 12 w et he re ll et a l. (2 01 1b ); us cp 11 4 cb t 10 .53 14 .03 55 51 o g 8 w hi te e t a l. (2 01 1) ; e ur op e ps yc ho sis 27 ta u 0.0 0 23 .08 34 22 o in d 10 treatment dropout in act 14 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ st ud y & r eg io n d is or de r n c on tr ol g ro up (s ) % dr op ou t a c t % dr op ou t co nt ro l gr ou p( s) m ea n a ge % fe m al e se tt in g fo rm at tx w ee ks w ic ks el l, m el in , l ek an de r, & o lss on (2 00 9) ; e ur op e lp p 32 m d t 0.0 0 0.0 0 15 78 o in d 12 w ol itz ky -t ay lo r, a rc h, r os en fie ld , & cr as ke (2 01 2) ; u s a nx ie ty 12 1 cb t 36 .36 25 .76 38 57 o in d 12 ze ttl e (2 00 3) ; u s m at he m at ic s a nx ie ty 24 sd 14 .29 36 .84 31 83 o in d 6 n ot e. n i = n ot in di ca te d; u s = un ite d st at es ; o cd = o bs es siv e co m pu lsi ve d iso rd er ; s p = so ci al p ho bi a; m ud = m et ha m ph et am in e us e d iso rd er s; sa d = s oc ia l a nx ie ty d iso rd er ; g a d = g en er al iz ed a nx ie ty d iso rd er ; c p = ch ro ni c p ai n; l pp = l on gs ta nd in g pe di at ric p ai n; t bi = t ra um at ic b ra in in ju ry ; b s = ba ria tri c s ur ‐ ge ry ; e d = e at in g di so rd er s; bp d = b or de rli ne p er so na lit y d iso rd er ; m s = m in im al s up po rt gr ou p; c bt = c og ni tiv e be ha vi or al t he ra py ; c t = co gn iti ve t he ra py ; pr t = pr og re ss iv e re la xa tio n tr ai ni ng ; s d = s ys te m at ic d es en sit iz at io n; s sr is = se le ct iv e se ro to ni n re up ta ke in hi bi to rs ; n cc = n on -s ta nd ar di ze d co nt ro l c on di ‐ tio n; r pt = r ec om m en de d ph ar m ac ol og ic al t re at m en t; ta u = tr ea tm en t a s u su al ; m m = m et ha do ne m ai nt en an ce ; i ts f = in te ns iv e tw el ve s te p fa ci lit at io n th er a‐ py p lu s m et ha do ne m ai nt en an ce ; p e = ph ys ic al e xe rc ise ; a r = a pp lie d re la xa tio n; m d t = m ul tid isc ip lin ar y tre at m en t a nd a m itr ip ty lin e; m ta u = m ed ic al tr ea t‐ m en t a s u su al ; e w = e xp re ss iv e w rit in g; s bt = s ta nd ar d be ha vi or al t re at m en t; sp m = s pe ci al ty m ed ic al m an ag em en t; bp = b up ro pi on r eg im en ; n rt = n ic ot in e re pl ac em en t t re at m en t; a ba = a pp lie d be ha vi or a na ly sis ; p w p = pe do m et er -b as ed w al ki ng p ro gr am ; t rt = t in ni tu s r et ra in in g th er ap y; w d i = w or kp la ce d ia ‐ lo gu e in te rv en tio n; r t = re la xa tio n tr ai ni ng ; b a = b eh av io ra l a ct iv at io n; s it = s tre ss in oc ul at io n tr ai ni ng ; h a b = ex po su re w ith h ab itu at io n ra tio na le ; p ct = pr es en t-c en te re d th er ap y; tc bt = t ra di tio na l c og ni tiv e be ha vi or al t he ra py ; o = o ut pa tie nt ; i np = in pa tie nt ; s = s el f-h el p; g = g ro up ; i nd = in di vi du al . karekla, konstantinou, ioannou et al. 15 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ regarding reasons reported for dropout, the majority of studies did not report data about client variables separately for dropout and completers. of the 65 studies presenting drop‐outs in the act condition, only 27 studies (41.54%) reported reasons for dropout. regard‐ing comparisons, all participants completed treatment in 11 studies, whereas for the re‐maining 65 studies with dropouts, only 30 (45.15%) reported dropout reasons. for act, the most frequently reported reasons for dropout were: lost contact (n = 15, 55.55%), per‐sonal (n = 12, 44.44%), transportation difficulties (n = 10, 37.04%) and therapy factors (n = 9, 33.33%). however, for comparison condition(s) the main reasons for dropout were: lost contact (n = 19, 63.33%), therapy factors (n = 11, 36.67%) and time demands (n = 10, 33.33%). for percentages of clients reporting each of the reasons for the included studies, see appendix a in supplementary materials. dropout rates across all studies and comparison conditions, the overall weighted mean dropout rate was 17.95%, 95% ci [15.12, 20.77]. act trials reported an average dropout rate of 17.35%, 95% ci [14.33, 20.37] and comparison conditions reported an average dropout rate of 18.62%, 95% ci [15.29, 21.96]. in the cma, the unconstrained model with the 76 studies of act vs. comparison conditions, showed that the heterogeneity detected using the fixedeffects model was very small and non-significant, with q(75) = 79.371, p = .343, i2 = 5.507%. it was thus justifiable to hypothesize that the random errors among the studies were not considerably different and that fixed-effects models could be followed. despite dropout rates in act appearing to be lower than in comparison groups when examining the overall weighted mean dropout rate the difference did not reach statistical signifi‐ cance, as the point estimate of the odds ratio and its confidence intervals included value 1 (i.e., equal odds/risk to dropout) with or = 0.931, 95% ci [0.809, 1.070], z = -1.011, p = .312; see appendix b in supplementary materials). the funnel plot for the investiga‐ tion of publication bias in the meta-analysis (see appendix b in supplementary materi‐ als) indicated no asymmetry, suggesting that there was no statistically significant publi‐ cation bias, with egger test t(74) = 0.591, 95% ci [-0.617, 0.334], p = .556) or the begg and mazumdar kendall’s tau, with τ = -0.079, p = .313. quantitative synthesis of the findings of the reviewed studies: meta-analysis participant moderators eight participant variables were first examined as moderators of therapy dropout (see table 3). treatment dropout in act 16 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ ta bl e 3 re su lts f ro m th e su bg ro up a na ly si s of p ar tic ip an t, st ud y an d pr ov id er c at eg or ic al m od er at or s on t he ra py d ro po ut m od er at or n m ea n d ro po ut r at e 95 % c i z p q p a c t c on tr ol a c t c on tr ol c lie nt d is or de r 7.1 01 0.5 26 a nx ie ty d iso rd er o r s oc ia l p ho bi a 14 19 .41 27 .27 13 .03 , 2 5.7 9 21 .05 , 3 3.4 9 -0 .66 3 0.5 07 d ep re ss io n 2 16 .82 19 .47 10 .57 , 2 3.0 6 -3 .62 , 4 2.5 6 -0 .56 7 0.5 71 su bs ta nc e ab us e or d ep en de nc e 6 28 .73 24 .91 11 .08 , 4 6.3 8 4.7 2, 45 .09 0.1 22 0.9 03 o th er h ea lth re la te d pr ob le m s 10 12 .80 12 .90 5.8 8, 20 .01 7.1 6, 18 .64 0.0 64 0.9 49 ch ro ni c p ai n 14 18 .23 11 .93 10 .89 , 2 5.6 6 5.6 1, 18 .24 0.7 38 0.4 61 ch ro ni c h ea lth co nd iti on s 7 13 .86 12 .23 6.9 2, 20 .81 6.3 3, 18 .13 0.2 15 0.8 29 ea tin g pa th ol og y/ di so rd er 8 12 .59 9.8 3 6.8 6, 18 .32 4.8 8, 14 .79 0.3 79 0.7 05 sm ok in g 5 31 .10 32 .23 16 .65 , 4 5.5 5 16 .81 , 4 7.6 5 -1 .26 5 0.2 06 se ve re p sy ch op at ho lo gy 10 10 .38 22 .37 5.8 4, 14 .92 12 .28 , 3 2.4 7 -2 .47 3 0.0 13 po pu la ti on 0.0 29 0.8 66 ch ild re n an d ad ol es ce nt s 3 11 .41 13 .59 -0 .45 , 2 3.2 6 -4 .54 , 3 1.7 2 0.7 59 0.4 48 ad ul ts 73 17 .59 18 .83 14 .49 , 2 0.7 0 15 .42 , 2 2.2 4 -1 .14 9 0.2 51 c ou nt ry 1.4 70 0.6 89 un ite d st at es 32 19 .75 23 .06 15 .02 , 2 4.4 9 17 .20 , 2 8.9 3 -1 .53 8 0.1 24 au st ra lia 8 17 .22 21 .68 4.8 2, 29 .62 9.6 0, 33 .76 -0 .44 1 0.6 59 eu ro pe 29 16 .28 14 .88 11 .70 , 2 0.8 6 10 .90 , 1 8.8 6 0.4 93 0.6 22 as ia 7 10 .96 10 .33 3.9 1, 18 .01 2.9 8, 17 .68 0.2 21 0.8 25 th er ap is t e xp er ie nc e le ve l i n a c t gr ou ps 5.6 11 0.4 68 m as te rs / m as te r l ev el th er ap ist s o r d oc to ra l st ud en ts , i nt er ns , r es id en ts 13 23 .26 24 .20 14 .56 , 3 1.9 6 15 .53 , 3 2.8 7 0.7 47 0.4 55 ph d th er ap ist s, do ct or at e 15 15 .24 14 .25 8.6 9, 21 .80 9.0 1, 19 .50 0.0 06 0.9 95 m ix p hd , s tu de nt s a nd o th er s 15 16 .34 21 .90 10 .17 , 2 2.5 2 13 .32 , 3 0.4 8 -2 .36 6 0.0 18 n ot in fo rm ed 5 10 .90 11 .57 3.0 8, 18 .73 0.2 0, 22 .94 -0 .73 8 0.4 61 ps yc ho lo gi st s m ix ed le ve ls 19 16 .15 18 .35 10 .34 , 2 1.9 5 11 .43 , 2 5.2 6 -0 .08 0 0.9 36 n o th er ap ist s ( on lin e) 8 19 .92 17 .43 8.8 7, 31 .16 6.1 0, 28 .75 0.0 59 0.9 53 n on -p sy ch ol og ist s 1 21 .74 12 .50 0.8 33 0.4 05 karekla, konstantinou, ioannou et al. 17 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ m od er at or n m ea n d ro po ut r at e 95 % c i z p q p a c t c on tr ol a c t c on tr ol th er ap is t e xp er ie nc e le ve l i n co m pa ri so n gr ou ps 5.9 90 0.5 41 m as te rs / m as te r l ev el th er ap ist s o r d oc to ra l st ud en ts , i nt er ns , r es id en ts 10 24 .37 23 .10 14 .65 , 3 4.0 9 13 .38 , 3 2.8 2 0.7 65 0.4 44 m ix p hd , s tu de nt s a nd o th er s 15 14 .99 20 .58 9.8 2, 20 .15 14 .21 , 2 6.9 5 -1 .47 9 0.1 39 ps yc hi at ris ts 2 34 .74 42 .46 31 .49 , 3 7.9 9 33 .91 , 5 1.0 1 -2 .08 7 0.0 37 ph d th er ap ist s, do ct or at e 9 17 .85 17 .84 7.3 7, 28 .34 10 .28 , 2 5.4 1 1.2 21 0.2 22 n on -p sy ch ol og ist s ( dr ug st af f, al co ho l co un se lo r, ph ys ic ia n, p sy ch oph ar m ac ol og ist ) 9 13 .49 18 .06 8.0 5, 18 .94 7.1 8, 28 .94 -0 .12 2 0.9 03 n ot in fo rm ed 12 14 .49 9.4 5 9.3 7, 19 .61 3.0 5, 15 .85 -0 .57 9 0.5 63 ps yc ho lo gi st s m ix ed le ve ls 13 15 .03 17 .29 6.4 1, 23 .66 8.0 5, 26 .52 0.0 60 0.9 53 n o th er ap ist s ( on lin e) 6 21 .53 21 .57 6.7 4, 36 .33 8.1 4, 35 .00 -0 .28 4 0.7 77 d ef in it io n of d ro po ut 0.1 66 0.9 99 fa ile d to co m pl et e tre at m en t/ di sc on tin ue tre at m en t/l ea ve b ef or e th e en d of tx /re fu se d to re tu rn in tx 53 15 .35 18 .40 11 .65 , 1 9.0 6 14 .36 , 2 2.4 3 -0 .23 4 0.8 15 at te nd ed le ss th an o r e qu al to 5 075 % of to ta l se ss io ns /w ee ks 11 22 .82 18 .68 15 .69 , 2 9.9 4 9.5 1, 27 .86 -1 .26 7 0.2 05 at te nd ed le ss th an o r e qu al to 7 690 % of to ta l se ss io ns 6 24 .63 20 .47 14 .94 , 3 4.3 1 5.7 0, 35 .23 -0 .35 8 0.7 20 fa ile d to a tte nd a ll se ss io ns 2 20 .54 21 .45 -5 .37 , 4 6.4 4 4.6 9, 38 .21 -0 .13 1 0.8 96 at te nd ed le ss th an o r e qu al to 2 540 % of to ta l se ss io ns o r g ro up s 2 21 .60 22 .41 8.9 6, 34 .24 -5 .62 , 5 0.4 4 -0 .31 7 0.7 51 fa ile d to su bm it pr e an d po st -tr ea tm en t d at a 2 10 .96 12 .15 1.4 8, 20 .43 5.0 2, 19 .28 -0 .27 9 0.7 81 st ud y ty pe 0.3 66 0.5 45 ef fic ac y 42 17 .37 20 .37 13 .06 , 2 1.6 7 15 .71 , 2 5.0 3 -1 .24 8 0.2 12 ef fe ct iv en es s 34 17 .33 16 .46 13 .10 , 2 1.5 6 11 .74 , 2 1.1 8 -0 .06 4 0.9 49 n ot e. t ab le d ar e w ei gh te d m ea n dr op ou t r at es o f c lie nt , d es ig n an d pr ov id er m od er at or s u sin g ra nd om -e ffe ct s a na ly sis . k = nu m be r o f r el ev an t s tu di es in cl ud ed in e ac h an al ys is; m ea n d ro po ut r at e = th e m ea n pe rc en ta ge o f p ar tic ip an ts te rm in at in g pr em at ur el y; c i = co nf id en ce in te r‐ va ls; z = tw ota ile d te st in di ca tin g w hi ch le ve ls of th e m od er at or s a re si gn ifi ca nt ; q = te st o f h et er og en ei ty b et w ee n le ve ls of e ac h m od er at or . *p < .0 5. ** p < .01 . * ** p < .00 1. treatment dropout in act 18 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ regarding categorical moderators, there were no significant differences between sub‐ groups. this was expected as heterogeneity among the studies was very small and the studies were generally favoring act groups but this finding did not reach statistical sig‐ nificance. however, separate investigation of the effect sizes in each subgroup of studies showed that a significant finding was noted in the subgroup analysis for the type of dis‐ order under investigation (see appendix c in supplementary materials); where in studies with a population with a severe psychopathology (i.e., borderline personality disorder, treatment resistant and psychosis) the dropouts were significantly lower in act groups compared to comparisons (or = 0.473, z = -2.473, p = .01). in terms of the six participant continuous moderators, meta-regression analyses based on the odds ratio using a meth‐ od-of-moments estimation showed that none of them (gender, marriage, ethnicity, em‐ ployment and mean age) were independent predictors of the effect size. treatment moderators eight treatment variables were tested as moderators of dropout rate (see table 4 for cate‐ gorical variables). subgroup analyses of treatment setting showed again non-significant between-group differences for all the variables examined. however, a statistically signifi‐ cant effect was noted in the subgroup analysis using the recruitment setting, as having recruited the population from a public outpatient clinic and/or community advertise‐ ments resulted in significantly lower odds of the population to drop out from act groups compared to comparison groups, or = 0.652, z = -2.985, p = .003. no significant differences were found among the rest of the examined treatment moderators and no other significant effect sizes in specific subgroups were noticed. provider and study moderators only a small amount of studies reported therapist gender, age, and ethnicity, deeming it impossible to analyze them as moderators. the experience levels of the therapists in act and comparison groups showed non-significant differences. however, in the subgroup analysis of the act therapists’ experience level a significant effect size was found for the subgroup of therapists from mixed experience levels, including doctoral level, student trainees, and others (e.g., licensed clinicians, psychiatrists, social workers, psychiatric nurses). the odds on dropout from act groups were significantly lower than from com‐ parison groups when the act therapists consisted of a multi-level and multi-domain team, with or = 0.734, z = -2.366, p = .018. also, in the subgroup analysis of the compari‐ son groups’ therapists a significant effect favoring act groups was found in the sub‐ group of psychiatrists. when the comparison groups had psychiatrists as the main and only therapists, then participants had significantly higher odds to dropout, compared to act groups, with or = 0.638, z = -2.087, p = .037. regarding study moderators, subgroup analyses based on region and type of study, or when examining the predictive ability of the year of publication in meta-regression analyses showed no significant results. karekla, konstantinou, ioannou et al. 19 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ ta bl e 4 re su lts f ro m th e su bg ro up a na ly si s of t re at m en t c at eg or ic al m od er at or s on t he ra py d ro po ut m od er at or n m ea n d ro po ut r at e 95 % c i z p q p a c t c on tr ol a c t c on tr ol tr ea tm en t f or m at in a c t gr ou ps 0.1 31 0.9 88 gr ou p 34 15 .92 15 .26 12 .32 , 1 9.5 2 11 .06 , 1 9.4 7 -0 .15 4 0.8 78 in di vi du al 30 16 .37 20 .96 11 .09 , 2 1.6 6 15 .12 , 2 6.8 0 -0 .51 8 0.6 05 co m bi ne d 3 38 .24 36 .31 31 .13 , 4 5.3 5 23 .28 , 4 9.3 4 -1 .11 2 0.2 66 se lfhe lp 9 19 .04 17 .62 8.9 7, 29 .10 7.6 2, 27 .61 -0 .52 1 0.6 02 d es cr ip ti on o f r ec ru it m en t s et ti ng 9.2 54 0.2 35 o ut pa tie nt cl in ic a ffi lia te d w ith h os pi ta l o r m ed -s ch oo l 11 16 .88 18 .72 6.2 8, 27 .48 7.4 6, 29 .98 0.7 38 0.4 61 pr iv at e ou tp at ie nt cl in ic /p ra ct ic e 2 12 .05 28 .03 7.6 4, 16 .45 -1 .04 , 5 7.1 0 -1 .35 1 0.1 77 pu bl ic o ut pa tie nt cl in ic a nd co m m un ity ad ve rti se m en ts 21 14 .44 21 .30 9.3 9, 19 .49 14 .84 , 2 7.7 6 -2 .98 5 0.0 03 re se ar ch o r s pe ci al ty cl in ic 6 17 .49 17 .91 6.9 4, 28 .03 11 .57 , 2 4.2 5 0.9 89 0.3 23 un iv er sit y af fil ia te d cl in ic (p sy ch ol og y tra in in g cl in ic a nd u ni ve rs ity co un se lin g ce nt er ) 10 26 .04 24 .41 19 .01 , 3 3.0 7 13 .98 , 3 4.8 4 -0 .44 9 0.6 53 in pa tie nt o r r es id en tia l t re at m en t 6 9.2 1 3.4 3 3.2 7, 15 .14 0.2 8, 6.5 7 0.4 42 0.6 59 a t h om e (se lfhe lp a nd w eb -b as ed tr ea tm en ts ) 11 19 .90 17 .54 11 .66 , 2 8.1 4 9.3 6, 25 .72 -0 .47 6 0.6 34 n ot in fo rm ed 9 18 .46 15 .66 8.7 2, 28 .21 8.7 6, 22 .56 1.0 31 0.3 02 tr ea tm en t s et ti ng 0.4 42 0.8 02 o ut pa tie nt 60 17 .77 20 .24 14 .34 , 2 1.2 0 16 .48 , 2 4.0 0 -1 .06 3 0.2 88 in pa tie nt 6 9.2 1 3.4 3 3.2 7, 15 .14 0.2 8, 6.5 7 0.4 42 0.6 59 se lfh el p (in cl ud in g w eb -b as ed ) 10 19 .71 18 .05 10 .61 , 2 8.8 1 9.0 7, 27 .02 -0 .40 5 0.6 86 tr ea tm en t s ta tu s 1.2 73 0.2 59 pr ov id in g tre at m en t 59 16 .31 19 .23 12 .92 , 3 1.9 5 15 .50 , 2 2.9 5 -1 .13 9 0.2 55 n on -p ro vi di ng tr ea tm en t 17 20 .94 16 .53 14 .50 , 2 7.3 9 8.9 3, 24 .13 -0 .03 5 0.9 72 treatment dropout in act 20 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ m od er at or n m ea n d ro po ut r at e 95 % c i z p q p a c t c on tr ol a c t c on tr ol c om pa ri so n gr ou p 2.8 45 0.7 24 cb t 17 18 .73 24 .25 11 .18 , 2 6.2 7 16 .89 , 3 1.6 1 -0 .18 8 0.8 51 ta u 17 14 .30 13 .60 10 .57 , 1 8.0 4 7.4 2, 19 .79 0.4 13 0.6 80 m ed ic at io n on ly 9 22 .63 23 .61 13 .08 , 3 2.1 8 12 .30 , 3 4.9 2 -1 .03 7 0.3 00 o th er a ct iv e tre at m en t 12 20 .58 21 .42 12 .07 , 2 9.0 9 11 .93 , 3 0.9 2 -1 .45 2 0.1 47 co m po ne nt o f c bt 12 17 .07 19 .36 10 .03 , 2 4.1 0 12 .83 , 2 5.8 9 -0 .59 6 0.5 51 ed uc at io n on ly 9 11 .30 7.7 7 1.7 8, 20 .82 1.7 7, 13 .77 1.2 33 0.2 18 n ot e. t ab le d ar e w ei gh te d m ea n dr op ou t r at es o f t re at m en t m od er at or s u sin g ra nd om -e ffe ct s a na ly se s. k = nu m be r o f r el ev an t s tu di es in cl ud ed in e ac h an al ys is; m ea n d ro po ut r at e = th e m ea n pe rc en ta ge o f p ar tic ip an ts te rm in at in g pr em at ur el y; c i = co nf id en ce in te r‐ va ls; z = tw ota ile d te st in di ca tin g w hi ch le ve ls of th e m od er at or s a re si gn ifi ca nt ; q = te st o f h et er og en ei ty b et w ee n le ve ls of e ac h m od er at or . *p < .0 5. ** p < .01 . * ** p < .00 1. karekla, konstantinou, ioannou et al. 21 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ sensitivity analyses we performed sensitivity analyses based on decisions taken before, or based on the pre‐ vious findings of the meta-analysis. the exclusion of the three studies that consisted of dissertations, showed that the main effect did not change significantly, with or = 0.951, 95% ci [0.826, 1.094], z = -0.705, p = .481, even though heterogeneity was slightly re‐ duced, with q(72)= 73.808, p = .419, i2 = 2.450. the next sensitivity analysis concerned the exclusion of studies with very wide confidence intervals of the odds ratio and showed again no change of the main effect. later on, we investigated the main effect when ex‐ cluding recent papers (2016-2018), as the meta-regression analysis for the predictive abili‐ ty of the year of publication showed a trend to significance. this sensitivity analysis (see appendix d in supplementary materials) showed that the main effect became marginally significant, with or = 0.852, 95% ci [0.727, 0.998], z = -1.984, p = .047, even though heter‐ ogeneity was slightly increased but remained at small levels, with q(54) = 60.961, p = .240, i2 = 11.418. the finding of the sensitivity analysis concerning the year of publi‐ cation suggested that when considering research done before 2016, the dropouts from act groups were significantly lower than from active comparison groups. discussion treatment dropout is an important parameter impacting treatment outcomes (barrett et al., 2008; wierzbicki & pekarik, 1993). despite the acknowledgement of the importance of considering dropout rates and how these influence treatment effectiveness conclusions, this phenomenon has not been extensively examined. this paper aimed to investigate the phenomenon of dropout in a relatively newly developed therapeutic approach, accept‐ ance and commitment therapy. compared to other cognitive behavioral approaches, act presents with advances in improving client engagement to treatment, emphasizes the therapeutic relationship, and provides meaning for any changes to be made during treatment, postulated to be associated with more participant engagement. indeed, change in values has been found to precede changes in suffering (gloster et al., 2017). as such, we aimed to examine if those advances presented in act could overcome some of the treatment acceptability criticisms presented with older generations of interventions, which may have contributed to increased dropout rates from psychological treatments. however, the overall dropout rate was not significantly different between act and com‐ parison groups in the present meta-analysis. as noted by others, we found that there is no consensus regarding the definition em‐ ployed by investigators. we adopted a broad definition of treatment dropout, utilizing what was reported by each study author and particularly considering dropouts to be the percentage of cases of individuals who began treatment but did not complete it as inten‐ ded by its developer. based on this definition, the yielded overall dropout rate across all treatment dropout in act 22 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ studies included in this meta-analysis was 17.95%, which is comparable to recent previ‐ ously meta-analytically reported rates (i.e., 19.70%; swift & greenberg, 2012). for act, the calculated mean dropout rate was 17.35%. this is similar again to the rates reported by galloway-williams, martin, clum, and cooper (2013) and ong et al. (2018) for act. when including all possible reasons and comparing across all comparison conditions, the dropout rate was not significantly different (18.62%) from act groups. however, the rea‐ son why individuals terminate their treatment prematurely needs to be considered in re‐ lation to dropout rates. unfortunately, the majority of examined studies did not include dropout reasons, lim‐ iting our ability to draw conclusions regarding the reasons for dropout. despite the limi‐ ted number of studies presenting reasons for dropouts, some important differences be‐ tween act and other groups were identified. for example, most individuals who drop‐ ped out from act groups did so because of lost contact and for (unrelated to therapy) personal reasons. dropout reasons in comparison conditions however, included addition‐ ally therapy-related reasons (e.g., not satisfied with the treatment or feeling that the ther‐ apy was too time consuming). in particular, when act was compared to cbt, the most frequent reason for dropping out of cbt was therapy factors (i.e., of the 5 studies who reported reasons for dropout from cbt, all of them mentioned therapy factors). in con‐ trast, in act, the reasons of time demands, transportation, personal and therapy were equally reported. this is in line with findings reported by karekla (2004) who found dif‐ ferences in the timing of dropout in relation to the treatment components between tcbt and act participants. the pattern of dropout in tcbt was linked to the initiation of ex‐ posure whereas the same pattern was not found for those in the act condition (where individuals who dropped out did so for unrelated reasons to treatment and discontinued at different time points and not before exposure was introduced). these findings lend support to the idea that act may be a more acceptable treatment choice over previous waves of tcbt, and may better prepare (e.g., via use of values) individuals to engage and ultimately benefit from even the most difficult of treatment content (e.g., exposure to feared stimuli; see also gloster et al., 2014, 2015). in the future, researchers are advised to examine and report upon the timing and reasons for dropout. in this review, we found that acts’ premature termination rates were lower for deal‐ ing with certain types of psychopathology (severe psychopathology). this finding may highlight the important addition of act skills for severe psychopathologic conditions; however this needs to be further explored. interestingly, participants’ age did not moder‐ ate dropout rates, suggesting that all age groups result in similar dropout rates. this is a divergence from the swift and greenberg (2012) meta-analysis, where younger individu‐ als had higher dropout rates (barrett et al., 2008). the subgroup analyses based on the description of the treatment setting showed that dropout rates from act groups were lower for studies in which the treatment was deliv‐ ered in a public outpatient clinic and population was recruited by community advertise‐ karekla, konstantinou, ioannou et al. 23 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ ments. however, one should note that these studies were highly heterogeneous, includ‐ ing participants with anxiety disorders, eating disorders, substance abuse, other health problems, chronic pain, health conditions/chronic illnesses, smoking, severe psychopa‐ thology (i.e., bpd, psychosis, treatment resistant), and depression. additionally, in most of these studies the comparison condition was not another psychologically active inter‐ vention (i.e., in 57% of them the comparison group was treatment as usual, medication only and education). due to the high heterogeneity of these studies, this finding should be interpreted with caution and further examined in the future. in terms of provider moderators, experience level of providers in act and compari‐ son groups were significantly related to dropout rates. specifically, when treatment was delivered by a multi-level and multi-domain team, act had lower dropout rates than comparison conditions. this is a divergence from the studies of ong et al. (2018) and swift and greenberg (2012), who reported no significant results when treatment was de‐ livered by multidisciplinary teams. in particular, in the study of ong et al. (2018), act had higher dropout rates than comparison groups when treatment was administered by master's-level clinicians/therapists whereas in the study of swift and greenberg (2012) dropout rates were higher when the treatment was provided by trainees. differences be‐ tween these studies may be a result of the definition used for therapist experience level, therefore more research is needed in this domain to be able to conclusively make recom‐ mendations as to the level of experience or the consistency of the therapeutic team that leads to higher effect sizes. for the guidance of future researchers examining dropouts in treatments, a checklist of definitions and variables to be collected which can be utilized before, during and while reporting their findings, to ensure that adequate information re‐ garding dropouts is available, is presented in appendix e (see supplementary materials). limitations this study has several limitations that need to be considered in the interpretation of find‐ ings. first, the inclusion criteria were made broad enough in order to include a large number of studies. all age groups were included; as well as various psychopathological and non-psychopathological problems, and studies combining act with other interven‐ tions or medication. though we attempted to deal with this heterogeneity in the disor‐ ders, interventions, populations and age conditions by examining moderators of interest, this heterogeneity may have still affected the clarity of any differences between act and comparison groups on dropout rates. a second limitation may be related to the coding procedure. specifically, for the vari‐ able of comparison condition, when a study had two comparison conditions we selected to compare only the active treatment (e.g., cbt) and excluded the inactive comparison condition (e.g., wait-list). a third limitation has to do with reasons reported for dropouts. specifically, the majority of studies did not report dropout reasons, making conclusions about true reasons for dropout impossible or biased for the studies that reported these treatment dropout in act 24 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ reasons. in order to further elucidate the phenomenon of treatment dropout, future stud‐ ies should examine and report reasons why participants drop out as well as the timing when this occurs. finally, in our meta-analysis it was not possible to carry out a compari‐ son between the demographic characteristics of dropouts and completers due to insuffi‐ cient data provided by studies. we would like to encourage researchers to ensure that they report information separately for completers and dropouts so as to facilitate further understanding into the phenomenon of dropout. clinical implications this review examined dropout rates of a third wave cbt intervention in a range of disor‐ ders, populations, ages and comparison conditions. our findings show that overall drop‐ out rates between act and comparison conditions were not found to differ significantly. additionally, moderation analyses suggest that experience level of therapists in act and comparison conditions, description of treatment setting, and client diagnosis are associ‐ ated with an increased likelihood of dropout. therefore, interventions aiming to lower attrition should plan a-priori how to better engage users belonging to these groups. our findings suggest that act may present some potential advances for improving client engagement and retention, such as emphasizing that any behavior change needs to be linked with the persons’ values, or it may include more interesting treatment content through the use of metaphors and experiential exercises. however, more research is still needed prior to being able to assertively make these conclusions. future research the findings of the present study offer possible hypotheses about which therapeutic pro‐ cesses are associated with client retention. however, more studies are needed that will examine particular reasons for premature treatment termination, timing when this phe‐ nomenon occurs and how it may be linked to specific treatment components, and associ‐ ated variables in third wave treatments. moderators of the dropout effect for different therapeutic approaches are critical in that they illuminate areas that may still have potential for improvement in the context of an otherwise effective intervention. this needs to be further examined. for example, even if act has lower dropout rates than some comparison conditions overall, but fe‐ males drop out more from act than comparison conditions, then act may need to con‐ sider how females are being engaged in the intervention and attempt to find ways to im‐ prove engagement (e.g., maybe more gender sensitive metaphors). additionally, common vs. specific factors in the psychotherapies being examined and in relation to how these may affect dropout also need to be examined. researchers are encouraged to examine and report the reasons for dropout when a person discontinues the treatment premature‐ ly. further understanding of these reasons should allow us to examine whether it is dis‐ karekla, konstantinou, ioannou et al. 25 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://www.psychopen.eu/ satisfaction with the common factors (e.g., therapeutic alliance, expectations, cultural adaptations, empathy) that contribute to premature discontinuation or whether dropout is related to specific factors (e.g., specific ingredients of the intervention provided). it is essential that participant engagement and premature termination continue to serve as topics of exploration in the clinical psychology arena, so as to improve the effectiveness of interventions, decrease treatment dropout rates, and enhance the possible treatment effects for participants. funding: the authors received no financial support for the research, authorship, and/or publication of this article. competing interests: the authors declare no conflicts of interest. acknowledgments: the authors have no support to report. data availability: datasets for the studies are freely available (see the supplementary materials section). supplementary materials the following data and materials are available for this study (for access see index of supplementa‐ ry materials below): via the psycharchives repository: • appendix a: percentages of clients reporting each of the reasons for the included studies • appendix b: forest and funnel plots of included studies • appendix c: forest plot of subgroup analyses based on the type of disorder under investigation • appendix d: sensitivity analysis for the year of publication • appendix e: checklist of definitions and variables to be collected in order to properly document dropouts via the international prospective register of systematic reviews (prospero): • preregistered protocol (crd42017068456) of the current study index of supplementary materials karekla, m., konstantinou, p., ioannou, m., kareklas, i., & gloster, a. t. 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(2003). acceptance and commitment therapy (act) vs. systematic desensitization in treatment of mathematics anxiety. the psychological record, 53(2), 197-215. https://doi.org/10.1007/bf03395440 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. treatment dropout in act 36 clinical psychology in europe 2019, vol.1(3), article e33058 https://doi.org/10.32872/cpe.v1i3.33058 https://doi.org/10.1037/0735-7028.24.2.190 https://doi.org/10.1037/a0029418 https://doi.org/10.1007/bf03395440 https://www.psychopen.eu/ treatment dropout in act (introduction) current study method literature search eligibility criteria coding procedures data analysis results characteristics of reviewed studies dropout rates quantitative synthesis of the findings of the reviewed studies: meta-analysis sensitivity analyses discussion limitations clinical implications future research (additional information) funding competing interests acknowledgments data availability supplementary materials references title of “ambassador of clinical psychology and psychological treatment” awarded to danutė gailienė letter to the editor, commentary title of “ambassador of clinical psychology and psychological treatment” awarded to danutė gailienė evaldas kazlauskas 1, andreas maercker 2 [1] center for psychotraumatology, institute of psychology, vilnius university, vilnius, lithuania. [2] department of psychology, division psychopathology and clinical intervention, university of zurich, zurich, switzerland. clinical psychology in europe, 2022, vol. 4(3), article e7747, https://doi.org/10.32872/cpe.7747 published (vor): 2022-09-30 corresponding author: andreas maercker, department of psychology, university of zurich, binzmuehlestrasse 14/17, ch-8050 zurich, switzerland. e-mail: maercker@psychologie.uzh.ch abstract the paper presents professional activities and the major works of an ambassador of the european association of clinical psychology and psychological treatment (eaclipt), prof. danutė gailienė. prof. gailienė is among the most influential european clinical psychologists who contributed to clinical psychology training, research, and practice in former post-communist east european countries. her entire career was dedicated to the development of clinical psychology, and through her work, prof. gailienė demonstrated how even in an oppressive and politically difficult environment, it is possible to keep the integrity and work up to higher standards. keywords danutė gailienė, psychotraumatology, suicidology, societal impact ambassador of the european association of clinical psychology and psychological treatment (eaclipt) prof. danutė gailienė was born in 1951 in lithuania which was oc­ cupied by the soviet union at a time. in 1969 the first psychology training program was launched at vilnius university in lithuania, and she enrolled at the university to study psychology that year. due to ideological reasons of refusal of any individuality, clinical psychology and psychotherapy were not approved by the communist regime (gailienė, 2000), and the psychology study program was focused on industrial and engineering psychology (bagdonas et al., 2008) at the time. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7747&domain=pdf&date_stamp=2022-09-30 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ however, danutė gailienė was very interested in clinical psychology, and since the beginning of her psychology studies, she has aimed to pursue a ca­ reer as a clinical psychologist. danutė gailienė, against the odds, managed to get the position of the first clinical psy­ chologist in a clinical setting in the country during soviet regime. thus, she began to make an outstanding con­ tribution to clinical psychology in the region. she has been the first professor of clinical psychology in the country and was the founder and chair of the clinical psychology program. early career during soviet occupation danutė gailienė graduated from vilnius university in lithuania in 1974. the head of the psychology department was prof. alfonsas gučas, who was very supportive of young professionals. prof. gučas managed to include a small number of special courses related to clinical or health psychology, even in a very restrictive political situation where political officials in moscow fully controlled the curriculum. danutė gailienė was very interested in clinical psychology during her studies and insistently searched for possibilities to work as a clinical psychologist after obtaining her diploma. however, such positions were not available due to the critical attitude of the soviet regime towards clin­ ical psychology. due to her persistence, danutė gailienė managed to get a position as a psychologist in one of the psychiatric hospitals in vilnius and was the first psychologist to work in a psychiatric hospital in the country and the baltic republics. danutė gailienė was searching for advanced training; however, the possibility of receiving a ph.d. degree in her preferred area in psychology was not possible due to the mentioned ideological reasons. it required a lot of dedication and hard work, especially to somebody not loyal to the communist party, to receive a ph.d. danutė gailienė worked on her ph.d. thesis (called 'candidate of sciences' at the time) on cognitive processes in schizophrenia supervised by the internationally famous experimental psy­ chologist, prof. bluma zeigarnik (herself born in lithuania; discoverer of a psychological cliffhanger effect named after her) from moscow. at the same time, she was working in vilnius in a clinical setting, was invited to teach at the university, and raised her three children. dr. gailienė received her ph.d. in psychology from moscow state university in 1985. prof. danutė gailienė – lithuanian psychologist and pioneer of clinical psychology behind 'iron curtain.' ambassador of clinical psychology and psychological treatment: danutė gailienė 2 clinical psychology in europe 2022, vol. 4(3), article e7747 https://doi.org/10.32872/cpe.7747 https://www.psychopen.eu/ during that time, psychology was highly affected by communist ideology (e.g., the primacy of the ruling party, the material sphere was to be given precedence over the subjective sphere) in the soviet union, and the regime was highly oppressive. the psychologist had very restricted or no access to international journals or books. so active and eager to get knowledge, professionals had to find ways for their professional development. a very significant impact on the development of danutė gailienė was a visit of prof. vytautas bieliauskas from usa in 1977 (bieliauskas, 1977), and following his visits. prof. bieliauskas was a lithuanian professor of clinical psychology in the us who managed to come to lithuania during soviet occupation and provided training and supervision for a selected group of professionals. the other ways of getting knowledge were poland and east germany, which had slightly less restrictive regimes and more access to international professional literature (leuenberger, 2001). it was also possible to visit poland and the east german democratic republic for training and conferences, and danutė gailienė used this opportunity to travel and meet professionals and achieve more specialized knowledge on clinical psychology and psychological treatments. not a communist party member and critical of communist party ideology danutė gailienė in the 1980s had limited possibilities for an academic or professional career as such professionals were under constant surveillance by the kgb. having to start her career during soviet times, which was marked by betrayal, opportunistic loyalty to the communist regime by some of her colleagues who wanted to have a faster and safe career, she has always understood the importance of integrity, a robust value system, and ethical behavior which guided all her professional career. the collapse of the soviet union and career breakthrough in the late 1980s, "perestroika" emerged, which was the first signal for the eventual collapse of the soviet union. the years of 1988–1990 was a turning point in society in lithuania and globally. brave intellectuals, and danutė gailienė, among them, participa­ ted in peaceful demonstrations against the soviet regime and soviet occupation. on march 11, 1990, the lithuanian parliament declared independence from the soviet union. almost immediately after the collapse of the soviet union, danutė gailienė with colleagues interested in clinical psychology (r. bieliauskaitė, g. gudaitė, r. kočiūnas) established the first department of clinical and social psychology, and the first clinical psychology program was launched in lithuania (kazlauskas & grigutyte, 2020). in the again independent country, danutė gailienė could be promoted to a full professor in clinical psychology (2001), was chair of the department of clinical (and social) psychol­ ogy (2000-2017). over the years, she supervised many ph.d. students who conducted research in clinical psychology and could write their dissertations in lithuanian. kazlauskas & maercker 3 clinical psychology in europe 2022, vol. 4(3), article e7747 https://doi.org/10.32872/cpe.7747 https://www.psychopen.eu/ prof. gailienė has been teaching a clinical psychology course for undergraduate students, trauma and crisis psychology course in a clinical psychology program (since 2000), and delivering post-diploma training in clinical psychology. without restrictions to travel abroad, she was a visiting researcher at munster university in germany (2003), antwerp and gent universities (2004). prof. gailienė was frequently participating in international conferences. since the start of her career, prof. gailienė maintained her clinical practice with at least one day per week meeting clients over decades of her professional activities, and expected her staff at the department of clinical psychology to have an active clinical practice, as an integral part of their professional life. one of her pioneering works in lithuania and the region was the first systematic study on suicide prevalence in her country (e.g., gailienė, 2004a; gailienė et al., 1995; gailienė & ružyte, 1997). furthermore, she was among the first to study the effects of the communist regime's political oppression in former post-communist countries. the major works by danutė gailienė taken together, danutė gailienė has been particularly interested in the impact of soci­ etal and cultural factors on mental health processes. her groundbreaking research in suicide prevention was published in her monograph "they should not have died. suicide in lithuania [jie neturėjo mirti. savižudybės lietuvoje]" (gailienė, 1998). this book is fundamental for its first comprehensive analysis of epidemiological data on suicide rates in lithuania. it analyzes social and cultural factors of a steep increase in around 10 times of suicide rates from the beginning of the 20th century to the last decade of the 20th century in lithuania, resulting in among the highest in europe and the world. prof. gailienė draws parallels in an increase in suicide rates as an indicator of the public mental health status in response to the social transitions and transformations, primarily associated with devastating effects of long-term political violence and oppression of the soviet regime. following an analysis of the suicidal behavior in the country, prof. gailienė edited a volume "ideas of suicide prevention [savižudybių prevencijos idėjos]" published in 2001. this influential volume included other leading suicidology experts working from lithuania, norway, canada, slovenia, and germany on effective suicide prevention programs. she became a widely known suicide researcher in europe as a result of this research, representing clinical psychology at many expert meetings and congresses across disciplines. after demonstrating the importance of societal and cultural factors on self-destruc­ tive behaviors, prof. gailienė made a profound impact in the area of research of political oppression by initiating the first large scale study of survivors of political violence in the country during the nazi and communist regimes in particular, former political prisoners and displaced population to the remote areas of siberia and other areas. the project was initiated in 2000 and was conducted in collaboration with the lithuanian genocide ambassador of clinical psychology and psychological treatment: danutė gailienė 4 clinical psychology in europe 2022, vol. 4(3), article e7747 https://doi.org/10.32872/cpe.7747 https://www.psychopen.eu/ and resistance research center. in the course of the research project, a much-acclaimed conference was organized in vilnius, which focused on the effects of political oppres­ sion (kazlauskas & zelviene, 2016). as a result of the conference, an important book, "the psychology of extreme traumatisation: the aftermath of political repression" was published in lithuanian in 2004 and english in 2005 (gailienė, 2004b, 2005). this volume was among the first fundamental works exploring the effects of political violence and oppression in the region of the former soviet hemisphere by showing how lithuanian historical trauma and psychotraumatology research should be included in the global agenda of traumatic stress studies. the next important monograph by prof. gailienė was published in lithuanian "what they did to us. lithuanian life in the view of trauma psychology [ką jie mums padarė: lietuvos gyvenimas trauma psichologijos žvilgsniu]" (gailienė, 2008). this book provided a deeper view of the impact of the soviet regime occupation on lithuanian mental health and is an important contribution to how the general population and professionals could use the theoretical conceptualization and empirical data from a psychotraumatology per­ spective to discuss complex social issues. the book was published in the context of some nostalgia of the soviet period in the population and attempts from former communist party leaders and their associates to clean their reputation in stating that they were doing their best in people's interest during the soviet regime. prof. gailienė's book had a significant impact of showing how the communist regime had negative long-term consequences on society (gailienė, 2008). this work resonated in other countries such as the baltic countries and poland, where her name thus became recognized. a further larger project by a major grant from the european social fund resulted in another book both in lithuanian and in english "lithuanian faces after translation" psychological consequences of cultural trauma" (gailienė, 2015a, 2015b). it reveals the diversity of the effects of political trauma and the multigenerational impact of prolonged traumatization. a chapter on cultural trauma is the highlight of this book which explores differences and similarities of psychological and cultural trauma based on the lithuanian historical context (gailienė, 2015c). final thoughts prof. danutė gailienė dedicated her life to the advancement of clinical psychology. her efforts in pursuing training in clinical psychology and psychological treatments, dissemi­ nation of clinical psychology knowledge, assisting patients, teaching clinical psychology at university, training other professionals, establishing a department and clinical psychol­ ogy program is a clear manifestation of how even under the conditions of an oppressive political regime it was possible to overcome barriers. as an excellent educator, over the years, prof. gailienė developed a much praised style of teaching. she received numerous kazlauskas & maercker 5 clinical psychology in europe 2022, vol. 4(3), article e7747 https://doi.org/10.32872/cpe.7747 https://www.psychopen.eu/ awards for her outstanding work in lithuania and frequently appeared in national media, commenting on various social and public health issues. moreover, prof. gailienė has always stressed the importance of the social responsi­ bility of clinical psychologists as professionals. from the perspective of prof. gailienė, clinical psychologists must use their knowledge not only to help and treat individual clients but also should be active in social and political life in the country, join professio­ nal networks, participate in legislation relevant to psychology and mental health, and be active in the dissemination of knowledge for general population via media. we can conclude that prof. gailienė is an outstanding european psychologist. her personal and professional integrity and dedication to establish the discipline of clinical psychology out of a hostile societal environment can as an ambassador of eaclipt inspire the future generation of psychologists worldwide. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references bagdonas, a., pociute, b., rimkute, e., & valickas, g. (2008). the history of lithuanian psychology. european psychologist, 13(3), 227–237. https://doi.org/10.1027/1016-9040.13.3.227 bieliauskas, v. j. (1977). mental health care in the ussr. the american psychologist, 32(5), 376–379. https://doi.org/10.1037/0003-066x.32.5.376 gailienė, d. (1998). jie neturėjo mirti. savižudybės lietuvoje [they should not have died: suicide in lithuania]. tyto alba. gailienė, d. (2000). perspectives from lithuania. in a. s. bellack & m. hersen (eds.), comprehensive clinical psychology (vol. 10, pp. 325–334). elsevier science. gailienė, d. (2004a). suicide in lithuania during the years of 1990 to 2002. archives of suicide research, 8(4), 389–395. https://doi.org/10.1080/13811110490476806 gailienė, d. (ed.). (2004b). sunkių traumų psichologija: politinių represijų padariniai [psychology of heavy traumatization: aftermath of political repression]. lggrtc. gailienė, d. (ed.). (2005). the psychology of extreme traumatisation: the aftermath of political repression. akreta. gailienė, d. (2008). ką jie mums padarė. lietuvos gyvenimas traumų psichologijos žvilgsniu [what they did to us: lithuanian life in the view of trauma psychology]. tyto alba. gailienė, d. (ed.). (2015a). gyvenimas po lūžio: kultūrinių traumų psichologiniai padariniai [life after the turning point: psychological consequences of cultural trauma]. eugrimas. ambassador of clinical psychology and psychological treatment: danutė gailienė 6 clinical psychology in europe 2022, vol. 4(3), article e7747 https://doi.org/10.32872/cpe.7747 https://doi.org/10.1027/1016-9040.13.3.227 https://doi.org/10.1037/0003-066x.32.5.376 https://doi.org/10.1080/13811110490476806 https://www.psychopen.eu/ gailienė, d. (ed.). (2015b). lithuanian faces after transition: psychological consequences of cultural trauma. eugrimas. gailienė, d. (2015c). trauma and culture. in d. gailienė (ed.), lithuanian faces after transition: psychological consequences of cultural trauma (pp. 9–23). eugrimas. gailienė, d., domanskiené, v., & keturakis, v. (1995). suicide in lithuania. archives of suicide research, 1(3), 149–158. https://doi.org/10.1080/13811119508251954 gailienė, d., & ružyte, i. (1997). ancient attitudes towards suicide in lithuania. nordic journal of psychiatry, 51(1), 29–35. https://doi.org/10.3109/08039489709109081 kazlauskas, e., & grigutyte, n. (2020). clinical psychology in lithuania: current developments in training and legislation. clinical psychology in europe, 2(1), article e2835. https://doi.org/10.32872/cpe.v2i1.2835 kazlauskas, e., & zelviene, p. (2016). trauma research in the baltic countries: from political oppression to recovery. european journal of psychotraumatology, 7(1), article 29259. https://doi.org/10.3402/ejpt.v7.29295 leuenberger, c. (2001). socialist psychotherapy and its dissidents. journal of the history of the behavioral sciences, 37(3), 261–273. https://doi.org/10.1002/jhbs.1034 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. kazlauskas & maercker 7 clinical psychology in europe 2022, vol. 4(3), article e7747 https://doi.org/10.32872/cpe.7747 https://doi.org/10.1080/13811119508251954 https://doi.org/10.3109/08039489709109081 https://doi.org/10.32872/cpe.v2i1.2835 https://doi.org/10.3402/ejpt.v7.29295 https://doi.org/10.1002/jhbs.1034 https://www.psychopen.eu/ ambassador of clinical psychology and psychological treatment: danutė gailienė (introduction) early career during soviet occupation the collapse of the soviet union and career breakthrough the major works by danutė gailienė final thoughts (additional information) funding acknowledgments competing interests references the cultural supplement: a new method for assessing culturally relevant prolonged grief disorder symptoms latest developments the cultural supplement: a new method for assessing culturally relevant prolonged grief disorder symptoms clare killikelly 1,2 , andreas maercker 1 [1] department of psychology, university of zürich, zurich, switzerland. [2] department of psychiatry, university of british columbia, vancouver, canada. clinical psychology in europe, 2023, vol. 5(1), article e7655, https://doi.org/10.32872/cpe.7655 received: 2022-03-02 • accepted: 2022-11-14 • published (vor): 2023-03-31 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: clare killikelly, department of psychology, university of zurich, binzmuehlestrasse 14/17, ch-8050 zurich, switzerland. e-mail: c.killikelly@psychologie.uzh.ch abstract background: the new diagnosis of prolonged grief disorder (pgd) is both an opportunity and a challenge for researchers, clinicians, and bereaved individuals. the latest definition of pgd includes a refreshing and novel feature: the cultural caveat, i.e., clinicians must determine that the grief presentation is more severe and of longer duration than would be expected by an individual’s culture and context. currently, there are no guidelines on how to operationalize the cultural caveat in mental health care settings. method: to respond to this important demand we have developed, piloted, and tested the cultural supplement module of the international prolonged grief disorder scale (ipgds). the cultural supplement aims to provide clinicians with a catalogue of culturally relevant symptoms of grief that indicate probable pgd alongside a simple framework for cultural adaptation for use in specific clinical settings. results: in this short report we outline the rationale and aim of the cultural supplement and provide a summary of our latest validation studies of the ipgds with bereaved german-speaking, chinese and swiss migrant individuals. we also provide a step-by-step framework for adaptation of the cultural supplement that clinicians and researchers may use when working with different cultural groups. conclusion: to date, this is the first pgd questionnaire based on the icd-11, and the first to include a cultural supplement that can be adapted to different contexts and groups. this cultural supplement will provide clinicians and researchers an easy-to-use assessment tool with the aim to improve the global applicability of the icd-11 pgd definition. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7655&domain=pdf&date_stamp=2023-03-31 https://orcid.org/0000-0003-2661-4521 https://orcid.org/0000-0001-6925-3266 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords prolonged grief disorder, icd-11, international prolonged grief disorder scale, cultural adaptation highlights • we explore the role of culture and the new diagnosis of prolonged grief disorder. • we provide the framework for a new method of cultural adaptation for a grief assessment measure. • we summarize new research using this new method in different cultural groups around the world. • we provide key recommendations for clinical practice. prolonged grief disorder in 2022 the latest revision of the icd-11 was implemented in clinical and research set­ tings around the world. prolonged grief disorder (pgd) is a new mental health disorder included in the icd-11. the inclusion of grief as a mental disorder has been hailed as both an opportunity and a challenge for researchers, clinicians, and patients (bryant, 2014; killikelly & maercker, 2017; stelzer, zhou, merzhvynska, et al., 2020; stroebe et al., 2008). in the latest iteration of the icd-11 the who outlined a new remit for the structure and content for disorder definitions. a strong emphasis on clinical utility and global applicability was prioritized over further delineation of accessory symptoms and subtypes (keeley et al., 2016). this led to the inclusion of refreshing new features in the diagnostic definition of pgd. the cultural caveat purports that for a diagnosis to be assigned, the symptoms of pgd must be more intense, more severe and of longer dura­ tion than would normally be expected for the individuals’ cultural or religious context. this is an exciting and novel feature for a diagnostic definition. it holds the promise of a more inclusive, globally applicable classification system, that may improve diagnostic accuracy, therapeutic rapport and treatment outcomes (aggarwal, 2013). however, the icd-11 falls short of providing clear guidance on how to operationalize the cultural caveat. questions remain about how to differentiate symptoms of ‘normal’ bereavement in different contexts (e.g., child loss, unnatural violent loss, ambiguous loss) alongside ‘disordered’ symptoms in different cultures around the world. historically the fields of culture, psychology, and psychiatry have only recently intersected to develop models and frameworks to explore the contribution of culture to psychopathology. earlier in the history of psychiatry, it had been largely assumed that the symptoms of disorder expressed in north american and european populations were representative globally. recent research has confirmed that the symptom content and structure, duration, chronicity and response to treatment can be highly dependent on culture (kohrt et al., 2014; nichter, 1981). this relativist view of disorder purports that the boundary between normal and abnormal is a social judgment or a social/cultural cultural supplement of the ipgds 2 clinical psychology in europe 2023, vol. 5(1), article e7655 https://doi.org/10.32872/cpe.7655 https://www.psychopen.eu/ norm and that the definition of abnormal will change depending on particular culture norms (canino & alegría, 2008). there are several examples of how disordered grief may manifest differently in different cultures. unique culturally bound symptoms of pgd have been identified worldwide (killikelly et al., 2018; rosenblatt, 2008). for example, in traumatically bereaved kurdish refugees one common expression of severe grief was to imitate the behaviours of the deceased (hall et al., 2014), 52% of cambodia refugees reported dreams of the deceased and this was associated with elevated pgd symptoms (hinton et al., 2013), in japan bereaved individuals will control their grief at funerals as they do not want to make others uncomfortable (killikelly et al., 2022). on the other hand, the universalist approach (or pan cultural approach) suggests that mental disorders have core symptoms of internal disorder however these symptoms may manifest differently in different contexts (canino et al., 1997). a famous study on experiences of grief around the world examined the expression of emotion after bereavement in 78 cultures (rosenblatt et al., 1976). they concluded that it is a basic human characteristic to react with emotions towards bereavement and for the majority of societies these emotions included crying, overt anger, and fear. in an early study comparing dutch and slovenian spouses who lost their partner due to unnatural causes it was found that there were more similarities than differences between cultures (cleiren et al., 1996). although in slovenian people symptoms of depression were slightly higher the overall pattern was very similar. there is a gap in the research field, as currently there are no up to date studies that directly compare symptoms of pgd across cultures, particularly the latest icd-11 definition of pgd. additionally, there are no culturally adapted questionnaires or measures of prolonged grief disorder. it is therefore difficult to ascertain if pgd symptoms follow a relativist or universalist trend, especially without adequate assessment measures. new research is consistently demonstrating the importance in cultural adaptation of mental health assessment interviews and questionnaires (hall et al., 2016). however cur­ rently, there is discourse and debate in the field over the level of cultural adaptation that is required to successfully evaluate mental disorders in cultures outside of europe and north america (harper shehadeh et al., 2016; heim & kohrt, 2019). there are currently two broad approaches to the development or adaptation of culturally sensitive mental health tools. the etic approach refers to a questionnaire or intervention developed out­ side of the culture whereas the emic approach refers to a questionnaire or intervention developed from within a culture (triandis & marin, 1983). both of these approaches have been used in the cultural clinical psychology field to varying degrees (heim et al., 2017; killikelly et al., 2018; rasmussen et al., 2014) and with conflicting results. some clinicians and researchers argue that the etic approach is enough to provide a clear and valid understanding of disorder, while others argue that the evaluation must stem from within the culture in order to be valid (aggarwal et al., 2014; berry, 1969). currently there is a dearth of both etic or emic approaches to assessment in the field of prolonged grief killikelly & maercker 3 clinical psychology in europe 2023, vol. 5(1), article e7655 https://doi.org/10.32872/cpe.7655 https://www.psychopen.eu/ diagnosis, assessment and treatment. here we consider both the emic and etic approach in a new combined pgd assessment methodology. ipgds and cultural supplement the international prolonged grief disorder scale (ipgds) is a two-part assessment ques­ tionnaire. this questionnaire is unique as it includes both emic and etic methodology within one questionnaire. the first part is the ‘standard scale’; a 14-item scale developed directly from the latest narrative definition of pgd from the icd-11. this represents the etic approach. it contains two core items (longing or yearning for the deceased, preoccupation with the deceased), accessory items including examples of emotional pain, time and impairment criteria and the cultural caveat. the standard scale can be used to determine a preliminary diagnosis of pgd and is a clinical diagnostic tool. the second part of the ipgds is the cultural supplement and uses an emic approach. the cultural supplement was developed from focus groups and key informant interviews from health care professionals and bereaved individuals from a range of cultural backgrounds. the aim was to collect a catalogue of possible pgd symptoms that may be culturally relevant above and beyond the standard icd-11 items (table 1). the cultural supplement is intended to provide a more in-depth assessment of possible pgd symptoms that may improve treatment decision making with clinical guidance. for example, recently a novel study of bereaved balinese family members revealed a probable caseness of 0% for pgd, 1% for posttraumatic stress disorder and 2% for depression. these findings are striking as usually rates of pgd are expected to be at least around 1% and more commonly less than 10% of the population. the authors conclude that there are perhaps aspects of the balinese culture that protect individuals from developing mental health disorders (djelantik et al., 2021). however, another explanation could be that the scale used to measure pgd was not culturally adapted from within the population and instead only used at etic approach. therefore, the scale may not have captured pgd symptoms that are most distressing or representative in this population. it was recently suggested that pgd assessment across cultures would benefit from the inclusion of both etic and emic methods within an assessment tool, such as provided by the ipgds (kokou-kpolou, 2021). below is a summary of our research exploring the development and first applica­ tions of this combined methodology using both the etic ‘standard scale’ and the emic cultural supplement of the ipgds in different cultural groups. cultural supplement of the ipgds 4 clinical psychology in europe 2023, vol. 5(1), article e7655 https://doi.org/10.32872/cpe.7655 https://www.psychopen.eu/ table 1 ipgds cultural supplement items: developing a catalogue culturally relevant of grief symptoms cultural supplement item germanspeaking sample chinese sample arabic migrant sample i experience strong physical problems since the loss (e.g., headache, problems with appetite). i would do anything to feel close to the deceased (e.g., visit their grave everyday, sleep next to their picture). if i could, would do anything to feel close to the deceased (e.g., visit their grave everyday, sleep next to their picture). (slightly reworded item) since the loss my behavior has changed drastically in an unhealthy direction (e.g., excessive alcohol consumption). the loss shattered my trust in life or faith in god/a higher spiritual power. the loss shattered my beliefs (i.e. my understanding of how the world should work, spiritual beliefs, religious beliefs). it is impossible for me to focus. my grief is so intense that i feel stuck in grief. i just can’t seem to fall back into a rhythm. i feel paralyzed and disconnected, (e.g., as if i am not in my own body). i have no energy or desire to engage in activities. this life holds no meaning since the death. i want to die to be with the deceased. i don’t feel close to other people or feel no satisfaction when being around others. i feel like i have completely lost control. i feel like i have completely lost control over my life or over myself. i am searching for the deceased with the hope to find him/her. killikelly & maercker 5 clinical psychology in europe 2023, vol. 5(1), article e7655 https://doi.org/10.32872/cpe.7655 https://www.psychopen.eu/ cultural supplement item germanspeaking sample chinese sample arabic migrant sample i constantly look back upon the past relationship. i feel so helpless since i lost him/her. i feel he/she is beside me. i cry loudly when i think of the loss. i can’t trust others since the loss. i feel disconnected from the new society i live in (e.g. the country i move to). without a funeral (body, or other burial ritual) i cannot move on with my life. tbc not knowing what happened to them is the worst part. tbc i would rather know they are dead then face this uncertainty. tbc if i were in my home country i would have more support for my grief. tbc i feel so overwhelmed with grief that i cannot deal with all the changes in my new country. tbc there are so many things to worry about in my new country that i never have time to grieve. tbc when i talk about the loss no one understands me. tbc i am grieving for multiple loved ones at the same time. tbc note. the first column represents the items of the ipgds cultural supplement. the subsequent columns indicate from which cultural group the item was developed and validated. the items with tbc indicate that these need to be validated in a large sample. the cultural supplement emerged from a bottom-up qualitative approach. items were developed from key informant interviews with german-speaking and chinese-speaking health care workers (killikelly et al., 2020; stelzer, höltge, et al., 2020; stelzer, zhou, cultural supplement of the ipgds 6 clinical psychology in europe 2023, vol. 5(1), article e7655 https://doi.org/10.32872/cpe.7655 https://www.psychopen.eu/ merzhvynska, et al., 2020), bereaved migrants and refugees (killikelly et al., 2021) and japanese health care professionals (killikelly et al., 2022). currently there are several versions of the cultural supplement that are being validated in different cultural groups. the chinese version has been psychometrically validated in a sample of n = 325 chinese bereaved (killikelly et al., 2020), the migrant cultural supplement (for bereaved migrant individuals living in a host country) has recently been validated in 121 bereaved migrants (in preparation). a japanese version and a version for arabic speaking refugees experi­ encing ambiguous loss are currently under development. summary of recent findings from the implementation of ipgds cultural supplement below we outlined how the cultural supplement of the ipgds has been used to explore culturally relevant symptoms in different cultural groups. to date the cultural supple­ ment has been used in two main ways 1) to compare and contrast a wide range of possible pgd symptoms between different cultural groups 2) to identify new culturally relevant symptoms of pgd within a cultural group or context. the earliest results from the implementation of the cultural supplement in the chinese bereaved sample show the value of the supplement. firstly, an item specific analysis revealed that certain items were endorsed more strongly in the chinese sample when compared to the german speaking sample. for example, the most strongly endorsed item in the chinese sample was item 15 (i constantly look back upon the past relationship) whereas for the german speaking sample it was item 17 (i feel he/she is beside me). additionally overall scores on the cultural supplement were higher in the chinese sample than the german speaking sample, possibly indicating the items were more culturally relevant for the chinese sample, as expected (killikelly et al., 2020). our recent study explored pgd in germanspeaking and chinese samples using a network analysis. we confirmed the presence of a core network of pgd symptoms consisting of yearning and emotional distress in both swiss and chinese participants (stelzer, höltge, et al., 2020). however, when culturally relevant items were included in the network this improved the predictability of the network for the chinese sample only, possibly indicating that the cultural supplement yielded a better fit. important network differences also revealed a strong connection between item 11 (wish to die to be with the deceased) and item 14 (searching for the deceased) for chinese participants that was not found for german-speaking participants. we concluded that separation distress is a particularly relevant therapeutic target for chinese participants. in our latest study, 121 migrants to switzerland completed the standard scale of the ipgds and the culturally adapted ‘migrant version’ of the cultural supplement. this version of the cultural supplement was developed from focus groups and interviews with syrian migrants. new items were developed based on these interviews (e.g., item 4: the killikelly & maercker 7 clinical psychology in europe 2023, vol. 5(1), article e7655 https://doi.org/10.32872/cpe.7655 https://www.psychopen.eu/ loss shattered my beliefs (i.e., my understanding on how the world should work, spiritual beliefs, religious beliefs), item 13: i feel like i have completely lost control over my life or over myself and item: 19 i feel disconnected from the new society i live in (e.g. the country i moved to). each of these items must be answered in response to the loss of a loved one. to reduce the item list of the cultural supplement, a preliminary analysis of the response rates to each item revealed that the most endorsed items included item 4 and item 19. this potentially indicates that the inclusion of these culturally relevant items improved the sensitivity of the migrant version of the cultural supplement. recommended methods for adaptation of the cultural supplement researchers and clinicians might be interested in developing a cultural supplement for the ipgds based on their own community and context. in line with this we propose the following steps for adaptation (see figure 1). figure 1 step by step method for cultural adaptation of the ipgds cultural supplement 1. item development step 1: identification of domain and item generation step 2: translation (who guidelines): forward translation + expert panel + back translation  focus groups (fgs) fg 1 = 6-10 health care workers fg 2 = 6-10 bereavement professionals note. meeting with cultural brokers, expert judges (clinicians)  discussion of the questions and evaluation of each item to determine whether they fit and represent the domain of interest or not (boateng et al., 2018) 2. scale pretesting step 3: content validity step 4: pre-testing of questions  6 cognitive interviews (cis) with bereaved note. “think-aloud” and “probing” methods (beatty & willis, 2007) with target users to evaluate sources of response error in the questionnaire (beatty & willis, 2007) 3. piloting and validation step 5: pilot study step 6: psychometric validation  pilot study with at least n = 20 target users note. feedback on feasibility, acceptability, useability  psychometric validation with n = 200 target users cultural supplement of the ipgds 8 clinical psychology in europe 2023, vol. 5(1), article e7655 https://doi.org/10.32872/cpe.7655 https://www.psychopen.eu/ however, first, in cross cultural research there are two important methodological caveats that should be transparently and forthrightly presented, particularly when comparing symptoms of mental disorder between different groups. first, the researchers definition of cultural group should be clearly stated and defined. cultural group can be defined in different terms with a focus on different features (ryder et al., 2011). in our research we define cultural group specifically in terms of the features that may intersect with mental disorder and pgd: a group of people who share a common language, regional history, beliefs, patterns of behaviour and values (national center for cultural competence, 2001). this should be measured transparently and systematically through a simple ques­ tionnaire. brief questions of cultural group and identity could be asked for example: what is your country of origin? which culture influences you the most? how connected do you feel to western culture? (killikelly et al., 2020). second, the effect of unmatched groups should be clearly presented to highlight any possible confounding factors. when possible, cultural groups should be matched in terms of characteristics that might affect the severity of pgd symptoms. for example, loss related characteristics should be similar across groups (e.g., relationship to the deceased, type of loss (natural or unnatural), time since loss). demographic characteristics such as age, gender, and co-morbid mental health disorders should also be clearly documented. the first step in the development of a new cultural supplement questionnaire is item development. a wide range of possible symptom items are gathered from cultural brokers or key experts such as clinicians or researchers that belong to the cultural group of interest and have key clinical knowledge. for example, ‘free listing’ is a technique used to elicit a large number of possible symptoms (kumar, 1989; world health organisation, 2012). focus groups may then reduce the number of items to the most highly endorsed and relevant. these items are then translated into the language of the group under study following the who’s recommended translation process. the second step is scale pretest­ ing (boateng et al., 2018). the content validity of newly suggested symptoms can then be established via cognitive interviews with a representative sample of bereaved individuals (e.g., gender, age, type of loss, duration of loss all represented). for information on how to conduct cognitive interviews including the think aloud and probing technique see (abi ramia et al., 2018; drennan, 2003; prince, 2008). the aim of this step is to ensure that the format and nature of the questions are clear, concise and valid. finally, the new questions should be piloted in a small sample of intended users. this can be followed by a larger scale psychometric validation study whereby standard psychometric properties of the scale (validity and reliability) are established (see killikelly et al., 2020). it should be noted that the cultural supplement should be used alongside the ‘stand­ ard scale’ i.e., the 14 items of the icd-11 pgd definition. this is particularly impor­ tant when establishing cross cultural prevalence rates, differences and similarities of symptom structure or establishing methodologically robust comparisons across different groups and contexts. the ‘standard scale’ provides the icd-11 pgd symptom list and killikelly & maercker 9 clinical psychology in europe 2023, vol. 5(1), article e7655 https://doi.org/10.32872/cpe.7655 https://www.psychopen.eu/ could be used in clinical samples for diagnosis. this assumes the universalist approach to mental disorders. the cultural supplement can add to this list for purposes of exploring alternative pgd symptoms and supporting treatment planning. for example, somatic symptoms are not included in the icd-11 pgd definition, however several different cultural groups have strongly endorsed physical symptoms following bereavement. after assessing with the ipgds, a clinician may then offer interventions and techniques to alleviate somatic symptoms if these are most distressing symptoms indicated. these somatic symptoms may not be discovered without the wide range of questions covered by the cultural supplement. implications and future research since 2022 the new icd-11 is used worldwide in clinics and research settings. research­ ers are presented with a unique opportunity to document the impact of the inclusion of a new mental health disorder, pgd on patient experience and clinical outcomes. additionally, the inclusion of the cultural caveat presents several challenges and op­ portunities. we invite clinicians and researchers to consider using the ipgds and the cultural supplement in their clinical and research settings to add to the growing database of literature exploring prolonged grief disorder in different cultural contexts. there are many questions that remain unanswered about the relationship and importance of culture and mental disorder. one outstanding research question concerns the etiology of prolonged grief disorder and its’ location on the universalist versus relativist spectrum. the development and testing of additional cultural supplements in different cultural groups worldwide could help identify which prolonged grief disorder symptoms are universal and which are culturally relative. one hypothesis could be that core symptoms of prolonged grief disorder are universal for example yearning and preoccupation with the deceased, while supplementary symptoms and examples of emotional distress may vary depending on cultural group. although currently we recommend assigning a pgd diagnosis following the guidance of the ipgds standard scale and the icd-11 pgd defi­ nition, treatment planning may be enhanced with a person-specific approach. therefore, the cultural supplement may be a valuable tool to improve clinician-patient relationship and treatment decision making. it is important to note that the cultural supplement is subject to some key limitations. for example, the definition of culture will be specific to the research group, the research question and the sampling method. researchers and clinicians should provide thorough and transparent information on how they selected participants and the sampling method used to determine the cultural group or context. additionally, it will be important to clearly document loss related variables, such as the type of loss, time since loss and the nature of the loss (sudden, violent etc.) as this may have a significant impact on the nature and severity of pgd symptoms particularly in different cultural contexts (djelantik et al., 2020). in conclusion, the inclusion of pgd as cultural supplement of the ipgds 10 clinical psychology in europe 2023, vol. 5(1), article e7655 https://doi.org/10.32872/cpe.7655 https://www.psychopen.eu/ a mental health disorder opens the door for further robust, systematic research on the relationship between grief and culture. funding: the authors have no funding to report. acknowledgments: we would like to thank the participants for taking the time to complete our research surveys. we would like to thank the following master’s students for their work on this research programme: alexandra reymond, olivia gabban, lea-martina christen, hanzhang xie. competing interests: the authors have declared that no competing interests exist. references abi ramia, j. a., shehadeh, m. h., kheir, w., zoghbi, e., watts, s., heim, e., & el chammay, r. 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(2012). who | assessing mental health and psychosocial needs and resources. http://www.who.int/about/licensing/copyright_form/en/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. cultural supplement of the ipgds 14 clinical psychology in europe 2023, vol. 5(1), article e7655 https://doi.org/10.32872/cpe.7655 https://doi.org/10.1111/j.1751-9004.2011.00404.x https://doi.org/10.1016/j.comppsych.2020.152211 https://doi.org/10.3389/fpsyg.2019.02982 https://doi.org/10.1159/000505074 https://doi.org/10.1177/0022002183014004007 http://www.who.int/about/licensing/copyright_form/en/ https://www.psychopen.eu/ cultural supplement of the ipgds prolonged grief disorder ipgds and cultural supplement summary of recent findings from the implementation of ipgds cultural supplement recommended methods for adaptation of the cultural supplement implications and future research (additional information) funding acknowledgments competing interests references international prolonged grief disorder scale addendum for refugees and displaced people (ipgds-ard): a study of arabic-speaking bereaved refugees research articles international prolonged grief disorder scale addendum for refugees and displaced people (ipgds-ard): a study of arabic-speaking bereaved refugees clare killikelly 1,2 , alexandra reymond 1, anaïs aeschlimann 1 , andreas maercker 1 , eva heim 3 [1] department of psychology, university of zurich, zurich, switzerland. [2] department of psychiatry, university of british columbia, vancouver, canada. [3] institute of psychology, university of lausanne, lausanne, switzerland. clinical psychology in europe, 2025, vol. 7(1), article e11435, https://doi.org/10.32872/cpe.11435 received: 2023-02-23 • accepted: 2024-07-02 • published (vor): 2025-02-28 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: clare killikelly, department of psychology, university of zurich, binzmuehlestrasse 14/17, ch-8050 zurich, switzerland. e-mail: c.killikelly@psychologie.uzh.ch supplementary materials: materials [see index of supplementary materials] abstract background: prolonged grief disorder (pgd) is a new and significant addition to the icd-11 who disease classification system and the dsm 5-tr. as a new disorder, it stands to improve diagnostic precision, enhance communication among health professionals and patients, provide better access to care and lead to effective treatments and intervention. however, it remains to be determined if the new diagnostic criteria for pgd are applicable to different cultural groups. method: here we sought to adapt the international prolonged grief disorder scale for refugees and displaced people. we conducted two focus groups with clinicians and health care workers and six cognitive interviews with bereaved arabic-speaking refugees. results: this formative research resulted in an addendum (comprised of three new scales) to the ipgds aimed to aid with treatment planning: the 42 item addendum for refugees and displaced people (ipgds-ard). here we present the steps for scale augmentation based on cultural considerations, a detailed description of clinical utility, feasibility and content validity established at each step, and an analysis of the percent of change in content at each step. conclusion: we conclude that the presented method of scale augmentation is a feasible and efficient approach that led to a culturally relevant, clinically useful addendum to an existing pgd questionnaire. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11435&domain=pdf&date_stamp=2025-02-28 https://orcid.org/0000-0003-2661-4521 https://orcid.org/0000-0001-7049-5131 https://orcid.org/0000-0001-6925-3266 https://orcid.org/0000-0001-7434-7451 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords grief, bereavement, prolonged grief disorder, cross-cultural relevance highlights • this study is one of the first formative research studies on culturally relevant items for treatment planning with bereaved refugees. • the additional scales developed seek to unpick the complex experiences of ambiguous loss, adjustment to host country and grief. • with this work we present a detailed description of qualitative research methods for scale augmentation for bereaved refugees. researchers and clinicians are increasingly confronted with a difficult and exciting ques­ tion: to what extent does cultural background contribute to the presentation, chronicity, and treatment of mental health disorders? the who’s icd-11 and the dsm-tr 5 now include cultural caveats in their definitions of mental disorders (boelen et al., 2020; killikelly & maercker, 2017; prigerson et al., 2021). for example, the new diagnostic defi­ nition of prolonged grief disorder (pgd) can only be diagnosed if symptoms persist for a longer period of time or are more intense than would be expected in the individuals’ culture and context (maercker et al., 2013). this novel addition to diagnostics catalyzes important discussions about the role of culture in mental disorder presentation and treat­ ment. however, there are several challenges that have so far been overlooked. it is not clear how to establish the cultural norms of an individual or culture and whether these have been violated by disorder. for example, in the case of grief, cultural norms prescribe a mourning period and if grieving persists beyond the culturally expected mourning period that cultural norm has been violated. clinicians, researchers, and health care workers on the frontline of mental health assessment are perplexed by the proposition that culture can quickly and easily be assessed in a diagnostic setting (stelzer et al., 2020). the new disorder definition of pgd provides a unique opportunity to explore the assessment of a mental health disorder with its emphasis on culture and global applica­ bility (first et al., 2015). core symptoms of pgd include longing for and preoccupation with the deceased, significant emotional distress and significant functional impairment that persist beyond half a year after the death of a loved one (killikelly & maercker, 2017). symptoms can differ in duration and expression according to the culture, religion, social status or gender of the bereaved (rosenblatt, 2008). therefore, although six months seem to be a good approximation of a grieving process, this duration is not exclusively limited. indeed, the main distinction in diagnostic criteria between the newly proposed icd-11 and dsm 5-tr pgd is the time criteria: the icd-11 purports that symptoms must persist for more than six months, and the dsm suggests more than 12 months. to date, when questions about the duration of symptoms arise, clinicians are advised to use cultural norms in diagnostic decision making (o’connor et al., 2015). currently there ipgds addendum for refugees and displaced people (ipgds-ard) 2 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ is only one pgd assessment questionnaire that includes an item examining the role of culture. the international icd-11 prolonged grief disorder scale (ipgds) was developed based on key icd-11 items from the prolonged grief disorder-13 (pg-13; (prigerson & maciejewski, 2008) and the structured clinical interview for complicated grief (sci-cg; bui et al., 2015; killikelly et al., 2020). this questionnaire was developed in two parts. part one examines the specific diagnostic items of the icd-11 (13 items) and includes one item related to the cultural caveat (item 14 my grief would be considered worse [e.g., more intense, severe and/or of longer duration] than for others from my community or culture). part one of this scale may be used to establish a preliminary diagnosis of pgd according to established diagnostic features. part two of the scale is a catalogue of possible grief symptoms that may have a stronger cultural fit depending on the individual assessed, (for example item 4: i had a strong loud emotional outburst after the loss) (killikelly & maercker, 2023). part two provides the patient and clinician a more in-depth assessment tool that may help with treatment planning, therapeutic rapport and further symptom delineation but is not used for diagnostics. this two-part assessment framework is modeled on the harvard trauma question­ naire (mollica et al., 1992). the htq was developed in several parts and contains a combination of checklist and open-ended questions about traumatic events and emotion­ al symptoms that are unique to a particular place and context. the htq is intended to be used in clinician interviews and not as a self-report. we have built on this framework by including a standard scale of well-known pgd symptoms alongside a supplementary assessment of additional symptoms that may be culturally relevant and particularly relevant for treatment planning. in addition, we provide a new simplified framework for how to adapt the ipgds to different cultural groups. presently, the ipgds has been used and adapted to assess pgd and wider symptoms of grief in german-speaking, chinese, japanese, syrian bereaved and a group of arabic speaking migrants (killikelly & maercker, 2023). the standard scale and the adapted cultural supplement have been psychometrically validated in german-speaking and chinese bereaved and preliminary validated in a group of swiss and canadian migrants from a variety of backgrounds (killikelly et al., 2020). the cultural supplement was found to be valid and reliable for use in each of these groups and in each case items were augmented with specific culturally relevant items. for example, chinese participants requested and strongly endorsed item 1 of the cultural supplement ‘i experience strong physical problems since the loss (e.g., headache, problems with appetite)’. humanitarian migrants comprise refugees, asylum seekers or displaced people with a population rising to more than 70 million around the world (unhcr, 2017). this group is affected by several challenges that have a negative impact on mental health including a high rate of traumatic events (bhugra & becker, 1999). the most common disorders are posttraumatic stress disorder (ptsd), depression and anxiety disorder (fazel et al., 2005). concerning pgd, killikelly et al. (2018) found that refugees are significantly more killikelly, reymond, aeschlimann et al. 3 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ affected than the normal population. for example up to 54% of refugees may experience symptoms of pgd while less than 10% of the general population (lechner-meichsner et al., 2024; rosner et al., 2021). research has shown that ethnic minorities, refugees and immigrants are more likely to be misdiagnosed with mental health disorders than patients from the main culture (bäärnhielm et al., 2015). indeed, patients and clinicians’ differences such as culture, gender, language, religion and ages can lead to a misunder­ standing of the illness (lewis-fernández & kirmayer, 2019). currently there is an urgent need for a measure of pgd that is relevant and acceptable for refugees and displaced people. the main aim of this study is to culturally refine and develop a pgd addendum for refugees and displaced people that considers the distinctive experiences of refugees. this addendum may be used to supplement to the standard icd-11 pgd diagnostic items (ipgds standard scale) in the effort to improve therapeutic rapport, identify missing symptoms or features and improve treatment and care planning with refugees. as a proof of concept, we have explored symptoms and experiences of grief in a small group of arabic-speaking refugees. augmentation of the ipgds for arabic-speaking refugees according to boateng et al. (2018) there are three phases to scale augmentation (item development, scale development, scale evaluation) including nine steps to create and validate a scale. this project has developed a simplified method that focuses on the two steps of the “item development” phase (identification of domain and item generation, content validity), and on the first step of the “scale development” phase, which consists in the pre-testing of questions to distill the most relevant and important information for cultural relevance (see figure 1). two focus groups (fgs) were conducted: the first focused on item generation and adapting the content of the questionnaire and a second focused on determining the feasibility and clinical utility of the questionnaire. the following research questions were addressed in the focus groups: 1. what content (specific items) from the existing ipgd scale is missing / needs to be added for bereaved arabic-speaking refugees? 2. is the ipgds feasible for use with arabic-speaking refugees in different clinical settings? is the ipgds for refugees clinically useful? the world health organization (who) procedure of translation and adaptation of in­ struments was followed to translate the ipgds for refugees in arabic (world health organization, 2019). to establish the preliminary content validity of the questionnaire in arabic, six cognitive interviews (cis) were conducted with bereaved arabic-speaking refugees (5 syrian, 1 iraqi) to evaluate the possible sources of errors in the questionnaire and acceptability of the items (beatty & willis, 2007). the following research question was examined in the ci’s: ipgds addendum for refugees and displaced people (ipgds-ard) 4 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ 3. is the content of the ipgds for arabic-speaking refugees valid and acceptable? figure 1 iterative process of cultural augmentation and testing step 1 • item adaptation and development • method: focus group with 6 health care workers • outcomes: changes to specific items step 2 • feasibility and clinical utility • method: focus group with 4 clinic experts • outcomes: changes to assessment process step 3 • content validity • method: cognitive interviews with 6 bereaved arabicspeaking refugees • outcomes: changes to content and translation method procedure ethical approval was obtained from the uzh faculty of arts and social sciences (grant no. 19.10.4.) measure: ipgds this scale comprises 13 previously used items integrating the pg-13 (prigerson & maciejewski, 2008) and the sci-cg (bui et al., 2015). the participants indicated how often they felt preoccupation, yearning and symptoms of emotional distress over the past month because of loss of a loved one, using a 5-point scale: 1 = almost never (less than once a month), 2 = rarely (monthly), 3 = sometimes (weekly), 4 = often (daily), and 5 = always (several times a day). an impairment item as well as screening items (for the length of time since bereavement and the violation of socio-cultural norms) were also included. as mentioned above item 14 assesses the cultural caveat. the original version of the cultural supplement consisted of 19 items developed from key informant inter­ views with health care workers and bereaved individuals from europe and china (stelzer et al., 2020). psychometric analysis confirmed the internal consistency, concurrent and criterion validity. in this current study we aim to develop a new cultural supplement, killikelly, reymond, aeschlimann et al. 5 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ now referred to as the addendum, from focus groups and interviews with bereaved refugees and migrants. step 1: item generation and augmentation of ipgds for refugees using a focus group the first fg was organized to generate new possible questionnaire items and discuss the adaptation of the ipgds for arabic-speaking refugees. five professional health care workers were invited to discuss the questions of the ipgds for refugees in general and evaluate items’ relevance for the bereaved arabic-speaking refugees in particular. this first meeting took place in december 2019 at the university of zürich. the meet­ ing lasted 2 hours and was facilitated by ck, post doctoral researcher and clinical psychologist with support from master’s students ar and aa. the purpose of the meeting was explained and the experts were asked to share their personal experiences of working clinically with bereaved refugees, to assess what should be added or could be missing from the standard ipgds questionnaire, and to share their feedback/comments. the meeting was audio recorded to collect the data and transcribed with maxqda (version 2020). in line with the first step of scale adaptation “identification of domain and item generation”, a draft catalogue of possible grief symptoms was collected based on the fg recommendations and with input from existing literature (hassan et al., 2016; kokou-kpolou et al., 2017; vromans et al., 2012). these included 57 new possible items were added to the 14 standard items of the international prolonged grief disorder scale (ipgds) (killikelly et al., 2020). step 2: feasibility and acceptability of the ipgds for refugees using a second focus group the second phase of the scale development aimed to assess the feasibility and clinical utility of the questionnaire. for this purpose, a second fg was organized with four other professional health care workers who evaluated the items to determine if the scales would be feasible for use in the clinic setting and if they would be clinically useful. the second fg took place at local psychosomatic clinic at the university hospital zurich in december 2019. this focus group lasted one hour. it was facilitated by ck and supported by ar and aa. the purpose of the focus group was explained, participants were asked to provide feedback on the scales, particularly considering the treatment of refugee patients who were suffering from grief. step 3: preliminary content validity of ipgds in refugees using cognitive interviewing cognitive interviews (cis) can be used to clarify how items could be understood or how participants will answer to specific questions (drennan, 2003). the main goal is to investigate how a participant arrives at an answer instead of the answer itself. there ipgds addendum for refugees and displaced people (ipgds-ard) 6 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ are two different alternatives or paradigms to conduct cis, the “think-aloud” method and “probing”, which both aim to gather information that can’t be seen in the questionnaire (beatty & willis, 2007). in the “think-aloud” method, the interviewer asks the participant to answer the questions by explicitly thinking out loud. it means that the interviewer asks the questions to the participant and looks at how they arrive at their answer. the other method, “verbal probing”, consists of asking the participant the questions and then to elaborate on their answer. probes can be used to ask about comprehension or interpretation of the questions, to paraphrase the questions, to ask about confidence judgment, to recall things, and to ask about very specific things as well as more general thoughts (beatty & willis, 2007). both “thinking-aloud” and “verbal probing” methods are often used together in cis as was done in the current study ((willis & artino, 2013). following the forward and back translation of the questions (who procedure), five cis were conducted to pre-test the ipgds for refugees. the interviews started with a presentation of the interviewer (ar master’s student) and the translator. a qualified clinical psychologist was always on hand (ck) in case participants became distressed. participants were also provided with a list of local resources and psychological services. all five interviews lasted between 60 and 90 minutes. the interviewer explained the purpose of the study and of the interview and gave instructions on how to answer the questions according to the “think-aloud” method. the interviewer used probes to go deeper when insufficient information was given. after five interviews the ipgds was adapted. a final ci with a sixth person was then conducted to pre-test this new version of the questionnaire. at the end of the interviews, participants received 30 swiss francs for their participation. recruitment and participants focus group and cognitive interviews the recruitment of professional health care workers for the fgs took place in november and december 2019. clinicians were mostly recruited from health clinics that specialize in the treatment of migrant and refugee communities, private practices and ngos in the german-speaking part of switzerland. the main criteria were “having experience work­ ing with refugees/migrants/asylum seekers for at least one year and having professional experience with grief”. the first fg consisted of six health care workers and the second of four clinicians, all of whom specialized in the treatment of trauma and grief in refugee populations. the recruitment of participants for the cis started in early january and lasted until the end of february 2020. participants were first recruited through ngos, language schools, associations, and refugee housing. the snowballing method was used for further recruitment. inclusion criteria included speaking arabic, the ability to provide written informed consent and having lost a loved one at least six months prior to the interview. people with severe mental health disorders (e.g., a diagnosis of major depression or killikelly, reymond, aeschlimann et al. 7 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ current diagnosis of schizophrenia), imminent risk of suicide, or currently receiving treatment from a psychiatric in-patient unit were excluded from the study. five partici­ pants were from syria and one from iraq (table 1). table 1 demographic information of cognitive interview participants category p1 p2 p3 p4 p5 p6 gender female female male male male female age 28 48 23 48 46 70 ethnicity syrian syrian syrian/kurd syrian/kurd syrian iraq residency status residency asylum seeker waiting to have the refugee status temporary visa residency asylum seeker cause of migration study war refugee political refugee war refugee political refugee war refugee political refugee war refugee relation to the deceased close friend parent cousin friends parent brother parent cause of the death homicide natural cause homicides natural cause homicide natural cause missing person no no no yes no yes analyses the fg and ci data was audio recorded and then transcribed with maxqda (version 2020). the framework method of qualitative analysis was used as this method is fre­ quently used for semi-structured interview transcripts (gale et al., 2013). the framework approach involves the categorization and organization of the qualitative data into a matrix to reduce and summarize the data with the aim to answer the research questions and to generate themes. the framework analysis was conducted according to the seven steps proposed by gale et al. (2013): “transcription”, “familiarization with the interview”, “coding”, “developing a working analytical framework”, applying the analytical frame­ work”, “charting data into the framework matrix” and “interpreting the data” using microsoft excel. regarding the first step of the analysis, all fgs and cis were transcribed using maxqda software. fgs were conducted in english and transcribed into english. cis were conducted in english with an arabic speaking translator and transcribed into english. this study received ethical approval from the university of zurich. results the results from this study are presented in two formats. the first type of results are the new questionnaire items and the structure for the new measure of grief. the step-by-step questionnaire adaptation and restructuring is presented in appendix 1 (see killikelly ipgds addendum for refugees and displaced people (ipgds-ard) 8 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ et al., 2025s). second, the results from the qualitative/descriptive data analysis of the fg and ci are presented. these results provide an in-depth rationale supporting the amendment and additions to the ipgds. they are organized into conceptual themes of clinical utility, feasibility, and content validity. the results of the framework analysis for the two fgs (combined) and cis are presented separately below. focus groups the first focus group resulted in a new structure of the ipgds for arabic-speaking refugees (see killikelly et al., 2025s, appendix 1, step 1 fg1 outcomes). the cultural supplement was replaced with three new scales a) loss of homeland and b) refugee adjustment and impact on grief and c) culturally specific items. the second focus group resulted in restructuring the scales to replace the loss of homeland section with an ambiguous loss section (see killikelly et al., 2025s, appendix 1, step 2 fg2 outcomes). framework analysis conducted on the two fgs revealed three major categories with several corresponding subthemes (see table 2). table 2 overview of framework analysis results: categories and themes resulting from fg and ci sample / category themes focus groups category 1: item generation and content adaptation content adaptation new content category 2: clinical utility systematic assessment treatment priorities category 3: feasibility duration cultural differences cognitive interviews content validity: category 1: sources of response error difficulties with response options inapplicable items language and meaning content validity: category 2: expected distress reactions strong emotions refusal to respond killikelly, reymond, aeschlimann et al. 9 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ category 1: item generation and content adaptation clinicians reviewed the content of the existing ipgds items and made suggestions for new content and for adaptation. theme: content adaptation — clinicians made several concrete suggestions for how the existing ipgds could be adapted to the refugee context. clinicians suggested includ­ ing a second step in the assessment process which would include assessing grief for the homeland. several clinicians identified how refugees may experience grief for the loss of a person but also for the loss of their community and culture (homeland). fg2: is it the same feeling "grieving for someone who is deceased" and "grieving for someone who we are just separated from"? regarding pgd, grieving while being a refugee (how being a refugee can have an impact on the grieving and vice versa) was a main topic. according to the participants, these two experiences overlap and are hardly separable from each other. fg1: i find it extremely complicated because refugees have an accumulated grief. and that kind of grief we have, it's connected socially, politically or religiously and normally we learn to suppress that and to deal with life as it is. [of note this clinician has a syrian background so could speak as a cultural broker]. other additions include revisions to the wording and structure of the scale. two exam­ ples are given below: fg1: i have another question: “my grief is worse because”, is it possible to make it the other way? “my grief would better if”? fg2: will you integrate multiple losses? because all these scales and criteria have been developed for people who face one loss. in the refugee context, they've lost brother and mother and friend. theme: new content — clinicians also suggested specific items that should be added to the existing icd-11 criteria including hopelessness, arousal, rituals, and conflicting symptoms. fifty-seven new items were ultimately added to the catalogue of possible symptoms. these new items included the loss of homeland and the unique challenges experienced by refugees. fg1: they are kind of preoccupied and at the same time they avoid all reminders. they can have both at the same time. it seems like paradoxical (…). ipgds addendum for refugees and displaced people (ipgds-ard) 10 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ fg1: this is a kind of avoidance, you kind of shut, you close it, life is over because someone has died. sometimes i have the feeling when i'm with this lady as if she resigned, she gives up. clinicians also mentioned typical circumstances that refugees are confronted with that should be assessed such as multiple losses, ambiguous losses (missing persons) or the lack of resources in the host country. fg1: one was ambiguous because the husband just was gone, gone until now no one knows what happened to him, if he's dead or he lives with another family somewhere happily or whatever, no one knows. category 2: clinical utility clinicians provided insight into how the assessment measure would be useful in the clinic environment. theme: systematic assessment — clinicians identified that grief is a common com­ plaint amongst refugees and that a questionnaire to assess it in refugees in a more systematic way is missing. they mentioned how they could use the ipgds for refugees with their patients, for example: fg2: it's not easy for many of our patients to differentiate between their feelings. for many, stress (or distress) is the most we can get from them. anger, guilt, shame and grief, that's too much for many of them, so that makes it more difficult to distinguish. theme: treatment priorities — clinicians reported the need to have a hierarchy of what’s the most important or acute symptom. refugees often suffer from many problems such as different types of pre and post migration stressors and various types of symp­ toms. clinicians must set treatment priorities in terms of what should be treated first and adjust treatment planning accordingly. for example: fg2: so that's surely an important issue, what is the most prominent symptom, what is causing the most suffering. clinicians saw an added value in using pre-post measures of the ipgds, as this would help to track treatment progress and to indicate which symptoms of pgd would have been improved after a certain treatment. fg1: what is the main fact […], is it less sadness or acceptance? what is our success? killikelly, reymond, aeschlimann et al. 11 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ category 3: feasibility clinicians provided specific feedback on how feasible and achievable a grief assessment for refugees would be in their clinic environments. theme: duration — the most common criticism of the questionnaire was the duration. many clinicians identified that there were too many items and the process may take too long in the clinic. they also pointed out the fact that as many refugees do not speak the language of their host country, clinicians must work with translators which adds extra time. fg1: so even a simple bdi questionnaire takes about one hour to be translated, so the shorter the better. all of the clinicians agreed that the ipgds should be shortened but they also argued that it should be able to capture important content. clinicians therefore suggested having two separated scales in the ipgds for refugees, one for the loss of a person and another one for the loss of a homeland. the different results on those scales could be compared: fg1: (…) then we could apparently differentiate grief or sadness related to a loss of home country or culture and to tear that apart and grief related to the loss of a loved one. that's not the same thing and almost all refugees of course suffer from grief, so to speak related to the loss of their home country or culture (…). theme: cultural differences — clinicians identified one of the biggest challenges in working with refugees as differences in belief systems and culture. indeed, clinicians expressed how each of their patients have their own way of expressing their problems or symptoms regarding their cultures or beliefs that are most of the time different from their own. they mentioned how their patients may fear being misunderstood due to cultural differences, and therefore may fear disclosing symptoms. fg1: i have one kurdish patient and he says "i see in switzerland you grieve for 10 days or two weeks, but i would do it for one year. people are expecting me to move on but i'm not ready at the moment". another common problem may be patients’ non-acceptance of the problem and, there­ fore, a non-adherence to treatment. this can make diagnostic and treatment decisions difficult. in the case of pgd, participants also pointed out the multiple ways in which the disorder can manifest itself and, again, this makes its diagnosis difficult. the use of a reference point or a cultural mediator to understand the culture of the patient was suggested. indeed, they often use a mediator or someone from the family to help them understand the problem in the patient’s context. the other strategies ipgds addendum for refugees and displaced people (ipgds-ard) 12 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ to develop a common cultural understanding included: to try to step in the patients’ shoes, to confront the patient with the problem, to use psychoeducation, and to plan a treatment in advance. cognitive interviewing: preliminary content validity the results from the six cognitive interviews revealed two main categories with several underlying themes. these results are based on both the ‘think aloud’ and probing meth­ ods used interchangeably throughout the interviews. category 1: sources of response error theme: difficulties with response options — the response options of the ipgds include a five-point likert scale (not at all, rarely, sometimes, often, always). during the interviews, participants rarely used those given options and were more likely to answer with “yes”, “no” or with other alternatives. when participants made an effort to answer in the manner requested, confusions or difficulties often occurred. for example, when asking participant 3 why he chose a specific option, he answered that he chose randomly and didn’t know if the response was really correct for him. interviewer: i try to avoid reminders of the deceased or the death as much as possible (like photos or memories). participant 1: absolutely theme: inapplicable items — participants identified items that did not apply to their experience of grief or where not relevant. for example, some questions were asked assuming that participants had not attended the funeral of their loved one. however, in many cases participants had been in the same country as the person who died and could be present at the funeral. in this case the question about inability to attend a funeral or other rituals did not apply. the question about visiting the grave of the deceased person was also deemed inapplicable by all participants. for example: interviewer: i would do anything to feel close to the deceased (e.g., visit their grave every day, sleep next to their picture). participant 5: it depends it's too far away, you can't imagine it's not realistic, because the grave it's too far away, i can't go to syria. another example is the question on acceptance: interviewer: i have trouble or just don’t want to accept the loss. killikelly, reymond, aeschlimann et al. 13 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ participant 1: i don’t really understand the question […] because what does it mean or how should you accept a loss at all? […] yes, but the second one doesn’t make sense for me. what does it mean to accept it. like to accept, it means that i’m okay with it? you can’t ask this question. i don’t know, this question is a bit confusing. the timeframe for assessment was also questioned. participants were asked to think about the previous week while answering the questions. most participants had difficul­ ties answering the questions while relating only to the last 7 days. theme: language and meaning — participants also provided feedback on the lan­ guage translation. for example: interviewer: i have intense feelings of sorrow, related to missing my family and friends. participant 3: it's more an egyptian word, not high arabic. [wrote a different word] at times participants pointed out when they encountered issues with the wording and how this specific way of writing in arabic prevented them from answering the question adequately. for example: interviewer: i have trouble or just don’t want to accept the loss. participant 1: there is a difference between “i have trouble or suffer from something” and “i can accept something”. some word problems affected all participants whereas others were only mentioned by a single person. in this case, it didn’t require a change after the revision of the question­ naire. category 2: expected distress reactions triggered during the interview two main themes, strong emotions (blaming and anger) and rejection of the question­ naire item (guilt, non-acceptance of the item) were observed as reactions to certain items. these are expected distress reactions as we expect certain emotional responses are likely to be triggered if these items are clinically valid and important. theme: strong emotions or distress — during the interviews, all participants expe­ rienced strong emotions or distress at some point. indeed, one participant felt very emotional when filling out the questions about how her loved one died and when she was asked if the death had been expected or not. over the course of the interview, ipgds addendum for refugees and displaced people (ipgds-ard) 14 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ most of the participants became more comfortable and were able to relax. however, two participants remained very emotional during the interview process. for example: interviewer: i’m longing or yearning for the deceased. participant 6: sure. she is always on my mind. [crying]. it is weird to talk about her with strangers. in most cases, participants could answer the questions without difficulties and without feeling overwhelmed. however, a few items seemed to provoke strong emotions for all participants. all participants expressed strong blame towards someone or something for the death of their loved one, or for the reason they had to leave their country. four out of six participants blamed others or the circumstances for the death and all six participants blamed others or the circumstances for the reason they had to leave the country: interviewer: i blame others on the circumstances for the death (like a higher power). participant 1: i blame the higher powers which are directly responsible for the problems, like the regime. yes. anger was also a strongly expressed emotion. five out of six participants felt very angry about the loss and, again, all of them reported feeling angry over being separated from their family and friends. interviewer: i’m angry over the death. participant 6: i always say: how did you leave me alone here and leave? theme: refusal to respond — it was observed that several items seemed to trigger a rejection or denial response from participants. one participant in particular had difficul­ ties answering certain questions in general, for example: interviewer: i feel that i lost a part of myself. participant 3: i won't answer. nevertheless, for most participants only a few items triggered rejection. questions about guilt triggered ambivalent responses and seemed to bring up discomfort in all partici­ pants. not only did they all report not feeling guilty for the death of their loved one, but some of them were even shocked or surprised by such a question, as if they would not allow themselves to be guilty: killikelly, reymond, aeschlimann et al. 15 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ interviewer: i feel guilty about the death or circumstances surrounding the death. participant 5: how should i be guilty of it? no for sure, i'm not guilty. i didn’t have to do anything with the death. when asked about feeling guilty about being separated from their family and friends, participants were more receptive. participants acknowledged feelings of guilt. importantly, one participant expressed a wish to die. some items seemed to cause him such distress that he refused to answer. he seemed particularly nervous during the whole interview but items specifically about death or his role in life triggered even more emotions and at times he did not want to answer: interviewer: i want to die in order to be with the deceased. participant 3: i don't want to answer. change analysis in addition to the qualitative framework analysis, we examined the percentage of change in the questionnaire items, afforded by each step of the adaptation process. here the results show that the number of changes at each step was reduced (e.g. from 80% of items changed in step 1 to 12.5% changed in step 3). this supports the content validity of the final questionnaire assessed by arabic-speaking refugees in step 3 (cognitive interviews). at this final stage only small changes to translation and some clarifications of content were required. discussion the ipgds is the only scale that is extended to include culturally specific symptoms of grief alongside items for a prolonged grief diagnosis (killikelly & maercker, 2023). so far, there is no questionnaire to assess pgd and grief more generally, taking the refugee experience into account. this formative, proof of concept, research project had two overarching aims 1) to use a step-by-step method of cultural augmentation to develop an ipgds addendum tailored to arabic-speaking refugees and displaced persons (ipgds-ard) and 2) to provide an in-depth description of the rationale supporting the new content and additional scales in terms of feasibility, clinical utility, and content validity. to this end we conducted two focus groups with experts and six cognitive interviews with bereaved arabic-speaking refugees. this resulted in a newly culturally relevant ipgds-ard questionnaires for bereaved arabic-speaking refugees. of note the current study aimed to develop and extend items for bereaved refugees more generally, ipgds addendum for refugees and displaced people (ipgds-ard) 16 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ however the resulting scales have only been piloted in a small group of arabic speaking refugees. this will be explored in follow up studies. in the first step of cultural augmentation, fg 1, the original ipgds standard scale measuring icd-11 pgd symptoms was preserved however the cultural supplement ques­ tions were replaced with a) loss of homeland scale, b) refugee adjustment and impact on grief and c) new culturally specific items. the rationale for the inclusion of these new sub-scales is captured by the themes revealed in the framework analysis: improved clinical utility (systematic assessment, definition of treatment priorities) and feasibility (duration, cultural differences) for use with bereaved refugees. in the second step, fg 2, the sub-scales were adapted again based on clinical utility and feasibility for use in the busy clinic environment. for example, the loss of homeland sub-scale was changed to the ambiguous loss sub-scale to reflect a more clinically useful phenomenon. in the final step of the adaptation the ci revealed few changes to the content of the questionnaires. small changes to translation and some re-phrasings of the items were made. overall, the few changes from the six ci support the content validity of the final ipgds-ard questions (see figure 2). figure 2 percentage of change in number of questionnaire items after each augmentation step 71 56 56 14 36 49 57 20 7 80 35 12,5 0 10 20 30 40 50 60 70 80 90 step 1 step 2 step 3 summary of changes to questionnaires total items original new percent changed culture is a crucial component for better understanding the expression of illness, that is, cultural differences must be understood and considered for an appropriate diagnosis and treatment (bhugra, 2005; bhugra & becker, 1999). in this study clinicians served as cultural brokers to provide a first window of insight into the clinical utility of a grief killikelly, reymond, aeschlimann et al. 17 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ measure for refugees. the qualitative analysis on the fgs and ci provided rich data supporting each step of cultural augmentation and restructuring. clinicians’ recommen­ dations and insights reflected main themes of improving the clinical utility, feasibility, and content validity of the questionnaires. these are touchstones of establishing ques­ tionnaire acceptability and validity, particularly for different cultural groups. previous research has used similar methods including focus groups and ci to develop the content of cultural adapted mental health measures. our previous work has also demonstrated the value of including a wide range of clinician and patient perspectives to establish cultural relevance and clinical utility of the ipgds. swiss and chinese health care workers examined the content of the icd-11 pgd guidelines and provided in depth qual­ itative interview data on their perspectives on the clinical utility and global applicability (stelzer et al., 2020). important themes were revealed including the role of stigma in preventing help seeking and treatment and the value of including somatic symptoms in the diagnostic guidelines. interviews with japanese health care workers confirmed the overall utility of the icd-11 pgd guidelines but included important possible barriers to clinical assessment such as the role of emotional control and the strong shame attached to seeking grief support (killikelly et al., 2023). health care workers can provide vital insight into their own illness beliefs and beliefs about the usefulness of assessments, as well as insight into their patients experiences and illness models. the outcome of this cultural adaptation is an addendum to the original standard ipgds scale with three new subscales: a) ambiguous loss, b) refugee adjustment and impact on grief and c) culturally specific items. the ambiguous loss section will be an extremely valuable measure for refugees and displaced people. ambiguous loss is in­ creasingly found to be a significant source of mental distress for displaced people (boss, 2006). it is defined as the loss of a loved one where death is not confirmed (solheim et al., 2016). until now there have been no validated scales or systematically developed measures to assess ambiguous loss in refugees. renner et al. (2021) found that ambiguous loss is associated with higher levels of depression and prolonged grief. we have built on the preliminary findings from the ipgds-ard to develop a shorter stand-alone scale, the al+ (comtesse et al., 2023). the section refugee adjustment and impact on grief seeks to examine how post migra­ tion experiences may hinder the grieving process as an experience specific to refugees and displaced people. hwang et al. (2008) recommend that cultural and contextual factors are considered in a timely and consistent manner when treatment planning and that this is re-evaluated systematically. this is especially important because many minorities share similar immigration experiences that could be targeted in prevention and treatment programs. indeed, in a study about the impact of migration on illness experience and help-seeking strategies of patients from turkey and bosnia, gilgen et al. (2005) examined explanatory models to investigate how those patients understood their illness and found that refugees attributed some of their migration experiences as causes of their illness. ipgds addendum for refugees and displaced people (ipgds-ard) 18 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ kim et al. (2017) found that traumatic events can impact or diminish the ability to grieve. in their study, participants reported that the psychological sequalae following traumatic events such as torture were more significant and impairing and they saw grief as a less significant problem. the ipgds-ard provides clinicians and patients with concrete questions that may help unpick the source of distress and guide further assessment and tailor treatment planning towards grief interventions or towards resource building and support for post migration living stress. it is important to note that these three new scales should be used in addition to the standard ipgds scale if a diagnosis is sought. only the standard ipgds scale based on the icd-11 pgd items can be used to confirm a diagnosis. the 3 scales in this new addendum can then be used to guide clinicians to assess and explore other grief related areas of possible concern and distress in refugee groups. limitations there are several limitations in this study. first, the small sample sizes for the focus groups and cognitive interviews indicate that our results should be considered a prelimi­ nary examination. a follow up study is underway to examine the psychometric validity of these new subscales in a larger bereaved refugee sample. in addition, the sample did not include a clinical sample of patients with a confirmed diagnosis of pgd. additional testing is needed to confirm the validity in a clinical sample of bereaved refugees with pgd. further adaptations may be necessary to ensure the clinical utility of the subscales for different refugee groups. at the moment there are several items in the subscales which increase the administration time. further reduction and refinement of the items may be required to improve the clinical utility. the analysis of percentage of change after each adaptation step may be biased as the participants in the ci may be hesitant to express criticism to the research team. as a next step it will be vital to further refine the addendum items through patient and clinician debriefing and to examine clinical decision making and rates of pgd diagnosis with and without the support of the addendum (see the method in lewis-fernández et al., 2017). conclusions and future directions in this study, clinicians carefully and thoughtfully described the difficulties they some­ times experience providing accurate culturally reliable assessment and treatment for patients from different cultural backgrounds with a particular focus of bereaved arabicspeaking refugees. they particularly emphasized the difficulty in assessing and treating pgd in refugees as patients often present with a myriad of symptoms and stressors. the ipgds for refugees, along with the newly developed subscales (ipgds-ard) were presented to assess pgd and grief experiences more wholistically in arabic-speaking refugees and with the aim to support other displaced people in the future. the new killikelly, reymond, aeschlimann et al. 19 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ ipgds-ard will help clinicians diagnose pgd with the standard scale as well as assess the importance and relevance of possible overlapping or co-occurring stressors such as post migration difficulties or ambiguous loss. due to the challenges with clinical utility including the large number of items, we recommend using a formulation approach to develop a symptom map of the most distressing and clinically relevant symptoms highlighted through both the standard ipgds scale and the addendum. an example formulation is included in appendix 2 (see killikelly et al., 2025s). additionally, the newly developed and tested ambiguous loss inventory + would directly assess the loss of missing loved ones (comtesse et al., 2023). clinicians will then be able to direct treatment to appropriate evidence-based interventions. funding: swiss national science foundation (snf): mobility fellowship p400ps_191001. acknowledgments: we would like to thank our participants for their time and effort in completing the interviews. competing interests: the authors have declared that no competing interests exist. ethics statement: the authors assert that all procedures contributing to this work and the process of informed consent comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the helsinki declaration of 1975, as revised in 2008. ethical approval was obtained from the university of zurich, faculty of arts and sciences (grant no. 19.10.4.). reporting guidelines: reporting standards for quantitative research in psychology: the apa publications and communications board task force report. preregistration: the study was not preregistered. related versions: this manuscript is based on the master’s thesis of ar: reymond, a. (2020). development and preliminary testing of the international prolonged grief disorder scale for refugees [unpublished master’s thesis, university of zurich, department of psychology]. data availability: data are available upon request. supplementary materials the supplementary materials contain the online appendices for the study (see killikelly et al., 2025s): • appendix 1. summary of questionnaire changes after each step, resulting in the addendum for refugees and displaced people (ipgds-ard): here we present the process of item reduction and generation resulting in the final version of the addendum. • appendix 2. sample formulation template for assessing grief in displaced people: here we present a template formulation for considering treatment planning for working with grief and displaced people. ipgds addendum for refugees and displaced people (ipgds-ard) 20 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://www.psychopen.eu/ index of supplementary materials killikelly, c., reymond, a., aeschlimann, a., maercker, a., & heim, e. 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(2019). process of translation and adaptation of instruments. https://terrance.who.int/mediacentre/data/whodas/guidelines/ whodas%202.0%20translation%20guidelines.pdf clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. ipgds addendum for refugees and displaced people (ipgds-ard) 24 clinical psychology in europe 2025, vol. 7(1), article e11435 https://doi.org/10.32872/cpe.11435 https://doi.org/10.3390/ijerph18083865 https://doi.org/10.1037/14498-010 https://doi.org/10.1016/j.jad.2021.03.058 https://doi.org/10.1111/famp.12130 https://doi.org/10.1159/000505074 http://www.unhcr.org/figures-at-a-glance.html https://doi.org/10.1097/nmd.0b013e31824cc458 https://doi.org/10.4300/jgme-d-13-00154.1 https://terrance.who.int/mediacentre/data/whodas/guidelines/whodas%202.0%20translation%20guidelines.pdf https://terrance.who.int/mediacentre/data/whodas/guidelines/whodas%202.0%20translation%20guidelines.pdf https://www.psychopen.eu/ ipgds addendum for refugees and displaced people (ipgds-ard) (introduction) augmentation of the ipgds for arabic-speaking refugees method procedure recruitment and participants analyses results focus groups cognitive interviewing: preliminary content validity discussion limitations conclusions and future directions (additional information) funding acknowledgments competing interests ethics statement reporting guidelines preregistration related versions data availability supplementary materials references make a wish – what are the wishes for clinical psychology and psychological treatment? editorial make a wish – what are the wishes for clinical psychology and psychological treatment? winfried rief 1 , cornelia weise 1 [1] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2021, vol. 3(4), article e7957, https://doi.org/10.32872/cpe.7957 published (vor): 2021-12-23 corresponding author: cornelia weise, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, gutenbergstrasse 18, 35032 marburg, germany. e-mail: weise@unimarburg.de it's the end of the year – and we look back to an enormously challenging year. we went through several restrictions in our professional and private lives, we adapted study programs to legal regulations on behaviour during the pandemic, we missed the direct personal contacts which in the past used to be so essential to find solutions during debates, and we saw things during zoom conferences that we didn’t want to see. our society is experiencing a deep and bitter division that is challenging psychology more than it has in a long time. it is quite understandable that people are annoyed, and have lost the motivation to reflect on the current situation. but still, it's also the time of the year that stands for dreams and wishes. a world without dreams and hopes and wishes is something we would not want to imagine. to exile such a nightmare, we needed an optimistic outlook which can bring us safely through the year 2022. therefore, we from cpe encouraged the members of our editorial board to take the time to express some of their wishes. and this is what came back: a new vaccination shot, filled with positive ideas, with perspectives and demands to our professional competences, with visions we would like to follow, and lots of optimism. the wishes show the strength of our collaboration to bring clinical psychology and psychological treatments forward for the benefit of the people. but, read yourself: in every european country psychological therapies are less available than they should be. a lesson from the english iapt programme is that politicians will invest more in therapy if we collect and report outcome data in our routine services. such data shows our value, our focus on patient benefit, and our openness to learning. my new this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7957&domain=pdf&date_stamp=2021-12-23 https://orcid.org/0000-0002-7019-2250 https://orcid.org/0000-0001-5216-1031 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ year wish is that clinical psychologists will once again lead the field in mental health by showing that we as a group embrace outcome monitoring. other professionals and funding will follow our leadership. (david clark, uk) that psychological treatments and all the strategies for care already available in clinical psychology reach everyone in need. (christina botella, spain) christmas time makes people focus more than usual on other people's needs, joys and concerns. as clinical psychologists, we are sensitive to the needs of our patients and clients, regardless of the season. may this attitude of listening and openness accompany our work, so that we can accompany those who ask for our professional help. (roman cieślak, poland) a significant portion of research in clinical psychology is unusable because of incomplete or poor reporting. descriptions of interven­ tions, particularly complex, psychosocial ones, are often sketchy and just reference a manual. my wish is that clinical research is reported more completely, by actually following (not just declaring to have followed) available reporting guidelines. (ioana a. cristea, italy/ usa) actually, i have a dozen wishes for clinical psychology, some for our patients or clients, others for ourselves. here's one: that in the bitter dispute between covid vaccine supporters and opponents, we can pro­ vide empathic communication strategies that both increase willingness to vaccinate and diminish the rifts between supporters and opponents. who, if not us, should provide such helpful interventions to the rest of society? (andreas maercker, switzerland) i wish that the awareness, at all levels of our society, of the core value of mental health during the covid crisis does not disappear once it is over. i also want european countries to invest heavily in research (which will then undoubtedly be published in the excellent cpe ;-) and in the implementation of prevention and intervention programmes to improve mental health that are accessible to all people living on european soil. (céline douilliez, belgium) a more widespread use of clinimetric strategies in psychological assess­ ment. (giovanni a. fava, usa/italy) editorial 2 clinical psychology in europe 2021, vol. 3(4), article e7957 https://doi.org/10.32872/cpe.7957 https://www.psychopen.eu/ particularly in current times that challenge mental health, i wish all european clinical psychologists loads of resilience, strength, wisdom and self-care. in my own country (belgium), clinical psychology is facing several important legislative and organisational transitions. i wish that once this phase of uncertainty and burden has passed, clinical psychology will find itself in a renewed and stronger posi­ tion to the benefit of our clients. (dirk hermans, belgium) my wish for 2022 is to be dancing with you all at conference parties again! (tania lincoln, germany) romanian wish for clinical psychology: day by day, in many ways, be more and more personalized, high-tech, and evidence-based, for the sake of people's wellbeing! (daniel david, romania) the role of clinical psychology is not evenly distributed in europe and not even within countries. given modern information technology it is technically easy to deliver treatments across borders. however, legal and administrative issues make it hard and sometimes even impossible to share treatments and do research. my wish is that we increase collaboration between countries and reduce administrative burden to facilitate spread of evidence-based treatments within europe. (gerhard andersson, sweden) may clinical psychology continue to flourish in the year 2022, contribute to an understanding of the basic processes of the devel­ opment of psychopathology and the principles of change in the treatment of psychological disorders (and help to overcome the pan­ demic!). (bernhard strauss, germany) i wish that we develop clear and agreed upon competencies of clinical psychologists that would help our profession and training of the next generation of clinical psychologists. (maria karekla, cyprus) i would like santa to become a spiritual member of the cpe team to help us make inter-european networking in the field of clinical psychology even more vibrant, to keep our fire of curiosity burning, and to remind us of the importance of bringing hope and light to those who need us. (robert masten, slowenia) wishing happy, healthy and peaceful lives for all. may we feel connec­ ted with our hearts and one another, during the holidays and through­ out the new year 2022! (jolanda meeuwissen, the netherlands) rief & weise 3 clinical psychology in europe 2021, vol. 3(4), article e7957 https://doi.org/10.32872/cpe.7957 https://www.psychopen.eu/ i wish more kindness in this world because we are all part of the same beautiful miracle. love, peace, and compassion. (stefan hof­ mann, germany/usa) 2022, please give us healthy clinical psychologists for research and practice in europe and around the world. (anonymous) personally, i have only the wish for "more time" (we need two more hours per day and an extra free day per week). professional­ ly, i wish: more collaboration [national, international (european)] in large scale studies; more research on moderators of treatment outcome in different groups of disorders; more research on media­ tors (mechanism) of change using psychological and biological basic science results; more support and funding for young (female) scien­ tists; more replication studies; less egoism and competition; and again, more personal meetings. (martin hautzinger, germany) what a time we have all had! i’d like to wish all of you and your families and friends in europe as well as further afield a restful time over the coming weeks, so that we can embrace 2022 with renewed energy. carpe diem. (trudie chalder, uk) i wish us all much inspiration in 2022 in generating new ideas to improve the impact of treatments for mental disorders, because that is what people suffering from these conditions very much need. (pim cuijpers, the netherlands) i wish for clinical psychology research to rapidly develop and empiri­ cally validate even better treatments for those with co-morbid chronic physical conditions – and for these to be recognized and implemented by national health care systems. (claus vögele, luxembourg) i send out a wholehearted thanks to all the psychological therapists who have managed to support and help people in mental health need by delivering treatments online or in person, whilst they them­ selves have often had challenges in their own lives and at home. my wish for 2022 is that clinical psychology can be at the forefront of preventing mental health problems across europe and beyond. (colette hirsch, uk) i wish clinical psychology in europe (and beyond) a contagious opti­ mism and resilience in 2022. (omer van den bergh, belgium) editorial 4 clinical psychology in europe 2021, vol. 3(4), article e7957 https://doi.org/10.32872/cpe.7957 https://www.psychopen.eu/ i wish you all merry christmas with, hopefully, some face-to-face gatherings with your loved ones. (claudi bockting, president of the eaclipt) now it’s your turn: take a minute and express your wish for your professional engage­ ment during the year 2022. finally to us: for 2022, we wish that our journal will again receive as much support as this year, be it from authors, reviewers, editors, readers, and the excellent team of our publisher psychopen, so that we can continue to strengthen the visibility of the many facets of clinical psychology in europe. as editors-in-chief of clinical psychology in europe, we promise to address all your and our wishes to the corresponding institution (see photo). we wish you a happy holiday season and a peaceful and prosperous new year. winfried rief & cornelia weise acknowledgments: the authors wish to thank all members of the editorial board of clinical psychology in europe for expressing their wishes for 2022. rief & weise 5 clinical psychology in europe 2021, vol. 3(4), article e7957 https://doi.org/10.32872/cpe.7957 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. editorial 6 clinical psychology in europe 2021, vol. 3(4), article e7957 https://doi.org/10.32872/cpe.7957 https://www.psychopen.eu/ the influence of alcohol on rumination and metacognitions in major depressive disorder research articles the influence of alcohol on rumination and metacognitions in major depressive disorder lana gawron 1 , anna pohl 1 , alexander l. gerlach 1 [1] institute of clinical psychology and psychotherapy, university of cologne, cologne, germany. clinical psychology in europe, 2022, vol. 4(4), article e5615, https://doi.org/10.32872/cpe.5615 received: 2021-01-30 • accepted: 2022-09-16 • published (vor): 2022-12-22 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: lana gawron, institute of clinical psychology and psychotherapy, pohligstraße 1, 50969 cologne, germany. e-mail: lana.gawron@uni-koeln.de supplementary materials: materials [see index of supplementary materials] abstract background and objectives: comorbidity between major depressive disorder (mdd) and alcohol use disorder (aud) is highly prevalent but reasons for this association are unclear. rumination may activate metacognitive beliefs that contribute to the development and maintenance of rumination and depression. negative metacognitions can further lead to other dysfunctional coping strategies (i.e., consumption of alcohol). we examined whether alcohol reduces (state) metacognitions, rumination and other disorder-specific processes in a group of individuals suffering from mdd. method: in an experiment with three randomized conditions we investigated whether the consumption of alcohol, placebo or no alcohol (orange juice) affects (meta-)cognitions, depressive symptoms and / or psychophysiological variables while participants ruminate. results: voluntary rumination increased self-reported sadness, tension and rumination, tensed facial muscles and increased heart rate, but did not affect (state) metacognitions and heart rate variability. the consumption of alcohol did not influence rumination, metacognitions, depressive or psychophysiological measures. limitations: we recruited a depressed population but excluded pathological alcohol use due to ethical considerations. conclusions: we found no evidence that alcohol consumption affects rumination, metacognitions and other disorder-specific processes in mdd. however, rumination had a negative effect on various depression-specific processes, although it did not activate (negative state) metacognitions. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5615&domain=pdf&date_stamp=2022-12-22 https://orcid.org/0000-0003-2664-5280 https://orcid.org/0000-0002-3761-5768 https://orcid.org/0000-0001-6794-5349 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords major depressive disorder, rumination, metacognitions, alcohol consumption, self-medication, alcohol use disorder highlights • the effect of alcohol on (meta-)cognitions, emotions, and psychophysiology was investigated with alcohol, placebo and a control group in mdd. • no group differences were found both before and after alcohol consumption. • induced rumination did not activate (state) metacognitions, but affected various depression-specific processes. • future studies could activate metacognitions by providing false feedback about the controllability of such processes. rumination, the repetitive negative thinking about past events, possible causes and consequences of negative emotions (nolen-hoeksema, 1991), contributes to the develop­ ment (e.g., huffziger et al., 2009) as well as maintenance and severity of depressive episodes (e.g., nolen-hoeksema et al., 2008). moreover, rumination has negative effects on somatic health, as illustrated by a number of psychophysiological changes such as decreased heart rate variability (hrv; e.g., ottaviani et al., 2015), increased heart rates (hr; ottaviani et al., 2016) and changes in muscular tension, e.g., in the corrugator emg (teasdale & rezin, 1978). according to the metacognitive model of rumination and depression (mcm), rumina­ tion is maintained by metacognitions reflecting on this type of perseverative thinking (papageorgiou & wells, 2003). negative thoughts or other triggers initially activate positive metacognitive beliefs about the usefulness of rumination (e.g., “in order to understand my feelings of depression, i need to ruminate about my problems.”), and mo­ tivate further rumination. however, rumination prevents effective problem solving and intensifies negative affect. as a result, negative metacognitive beliefs emerge regarding the uncontrollability and harmfulness of rumination and its social consequences (e.g., “i cannot stop myself from ruminating.”; “people will reject me if i ruminate.”), thereby in­ creasing the accessibility of negative and threatening information (e.g., negative thoughts or emotions), and thus exacerbating and maintaining depressive symptoms as well as promoting further rumination (papageorgiou & wells, 2004). both, clinical (e.g., papageorgiou & wells, 2003) and nonclinical studies (e.g., solem et al., 2016) have shown that metacognitive beliefs about rumination are significant for the onset (faissner et al., 2018; papageorgiou & wells, 2009) and maintenance (e.g., solem et al., 2016) of depressive states / depression. negative metacognitions may also promote the use of dysfunctional behavioral strat­ egies, such as the use of alcohol, to control or avoid recurrent negative thoughts. in the long term, however, these strategies may maintain negative metacognitions (cf. meta­ the influence of alcohol on cognitions in mdd 2 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ cognitive model of generalized anxiety disorder; wells, 2005; wells, 2011). although the mcm of generalized anxiety disorder focuses on worry and meta-worry, we assume that the assumptions regarding the use of other coping strategies can also be applied to the mcm for depression and rumination. thus, we take a step beyond the original model by postulating that alcohol use functions as a cross-model coping strategy that can reduce rumination (see, e.g., mollaahmetoglu et al., 2021) and possibly negative metacognitions (in the short term), making these thoughts and processes seem less uncontrollable and threatening. according to the appraisal disruption model, alcohol can disrupt the appraisal of threatening information (i.e., cognitions; sayette, 1993). more specifically, alcohol may interfere with the initial perception of stressful information by preventing negative memories and associated stressful concepts from being activated. moreover, cognitive abstraction capacity is supposed to be reduced by alcohol (sayette, 1993), which may also impede perseverative thinking and related metacognitions. finally, when intoxication precedes a stressor, it can buffer the stress by attenuating appraisal, thereby protecting the person drinking from fully experiencing the stressor (sayette, 2017). applied to the context here, negative thoughts and processes promoted by metacognitions can also be defined as a type of threatening information whose appraisal can be attenuated by alcohol consumption. furthermore, intoxication could prevent concepts associated with negative metacognitions, such as ruminative thoughts, from being activated, possibly leading to relief in terms of less threatening rumination or generally less aversive emo­ tional states. since this dysfunctional coping strategy is only helpful in the short term, alcohol may be consumed repeatedly in order to feel a facilitating effect (negative rein­ forcement). this could then lead to the development of a problematic drinking pattern or an alcohol use disorder (aud). empirical evidence suggests that these negative metacognitions are in particular associated with problematic alcohol use (e.g., spada et al., 2007). the higher the levels of maladaptive metacognitions are, the more likely alcohol is consumed in response to unpleasant aversive states (moneta, 2011). in line with this, rumination is associated with alcohol consumption (e.g., devynck et al., 2019) and with increased alcohol-related problems (e.g., willem et al., 2011). in a group of individuals with risky consumption, the direct effects of alcohol on rumination and mood were examined and it was found that alcohol reduced rumination directly and also indirectly by changing mood (mollaahmetoglu et al., 2021). apart from the study of mollaahmetoglu et al. (2021), most empirical evidence for the association of rumination, depressed mood and alcohol use (disorder) is correlative (e.g., heggeness et al., 2019). moreover, these relationships have mostly been examined in analogue samples (e.g., bravo et al., 2018), and metacognitions have been assessed as a trait variable (e.g., faissner et al., 2018; papageorgiou & wells, 2009). however, it has been argued that mimicking typical problematic situations may also provoke the gawron, pohl, & gerlach 3 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ presence of state-dependent metacognitive beliefs about perseverative cognitions as well as their consequences, especially in clinical populations (andor et al., 2008). consistent with this, negative metacognitions following worrying, so negative state metacognitions, were more pronounced in patients with generalized anxiety disorder compared with control participants when they received feedback that indicated arousal while being asked to relax (andor et al., 2008). in light of previous findings, we believe it is important to examine the direct effects of alcohol consumption on perseverative cognitions, such as rumination, and negative state metacognitions in an experimental setting: indeed, if it is shown that people with depression can alter cognitive processes with the help of alcohol, this could provide a significant clue to the mechanisms underlying the high comorbidity of major depressive disorder (mdd) and aud (e.g., brière et al., 2014), with, for example, odds ratios between 2.0 (kessler et al., 1997) and 3.8 (grant & harford, 1995). namely, depression-related cognitive / ruminative and metacognitive processes that appear uncontrollable and threatening may erroneously appear controllable and less threatening after alcohol consumption, which may be relieving in the short term, thus promoting further consumption and the development of aud. to our knowledge, no study has yet examined the direct effects of alcohol on neg­ ative (meta)cognitions and depression in a clinically depressed sample. our aim was therefore to examine these effects on rumination and metacognition in mdd. we specif­ ically focused on (negative) state metacognitions (cf. andor et al., 2008). the negative appraisal of these state metacognitions may be interrupted by alcohol consumption and consequently appear less threatening (cf. sayette, 1993). for a holistic understanding of the effects of alcohol on disorder-specific processes, we also wanted to investigate the influence of alcohol on emotional states and psychophysiology (heart rate, heart rate variability, muscle tension). according to some studies, alcohol can lead to an increase in heart rate (weise et al., 1986), a reduction in hrv (koskinen et al., 1994), and a decrease in muscle tension (stockwell et al., 1982). our hypotheses were as follows: given that rumination has an unfavorable impact on negative affect and psychophysiology (see, e.g., ottaviani et al., 2016), we hypothesized that (h1) induced rumination has a negative effect on sadness, tension, and on the extent of rumination itself, as well as on psychophysiological processes. we also hypothesized that (h2) alcohol consumption reduces rumination, (h3) alcohol consumption reduces negative state metacognitions about rumination that, according to the mcm of rumi­ nation and depression, should be triggered by induced rumination, and (h4) alcohol consumption reduces negative emotions such as sadness and experienced muscle tension intensified by rumination. finally, in addition to rumination, alcohol consumption may also affect psychophysiology, although the direction of the effect in mdd is still unclear. we assumed an increase in hr and a decrease in hrv and muscle tension in individuals with depression (h5). the influence of alcohol on cognitions in mdd 4 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ method recruitment participants were recruited online (e.g., via facebook), with publicly distributed leaflets, posters and at the outpatient treatment center for psychotherapy. all participants re­ ceived a compensation of 8.50 euros per hour and were offered counselling. exclusion criteria were current or past substance use disorder or aud, complete abstinence of alcohol, gad, current use of psychoactive medication, liver damage, current or past psy­ chotic episodes, and pregnancy. gad was excluded to ensure that the main problem with repetitive negative content was rumination and not worrying. all participants signed an informed consent. the ethics committee of the german psychological association approved this study (ss 042017). participants sixty-five participants (46 women) diagnosed with current mdd using a structured clinical interview (see procedure) completed the study. thirty-nine participants (40.5%) were diagnosed with additional comorbid disorders. twenty-seven suffered from anxiety disorders (41.5%), ten from posttraumatic stress disorder (15.4%), three from obsessive compulsive disorder (4.6%), three from an eating disorder (4.6%), and five from somat­ ic symptom disorders (7.7%). sociodemographic data is presented in table 1. further characteristics can be found in table a1 (supplementary materials). power analyses according to g*power 3 (faul et al., 2007) indicated a required sample size of at least 54 participants, expecting a medium effect size f = .25 for the analysis of a repeated measures anova (within-between interaction) at an alpha level of .05 and 95% power (cf. andor et al., 2008; stevens et al., 2017). procedure participants were telephone screened and then received information about the experi­ ment. they had to agree to participate in the study irrespective of whether they would receive alcohol or not. participants with depressive symptoms were invited for a 2 h diagnostic session using the german version of the structured clinical interview for the diagnostic and statistical manual of mental disorders, 4th version (scid-i; wittchen et al., 1997). a trained clinical psychologist conducted the interviews. participants with mdd then completed several questionnaires (see baseline questionnaires) and were invi­ ted for a laboratory session. at this point, participants were fully randomized to three conditions (see drinking procedure). at the beginning of the laboratory session, electro­ des for physiological measurement were attached and participants estimated their blood alcohol level (bal). then the bal was measured. a three-minute resting period (first baseline) and an additional three-minute task (schandry, 1981) followed, which will not gawron, pohl, & gerlach 5 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ be reported here. then, a drinking phase of 15 minutes drinking and a five-minute break allowing for absorption of the alcohol followed. participants again estimated their bal and it was also measured. after a second three-minute resting period (second baseline), participants estimated their level of rumination, sadness and tension, and completed the state metacognitions questionnaire (mcq-state; andor et al., 2008). the rumination induction procedure (a variant of the worry induction procedure; borkovec & inz, 1990) followed. participants were asked to write down three topics they regularly ruminated about and were to choose the currently most troubling one. they were then instructed to ruminate about this topic “like they normally did”. after ruminating for three minutes (rumination episode), participants reported their rumination, sadness and tension again table 1 demographic data of all participants separated by group variable ac (n = 22) pc (n = 22) oc (n = 21) mean age (sd) 33.6 (11.5) 30.2 (11.8) 30.7 (12.9) sex, n (%) women 15 (68.2) 16 (72.7) 15 (71.4) men 7 (31.8) 6 (27.3) 6 (28.6) education, n (%) o level 4 (18.2) 16 (72.7) 1 (4.8) specialized a level 1 (4.5) 3 (13.6) 6 (23.8) a level 15 (68.2) 3 (13.6) 15 (71.4) still attending school 2 (9.1) – – family status, n (%) unmarried 17 (77.3) 20 (90.9) 17 (81.0) married – living together 1 (4.5) 1 (4.5) 3 (14.3) divorced 3 (13.6) 1 (4.5) – registered civil partners – – 1 (4.8) widowed 1 (4.5) – – treatment, n (%) current outpatient treatment 4 (18.2) 2 (9.1) 4 (19.0) past outpatient treatment 16 (72.7) 15 (68.2) 12 (57.1) past psychiatric inpatient treatment 7 (31.8) 7 (31.8) 5 (23.9) past antidepressant medication 5 (22.6) 7 (31.8) 8 (38.1) note. ac = alcohol condition; pc = placebo condition; oc = control / orange juice condition. o level = ordinary level high school certificate; a level = advanced level high school certificate. the groups did not differ significantly. the influence of alcohol on cognitions in mdd 6 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ and completed the mcq-state. they were instructed to ruminate for another minute and then asked to relax for three minutes (relaxation episode). following the relaxation, participants completed the self-reports and mcq-state a third time as well as the wbsi, tcq-r and cas-i (see questionnaires used during the experiment). in the end, they estimated their bal and the bal was measured one last time. after the experiment, participants were debriefed. the procedure is visualized in figure 1. figure 1 procedure note. timing and overview of the two sessions. the blood alcohol level (bal) was measured at the beginning, after the phase of drinking and at the end of the experiment. self-reports (sr) and mcq-state were assessed at three time points: before rumination, after rumination and after relaxation. an overview of all baseline questionnaires and all questionnaires used during the experiment can be found in section measurements. ac = alcohol condition (n = 22); pc = placebo condition (n = 22); oc = control condition / orange juice (n = 21). bals = participants' estimated bal before each measurement of bal; bal-m = measured breath alcohol level. sr = self-reports, i.e., estimated levels of sadness, rumination, and tension. mcq-state = two subscales of the metacognitions questionnaire, german version. hr = heart rate; hrv = heart rate variability; emg = facial electromyography. gawron, pohl, & gerlach 7 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ drinking procedure all participants were asked to eat a light meal, specified in a handout, four hours prior to the experiment and to forego food and drinks containing caffeine from then on. they were requested to abstain from alcohol 24 hours prior to the experiment. participants in the control condition (oc) were told that they would receive orange juice. participants in the alcohol (ac) and placebo condition (pc) were both given the information that they would receive alcohol and that they would have to be picked up or wait until their bal decreased below 0.3 ‰. all participants were tested at 4:00 pm. female participants in the ac or pc were pregnancy tested. none of the participants tested positive. finally, height and weight were measured. participants in the ac consumed a drink of 1:2 vodka and orange juice. following a modified version of the widmark formula, participant’s sex, weight, height and age was used to estimate the necessary amount of alcohol to reach a blood alcohol level of about 0.6 ‰ (gerlach et al., 2006). the nonalcoholic beverage in the oc and pc was orange juice in comparable drinking quantity. in the pc, immediately before serving the beverages, a few milliliters of vodka were dropped on the orange juice and applied along the rims using a pipette (stevens et al., 2014). participants received three glasses with equal amounts of chilled beverage, each to be finished within five minutes. after drinking, participants waited five minutes. breath alcohol concentration was assessed by breathalyzer with an accuracy of +/ 0.03 mg/l (dräger, alcotest, 7410 plus). in the pc, the first measurement used a standard breathalyzer to ensure a bal of zero. then, a rigged breathalyzer with identical built was used giving a false feedback of 0.6 ‰ and then 0.7 ‰ bal. measurements baseline questionnaires alcohol use disorder identification test (audit) — the audit (dybek et al., 2006) is a brief screening scale developed by the world health organization (who) for early detection of problematic drinking. the original as well as the german version includes 10 questions regarding alcohol consumption, dependency symptoms and alcohol related problems. for each question, one of five statements related to alcohol use in the past year can be selected on a 5-point likert-type scale ranging from 0 (“never”) to 4 (e.g., “daily or almost daily”). cronbach’s α = .76. simplified beck depression inventory (bdi-s) — the bdi-s (schmitt et al., 2003) assesses current depressive symptoms with 20 items on a 6-point likert-type scale ranging from 0 (“never”) to 5 (“almost always”), for example, “i feel sad.”. cronbach’s α = .87. the influence of alcohol on cognitions in mdd 8 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ metacognitions questionnaire 30 (mcq-30) — the german version of the mcq-30 (arndt et al., 2011; a shortened version of the original metacognitions questionnaire; cartwright-hatton & wells, 1997) is used to assess thoughts and beliefs (metacognitions) about worry. the questionnaire consists of five subscales (positive worry beliefs, beliefs about uncontrollability and danger, metacognitive efficiency, general negative beliefs, cognitive self-consciousness) assessed by 30 items (e.g., “not being able to control my thoughts is a sign of weakness.”). items/statements can be rated on 5-point likert-type scales ranging from 1 (“not agree”) to 4 (“agree very much”). cronbach’s α = .84. penn state worry questionnaire (pswq) — the german version of the pswq (stöber, 1995) is a 16-item questionnaire assessing intensity, excessiveness and uncon­ trollability of worry (e.g., “i worry all the time.”) on a 5-point likert-type scale ranging from 1 (“not at all typical of me”) to 5 (“very typical of me”). cronbach’s α = .89. response styles questionnaire (rsq) — the german version of the rsq (kühner & weber, 1999) assesses people’s cognitive and behavioral strategies to cope with depressed mood with 32 items on 4-point likert-type scales ranging from 1 (“almost never”) to 4 (“almost always”). the rsq consists of the subscales rumination with 21 items (e.g., “when i am sad, i think about how sad i feel.”) and distraction with 11 items (e.g., “when i am sad, i go to my favorite place to get my mind off my feelings.”). cronbach’s α = .69. questionnaires used during the experiment assessment of state metacognitions (mcq-state) — since state-dependent changes in metacognitions can be assessed using the mcq (cf. andor et al., 2008), two subscales of the mcq-30 (beliefs about uncontrollability and danger, general negative beliefs) were adapted to the experiential situation. an example is “my ruminating could make me go mad.”. cronbach’s α = .97. rumination score (rs) — the levels of sadness, tension and rumination were assessed on one rating scale each, ranging from zero (“absolutely not”) to 100 (“extremely so”) and then averaged. cronbach’s α = .83. white bear suppression inventory (wbsi) — the german version of the wbsi (fehm et al., 2000) measures thought suppression with 15 items (e.g., “there are things i prefer not to think about.”) on a 5-point likert-type scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). cronbach’s α = .85. thought control questionnaire (tcq) — the german version of the tcq (fehm & hoyer, 2004) is a 30-item self-report measure assessing rumination, intrusive and unwanted thoughts. items can be rated on 4-point likert-type scales ranging from 1 (“never”) to 4 (“almost always”). cronbach’s α = .67. gawron, pohl, & gerlach 9 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ cognitive attentional syndrome-inventory (cas-i) — the german version of the cas-i (wells, 2011) assesses maladaptive coping strategies (e.g., worrying, avoidance, use of alcohol/drugs) for dealing with negative thoughts, and negative and positive metacog­ nitive beliefs. in total, the cas-i consists of four questions. the first three questions are answered using a scale from 0 (“not at all”) to 8 (“all the time”) and refer to how much dealing with problems or worries about problems was done in the past week and how it was dealt with. the fourth question refers to positive and negative metacognitions, answered using a scale from 0 (“i do not believe in this belief at all.”) to 100 (“i am absolutely convinced that this belief is true.”). cronbach’s α = .75. psychophysiological data recording, sampling and analysis psychophysiological data (heart rate, respiration and facial muscle tension) were recor­ ded using the varioport (becker meditec, karlsruhe, germany). ecg was recorded at 512 hz sample rate from three electrodes. the active electrodes were placed on the lowest left rib and on the right collarbone. ground was affixed to the left collarbone. respiration was assessed with a respiratory belt (128 hz sample rate). facial electromyography (emg) was recorded in mv at 256 hz sample rate over the corrugator supercilii on the left side of the face with two electrodes (tiga-med, germany ltd.). the emg signal was preprocessed using an infinite impulse response high pass filter at 10 hz. it was notch filtered at 50 hz with a width of 3 hz and rectified and smoothed using a two-step low pass filter with eight point moving average. for hrv, the root mean square successive differences (rmssd) was calculated (cf. task force of the european society of cardiology and the north american society of pacing and electrophysiology, 1996; bertsch et al., 2012). mean values were computed for each experimental 3-minute episode (baseline 2, rumination, relaxation). data analysis group differences concerning sociodemographic characteristics and self-reported bal were tested using an anova1 and bonferroni-corrected post-hoc tests. group differ­ ences concerning psychopathological variables (questionnaires) were analyzed using a manova. a pearson correlation was performed between problematic alcohol consump­ tion (audit) and the level of alcohol as a coping strategy (cas-i). to test our hy­ potheses, we conducted several repeated measures anovas2 with bonferroni-corrected post-hoc tests. each anova was analyzed by group (alcohol, placebo, orange juice). 1) initial exploratory analyses revealed a few outliers. however, there was no relevant change in the pattern of results when including vs. excluding outliers. thus, results from the complete data set are reported. deviations from the original data set are indicated in the data analysis (e.g., mcq-state ratings). 2) the assumption of normality (anova) or the equality of variances (repeated measures anovas) was not met. since the f-test is relatively robust for violation of assumption (finch, 2005; tabachnick & fidell, 2007), the anova the influence of alcohol on cognitions in mdd 10 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ to test h1 (rumination increases sadness, tension, rumination, and worsens psycho­ physiology) the measurement time points of all variables from “second baseline” to “rumination” were examined. h2 (alcohol reduces rumination) and h4 (alcohol reduces sadness and tension intensified by rumination) were tested in one model: for this, rs over time were analyzed. to test h3 (alcohol reduces negative state metacognitions), metacognitions ratings (mcq-state) were analyzed. to test h5 (alcohol influences psy­ chophysiology), emg, hr and hrv over time were analyzed. in case sphericity was violated, the greenhouse–geisser adjustment was used. results manipulation check coping strategies the correlation of audit and cas-i was significant (r = .46, p < .001). the most frequently used coping strategy was “to control emotions” (m = 6.0, sd = 2.0), followed by “the attempt not to think about anything” (m = 5.2, sd = 2.2), “to avoid situations” (m = 2.8, sd = 2.5), “to control symptoms” (m = 4.2, sd = 2.2), “to seek reassurance” (m = 3.5, sd = 2.3). the least used strategy was “to consume alcohol or drugs” (m = 2.5, sd = 2.0). self-reported alcohol level and measured blood alcohol level compared to baseline, in both ac and pc self-estimated alcohol levels (in ‰) were higher after drinking (mac = 0.6, sd = 0.2, mpc = 0.2, sd = 0.1) and after finishing the experiment (mac = 0.7, sd = 0.2, mpc = 0.4, sd = 0.2). the manipulation in the pc can be considered successful: 20 of 22 participants believed that they had been given alcohol. two subjects (pcs) were excluded because their self-estimated bal was 0.0 ‰ at all measurement points and then assigned to the control condition for subsequent analyses. in the ac, the measured bal was 0.8 ‰ (sd = 0.2) after the drinking period and 0.7 ‰ (sd = 0.2) at the end of the experiment (see figure 2). and the repeated measures anovas were nevertheless conducted and results reported. because the number of subjects varied across the variables, no repeated measures manova could be calculated for the self-reports or for the biodata. instead, several repeated measures anovas were conducted with bonferroni-corrected post-hoc tests. gawron, pohl, & gerlach 11 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ figure 2 blood alcohol level note. measured and estimated bal. data points represent values before and after the drinking procedure and at the end of the experiment; error bars depict 95% ci. ac = alcohol condition (n = 22); pc = placebo condition (n = 20). bal = measured breath alcohol level in ac; bal-self = participants' estimated bal before each measurement of bal. control condition is not included. rumination induction procedure (h1, h5) self-report: an initial univariate anova revealed no significant group differences in the self-reports (f(2, 62) = .86, p = .427) and mcq-state-ratings3 (f(2, 42) = .26, p = .772) before rumination induction. after rumination, rs were significantly higher (see table 2 and figure 3), whereas mcq-state-ratings did not change (see table 2). psychophysiological measures: an initial univariate anova4 revealed no significant group differences in hr (f(2, 61) = .37, p = .690), hrv (f(2, 61) = 1.46, p = .240) or emg (f(2, 58) = .36, p = .702) before rumination. hr and emg increased significantly with rumination. regarding hrv, there was no significant change in rmssd during rumination or relaxation (see table 2 and figures 4, 5). 3) since the first measuring time of the mcq-ratings was subsequently integrated into the experiment, the repeated measures anova was conducted with only n = 45. 4) regarding emg, three subjects (pc) were excluded from further analyses because they were identified as outliers in at least four of five relevant time intervals. another subject was excluded because the recording of biodata failed. see table a3 (supplementary materials) for an overview of all participants per condition. the influence of alcohol on cognitions in mdd 12 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ figure 3 results over time separated by group: a) rumination score note. data points represent the mean values before, after the rumination induction and after relaxation; error bars depict 95% ci. estimates of depression (sadness, rumination, tension) were rated on a scale from 0 to 100. figure 4 results over time separated by group: b) heart rate note. data points represent the mean values of three time intervals: during second baseline, rumination and relaxation; error bars depict 95% ci. gawron, pohl, & gerlach 13 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ figure 5 results over time separated by group: c) emg note. data points represent the mean values of three time intervals: during second baseline, rumination and relaxation; error bars depict 95% ci. repeated measures anovas (h2-h5) anovas revealed a significant main effect of time for rs (f(1.52, 94.38) = 16.45, p < .001, ηp = .21), hr (f(2, 122) = 14.12, p < .001, ηp = .19), and emg (f(2, 116) = 5.41, p = .006, ηp = .09). from “second baseline” (t1) to “rumination episode” (t2) there was a significant increase in rs, hr and emg. from t2 to “relaxation” (t3) there was a significant decrease in rs (see figure 3). from t2 to t3 there was no significant change in hr and emg (see figures 4, 5). no significant effect for group and no interaction effect for time × group was found in any variable (see table 2 and a2, supplementary materials, for all significant and nonsignificant effects, table a3, supplementary materials for mean values). the influence of alcohol on cognitions in mdd 14 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ table 2 repeated measures anovas results effects / measures f df p ηp2 time rs 16.45 1.52, 94.38 < .001 .21 mcq-state .32 2, 84 ns .01 hr 14.12 2, 122 < .001 .19 hrv 1.57 1.50, 91.26 ns .03 emg 5.41 2, 116 .006 .09 group rs .57 2, 62 ns .02 mcq-state .31 2, 42 ns .02 hr .32 2, 61 ns .01 hrv 1.08 2, 61 ns .03 emg .74 2, 58 ns .03 time × group rs .38 3.05, 94.38 ns .01 mcq-state .15 4, 84 ns .01 hr .56 4, 122 ns .02 hrv 1.69 2.99, 91.26 ns .05 emg .37 4, 116 ns .01 note. rs = rumination score; mcq-state = state version of the metacognitions questionnaire; hr = heart rate, beats per minute (bpm); hrv = heart rate variability, rmssd; emg = facial electromyography, absolute emg values (uv). ns = nonsignificant. discussion we directly studied if alcohol affects disorder-specific processes in individuals suffering from mdd. in particular, we wanted to understand whether and how alcohol affects rumination and state metacognitions about rumination. in addition, we were interested in determining the extent to which rumination negatively affects other disorder-specific processes, such as intensifying sadness, and in terms of the mcm, is associated with negative metacognitions. the rumination induction was successful: self-reported levels for rumination, tension, and sadness increased, as did hr and muscle tension. however, hrv and state metacog­ nitions did not change. we were able to successfully establish a placebo condition (i.e., induce the belief of having consumed alcohol) in almost all participants. in addition, participants who reported higher alcohol consumption were more likely to report using alcohol for coping. yet, alcohol use was the least reported coping strategy for aversive states in our sample. gawron, pohl, & gerlach 15 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ in contrast to our first hypothesis, we did not find an increase in negative state metacognitions after rumination. it is possible that the type and implementation of the rumination induction procedure influenced our result. the procedure was originally developed for the induction of worry (borkovec & inz, 1990). given, however, that worry and rumination are often transdiagnostically conceptualized as two forms of perseverative negative cognitions (e.g., mcevoy et al., 2013), the procedure for inducing rumination should have been sufficient to induce metacognitions about rumination, just as inducing worry was sufficient to induce metacognitions about worry (andor et al., 2008). yet, andor and colleagues (2008) studied individuals with generalized anxiety disorder whose negative (trait) metacognitions are more pronounced than in individuals with mdd (sun et al., 2017). participants in the andor study received false arousal feedback during the relaxation phase, making it more likely to experience worry and relaxation as uncontrollable. in other words, it was directly suggested to the participants in this study that their condition was not controllable. it is likely that both the type of disorder and the type of manipulation influenced the intensification of metacognitions. one approach for future studies might be to examine both state and trait metacognitions in relation to rumination and depressive symptomatology and to directly induce a sense of uncontrollability to participants. however, another consideration against the background of the mcm is conceivable. in the andor study as well as in our experiment, negative metacognitions were measured via two subscales of the mcq-30. these scales assess the uncontrollability and danger of worry (reworded to rumination in our study), but not negative metacognitions with regard to social consequences of rumination, which, in terms of the mcm, are also typical for the perpetuation of depression. after successful induction, we did not find more pronounced metacognitions in terms of uncontrollability and danger, but we might have found changes in terms of metacognitions related to the social consequences of rumination. one way to measure both types of negative metacognitive beliefs about rumination would have been to include the negative beliefs about rumination scale (nbrs; papageorgiou & wells, 2001) in our experiment. in this way, we would have been even closer to the original model and the respective measurement methods (cf. papageorgiou & wells, 2003). also, it is possible that negative metacognitions do not need to be reinforced in certain situations to have a negative effect on perseverative thinking. it may be suffi­ cient that these assumptions exist in the first place to maintain depressive states (e.g., papageorgiou & wells, 2009). if negative (state) metacognitions cannot be intensified even with the use of other experimental procedures, we nonetheless consider it advisable to reassess the long-term effects of negative metacognitions on the development of depression in a vulnerable group of participants. this would allow to further investigate the extent to which negative metacognitions are causal in the development and mainte­ nance of depression. the influence of alcohol on cognitions in mdd 16 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ contrary to our hypotheses (h2-h5), we could neither show that alcohol consump­ tion reduced experienced rumination, sadness, or muscle tension, nor that it reduced state metacognitions about rumination. the three groups did not differ regarding their rs nor in their ratings of metacognitions. there were also no differences between groups in terms of psychophysiological data. alcohol did not change the negative effect of rumination on psychophysiological variables, nor did it increase physiological reactivity. thus, surprisingly, we did not find evidence of alcohol effects on any process potentially relevant for the formation and maintenance of depression. conger (1956) suggested that alcohol may be used because it reduces muscular ten­ sion. however, alcohol did not reduce muscle tension nor change other measures of arousal. whereas conger’s notion can be found in many textbooks, the pharmacological (stress-reducing) effects of alcohol have only rarely been illustrated. according to a review of studies in social anxiety, for example, alcohol expectancy effects were more likely to be responsible for a reduction of aversive states such as anxiety than alcohol’s pharmacological properties (battista et al., 2010). thus, people who consume alcohol and expect a stress and tension-relieving effect, may experience such an effect regardless of pharmacological effects. such positive alcohol expectancies should have been evident in both the ac and pc in comparison to the oc. yet, in both self-reports and emg the numerically highest values (indicating distress) were found in the pc. since conger's hypothesis refers mainly to anxiety-provoking situations, it should be noted that these assumptions may not apply in situations where other emotions, such as depression or sadness, are prominent. or possibly, individuals might assume that alcohol is a helpful strategy, but notice when drinking that the strategy proves unsuccessful. significant positive correlations have previously been found between metacognitions and alcohol consumption as well as between anxiety, depression and alcohol consump­ tion (spada et al., 2007). the consumption of alcohol can therefore be regarded as a conscious strategy for dealing with aversive states (quitkin et al., 1972). in the ac, however, alcohol consumption did not result in feeling less emotionally distressed than in the other two groups. thus, we found no evidence that alcohol consumption reduces rumination, state metacognitions, or sadness in depressed individuals. interestingly, our findings are consistent with those of a recent study on social anxiety, in which alcohol consumption had no attenuating effect on negative (post-event) rumination (hagen et al., 2020), although consumption reduced (social) anxiety (stevens et al., 2014). mollaahmetoglu and colleagues (2021) found that alcohol had an effect on ruminative thoughts and mood at a low dose (about 0.2 mg/l) but not at a high dose (about 0.6 mg/l). it is therefore worth considering whether the desirable effects of alcohol in our study would also have been observed if we had used a lower dose. a promising approach for further studies could be to examine alcohol effects on rumination, metacognitions and depressive mood depending on the dose administered. also, the question arises to what extent the model assumptions on alcohol effects (for a review see sayette, 2017), gawron, pohl, & gerlach 17 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ which were investigated in the context of anxiety (disorders), can be transferred to other disorders and / or other emotional states, such as depression. it should be noted, however, that according to sayette’s model (1993), appraisal disruption is expected only at higher levels of alcohol (i.e., at an amount of alcohol sufficient to cause cognitive im­ pairment), and that we based our hypotheses on this model. nonetheless, if alcohol may not be the usual choice for our participants, e.g., to control unpleasant cognitions, state metacognitions or emotions, it simply may not have this effect in the present sample due to selection bias. in order to ensure that alcohol is a preferred coping strategy, it would have been necessary to pre-screen, for example with the cas-i (wells, 2011). regarding the effects of alcohol consumption on (meta-)cognitive, emotional, and psychophysiological processes and its function in coping with depression, it can be stated that further research is needed to investigate these relationships in more detail. limitations one limitation of our study relates to the sample size, due to which only moderate effects could be detected. however, compared to the results of other clinical studies dealing with the effects of alcohol (e.g., in social anxiety disorder), the sample size we recruited can be considered sufficient (cf. stevens et al., 2017). another limitation relates to our procedure, which can be considered rather exploratory, as the direct effect of alcohol on state metacognitions has not been investigated before and therefore we could only assume that alcohol consumption may prevent negative state metacognitions from being appraised as threatening (cf. sayette, 1993). in addition, it would have been helpful to assess the expected effects of alcohol on rumination or metacognitions before or during the experiment to include trait and actual expectancies of alcoholic effects into statistical analyses. a final limitation relates to the assessment of rumination. here, for example, a rumination-related questionnaire with better psychometric properties may have been more suitable, (e.g., the brief state rumination inventory; marchetti et al., 2018). conclusions to our knowledge, this was the first study to directly examine the association between aud and by assessing the effects of alcohol on rumination and state metacognitions in a sample of clinically depressed individuals. we did not find that alcohol reduced rumination, state metacognitions about rumination, or depressive symptoms. thus, our results suggest that previous models of alcohol effects from the domain of anxiety disorders (e.g., sayette, 1993) may not be easily transferable to the domain of depressive disorders. consistent with the findings of previous studies (see, e.g., nolen-hoeksema et al., 2008; ottaviani et al., 2016), we were able to show that rumination negatively affects disorder-specific processes in mdd. surprisingly, rumination did not elicit negative met­ the influence of alcohol on cognitions in mdd 18 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://www.psychopen.eu/ acognitions about the uncontrollability and danger of rumination, although this would have been expected in terms of the mcm. however, due to the novelty of this research approach, further studies are needed to further test existing models / theories linking depression and alcohol. for example, this could include studies with individuals who drink more and use alcohol more regularly for coping, with a modified paradigm, i.e., with other forms of rumination induction, with manipulated arousal feedback, or with a lower dose of administered alcohol, and / or with other (physiological) measurement methods. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. author note: this study was part of the first author’s doctoral thesis (gawron, 2022), which focused on the function of cognitive processes to explain the association of alcohol (consumption) and depression. supplementary materials the supplementary materials include the descriptive statistics of all questionnaires used, the results of the bonferroni-corrected post-hoc tests for repeated measures anovas, and the means of all measures across the three measurement time points (for access see index of supplementary materials below). index of supplementary materials gawron, l., pohl, a., & gerlach, a. l. 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(1997). scid-i: structured clinical interview for dsm–iv. hogrefe. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. the influence of alcohol on cognitions in mdd 24 clinical psychology in europe 2022, vol. 4(4), article e5615 https://doi.org/10.32872/cpe.5615 https://doi.org/10.1016/j.paid.2010.12.020 https://www.psychopen.eu/ the influence of alcohol on cognitions in mdd (introduction) method recruitment participants procedure drinking procedure measurements psychophysiological data recording, sampling and analysis data analysis results manipulation check repeated measures anovas (h2-h5) discussion limitations conclusions (additional information) funding acknowledgments competing interests author note supplementary materials references blended delivery of imagery rescripting for childhood ptsd: a case study during the covid-19 pandemic research articles blended delivery of imagery rescripting for childhood ptsd: a case study during the covid-19 pandemic nathan bachrach 1,2,3 , sanja giesen 2, arnoud arntz 4 [1] department of medical and clinical psychology, tilburg university, tilburg, the netherlands. [2] ggz oost brabant, boekel, the netherlands. [3] rino zuid, eindhoven, the netherlands. [4] department of clinical psychology, university of amsterdam, amsterdam, the netherlands. clinical psychology in europe, 2022, vol. 4(3), article e7815, https://doi.org/10.32872/cpe.7815 received: 2021-11-12 • accepted: 2022-02-21 • published (vor): 2022-09-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: nathan bachrach, warandelaan 2, 5037 ab tilburg, the netherlands. e-mail: n.bachrach@tilburguniversity.edu abstract background: despite the growing evidence that trauma-focused treatments can be applied as first-line approaches for individuals with childhood trauma-related ptsd (ch-ptsd), many therapists are still reluctant to provide trauma-focused treatments as a first-choice intervention for individuals with ch-ptsd, especially by telehealth. the current manuscript will therefore give an overview of the evidence for the effectiveness of trauma-focused therapies for individuals with chptsd, the delivery of trauma-focused treatments via telehealth, and a case example on how a specific form of trauma focused therapy: imagery rescripting (imrs) can be applied by telehealth. method: this article presents a clinical illustration of a blended telehealth trajectory of imagery rescripting (imrs) ch-ptsd delivered during the covid-19 pandemic. results: the presented case shows that imrs can be safely and effectively performed by telehealth for ch-ptsd, no stabilization phase was needed and only seven sessions were needed to drastically reduce ch-ptsd and depressive symptoms, and to increase quality of life. conclusion: this case report shows the effectiveness of imrs by telehealth for ch-ptsd, which gives hope and additional possibilities to reach out to patients with ch-ptds. telehealth treatment might have some of advantages for specific patients, especially, but certainly not only, during the pandemic. keywords imagery rescripting, ptsd, telehealth, childhood trauma-related ptsd this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7815&domain=pdf&date_stamp=2022-09-30 https://orcid.org/0000-0002-0746-2692 https://orcid.org/0000-0002-7992-2272 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • imrs is an effective and highly acceptable procedure for both patients as therapists and seems a very good option for treating ch-ptsd effectively. • in the presented case only seven sessions were needed to reduce ch-ptsd and depressive symptoms drastically, and increase quality of life. • the delivery of imrs by telehealth did not have a negative impact on the effectiveness, quality and patient satisfaction; which is in line with systematic reviews on effectiveness of psychological telehealth treatments for ptsd (not imrs and not specifically ch-ptsd). meta-analytic reviews and practice guidelines recommend trauma-focused cognitive behavior therapy (tf-cbt) and eye movement desensitization and reprocessing (emdr) as first-line treatments for ptsd (lewis et al., 2020). despite the growing evidence that trauma-focused treatments can be applied as first-line approaches for individuals with childhood trauma-related ptsd (ch-ptsd), many therapists are still reluctant to provide trauma-focused treatments as a first-choice intervention for individ­ uals with ch-ptsd, especially by telehealth (wild et al., 2020). the current manuscript will therefore give an overview of the evidence for the effectiveness of trauma-focused therapies for individuals with ch-ptsd, the delivery of trauma-focused treatments via telehealth, and a case example on how a specific form of trauma focused therapy: imagery rescripting (imrs) can be applied by telehealth. individuals with ch-ptsd are characterized by more complex ptsd symptoms, such as emotional regulation problems, interpersonal difficulties and impaired self-concept (ehring et al., 2014; messman-moore & bhuptani, 2017). there is a limited number of studies investigating trauma-focused treatment among ch-ptsd patients (ehring et al., 2014). a meta-analysis of psychological treatments for ch-ptsd (ehring et al., 2014) found evidence that patients with ch-ptsd can be treated safely with trauma-focused therapies, and that these treatments are effective (moderate to high effect sizes) in reducing ptsd symptoms as well as related symptoms, such as depression, anxiety and dissociation. furthermore, recent randomized controlled studies show that direct applications of trauma-focused therapies such as prolonged exposure, emdr, and image­ ry rescripting are very effective and can be performed safely with ch-ptsd patients (boterhoven de haan et al., 2020; oprel et al., 2021). these studies found large effect sizes for reducing ptsd symptoms as well as other symptoms such as depression, dissociation and trauma related cognitions with trauma-focused treatments in ch-ptsd patients, with notably low dropout rates (7%) for emdr and imrs compared to prolonged expo­ sure and intensified prolonged exposure (27% and 29%) and low rates of serious adverse events (boterhoven de haan et al., 2020; oprel et al., 2021). imrs as a stand-alone treatment for ch-ptsd has been studied far less compared to other first line ptsd treatments such as emdr, prolonged exposure, cognitive process­ blended delivery of imrs 2 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ ing therapy and tf-cbt. recent findings show that imrs is a very effective procedure and is highly acceptable for both patients as therapists (boterhoven de haan et al., 2020; boterhoven de haan et al., 2021; morina et al., 2017; raabe et al., 2015). very large treat­ ment effects on the clinician administered ptsd scale for dsm-5 between baseline and one-year follow-up (i.e., pre-post d = 2.26 for imrs and d = 1.88 for emdr) were found in a recent rct in which emdr was compared to imrs. moreover, the drop-out rates were low, at 7.7%, suggesting that the treatments were well tolerated by participants (boterhoven de haan et al., 2020). no differences in effectiveness and dropout between emdr and imrs for ch-ptsd, were found. however, imrs was superior for those with comorbid depression, which is highly prevalent in ptsd patients (70% in the irem sample) (assmann et al., 2021). to date, cost effectiveness studies in imrs have not yet been performed. imrs might be potentially more cost-effective than emdr, because of lower training costs and shorter sessions (60 vs 90 minutes). it is also still not clear how session frequency impacts the effectiveness of ptsd treatments, whether treatment type moderates the frequency effect, and which treatment type and frequency works best for which patient (wibbelink et al., 2021). imrs uses a different method compared to prolonged exposure and emdr, therefore, imrs might additionally work for patients who do not benefit from other ptsd treatments. research shows that imrs compared to prolonged exposure leads to less dropout (arntz et al., 2007) is experienced as less distressing (siegesleitner et al., 2019) and is more effective regarding anger control, hostility and guilt. imrs might therefore be indicated especially for a specific group of patients who experience difficulties in these areas and ptsd patients with comorbid depression (assmann et al., 2021; bosch & arntz, 2021). in imrs for ptsd, patients are asked to vividly recall a traumatic experience where­ after patients are asked to imagine that an intervention takes place that changes the course of the original memory into an image in which the needs of the patient are fulfilled (arntz, 2012; arntz & weertman, 1999). in imrs several therapeutic steps are used to modify the content of traumatic memories into new positive images in order to change the meaning of the trauma memory representation, by adding new and corrective information about the meaning of the event. imrs is thought to reevaluate unconditioned stimuli and thereby reduce conditioned stimuli-elicited affects (arntz, 2012). this is done by adding new information into the memory representation of the unconditioned stimuli; by for instance adding information on the needs of little children and taking care of the patients’ needs in the traumatic event. imrs for ptsd is performed in phases. in the first phase, which usually has a duration of six sessions, patients are asked to close their eyes and imagine a concrete negative traumatic experience as vividly as possible, until enough emotional arousal is achieved usually around a specific traumatic moment in the memory representation. prolonged exposure to the most traumatic aspect of the memory is not necessary, the therapist enters the image when arousal levels are still manageable for the patient. the therapist rescripts the image by establishing safety for the child, bachrach, giesen, & arntz 3 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ and in the following steps, further needs of the child are taken care of, and the child's emotions are validated. the perpetrator is confronted and hold accountable for their ac­ tions and responsibility and, if necessary, helped to do better in the future or to punished and/or eliminated so he/she cannot cause any harm. in the second phase of treatment, usually after 6 sessions, after trauma-memory activation (from the child perspective), imrs is performed in three steps (1) patients are asked to imagine the image as an adult in order to experience what they feel, think and are inclined to do from their present adult perspective. (2) thereafter they are stimulated to intervene in the image and do whatever they think is needed for their own little child. (3) patients are subsequently asked to experience the interventions by their adult self again from the perspective of the child in order to experience how it feels when needs are fulfilled (arntz & weertman, 1999). a recent study investigated the perspectives of patients and therapists regarding the elements of change in imrs. patients mention, caring for the child by the therapist when the therapist rescripts the traumatic event, speaking up to the perpetrator, the positive connection they had with the therapist and the encouragement they received from him or her as important elements of change (bosch & arntz, 2021). delivering imrs by telehealth (e.g., delivering psychological therapy remotely via video teleconferencing) to patients with ptsd poses challenges to both therapist and patients (paulik et al., 2021). the need for remote delivery of psychological treatments increased drastically due to the covid-19 pandemic, because of closure of outpatient facilities, travel restrictions, and home confinement. up to date, the study of delivery of imrs via telehealth has been limited to a few cases (paulik et al., 2021). however, several systematic reviews on effectiveness of psychological telehealth treatments for various disorders including ptsd (not imrs and not specifically ch-ptsd) have been performed, which in general show that the effectiveness, drop-out rates, quality and patient satisfaction, is comparable to face-toface therapies (berryhill et al., 2019; bolton & dorstyn, 2015; finkelstein et al., 2006; simpson, 2009; sunjaya et al., 2020; varker et al., 2019). despite this ample evidence to support the use of telehealth therapy for mental health conditions, therapists and patients however may be hesitant to perform telehealth therapies targeting memories of traumatic experiences. paulik and colleagues (2021) describe key clinical considerations and recommendations for delivering imrs by telehealth: the importance to consider the context (living condition, level of privacy during therapy, levels of covid-19 restrictions, voluntariness of choice for telehealth) perceived and real safety (being physically safe and having a safe place to perform imrs); practical (travelling time, preparation structure of sessions, camera position, exhaustion levels of therapist, quiet environment) and technological issues (stable connection, type of device) therapeutic alliance (reduced level of eye contact, more difficult observation of body language); depth of emotional processing (stimulating visualization and emotion­ ally connect to the image); and dissociation (strategies to stop dissociation). imrs might be more easily adapted to telehealth delivery than other trauma-focused methods such blended delivery of imrs 4 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ as emdr because imrs does not require dual stimulation tasks, and during rescripting patients have their eyes closed and are not focused on the therapist. imrs also does not require the provision of materials in the sessions, such as handouts for completion of homework (paulik et al., 2021). in the following a case illustration is given of the application imrs protocol by telehealth. case illustration presenting problem and client description the case report is presented with permission of the patient, for privacy reasons several changes were made to the report (e.g. names, dates). larry is a 42-year-old divorced, unemployed man, who was referred by the assertive community treatment team (act) to the trauma department of a mental health care center in the netherlands for treatment of ch-ptsd. act is a service-delivery treatment model that provides comprehensive, locally based treatment to people with serious and persistent mental illnesses (drukker et al., 2011). during the assessment phase the following dsm-5 classification was made based on the following semi-structured clinical interviews: scid-5-p (first et al., 2015); scid-5-cv (first et al., 2016) and caps-5 (weathers et al., 2018): antisocial personality disorder with schizoidand borderline personality traits; depression, adhd and chronic childhood ch-ptsd. he suffers from low self-esteem, difficulties in aggression regula­ tion, and difficulties with maintaining intimate relationships. he feels detached from others, is hyperalert, worries a lot and can be impulsive, experiences nightmares and sleeping problems. larry functioned on the fringes of society for several years, but has recently found a volunteer job and now lives independently. he has a limited social network because of his distrust of others. larry grew up in a family in which he did not feel safe and connected. larry was the middle child of three. larry has few memories of his childhood and mentions that he was a hyperactive and difficult child. he felt unwanted as a child and had an emotionally detached father who worked a lot and a gentle mother who was a housewife. she died in a car accident caused by a drunken driver when larry was 6 years old. larry was not allowed to attend the funeral because his father did not let him attend it. after his mother passed away, his brother, grandparents, and friends looked after larry when larry’s dad attended work. larry was sexually abused by the father of a befriended family, who baby-sat larry, from his seventh till tenth year of age. at school larry experienced concentration and behavioral problems and regularly got into fights. there was very little support and attention for him at home. he went to technical secondary vocational education. he quit school after getting beaten up by a group of boys at age sixteen. he met his wife at age eighteen, they married after she got pregnant. larry once forced his wife to have sex after which she filed a divorce. she left him with their child, bachrach, giesen, & arntz 5 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ which was three years old at that time. after the divorce, larry did not see his daughter anymore. larry held numerous jobs and often experienced conflicts at work. he got addicted to gambling and into serious debts, he lost his house and lived on the street for three years. during this stressful period, he experienced several psychotic episodes; the first around age of thirty-two. because of the psychotic experiences larry sought mental help and his general practitioner referred him to a act team. the act team helped him to reduce psychotic problems, depressive complaints and helped him to live independently again. he found volunteer work and restored contact with one brother and one friend. his psychotic symptoms were resolved and he succeeded in living independently again. he now lives a tranquil and isolated life, with which he seemed satisfied. larry drank about five beers a day and smoked weed occasionally; he received anti-psychotic-, anti-depressants-, anti-adhdand sleep medication. he was referred for trauma therapy by the act team and was offered to take part in the irem-freq study. the irem-freq study design is registered in ntr7153 and approved by the ethics committee of the university amsterdam. the design manuscript of the study was sub­ mitted recently (wibbelink et al., 2021). larry was randomly allocated to the two times a week imrs condition, 90 minutes per session with a maximum of 12 sessions. in the irem-freq imrs protocol the therapist rescripts the traumatic situation in the first six sessions, from the seventh session till twelfth session the patient as his current self-rescripts the traumatic event (boterhoven de haan et al., 2020). due to the pandemic, the face-to-face sessions had to be stopped, and treatment was continued online. because of methodological considerations, the study participants that could not be treated visà-vis were excluded from the irem-freq study (see wibbelink et al., 2021, and trial registration). therefore, the case of larry could be separately presented. larry was a friendly, quiet, reserved but cooperative man who made the impression to be at ease living an isolated life. the therapist felt sympathy and empathy for him. larry did not show any aggressiveness to the therapist, nor did he evoke any negative or intense countertransference emotions. course of treatment the first two sessions were delivered face-to-face, after which the covid-pandemic led to delivering the treatment online. in the first session trauma processing does not takes place. in this session the therapist got acquainted with larry and explained the rational of imrs. the therapist and larry made a list of traumas that larry wanted to address. this list included trauma’s that contributed to the ptsd diagnosis as well as traumas that did not qualify for the a-criterion of ptsd in the dsm-5 definition of ptsd. the list is considered to be flexible, the patient can add trauma’s during treatment and/or can change the order in which traumas are addressed. in the first session a trial imrs intervention with a mildly negative memory, preferable before age of 12, is provided to blended delivery of imrs 6 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ let patients become familiar with imrs. in larry’s case this was getting beaten up at school. larry’s list of traumas included the following themes: • sexual abuse at age seven till ten years of age • death of his mother at the age of six • getting beaten up by a group of boys at age 16 • being threatened by a motorcycle gang at age 40 • aggressive behavior against and sexual abuse of his ex-wife at age 22 in the second session, the first active imrs session, the loss of his mother due to a car accident was processed. larry was not allowed to see his mother after the accident and to attend the funeral. larry therefore was not able to properly take part in his mother’s farewell. his family members didn’t talk about her death after the funeral. therapist: please close your eyes larry, i would like you to speak in the present tense and the i-form as if the situation which we will process is happening right now. please go back to the situation where your mother died. where are you? what is happening? larry: i see my mom; she is crushed in the car (crying). i’m overwhelmed and feel sad. therapist: what do you need? larry: i’m so lonely. somebody should comfort me. therapist: i’m here. oh larry, this must be so sad for you. it is okay to cry, losing your mommy is a great loss. i’ll take care of you. let me comfort you. i’ll put my arms around you. is there anything else you need? larry: i feel calmer now. therapist: and the drunk driver, is something needed towards him? larry: yes! he gets away with it. he should be punished. therapist: okay, i’m still there, i’ll confront this driver. how can you be so irresponsible? do you realize what you have done? you just killed a mother of this friendly little boy who needs his mother. and how dare you to just leave the scene of the accident and just drive through. this is a crime; you belong in jail! police officer please incarcerate this man. larry: i see them taking him away. bachrach, giesen, & arntz 7 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ therapist: what would you like to happen now? larry: i want to see my mom and tell her that i love her. i want to say goodbye. in the rescripting larry felt very lonely and in need of support and comfort. he felt relieved to get comforted in the rescripting and experienced a reduction of feelings of revenge towards the drunken driver. because of the covid-19 pandemic and the government restrictions of the lockdown larry was not able to attend physical appointments. larry was therefore asked if he would like to continue the imrs by telehealth, to which he agreed. in the following session the use of telehealth by secured video call was set up, because the sound of the video call was of poor quality the audio of the videocall was delivered by phone. the third imrs session was performed via telehealth. notably larry was very much at ease at his own home, he was drinking coffee, smoked cigarettes and spontaneous­ ly interrupted the sessions by going to the toilet and was distracted by his cat who walked on his keyboard. these behaviors are not uncommon when delivering therapy by telehealth (paulik et al., 2021). practical agreements such as quiet environment without distractions should be made, preferably in advance, in order to perform imrs successfully by telehealth. the therapist and larry therefore discussed how larry could best profit from the telehealth sessions. they agreed on larry attending telehealth sessions similar to the face-to-face sessions (e.g. no distraction, drinks and toilet visits, the imrs proce­ dure could thereafter proceed in exactly the similar manner as to face-to-face imrs. after these ground rules were set, therapist and larry carried on with the imrs procedure and succeeded to process the most important index trauma the sexual abuse. the (index) trauma that they worked on was memory of the first time that the sexual abuse took place. this was a situation in a car in which he had to perform oral sex the abuse always took place in this car; therefore, this situation was exemplary of the majority of the sexually abuse experiences. in the rescripting larry felt very anxious and in need of protection. therapist: i step into the image, do you see me? i take you out of the car immediately, come and stay behind me larry. i lock the car, he cannot get out anymore. what are you doing? you are damaging larry, that is very bad and mean. i brought police officers with me. arrest this man! he is abusing larry. incarcerate this filthy man! what do you see larry? larry: i see him being taken away. therapist: what else do you need? larry: i feel shaky and anxious. what happens when they let him go? blended delivery of imrs 8 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ therapist: i’ll tell the police to lock him up forever. he will not be able to hurt you anymore. you are safe now larry. is there anything else you need? larry: i feel lonely and sad. delivering safety to larry was followed by condolement. larry wished his dad would comfort and help him. in the rescripting it became clear that larry’s father was not able to comfort larry, he neglected larry. the therapist therefore confronted larry’s dad that it is his task as a parent to take care for larry and provided safety and comfort to little larry. thereafter, therapist continued rescripting by giving comfort to little larry. little larry was explained that he was not guilty of the abuse, but the perpetrator was, and that the man who abused him misused the vulnerability of larry and should be punished for his actions. the therapist reassures little larry that if needed the therapist would be there for larry, therapist: every time you’ll need me, i’ll be there for you. at the end of the rescripting larry wants to play soccer with a friend. larry feels happier and less guilty at this point. in the 4th session (second telehealth session) larry wanted to address his own sexual­ ly aggressive behavior towards his ex-wife, which led to a divorce and loss of contact with his child. the hotspot in this situation was his sexually behavior in their bedroom. therapist: okay larry, i’m here. what do you need right now? larry: i feel so bad, i want to stop myself. because larry explicitly wanted to take action himself, the therapist decided to violate the imrs protocol by letting adult larry rescript the situation (fourth session instead of seventh session), assuming that it would be more powerful and effective when larry would address his own aggressive behavior. therapist: what does adult larry want tell to the twenty-two-yearold larry, go ahead tell him. larry: you fool, stop immediately. you should never do this; this is so wrong. get out, you are destroying your life and that of your family. therapist: how does the twenty-two-year-old larry react? larry: he startles, he’s ashamed so badly (crying). therapist: what else would you like to do? larry: i want to tell my wife i’m sorry. therapist: okay, tell her as current larry what you want to say, go ahead. bachrach, giesen, & arntz 9 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ in the rescripting, current larry acknowledges to his ex-wife that he has a deep remorse. therapist: is there anything else you feel like doing? larry: i want to tell my daughter how sorry i am. that i’ve been wrong. i don’t want to take the father role in her life. but i want her to know i miss her. therapist: go ahead larry. current larry apologizes to his current daughter in the rescripting. after that he feels the need for comfort because of all his losses, the therapist offers this to him in the image by giving him a hug and by validating his feelings and speaking out comforting words. he feels relieved afterwards. in the 5th session (third via telehealth) larry addresses a situation in which he was beaten up by a group of boys. the sudden confrontation appeared to be the most traumatic point of the memory of this situation. little larry felt in need of safety and wanted to escape the boys. therapist: i want you to know that it is not your fault. this must have been very scary for you. they should be ashamed that they’re threatening you and beat you up while they’re with so many. how do you feel now? what do you need? larry: i’m very angry. they should be punished. they should experience the same as what they did to me. therapist: you guys are so bloody mean; you should feel ashamed of yourselves. i’ll hit you and kick you wherever i can. if you’ll do this again, you’ll meet me once again. how do they react? did i punish them enough or is more needed? larry: i don’t know. it feels bad to see them beaten up. i rather have the police take them into custody, let them be scared. therapist: very well, we rewind the film. therapist: you have no right to be so cruel to this boy. i have brought police officers with me. police officers take care of this scum, make sure they’ll never harm larry again and to inform their parents about their gratuitous violence. once larry felt safe he felt that the boys needed to be punished for their deeds and he wanted to be sure that they would never harm him again. the therapist informed the police who took the boys into custody. blended delivery of imrs 10 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ therapist: does it feel okay for you now, or are you in need of something else? larry: it is okay, i feel calm now. therapist: shall we do something nice? larry: let’s play soccer. therapist: let’s go to the square and have some fun. feel the sun, smell the grass. enjoy playing soccer for a while…… open your eyes and return to the here and now. larry felt relieved and at ease after the imrs. in the 6th session larry chose a situation in which he was threatened by a motorcycle gang whereby he felt very unsafe for several days. at the start of the threats, he didn’t dare to go to sleep for days which resulted in sleep deprivation and subsequently a psychotic episode. the most traumatic moment of the memory in this situation was the moment he was told that he was dating a former girlfriend of a member of the motor cycle gang and he realizes he is in trouble. in the rescripting larry feels anxious and is in need of safety. therapist rescripts the situation by rescuing larry by taking him out of the situation. after larry is safe, he wants to be sure they’ll never harm him again. the motor gang is incarcerated by the police and they get locked up. larry feels relieved and at ease after the rescripting. from the 7th session (fifth telehealth session), following the protocol, the patient rescripts the traumatic event as his current self and therapist coaches the adult-self when necessary, to do what is needed. at the start of the session larry shares that he no longer feels anxious when he hears the sounds of motor bikes. in this session larry wants to address the sexual abuse because it is still bothering him, the same traumatic situation in which larry got abused again was processed for a second time. at first larry was asked to step into the situation as little larry. the most traumatic aspect of the memory of the situation was the moment at which the sexual abuse was going to take place. therapist: what do you need right now? larry: i want to get out of the car, i want to get away. therapist: okay, keep your eyes closed and step into the situation as adult larry. what is happening? what do you see? larry: i see little larry, he is so scared. it makes me angry. therapist: what would you like to do right now? bachrach, giesen, & arntz 11 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ larry: i want to beat the man up and to have the police lock him up forever. he is not allowed to abuse little larry. therapist: okay. go ahead, do what you want to do. adult larry confronts the abuser. larry: i tell him he is not worth living, that he is really disgusting and that everybody should know what he has done, you’re a fucking loser. i beat the hell out of him. therapist: how does little larry react? larry: he feels that justice is done. he is peaceful now. therapist: larry what inclination do you have now? larry: i want to tell little larry that he can’t help it, he is innocent and a good boy. i am always there for him. therapist: very well, just say that directly to little larry. larry: [speaks directly to little larry] therapist: is there anything else that’s needs to be done? larry: no, it is okay now. therapist: what about your father, does he need to know? larry: maybe. i don’t know, we can try. therapist: let’s go to your father, what do you want to tell him? larry: i tell him what happened. therapist: how does your father react? larry: he startles. he feels uncomfortable. he doesn’t know how to react. therapist: is there anything else you want to tell him? larry: you should have been more careful, and looked after little larry; he needs you to be there for him. therapist: how does little larry react? blended delivery of imrs 12 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ larry: he is sad. he needs a hug. my father is never going to give him that. therapist: is there anything you can do for little larry? larry: i’ll hug him till he is calm. when adult larry feels satisfied the therapist tells larry: ok, keep your eyes shut. go back to the situation, but now as little larry and start the film from beginning and tell me what happens when adult larry intervenes? in the end the therapist asks little larry: what would you want to happen right now? little larry: it feels awkward that my father doesn’t know how to react. i want adult larry to tell it is not my fault. therapist: go ahead, ask adult larry what you need. what does adult larry do? little larry: he tells me i’m a good boy, that it is not my fault that father is clumsy. a father shouldn’t be that neglective but should be giving his son attention and see his need for comfort after having lost his mother and after what he went through during the abuse. he tells me that father is not capable of giving that to me. he gives me a hug. after which they leave the house to play soccer together, they have fun and the little larry feels relaxed. in the eight session (sixth telehealth session) larry states that he is no longer expe­ riencing nightmares and flashbacks and feels that he has progressed enormously in treatment; he does not have any situations anymore which he wants to address. larry also feels at ease that there currently is no contact with his daughter and grandchildren, he feels resignation about this situation. larry wished that he received imrs much earlier in his life. after ptsd treatment, larry was able to reduce his antidepressant (90%) and sleep medication (50%). larry was inclined to stop with the act treatment which he received for several years. therapy outcome and prognosis larry was considered an early completer because he only needed seven out of twelve sessions. therapy outcome and prognosis for larry, were very good. the follow-up as­ sessment of self-reported and clinician administered ptsd symptoms, quality of life, gen­ eral psychiatric symptoms and trauma related cognitions about self and others showed dramatic, significant and clinical improvements (see table 1). the prognosis of larry is expected to be very good based on the follow up results after 1 year. bachrach, giesen, & arntz 13 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ table 1 results on outcome measures at baseline, after completion of imrs and follow up measure baseline after completion of imrs 1 year follow up clinician administered ptsd scale for dsm-5 (weathers et al., 2018) 33 9 3 pcl-5 index trauma (weathers et al., 2013) 51 10 15 pcl-5 other traumatic events 51 9 15 whodas 2.0 (üstün et al., 2010) 47.92 16.67 12.50 symptom check list-90 hostility (derogatis & unger, 2010) 6 6 6 ptci (foa et al., 1999) negative cognitions about self 4.48 2.14 1.86 negative cognitions about world 5.57 2.86 1.71 self-blame 5.40 2.40 4.40 euroqol eq-5d-5l quality of life vas (busschbach et al., 2016). average of general dutch population age group 40-49 = .85, sd = .20) 0.43 0.77 0.85 beck depression inventory bdi-ii (beck et al., 1996). 28 6 7 happiness (abdel-khalek, 2006). fairly unhappy fairly happy entirely happy discussion larry’s case is unfortunately exemplary for patients with ch-ptsd in which underdiag­ nosis and undertreatment is common. ptsd is often not diagnosed; only 2% to 11% of the patients with ptsd actually have their diagnosis noted in the medical record in primary care and 18-35% in mental health care centers (kantor et al., 2017; meltzer et al., 2012). unfortunately, less than half of the patients with ptsd diagnosed, or even fewer, actually receive treatment for ptsd (kantor et al., 2017; meltzer et al., 2012). this creates a major risk for escalation of clinical disorders (such as psychosis in larry’s case), chronicity and long treatments, poor quality of life and high societal costs. early detection and treatment of ptsd urgently is needed in order to counter these negative effects. imrs has proven to be an effective and highly acceptable procedure for both patients as therapists and seems a very good option for treating ch-ptsd effectively (boterhoven de haan et al., 2020; morina et al., 2017; raabe et al., 2015). in larry’s case, blended delivery of imrs 14 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ which at forehand seemed to be a very complex case, only seven sessions were needed to reduce ptsd and depressive symptoms drastically, and increase his quality of life. by just following the treatment protocol, the application of imrs could be performed by telehealth in a regular manner in quiet a complex case. this is in line with research previous findings which show that trauma focused therapy (e.g., emdr and imaginal exposure) is effective, safe, and feasible in patients with ptsd and complex symptoms such as severe psychotic disorder (van den berg et al., 2015). the delivery of imrs by tel­ ehealth did not seem to have a negative impact on the effectiveness, quality and patient satisfaction; which is in line with systematic reviews on effectiveness of psychological telehealth treatments for ptsd (not imrs and not specifically ch-ptsd) (berryhill et al., 2019; bolton & dorstyn, 2015; finkelstein et al., 2006; simpson, 2009; sunjaya et al., 2020; varker et al., 2019). in larry’s case the delivery of imrs by telehealth proceeded similar to face-to-face sessions. it might have helped that the initial start of the trajectory was face-to-face due to which patient and therapist got acquainted before switching to telehealth. larry’s context might be favorably to telehealth, he had had a good internet connection, lived by himself –privacy was guaranteed and was motivated to continue treatment by telehealth. it however might be helpful if basic agreements on how imrs by telehealth is delivered and in which manner patients can take care for privacy, quiet en­ vironment, good stable internet connection, focus during sessions and how to deal with possible dissociation, were discussed in advance (paulik et al., 2021). it is important to investigate the effectiveness of delivering imrs by telehealth in an adequately designed and powered study. furthermore, it is unlikely that telehealth is applicable to all patients; some patients might respond better to face-to-face imrs compared to imrs delivered by telehealth. it is important to investigate patient and context characteristics in order to improve treatment selection. it is important to note that application of telehealth and effectivity of telehealth might also depend on therapists' attitudes towards telehealth applications. therapists might be reluctant to perform ptsd treatments online, which might interfere with outcomes and extensive application of telehealth. however, several systematic reviews on effectiveness of psychological telehealth treatments for various disorders including ptsd show that the effectiveness, drop-out rates, quality and patient satisfaction, is comparable to face-to-face therapies (berryhill et al., 2019; bolton & dorstyn, 2015; finkelstein et al., 2006; simpson, 2009; sunjaya et al., 2020; varker, brand et al., 2019). which might indicate that this reluctance and attitudes towards telehealth might not be justified. in conclusion, larry’s case illustrates that imrs can be safely and effectively performed by telehealth for ch-ptsd, no stabilization phase was needed and only seven sessions were needed to drastically reduce ch-ptsd and depressive symptoms, and to increase quality of life. this gives hope and additional possibilities to reach out to patients with ch-ptds due to the fact that telehealth might have some of advantages for patients, especially, but certainly not only, during the pandemic. this bachrach, giesen, & arntz 15 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://www.psychopen.eu/ patient group is so often undertreated for their ptsd, this case report shows that the reluctance for direct ptsd treatment through telehealth is not rightfully. funding: the authors have no funding to report. acknowledgments: we thank research assistant melissa kir and phd student sophie rameckers for the data collection and data processing. competing interests: the authors have declared that no competing interests exist. references abdel-khalek, a. m. 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(2020). treating posttraumatic stress disorder remotely with cognitive therapy for ptsd. european journal of psychotraumatology, 11(1), article 1785818. https://doi.org/10.1080/20008198.2020.1785818 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. bachrach, giesen, & arntz 19 clinical psychology in europe 2022, vol. 4(3), article e7815 https://doi.org/10.32872/cpe.7815 https://doi.org/10.1037/pas0000486 https://www.ptsd.va.gov https://doi.org/10.1186/s13063-021-05712-9 https://doi.org/10.1080/20008198.2020.1785818 https://www.psychopen.eu/ blended delivery of imrs (introduction) case illustration presenting problem and client description course of treatment therapy outcome and prognosis discussion (additional information) funding acknowledgments competing interests references cultural adaptation of cbt for afghan refugees in europe: a retrospective evaluation latest developments cultural adaptation of cbt for afghan refugees in europe: a retrospective evaluation schahryar kananian 1 , annabelle starck 1, ulrich stangier 1 [1] department of clinical psychology and psychotherapy, goethe university frankfurt, frankfurt, germany. clinical psychology in europe, 2021, vol. 3(special issue), article e5271, https://doi.org/10.32872/cpe.5271 received: 2020-11-25 • accepted: 2021-05-09 • published (vor): 2021-11-23 handling editor: eva heim, university of lausanne, lausanne, switzerland corresponding author: schahryar kananian, goethe university frankfurt, department of clinical psychology and psychotherapy, varrentrappstr. 40-42, 60486 frankfurt, germany. tel: 0049 69 25367. e-mail: kananian@psych.unifrankfurt.de related: this article is part of the cpe special issue “cultural adaptation of psychological interventions”, guest editors: eva heim & cornelia weise, clinical psychology in europe, 3(special issue), https://doi.org/ 10.32872/10.32872/cpe.v3.si abstract background: culturally adapted cbt (ca cbt) is a well-evaluated, culture-sensitive intervention for refugees that utilizes psychoeducation, problem solving training, meditation, and stretching exercises. however, there is a lack of standard procedures for adapting psychotherapeutic interventions to a specific cultural context. our working group adapted ca cbt for afghan refugees at two different stages, which yielded promising results from a pilot trial and an rct with a waitlist control group. this article aimed to illustrate the ongoing adaptation process of ca cbt for afghan refugees over the course of several trials and to highlight potential limitations by evaluating how systematic adaptations were performed. method: the adaptation process of ca cbt was described in detail, including the methods and rationale for changes to the protocol. this process was analyzed according to a new set of proposed reporting criteria. results: according to the defined target population and based on multiple research strategies, culturally-specific components, such as the rationales for interventions, metaphors, and idioms of distress, were adapted. relevant surface adaptations were implemented. however, although the steps of our adaptation process corresponded with the reporting criteria, some of the adaptation processes did not follow explicit criteria but resulted from implicit judgments. conclusion: in the future, compliance with and the documentation of adaptation processes following explicit guidelines are crucial for the transfer of evidence-based approaches for managing the diversity of refugee populations. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5271&domain=pdf&date_stamp=2021-11-23 https://orcid.org/0000-0002-9783-3978 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords reporting criteria, cultural adaptation, afghan refugees, transdiagnostic, group therapy highlights • the reporting criteria (heim et al., 2021, this issue) can be applied to analyze the documentation process of cultural adaptation in a post hoc analysis. • the documentation process of culturally adapted cbt for afghan refugees shows a high agreement with the reporting criteria. • this detailed documentation of the adaptation process for afghan refugees may facilitate the cultural adaptation for similar subgroups in future studies. approximately 18% of the refugees arriving in germany in 2016 originated from afgha­ nistan. epidemiological studies revealed high prevalence rates for ptsd (32.2%), affective disorders (21.9%), and anxiety disorders (33.9%) among afghan refugees (richter et al., 2015). in afghanistan, war and armed conflicts have occurred since 1979, with only short periods of truce. however, after fleeing and seeking asylum in western countries, distress can persist, due to long asylum procedures and restrictive housing regulations. this postmigration stress may contribute to the worsening or even development of psychopathological symptoms (li et al., 2016; miller & rasmussen, 2017; schock et al., 2016). a noticeable gap between the high prevalence rates of mental disorders and the low rates of seeking of treatments (german organization for psychotherapists [bptk], 2015) may indicate a low acceptance and familiarity with cbt among afghan refugees, which is also reflected by the higher dropout rates (de haan et al., 2018). this may be related to the western influence on cbt and how this may conflict with the values of ethnic minorities (scorzelli & reinke-scorzelli, 1994). as a low-threshold and easily accessible program, culturally adapted cbt (ca cbt), which was developed by hinton et al. (2005), was chosen as the basic treatment concept (hinton et al., 2005, 2009). although other cbt interventions, as well as trauma-focused approaches, have been culturally adapted and evaluated with promising results (hall et al., 2016; shehadeh et al., 2016), ca cbt has been evaluated for several ethnicities, including cambodian, vietnamese, egyptian, and hispanic refugees (hinton et al., 2005; jalal et al., 2017). the treatment program focuses on the development of resilience, psychological flexibility, and emotional regulation. furthermore, the group setting of ca cbt aims at overcoming the often experienced sense of isolation and in helping to establish new social networks. finally, within a stepped care approach, ca cbt can be integrated into existing community settings and activities; thus offering the perspective to meet some of the principles that have been postulated for an ecological approach to mental health care for refugees (miller & rasco, 2004). as a theoretical framework for the adaptation process, we followed the guidelines by barrera et al. (2013), which included five stages: information gathering, preliminary adaptation design, preliminary adaptation ca cbt adaptation for afghan refugees 2 clinical psychology in europe 2021, vol. 3(special issue), article e5271 https://doi.org/10.32872/cpe.5271 https://www.psychopen.eu/ tests, adaptation refinement, and cultural adaptation trials. although the effectiveness of cultural adaptation has been shown in several meta-analyses (hall et al., 2016; shehadeh et al., 2016), there is currently a lack of standardized documentation criteria. in this article, we aimed to illustrate the adaptation process of ca cbt for afghan refugees and to depict the adaptations that were administered throughout ongoing trials by applying the criteria for reports of cultural adaptation, as suggested by heim et al. (2021, this issue). culturally adapted cbt (ca cbt) the program is conceptualized as being resilience-focused and subclinical, and it can be delivered in an individual or group setting and includes 14 sessions. interventions, such as psychoeducation, stretching, meditation, guided imagery, and cognitive techniques (e.g., socratic questioning), are a part of each session. it should be mentioned that due to its resilience-focused and transdiagnostic nature, ca cbt does not include prolonged exposure to trauma memories; instead, it focuses on emotional regulation and addresses different psychopathological symptoms, including depression, anxiety disorders, and somatic symptoms, as well as related disorders. the original ca cbt group program by hinton contained transcultural concepts and key idioms of distress, such as “thinking a lot” (hinton et al., 2016), which are meant to be suitable for a variety of ethnic groups and were included in the protocol for afghan refugees. additionally, hinton and colleagues (jalal et al., 2017) adapted specific components, such as the rationales for meditation and guided imagery, for refugees from middle eastern islamic cultures. the analysis of the modifications in the different protocols by hinton and colleagues provided a blueprint of scalable components that we used to adapt the program to the afghan culture. method focus groups subsequently, for the pilot trial (kananian et al., 2017), a focus group was conducted to assess the experiences of the participants. in addition, the proposed changes to the ongoing ca cbt trials were evaluated. the focus group consisted of n = 7 participants who had participated in the group program and whose native language was farsi/dari; additionally, the participants were male and over 18 years of age. the interview was con­ ducted for approximately one hour and was audio-recorded, transcribed, and translated into german. the results were discussed by a group of experts, native speakers, and key informants. no specific qualitative analysis of the data was applied. experts were defined as professionals who had been working in the field of counsel­ ing psychotherapy with refugees or migrants for at least three years. kananian, starck, & stangier 3 clinical psychology in europe 2021, vol. 3(special issue), article e5271 https://doi.org/10.32872/cpe.5271 https://www.psychopen.eu/ adaptations following the reporting criteria in the following, cultural adaptions of the ca cbt are described based on the reporting criteria by heim and colleagues (2021, this issue). definition of the target population at an early stage, we defined farsiand dari-speaking refugees as the target population. in addition to afghan and syrian refugees, iranian refugees constituted the third largest group of refugees in germany in 2015 (richter et al., 2015). we discussed similarities be­ tween afghan and iranian cultures. although key informants raised concerns regarding potential conflicts between these two groups, due to their major differences in history and culture, many cultural similarities were recognized. this was also reflected in several articles that included afghan and iranian patients in a joint sample (e.g., shishehgar et al., 2015; steel et al., 2011). nevertheless, throughout the group program, we identified idioms of distress that were not understood by all of the participants. cultural concepts of distress literature review — we mostly derived the cultural concept of distress (ccd) for afghan and iranian refugees from qualitative studies that were conducted via interviews with afghan populations (alemi et al., 2016; sulaiman-hill & thompson, 2011; yaser et al., 2016). after a thorough review of the existing literature following idioms of distress for farsi/dari-speaking refugees, we included ‘asabi’ (nervous agitation), ‘gham’ (sadness), ‘jigar khun’ (a general expression of intense psychological distress), ‘tashwee­ sh’ (worry, as proposed by miller et al., 2006), ‘goshe-giri’ (self-isolation), ‘fekro khial’ (rumination and worrying), and ‘faramooshi’ (forgetfulness, as proposed by alemi et al., 2016). qualitative interviews — first, we evaluated ca cbt in individual treatments of af­ ghan refugees. after the treatment, we interviewed the respective patients and integrated specific suggestions into the first group manual. many patients expressed concerns that “[they] might go crazy” and that the occurrence of the symptoms was a consequence of personal sin. although we did not systematically analyze the qualitative data, we extended the ccd by the information that was gathered through these interviews. further idioms of distress were identified through interviews with key informants and experts. formative research although the main aspects of the adaption process in addition to the publications of the pilot trial and the rct (kananian et al., 2020) were reported, no additional papers on formative research were published. ca cbt adaptation for afghan refugees 4 clinical psychology in europe 2021, vol. 3(special issue), article e5271 https://doi.org/10.32872/cpe.5271 https://www.psychopen.eu/ documenting the decision-making process we documented the statements of the experts, key informants, and native speakers who were involved in the adaptation process. nevertheless, we did not systematically document how specific decisions were derived. team and roles — professor devon e. hinton, associate professor of psychiatry, developed the original protocol of ca cbt for several ethnic groups (hinton et al., 2005, 2009; jalal et al., 2017). professor ulrich stangier, professor in clinical psychology and psychotherapy, who is the head of the center for psychotherapy and of the counseling center for refugees, as well as a supervisor and licensed psychotherapist. ph.d. sarah ayoughi, who had many years of experience in counseling in kabul, afghanistan, and in speaking farsi/dari. monitoring and documentation — the adaptation process did not follow a documen­ tation or monitoring methodology. diagnostics and outcome assessment clinical interviews — all of the diagnostic interviews were conducted by independent farsi-speaking postgraduate psychologists. the m.i.n.i. in the original english version (sheehan et al., 1998) was used for the assessment, whereas key symptoms of the respec­ tive disorders were translated in advance for a more fluent and standardized assessment. questionnaires — if they were not already available and validated in farsi, all of the instruments were translated and back-translated, in accordance with the suggested standard procedure that were proposed by van ommeren et al. (1999). deep structure adaptations specific components — inner child metaphor. some trauma-focused approaches to ptsd use the inner child metaphor to explain symptoms and trauma-related catastrophic cognitions (hestbech, 2018). we did not-presume the use of this technique because it was not accepted by refugees who were individually treated. instead, we used the metaphor of an alarm system, which was suggested to be more neutral and accessible for our specific refugee group. nevertheless, we used the “soothing” metaphor for emotion regulation processes that were associated with the awareness of a secure environment. meditation and guided imagery. due to the fact that association with positive imagery is one of the key techniques for bridging cultural barriers in psychotherapy with refugees (hinton et al., 2005), we included guided imagery of a peaceful garden (‘bagh’) for afghan refugees. kananian, starck, & stangier 5 clinical psychology in europe 2021, vol. 3(special issue), article e5271 https://doi.org/10.32872/cpe.5271 https://www.psychopen.eu/ problem-solving training. inspired by treatments that were developed in programs by rahman et al. (2016) and sijbrandij et al. (2017), we added problem-solving training to the treatment program, which was labeled ca cbt+. moreover, the implementation of prob­ lem-solving targets was meant to empower patients to take independent actions within their social contexts, to further their basic needs, and to broaden their socioeconomic adversities, as suggested by miller and rasco (2004). unspecific components — the explanation of the treatment rationale was adapted to make it plausible and meaningful for the patients. when conveying information about the treatments to the patients, the detected ccds and adapted specific components were taken into account to provide the treatment rationale in a culturally sensitive (e.g., values) and culturally understandable (e.g., easy language) manner. our therapists were native speakers, which included different nonspecific components, such as a sense of belonging-and familiarity. surface adaptations — all of the interventions (psychoeducation, problem solving training, yoga/stretching, and meditation) were explained in short written handouts in farsi. to improve the comprehension of this information, these handouts were also au­ dio-recorded, and both the written handouts and audiotaped information were uploaded on a website that was accessible by the participants (stangier et al., 2020). mode of delivery — ca cbt is available as an individual and as a group treatment. we chose a group setting for the following reasons: destigmatization through exchanges about symptoms with members of the same culture or peer group, the use of group cohesion to enhance feelings of connectedness, and dialogue about one’s experience regarding the asylum procedures. translation — due to the fact that all of the group therapists were native speakers, no translations were required in addition to the material. matching materials — all of the material was edited in a culturally sensitive manner and translated into farsi/dari via translation and retranslation. cultural sensitivity, as for all of the other aspects of the adaptation procedure, implies the consideration of the cultural concepts of distress, gender, or religious aspects that may conflict with the values that are present in afghan society (eggerman & panter-brick, 2010). to ensure easier access to the content, audio material was prepared. documentation of adaptations during the trials (“on the fly”) some of the on-the-fly adaptions were incorporated into the group manual (stangier et al., 2020). for example, problem-solving training has been misunderstood as a technique for simultaneously solving all problems. the rationale for the selection of problems ca cbt adaptation for afghan refugees 6 clinical psychology in europe 2021, vol. 3(special issue), article e5271 https://doi.org/10.32872/cpe.5271 https://www.psychopen.eu/ was explained as “picking only one stone at once from mountain”. however, we did re-evaluate on-the-fly adaptation through further discussions. discussion the examination of how we adapted ca cbt to afghan refugees in germany comprised a complex sequence of implicit and explicit developmental steps over three years. to analyze this process in a post hoc manner, we applied the criteria as suggested by heim et al. (2021), this issue. the process clearly showed that cultural adaptation contains multiple levels and aspects of an intervention, and the feedback of our interviews demonstrated its major contribution to the acceptance and, thereby, to the potentially increased effectiveness of an intervention. due to the staged nature of cultural adaptation, even in our case of adapting an intervention that was already adapted to another culture, it remains a highly difficult and nearly impossible challenge to document all of the facets. this can be illustrated by the farsi idiom for “thinking too much”. after the decision for the farsi idiom “fekro khial”, we had experiences with several interpreters who suggested other translations that would be more adequate regarding the meaning of the original idiom. throughout the varying translations of “thinking too much”, we also experienced mixed reactions from patients. the specific interpretation of the idiom that was used was dependent on the region that the patient came from. this effect demonstrated how cultural adaptation can be a meandering procedure at various times. detailed documen­ tation may enable other mental health professionals to profit from the thoughts, ideas, and particular adaptation steps for their own adaptation process. our documentation shows adaptation at different steps in a way that can possibly be exemplary for other professionals. when regarding adaptation to other target groups, it may be possible to transfer or adjust adaptations, due to detailed documentation. in the clinical context, we assume that a complete traceability of adaptations will enhance the adherence of therapists for adaptations that may seem alien to them. fur­ thermore, knowledge of the reasons for adaptations will increase the cultural sensitivity of mental health professionals, not only for the specific intervention, but also for the entire treatment situation. this may prevent other misunderstandings. nevertheless, this complexity in the communication between therapists and refugees highlights how important it is to control as much of the process as possible, in order to make the process as transparent and comprehensive as possible. only through a stand­ ardized approach for cultural adaptation can the need for culturally sensitive psychother­ apy be met. the application of explicit criteria is an important tool for establishing a standard procedure for cultural adaptations. kananian, starck, & stangier 7 clinical psychology in europe 2021, vol. 3(special issue), article e5271 https://doi.org/10.32872/cpe.5271 https://www.psychopen.eu/ funding: this work was supported by the bundesministerium für bildung und forschung (grant no.: 01ef1804a). acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references alemi, q., james, s., & montgomery, s. 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(2016). beliefs and knowledge about post-traumatic stress disorder amongst resettled afghan refugees in australia. international journal of mental health systems, 10(1), article 31. https://doi.org/10.1186/s13033-016-0065-7 ca cbt adaptation for afghan refugees 10 clinical psychology in europe 2021, vol. 3(special issue), article e5271 https://doi.org/10.32872/cpe.5271 https://doi.org/10.3402/ejpt.v7.32106 https://doi.org/10.1177/0011000094224006 https://doi.org/10.2196/mental.5776 https://doi.org/10.1186/s12914-015-0058-7 https://doi.org/10.1080/20008198.2017.1388102 https://doi.org/10.1016/j.socscimed.2011.02.007 https://doi.org/10.1186/1472-698x-11-2 https://doi.org/10.1177/136346159903600304 https://doi.org/10.1186/s13033-016-0065-7 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. kananian, starck, & stangier 11 clinical psychology in europe 2021, vol. 3(special issue), article e5271 https://doi.org/10.32872/cpe.5271 https://www.psychopen.eu/ ca cbt adaptation for afghan refugees (introduction) culturally adapted cbt (ca cbt) method focus groups adaptations following the reporting criteria discussion (additional information) funding acknowledgments competing interests references selected trends in psychotherapy research: an index analysis of rcts systematic reviews and meta-analyses selected trends in psychotherapy research: an index analysis of rcts winfried rief 1 , melina kopp 1, roya awarzamani 1, cornelia weise 1 [1] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2022, vol. 4(2), article e7921, https://doi.org/10.32872/cpe.7921 received: 2021-12-06 • accepted: 2022-04-05 • published (vor): 2022-06-30 handling editor: ulrich stangier, goethe university, frankfurt, frankfurt, germany corresponding author: winfried rief, philipps-university of marburg, department of psychology, division of clinical psychology and psychotherapy, gutenbergstrasse 18, 35032 marburg, germany. e-mail: rief@staff.unimarburg.de supplementary materials: materials [see index of supplementary materials] abstract background: we wanted to analyze trends in psychotherapy research during the last decade. we used published randomized clinical trials (rcts) that are cited in web of science (wos) as an index for these activities. method: we searched for rcts published between the years 2010 and 2019. search criteria included cognitive-behavioral treatments (cbt), e-mental health, acceptance and commitment therapy (act), psychodynamic treatments, interpersonal therapy (ipt), schema therapy, systemic therapy, mindfulness treatments, and emotion-focused therapy (eft). the numbers of publications for each treatment approach were accumulated for 5-year blocks (2010 to 2014; 2015 to 2019). results: the search revealed 4,523 hits for the selected treatment options, of which 1,605 were finally included in the analysis. there was a continuous increase in published rcts, with 68% more trials during the second five-year block. cbt (68%) and ehealth interventions (18%) show an increase in the number of studies, but there were no significant changes in its percentage in relation to all published rcts. the next frequent treatments were act (4%), psychodynamic treatments (2%), ipt (2%), and mindfulness interventions (2%). we found a significant increase of the percentage of mindfulness (p = .008) and a significant decrease of the percentage of psychodynamic treatments (p = .02). systemic (1.1%), emotion-focused (0.7%) and schema therapy (0.6%) represented smaller parts of published rcts. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7921&domain=pdf&date_stamp=2022-06-30 https://orcid.org/0000-0002-7019-2250 https://orcid.org/0000-0001-5216-1031 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: a continuous increase of published rcts underlines an active field of research on psychological interventions. third wave treatments such as mindfulness increased their representation in research, while the part of psychodynamic treatments decreased. keywords psychotherapy research, randomized clinical trials rct, cbt, psychodynamic treatments, act, ehealth, mindfulness, schema therapy, systemic therapy, mental health care highlights • over the period from 2010 to 2019, the number of randomized clinical trials (rcts) of psychological treatments continuously increased, with cbt representing the majority of published rcts. • the number of trials on ehealth-interventions increased over time, but their percentage in relation to all clinical trials did not increase significantly. • third wave interventions either already represented a significant proportion of rcts (e.g., act), or showed significantly increasing numbers (mindfulness interventions). • more traditional approaches represented very small percentages of rcts (e.g., systemic treatments), or even showed a significant decreased percentage of all rctbased research (i.e., psychodynamic therapy). evidence based psychotherapy is a dynamic field of research. in particular, the last 30 years were characterized by innovations in the field of psychological treatments. advances have been made both in terms of newly developed interventions (e.g. “third wave”-therapies like act or mindfulness-based interventions (haller, breilmann, schroter, dobos, & cramer, 2021; hayes, luoma, bond, masuda, & lillis, 2006; hofmann & asmundson, 2008; teasdale et al., 2000); mentalization based therapy (bateman & fonagy, 2010; taubner & volkert, 2019), and new formats to provide psychological treat­ ment (e.g. using electronic media such as the internet and mobile phones; andersson et al., 2019; miloff, lindner, & carlbring, 2020). however, clear data proving these trends in terms of research activities (i.e. clinical trials) are lacking. how do the flagships of psychotherapy such as psychodynamic treatments, cbt, and others progress in this continuously changing field? do they lose terrain to new concepts, or are they able to maintain their positions? more knowledge about current research trends in psychotherapy is helpful to esti­ mate and predict future developments. it can be postulated that those approaches that are currently under investigation will likely influence the future delivery of psychother­ apy in health care systems that are based on empirical evidence (awmf, 2021; berry & haddock, 2008; clark, 2011, 2018; nhs, 2019). to date, several countries aim to link the provision of psychotherapy to its evidence base; however, there is still a wide range. while some countries provide mental healthcare that is more linked to traditional orientations (e.g. china; ng et al., 2017), other countries offer (and permit) nearly all selected trends in psychotherapy research: an index analysis of rcts 2 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://www.psychopen.eu/ orientations of psychotherapy without making a link to their differing evidence base (e.g. austria; laireiter & weise, 2019). a pioneer in this context is england, which tries to implement a fully evidence-based system for psychological therapies, the "improving access to psychological therapies"-program (iapt; nhs, 2019). if countries want to move forward with their health care systems in the direction of evidence-based psycho­ logical treatments, they need to know current trends and developments in psychotherapy research. in the german healthcare system we find an example for the interaction between evi­ dence-base and health care regulations. the federal government established a scientific advisory board on psychotherapy ("wissenschaftlicher beirat psychotherapie" [wbp]), that evaluates whether psychotherapeutic approaches are considered as evidence-based for a broad variety of mental disorders. a final positive vote opens the door for the respective treatment to enter a publicly financed health care system. such a positive statement was given for psychodynamic treatments, systemic treatments and cbt. a re­ cent application for approval of humanistic treatments (including rogerian psychothera­ py) was rejected on the grounds that the quantity of submitted studies were considered insufficient, and the quality criteria of studies did not meet current standards (wbp, 2018). a clear decline of research activities in this field in the 90ies was evident. human­ istic and rogerian psychotherapy is therefore not a stand-alone treatment of the german public health care system. the current manuscript reports on a databased analysis of research trends in psycho­ logical treatments. while we did not aim to detect all published trials, we focus on the use of a plausible index of publication activities (index approach). we limit our analysis to one of the major global citation databases (i.e. web of science, wos), in which indexed journals have to go through a thorough editorial selection process ensuring sufficient quality of the included journal (e.g. journal must contain primarily original scholarly material). furthermore, we limit our research to randomized clinical trials (rct). these results are used as an index of current trends in psychotherapy research. we are aware that these results only indicate trends, and are not a comprehensive summary of all potentially relevant research activities. our approach is limited to the used search terms, and treatments of interest. we decided to focus on the three traditional and approved treatment for which evidence has been sufficiently proven and which were commonly used in mental health care (psychodynamic, systemic, cbt), to compare them to newer developments such as act, mindfulness, ipt, schema therapy, emotion-focused treat­ ments, or ehealth applications. mentalization-based interventions were grouped with psychodynamic treatments. a specific problem is evident for cbt treatments, although it partly applies to other treatments as well: labels and approaches for one treatment approach can be very diverse, thus preventing them to be covered by search terms (e.g., some textbooks on cbt report up to 100 different techniques). therefore again, our rief, kopp, awarzamani, & weise 3 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://www.psychopen.eu/ analysis is only able to reveal indices, but not a complete picture for general trends in psychotherapy research. method search procedure we chose the citation database “web of science” to search for research activities during the last decade for the following reasons: (1) we wanted to ensure a certain quality of trials. wos requires indexed journals to provide a minimum of quality criteria (e.g. peer review, content relevance, appropriate citations). (2) wos is less focused on medical research, and includes more psychological and social science studies than pubmed. it includes all publications of the science citation index and the social science citation index (falagas, pitsouni, malietzis, & pappas, 2008). (3) wos has a strong focus on peer-reviewed journal publications of research studies, while other databases also include conference abstracts or monographies (e.g. scopus). in a recent analysis exploring the op­ timal combination of databases needed for a systematic review, wos had an overall recall rate of 68% (bramer, rethlefsen, kleijnen, & franco, 2017). yet, it must be considered that recall rates are topic-sensitive and that we did not aim to conduct a systematic review. since exploratory searches revealed publications of the non-clinical field (e.g. system­ ic approaches to strengthen the impact of a business, or to improve performance in a school-based setting), we selected specific wos-categories for our search (e.g., “psycholo­ gy, clinical” or “neurosciences”). the complete list of selected categories as well as the specific search terms are available in the supplementary materials). language restrictions were not applied to the searches. the search was conducted in november 2020 and was updated in august 2021. eligibility criteria studies were included if they met the following criteria: a. the study reported results of a randomized clinical trial. b. the rct investigated one or more of the following psychological treatment approaches: cognitive behavior therapy (cbt), psychodynamic treatments, internetbased psychological treatments and other digital approaches using new technologies (ehealth, mhealth, uhealth), mindfulness-based intervention (mindfulness-based stress reduction (mbsr), mindfulness-based cognitive therapy (mbct)), acceptance and commitment therapy (act), interpersonal therapy (ipt), systemic psychological therapy, schema therapy and emotion-focused therapy (eft). c. the study was published between 2010 and 2019. this criterion was chosen as we were interested in the most recent trends in psychotherapy research. selected trends in psychotherapy research: an index analysis of rcts 4 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://www.psychopen.eu/ we included studies on all age groups (e.g. adults, children, adolescents), all clinical indications for psychotherapy and all countries of origin. study selection only articles reporting the major results of the trials were included (i.e. corrections, conference abstracts, comments etc. were excluded to avoid double-counting). in the case of multiple publications of one trial (e.g., post-treatment findings, follow-up data, other secondary analyses), we selected the publication reporting the primary outcomes at post-treatment. ehealth interventions were only counted under this category, but not further according to the conceptual background. the search was conducted stepwise for all treatment approaches, reviewed by two co-authors (mk, ra); weekly consensus meetings took place. in case of uncertainty, the main supervisor (wr) gave advice. if a study investigated two or more of the above-mentioned treatment approaches in the investigated treatment arms (e.g. cbt versus act), the study was counted for both treatments. due to their own theoretical background, we did not consider “third wave interven­ tions” as variants of cbt, but counted act, mindfulness, schema therapy, ipt etc. as separate groups, without considering them as cbt variants. analyses publications were first grouped according to treatment approach, publication year, and national origin of the principal investigators, to enable an examination of potential regional differences. for the first analysis of publication trends and to avoid too small cell numbers, publications were additionally grouped into five-year periods (2010 to 2014, and 2015 to 2019). for each treatment group, we compared the number of publications between these two time blocks using the chi2 test. in case of more than an average of ten annual publications per treatment approach, we report both, analyses of five-year blocks and annual number of rcts. additionally, the percentage of publications per treatment approach of all publication hits is computed for the five-year blocks. we also computed the determination coefficient r 2 according to holt (holt, 2004) and investigated linear trends in the relationship between publication year and number of publications. this analysis did not only focus on observed data, but also provides an estimation of future developments according to times series modeling. all analyses were conducted using ibm spss (version 26.0) (ibm corp., 2019). results table 1 shows the number of hits of the original searches, and the number of finally included trials after checking the inclusion criteria. from the first to the second five-year rief, kopp, awarzamani, & weise 5 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://www.psychopen.eu/ block of the last decade (i.e. from 2010-2014 to 2015-2019), we found an overall increase in published rcts in psychotherapy from 598 to 1,007 (increase of 68%). from 2010 to 2019, the annual number of published rcts (subsumed over all treatments) increased from 67 to 230 (343%). table 1 comparison of search hits and finally included trials treatment hits finally included cbt 3081 1094 ehealth 931 294 psychodynamic treatments 96 53 act 140 61 systemic therapy 86 21 ipt 87 42 mindfulness-based interventions 72 21 schema therapy 18 10 eft 12 9 total 4523 1605 most frequently investigated psychological treatments cbt continues to represent a major part of psychotherapy research with a slight, but non-significant increase from 66% to 68% of all publications comparing the first and the second time block (table 2). this proportional increase is founded in a more substantial increase in the number of annually published treatment arms using cbt from year to year (see figure 1a). considering absolute annual numbers, cbt arms in randomized clinical trials have more than doubled from 2010 to 2019. holt’s r 2 of .95 indicates that this trend of increasing publications on cbt is highly robust. the second most frequently investigated psychological treatment approach is ehealth interventions. however, considering the overall increase of published clinical trials, the proportion of ehealth interventions remained constant from the first to the second five-year period. the increase was based on a continuous increase in published trials on ehealth interventions per year (see figure 1b) and parallels the growing numbers for psychotherapy trials in general. selected trends in psychotherapy research: an index analysis of rcts 6 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://www.psychopen.eu/ table 2 treatment arms in rcts from 2010 to 2019 (five-year blocks) treatment approach 2010–2014 2015–2019 p (χ2) r 2 (holt; prediction per year) cbt 396 (66.2%) 698 (68.2%) 0.20 (1.52) .94 ehealth 113 (18.9%) 181 (17.7%) 0.64 (0.21) .85 act 22 (3.7%) 39 (3.8%) 0.84 (0.04) .62 psychodynamic treatments 28 (4.7%) 25 (2.4%) 0.02 (5.69)* -.15 ipt 21 (3.5%) 21 (2.1%) 0.08 (3.00) -.12 schema therapy 4 (0.7%) 6 (0.6%) 0.86 (0.03) -.06 systemic therapy 10 (1.7%) 11 (1.1%) 0.32 (0.08) -.17 mindfulness-based interventions 2 (0.3%) 19 (1.9%) 0.008 (7.02)** .83 eft 2 (0.3%) 7 (0.7%) 0.35 (0.88) .53 total 598 1007 note. cbt: cognitive behavior therapy; ehealth: internet-based psychological treatments and other digital approaches using new technologies; act: acceptance and commitment therapy; ipt: interpersonal therapy; eft: emotion-focused treatments. please note: because of its linear model, holt’s r 2 can be negative even if five-year block comparisons indicate a significant increase in published treatment arms (e.g., for schema therapy). figure 1 frequency of published studies including treatment arms testing cbt interventions (figure 1a) and ehealth/ mhealth interventions (figure 1b) per year from 2010 to 2019 0 20 40 60 80 100 120 140 160 180 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 n um be r of p ub lis he d st ud ie s cbt publications 0 5 10 15 20 25 30 35 40 45 50 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 n um be r of p ub lis he d st ud ie s ehealth publications a b rief, kopp, awarzamani, & weise 7 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://www.psychopen.eu/ for all other types of psychological treatments, the numbers of published trials were not large enough (each less than 5% of all trials) to allow for robust predictions of developments based on annual changes. the specific numbers are listed in table 1 in the supplementary materials. changes from the first to the second five-year block after cbt and ehealth interventions, the next most commonly studied treatments are act (2015-2019: 4%), psychodynamic treatments (2%), ipt (2%), and mindfulness interventions (2%). we found a significant increase in the percentage of mindfulness interventions (p = .008) and a significant decrease in the percentage of psychodynamic treatments (p = .02). systemic therapy (1.1%), emotion-focused treatments (0.7%) and schema therapy (0.6%) represent smaller parts of published rcts. together with systemic therapies, psychodynamic treatments have the highest nega­ tive r 2. however, the scores are still very close to zero, indicating that future develop­ ment is hard to predict. although only on a trend level, the situation for ipt seems similar. the number of published treatment arms using this intervention remains stable, but in light of the increasing overall numbers, the proportion of ipt trials is decreasing. finally, the low number of eft treatment arms does not allow for any predictions about developments. countries of origin interestingly, the countries of origin of the principal investigator differed depending on the treatment approach. studies on cbt are dominant in the anglo-american field (us: 295 treatment arms, uk: 126 treatment arms, australia: 112 treatment arms). ehealth studies mainly originate from sweden (67 trials), but also from australia (48) and ger­ many (45). studies on act show a strong dominance in the us (20) and sweden (15). mindfulness trials originate from many different countries (e.g., us: 4, the netherlands: 3, and 2 trials each from china, germany and iran). studies with treatment arms using psychodynamic interventions mainly originate from germany (21), while rarely coming from other countries (uk: 6; sweden and den­ mark: 5). finally, ipt trials have a strong dominance in the us (19), with some further activities in china (5) and germany (4). discussion with our study, we wanted to investigate indices for research trends. to ensure some basic methodological quality, we limited our search to studies quoted in “web of science”, and included only rcts. using these specifications, we found a substantial and continu­ ous increase in published research trials on psychotherapy from 2010 to 2019, which selected trends in psychotherapy research: an index analysis of rcts 8 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://www.psychopen.eu/ more than doubled in this period. considering the five-year blocks, the increase was 71% in 2015-2019 as compared to 2010-2014. cbt continues to be the most frequently investigated treatment condition, currently representing 68% of treatment arms in rcts. the increase in cbt studies is quite robust, and statistical predictions indicate that it will continue this way in coming years. ehealth interventions are considered an emerging field in psychotherapy research. indeed, the total number of published trials continuously increased from 2010 to 2019. the proportion of ehealth interventions in psychotherapy research remained stable. research activities on third-wave interventions are also very dynamic and characterized by a continuous increase in published trials. on­ ly for mindfulness interventions and schema therapy did we find a significant increase in the proportion of trials in relation to other published rcts. the role of the more traditional treatment approaches such as psychodynamic inter­ ventions and systemic therapies seems to have continuously decreased. we found signif­ icantly smaller proportions of studies that characterized by psychodynamic treatment arms, and a slight (but not significant) decrease in the proportion of systemic treatment arms. in the 2015-2019 period, psychodynamic approaches accounted for only 2.4% of all psychotherapy treatment trials. interestingly, the various treatment approaches are differently represented across countries. for example, a large proportion of studies on ehealth interventions originate from sweden and australia, whereas cbt treatment arms are dominant in studies from the us. the reasons for these differences can be manifold: regulations of the national health care systems, financial issues imposed by health care providers and pressure for the provision of short-term interventions, the need for cultural adaptation, or regional conditions such as the distance to available health care providers are just a few of the variety of reasons that can contribute to these national differences (andersson et al., 2019). obviously, the reasons for the trends shown can be manifold. while some people might argue that cbt is over-investigated, others might favor a position that cbt reveals robust results, and is thus the best anchor for comparisons with other/new interventions. not surprisingly, cbt has been frequently used as comparison group in non-inferiority trials (rief & hofmann, 2018). the decreasing influence of the more traditional approaches, which have also been surpassed by third-wave interventions (e.g. act) also poses several questions. is this just the regular up and down in dynamic research fields that should be accepted and called “progress”? especially psychotherapy is a vivid field that can reflect the cultural and attitude changes in societies. moreover, the success of psychotherapy as a first line treatment for most mental disorders also changed psychotherapy itself. it should no longer be a luxurious and costly treatment option for a few rich people of societies – given the strong evidence base of several psychological treatments, a responsible health care system has the highly important task to develop strategies on how affordable psychological treatment can rief, kopp, awarzamani, & weise 9 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://www.psychopen.eu/ be made available to all patients who need it (corscadden, callander, & topp, 2018). this need for better availability of evidence-based treatments increases the pressure to develop economic, fast-acting and easily accessible treatments. accordingly, attempts on how to provide psychological treatments sufficiently on a community and society level are highly laudable, like the iapt program in england (clark, 2018). is more research needed in psychotherapy? first, there are still clinical fields where too few studies on psychological treatments are available, e.g. anorexia and dissociative disorders (zhu et al., 2020). moreover, it is the continuous competition of approaches that helps to better specify and increase the efficacy of interventions. trends in psycho­ therapy research cannot only indicate what is more effective, but also what is more suitable for the current needs in society. for example, the rising availability and use of modern technologies (i.e. the internet and smartphones) has laid the groundwork for the development of ehealth interventions. bringing these treatments to regular health care increases the number of people who can access and benefit from psychological interventions, and enables the treatment for people who would otherwise not have been able to participate in face-to-face treatments (e.g. because of long distances to the closest therapist, andersson & titov, 2014). continuous psychotherapy research is also the basis for continuing the journey of psychotherapy to become an evidence-based part of most national health care systems. first, there are several clinical conditions for which only very few psychological treat­ ments can be considered as evidence-based (such as in schizophrenia, obsessive-compul­ sive disorder, insomnia). it was a huge success for the field of psychotherapy to show that specific psychological treatments are effective in psychosis (lincoln et al., 2012; lincoln & pedersen, 2019), even if no concurrent medication is used (morrison et al., 2018). others found better effects for depression-specific interventions compared to plausible, but disorder-unspecific treatments (schramm et al., 2017). these are just a few examples confirming the potential of current psychotherapy research. further, the more treatment studies we have for one condition, the better we can predict expected treatment outcome. this allows us to compare new study results with these anchors of expected effects. and even if many comparison studies have not revealed significant differences between distinct interventions, some studies did (poulsen & lunn, 2014; schramm et al., 2017; simon et al., 2021). all these studies on psychological treatments provide important information for scientists, clinicians and stakeholders of health care systems alike. some people argue that psychotherapy research is just a reflection of the feasibility of some interventions being used in clinical trials, which does not mirror the necessity of these interventions in clinical practice (bohart, 2000). this can be considered right and wrong. however, before implementing insufficiently evaluated interventions in a national health care system, studies using controlled designs and valid outcome measures are necessary to prove their efficacy and thus justify their implementation. selected trends in psychotherapy research: an index analysis of rcts 10 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://www.psychopen.eu/ our analysis has some specific limitations, such as the focus on one database (wos) and on randomized clinical trials. we did not aim for a complete representation of all trials investigating all specific treatments, but rather aimed to find indices of current treatment trends. whatever approach is selected to find these indices, it always has its specific characteristic and limitations, therefore, we consider our limitations also as a characteristic of this analysis. others might follow with similar analyses, but using other data sets and other inclusion criteria. for instance, a more hierarchical approach could al­ so be suitable to reveal insights in research developments, starting with a major category (e.g., cbt), and continuing with more detailed analyses (e.g., ehealth interventions using cbt). of special note is our limitation to rcts. we are aware that much more clinically relevant studies exist, such as process-oriented trials, qualitative research, effectiveness trials with mere pre-post-comparisons etc. it was our specific aim to focus on rcts, as this is the study design with the most influence on treatment guidelines (e.g., guide­ lines of national institute for health and care excellence nice; arbeitsgemeinschaft wissenschaftlich-medizinischer fachgesellschaften awmf). however, we agree that the development of psychotherapy research from more traditional approaches investigating one treatment package for one clinical condition, to more process-based treatments and competence-based training of psychotherapists will have consequences for adequate trial designs and thus future trends in psychotherapy research (hofmann & hayes, 2019; rief, 2021). a further unique part that defines the limitations of our approach is the selection of psychological treatments, and the selection of search terms. we focused on comparing three major treatment approaches with a long history (psychodynamic, systemic and cbt) with more recently developed and outlined approaches, such as act, schema ther­ apy, mindfulness, emotion-focused therapy and ipt. furthermore, we wanted to know what role ehealth developments play in relation to these interventions that are typically provided face-to-face. of course, this method left many developments unconsidered, such as unified protocol approaches, emdr, or cbasp, to name a few. however, using a comprehensive list of search terms and specific techniques would have been nearly impossible, particularly for cbt techniques. therefore, we decided to limit this search to major techniques, hereby neglecting further trials that focus on cbt techniques such as stimulus control, habit reversal, or dbt. further, especially considering this large field of cbt trials, we do not expect substantial differences in percentages if a more inclusive approach would be selected. finally, such a database invites to do more detailed analyses on further variables, such as sample sizes, diagnostic unities, study quality, comorbidity, to name just a few. for this first article, this was beyond the scope of the paper. to conclude, our study confirms the dynamic character of the field of psychotherapy research, with continuously increasing numbers of published trials. it further strengthens the note that the field is not constant, but in continuous change. while new interven­ rief, kopp, awarzamani, & weise 11 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://www.psychopen.eu/ tions conquer more and more parts of the field, others are losing their representation. unless we have evidence for negative effects due to these developments, they are primar­ ily to be interpreted as dynamic changes in a developing field. with these changes, challenges for health care systems become evident: how can new developments be considered and eventually included in notoriously conservative health care systems? our active field of psychotherapy research has shown that it provides specific, evidencebased treatments for most mental disorders, and accordingly, the most powerful and evidence-based treatments should be made available to all patients who need it. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: winfried rief is head of a psychotherapy outpatient clinic, with a focus on cbt and new developments (e.g., expectation-focused psychological interventions), and that will be extended with family therapy in 2022. he receives royalties for book publications on psychotherapy, and as an editor of a book series on progress in psychotherapy. he is also member of several boards of scientific journals, and editor in chief of “clinical psychology in europe”. however, he did not play an editorial role for this manuscript, and he did not intervene in any form in the peer review process. cornelia weise is one of the editors-in-chief of clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. supplementary materials further details about the search process and origin of studies are presented in the supplementary materials (for access see index of supplementary materials below). index of supplementary materials rief, w., kopp, m., awarzamani, r., & weise, c. 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(2020). psychological treatments for people with severe and enduring anorexia nervosa: a mini review. frontiers in psychiatry, 11, article 206. https://doi.org/10.3389/fpsyt.2020.00206 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. rief, kopp, awarzamani, & weise 15 clinical psychology in europe 2022, vol. 4(2), article e7921 https://doi.org/10.32872/cpe.7921 https://doi.org/10.1001/jamapsychiatry.2020.2496 https://doi.org/10.32872/cpe.v1i2.30639 https://doi.org/10.1037/0022-006x.68.4.615 https://doi.org/10.3238/arztebl.2018.gut_hpt01 https://doi.org/10.3389/fpsyt.2020.00206 https://www.psychopen.eu/ selected trends in psychotherapy research: an index analysis of rcts (introduction) method search procedure eligibility criteria study selection analyses results most frequently investigated psychological treatments changes from the first to the second five-year block countries of origin discussion (additional information) funding acknowledgments competing interests supplementary materials references a self-report measure of perfectionism: a confirmatory factor analysis of the swedish version of the clinical perfectionism questionnaire research articles a self-report measure of perfectionism: a confirmatory factor analysis of the swedish version of the clinical perfectionism questionnaire allison parks 1, jakob clason van de leur 2,3, marcus strååt 4,5, fredrik elfving 5, gerhard andersson 1,6, per carlbring 5, roz shafran 7, alexander rozental 1,3,7 [1] department of clinical neuroscience, karolinska institutet, stockholm, sweden. [2] pbm, stockholm, sweden. [3] department of psychology, uppsala university, uppsala, sweden. [4] prima barn och vuxenpsykiatri ab, stockholm, sweden. [5] department of psychology, stockholm university, stockholm, sweden. [6] department of behavioural sciences and learning, linköping university, linköping, sweden. [7] great ormond street institute of child health, university college london, london, united kingdom. clinical psychology in europe, 2021, vol. 3(4), article e4581, https://doi.org/10.32872/cpe.4581 received: 2020-10-19 • accepted: 2021-10-20 • published (vor): 2021-12-23 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: alexander rozental, department of psychology, uppsala university, von kramers allé 1a och 1c, 751 42 uppsala, sweden. phone: +46 73 693 79 48. e-mail: alexander.rozental@psyk.uu.se supplementary materials: materials [see index of supplementary materials] abstract background: perfectionism is often defined as the strive for achievement and high standards, but can also lead to negative consequences. in addition to affecting performance and interpersonal relationships, perfectionism can result in mental distress. a number of different self-report measures have been put forward to assess perfectionism. specifically intended for clinical practice and research, the clinical perfectionism questionnaire (cpq) was developed and is presently available in english and persian. to promote its use in additional contexts, the current study has translated and investigated the psychometric properties of the swedish version of the cpq. method: a confirmatory factor analysis was performed to examine the best fit with data, using a priori-models and a sample of treatment-seeking participants screened for eligibility to receive internet-based cognitive behavior therapy (n = 223). results: the results indicated a lack of fit with data. a two-factor structure without the two reversed items (2 and 8) exhibited the best fit, perfectionistic strivings and perfectionistic concerns, but still had poor structural validity. correlations with self-report measures of perfectionism, depression, anxiety, dysfunctional beliefs, self-criticism, quality of life, and self-compassion were this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4581&domain=pdf&date_stamp=2021-12-23 https://orcid.org/0000-0002-1019-0245 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ all in the expected directions. eight-week test-retest correlation was pearson r = .62, 95% confidence interval [.45, .74], using data from 72 participants in the wait-list control, and the internal consistency for the cpq, once removing the reversely scored items, was cronbach’s α = .72. conclusion: the cpq can be used as a self-report measure in swedish, but further research on its structural validity is needed. keywords perfectionism, swedish, psychometrics, clinical perfectionism questionnaire, confirmatory factor analysis highlights • the clinical perfectionism questionnaire is available in swedish. • two factors emerged: perfectionistic strivings and perfectionistic concerns. • eight-week test-retest correlation was pearson r = .62. • further research on its construct validity is needed. perfectionism can result in the refusal to accept any standard short of perfection and the relentless pursuit of achievements (egan et al., 2011). shafran et al. (2002) define this as the “overdependence of self-evaluation on the determined pursuit of personally demanding, self-imposed standards in at least one highly salient domain, despite adverse consequences.” (p. 778), noting that certain individuals become dependent on attaining high standards, experiencing distress when these are not met. a highly perfectionistic person is thought to derive its self-worth on success in one or a few domains, such as school or work, and to rely on highly inflexible behaviors, e.g., repeated checking, seeking reassurance, and comparing oneself to others (egan et al., 2011). this is also maintained by cognitive biases, such as dichotomous thinking (e.g., “either you succeed or you fail”). perfectionism can have a detrimental impact on interpersonal relationships, performance, and well-being (shafran et al., 2002). in a systematic review and meta-anal­ ysis, limburg et al. (2017) found moderate to strong correlations between self-rated perfectionism and many psychiatric disorders. also, egan et al. (2011) reviewed some of the issues a high degree of perfectionism might impose on treatment, e.g., achieving poorer outcomes for patients with depression and worse therapeutic alliance, suggesting that it constitutes a transdiagnostic process that may warrant clinical attention. to assess and determine the nature and severity of perfectionism, different forms of self-report measures have been developed (stoeber, 2018). among the first and most widespread are the frost multidimensional perfectionism scale (fmps; frost et al., 1990) and the multidimensional perfectionism scale (mps; hewitt & flett, 1990). both self-re­ port measures conceptualized perfectionism as a multidimensional construct, although being composed of somewhat different factors. regardless of what type of self-report measure is used, perfectionism is considered to involve two higher-order dimensions; the clinical perfectionism questionnaire in swedish 2 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ perfectionistic strivings, i.e., perfectionistic personal standards and a self-oriented striv­ ing for perfection, and perfectionistic concerns, i.e., concern over mistakes, perceived discrepancy between standards and performance, and the notion of being judged nega­ tively by others (stoeber, 2018). a criticism of the two self-report measures is their focus on issues that are a bit outside the scope of the two higher-order dimensions. this includes such subscales as organization on the fmps (i.e., need for order and neatness) and other-oriented perfec­ tionism on the mps (i.e., imposing unrealistic standards toward others), which have been recommended for removal (stoeber & otto, 2006). furthermore, it has been argued that many items are not associated with perfectionism at all, such as those belonging to the factors parental expectations and parental criticism on the fmps (frost et al., 1990), which can be seen as developmental antecedents (i.e., having parents that emphasize the need for performance and who are highly critical of their child) (limburg et al., 2017). in an attempt to overcome some of these issues, fairburn, cooper, and shafran (2003) developed the clinical perfectionism questionnaire (cpq), arguing that it measures behaviors and cognitions related to the clinically relevant aspects of perfectionism, e.g., “have you pushed yourself really hard to meet your goals” (item 1). in comparison to other self-report measures on perfectionism, it also prompts respondents to think about life domains relevant for their perfectionism and how perfectionism has affected them during the last month. furthermore, given the multidimensional nature of many self-report measure of perfectionism (six for the fmps and three for the mps), these might not be sensitive enough to detect change during treatment, suggesting that the cpq might be more clinically relevant. at present, the cpq has been administered in several clinical trials of perfectionism (e.g., rozental, shafran, et al., 2017; shafran et al., 2017; zetterberg et al., 2019), and a number of studies have also explored its psychometric properties in english (dickie et al., 2012; egan et al., 2016; stoeber & damian, 2014), persian (moloodi et al., 2017), and german (roth et al., 2021). overall, it seems to load on two factors, i.e., perfectionistic strivings and perfectionistic concerns, and the internal consistency, cronbach’s α, has been found to be within the acceptable range (.71-.82 for the full self-report measure), de­ pending on the study and sample. however, the results also indicate that its two reversed items can be removed to increase reliability, as is often the case with reversely scored statements (weijters et al., 2013). also, two other items have demonstrated cross-loadings (items 7 and 9) in some studies (egan et al., 2016; stoeber & damian, 2014), which could reflect the fact that the two higher-order dimensions are supposed to be correlated with each other (limburg et al., 2017), or indicate a more severe problem associated with the factorial structure of the cpq. further, in terms of its temporal stability, dickie et al. (2012) collected data from 142 undergraduate students and found a four-month test-retest correlation of r = .49-.67, depending on the factor investigated. as for its validity, the cpq has been found to be related to different self-report measures of perfectionism parks, van de leur, strååt et al. 3 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ and their respective subscales, e.g., concern over mistakes (r = .61) as well as personal standards (.47-.57) on the fmps, and the same goes for self-oriented perfectionism and socially prescribed perfectionism (.42-.59) on the mps, as shown, for example, in the studies by dickie et al. (2012) and stoeber and damian (2014). only one investigation assessed its relation with variables concerning psychiatric disorders (moloodi et al., 2017). here, items on the cpq belonging to the factor perfectionistic concerns were related to rumination (.49-.51) on the perfectionism inventory (hill et al., 2004), as well as depression (.44-.48), anxiety (.37-.43), and stress (.45-.51) on the dysfunctional attitudes scale (weissman & beck, 1978) (with higher correlations belonging to the clinical group, in comparison to the general population group). to promote its use in clinical practice and research in sweden, the cpq was transla­ ted into swedish as part of a series of clinical trials (rozental, magnusson, et al., 2017; zetterberg et al., 2019). however, no psychometric study of this translation has yet been reported, warranting an examination of its factorial structure, internal consistency, valid­ ity, and test-retest correlation. in addition, with the exceptions of moloodi et al. (2017) and prior et al. (2018), all attempts at examining the cpq have used exploratory factor analysis or principal component analysis. although being useful ways of investigating plausible factors or components among items, these methods should primarily be used when there is no available hypothesis regarding the underlying construct (hurley et al., 1997). seeing as there are presently several studies of the cpq in both english and persian, there is sufficient evidence to test a priori-models using confirmatory factor analysis (cfa). this method could help to explore not only the reliability of the swedish version but also to check the proposed two-factor structure using collected data, in line with the recommendations by stoeber and damian (2014). hence, the current study aims to investigate the psychometric properties of the cpq in swedish to facilitate its use in sweden, and to assess the best fitting factorial structure based on previous research. the data is derived from a treatment-seeking sample of participants that were recruit­ ed for a clinical trial of internet-based cognitive behavior therapy for perfectionism (rozental, shafran, et al., 2017). furthermore, internal consistency will also be explored, and convergent and divergent validity will be examined using self-report measures of perfectionism, depression, anxiety, dysfunctional beliefs, self-criticism, quality of life, and self-compassion. test-retest correlation will also be assessed using the wait-list control, i.e., participants who were assigned to a waiting-period of eight weeks in the clinical trial, as these are not subject to an intervention that might affect their scores. the clinical perfectionism questionnaire in swedish 4 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ method participants participants were recruited through social media, the recruitment website www.stud­ ie.nu, posters set up at linköping university, stockholm university, and a number of health centers in linköping, a local public radio show, and a local newspaper. these advertisements declared that anyone who experienced severe problems of perfectionism and were interested in the study could register and fill out the self-report measures on the study’s website. inclusion criteria were as follows: being over the age of 18, fluent in swedish, and having severe problems of perfectionism. eligibility was determined using both self-report measures (i.e., the cpq and the fmps, subscales concern over mistakes and personal standards), and through a case management conference (where each case was reviewed and discussed together with an experienced clinician and researcher, ga). no cutoff was employed for any of the self-report measures, but each individuals’ scores were checked on a case-by-case basis. exclusion criteria included; pregnancy (given that it could have interfered with the completion of treatment), ongoing psychological treat­ ment, any change to psychotropic medication less than twelve weeks prior to entering the clinical trial, and the need for other or more extensive psychological treatment, such as when having anorexia nervosa or elevated suicide ideation, as assessed over the telephone using the mini-international neuropsychiatric interview (sheehan et al., 1998). other psychiatric disorders were allowed as long as perfectionism was deemed to be the primary concern. in total, 273 individuals registered on the study’s website, of which 223 (81.7%) completed all of the self-report measures and were included in the current psychometric study, regardless of whether they were included in the clinical trial or not. of those eligible for inclusion, 78 were randomized to a wait-list control and were used to estab­ lish the test-retest correlation of the cpq (eight weeks), with 72 (92.3%) completing the second round of assessments. for more detailed information concerning the screening procedure, see rozental, shafran, et al. (2017). although data in the current psychometric study are derived from the clinical trial, there are no overlaps in study design, statistical analyses, or the presentation of data or results. table 1 includes the sociodemographics of the participants. parks, van de leur, strååt et al. 5 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 http://www.studie.nu http://www.studie.nu https://www.psychopen.eu/ table 1 sociodemographic characteristics of the participants sociodemographics total sample (n = 223) women: n (%) 193 (86.5) age (years): m (sd) 34 (9.6) relationship status: n (%) single 63 (28.3) married/partner 154 (69.1) divorced/widowed 5 (2.2) answer missing 1 (0.4) children: n (%) yes, at home 74 (33.2) yes, not at home 10 (4.5) no 134 (60.1) answer missing 5 (2.2) pregnant: n (%) 2 (0.9) highest education level: n (%) elementary school 4 (1.8) high school 57 (25.6) university 156 (70.0) graduate school 6 (2.7) employment: n (%) unemployed 8 (3.6) student 57 (25.6) employed 141 (63.2) parent leave 6 (2.7) sick leave (> 3 months) 5 (2.2) other 5 (2.2) currently diagnosed with a psychiatric diagnosis: n (%) 24 (10.8) ongoing psychological treatment: n (%) 15 (6.7) regularly taking psychotropic medication: n (%) 39 (17.5) procedure individuals having registered their interest to participate completed a screening proc­ ess on a secure online platform (vlaescu et al., 2016), consisting of sociodemographic information and self-report measures. during the registration, individuals received an auto generated identification code, e.g., 1234abcd, guaranteeing their anonymity. prior to recruitment and data collection, ethics approval was granted by the regional ethical the clinical perfectionism questionnaire in swedish 6 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ board in linköping, sweden (dnr: 2015/419-31), and informed consent was obtained from all participants during the screening process. measures clinical perfectionism questionnaire the cpq includes the definition of perfectionism as put forward by shafran et al. (2002), followed by a yes/no question of whether the individual has tried to achieve high standards during the last month regardless of having succeeded at this, and what life domain(s) this pertains, e.g., performance at work (however, none of these parts are analyzed quantitatively). it is then followed by twelve items concerning clinically relevant aspects of perfectionism that are scored on a four-point likert-scale 1-4 (not at all to all of the time), with two reversed items (items 2 and 8), and employing a time-frame of one month. for more information regarding the factorial structure and validity of the cpq, please see the introduction. the swedish version of the cpq was developed in relation series of clinical trials (rozental, shafran, et al., 2017; zetterberg et al., 2019), with translation and back-transla­ tion being made by the researchers of the current study to ensure that nothing was lost in the process of translating the self-report measure. other self-report measures several self-report measures were also used in the current study to establish the conver­ gent and divergent validity of the cpq. the fmps was administered to establish the relationship with another self-report measure of perfectionism (frost et al., 1990). the fmps is rated on a five-point likert-scale 1-5, strongly disagree (1) to strongly agree (5), with 35 items covering the subscales concern over mistakes, personal standards, doubts about action, parental expectations, parental criticism, and organization. the fmps has been shown to correlate with other self-report measures of perfectionism and different symptoms of psychiatric disorders (e.g., purdon et al., 1999). with regard to internal consistencies, α ranges from adequate to excellent, .77-.93 (frost et al., 1990), see table 2 for this estimate for the fmps and the other self-report measures in the current study. the fmps does not include a predefined time-frame. moreover, the nine-item patient health questionnaire (phq-9; löwe et al., 2004) was distributed to evaluate the degree of depression and is scored on a four-point likert­ scale, not at all (0) to nearly every day (3). the phq-9 is often used as a screening tool for depressive symptoms, employs a time-frame of two weeks, has been validated against other self-report measures and clinical interviews of depression, and has an excellent in­ ternal consistency, .89 (löwe et al., 2004). the seven-item generalized anxiety disorder (gad-7; spitzer et al., 2006) determines the level of anxiety and worry and is scored on a four-point likert-scale, not at all (0) to nearly every day (3). the gad-7 is often used as parks, van de leur, strååt et al. 7 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ a screening tool for anxiety symptoms, employs a time-frame of two weeks, corresponds well with other self-report measures of anxiety and clinical interviews of generalized anxiety disorder, and has an excellent internal consistency, .92 (e.g., dear et al., 2011). the 40-item dysfunctional attitude scale, sometimes referred to as form a (as compared to the original version of 100-item) (das; weissman & beck, 1978) assesses various maladaptive beliefs, e.g., self-criticism. the das is scored on a seven-point likert-scale, strongly disagree (1) to strongly agree (7), is correlated with other self-report measures of depression (e.g., oliver & baumgart, 1985), and has an excellent internal consistency, .90 (cane et al., 1986). moreover, the 15-item subscale self-criticism was explored separately in the current study given its relationship with perfectionism (e.g., dunkley et al., 2009; imber et al., 1990). the das does not include a predefined time-frame. the 12-item table 2 range in scores, means, standard deviations, and internal consistencies of the self-report measures (n = 223) self-report measure range in scores m (sd) internal consistencies cronbach α cpq 12-48 38.3 (4.6) .68 psa 1-24 15.0 (2.7) .58 pca 1-20 17.0 (2.4) .69 fmps 35-175 97.9 (16.3) .89 pst. 35 28.3 (4.1) .69 cm 45 34.2 (6.6) .86 da 20 13.7 (3.3) .61 pc 20 9.5 (4.4) .86 pe 25 12.3 (5.5) .90 o 30 24.4 (4.4) .83 phq-9 0-27 10.3 (5.9) .85 gad-7 0-21 8.6 (5.3) .88 das-40 40-280 175 (31.7) .91 sc 15-105 63.1 (15.7) .90 bbq 0-96 41.8 (16.8) .71 scs-sf 12-60 26.1 (6.3) .79 note. cpq = clinical perfectionism questionnaire; ps = perfectionistic strivings; pc = perfectionistic concerns; fmps = frost multidimensional perfectionism scale; pst. = personal standards; cm = concern over mistakes; da = doubts about action; pc = parental criticism; pe = parental expectations; o = organization; phq-9 = patient health questionnaire; gad-7 = generalized anxiety disorder; das-40 = dysfunctional attitude scale; sc = self-criticism; bbq = brunnsviken brief quality of life scale; scs-sf = self-compassion scale short form. abased on the best fitting model in the current study, i.e., stoeber and damian (2014), without reversed items and with item 7 belonging to the factor perfectionistic concerns. the clinical perfectionism questionnaire in swedish 8 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ brunnsviken brief quality of life scale (bbq; lindner et al., 2016) explores the quality of life within six different areas, e.g., leisure and learning, and level of importance, e.g., “my leisure time is important to me”. the bbq is scored on a four-point scale from strongly disagree (1) to strongly agree (4). the bbq demonstrates good convergent and divergent validity, good classification ability, and has an adequate internal consistency, .76 (lindner et al., 2016). the bbq does not include a predefined time-frame. lastly, the twelve-item self-compassion scale short form (scs-sf) (as compared to the full self-report measure of 26 items) tests the degree of self-compassion and is scored on a five-point scale from almost never (1) to almost all of the time (5), range in scores 5-60. the scs-sf has been shown to be negatively correlated with self-report measures of symptoms of psychiatric disorders, and has a good internal consistency, .86 (raes et al., 2011). the scs-sf does not include a predefined time-frame. all of the self-report measures used in the current study have previously been translated and/or were available in swedish. for an overview of the means and standard deviations of all self-report measures used in the current study, see table 2. data analysis in order to investigate the factorial structure of the swedish version of the cpq and to relate the results to previous studies on the same self-report measure, cfa was used on the total sample (n = 223). in comparison to employing an exploratory factor analysis or principal component analysis, cfa allows the researcher to test one or several a priori-model(s), making it possible to assess the reliability of the cpq as well as to confirm or refute prior findings (brown, 2015), in this case with regard to its previously proposed two-factor structure. for comparison, a single factor model with and without the reversed items were also analyzed. model fit was subsequently examined using the likelihood-ratio χ2-test (p > .05), the tucker-lewis index (tli; > .95), the comparative fit index (cfi; > .95), the root mean square error of approximation (rmsea; < .06), with cutoffs for indices presented in parentheses (brown, 2015). given that the cpq violated assumptions of normality, weighted least squares was used as estimator. items with cross-loadings were added to the factor with the highest positive loading. internal consistencies were explored using cronbach’s α, and the convergent and divergent validity were investigated by examining the correlations between the manifest scale scores of the cpq and the other self-report measures administered in the current study. meanwhile, test-retest correlation was determined by studying the correlation on the cpq for the wait-list control (n = 78) between two points of measurement that were eight weeks apart. all analyses were performed in r studio 1.4.1717 (rstudio team, 2020). parks, van de leur, strååt et al. 9 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ results confirmatory factor analysis each a priori-model from the previous studies of the cpq were tested separately using cfa. however, none of them demonstrated an acceptable fit, as seen in table 3. with the exception of significant likelihood-ratio χ2-tests, the tli, cfi, and rmsea all exhibited indices that were below/above the cutoffs. similar results were obtained for a single factor model and the two models without the reversed items. table 3 goodness of fit indices for each priori-model from prior research on the clinical perfectionism questionnaire (n = 223) model χ2 df tli cfi rmsea 95% ci two-factor structure dickie et al. (2012) 101* 34 .59 .69 .09 .07, .12 factor 1: 1, 3, 6, 9, 10, 11 factor 2: 2, 4, 5, 12 stoeber and damian (2014)a 116* 49 .72 .79 .08 .06, .10 factor 1: 1, 3, 5, 6, 7, 8, 9, 10, 11 factor 2: 2, 4, 5, 7, 8, 9, 12 stoeber and damian (2014)a, without reversed items 76* 31 .73 .81 .08 .06, .11 factor 1: 1, 3, 5, 6, 7, 9, 10, 11 factor 2: 4, 5, 7, 9, 12 egan et al. (2016)b nac na na na na na factor 1: 1, 3, 6, 7, 8, 9, 10, 11 factor 2: 1, 2, 4, 5, 8, 12 moloodi et al. (2017)d 114* 43 .66 .74 .09 .07, .11 factor 1: 1, 3, 6, 7, 9, 10, 11 factor 2: 2, 4, 5, 12 single factor structure single factor 142* 54 .67 .73 .09 .07, .10 single factor without reversed items 91* 35 .70 .77 .09 .06, .11 note. likelihood-ratio χ2-test (p > .05), the tucker-lewis index (tli; > .95), the comparative fit index (cfi; > .95), the root mean square error of approximation (rmsea; < .06), cutoffs for indices presented in parenthe­ ses. df = degrees of freedom; ci = confidence interval. abased on the results reported for the first exploratory factor analysis. bbased on the results reported for study 1. cmodel did not converge. dbased on the results reported for the general population. *p < .05. the clinical perfectionism questionnaire in swedish 10 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ table 4 contains the factor loadings for each item using the model with the best fit in the current study, i.e., stoeber and damian (2014), without reversed items. factor 1 (items 1, 3, 6, 7, 9, 10, and 11) fits well with the first higher-order dimension of perfectionistic strivings, while factor 2 (items 4, 5, 7, 9, and 12) corresponds to the second, perfectionistic concerns. one item exhibited a significant cross-loading between factors, item 7, “have you judged yourself on the basis of your ability to achieve high standards?”. given its emphasis on negative evaluation, it was deemed more appropriate to include it in factor 2 (i.e., perfectionistic concerns). table 4 standardized factor loadings for each item using the best fitting a priori-model in the current study, i.e., stoeber and damian (2014), without reversed items (n = 223) items skewness factor 1: perfectionistic strivings factor 2: perfectionistic concerns 1. have you pushed yourself really hard to meet your goals? -0.67 .57* 3. have you been told that your standards are too high? -1.27 .55* 4. have you felt a failure as a person because you have not succeeded in meeting your goals? -1.30 .64* 5. have you been afraid that you might not reach your standards? -1.05 .07 .54* 6. have you raised your standards because you thought they were too easy? 0.04 .36* 7. have you judged yourself on the basis of your ability to achieve high standards? -0.98 .11* .53* 9. have you repeatedly checked how well you are doing at meeting your standards (for example, by comparing your performance with that of others)? -0.72 .16 .45* 10. do you think that other people would have thought of you as a ”perfectionist”? -0.42 .35* 11. have you kept trying to meet your standards, even if this has meant that you have missed out on things? -0.57 .63* 12. have you avoided any tests of your performance (at meeting your goals) in case you failed? -0.86 .49* *p < .05. parks, van de leur, strååt et al. 11 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ convergent and divergent validity the manifest scale scores of the cpq were correlated with the other self-report measures distributed to the participants (see table 5 for the correlation matrix, and table 6 and 7 in the online appendix, supplementary materials, for partial correlations controlling for each factor). overall, the cpq demonstrated moderate to large positive correlations with fmps (the full self-report measure) and the subscales personal standards and concern over mistakes, which are often used to examine levels of perfectionism in many clinical trials. meanwhile, the cpq exhibited small positive correlations with the rest of the sub­ scales, which are considered antecedents to, or, in the case of the subscale organization, unrelated to perfectionism. the cpq also exhibited moderate positive correlations with depression, anxiety, and self-criticism. furthermore, the cpq was negatively related to self-report measures of quality of life and self-compassion with correlations in the small to moderate range. table 5 correlations between the self-report measures (n = 223) selfreport measure cpq ps pc fmps pst. cm da pc pe o phq-9 gad-7 das-40 sc bbq scs-sf cpq – .84* .77* .49* .48* .46* .33* .23* .16* .26* .34* .41* .47* .44* -.20* -.38* ps – .41* .38* .45* .24* .24* .22* .17* .28* .23* .31* .31* .28* -.06 -.18* pc – .51* .35* .56* .37* .24* .16* .13 .43* .44* .54* .54* -.27* -.42* fmps – .66* .74* .48* .74* .71* .26* .27* .34* .55* .58* -.22* -.29* pst. – .48* .29* .22* .28* .39* .24* .32* .31* .30* -.07 -.20* cm – .38* .27* .19* .15* .33* .38* .70* .72* -.22* -.44* da – .13 .04 .18* .21* .33* .33* .37* -.17* -.10 pc – .82* .10 .10 .12 .26* .32* -.16* -.09 pe – .11 .02 .01 .14* .16* -.11 -.05 o – .07 .20* .04 .00* -.02 -.03 phq-9 – .72* .34* .36* -.28* -.26* gad-7 – .37* .36* -.28* -.30* das-40 – .92* -.28* -.51* sc – -.26* -.43* bbq – .33* scs-sf – note. cpq = clinical perfectionism questionnaire; ps = perfectionistic strivings; pc = perfectionistic concerns; fmps = frost multidimensional perfectionism scale; pst. = personal standards; cm = concern over mistakes; da = doubts about action; pc = parental criticism; pe = parental expectations; o = organization; phq-9 = patient health questionnaire; gad-7 = generalized anxiety disorder; das-40 = dysfunctional attitude scale; sc = self-criticism; bbq = brunnsviken brief quality of life scale; scs-sf = self-compassion scale short form. abased on the best fitting model in the current study, i.e., stoeber and damian (2014), without reversed items and with item 7 belonging to the factor perfectionistic concerns. *p < .05. the clinical perfectionism questionnaire in swedish 12 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ inspecting the two factors of the cpq more closely, both perfectionistic strivings and perfectionistic concerns show similar relationships with the other self-report measures when looking at the overall correlations. however, the partial correlation revealed that perfectionistic strivings (controlling for perfectionistic concerns) was primarily associ­ ated with the subscales perfectionistic standards and organization, while perfectionistic concerns (controlling for perfectionistic strivings) was most notably related to concern over mistakes and doubts about action. overall, perfectionistic concerns can also be distinguished by its stronger positive correlations to depression, anxiety, dysfunctional beliefs, self-criticism, and stronger negative correlations with quality of life and self-com­ passion, even after controlling for perfectionistic strivings. test-retest correlation of the 78 participants who were randomized to wait-list control, 72 (92.3%) completed the cpq at both measurement points. using this data, the eight-week test-retest corre­ lation was pearson r = .62, 95% confidence interval (ci) [.45, .74]. for perfectionistic standards, r = .49, 95% ci [.30, .65], and perfectionistic concerns, r = .65, 95% ci [.50, .77]. internal consistency internal consistencies for the cpq are shown in table 2. the reliability statistic for the full scale also indicated that it would increase if items 2 and 8 were removed (from .68 to .72), suggesting a somewhat improved reliability if the two reversely scored statements were to be excluded. with regard to the best fitting model, the reliability statistic was .58 for perfectionistic strivings and .69 for perfectionistic concerns. discussion the current study explored the psychometric properties of the swedish version of the cpq. based on the results from the cfa, none of the a priori-models examined showed an acceptable fit. the single-factor model demonstrated poorest fit with data, refuting a unidimensional construct, as already noted in prior research of the self-report measure (dickie et al., 2012; egan et al., 2016; moloodi et al., 2017; stoeber & damian, 2014). this is in line with the theoretical notion as well as empirical findings of perfectionism being comprised of two higher-order dimensions, that is, perfectionistic strivings and perfectionistic concerns (stoeber, 2018). using the same single factor model without the two reversed items (2 and 8) increased the fit slightly, albeit still not being satisfactory. meanwhile, using the model proposed by stoeber and damian (2014), and excluding the two reversed items, resulted in the best fit in the current study, yet still without meeting cutoffs on the indices. of note is that one significant cross-loading was found; item 7, “have you judged yourself on the basis of your ability to achieve high standards?”. this parks, van de leur, strååt et al. 13 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ could indicate that there is an inherent problem with this item or that it challenges the proposed factorial structure of the cpq, that is, being related to both higher-order dimensions of perfectionism, i.e., setting high standards and being demanding of oneself (perfectionistic standards) and critically appraising one’s own behavior (perfectionistic concerns). in the current study, item 7 was included in latter factor, but the decision was data-driven rather than based on theory as there is no consensus in the literature on how to deal with this issue. judging by its wording, it could however be assumed that it relates to the core concept of perfectionism, as conceptualized by shafran et al. (2002), i.e., an overdependence of self-evaluation. this might be explored further by, for example, including additional items related to self-worth and investigating their loadings on either of the two factors. similarly, item 8, which is a reversed statement, demonstrated a negative correlation with one factor and positive correlation with the second. moreover, two additional, albeit not significant, cross-loadings were observed, items 5 and 9, “have you been afraid that you might not reach your standards?” and “have you repeatedly checked how well you are doing at meeting your standards (for example, by comparing your performance with that of others)?”. in the current study, these belonged to the factor perfectionistic concerns, but also taps into the concept of setting high standards (i.e., perfectionistic standards), perhaps explaining this finding. however, because there is no agreement on a theoretical concept behind the cpq with regard to what items belong to what factor, there is an inherent problem in examining different models. this makes it difficult to understand and manage cross-loadings as well as how to develop the self-report measure further, warranting a more collaborative approach to generating a theoretical concept of perfectionism and model testing. given the results from the cfa, a two-factor solution seems most reasonable. howev­ er, this still displayed a poor fit, suggesting that further research on its structural validity is needed. furthermore, a shorter version of the cpq with 10 items, excluding items 2 and 8, might be more useful to administer in the future, as has already been proposed by prior et al. (2018). the removal of these two reversed items improved the factorial structure, in line with stoeber and damian (2014), suggesting that the findings from the current study should not be a translational issue. still, there may be diagnostic reasons to retain reversely scored items, such as to preventing the risk of acquiescence bias. future research should explore the structural validity of the cpq in greater detail by employing larger samples and both clinical and non-clinical participants, as well as determining how to manage the more problematic items, i.e., 2, 7, and 8. meanwhile, the analysis of convergent and divergent validity shows that the cpq is positively correlated with the fmps, both for the full self-report measure and for the clinically most relevant subscales personal standards and concern over mistakes, as has been found previously in the literature (limburg et al., 2017). these estimates are similar, albeit a bit smaller than what has been found in other studies, such as .57 for personal standards and .61 for concern over mistakes (stoeber & damian, 2014). the the clinical perfectionism questionnaire in swedish 14 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ two factors of the cpq, perfectionistic strivings and perfectionistic concerns, also had somewhat different relationships with other variables, but all in the expected directions. when controlling for perfectionistic strivings, the correlations between the cpq and the fmps are stronger for the subscales concern over mistakes and doubts about action. meanwhile, when controlling for perfectionistic concerns, the cpq is more strongly related to the subscales personal standards and organization. these results were antici­ pated and corresponds to the findings by, for example, dickie et al. (2012). in addition, a high degree of perfectionism as assessed using the cpq, and in particular the factor perfectionistic concerns, seems to be associated with such issues as depression, anxiety, and self-criticism, while at the same time being linked to a lower quality of life and less of a compassionate stance towards yourself, confirming the results from moloodi et al. (2017). in terms of the test-retest correlation, the results for the wait-list control between the two points of measurement (i.e., eight weeks) was r = .62, which was slightly higher for perfectionistic concerns than perfectionistic strivings, r = .65 compared to .49. albeit in line with the estimates found by dickie et al. (2012), the correlation is still lower than many self-report measures used to assess symptoms of psychiatric disorders, e.g., the penn state worry questionnaire, r = .84 (pallesen et al., 2006). the reason and implication of this is unclear. on the one hand, it might be argued that the cpq is expected to exhibit greater temporal stability given its many trait-like features and the fact that no intervention was provided during the waiting period. on the other hand, it is not unlikely to see spontaneous remission and deterioration among participants in a wait-list control (e.g., rozental, magnusson, et al., 2017), as well as other external factors influencing their scores, such as being on holiday or not being exposed to triggers for their perfectionism at the second round of assessment, thereby affecting the test-retest correlation. another explanation may be that the cpq captures how cognitions and behaviors related to perfectionism fluctuates depending on situations the individual is exposed to, resulting in some variation in scores between assessments. additional research is required in order to get a better impression of the test-retest correlation of the cpq, preferably by using a normal population and a shorter time-frame, such as one or two weeks, as recommended by tingey et al. (1996). also, longitudinal studies could investigate the theoretical assumptions behind the test-retest correlation, such as factorial invariance and reliability index. the current study has a number of strengths as well as limitations that need to be addressed when reviewing the results. similar to prior et al. (2018), it used a clinical sample, in line with the intended use of the cpq in clinical settings. the average levels of perfectionism on the self-report measures were therefore high at screening, cpq 38.3 (sd = 4.6), and personal standards 28.3 (sd = 4.1) and concern over mistakes 34.2 (sd = 6.6) on the fmps, implying that they probably had quite severe problems before treatment. symptoms of depression and anxiety were also evident, for example phq-9 parks, van de leur, strååt et al. 15 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ 10.3 (sd = 5.9) and gad-7 8.6 (sd = 5.3), indicating slightly elevated levels of depression and anxiety. however, the inclusion of participants from a normal population would have been helpful to distinguish clinical from non-clinical perfectionism and should be pursued in future research. using a larger sample size and interviews with regard to the clinical implications of the participants’ perfectionism could also be used to assess classification accuracy. meanwhile, data was solely based on the responses at screening as part of being assessed for eligibility to participate in a clinical trial. this made it possible to explore convergent and divergent validity to a greater extent than before as other self-report measures were administered at the same time. yet, this recruitment method could be affected by self-presentation bias, that is, exaggerating one’s problems in order to be eligible for inclusion in treatment. an alternative would have been to administer the cpq to patients already in a clinical setting to confirm the results from the current study, e.g., eating disorders, which is advised in future psychometric studies of the self-report measure. similarly, participants included in the analyses were predom­ inantly in their 30’s, women (86.5%), having a university degree, and being employed, which might affect generalizability. although such sociodemographics are not uncom­ mon in treatment-seeking populations (vessey & howard, 1993), especially in terms of internet-based cognitive behavior therapy (lindner et al., 2015; titov et al., 2010), it does raise some questions concerning the self-report measure’s application across groups, e.g., age and gender, therefore research should try to include more diverse samples in upcoming studies. in addition, other aspects warranting further investigation is to determine the validity of the time-frame used in the instructions for the cpq, i.e., one month, perhaps by employing a longitudinal study design. on a different note, exploring rank order stability is also important, that is, how well the self-report measure functions for different symptom severity levels among individuals undergoing treatment. funding: this research was made possible thanks to a professor’s grant from linköping university to one of the authors (ga). all research at great ormond street hospital nhs foundation trust and ucl great ormond street institute of child health is made possible by the nihr great ormond street hospital biomedical research centre. the views expressed are those of the author(s) and not necessarily those of the nhs, the nihr, or the department of health. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have no conflict of interest to report. author note: the self-report measure evaluated in the current study, the clinical perfectionism questionnaire, is free to use in both english and swedish and can be located in the online appendix (see supplementary materials). the clinical perfectionism questionnaire in swedish 16 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://www.psychopen.eu/ supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • table 6: partial correlations between the self-report measures, controlling for perfectionistic strivings (n = 223) • table 7: partial correlations between the self-report measures, controlling for perfectionistic concerns (n = 223) • english and swedish translations of the clinical perfectionism questionnaire index of supplementary materials parks, a., van de leur, j. c., strååt, m., elfving, f., andersson, g., carlbring, p., shafran, r., & rozental, a. 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(2019). internetbased cognitive behavioral therapy of perfectionism: comparing regular therapist support and support upon request. internet interventions, 17, article 100237. https://doi.org/10.1016/j.invent.2019.02.001 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. the clinical perfectionism questionnaire in swedish 20 clinical psychology in europe 2021, vol. 3(4), article e4581 https://doi.org/10.32872/cpe.4581 https://doi.org/10.1016/j.paid.2014.01.003 https://doi.org/10.1207/s15327957pspr1004_2 https://doi.org/10.1080/10503309612331331638 https://doi.org/10.1371/journal.pone.0010885 https://doi.org/10.1037/0033-3204.30.4.546 https://doi.org/10.1016/j.invent.2016.09.006 https://doi.org/10.1037/a0032121 https://doi.org/10.1016/j.invent.2019.02.001 https://www.psychopen.eu/ the clinical perfectionism questionnaire in swedish (introduction) method participants procedure measures data analysis results confirmatory factor analysis convergent and divergent validity test-retest correlation internal consistency discussion (additional information) funding acknowledgments competing interests author note supplementary materials references announcement of the registered report “can a variant of the implicit association test detect nonsuicidal self-injury in a clinical population? a registered report” announcements announcement of the registered report “can a variant of the implicit association test detect nonsuicidal selfinjury in a clinical population? a registered report” femke cathelyn 1 § , tilia linthout 1 § , pieter van dessel 1 , laurence claes 2,3 , jan de houwer 1 [1] department of experimental clinical and health psychology, ghent university, ghent, belgium. [2] faculty of psychology and educational sciences, university of leuven, leuven, belgium. [3] faculty of medicine and health sciences, university of antwerp, antwerp, belgium. §these authors contributed equally to this work. clinical psychology in europe, 2023, vol. 5(1), article e11499, https://doi.org/10.32872/cpe.11499 published (vor): 2023-03-31 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: tilia linthout, department of experimental clinical and health psychology, ghent university, h. dunantlaan 2, 9000 ghent, belgium. tel: +32 479 19 31 25. e-mail: tilia.linthout@ugent.be editor's note: this is an announcement of a registered report which received in-principalacceptance (ipa) to be published in “clinical psychology in europe”. the study protocol is publicly accessible at https://doi.org/10.23668/psycharchives.12576. in this announcement, a brief summary of the study protocol is presented. background nonsuicidal self-injury (nssi) is a severe and prevalent mental health problem (nock, 2010). measures to detect which individuals are at risk for nssi would be valuable for clinical practice. however, we still lack strong predictors of future nssi behaviour, with the most notable exception being prior nssi behaviour (franklin et al., 2017; griep & mackinnon, 2022; kiekens et al., 2018; turner et al., 2013; whitlock et al., 2013). yet, the measurement of prior nssi behaviour with self-report measures can be difficult because individuals may be motivated to conceal this harmful behaviour (long, 2018; macdonald et al., 2020; simone & hamza, 2020). to overcome this problem, an implicit measure has been developed that assesses automatic responding to statements about prior nssi behaviour (i.e., the past nonsuicidal self-injury implicit association test: p-nssi-iat; this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11499&domain=pdf&date_stamp=2023-03-31 https://orcid.org/0000-0003-4073-0465 https://orcid.org/0000-0001-7448-179x https://orcid.org/0000-0002-3401-780x https://orcid.org/0000-0002-2287-3158 https://orcid.org/0000-0003-0488-5224 https://doi.org/10.23668/psycharchives.12576 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ cathelyn et al., 2021). previous studies tested the predictive utility of this measure in online studies with samples of at risk participants and produced promising results (franklin et al., 2017; sohn et al., 2021). aims the main aim of this study is to validate the p-nssi-iat by assessing its ability to detect prior nssi behaviour in a sample of clinical patients. method we will target patients who receive outpatient treatment for various conditions. partici­ pants will first complete the p-nssi-iat. next, they will be asked how many times they have intentionally cut or carved their skin without intending to kill themselves in the past twelve months and the past 30 days and how likely they would be to intentionally cut or carve their skin without intending to kill themselves in the future. discussion the registered study is the first to examine the clinical utility of a new implicit measure for prior nssi behaviour (the p-nssi-iat). it will provide an answer to the question whether the p-nssi-iat allows detection of self-rated prior nssi and future likelihood of nssi in a sample of clinical patients. funding: this manuscript is supported by ghent university grant bof16/met_v/002 to jdh. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. supplementary materials the study protocol for this registered report is publicly accessible via psycharchives.org (see index of supplementary materials below). index of supplementary materials cathelyn, f., linthout, t., van dessel, p., claes, l., & de houwer, j. (2023). supplementary materials to "announcement of the registered report “can a variant of the implicit association test detect nonsuicidal self-injury in a clinical population? a registered report”" [pre-registration protocol]. psycharchives. https://doi.org/10.23668/psycharchives.12576 registered report announcement 2 clinical psychology in europe 2023, vol. 5(1), article e11499 https://doi.org/10.32872/cpe.11499 https://doi.org/10.23668/psycharchives.12576 https://www.psychopen.eu/ references cathelyn, f., van dessel, p., & de houwer, j. (2021). predicting nonsuicidal self‐injury using a variant of the implicit association test. suicide and life-threatening behavior, 51(6), 1259–1271. https://doi.org/10.1111/sltb.12808 franklin, j. c., ribeiro, j. d., fox, k. r., bentley, k. h., kleiman, e. m., huang, x., musacchio, k. m., jaroszewski, a. c., chang, b. p., & nock, m. k. (2017). risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. psychological bulletin, 143(2), 187–232. https://doi.org/10.1037/bul0000084 griep, s. k., & mackinnon, d. f. (2022). does nonsuicidal self-injury predict later suicidal attempts? a review of studies. archives of suicide research, 26(2), 428–446. https://doi.org/10.1080/13811118.2020.1822244 kiekens, g., hasking, p., boyes, m., claes, l., mortier, p., auerbach, r. p., cuijpers, p., demyttenaere, k., green, j. g., kessler, r. c., myin-germeys, i., nock, m. k., & bruffaerts, r. (2018). the associations between non-suicidal self-injury and first onset suicidal thoughts and behaviors. journal of affective disorders, 239, 171–179. https://doi.org/10.1016/j.jad.2018.06.033 long, m. (2018). ‘we’re not monsters … we’re just really sad sometimes:’ hidden self-injury, stigma and help-seeking. health sociology review, 27(1), 89–103. https://doi.org/10.1080/14461242.2017.1375862 macdonald, s., sampson, c., turley, r., biddle, l., ring, n., begley, r., & evans, r. (2020). patients’ experiences of emergency hospital care following self-harm: systematic review and thematic synthesis of qualitative research. qualitative health research, 30(3), 471–485. https://doi.org/10.1177/1049732319886566 nock, m. k. (2010). self-injury. annual review of clinical psychology, 6(1), 339–363. https://doi.org/10.1146/annurev.clinpsy.121208.131258 simone, a. c., & hamza, c. a. (2020). examining the disclosure of nonsuicidal self-injury to informal and formal sources: a review of the literature. clinical psychology review, 82, article 101907. https://doi.org/10.1016/j.cpr.2020.101907 sohn, m. n., mcmorris, c. a., bray, s., & mcgirr, a. (2021). the death-implicit association test and suicide attempts: a systematic review and meta-analysis of discriminative and prospective utility. psychological medicine, 51(11), 1789–1798. https://doi.org/10.1017/s0033291721002117 turner, b. j., layden, b. k., butler, s. m., & chapman, a. l. (2013). how often, or how many ways: clarifying the relationship between non-suicidal self-injury and suicidality. archives of suicide research, 17(4), 397–415. https://doi.org/10.1080/13811118.2013.802660 whitlock, j., muehlenkamp, j., eckenrode, j., purington, a., baral abrams, g., barreira, p., & kress, v. (2013). nonsuicidal self-injury as a gateway to suicide in young adults. journal of adolescent health, 52(4), 486–492. https://doi.org/10.1016/j.jadohealth.2012.09.010 cathelyn, linthout, van dessel et al. 3 clinical psychology in europe 2023, vol. 5(1), article e11499 https://doi.org/10.32872/cpe.11499 https://doi.org/10.1111/sltb.12808 https://doi.org/10.1037/bul0000084 https://doi.org/10.1080/13811118.2020.1822244 https://doi.org/10.1016/j.jad.2018.06.033 https://doi.org/10.1080/14461242.2017.1375862 https://doi.org/10.1177/1049732319886566 https://doi.org/10.1146/annurev.clinpsy.121208.131258 https://doi.org/10.1016/j.cpr.2020.101907 https://doi.org/10.1017/s0033291721002117 https://doi.org/10.1080/13811118.2013.802660 https://doi.org/10.1016/j.jadohealth.2012.09.010 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. registered report announcement 4 clinical psychology in europe 2023, vol. 5(1), article e11499 https://doi.org/10.32872/cpe.11499 https://www.psychopen.eu/ ‘open source’ opportunities for enhanced collaboration in psychotherapy science letter to the editor, commentary ‘open source’ opportunities for enhanced collaboration in psychotherapy science conal twomey 1, richard cody 2, john a. johnson 3, gary o’reilly 4 [1] health service executive, dublin, ireland. [2] púca technologies limited, dublin, ireland. [3] department of psychology, pennsylvania state university, state college, pa, usa. [4] school of psychology, university college dublin, dublin, ireland. clinical psychology in europe, 2021, vol. 3(2), article e6569, https://doi.org/10.32872/cpe.6569 published (vor): 2021-06-18 corresponding author: conal twomey, ballyfermot & palmerstown primary care & mental health centre, upper ballyfermot road, dublin 10, d10 c973, ireland. e-mail: conal.twomey@hse.ie according to marvin goldfried, psychotherapy remains an infant science characterised by a lack of consensus surrounding core and basic principles, research-practice disparity, and excessive theory-reinvention by competing schools of therapy (goldfried, 2020). goldfried’s concerns together point to suboptimal collaboration within the psychothera­ py research community. in our view, collaboration could be improved through the wider application of ‘open source’ software development principles (e.g., open access, free distribution, and unconstrained modification) to psychotherapy science. the origins of open source illustrate its promotion of collaboration. initially, soft­ ware products were invariably perfected ‘behind-closed-doors’ before being released as copyrighted products. in the mid-1990s, however, the internet enabled a new way of working: members of online developer communities started to freely share modifiable software source code with each other, leading to the creation of open and free networks of online collaboration (raymond, 1999), and subsequently to the production of several high-quality software and internet products (e.g., linux and wikipedia) and mainstream adoption across industries. like open source, science is—at its best—an open, collaborative endeavor (johnson, 2014). it is therefore unsurprising that open source has increasingly infiltrated science in recent years, most notably in the ‘open science’ movement, which promotes meth­ odological transparency and open access to data and research outputs (vicente-saez & martinez-fuentes, 2018); but also in the production of laboratory equipment (pearce, 2014), off-patent medications (woelfle et al., 2011), and psychometric questionnaires (dworak et al., 2021; goldberg et al., 2006). regarding psychotherapy, journals routinely this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6569&domain=pdf&date_stamp=2021-06-18 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ promote open-science practices, data from psychotherapy studies are often shared (e.g., in patient level meta-analyses), many outcome measures are freely available online, and there are an increasing number of open research networks. regrettably given their potential to enhance the open collaboration inherent in good science, there exist few applications of open source principles to the development of psy­ chotherapy interventions. most intervention manuals are not freely available online, lim­ iting access and creating a financial barrier to the exploration of manuals from different schools of therapy. moreover, for the vast majority of psychotherapies, copyright control and vested interests discourage (a) the collaborative modification and distribution of new versions of intervention manuals, and (b) the collaborative combination of components from different schools of therapy into transtheoretical interventions, or ‘process-based therapies’ (hofmann & hayes, 2019). regarding (a), such collaboration could be enabled if freely modifiable versions of intervention manuals were periodically released on open source platforms such as the open science framework (https://osf.io). this would signpost progress and later facilitate the empirical comparison of different versions, in turn facilitating ‘component analyses’ that tap into basic principles. on a cautionary note, there is potential for the misuse of open source intervention manuals by unqualified persons and this should be closely monitored (goldberg et al., 2006). regarding (b), the vested interest of a school of therapy is to keep the learner within their school, so that the learner can eventually graduate as a proponent of the school’s teachings; however, the wider community interest is to build unifying theories that transcend the teachings of particular schools (goldfried, 2020). transtheoretical open source interventions provide a means for this theory unification. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references dworak, e. m., revelle, w., doebler, p., & condon, d. m. (2021). using the international cognitive ability resource as an open source tool to explore individual differences in cognitive ability. personality and individual differences, 169, article 109906. https://doi.org/10.1016/j.paid.2020.109906 goldberg, l. r., johnson, j. a., eber, h. w., hogan, r., ashton, m. c., cloninger, c. r., & gough, h. g. (2006). the international personality item pool and the future of public-domain personality measures. journal of research in personality, 40(1), 84-96. https://doi.org/10.1016/j.jrp.2005.08.007 ‘open source’ in psychotherapy 2 clinical psychology in europe 2021, vol. 3(2), article e6569 https://doi.org/10.32872/cpe.6569 https://osf.io https://doi.org/10.1016/j.paid.2020.109906 https://doi.org/10.1016/j.jrp.2005.08.007 https://www.psychopen.eu/ goldfried, m. r. (2020). the field of psychotherapy: over 100 years old and still an infant science. clinical psychology in europe, 2(1), article e2753. https://doi.org/10.32872/cpe.v2i1.2753 hofmann, s. g., & hayes, s. c. (2019). the future of intervention science: process-based therapy. clinical psychological science, 7(1), 37-50. https://doi.org/10.1177/2167702618772296 johnson, j. a. (2014). measuring thirty facets of the five factor model with a 120-item public domain inventory: development of the ipip-neo-120. journal of research in personality, 51, 78-89. https://doi.org/10.1016/j.jrp.2014.05.003 pearce, j. m. (2014). laboratory equipment: cut costs with open-source hardware [correspondence]. nature, 505(7485), 618. https://doi.org/10.1038/505618d raymond, e. (1999). the cathedral and the bazaar: musings on linux and open source by an accidental revolutionary. o’reilly media. vicente-saez, r., & martinez-fuentes, c. (2018). open science now: a systematic literature review for an integrated definition. journal of business research, 88, 428-436. https://doi.org/10.1016/j.jbusres.2017.12.043 woelfle, m., olliaro, p., & todd, m. h. (2011). open science is a research accelerator. nature chemistry, 3(10), 745-748. https://doi.org/10.1038/nchem.1149 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. twomey, cody, johnson, & o’reilly 3 clinical psychology in europe 2021, vol. 3(2), article e6569 https://doi.org/10.32872/cpe.6569 https://doi.org/10.32872/cpe.v2i1.2753 https://doi.org/10.1177/2167702618772296 https://doi.org/10.1016/j.jrp.2014.05.003 https://doi.org/10.1038/505618d https://doi.org/10.1016/j.jbusres.2017.12.043 https://doi.org/10.1038/nchem.1149 https://www.psychopen.eu/ did a nocebo effect contribute to the rise in special education enrollment following the flint, michigan water crisis? research articles did a nocebo effect contribute to the rise in special education enrollment following the flint, michigan water crisis? siddhartha roy 1,2 , keith j. petrie 3 , greg gamble 4 , marc a. edwards 1 [1] department of civil and environmental engineering, virginia tech, blacksburg, va, usa. [2] unc water institute, gillings school of global public health, university of north carolina, chapel hill, nc, usa. [3] department of psychological medicine, university of auckland, auckland, new zealand. [4] department of medicine, university of auckland, auckland, new zealand. clinical psychology in europe, 2023, vol. 5(1), article e9577, https://doi.org/10.32872/cpe.9577 received: 2022-05-28 • accepted: 2023-02-21 • published (vor): 2023-03-31 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: siddhartha roy, the water institute, university of north carolina, 4114 mcgavrangreenberg hall, chapel hill, nc 27516, usa. e-mail: sidroy@vt.edu supplementary materials: materials [see index of supplementary materials] abstract background: exposure to waterborne lead during the flint water crisis during april 2014october 2015 is believed to have caused increased special education enrollment in flint children. method: this retrospective population-based cohort study utilized de-identified data for children under six years of age who had their blood lead tested during 2011 to 2019, and special education outcomes data for children enrolled in public schools for corresponding academic years (2011-12 to 2019-20) in flint, detroit (control city) and the state of michigan. trends in the following crisisrelated covariates were also evaluated: waterborne contaminants, poverty, nutrition, city governance, school district policies, negative community expectations, media coverage and social media interactions. results: between 2011 and 2019, including the 2014-15 crisis period, the incidence of elevated blood lead in flint children (≥ 5µg/dl) was always at least 47% lower than in the control city of detroit (p < .0001) and was also never significantly higher than that for all children tested in michigan (p = 0.33). nonetheless, special education enrollment in flint spiked relative to detroit and michigan (p < .0001). there is actually an inverse relationship between childhood blood lead and special education enrollment in flint. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9577&domain=pdf&date_stamp=2023-03-31 https://orcid.org/0000-0001-6443-1393 https://orcid.org/0000-0002-6337-2480 https://orcid.org/0000-0003-0412-3203 https://orcid.org/0000-0002-1889-1193 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: this study failed to confirm any positive association between actual childhood blood lead levels and special education enrollment in flint. negative psychological effects associated with media predictions of brain damage could have created a self-fulfilling prophecy via a nocebo effect. the findings demonstrate a need for improved media coverage of complex events like the flint water crisis. keywords blood lead, lead exposure, flint water crisis, nocebo effect, special education highlights • waterborne lead exposure during the flint crisis did not correlate with special education enrollment. • flint children were repeatedly labeled as lead poisoned and brain damaged in the aftermath. • a nocebo effect could have contributed to negative educational outcomes in flint. • erroneous, negative media labels can be internalized and lead to psychological harm in children. in april 2014, the city of flint, michigan stopped purchasing treated lake huron water from detroit and switched to corrosive flint river water as a cost savings measure. the city also interrupted the addition of corrosion control chemicals to the treated water, which were required under federal regulations to reduce the leaching of the neurotoxin lead from lead pipes and home plumbing. this increased lead levels in tap water and children’s blood mainly in the months of june-august 2014 (roy et al., 2019). in response to residents’ concerns, two of the authors assisted with sampling 269 flint homes in 2015, proving the 90th percentile water lead level (27 μg/l) was almost twice the us environmental protection agency (epa) action level of 15 μg/l (pieper et al., 2018). it was later revealed that the proportion of children < 6 years of age with elevated blood lead, i.e., ≥ 5 μg/dl us centers for disease control and prevention (cdc) reference level, increased following the water switch (hanna-attisha et al., 2016), primarily in june-august 2014 (roy et al., 2019). michigan officials later announced a legionnaire’s disease outbreak that killed at least 13 people (rhoads et al., 2017). these events became known in the media as the flint water crisis (fwc). after the water problems were exposed, flint reconnected to detroit water in october 2015, a federal emergency was declared in january 2016, and over us$1.2 billion in relief funds have been appropriated for residents including free bottled water (through april 2018), free lead faucet filters, health interventions, settlement money for lead-exposed children, special education serv­ ices, and replacement of around 12,000 lead pipes to be completed in 2023 (bosman, 2020; city of flint, 2022; roy & edwards, 2019a; roy & edwards, 2020). flint water has met all federal standards since late 2016 and many residents still consume only bottled water due nocebo effect and special education in flint 2 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ to lost trust (flint cares, 2018; fonger et al., 2019; reuben et al., 2022; roy, 2017; roy & edwards, 2019b; sobeck et al., 2020). recent media reports (see supplementary materials [sm] table s1) attribute increas­ ing rates of special education enrollment and diagnoses of learning disabilities in flint children to lead exposure and “lead poisoning” from the fwc (alfonsi, 2020; green, 2019) but none of these conclusions are based on peer reviewed data. blood lead levels have been steadily dropping in the united states and in flint for the past 50 years following the banning of lead from gasoline, paint and pipes (dignam et al., 2019; gómez et al., 2018). the peak childhood blood lead levels during the fwc (2014-15) were well below those recorded in flint during 2011 (gómez et al., 2018; roy et al., 2019). in this study, we investigate the hypothesis that increased negative educational out­ comes were caused by lead exposure from the fwc as has been stated by the media and experts (aclu, 2016; alfonsi, 2020; green, 2019; redlener, 2018; riley, 2018; strauss, 2019). trends in blood lead levels of flint children were compared to the control city of detroit, which has comparable socioeconomic and racial make-up (table 1) and also used the same drinking water for over 50 years except for the 18 months of the fwc. we also compare flint to state-wide trends from michigan, and evaluate relevant extraneous factors that may have affected educational outcomes in flint children. table 1 key demographic factors of comparison for flint and detroit (control city) measure flint detroit (control) water source during: 1950s – apr 2014 lake huron lake huron apr 2014 – oct 2015 flint river lake huron oct 2015 – present lake huron lake huron approximate count of lead service line connections (% of total water connections) pre-2016: 12,000 (40%) current: <1,400 (4.7%) 80,000 (40%) drinking water source in public schools bottled water (sep 2015-feb 2022) filtered water (feb 2022-present) bottled water aug 2018-aug 2019) filtered water (aug 2019-present) net change in population (2011 to 2019), %* # –8.4% (105,391 to 96,559) –8.6% (738,223 to 674,841) population < 5 years old (range during 2011-19), %* 7.5-8.3% 7.0-7.3% persons per household, 2014-18 2.36 2.55 net change in unemployment rate (2011 to 2019), %† –52.1% (19% to 9.1%) –58.1% (20.5% to 8.6%) roy, petrie, gamble, & edwards 3 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ measure flint detroit (control) net change in median household income (2011 to 2019), %* +8.3% ($26,621 to $28,834) +10.9% ($27,862 to $30,894) health outcomes (range during 2011-2019), overall rank in michigan 77-82 of 83 (genesee co.) 81-83 of 83 (wayne co.) percent below poverty level (range during 2011-19), %* 38.8-41.9% 35-40.9% worst american city to live in, rank (based on 2015 data) #1 #3 % decline in total students attending public schools in 10 years (2009-10 till 2018-19) 43.1% 68.4% % of total resident students attending charter schools, 2018-19 (national rank in charter school enrollment) 45.6% (#3) 37.9% (#2) *data from american community survey 5-year estimates data profiles via us census (us census bureau, 2022). #us census language: estimates are not comparable to other geographic levels of health estimates (due to methodology differences that may exist between different data sources). †data from michigan bureau of labor market (michigan department of technology management and budget, 2022). other data references: city of flint, 2022; david et al., 2017; goetz, 2022; mack, 2019; sauter et al., 2017; university of wisconsin population health institute, 2022. after demonstrating that covariates unlikely played a primary role (see text s1, supplementary materials), we probe the possibility of a nocebo effect (barsky et al., 2002; petrie & rief, 2019) or a self-fulfilling prophecy, associated with repeated predictions of brain damage to flint children via the intense publicity associated with the fwc. research has shown that parents’ and teachers’ negative expectations of children can have adverse effects on educational outcomes. past studies also suggest that these effects are cumulative and have a greater impact on disadvantaged populations (jussim et al., 2009; madon et al., 1997; madon et al., 2011; rosenthal & jacobson, 1968). to examine the interaction between media stories and community perceptions, we evaluated a) representative national and local media stories and associated social media interactions, b) public statements of government, medical and school leaders, and c) resident feedback in media’s news stories, highlighting the purported effects of lead and “lead poisoning” during the fwc period on children and their educational outcomes in flint and the control city of detroit. nocebo effect and special education in flint 4 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ materials and method elevated blood lead childhood blood lead testing is required under medicaid, where all children receive a screening blood lead test at ages 1 and 2 years, and up to 5 years (cantor et al., 2019; us preventive services task force et al., 2019), but not all children receive such tests in practice. the state of michigan sampling methodology and reporting guidelines have not changed markedly since 1998 (michigan department of health and human services, 2020). the percentage of children under six years of age with blood lead above the 2012-21 cdc reference level of 5 μg/dl, and the pre-2012 cdc “level of concern” of 10 μg/dl, were calculated for flint, detroit, and michigan for the years 2011-19 using a dataset with 1,445,808 blood lead levels of all michigan children tested, obtained from the michigan department of health and human services (mdhhs) through a data user agreement (#202103-144) following irb approval (irb #202103-04-nr). separately, de-duplicated data were also provided to us after mdhhs epidemiologists extracted the highest blood lead values per child per year using the following standard criteria (in order of preference): • the highest venous blood lead test result available during the calendar year • if there is no venous test result available, the highest capillary blood lead test result available during the calendar year • if there is no test result with blood type available, the highest test result available during the calendar year educational outcomes the data on all special education outcomes and general education 3rd grade reading proficiency for students enrolled in flint community schools, detroit public schools community district, and all public schools in michigan for the academic years 2011-12 until 2019-20 (or, latest available) were downloaded from the michigan department of education’s website www.mischooldata.org. the special education enrollment data during 2006-07 to 2010-11 was obtained through freedom of information act requests to the michigan department of education. poverty and nutrition the rates of poverty and households with children aged 0-18 years receiving food assistance (i.e., on supplemental nutrition assistance program) for flint, detroit and michigan for 2011-19 were obtained from the us census bureau (us census bureau, 2022). roy, petrie, gamble, & edwards 5 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 http://www.mischooldata.org https://www.psychopen.eu/ media coverage and social media interactions a representative list of national and local media stories on lead exposure and educa­ tional outcomes of flint children and detroit children during october 2015-january 2021 (table s1) was gathered using google searches with keywords “lead”, “children”, “education”, “flint” with and without the term “-detroit” (i.e., removes all search results with “detroit”), and “detroit” with and without “-flint”. the crowdtangle extension v3.0.29 in google’s chrome browser was utilized to gather total “interactions” (reactions, comments, and shares) of all facebook users and total follower counts of public pages (e.g., celebrities, news organizations, and politicians) and public groups who shared the media stories on facebook from publishing date until the time of conducting research (august 2020-september 2021). the representative negative expectations commentary of community leaders, teachers, parents and schoolchildren about lead exposure during the fwc period and educational difficulties for flint and detroit (table s2) were gath­ ered through manual screening of articles, posts and videos published during october 2015-january 2021, which were in turn obtained through open-ended google searches using multiple keywords, including “flint” (flint only), “detroit” (detroit only), “flint water crisis” (flint only), “lead”, “poisoning”, “education”, and “children”. separately, the total count and number of interactions data for all posts and web links shared on official facebook pages of michigan local media (data s1) with the keywords “lead poisoned” during january 2016-november 2020 were downloaded from crowdtangle (www.crowdtangle.org) and network maps were plotted in gephi v0.9.2 (crowdtangle, 2020). statistical analyses all analyses were conducted in excel® 2016 (microsoft), sas® 9.4 (sas institute, cary nc), or graphpad prism 8.4.3 (graphpad software). general linear mixed-effects model­ ing was used to model changes in binary effects over time, between flint and detroit (both nested within michigan). data are presented as mean with 95% confidence inter­ vals. pairwise planned comparisons sliced through each year were made and p < .05 was considered significant after false discovery rate adjustment within each outcome. all tests were two tailed. no further adjustment for multiple comparisons was performed. ordinary least squares regression lines were fitted between log of percentage students enrolled in special education and log %ebl in the same years and the slopes compared within graphpad prism. results this retrospective population-based cohort study utilized longitudinal datasets (de-iden­ tified aggregated yearly data) for flint, the control city detroit, and the entire state nocebo effect and special education in flint 6 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 http://www.crowdtangle.org https://www.psychopen.eu/ of michigan to examine the hypothesized link between lead exposure and educational outcomes. elevated blood lead the proportion of children < 6 years with elevated blood lead (%ebl) at or above the 5 μg/dl cdc reference level decreased significantly from 2011 to 2019, p(time) < .0001, in flint, detroit and michigan overall. the %ebl in flint steadily decreased by 65.8% between 2011-19 from 5.42% to 1.85%, risk ratio = 0.43, 95% ci [0.33, 0.56], p < .0001, notwithstanding the fwc increase that occurred in the months of june-august 2014 immediately following the water switch (1,17). the corresponding %ebl in detroit and michigan also saw large decrements of 41.3%, risk ratio = 0.69, 95% ci [0.65, 0.74], p < .0001) and 55.3%, risk ratio = 0.58, 95% ci [0.56, 0.61] from 2011-2019, respectively (figure 1a). there were also substantial differences in %ebl between flint, detroit and all of michigan (figure 1a) (p(time*center) < .0001). specifically, %ebl in flint was 47-77% lower than for detroit during 2011-19. even in the worst fwc year of 2014, children in detroit had more than double the %ebl of flint. the %ebl in flint (which comprised 2.2% to 2.4% of the state population) was also 13-35% lower than for the state of michigan between 2012-19, with the exception of 2014 when flint exceeded the %ebl in michigan by 0.20 percentage points (i.e., 3.72% in flint vs. 3.52% in michigan). in other words, the net effect of the fwc, was to temporarily raise the blood lead of flint children, up to the average for all data reported by the state of michigan. the relative trends between flint, detroit, and michigan at the pre-2012 cdc 10 μg/dl “level of concern” blood lead threshold (%ebl10) were somewhat similar (figure s1) to those seen at the 5 μg/dl level (%ebl). the %ebl10 for flint was statistically indistinguishable from michigan during 2011-19 even during the 2014 and 2015 fwc years. finally, the %ebl10 for flint was 65-77% lower than detroit (p < .00001) for the entire 2011-19 time period. roy, petrie, gamble, & edwards 7 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ figure 1 childhood blood lead and educational outcomes 2011 2012 2013 2014 2015 2016 2017 2018 2019 12 10 8 6 4 2 0% c hi ld re n ≤ 5 ye ar s ol d w ith el ev at ed bl oo d le ad (≥ 5μ g/ dl ) fwc flint 0.20 percent points higher than michigan during worst fwc year 0 20 40 60 80 % 3r d g ra de re ad in g pr of ic ie nc y fwc meap m-step 0 5 10 15 20 25 % sp ec ia le du ca tio n fwc 0 5 10 15 % sp ec ia le du ca tio n: su sp en si on /e xp ul si on ra te fwc target: <3.7-4.5% d. 20 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 log(% elevated blood lead) 1.0 1.1 1.2 1.3 1.4 lo g( % sp ec ia le du ca tio n) 2011 2015220101342016 2012 20128017 2019 2011 2013 2014 2015 2016 2017 2019 2011 20122017 202125010416 2200123 20192018 detroit (slope= +0.28 (95% ci -0.14, +0.70) p=0.16) flint (slope= -0.51 (95% ci -0.90, -0.12) p=0.02) michigan (slope= -0.02 (95% ci -0.10, +0.05) p=0.46) } p=0.005 35 30 25 20 15 10 5 0 % sp ec ia le du ca tio n: d ro po ut ra te fwc a. b. c. 2018 e. f. note. trends in (a) percentage of children < 6 years of age with elevated blood lead ≥ 5 μg/dl (%ebl), (b) enrollment of public school students in special education programs, (d) special education suspension/expulsion rates, (e) special education dropout rates, and (f) general education 3rd grade reading proficiency*, for flint, detroit, and michigan, 2011-19 (and corresponding school years of 2011-12 to 2019-20). error bars are +/95% confidence intervals and maybe contained within symbols. (c) scatter plot between %ebl vs. special education enrollment rate for flint, detroit, and michigan by year. 95% confidence bands for the ordinary least squares fits are shown. p value shown is for comparison of slopes. *the state of michigan followed the michigan educational assessment program (meap) testing standards until 2013-14 and then switched to michigan student test of educational progress (m-step) starting 2014-15. nocebo effect and special education in flint 8 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ analysis at the individual child-level was conducted to consider isolated cases of anoma­ lously high blood lead from acute exposure during the fwc that were possibly masked by yearly aggregated trends (i.e., figure 1a). plotting blood lead measurements of every tested child in flint and detroit with blood lead ≥ 5 µg/dl (figure 2a-2b) and comparing the count and percentage of children in flint, detroit, and michigan with blood lead ≥ 5, 10, 20, 25 and 40 µg/dl (figure 3) during the fwc period of 539 days (april 25 2014-october 16 2015) revealed: a. the mean blood lead of all children with blood lead ≥ 5 µg/dl in detroit was 12.4% higher than in flint (unpaired two-tailed t-test; p < .05). b. the count of detroit children was higher than flint children in every blood lead category (≥ 5-40 µg/dl). c. detroit children had statistically higher blood lead than flint children at and above the 5 and 10 µg/dl blood lead thresholds. d. data for flint children were statistically indistinguishable from that reported for all state of michigan children in every blood lead category (≥ 5-40 µg/dl). e. there were 28 children who tested at or above 40 µg/dl in michigan during the fwc period, of which half (14) were in detroit and none (0) in flint. f. there were four flint children with blood lead at or above 25 µg/dl, both during the fwc and in the same time duration pre-fwc (november 1 2012 – april 24 2014). overall educational outcomes of 23 special education outcomes monitored each academic year, nine worsened, nine improved and five did not change (≤±1% change) in flint after the crisis vis-à-vis before the water crisis (see text s2, supplementary materials). in a simple comparison relative to detroit, only three outcomes worsened and another three improved in flint. despite these overall neutral trends, four worsening outcomes in flint were nonethe­ less emphasized and attributed to lead exposure from the fwc by the national media and experts (aclu, 2016; alfonsi, 2020; green, 2019; redlener, 2018; riley, 2018; strauss, 2019) including: a) special education enrollment; b) suspension or expulsion for children in special education; c) dropout for children in special education, and d) worsening reading proficiency of 3rd grade students in general education. roy, petrie, gamble, & edwards 9 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ figure 2 individual child-level blood lead measurements ≥ 5 µg/dl during the fwc period (april 25 2014-october 16 2015) 0 20 40 60 80 100 25.04.2014 21.10.2014 19.04.2015 16.10.2015 bl oo d le ad le ve ls ≥ 5 μg /d l detroit (n=2768) 0 20 40 60 80 100 25.04.2014 21.10.2014 19.04.2015 16.10.2015 bl oo d le ad le ve ls ≥ 5 μg /d l flint (n=202) a. b. note. (a) detroit and (b) flint. the data is de-duplicated; i.e., only highest blood lead value per child is shown. figure 3 percentage of children < 6 years of age with blood lead ≥ 5 – 40 µg/dl in flint, detroit, and michigan during april 25, 2014 – october 16, 2015 12 10 8 6 4 2 0 3. 6% 8. 1% 4. 1e -0 02 % 1. 3e -0 02 % 3. 9% 0. 6% 1. 8% 0. 6% 0. 1% 0. 4% 0. 1% 0. 1% 0. 2% 0. 1%% ab ov e th re sh ol d 5 μg/dl 10 μg/dl 20 μg/dl 25 μg/dl 40 μg/dl flint detroit michigan note. the cdc threshold for elevated blood lead was 40 µg/dl between 1973-75, 25 µg/dl between 1985-90, 10 µg/dl until 2012 and 5 µg/dl until 2021. nocebo effect and special education in flint 10 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ each of these attributions is examined in greater detail for flint community schools, detroit public schools community district, and all public schools in michigan using data for the academic years 2011-12 until 2019-20. special education enrollment was also examined from 2006-07 onwards to identify a baseline (figure 4), and 3rd grade reading proficiency was not analyzed in 2019-2020 since tests were cancelled due to the covid-19 pandemic. figure 4 special education enrollment in flint relative to detroit and michigan, 2006-20 -5 0 5 10 r el at iv e sp ec ia le du ca ti on en ro llm en t %( fl in t% -m ic hi ga n %) or (f lin t% d et ro it %) fwcflint rel. to michigan flint rel. to detroit mean 2006-2011 special education enrollment special education enrollment trends are routinely gathered under federal and state laws (individuals with disabilities act, 2004; michigan department of education, 2020; weiss & mettrick, 2010), and the data are significantly different for michigan, detroit and flint (p < .0001, figure 1b). overall, in the state of michigan, the proportion of children in special education remained stable between 2011-12 and 2019-20 at 12.9-13.5%. the special education enrollment rate in detroit slightly increased from 2011-12 to 2016-17 followed by a downtrend during 2017-18 to 2019-20 (figure 1b). the special education enrollment rate in flint started lower than detroit (p < .0001) in 2011-12 as would be expected due to lower blood lead levels alone, but began rising in 2015-16 (relative to the previous three academic years) after the federal emergency and aggressive national and roy, petrie, gamble, & edwards 11 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ international reporting on the fwc (green, 2019; jackson, 2017; pew research center, 2017). flint special education enrollment even surpassed that in detroit in 2017-18 (p < .0001). notably, the spike in flint special education enrollment rate only occurred in the 6-21 year age group, whereas the age group that would be considered most vulnerable to water lead exposure (i.e. those in the womb or up to age 1 during the fwc) saw no significant increase (figure s2). the special education enrollment rate in flint relative to michigan during 2013-15, including the first fwc year, was comparable to the 2006-11 baseline, but began to spike in the second fwc year (2015-16), when media coverage on the crisis increased markedly (see figure 4, “flint relative to michigan”). this was associated with a strong diverging trend between the special education rates for flint and detroit starting in 2016-17 (figure 1b). similarly, flint special education enrollment was much lower relative to detroit between 2011-16 (see figure 4, “flint relative to detroit”), became comparable in 2016-17, and increased dramatically from 2017-20. there is actually a strong inverse relationship (figure 1c) between %ebl and special education enrollment rate in flint, r = -0.79, 95% ci [-.96, -0.18], p = .021, but there is no such relationship for the same time period in detroit, r = 0.20, 95% ci [-0.59, 0.79], p = 0.63, or michigan, r = 0.09, 95% ci [0.66, 0.75], p = 0.83). special education suspension/expulsion rates the special education suspension/expulsion rates in flint increased 7.4 times in 2013-14 (13.6%) before the fwc began (figure 1d) compared to the previous two school years, and peaked in the first fwc year 2014-15 (14.1%), before dropping more than half in the second fwc year 2015-16 (6%). rates progressively rose during 2016-19 (9% to 11.2%) after the fwc came to light. special education dropout rates the special education dropout rates in flint roughly doubled in the 2017-20 school years (22.1%) versus 2014-17 (11.5%), after a steady decline during 2011-17 analogous to that occurring in detroit and michigan (figure 1e). general education reading proficiency after the state of michigan adopted the stricter michigan student test of educational progress (m-step) standard in the 2014-15 school year, both flint (22.3 percentage points) and michigan (19.9 percentage points) witnessed identical drops (around 20 percentage points) in 3rd grade reading proficiency between 2013-14 and 2014-15, but detroit fell even more precipitously (31 percentage points) (figure 1f). during the fwc (2014-16 school year) and until the 2018-2019 school year, 3rd grade reading proficiency stayed roughly the same in detroit, however flint continued to decrease until reaching the same level as detroit. nocebo effect and special education in flint 12 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ potential fwc covariates that could explain rising special education enrollment analyses of trends in covariates including waterborne contaminants besides lead, pover­ ty, poor nutrition, city of flint’s administration and emergency management decisions, and flint community schools’ policies and funding do not appear to be primarily asso­ ciated with the post-fwc rise in special education enrollment in flint (see text s1, supplementary materials). negative community expectations and media coverage the aggregated data from facebook, the dominant social media platform in the united states (perrin & anderson, 2019), obtained using the crowdtangle (www.crowdtangle.com) public insights tool owned and operated by facebook, indicate news around lead “poisoning” of flint children and worsening educational outcomes was interacted with hundreds of thousands of times and potentially reached tens of millions of users on facebook alone between 2015-21 (table s1). in contrast, there were just two articles about detroit children that saw just over 22,000 interactions. on average, 12.2% web traffic to news websites originate from social media, and, therefore, these reported values are gross underestimates of the total “reach” of news, which would include all newspaper and magazine hard copies read, news channel broadcasts watched, and radio programs and podcasts heard (alexa, 2020). to illustrate, the 60 minutes flint special edu­ cation episode (alfonsi, 2020) alone was interacted with over 27,000 times and potentially reached ~10 million users on facebook, and its television broadcast was also watched by over 10 million viewers on the cbs channel (table s1). negative pronouncements about lead exposure during the fwc period and educational difficulties in the media disproportionately originated from flint community leaders describing flint children, but similar claims were not made publicly by detroit community leaders (table s2) despite the much higher blood lead for detroit children (figure 1a, figure 2a, 2b, figure 3 and figure s1). a search for all posts and weblinks shared on official facebook pages of michigan local media (data s1) with the keywords “lead poisoned” and no mention of “flint” or “detroit” during january 2016-november 2020 time period using crowdtangle revealed over 80% articles (data s2) discussed the fwc. network mapping of these posts (fig­ ure 5) revealed the media outlets who shared the most articles and links to be from flint (wnem tv5, abc12, and the flint journal/mlive; collective n = 32) followed by prominent state-level newspapers detroit free press and the detroit news. moreover, the postings from michigan’s top three dailies by circulation (i.e., detroit free press, the flint journal/mlive, and detroit news) (agility pr, 2020) saw the most interactions (~35,000) in the form of reactions, shares, and comments. roy, petrie, gamble, & edwards 13 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 http://www.crowdtangle.com https://www.psychopen.eu/ fi gu re 5 n et w or k m ap pi ng o f a ll po st s an d w eb lin ks s ha re d on o ff ic ia l f ac eb oo k pa ge s of m ic hi ga n lo ca l m ed ia w ith th e k ey w or ds “ le ad p oi so ne d, ” ja n 20 16 -n ov 2 02 0 n ot e. (a ) m ed ia o ut le ts a rr an ge d by to ta l n um be r of p os ts /li nk s sh ar ed . ( b) m ed ia o ut le ts a rr an ge d by to ta l i nt er ac tio ns (r ea ct io ns , s ha re s, a nd c om m en ts ) o n po st s/ lin ks s ha re d. r aw v al ue s fo r al l m ed ia b ub bl es in th e m ap s ar e pr ov id ed in s i ( ta bl e s4 ). (i) t he s iz e of th e m ed ia b ub bl es is r el at iv e; i. e. , h ig he r th e m et ri c of in te re st , l ar ge r th e bu bb le . t he n um er ou s lin ks e m er gi ng fr om e ac h bu bb le in di ca te r es ha ri ng o f th e po st s/ lin ks to o th er f ac eb oo k pa ge s an d th e re pr es en ta tiv e bu bb le s ar e al so r el at iv el y si ze d ac co rd in g to th e m et ri c of in te re st . ( ii) t he f lin t j ou rn al b el on gs to th e pa re nt m ed ia c om pa ny m li ve a nd b ot h ha ve s ep ar at e fa ce bo ok p ag es . t he re fo re , w hi le th e pa ge s ap pe ar s ep ar at el y in th e le ft n et w or k m ap a s th ey d o in fa ce bo ok , t he ir in te ra ct io n m et ri cs a re a gg re ga te d in te xt . nocebo effect and special education in flint 14 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ discussion this investigation confirms that the proportion of young children with elevated blood lead in flint, detroit and michigan as a whole has been declining over the past 10 years. the %ebl trend in flint is very similar to that observed across michigan and has always been much lower than detroit. in fact, the %ebl in flint has now dropped below data for the united states (us centers for disease control and prevention, 2020). for additional perspective, the geometric mean blood lead even during the worst fwc year as reported in previous research (gómez et al., 2018), was lower than that reported in the european nations of france and poland (table s3). paradoxically, since the fwc was revealed in 2015 and residents were further protected from exposure to waterborne lead, flint saw a dramatic spike in special education enrollment, while such enrollment remained steady across michigan and even declined after 2015-16 in the control city of detroit. while lead is a neurotoxin with known potential for worsening educational outcomes (jusko et al., 2008; mendelsohn et al., 1998; surkan et al., 2007; watt et al., 1996), analysis of the data in flint relative to detroit is inconsistent with the attribution of rising special education enrollment in flint to lead exposure. the worst lead exposure from the fwc was of relatively short duration (about one-sixth of the entire time on flint river water; roy et al., 2019), and is set against a historic decline in blood lead in flint as well as detroit, michigan and nationally (dignam et al., 2019; gómez et al., 2018). the elevation in flint childhood blood lead was above the relatively new 5 μg/dl cdc reference threshold but not the 10 μg/dl threshold “level of concern” exceeded in washington dc children during its 2001-04 lead in drinking water crisis (roy et al., 2019). the number of individual children testing ≥ 25 μg/dl, a threshold above which it is reported that 20% of children require an average of nine years of special education (swinburn, 2016), was 18 times higher in detroit (0.21% of all children tested; n = 73) than in flint (0.08% of all children tested; n = 4) during the fwc. as early as january 2016, it was acknowledged that the worst-case incidence of elevated blood lead during the fwc was always less than half of the incidence in other michigan cities of detroit, grand rapids, and muskegon, and 3,800 other communities across the united states (frazier, 2018; lanphear, 2017a; mack, 2016; pell & schneyer, 2016; wilkinson, 2016). moreover, since %ebl in detroit was always at least twice that in flint before, during and after the fwc, worse outcomes, whether concurrent or lagged, would always be expected for detroit children, but such an impact is not observed in the time period of interest. instead, there is an incongruous inverse relationship between childhood blood lead and special education enrollment in flint, while no such relationship exists for detroit and michigan. despite an equal number of overall special education outcomes worsening and im­ proving (see text s1, supplementary materials), only those that superficially appeared to be worsening were publicized in the media. our detailed analysis shows these outcomes roy, petrie, gamble, & edwards 15 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ are insignificant or inconsistent with the actual lead exposure that occurred. specifically, the seven-fold jump in suspension/expulsion rates of special education students had occurred in 2013-14 before the onset of the crisis, and the comparison with detroit further discounts an association with lead exposure. indiscriminate enforcement of sus­ pension/expulsion policies before the fwc (d.r. v. michigan department of education, 2016) may have contributed to this spike. the special education dropout rates in flint only started to rise in 2017-18 post-fwc after expectations of such an outcome was widely publicized in the media starting late 2016. finally, the reduction in flint general education 3rd grade reading proficiency after adoption of a new academic standard in 2014-15 was also observed in the detroit control group, and could be attributed to the changed tests. the rise in special education enrollment in flint following the fwc was not associ­ ated with confounders of waterborne contaminants besides lead during the fwc, pover­ ty, poor nutrition, and emergency management. the flint schools’ failure to properly enforce special education policies and a severe budget deficit since the early 2010s may have contributed to less flint students being enrolled in special education programs pre-fwc, but the enrollment rate had returned to historical norms during the fwc. a nocebo effect is consistent with the trend of rising special education enrollment after the fwc was exposed (colloca & barsky, 2020; petrie & rief, 2019). as a top news story of 2016, the crisis engendered negative psychological effects described by residents as “flint fatigue,” and the surrounding international media coverage has contin­ ued for over five years with negative headlines (adams, 2016; associated press, 2020; cuthbertson et al., 2016; goodnough & atkinson, 2016; heard-garris et al., 2017; may, 2016). the news reports and their popularity on social media (table s1, figure 5) and negative perceptions of flint community leaders and parents (table s2) could have heightened negative expectations about the effects on children, who readily accept and act on information from those they trust (harris & corriveau, 2011; jaswal et al., 2010; landrum et al., 2013). contaminated water creates high public anxiety compared to other environmental concerns (petrie et al., 2001). for example, the psychological impact of the fwc caused increased tap water avoidance amongst us children nationwide after the fwc came to light (rosinger & young, 2020). the early speculation and worst case pre­ dictions of impacts on flint children were also made in a vacuum of trust, uncertainties in the timing and magnitude of the water lead exposure due to manipulation of official test results, and an acknowledged “failure of government at all levels” that caused the fwc (roy & edwards, 2019a). from 2016-18 arguments over the possible negative consequences of labeling flint children “poisoned” versus “exposed” played out in the media (clark & filardo, 2018; drum, 2017; gómez & dietrich, 2018; mays, 2018; schneider et al., 2016; shell, 2016). the worst negative expectations for special education enrollments in years following the fwc appear to have been realized, even though comprehensive blood and water nocebo effect and special education in flint 16 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ lead analyses eventually published in 2018-20 (gómez et al., 2018; gómez et al., 2019; roy et al., 2019; roy & edwards, 2020) contradict the popular belief that flint children experienced an unprecedented environmental lead exposure (figure 1a). moreover, in many cases, the national media – e.g., the new york times (green, 2019) and cbs 60 minutes (alfonsi, 2020) – have provided even worse prognoses, labeling flint children as brain damaged or lead poisoned (table s1). no comparable media labeling was applied to children in detroit (table s1, figure 5) or the other michigan cities with much higher %ebl incidence. a significant percentage of flint households experience water crisis-related stress and other negative psychological effects, are meeting criteria for psychological trauma, report behavioral problems in their children, and believe that “the crisis would never be fixed” (bosman & greeson, 2020; brooks & patel, 2022; ezell & chase, 2021; jones et al., 2022; reuben et al., 2022; sneed et al., 2020; trejo et al., 2022). a perception that flint’s water is still unsafe and a source of ongoing community concern is supported by continued high rates of bottled water use five years after the switchback to detroit water. bottled water use has persisted despite distribution of free lead filters, replacement of over 90% of lead pipes, and independent tests showing current flint water lead levels to be lower than observed in other michigan cities with old pipes (alfonsi, 2020; city of flint, 2022; flint cares, 2018; reuben et al., 2022; roy & edwards, 2019a, 2020). in fact, it is reported that some of flint’s youngest children have only bathed in and consumed bottled water their entire lives (alfonsi, 2020; fonger et al., 2019; herndon, 2018). exposure to feared contaminants such as lead is known to create nocebo responses (blettner et al., 2009; crichton et al., 2014; gruber et al., 2018; petrie et al., 2005; small & borus, 1987; witthöft & rubin, 2013). other suspected water contamination incidents have caused health complaints that were difficult to explain by the level of toxicological exposure (david & wessely, 1995; page et al., 2006). in the camelford water contamina­ tion incident in cornwall, england, health complaints were intensified by media interest, concerns about a conspiracy and litigation (david & wessely, 1995). however, in contrast to the fwc, those studies did not have direct data from continuous monitoring of the contaminant of concern in the blood of the affected population, or suitable control groups for comparison as in the research results presented herein. it has also been argued that the actual (and small) magnitude of elevation in children’s blood lead from the fwc does not matter in terms of the resulting health harm (e.g., hanna-attisha et al., 2018; kuehn, 2016; oleske et al., 2016; schmidt, 2018; schneider et al., 2016; stateside staff, 2018). however, the epidemiological study by lanphear and colleagues noted an inverse, supralinear dose-response relationship: a net decrease of 6.9 iq points, 95% ci [4.2, 9.4] for blood lead increment of 2.4 to 30 µg/dl, with the steepest drop of 3.9 iq points, 95% ci [2.4, 5.3] occurring for the lowest blood lead range of 2.4 to 10 µg/dl (lanphear et al., 2005). while the underlying (biological) roy, petrie, gamble, & edwards 17 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ mechanism has not been elucidated (lanphear, 2017b), the supralinear curve confirms the scientific principle that “the dose makes the poison” for lead. these data suggest that the rising enrollment in special education attributed to the fwc, may be associated with widespread negative expectations and not an elevation in blood lead. this possible nocebo effect in flint represents an unfortunate natural large-scale experiment, in which a population has been repeatedly informed by trusted national and international media sources that an unprecedented lead exposure event had occurred with severe long-term adverse repercussions to children, even when the data indicate that the actual lead exposure was normal for the state and less than nearby communities. two of this paper’s authors (mae/sr) personally witnessed such expectations during a science outreach program for over 1,000 k-12 flint students in march 2017 (edwards, 2017; jacques, 2018), where several teachers openly expressed their belief that flint children had been brain damaged, were incapable of learning, and that there was little point in trying to teach them (bouffard, 2018; edwards, 2017; jacques, 2018; roy & edwards, 2019c). trust of teachers in students and parents is a significant predictor of student achievement (goddard et al., 2001). these and similar expectations have been broadcast in the media for over five years (e.g., tables s1 and s2, figure 5) and can strongly influence children’s school performance and behavior, such as those previously documented in younger and stigmatized children from african-american and lower socioeconomic backgrounds (jussim et al., 1996). students who require and receive special education services do benefit from them (ballis & heath, 2021) and higher special education enrollments are not necessarily indicative of permanent brain damage or health harm from the water lead exposure. in fact, part of the rise might be viewed as part of a proactive effort to compensate for the failures of government at all levels that caused the fwc (wagner & kennedy, 2016). in any event, the media have never publicized this possible positive interpretation. importantly, the media messaging has not changed, in spite of ample evidence that the actual lead exposures in flint were not abnormally high relative to all of michigan and were much lower than neighboring detroit. it is possible that the harm from such messaging is continuing. for instance, the special education enrollment rate in flint for 2019-20 (22.7%) is now over 1.5-1.7 times the rates in detroit (14.7%), and is higher than michigan (13.5%) and the united states overall (14.1%) (us department of education, 2020), despite the fact that detroit children have always had more than double the incidence of %ebl than flint (figure 1a). this trend may even be accelerating due to universal special neuropsychological screening now being conducted for flint children, which has recently indicated an 80% diagnosis rate for “language, learning or intellectual disorders'' that are attributed to lead exposure from the fwc (alfonsi, 2020; chambers, 2019). nocebo effect and special education in flint 18 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ our study has limitations. this study is limited by reliance on existing blood lead datasets collected under standard screening practices, covering about 23% of young chil­ dren in michigan, 40% in detroit and 39% of genesee co. in 2016 (michigan department of health and human services, 2018). since this is a population-based study, we did not have educational outcomes data at the individual level to adjust for potential confound­ ers or to identify if multiple adverse outcomes were occurring for the same children. our study is also limited by the lack of charter school data. and finally, our central analyses were correlational, and should be interpreted with caution. in contrast, the strength of this population-based study is the utilization of over 1.44 million individual childhood blood lead measurements and annual monitoring of outcomes in general and special education occurring under uniform michigan educational policies in two cities with comparable demographics, using the same source of treated drinking water from lake huron except for the 18 months flint was served by the flint river and suffered the manmade public health crisis. the educational outcomes data are representative as they are weighted by city-level population instead of individual schools. the novel contribution of this study is uncovering of possible nocebo effect in the aftermath of a public health emergency involving a known neurotoxin, via an unfortunate natural experiment that could never have been studied intentionally. roy, petrie, gamble, & edwards 19 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://www.psychopen.eu/ funding: us environmental protection agency (#8399375); spring point partners, llc. acknowledgments: we are grateful to michigan department of health and human services’ childhood lead poisoning prevention program and especially their departmental specialist mr. daniel albright (access to the complete 2011-19 michigan blood lead dataset and review of this manuscript under the data user agreement), facebook crowdtangle and their former academics and research lead ms. naomi shiffman (onboarding and access to facebook crowdtangle), and the described and captioned media program (access to the 2017 “voices of flint” documentary). competing interests: mae and sr worked with flint residents to expose the flint water crisis, and their data, testimony and emails have been subpoenaed in several lawsuits. they are not party to any of these lawsuits. mae has been subpoenaed as a fact witness in many of the lawsuits, but he has refused all financial compensation for time spent on those activities. sr is serving as a scientific consultant in a flint lawsuit for vna starting december 21 2022 on biosolids research, a topic unrelated to this manuscript, and is expected to be financially compensated for that work. all other authors declare they have no competing interests. author contributions: s.r., k.j.p, and m.a.e. designed research; s.r., m.a.e. and g.d.g. performed research; s.r. and g.d.g. analyzed data; and s.r., k.j.p, g.d.g., and m.a.e. wrote the paper. twitter accounts: @siddharthaxroy, @keithpetrie data availability: all education data are publicly available on michigan department of education’s website www.mischooldata.org. blood lead data were obtained from michigan department of health and human services under a data user agreement (dua #202103-144) following irb approval (irb #202103-04-nr). the data can be made available from mdhhs upon completion of a data use agreement with the agency. the authors assume full responsibility for the analysis and interpretation of the data. all poverty and food assistance data are publicly available from the us census. all media coverage and facebook interactions data downloaded from crowdtangle are available in the supplementary materials. supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • figures s1 to s2 • tables s1 to s4 • texts s1 (including figure s3) to s2 (including figures s4 to s22 and table s5) • references • data s1 to s2 nocebo effect and special education in flint 20 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://twitter.com/siddharthaxroy https://twitter.com/keithpetrie http://www.mischooldata.org https://www.psychopen.eu/ index of supplementary materials roy, s., petrie, k. j., gamble, g., & edwards, m. a. 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(2022). understanding the psychosocial effects of the flint water crisis on school-age children in michigan. um education policy initiative. nocebo effect and special education in flint 28 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://doi.org/10.1016/j.watres.2019.05.091 https://247wallst.com/special-report/2017/06/16/50-worst-cities-to-live-in/11/ https://undark.org/2018/03/21/lead-testing-child-blood-levels/ https://www.scientificamerican.com/article/flint-s-lead-tainted-water-may-not-cause-permanent-brain-damage/#comment-1-f4ed7e7e-28e4-4dd5-bab17d9b3777606f https://www.scientificamerican.com/article/flint-s-lead-tainted-water-may-not-cause-permanent-brain-damage/#comment-1-f4ed7e7e-28e4-4dd5-bab17d9b3777606f https://www.scientificamerican.com/article/flint-s-lead-tainted-water-may-not-cause-permanent-brain-damage/ https://www.scientificamerican.com/article/flint-s-lead-tainted-water-may-not-cause-permanent-brain-damage/ https://doi.org/10.1007/bf01064608 https://doi.org/10.1007/s10597-019-00520-7 https://doi.org/10.1080/08964289.2020.1729085 https://www.michiganradio.org/post/pediatrician-says-poisoned-accurate-description-what-happened-flint-children https://www.michiganradio.org/post/pediatrician-says-poisoned-accurate-description-what-happened-flint-children https://www.washingtonpost.com/education/2019/07/03/how-flint-water-crisis-set-back-thousands-students/ https://www.washingtonpost.com/education/2019/07/03/how-flint-water-crisis-set-back-thousands-students/ https://doi.org/10.1097/01.ede.0000276597.40442.62 https://www.ecocenter.org/sites/default/files/2022-01/lead.report.designed.final__0.pdf https://www.psychopen.eu/ https://edpolicy.umich.edu/research/epi-policy-briefs/understanding-psychosocial-effects-flintwater-crisis-school-age university of wisconsin population health institute. 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(2016). kids' lead levels high in many michigan cities. the detroit news. https://www.detroitnews.com/story/news/michigan/flint-water-crisis/2016/01/27/manymichigan-cities-higher-lead-levels-flint/79438144/ witthöft, m., & rubin, g. j. (2013). are media warnings about the adverse health effects of modern life self-fulfilling? an experimental study on idiopathic environmental intolerance attributed to electromagnetic fields (iei-emf). journal of psychosomatic research, 74(3), 206–212. https://doi.org/10.1016/j.jpsychores.2012.12.002 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. roy, petrie, gamble, & edwards 29 clinical psychology in europe 2023, vol. 5(1), article e9577 https://doi.org/10.32872/cpe.9577 https://edpolicy.umich.edu/research/epi-policy-briefs/understanding-psychosocial-effects-flint-water-crisis-school-age https://edpolicy.umich.edu/research/epi-policy-briefs/understanding-psychosocial-effects-flint-water-crisis-school-age https://www.countyhealthrankings.org https://data.census.gov/ https://www.cdc.gov/nceh/lead/prevention/blood-lead-levels.htm https://nces.ed.gov/programs/digest/d19/tables/dt19_204.50.asp https://doi.org/10.1001/jama.2019.3326 https://www.npr.org/sections/thetwo-way/2016/03/17/470792212/watch-michigan-gov-rick-snyder-testifies-on-the-flint-water-crisis https://www.npr.org/sections/thetwo-way/2016/03/17/470792212/watch-michigan-gov-rick-snyder-testifies-on-the-flint-water-crisis https://doi.org/10.1136/bmj.313.7063.979 https://www.detroitnews.com/story/news/michigan/flint-water-crisis/2016/01/27/many-michigan-cities-higher-lead-levels-flint/79438144/ https://www.detroitnews.com/story/news/michigan/flint-water-crisis/2016/01/27/many-michigan-cities-higher-lead-levels-flint/79438144/ https://doi.org/10.1016/j.jpsychores.2012.12.002 https://www.psychopen.eu/ nocebo effect and special education in flint (introduction) materials and method elevated blood lead educational outcomes poverty and nutrition media coverage and social media interactions statistical analyses results elevated blood lead overall educational outcomes potential fwc covariates that could explain rising special education enrollment discussion (additional information) funding acknowledgments competing interests author contributions twitter accounts data availability supplementary materials references explaining the efficacy of an internet-based behavioral activation intervention for major depression: a mechanistic study of a randomized-controlled trial research articles explaining the efficacy of an internet-based behavioral activation intervention for major depression: a mechanistic study of a randomized-controlled trial zhongfang fu 1, huibert burger 2, retha arjadi 3,4, maaike h. nauta 4, claudi l. h. bockting 1,5 [1] department of psychiatry, amsterdam university medical centers, location amc, university of amsterdam, amsterdam, the netherlands. [2] department of general practice and elderly care medicine, university medical center groningen, university of groningen, groningen, the netherlands. [3] faculty of psychology, atma jaya catholic university of indonesia, jakarta, indonesia. [4] department of clinical psychology and experimental psychopathology, university of groningen, groningen, the netherlands. [5] centre for urban mental health, university of amsterdam, amsterdam, the netherlands. clinical psychology in europe, 2021, vol. 3(3), article e5467, https://doi.org/10.32872/cpe.5467 received: 2020-12-20 • accepted: 2021-08-16 • published (vor): 2021-09-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: claudi l. h. bockting, meibergdreef 5, 1105 az amsterdam, the netherlands. e-mail: c.l.bockting@amsterdamumc.nl supplementary materials: materials [see index of supplementary materials] abstract background: behavioral activation is an effective treatment for depression that is theorized to facilitate structured increases in enjoyable activities that increase opportunities for contact with positive reinforcement; to date, however, only few mechanistic studies focused on a standalone intervention. method: interventions using internet-based behavioral activation or psychoeducation were compared based on data from a randomized-controlled trial of 313 patients with major depressive disorder. activation level and depression were measured fortnightly (baseline, weeks 2, 4, 6, 8, 10), using the patient health questionnaire-9 and the behavioral activation for depression scale-short form, respectively. analysis was performed to determine if a change in activation level mediated treatment efficacy. results: latent growth modeling showed that internet-based behavioral activation treatment significantly reduced depressive symptoms from baseline to the end of treatment (standardized coefficient = −.13, p = .017) by increasing the rate of growth in the activation level (mediated effect this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5467&domain=pdf&date_stamp=2021-09-30 https://orcid.org/0000-0002-9220-9244 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ estimate = −.17, 95% ci [−.27, −.07]. results from mixed effects and simplex models showed that it took 4 weeks before mediation occurred (i.e., a significant change in activation that led to a reduction in depressive symptoms). conclusion: activation level likely mediated the therapeutic effect of behavioral activation on depression in our intervention. this finding may be of significant value to clinicians and depressed individuals who should anticipate a 4-week window before seeing a prominent change in activation level and a 6-week window before depressive symptomatology reduces. future research must consolidate our findings on how behavioral activation works and when mediation occurs. keywords psychological interventions, working mechanisms, behavioral activation, depression, internet-based intervention, lay counselors highlights • activation level mediates depression outcomes in an 8-week internet-based behavioral intervention. • internet-based behavioral activation appeared to work by changing the level of activation at week 4 and reducing depressive symptoms over the next 2 weeks. • internet-based treatment requires patience and perseverance from clinicians and patients. background depression is a prevalent and disabling mental health condition characterized by sadness and lack of interest (american psychiatry association, 2015). behavioral activation is well-established as an effective treatment (cuijpers, van straten, & warmerdam, 2007; stein, carl, cuijpers, karyotaki, & smits, 2021) and as a standalone therapy in relevant clinical guidelines (national collaborating centre for mental health [uk], 2010). it is also considered a cost-effective therapy that can be delivered easily and disseminated in a range of formats (arjadi et al., 2018; carlbring et al., 2013). however, more research is needed to clarify uncertainties about how behavioral activation exerts its clinical effects (janssen et al., 2020). rooted in behavioral frameworks, the theory underpinning behavioral activation con­ ceptualizes depression as the result of low levels of (response-contingent) positive rein­ forcement: the consequences of environmental interaction that increase the likelihood of a given behavior (ferster, 1973, 1981; lazarus, 1972; lewinsohn, 1974). the theory posits that a lack of this positive reinforcement can result in decreased behavioral activation or withdrawal from the environment, which precipitates depression (manos, kanter, & busch, 2010). therefore, actively engaging in behavioral activation can help to break the negative cycle of depression by promoting meaningful and adaptive engagement in life (martell, dimidjian, & herman-dunn, 2013). this strong theoretical basis allows for mechanism of behavioral activation intervention 2 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ changes in levels of activation and avoidance (i.e., the activation level) to be evaluated as the hypothesized mediator of change in depressive symptoms during treatment (curry & meyer, 2016). however, two research gaps remain. first, contrasting starkly with research into cognitive processes, there is limited empirical evidence of activation level as a potential mediator (lemmens, müller, arntz, & huibers, 2016; moreno-peral et al., 2020). second, mediators have rarely been examined in randomized-controlled trials (rcts) of behavioral activation as a standalone treatment (janssen et al., 2020). further study is needed to correct this lack of mechanistic research into mediation processes. most research into behavioral activation has investigated it as a component of cog­ nitive behavior therapy (e.g., van luenen, kraaij, spinhoven, wilderjans, & garnefski, 2019), for which the underlying theoretical assumption differs, suggesting instead that behavioral change helps to improve symptoms through cognitive restructuring. to date, ten studies have examined activation level for the treatment of depression (dimidjian et al., 2017; forand et al., 2018; gaynor & harris, 2008; nasrin, rimes, reinecke, rinck, & barnhofer, 2017; richards et al., 2017; rovner et al., 2014; santos et al., 2019; silverstein et al., 2018; van luenen et al., 2019; weidberg, gonzález-roz, garcía-fernández, & secades-villa, 2021). among these, four investigated a standalone behavioral activation intervention, producing inconsistent results, and none assessed both depression and activation during treatment, precluding mediation analyses. the inconsistent findings likely result from clinical heterogeneity and a failure to meet specific methodological requirements, such as using an rct design, examining variables of interest longitudinal­ ly to assess temporal ordering, and being sufficiently large to ensure robust statistical analyses (curran et al., 2010; kazdin, 2007; lemmens et al., 2016). studies assessing the activation level as a mediator of depression treatment have not complied with all these requirements (janssen et al., 2020), with some adopting small samples (e.g., <40 per trial arm) (gaynor & harris, 2008) and others using too few repeat observations (e.g., <3) (richards et al., 2017; weidberg et al., 2021) or no control group (e.g., santos et al., 2019). thus, adequately powered trials of standalone behavioral activation interventions for depression are needed to clarify the extent to which the activation level mediates treatment outcomes. our group has previously conducted an rct for an internet-based intervention in­ volving a large sample of patients with major depressive disorder treated by behavioral activation under the guidance of lay counselors (intervention) compared with psycho­ education (controls) (arjadi et al., 2018). in that study, we concluded that, after 10 weeks, patients in the intervention group reported significantly fewer depressive symptoms (effect size, 0.24) and had a 50% higher chance of remission than those in the control group. crucially, this study complied fully with the methodological requirements of mechanistic research into mediation processes. in the present study, we therefore aimed to use data from that study to demonstrate that the activation level mediates the relation­ ship between treatment with behavioral activation and improved depression. this was fu, burger, arjadi et al. 3 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ considered achievable if we could demonstrate two criteria (kazdin, 2007; mackinnon, 2008). first, that the treatment condition correlated with changes in the activation level, which in turn, correlated with changes in depressive symptoms and was conditional on treatment allocation (criterion 1). second, that the change in activation level produced the change in depressive symptoms, and not vice versa (i.e., temporal ordering; criteri­ on 2). materials and method design this study reports on a post-hoc analysis of an earlier two-group rct of an inter­ net-based behavioral activation program for patients with major depressive disorders (n = 313). details of the original rct are reported elsewhere (arjadi et al., 2018). all assessments were completed on the qualtrics survey platform and administered at baseline and every 2 weeks thereafter up to the main post-treatment evaluation at week 10 (endpoint), with follow-up at 12 and 24 weeks after baseline. for the purposes of the current study, depression and activation level were examined fortnightly at baseline and at weeks 2, 4, 6, 8, and 10. participants and randomization in total, 313 participants were included and randomized into the treatment (n = 159) and control (n = 154) groups (see arjadi et al., 2018, for a detailed flowchart). the baseline characteristics we comparable in each group, as presented in table 1, indicating successful randomization. participants were recruited via online self-referral. eligible participants were aged ≥16 years, scored ≥10 on the patient health questionnaire-9 (phq-9), and had a principal diagnosis of major depressive disorder or persistent de­ pressive disorder defined according to the diagnostic and statistical manual of mental disorders, fifth edition. diagnosis was by semi-structured diagnostic interview (scid-5) (first et al., 2015). participants with current substance use disorder, current or previous manic or hypomanic episodes, psychotic disorder, or acute suicidality were excluded, as were those receiving psychological interventions. eligible participants were allocated (1:1) by a research assistant in a random permuted block design stratified by sex and depression severity (score 10–14 or ≥15 on the phq-9) via a web-based program. current depressive episodes and post-traumatic stress disorder were assessed by clinical diagnostic interview conducted by trained clinical interviewers who were required to hold at least a bachelor’s degree in psychology. mechanism of behavioral activation intervention 4 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ table 1 descriptive statistics of baseline demographic characteristics demographic information gaf (n = 159)a pe (n = 154)a age (m, sd) 24.5 (4.9) 24.5 (5.2) sex female 128 125 male 31 29 current ptsd yes 22 30 no 137 124 education above bachelor 89 81 others 70 73 living area urban 93 96 others 67 58 socioeconomic class low 32 27 middle 98 100 high 29 27 ethnicity java 69 64 tionghoa 30 18 sunda 21 22 others 39 40 anote that all patients were in a depressive episode. abbreviations: gaf = guided act-and-feel-indonesia; pe = psychoeducation; ptsd = post-traumatic stress disor­ der; sd = standard deviation. treatments intervention group: guided act-and-feel-indonesia (gaf-id) participants in the intervention group received an internet-based behavioral activation intervention (the gaf-id) supported by lay counselors. the intervention program was adapted from an online intervention for behavioral activation based on lewinsohn’s (1974) theory of depression. the original program was published in dutch (doe en voel; bockting & van valen, 2015) and was translated to bahasa indonesian. the gaf-id program was delivered using an online platform in eight structured modules delivered weekly. each module was expected to be completed online in 30–45 minutes. the inter­ vention group was guided and supported by lay counselors who were supervised by fu, burger, arjadi et al. 5 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ a licensed clinical psychologist. a detailed description of the guidance and support is available elsewhere (arjadi et al., 2018). control group: online psychoeducation participants in the control group were given access to another online platform from which they could find basic psychoeducation on depression and brief tips on coping with depression in general. this information was distilled from the psychoeducation module of the gaf-id program, but no guidance or support was provided. measures demographic information was collected at baseline, including age, gender, ethnicity, education (above bachelor/other), living area (urban/other), and socioeconomic class. the latter was determined by monthly expenditure in indonesian rupiah (idr): low, <1 million; middle, 1–5 million; and high, >5 million. in addition, the phq-9 and behavioral activation for depression scale-short form (bads-sf) were completed fortnightly. patient health questionnaire-9 item version the phq-9 is a 9-item self-report questionnaire in which participants rate how they felt during the previous two weeks (e.g., “feeling tired or having little energy”). each question is scored 0 to 3 (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day). sum scores range from 0 to 27, with higher scores representing higher levels of depression. the phq-9 has acceptable validity and reliability (carroll et al., 2020), and the cronbach’s alphas in the current study ranged from .78 to .87 at the different assessments. behavioral activation for depression scale-short form the bads-sf is a 9-item self-report questionnaire that measures changes in activation and avoidance in the previous week (e.g., “there were certain things i needed to do that i didn’t do”). each question is scored 0 to 6 (0 = not at all, 6 = completely). items 1, 6, 7, and 8 are reverse-coded. sum scores can range from 0 to 54, with higher scores representing higher activation. the validity and reliability of bads-sf have been established (manos, kanter, & luo, 2011), and the cronbach’s alphas in the current study ranged from .78 to .88 at different assessments. data analysis mixed effects model to compare mean depression and activation levels mixed effects models were used to inspect how treatment influenced activation level and depression at each time point. baseline and follow-up measures were treated as response variables. missing values were imputed by multiple imputation, including treatment mechanism of behavioral activation intervention 6 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ allocation and all phq-9 and bads-sf assessments in the predictor matrix. given that the functional form of the mean responses during treatment can be difficult to anticipate, time was specified as a class effect in an unstructured manner. the contrasts between treatment groups at each time point were obtained by comparing the least squares means of the variables of interest. mixed effect analyses were conducted using the nlme r package (pinheiro, bates, debroy, sarkar, & r core team, 2020), and for multiple imputations, we used the mice r package (van buuren & groothuis-oudshoorn, 2011). mediation analyses using latent growth and simplex mediation models mediation analyses were based on latent growth models to address criterion 1 (mackinnon, cheong, & pirlott, 2012) and simplex mediation models to address criterion 2 (goldsmith et al., 2018) in a structural equation model framework. we refer to the path estimating the relationship between treatment allocation (t) and activation level (m) as the a path and refer to the path between activation level and depression (y) as the b path. the direct effect from treatment allocation to depression is noted as the c path, after accounting for m as c′. the product of a × b coefficients method was used to indicate the indirect effect (goldsmith et al., 2018). coefficients were provided based on a completely standardized solution, and the confidence intervals of a × b were estimated by bootstrapping (1,000 times). a mediated effect was deemed statistically significant if the 95% confidence interval (95% ci) did not cross zero. latent growth model analyses were performed in three steps to model the rela­ tionship between treatment and the growth trajectories of activation and depression (cheong, mackinnon, & khoo, 2003). first, to investigate the shape of the growth trajec­ tories for depression and activation, unconditional growth models were built. second, to examine if the growth rates of depression and activation differed by treatment con­ dition, two conditional models were constructed with the treatment conditions. third, to assess the indirect effect of treatment allocation on the outcome, via the mediator (activation level), we combined the two conditional growth models into a parallel process growth model. in this, the path coefficients (a, b, c, and c′) of the mediation model were estimated and the contributions of baseline characteristics as covariates were examined (e.g., sex, ethnicity, urban/rural, socioeconomic status, post-traumatic stress disorder, and education level). a simplex mediation model was then adopted to determine if there was temporal ordering. this was achieved by evaluating whether a prior activation level was associ­ ated with the level of depression at a subsequent measurement. we specified models as either a lagged b path (activation affects depression at adjacent time points) or a contemporaneous b path (activation affects depression at the same time point). we added treatment allocation as a time-invariant antecedent variable to predict depression and activation level at each time point. autoregressive and cross-lagged effects were constrained to be equal over time (goldsmith et al., 2018). to assess the timing of the fu, burger, arjadi et al. 7 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ potential mediation process, a paths were freely estimated. in addition, to evaluate the extent to which prior depression influenced the subsequent activation level, we reversed the position of depression and activation level in a supplementary analysis (see supple­ mentary materials). the time-specific indirect effect was estimated using a series of product terms to indicate the possible timing of the putative mediator taking effect. figure 1 shows an example simplex model with lagged b paths: for the third time point, depression y3 (i.e., week 4 depression), one indirect effect of treatment could be t→ m2 →y3. calculation was performed as a2 × b23, where the subscripts indicated direction (e.g., the coefficient a2 was the effect to activation at point 2, and b23 was the effect from activation at point 2 to depression at point 3, and all b paths were considered equal). a significant result could suggest a lagged mediation effect from week 2 activation (m2) to week 4 depression (y3). the overall indirect effect in the model for y3 was the sum of all time-specific indirect effects estimated by the products of the parameters that estimated the paths between t and y3 and passed through the mediator. coefficient a at baseline (i.e., a1) was fixed at zero because treatment had not been implemented at this time. figure 1 example diagram of simplex models for mediation with contemporaneous b paths (right side) and lagged b paths (left side) with depression at third timepoint (week 6) as outcome note. abbreviations: a2 = parameter estimated coefficient from treatment to week 4 behavioral activation; b = parameter estimated coefficient from mediator to outcome; b0 = parameter estimated coefficient from baseline mediator to week 2 depression; ba, behavioral activation; bads(1, 2, 3, 4, 5, 6) = behavioral activation of depression scale-short form (baseline and 2, 4, 6, 8, 10 weeks, respectively); c′2, c′3 = parameter estimated coefficient from treatment to week 4, 6 depression after controlled for intermediate behavioral activation; phq(1, 2, 3, 4, 5, 6) = patient health questionnaire-9 items (baseline and 2, 4, 6, 8, 10 weeks, respectively). data were assumed to be missing at random or completely at random (graham, 2009), so we used a full-information maximum likelihood estimation in the structural equation mechanism of behavioral activation intervention 8 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ modeling analysis. participants who had at least one measurement for depression were retained in the model and analysis performed on an intention-to-treat basis. model fit was assessed by the comparative fit index (cfi), tucker–lewis index (tli), root mean squared error of approximation (rmsea), and standardized root mean square residual (srmr). we used established guidelines of acceptable fit, requiring that the cfi and tli should exceed 0.90–0.95, that the rmsea should not exceed 0.06–0.10, and that the srmr should not exceed 0.08. all structural equation modeling analyses were performed in mplus 8.3 (muthén & muthén, 2019). results a full overview of the levels of activation and depression at each measurement is presented in table 2. table 2 means and standard deviations of phq-9 and bad-sf for each group at each assessment measure gaf-id pe missing means sd missing means sd depression (phq-9) week 0 (baseline) 0 17.92 5.39 0 18.01 5.05 week 2 21 12.04 6.05 2 12.81 5.97 week 4 33 10.53 6.04 10 11.33 6.01 week 6 31 9.79 5.80 8 11.18 5.85 week 8 43 9.07 6.22 11 10.48 6.12 week 10 (endpoint) 39 8.50 5.75 9 10.83 6.21 behavioral activation (bads-sf) week 0 (baseline) 0 16.67 6.72 0 16.38 6.29 week 2 21 19.59 6.75 2 18.68 6.64 week 4 33 23.22 7.32 10 19.93 6.87 week 6 31 24.11 7.94 8 20.57 7.61 week 8 43 24.93 8.06 11 22.22 7.72 week 10 (endpoint) 39 24.12 7.37 9 20.73 7.45 note. abbreviations: bads-sf = behavioral activation for depression scale – short form; gaf = guided act­ and-feel-indonesia; pe = psychoeducation; phq-9 = patient health questionnaire-9; sd = standard deviation. each fortnightly assessment was completed by at least 83% of the sample, but 17.5% of all data points were missing in the gaf-id group versus 4.3% in the control group. participants in both groups had at least 4 data points (83.6% for the gaf-id group and 95.4% for the control group). the main reasons for dropout at week 10 were “no time” fu, burger, arjadi et al. 9 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ (18 in the gaf-id group) and “no improvement” (12 in gaf-id group and 6 in the control group). mixed effects model: differences of depression and activation level treatment allocation had significant effects on depression (p < .001) and activation (p < .001) across all included time points. as shown in table 3, the mean differences in activation and depression increased over time between the treatment and control groups, reaching statistical significance from week 4 (assessment 3) for activation and week 6 (assessment 4) for depression. table 3 means difference of depression and activation between treatment and control groups over time (unstructured time model) time point lsmd se 95% ci p value behavioral activation (bads-sf) week 0 (baseline) 0.30 0.74 [−0.77, 1.36] .688 week 2 0.70 0.77 [−0.46, 1.87] .360 week 4 3.47 0.94 [1.72, 5.21] < .001 week 6 3.41 1.01 [1.39, 5.42] .002 week 8 2.86 0.96 [1.05, 4.63] .004 week 10 (endpoint) 3.36 0.89 [1.82, 4.91] < .001 depression (phq-9) week 0 (baseline) −0.08 0.59 [−0.77, 0.60] .890 week 2 −0.61 0.69 [−1.55, 0.33] .379 week 4 −0.97 0.72 [−1.97, 0.04] .178 week 6 −1.41 0.68 [−2.31, −0.50] .039 week 8 −1.76 0.74 [−0.68, −2.84] .019 week 10 (endpoint) −2.59 0.71 [−3.56, −1.61] < .001 note. abbreviations: bads-sf = behavioral activation for depression scale-short form; ci = confidence interval; lsmd = least squares mean difference; pe = psychoeducation; phq-9 = patient health questionnaire-9; se = standard error. latent growth model for mediation unconditional growth model model fit indices, as shown in table 4, were acceptable. the rmsea for the model of depression was higher than that of activation level, suggesting that the variance in depression could be explained by a potential covariate (e.g., treatment). mechanism of behavioral activation intervention 10 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ table 4 fit indices of latent growth models model cfi tli rmsea (90%ci) srmr depression (unconditional model) 0.96 0.94 0.11 [0.08, 0.14] 0.07 treatment–depression 0.96 0.94 0.09 [0.07, 0.12] 0.06 ba (unconditional model) 0.99 0.99 0.04 [0, 0.08] 0.04 treatment–ba 0.99 0.99 0.04 [0, 0.07] 0.04 treatment–ba–depression 0.97 0.96 0.05 [0.04, 0.07] 0.05 note. abbreviations: ba = behavioral activation; cfi = comparative fit index; ci = confidence interval; rmsea = root mean squared error of approximation; srmr = standardized root mean square residual; tli = tucker–lewis index. conditional growth models: the effect of treatment the fitness of both conditional models appeared acceptable (table 4). the gaf-id group showed a larger increase in activation (standardized coefficient = .27, p < .001) and a larg­ er reduction in depression compared with the control group (standardized coefficient = −.13, p = .017). this confirmed that treatment was efficacious in producing a difference in trajectories between the treatment and control groups. parallel process growth models: the mediation effect model fit of the parallel process growth model was acceptable (figure 2). factor loadings of the slope growth factor indicating the predicted trajectory of depression and activa­ tion are presented in table 5. table 5 growth factor loadings for intercept and slope factors in the parallel latent growth models for depression and activation level time point depression (phq-9) behavioral activation (bads-sf) intercept slope intercept slope week 0 (baseline) 1 0 1 0 week 2 1 0.65 1 0.42 week 4 1 0.85 1 0.84 week 6 1 0.93 1 1.00 week 8 1 1.01 1 1.17 week 10 (endpoint) 1 1.00 1 1.00 note. abbreviations: bads-sf = behavioral activation for depression scale-short form; phq-9 = patient health questionnaire-9. fu, burger, arjadi et al. 11 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ consistent with the plotted growth trajectory for depression based on data for the whole sample (see figure 3a), there was a sharp decrease (0.65 unit) in depressive symptoms from the second week. the reduction in depression continued, reaching a trough at week 8 that persisted to week 10 (endpoint). a slightly different pattern was observed for the trajectory of the activation level. as shown in figure 3b and table 5, activation increased by 0.42 units after the second week of treatment, peaking at week 8 before decreasing slightly at week 10 (endpoint). figure 2 parallel process latent growth model of depression and activation level conditioned on treatment groups note. rectangles denote observed variables, and ellipses denote latent variables. bolded arrows indicated the significant prediction from treatment to growth of activation, growth of activation to growth of depression. dashed arrow indicated the insignificant prediction from treatment to growth of depression. abbreviations: bads(1, 2, 3, 4, 5, 6) = behavioral activation of depression scale-short form (baseline and 2, 4, 6, 8, 10 weeks, respectively); i.dep = intercept growth factor of depression; i.ba = intercept growth factor of behavioral activation; phq(1, 2, 3, 4, 5, 6) = patient health questionnaire-9 items (baseline and 2, 4, 6, 8, 10 weeks, respectively); s.ba = slope growth factor of behavioral activation; s.dep = slope growth factor of depression. mechanism of behavioral activation intervention 12 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ figure 3a trajectories of depression (phq-9) across measurements in treatment (gaf) and control (pe) groups note. gaf = guided act and feel treatment; pe = psychoeducation. figure 3b trajectories of activation (bads-sf) across measurements in treatment (gaf) and control (pe) groups note. gaf = guided act and feel treatment; pe = psychoeducation. fu, burger, arjadi et al. 13 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ treatment condition (gaf-id or control) was significantly associated with the slope factor of activation level (path a, standardized coefficient = 0.28, p < .001), which in turn was associated with the slope factor of depression (path b, standardized coefficient = −0.60, p < .001). after accounting for the growth trajectory of the activation level, the prediction that treatment affected depression was no longer significant (path c′, standar­ dized coefficient = 0.03, p = .483). table 6 shows that the estimated mediated effect (a × b product) was standardized as −0.17, 95% ci [−0.27, −0.07], p = .001. after adding the baseline characteristics as covariates, model fit was similar, cfi = 0.97, tli = 0.96, rmsea = 0.04, 90% ci [0.03, 0.05], and srmr = 0.05. the estimated mediated effect in this model was similar to that in the model without baseline characteristics as covariates, standardized estimate = −0.15, 95% ci [−0.25, −0.08], p < .001. table 6 regression coefficients of mediational parallel process growth models model standard coefficient se p value conditional models treatment–depression −0.13 0.06 .017 treatment– ba 0.27 0.06 < .001 parallel process model treatment–ba (a path) 0.28 0.06 < .001 ba–depression (b path) −0.60 0.08 < .001 treatment–depression (c′ path) 0.03 0.05 .483 a × b product −0.17 0.05 .001 note. abbreviations: ba = behavioral activation; se = standard error. time-specific mediation effect in the simplex models for the simplex models with activation level as a mediator, fit indices with a contempo­ raneous b path were adequate, cfi = 0.96, tli = 0.95, rmsea = 0.06, 90% ci [0.05, 0.08], and srmr = 0.07. table 7a shows that the contemporaneous indirect effect reached significance from week 6. table 7b summarizes the results with only significant lagged indirect paths, showing that the paths all passed through m3 (i.e., activation level at week 4) to influence either contemporary depression or subsequent mediators (mn), and ultimately, later depression. fit indices of the simplex mediation model with the lagged b path were adequate, cfi = 0.95, tli = 0.94, rmsea = 0.07, 90% ci [0.06, 0.08], and srmr = 0.08. as shown in table 7b, the indirect effect reached significance from week 6 onwards. as with the contemporaneous b paths, m3 was the only mediator to be passed through during the treatment. mechanism of behavioral activation intervention 14 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ table 7a simplex model with contemporaneous b paths for activation level as a mediator simplex for mediation with contemporaneous b path se p 95% ci time-specific outcome / significant paths and effect of treatment standardized estimate ll ul week 2 depression (y2) total effect −0.05 0.05 .320 −0.17 0.06 indirect effect −0.01 0.01 .379 −0.03 0.01 week 4 depression (y3) total effect −0.08 0.06 .189 −0.20 0.05 indirect effect −0.09 0.04 .035 −0.19 −0.001 t→m3→y3 −0.04 0.02 .006 −0.08 −0.01 week 6 depression (y4) total effect −0.13 0.06 .028 −0.25 −0.004 indirect effect −0.12 0.05 .016 −0.22 −0.01 t→m3→y3→y4 −0.03 0.01 .005 −0.06 −0.01 t→m3→m4→y4 −0.04 0.02 .006 −0.08 −0.02 week 8 depression (y5) total effect −0.15 0.06 .012 −0.27 −0.02 indirect effect −0.14 0.05 .003 −0.25 −0.04 t→m3→y3→y4→y5 −0.02 0.01 .004 −0.04 −0.01 t→m3→m4→y4→y5 −0.03 0.01 .004 −0.05 −0.01 t→m3→m4→m5→y5 −0.04 0.01 .005 −0.07 −0.01 week 10 depression (endpoint, y6) total effect −0.22 0.06 < .001 −0.34 −0.09 indirect effect −0.16 0.05 .001 −0.26 −0.06 t→m3→y3→y4→y5→y6 −0.02 0.01 .004 −0.03 −0.01 t→m3→m4→y4→y5→y6 −0.02 0.01 .004 −0.03 −0.01 t→m3→m4→m5→y5→y6 −0.03 0.01 .004 −0.05 −0.01 t→m3→m4→m5→m6→y6 −0.04 0.01 .005 −0.06 −0.01 note. only significant paths are shown to save space. abbreviations: m3, m4, m5 = mediator measurements (taken at weeks 4, 6, and 8, respectively); se = standard error; t = treatment allocation (treatment group = 1, control group = 0); y2, y3, y4, y5, y6 = outcome measurements (taken at weeks 2, 4, 6, 8, and 10, respectively). fu, burger, arjadi et al. 15 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ table 7b simplex model with lagged b paths for activation level as a mediator simplex model for mediation with lagged b path se p 95% ci time-specific outcome / significant paths and effect of treatment standardized estimate ll ul week 4 depression (y3) total effect −0.08 0.06 .187 −0.21 0.05 indirect effect −0.05 0.05 .269 −0.15 0.03 week 6 depression (y4) total effect −0.13 0.06 .025 −0.25 −0.01 indirect effect −0.11 0.05 .033 −0.22 0.001 t→m3→y4 −0.04 0.02 .01 −0.07 −0.01 week 8 depression (y5) total effect −0.16 0.06 .01 −0.28 −0.02 indirect effect −0.15 0.05 .003 −0.26 −0.04 t→m3→y4→y5 −0.03 0.01 .008 −0.05 −0.01 t→m3→m4→y5 −0.04 0.02 .01 −0.07 −0.01 week 10 depression (endpoint,y6) total effect −0.22 0.06 < .001 −0.35 −0.09 indirect effect −0.15 0.05 .002 −0.26 −0.04 t→m3→y4→y5→y6 −0.02 0.01 .007 −0.04 −0.01 t→m3→m4→y5→y6 −0.03 0.01 .008 −0.05 −0.01 t→m3→m4→m5→y6 −0.04 0.01 .009 −0.07 −0.01 note. only significant paths are shown to save space. abbreviations: m3, m4, m5 = mediator measurements (taken at weeks 4, 6, and 8, respectively); se = standard error; t = treatment allocation (treatment group = 1, control group = 0); y2, y3, y4, y5, y6 = outcome measurements (taken at weeks 2, 4, 6, 8, and 10, respectively). for the simplex models with depression as a mediator, the fit indices were acceptable for both contemporary b paths, cfi = 0.97, tli = 0.95, rmsea = 0.06, 90% ci [0.05–0.08], srmr = 0.06, and lagged b paths, cfi = 0.95, tli = 0.93, rmsea = 0.07, 90% ci [0.06– 0.09], srmr = 0.08. none of the significant indirect effect from treatment allocation to activation level at each time point passed through depression, indicating that our intervention works though the impact of activation on depression rather than the other way around. more detailed results are provided in the supplementary materials. mechanism of behavioral activation intervention 16 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ discussion in this study of data from a large rct, we provide evidence that activation level un­ derpinned the clinical response to a guided internet-based intervention for depression. during the 8-week treatment period, we showed that (1) our treatment improved activa­ tion levels from week 4 and reduced depressive symptoms from week 6, and (2) the activation level acted as a mediator for the change in depressive symptoms. these findings support the theory that a change in depression is contingent on a change in activation level (e.g., lewinsohn, 1974). we first confirmed that statistically significant associations existed between treatment allocation, activation, and depression level that were not affected by controlling for baseline characteristics. we further sup­ ported this by demonstrating temporal order, evidencing that the significant increase in activation level at week 4 preceded the significant decrease in depressive symptoms at week 6. this was strengthened by the lack of a “reverse” effect of depression on the activation level when conditioned on treatment. together, these findings strongly suggest that the hypothesized mediation process occurred around week 4. our findings are consistent with those of similar randomized studies (e.g., dimidjian et al., 2017; nasrin et al., 2017; santos et al., 2017), but conflict with those presented else­ where. for example, richards et al. (2017) observed no mediation effect of activation level in a large rct comparing behavioral activation and cognitive behavioral therapy, nor did rovner et al. (2014), when they compared behavioral activation and supportive therapy to prevent depression in older adults. there are a couple of plausible explanations for these incongruencies. first, different control conditions were used, with inactive control groups in the first two (waitlist control or usual obstetric care; similar to ours) (dimidjian et al., 2017; nasrin et al., 2017) and active control groups in the latter two (richards et al., 2017; rovner et al., 2014). second, measurements were taken at different times, with previous studies assessing mediation either immediately (dimidjian et al., 2017; nasrin et al., 2017) or 4 to 6 months (richards et al., 2017; rovner et al., 2014) after completing the intervention. delaying measurements in this way is less likely to capture significant changes caused by the mediator during treatment. two studies have used interventions for depression in which the activation level was examined as a putative mediator, and among these, our findings agree with one and disagree with another. in the research by van luenen et al. (2019) who adopted a similar intervention timeframe (eight sessions completed in 8–10 weeks), it was concluded that the investigated mediation occurred between weeks 3 and 5. however, this was not apparent in the research by forand et al. (2018) in another 10-week internet-based trial of cognitive behavioral therapy for depression, who found that the change in activation from baseline to week 3 did not predict the subsequent change in depression. this inconsistency could be attributed to the fact that forand et al. (2018) included another potential mediator (cognitive skills) in their mediation model. if activation level were a proximal process that led to another mediation process, controlling for this specific fu, burger, arjadi et al. 17 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ factor may fail to reveal the activation level as a mediator. it could also be that mediation occurred after week 3 of the intervention; therefore, a test based on earlier change will not have captured the required period. nevertheless, although the weight of evidence may be shifting, these inconsistencies point to a requirement for more evidence to confirm the mediational role of activation level. regarding missing data, more was missing in the intervention group (17.5%) than in the control group (4.3%). this was presumably because the gaf-id intervention deman­ ded greater effort to accomplish and because some participants could not afford the time. alternatively, sending the fortnightly measurements via email separately to monitoring within the intervention may have led to some participants erroneously believing that they had already completed the questionnaires. our results help to clarify how internet-based and lay-counselor-guided behavioral activation treatments work. clinicians can use this new knowledge to prepare patients with depression for a 4to 6-week lag before a major change occurs in their activation level, and subsequently, their symptoms of depression improve. this may encourage depressed individuals to persevere with treatment when they encounter difficulties in­ creasing activity levels in the first phase of treatment. clinicians and patients alike can be reassured that persistence with therapy will reduce depressive symptoms and lead to recovery. the present study has several strengths. first, we used data from a well-powered rct to ensure that the effect estimates from treatment allocation to activation level and depression could be readily and precisely interpreted as causal. the sample size calcula­ ted for the rct was ample for the current mediation analysis, for which a sample size of at least 100 with at least three repeated observations per individual was considered appropriate (curran et al., 2010). second, the fortnightly measures added precision and the low dropout rate (0.20%) contributed to both precision and low risk of bias. third, we adopted latent growth and simplex mediation modeling to estimate, as precisely as possible, the association between the mediator and depression while controlling for the within-participant change. according to criteria set by lemmens et al. (2016), our work constitutes a high-quality mediation study. some limitations also warrant discussion. notably, the mediator–outcome relation­ ship could still have been confounded by a third unmeasured variable (e.g., cognition). in addition, we only included a single mediator in our model, limiting us to identifying activation as the mediator. other working mechanisms correlated with activation level may have mediated part its effect, such as a change in cognition that may have preceded the reduction in depressive symptomatology. aside from using the scid-5 to assess unipolar depressive disorder before and after treatment, measurements in the rct relied on self-reporting every 2 weeks. thus, the assessments of activation level may not have been objective and may have missed a more nuanced dynamic (folke et al., 2015). moreover, lay counselors had no role in assessment of the participants and the effect of mechanism of behavioral activation intervention 18 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://www.psychopen.eu/ change in activation level on depression outcomes was also not assessed by lay counse­ lors and fully independently conducted from these counselors. therefore, although some bias can never be fully excluded, it is unlikely bias explained the outcomes. future research must seek to replicate our findings with different control groups. it should have a more temporally sensitive design (e.g., experience sampling method), more objective measures of activation, and include other variables (e.g., cognitive varia­ bles). such research may also benefit from experimental manipulation of mediator levels (e.g., component analysis) (emmelkamp et al., 2014) and micro-trials using experimental designs, such as rcts with temporally sensitive designs (brouwer et al., 2020; slofstra et al., 2018), to reach firm (causal) conclusions (lorenzo-luaces, lemmens, keefe, cuijpers, & bockting, 2021). conclusion this study provides evidence that a change in activation level underpinned the effects of a guided internet-based intervention using behavioral activation to treat depression. in a large-scale rct, it took 4 and 6 weeks to change activation levels and depressive symptoms, respectively. more studies are still required to support these findings and optimize treatment strategies. funding: this work was supported by the indonesia endowment fund for education (lembaga pengelola dana pendidikan), ministry of finance, republic of indonesia (no. 790/lpdp/2013) and by a chinese scholarship council grant (no. 201606040157). the funding sources had no role in the design or execution of the research. acknowledgments: dr robert sykes (www.doctored.org.uk) provided technical editing services for the final drafts of this manuscript. competing interests: mhn reports grants from the indonesia endowment fund for education (awarded to ra for a phd at the university of groningen) during the study, development, and translation of the cognitive behavioral therapy treatment manuals, including a blended internet-based treatment program unrelated to the current project, for which she receives no direct payments. mhn also reports travel expenses, some subsistence, and speaker honoraria for lectures and clinical training workshops paid for by mental health centers. clhb developed the intervention used in this study but has received no direct payment. she reports grants from the indonesia endowment fund for education (awarded to ra for a phd at the university of groningen) during the study, is a member of the dutch multidisciplinary guideline for anxiety and depression (non-remunerated), a co-editor of plos one and european psychology (non-remunerated), and a member of the scientific board in the dutch national statutory insured package, for which she receives an honorarium. she has received honoraria for keynote addresses at the european association for behavioral and cognitive therapies, the european psychiatry association, and the european conference association, as well as for clinical training workshops (paid by mental health centers). she also receives book royalties. all other authors declare no competing interests. ra reports grants from the indonesia endowment fund for education (awarded to complete a phd program at the university of groningen, during which data collection took place for the current study). zf and hb have no conflicts of interest to declare. fu, burger, arjadi et al. 19 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 http://www.doctored.org.uk https://www.psychopen.eu/ supplementary materials detailed results for the mediation examination in simplex models with depression as mediator were provided in the supplementary materials (for access see index of supplementary materials below). index of supplementary materials fu, z., burger, h., arjadi, r., nauta, m. h., & bockting, c. l. h. 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(2021). activation level as a mediator between behavioral activation, sex, and depression among treatment-seeking smokers. addictive behaviors, 114, article 106715. https://doi.org/10.1016/j.addbeh.2020.106715 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. mechanism of behavioral activation intervention 24 clinical psychology in europe 2021, vol. 3(3), article e5467 https://doi.org/10.32872/cpe.5467 https://doi.org/10.1016/j.addbeh.2020.106715 https://www.psychopen.eu/ mechanism of behavioral activation intervention (introduction) background materials and method design participants and randomization treatments measures data analysis results mixed effects model: differences of depression and activation level latent growth model for mediation time-specific mediation effect in the simplex models discussion conclusion (additional information) funding acknowledgments competing interests supplementary materials references fear of happiness predicts concurrent but not prospective depressive symptoms in adolescents research articles fear of happiness predicts concurrent but not prospective depressive symptoms in adolescents merle kock 1,2,3 , eline belmans 1,2 , filip raes 1,2,3 [1] centre for the psychology of learning and experimental psychopathology, ku leuven, leuven, belgium. [2] child & youth institute, ku leuven, leuven, belgium. [3] leuven mindfulness centre, ku leuven, leuven, belgium. clinical psychology in europe, 2023, vol. 5(2), article e10495, https://doi.org/10.32872/cpe.10495 received: 2022-10-18 • accepted: 2023-02-21 • published (vor): 2023-06-29 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: merle kock, tiensestraat 102, box 3712, 3000 leuven, belgium. phone: +32 16 71 02 37. email: merle.kock@kuleuven.be supplementary materials: materials [see index of supplementary materials] abstract background: it is increasingly recognised that the study of responses to positive emotions significantly contributes to our understanding of psychopathology. notably, positive emotions are not necessarily experienced as pleasurable. instead, some believe that experiencing happiness may have negative consequences, referred to as fear of happiness (foh), or they experience a fear of losing control over positive emotions (folc). according to reward devaluation theory, such an association of positivity with negative outcomes will result in positive stimuli being devalued over time, contributing to or maintaining depressive symptoms. the prospective relationship between fears of positivity and depressive symptoms is yet to be examined in adolescents. the present longitudinal study investigated whether foh and folc prospectively predict depressive symptoms. method: 128 adolescents between 16-18 years of age (m = 16.87, sd = 0.80) recruited from two secondary schools in flanders, belgium, completed measures of depressive symptoms (depression anxiety stress scales) including consummatory anhedonia, foh (fear of happiness scale), and folc (affective control scale) in their classroom at baseline and 2-months follow-up. regression analyses were performed to test the association between foh, folc, and depressive symptoms. results: foh concurrently, but not prospectively, predicted depressive symptoms. there was no significant association between foh and consummatory anhedonia. folc was not a significant predictor of depressive symptoms or consummatory anhedonia. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10495&domain=pdf&date_stamp=2023-06-29 https://orcid.org/0000-0001-9429-6321 https://orcid.org/0000-0001-9979-512x https://orcid.org/0000-0003-2770-2806 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: these findings suggest that foh may only be concurrently related to depressive symptoms. considering prior findings in adults, future research should investigate the association of foh with anticipatory anhedonia in adolescents. keywords adolescents, dampening, depression, fear of happiness, positive affect, anhedonia highlights • concurrent and prospective associations between fears of positivity and adolescents’ depressive symptoms were tested. • fear of happiness was concurrently but not prospectively associated with depressive symptoms. • fear of happiness did not predict consummatory anhedonia; anticipatory anhedonia was not assessed. • fear of losing control over positive emotions did not predict depressive symptoms or anhedonia. the ability to regulate emotional experience plays a vital role in development and maintenance of emotional disorders in adolescents (young et al., 2019). research into emotion regulation has to date primarily focused on negative emotions but it is increas­ ingly recognised that studying positive emotions is also of great value. because positive and negative emotions are independent of each other, emotion regulation may function differently in each domain (wood et al., 2003). moreover, deficits in experience and regulation of positive emotions are present across various forms of psychopathology (dillon & pizzagalli, 2010). from a clinical perspective, most psychological treatments are targeting negative emotions and are often ineffective for improving deficits in positive emotion regulation (dunn, 2012). thus, investigating positive emotion regulation may contribute to our understanding of psychopathology, particularly depressive disorders, over and above insights gained through research into negative emotion regulation. defining foh and folc notably, positive emotions are not necessarily experienced as pleasurable. instead, em­ pirical evidence suggests that some individuals are even afraid of positive emotions. one reason may be the belief that experiencing happiness may have negative consequences, referred to as fear of happiness (foh; joshanloo, 2013). individuals may experience foh because they are more afraid of the loss after feelings of happiness have ended than they value experiencing feelings of happiness. other individuals experience foh because they have repeatedly been disappointed when looking forward to pleasurable activities and are afraid of being disappointed again. another reason for fearing positive emotions may be that individuals are afraid of losing control over their positive emotions (folc; foh predicts concurrent depressive symptoms 2 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ williams et al., 1997), for example because they get carried away with their excitement and consequently become careless. generally, deficits in the experience of positive emotions predict a poor prognosis of depression (morris et al., 2009), possibly because positive emotions were found to increase resilience against negative life events (tugade & fredrickson, 2004). however, fear of positive emotions may prevent individuals from savouring positive emotions and using them to cope with adversities. for example, a patient with an agoraphobic mother reported getting excited to go to the beach as a child, which repeatedly ended in her mother experiencing a panic attack, triggering an argument with her father, and creating a terrible atmosphere. as a result, the patient felt she would be better off not looking forward to enjoyable activities because she got to associate positive emotions with negative outcomes (p. gilbert, 2007). according to reward devaluation theory, such a repeated association of positive emotions with either an ultimate negative outcome or simultaneous negative emotions may result in positive stimuli being devalued over time (winer & salem, 2016). positive stimuli are consciously inhibited or avoided because individuals fear that their initially positive experience will result in negative outcomes. ultimately, positivity becomes a signal of negative affect (jordan et al., 2021), which may be reflected in foh. a meta-analysis (winer & salem, 2016) provides evidence for reward devaluation theory by showing that depressed patients are more likely to avoid positive information in a dot probe task compared to anxious patients and healthy controls. moreover, two experimental studies demonstrated that pairing environmental reward with inhibition of rewarding behaviour slowed responses to reward or reduced the reward value (veling et al., 2011; veling & aarts, 2009). notably, inhibition of reward was only visible in participants initially sensitive to the reward, suggesting the initiallyrewarding stimulus was devalued rather than lacked value from the start. because foh is characterised by deficits in the positive affect system, it may be specifically related to anhedonia, a hallmark symptom of depression. anhedonia encom­ passes both deficits in looking forward to pleasurable events (anticipatory anhedonia) and deficits in experiencing pleasure during an enjoyable event (consummatory anhedo­ nia) (gard et al., 2006). since individuals with foh associate happiness with negative consequences, they may lack motivation to approach pleasurable events and may in turn develop anticipatory anhedonia. ultimately, this increase in anticipatory anhedonia may contribute to the development of other symptoms of depression such as sadness and lack of hope because individuals lack motivation to approach reward. this was supported by jordan et al. (2018) who found anticipatory anhedonia to mediate the relationship between fear of positive evaluation, another fear of positivity related to foh, and other depressive symptoms in adults. on the other hand, individuals with foh may also experience consummatory anhedonia when confronted with positive events because they associate positivity with negative outcomes. this may trigger other depressive symptoms such as lack of hope or sadness when they realise that they cannot enjoy positive kock, belmans, & raes 3 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ experiences anymore. for adolescents, who cannot withdraw as easily when caregivers confront them with pleasurable experiences, this may be especially relevant. hence, foh may be associated with and predict anticipatory and consummatory anhedonia, which in turn contributes to other depressive symptoms. previous research found that foh is strongly correlated with depression, anxiety, and stress (p. gilbert et al., 2012). using a slightly different measure of foh, joshanloo et al. (2014) showed that foh predicted lower life satisfaction above a set of recognized predictors at the individual (e.g., autonomy) and cultural level (e.g., wealth). these findings of cross-sectional studies demonstrate that foh is associated with lower wellbeing and psychopathology. there is currently only one study providing evidence for a significant positive prospective link between foh and depressive symptoms in adults (jordan et al., 2021). in contrast to foh, folc reflects losing control over positive emotions and may therefore be more related to bipolar disorder. given folc’s effect on the positive valence system, it may be especially associated with anhedonia. individuals with folc may be unable to look forward to pleasurable events (anticipatory anhedonia) because they anticipate losing control of their emotions, but they may also be unable to enjoy pleasur­ able events in the moment (consummatory anhedonia) because they fear to lose control any moment instead of enjoying the experience. this feeling of lack of control may be especially prominent in adolescents as affective control is reduced during adolescence compared to childhood and adulthood (schweizer et al., 2020). notably, poor affective control is associated with mental health problems. also fear of losing affective control (i.e. folc) has been associated with increased depressive symptoms (yoon et al., 2018). yet, findings are limited by the cross-sectional design of previous studies and folc’s influence on depressive symptoms requires further investigation. importance of assessing an adolescent sample adolescence is a crucial period with regard to mental health because a substantial amount of depressed patients experience their first episode in adolescence (zisook et al., 2007). given the possible role of foh and folc in the development of depressive disorders, it is important to study the associations of foh and folc with depressive symptoms not only in adults, which has been done in prior research, but also in adolescents. understanding which factors contribute to the development of depressive symptoms in adolescence would allow us to counteract the alarming rise of mental disorders among young people (patel et al., 2007). this rise is to be expected considering that adolescents undergo an emotionally challenging period, in which they develop strategies to regulate their emotions more independently. however, research on the use, adaptiveness, and effectiveness of emotion regulation strategies in adolescents is scarce (riediger & klipker, 2014). two experimental studies found that inducing thoughts to downregulate positive emotions (dampening) completely reduced the effects of a positive memory recall in adults while in adolescents the positive memory still positively foh predicts concurrent depressive symptoms 4 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ impacted happiness (dunn et al., 2018; yilmaz et al., 2019). these findings support the idea that appraisal-based emotion regulation strategies like dampening are less potent in adolescents because top-down cognitive control is still developing (skinner & zimmergembeck, 2016). in sum, adolescence is an important period for emotional development. given that emotion regulation strategies, or at least their effects, seem to differ between adults and adolescents it is important to better understand how adolescents respond to emotions in order to counteract the alarming rise in mental disorders. the present study this study aims to investigate whether foh and folc prospectively predict depressive symptoms. 128 adolescents completed self-report questionnaires of depressive symptoms (including consummatory anhedonia), foh, and folc at baseline and 2-months later. based on prior cross-sectional research, we hypothesized that foh and folc would cross-sectionally and prospectively predict depressive symptoms including anhedonia. hypotheses were formulated prior to data analysis. method participants our sample was recruited as part of a larger study aiming to test whether negative self-referent processing predicts depressive symptoms in adolescents (belmans et al., 2023). for this larger study, a power analysis in g*power (faul et al., 2007) indicated a required sample of n = 58 participants to reach a power of .80 with α = .05 based on a cross-sectional effect size of cohen’s d = .82 (iijima et al., 2017). the larger study oversampled to account for attrition and because smaller prospective effects were expec­ ted compared to previously observed cross-sectional effects. school classes, rather than individual participants, were recruited from two secondary schools in flanders, belgium, resulting in a total sample of 128 adolescents (60.63% female). adolescents were 16-18 years old (m = 16.87, sd = 0.80) and most were of belgian origin (80%). at follow-up assessment, 11 adolescents (8.7%) did not participate because they were absent from school on the day of assessment. the age group was chosen to ensure that participants understand the computer task in the larger study. sensitivity analyses conducted in g*power revealed that the present study was able to detect a small-to-medium effect (cohen’s f = .28) in concurrent and prospective multiple regression models given n = 128, a power of .80, and α = .05. the study was approved by the social and societal ethics committee at ku leuven (g-2018-01-1090) and all participants provided informed consent in accordance with the declaration of helsinki (world medical association, 2013). kock, belmans, & raes 5 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ measures depression subscale of depressive anxiety stress scales (dass-d) depressive symptoms were assessed with the 7-item dass-d (lovibond & lovibond, 1995). participants indicated on a 4-point scale, from did not apply to me at all to applied to me very much, or most of the time, how they felt during the past week (e.g., i felt down-hearted and blue). one item assesses consummatory anhedonia (i couldn’t seem to get any enjoyment out of the things i did). the total score is calculated as the sum of all item scores. the dutch dass-d has good psychometric properties (de beurs et al., 2001). fear of happiness scale (fohs) to assess fear of happiness, the dutch fohs was used (joshanloo, 2013; nelis et al., n.d.). its 5 items are scored on a 7-point scale ranging from strongly disagree to strongly agree (e.g., i prefer not to be too joyful, because usually joy is followed by sadness). positive affect subscale of affective control scale (acs-pa) folc was assessed with the 13-item acs-pa (raes et al., 2017; williams et al., 1997). on a 7-point scale ranging from very strongly disagree to very strongly agree, participants in­ dicated how they respond to positive affect (e.g., when i feel really happy, i go overboard, so i don’t like getting overly ecstatic). procedure at baseline and 2-months follow-up, participants completed all questionnaires and a computer task that is not part of this study collectively in their classrooms. the duration of follow-up was chosen such that both assessments took place in the same school year to minimise attrition. statistical analyses to test whether foh and folc predicted concurrent and prospective depressive symp­ toms, regression analyses with dass-d scores as criterion variable were performed for cross-sectional and prospective data separately. foh and folc scores were entered as predictors and the dummy-coded variable female was added as covariate. for prospective analyses, dass-d scores at baseline were entered as in a first step, before all other pre­ dictors were entered. since previous studies identified anhedonia as a mediator between fear of positive evaluation and depressive symptoms, we performed post-hoc analyses to test the association between fears of positivity and the single-item measure of consum­ matory anhedonia from the dass-d scale (item 1). using this item as criterion variable, we conducted an additional ordinal logistic regression. predictor variables were the same as in aforementioned analyses except for prospective analyses, in which the baseline foh predicts concurrent depressive symptoms 6 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ consummatory anhedonia score was entered in the first step. z-scores of continuous predictors were added to compute standardised odds ratios as a measure of effect size. collinearity between predictors was assessed by a variance inflation factor (vif) larger than 10. to confirm that the proportional odds assumption was met, the brant test was applied (brant, 1990). additionally, the proportional odds assumption for each predictor was checked using likelihood ratio tests comparing a proportional odds model with a partial proportional odds model for which the proportional odds assumption was relaxed for the respective predictor. benjamini-hochberg adjustment for multiple testing was applied to all p-values ex­ cept those testing a priori hypotheses. we reported partial r 2 as effect size with .02, .13, and .26 indicating small, medium, and large effects, respectively (cohen, 1992). for the ordinal regression analysis, we reported or as effect size with 1.44, 2.48, and 4.27 indicating small, medium, and large effects, respectively (sánchez-meca et al., 2003). missing data was limited. 11 participants were lost to follow-up because they were not present at school on the day of assessment. only their baseline data was included in the analysis. additionally, single items were missing from the dass-d and folc scales for individual participants. in total, there were 0.002% of dass-d items missing at baseline, 0.004% of folc items missing at baseline, and 0.0007% of folc items missing at follow-up. little’s test for mcar demonstrated that missing data at both time points were missing completely at random (little, 1988). missing items were imputed using the mean score of all remaining questionnaire items. analyses were conducted in r (r core team, 2021) using the stats package (version 4.1.1) for linear regression analyses and the vgam package (version 1.1-7) for ordinal regression analyses (yee, 2022). results descriptive statistics and internal consistency means, standard deviations, ranges, and cronbach’s α for all measures are reported in table 1. correlational analyses zero-order pearson correlations revealed significant correlations of depressive symptoms with foh and folc at baseline (table 2). higher levels of depressive symptoms were associated with greater foh and folc. zero-order correlations between predictors at baseline and depressive symptoms at follow-up yielded similar results. kock, belmans, & raes 7 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ table 1 descriptive information for baseline and follow-up measures variable n m sd min max α assessment t1 dass-d 127 4.39 3.98 0 17 .84 foh 127 13.69 6.85 5 35 .89 folc 127 39.38 9.54 15 60 .82 assessment t2 dass-d t2 116 3.92 3.68 0 15 .83 foh t2 116 12.21 6.34 5 28 .89 folc t2 116 37.20 10.33 13 60 .83 note. α = cronbach’s alpha. table 2 pearson correlations between depressive symptoms (dass-d), fear of happiness, and fear of losing control over positive emotions variable 1 2 3 4 5 6 1. dass-d ‒ .45*** .26** .69*** .37*** .27** 2. foh [.30, .58] ‒ .50*** .36*** .69*** .39*** 3. folc [.09, .42] [.35, .62] ‒ .25** .41*** .68*** 4. dass-d t2 [.58, .77] [.19, .51] [.07, .41] ‒ .45*** .34*** 5. foh t2 [.20, .52] [.58, .78] [.25, .55] [.29, .58] ‒ .52*** 6. folc t2 [.09, .43] [.23, .54] [.57, .77] [.17, .49] [.38, .64] ‒ note. pearson correlations with benjamini-hochberg adjustment for multiple testing are reported above the diagonal. 95% confidence intervals are reported below the diagonal. *p < .05. **p < .01. ***p < .001. regression analyses results of regression analyses are displayed in table 3 and will be reported using effect sizes and corresponding confidence intervals (cis). an effect size of zero indicated that the predictor did not significantly impact the outcome. hence, when a ci does not include zero, the effect is considered significant. foh was significantly associated with depressive symptoms at baseline with a medi­ um effect size (partial r 2 = .14, 95% ci [.05, .26]), with greater foh predicting higher levels of depressive symptoms. foh did not significantly predict depressive symptoms at follow-up when controlling for depressive symptoms at baseline, which is reflected in the effect size falling below the cut-off for a small effect (partial r 2 = .004, 95% ci [0, .04]). however, foh significantly predicted depressive symptoms at follow-up with foh predicts concurrent depressive symptoms 8 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ a small-to-medium effect size when baseline depressive symptoms were deleted from the model (partial r 2 = .07, 95% ci [.004, .19]; see appendix a in the supplementary materials). folc was not significantly associated with depressive symptoms at baseline nor at follow-up. the effect size for both concurrent and prospective associations of folc with depressive symptoms fell well below the threshold for a small effect (see ta­ ble 3). an examination of vifs confirmed no violations of multicollinearity (see table 3). table 3 summary of regression analyses for variables predicting depressive symptoms (dass-d) at t1 and t2 variable b (se) b 95% ci β p partial r 2 r 2 vif dv: dass-d t1 constant 0.04 (1.40) [-2.72, 2.81] .97 female 0.21 (0.65) [-1.08, 1.51] .03 .74 .001 [0, .03] 1.01 foh t1 0.25 (0.05) [0.14, 0.35] .43 < .001 .140 [.05, .26] 1.34 folc t1 0.02 (0.04) [-0.06, 0.10] .05 .59 .002 [0, .03] .21 1.33 dv: dass-d t2 step 1 constant 0.90 (0.47) [-0.03, 1.83] .06 female 0.30 (0.52) [-0.73, 1.33] .04 .56 .002 [0, .03] 1.02 dass-d t1 0.66 (0.07) [0.53, 0.80] .68 < .001 .460 [.28, .61] .48 1.02 step 2 constant -0.19 (1.08) [-2.33, 1.95] .86 female 0.25 (0.52) [-0.79, 1.28] .03 .64 .001 [0, .03] 1.04 dass-d t1 0.62 (0.07) [0.48, 0.77] .64 < .001 .340 [.18, .51] 1.20 foh t1 0.04 (0.05) [-0.05, 0.13] .07 .37 .004 [0, .04] 1.49 folc t1 0.02 (0.03) [-0.04, 0.08] .05 .52 .002 [0, .03] .49 1.33 note. 95% percentile bootstrap confidence intervals for partial r 2 are reported in brackets. ordinal logistic regression analyses using the single-item anhedonia score as criterion variable are displayed in table 4 and will be reported using odds ratios (or) and corre­ sponding cis. an or of one indicated that there is no association between predictor and outcome. hence, when a ci does not include one, the effect is considered significant. due to low frequencies of the outcome categories “applied to me to a considerable degree or a good part of time” and “applied to me very much or most of the time” for consum­ matory anhedonia, these two categories were combined to increase statistical power of the overall model. for the model predicting anhedonia at baseline, the proportional odds assumption for folc was violated and a partial proportional odds model was used kock, belmans, & raes 9 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ instead. for all other predictors in both models, the proportional odds assumption was satisfied. table 4 summary of ordinal logistic regression analyses for variables predicting consummatory anhedonia (single item dass-d) at t1 and t2 variable β (se) p or or 95% ci vif dv: anhedonia t1 female 0.38 (0.36) .71 1.46 [0.73, 2.93] 1.01 foh t1 0.47 (0.21) .06 1.61 [1.07, 2.41] 1.34 comparison: (applied to a considerable degree & applied to some degree) vs. did not apply at all folc t1 -0.01 (0.21) .97 0.99 [0.66, 1.49] 1.33 comparison: applied to a considerable degree vs. (applied to some degree & did not apply at all) folc t1 -0.60 (0.30) .29 0.55 [0.31, 0.99] nagelkerke pseudo-r 2 = 0.09 dv: anhedonia t2 female 0.15 (0.39) .71 1.16 [0.54, 2.50] 1.04 anhedonia at t1 [not at all as reference] to some degree 1.11 (0.41) .01 3.02 [1.34, 6.80] 1.03 to a considerable degree 2.01 (0.65) .01 7.46 [2.08, 26.81] fears of positive emotions foh t1 0.44 (0.22) .07 1.56 [1.01, 2.41] 1.37 folc t1 0.22 (0.22) .64 1.24 [0.81, 1.91] 1.33 note. nagelkerke pseudo-r 2 = 0.23. after multiple testing correction, there was a trend towards an association between foh and consummatory anhedonia at baseline (or = 1.61; 95% ci [1.07, 2.41]), meaning that a one unit increase in foh at baseline was associated with a 61% increase in the odds to experience consummatory anhedonia at baseline to some or a considerable degree as compared to not at all. similarly, there was a trend towards an association between foh at baseline and consummatory anhedonia at follow-up when controlling for consummatory anhedonia at baseline (or = 1.56; 95% ci [1.01, 2.41]), meaning that a one unit increase in foh at baseline was associated with a 56% increase in the odds to experience anhedonia at follow-up to some or a considerable degree as compared to not at all. folc was not significantly associated with consummatory anhedonia at baseline nor at follow-up (see table 4). an examination of vifs confirmed no violations of multicollinearity (see table 4). foh predicts concurrent depressive symptoms 10 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ discussion this study aimed to investigate whether foh and folc concurrently and prospectively predict depressive symptoms in adolescents. results showed that higher levels of foh are related to higher concurrent depressive symptoms but were not predictive of depres­ sive symptoms two months later. folc was not a significant predictor of depressive symptoms or anhedonia at the concurrent or prospective level. importantly, it is unlike­ ly that the lack of significant prospective associations with depressive symptoms was caused by low power. a post-hoc sensitivity analysis revealed that the minimum detecta­ ble effect size in this study was small-to-medium (f 2 = 0.085) given α = .05 and a power of .80. from a clinical perspective, effects that are smaller than this small-to-medium effect are unlikely to make a meaningful impact in clinical practice as small effects can easily be overshadowed by other influencing factors. thus, the current study was sufficiently powered to detect an effect that is clinically meaningful. this suggests that the lack of significant prospective associations is not caused by low power but may be explained by a negligible prospective association between foh, folc, and depressive symptoms in our sample. our findings are in line with prior research on a closely related construct, i.e. damp­ ening (feldman et al., 2008; nelis et al., 2015). dampening is defined as downgrading positive emotions by decreasing intensity and duration of positive mood states (feldman et al., 2008). therefore, dampening can be regarded as a broader concept that partly encompasses the construct of foh because some dampening thoughts include the fearrelated aspect of foh while other dampening thoughts are not related to foh. in alignment with our findings, increased dampening has been consistently associated with higher levels of concurrent depressive symptoms in adults and adolescents (feldman et al., 2008; nelis et al., 2015). however, results on the prospective association between dampening and depressive symptoms are mixed, with some studies reporting that damp­ ening predicts increased depressive symptoms (hudson et al., 2015; raes et al., 2012) and others reporting absence of effects (k. e. gilbert et al., 2013; nelis et al., 2015). notably, there is some evidence that dampening may be specifically predictive of anhedonia (nelis et al., 2018). since anhedonia includes diminished pleasure in positive experiences, it might be more strongly linked to dampening responses compared to general depressive symptoms. similarly, fear of positive evaluation, another type of fear of positivity closely linked to foh, has been shown to affect depressive symptoms via anticipatory anhedonia (jordan et al., 2018). considering the similarities of, and strong correlation between dampening and foh, foh may display similar correlation patterns with anhedonic symptoms compared to general depressive symptoms. in this study, we observed a trend towards a concurrent and prospective association between foh and consummatory anhedonia but no prospective association between foh and general de­ pressive symptoms. moreover, the prospective association between foh and depressive symptoms decreased when the consummatory anhedonia item was excluded from the kock, belmans, & raes 11 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ measure of depressive symptoms (see appendix b in the supplementary materials). however, the size of the association between foh and consummatory anhedonia is rather small and did not pass the multiple testing correction. one possible explanation for this non-significant association of foh with consummatory anhedonia may be the use of a single-item measure. this measure may be problematic because single-item measures are more affected by measurement error as they cannot be compared to corresponding items measuring the same construct, resulting in lower or at least un­ known reliability compared to multi-item scales (allen et al., 2022). moreover, the used single-item measure only captures consummatory but not anticipatory anhedonia. this is important given that jordan et al. (2018) found that anticipatory, but not consummatory, anhedonia mediates the effect of fear of positive evaluation on depressive symptoms. it is possible that foh, like fear of positive evaluation, mainly affects anticipatory and to a lesser extent consummatory anhedonia. future studies should use a more fine-grained measure of anhedonia to differentiate the relationships between foh, anticipatory and consummatory anhedonia, and depressive symptoms. this study was carried out in a non-clinical sample. it is possible that the prospective association between foh and depressive symptoms is only evident in clinical popula­ tions with stronger depressive symptoms at baseline. however, one prior study did not find a prospective association between dampening and depressive symptoms in remitted depressed patients (k. e. gilbert et al., 2013), suggesting that there is no prospective link between dampening and depressive symptoms in clinically-depressed populations. on the other hand, jordan et al. (2018) found an effect of fear of positive evaluation on depressive symptoms via anticipatory anhedonia in a community sample with mild depressive symptoms. future studies should disentangle the relationship between fears of positivity and depressive symptoms in clinical samples. unexpectedly, we did not find any association between folc and depressive symp­ toms. one possible explanation is that the original factor structure of the acs is based on expert opinion and does not provide acceptable fit in factor analyses (melka et al., 2011). however, re-analysing the data with the factor structure derived from exploratory factor analysis did not change the results (see appendix c in the supplementary materials), suggesting that folc has no association with depressive symptoms in adolescents, at least not in our sample. the main limitations of our study were the reliance on self-report measures and the use of the dass as only measure of depressive symptoms. the dass mainly assesses symptoms related to negative emotions and only includes one item measuring consum­ matory anhedonia. moreover, the average scores on the dass-d are quite low in our sample compared to a dutch-speaking clinically depressed sample (de beurs et al., 2001). future studies should investigate the relationship between foh, folc, and depressive symptoms in adolescent samples with more prominent depressive symptoms. another limitation of this study is the failure to measure positive emotions. future studies should foh predicts concurrent depressive symptoms 12 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ specifically assess positive emotions to examine whether the association of foh and depressive symptoms is dependent on the current level of positive emotions. in conclusion, this study shows that foh is concurrently but not prospectively asso­ ciated with depressive symptoms. there was no significant association between foh and the single-item measure of consummatory anhedonia, however, anticipatory anhedonia was not assessed. in light of prior findings on the effect of related fears of positivity on anticipatory anhedonia in adults, future research should investigate the concurrent and prospective association between foh and anticipatory anhedonia in adolescents using a more fine-grained measure of anhedonia. funding: this work was supported by the research foundation – flanders (fwo-vlaanderen) under a red noses grant (g0f5617n) and research grant (g068318n). merle kock was supported by the research foundation – flanders (fwo-vlaanderen) under a red noses grant (g049019n) and is supported under a phd fellowship (11i1622n). eline belmans is supported by the research foundation – flanders (fwo-vlaanderen) under a phd-fellowship (1177820n). acknowledgments: we thank brecht hugaerts, myrthe keiren, and toke laemont for their assistance in collecting the data and liesbeth bogaert for her support in writing the manuscript. competing interests: the authors have declared that no competing interests exist. ethics statement: this study was approved by the social and societal ethics committee at ku leuven (g-2018-01-1090). all participants provided informed consent after being informed about all aspects of the study in accordance with the declaration of helsinki (2013). twitter accounts: @kockmerle, @elinebelmans, @raziraes data availability: the data that support the findings of this study are available on request from the corresponding author. the data are not publicly available due to privacy or ethical restrictions. supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • code used for analyses • appendix a: regression analysis for variables predicting depressive symptoms (dass-d) at t2 without controlling for baseline depressive symptoms • appendix b: hierarchical regression analysis for variables predicting depressive symptoms excluding the anhedonia item (dass-d 2) at t2 • appendix c: hierarchical regression analyses for variables predicting depressive symptoms (dass-d) at t2 using the updated factor structure of acs kock, belmans, & raes 13 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://twitter.com/kockmerle https://twitter.com/elinebelmans https://twitter.com/raziraes https://www.psychopen.eu/ index of supplementary materials kock, m., belmans, e., & raes, f. 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(2007). effect of age at onset on the course of major depressive disorder. american journal of psychiatry, 164(10), 1539–1546. https://doi.org/10.1176/appi.ajp.2007.06101757 kock, belmans, & raes 17 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://doi.org/10.1016/j.jesp.2009.04.020 https://doi.org/10.1016/j.appet.2011.02.018 https://doi.org/10.1016/s0005-7967(96)00098-8 https://doi.org/10.1037/bul0000022 https://doi.org/10.1037/0022-3514.85.3.566 https://doi.org/10.1001/jama.2013.281053 https://doi.org/10.1016/j.brat.2019.103476 https://doi.org/10.1016/j.jad.2018.02.009 https://doi.org/10.3390/brainsci9040076 https://doi.org/10.1176/appi.ajp.2007.06101757 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. foh predicts concurrent depressive symptoms 18 clinical psychology in europe 2023, vol. 5(2), article e10495 https://doi.org/10.32872/cpe.10495 https://www.psychopen.eu/ foh predicts concurrent depressive symptoms (introduction) defining foh and folc importance of assessing an adolescent sample the present study method participants measures procedure statistical analyses results descriptive statistics and internal consistency correlational analyses regression analyses discussion (additional information) funding acknowledgments competing interests ethics statement twitter accounts data availability supplementary materials references developmental coordination disorder (dcd): relevance for clinical psychologists in europe scientific update and overview developmental coordination disorder (dcd): relevance for clinical psychologists in europe emily j. meachon 1 , martina zemp 1,2 , georg w. alpers 1 [1] department of psychology, school of social sciences, university of mannheim, mannheim, germany. [2] department of clinical and health psychology, university of vienna, vienna, austria. clinical psychology in europe, 2022, vol. 4(2), article e4165, https://doi.org/10.32872/cpe.4165 received: 2020-08-04 • accepted: 2022-02-04 • published (vor): 2022-06-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: georg w. alpers, l13, 17, mannheim germany 68131. phone: +49 621 181-2106. e-mail: alpers@uni-mannheim.de abstract background: developmental coordination disorder (dcd) is a common neurodevelopmental disorder primarily characterized by fine and gross motor coordination difficulties. yet, many aspects remain unclear regarding the clinical presentation of secondary symptoms and their implications for clinical psychology. therefore, the purpose of this review is to provide an update about the current understanding of dcd for clinical psychologists and psychotherapists across europe, particularly based on new insights stemming from the last decade of research. method: we provide a narrative review of articles published in the last decade on the topic of dcd, and relevant aspects to clinical psychologist, including lesser known aspects of dcd (e.g., executive functions, psychological consequences, and adult dcd). results: dcd is a highly prevalent, disruptive, and complex disorder, which should be investigated further in many areas (e.g., co-occurrence to adhd). existing evidence points toward a key role of executive functioning difficulties at all ages. most patients report secondary psychological problems, but little headway has been made in examining the effectiveness of psychotherapy for dcd. conclusions: insights and remaining research gaps are discussed. it is critical for psychologists and clinical researchers to raise awareness for dcd, take note of the growing literature, and foster continued interdisciplinary approaches to research and treatment of dcd. keywords dyspraxia, neurodevelopmental disorders, motor coordination, clinical practice, psychotherapy this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4165&domain=pdf&date_stamp=2022-06-30 https://orcid.org/0000-0002-1456-4515 https://orcid.org/0000-0003-0065-5966 https://orcid.org/0000-0001-9896-5158 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • awareness about developmental coordination disorder (dcd) is low among some european psychologists. • growing knowledge about dcd should be disseminated among psychotherapists. tanja1 is a 20-year-old female from germany who studies part time at university and has a part-time job as a store manager. she has noticed she takes much longer than her peers to type her papers, and she often struggles to pay attention to long lectures. when she was younger, she had trouble learning how to ride a bike, and struggled to grip her pencils correctly, however, she improved both skills during childhood. she has found that her struggles to pay attention and difficulties with typing are becoming problems at work, but her classmates and colleagues do not seem to notice she is struggling. as the demands of her job and studies increased, her difficulties have become extremely burdensome. therefore, tanja is seeking psychotherapy to manage her stress. at first glance, some clinicians may suspect the patient has attention-deficit/hyper­ activity disorder (adhd) based on the characteristic problems with sustained attention. however, she also exemplifies several hallmark symptoms of developmental coordi­ nation disorder (dcd). a correct diagnosis in tanja’s case could be critical because treatment for adhd may require different strategies (i.e., medication). considering the common misconceptions and lack of knowledge surrounding dcd, it is important clinicians treating complex cases like these are aware of the current clinical picture of dcd. key aspects of developmental coordination disorder dcd is a neurodevelopmental disorder with primary deficits in fine and gross motor coordination (american psychiatric association, 2013). the dsm-5 criteria for a dcd diagnosis include: (1) the acquisition and execution of motor skills and related coordi­ nation are below what is expected based on age, (2) the deficits of motor skill and coordination significantly interfere with daily life in the domains of self-care, scholastics, work, leisure, and play, (3) the symptoms began in childhood, and (4) the deficits cannot be better explained by any other condition (e.g., cerebral palsy or neurodegenerative disorder; american psychiatric association, 2013; see table 1). dcd has a profound impact on the lives of individuals suffering from the disorder. 1) this case is based on collective experiences of individuals with dcd, and is not based on any one real person. dcd: relevance to clinical psychologists 2 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ table 1 diagnostic criteria and examples of symptoms of dcd diagnostic manual / criteria practical example recommendations dsm 5: developmental coordination disorder (a) the acquisition and execution of motor skills and related coordination are below what is expected based on age the individual might have taken longer to learn to crawl, walk, ride a bike, write, kick a football, climb or descend stairs, etc. they might have also learned motor skills but struggle to execute them in a coordinated fashion. in children, the mabc-2 (henderson et al., 2007) can be used to objectively assess motor functions in comparison to same-aged peers (in a percentile score based on age-band). in adults, mabc-2 can be used loosely, a selfreport by the patient of novel motor experiences in adulthood might be considered, e.g., a new skill in the workplace or school: typing, driving. (b) the deficits of motor skill and coordination significantly interfere with daily life in the domains of self-care, scholastics, work, leisure, and play the individual might avoid socialization, or team sports, in fear of embarrassment for lack of coordination. screen for impact of motor skills on daily life, and other psychosocial factor (e.g., cooccurring anxiety, depression). (c) the symptoms began in childhood – if patient is an adult at the time of assessment, the adult dcd checklist (adc; kirby et al., 2010) section 1 can be used as a proxy for symptoms in childhood. (d) the deficits cannot be better explained by any other condition patient should not have cerebral palsy, huntington’s disease, acquired brain injury, difficulties related to surgery, etc. complete diagnostic history, including physical, mental, and genetic conditions, should be considered. icd-10: specific developmental disorder of motor function (f82) (1) a disorder with primary deficits of motor coordination as listed in dsm 5 criterion (a) above. as listed in dsm 5 criterion (a) above. (2) impairments in fine and gross motor coordination general difficulties might involve fine motor tasks such as trouble gripping objects, poor handwriting, challenges typing on a keyboard. difficulties might also involve gross motor functions, such as, trouble walking in a coordinated manner, frequently tripping over or bumping into objects, difficulties kicking or catching a ball. as listed in dsm 5 criterion (a) above. (3) not better explained by an intellectual disability or acquired neurological disorder patient should not have disorder of intellectual development, cerebral palsy, huntington’s disease, acquired brain injury, difficulties related to surgery, etc. as listed in dsm criterion (d) above. potential rationale for iq testing. note. the icd-11 “developmental motor coordination disorder” lists symptoms entirely in line with the dsm 5, adding that symptoms must begin in childhood. notably, the different name contradicts nomenclature stand­ ards set out by dcd experts (see blank et al., 2019) and the patient preferred name “dyspraxia.” diagnostic criteria are summarized from the latest guidelines of each diagnostic manual (dsm-5-tr; american psychiatric meachon, zemp, & alpers 3 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ association, 2022; icd-11; world health organization, 2020). in the new dsm-5-tr, dcd is listed under a further subcategory entitled “motor disorders. accumulating research highlights the psychological effects of dcd symptoms still re­ main unclear (e.g., kirby et al., 2013; tal saban & kirby, 2018; zwicker et al., 2018) and executive functioning differences may be present (e.g., bernardi et al., 2018; sartori et al., 2020). furthermore, there is a lack of established gold standard diagnostic procedure for adults with dcd despite increasing evidence that motor symptoms and psychosocial consequences continue into adulthood in most cases (purcell et al., 2015; tal saban & kirby, 2018). dcd is a common neurodevelopmental disorder, with a prevalence frequently cited as 5% (blank et al., 2019). despite this, dcd has received minimal attention in research, especially compared to other neurodevelopmental disorders (see figure 1; bishop, 2010). even child and adolescent psychiatrists have been reported to profess poor general knowledge of dcd (wilson et al., 2013). this alludes to a history of potentially overlook­ ing individuals with dcd. figure 1 publications with the term “developmental coordination disorder” in the title, abstract, or key words from 2000-2020 note. a) a total of k = 2,068 articles were retrieved from the search in web of science in june 2021. while many search topics have increased in research volume over the years, as a closer comparison, the search term “attention deficit hyperactivity disorder” returned k = 28,533 articles from the same time period with at least k = 1,000 per year from 2009 on, and k = 2,480 in 2020 alone; exceeding the number in one year for all dcd articles across 20 years. dcd: relevance to clinical psychologists 4 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ while the number of publications and citations for papers about dcd is still far behind comparable conditions (e.g., adhd), there has been a promising increase in publications over the last decade (see figure 1). in addition, international guidelines for most aspects of dcd were recently released for health care professionals of all fields (blank et al., 2019). the guidelines solidify that dcd is a unique condition to be recognized by psy­ chologists and offer important insights. therefore, in this narrative review, we (1) extend upon these guidelines to include an overview on the current state of lesser understood features of dcd (e.g., executive functions, co-occuring adhd, adult dcd), and (2) highlight available resources specifically for european psychologists (e.g., tools available in various european languages). we include recent insights with research primarily published in the last decade to provide an up-to-date overview of dcd. method the present review is narrative in nature and included evidence from several systematic searches on the psycinfo and web of science databases in november 2020. search terms included “developmental coordination disorder,” “dyspraxia,” and “dcd” in all sections, and some subsections required separate extensive searches. for example, screening tools for dcd were searched by name (i.e., mabc-2; bot-2; dcd-q; adult developmental coordination disorders/dyspraxia checklist; aac-q). in order to find a comprehensive list of these tools in all european languages, additional searches were conducted on google scholar with the name of the language as an additional search term for each of the screening tools (see table 2). eligible records were those published between 2009-2020, which were reviews, expert consensus papers, empirical papers, and metaanalyses regarding dcd and relevant aspects to clinical psychology (e.g., psychosocial consequences; executive functions; dcd in adults). table 2 published and validated screening tools for developmental coordination disorder in european languages language motor screening tests questionnaires for children questionnaires for adults mabc-2 (ages 3 to 16) bot-2 (ages 4-21) dcd-q (ages 5-15) little dcd-q (ages 3-4) adc (ages 17 42) aac-q (ages 16-35) language relevant to europe czech psotta et al., 2012 n/a n/a n/a n/a n/a danish reported available by blank et al., 2019 n/a milidou et al., 2015 n/a n/a n/a meachon, zemp, & alpers 5 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ language motor screening tests questionnaires for children questionnaires for adults mabc-2 (ages 3 to 16) bot-2 (ages 4-21) dcd-q (ages 5-15) little dcd-q (ages 3-4) adc (ages 17 42) aac-q (ages 16-35) dutch schoemaker et al., 2012 n/a dcdq-nl; schoemaker et al., 2006 ldcdq-nl; cantell et al., 2019 n/a n/a english uk, henderson et al., 2007a usa, bruininks & bruininks, 2005a wilson et al., 2009a canadian, wilson et al., 2015 uk, kirby et al., 2010a tal saban et al., 2012a flemish n/a n/a n/a reported available by rihtman et al., 2015 l-dcd-q-vl moret et al., 2019 n/a n/a french marquet-doléac et al., 2016 n/a dcdq-fe: raykaeser et al., 2019 reported available by rihtman et al., 2015 n/a n/a german petermann, 2008 blank et al., 2014 dcdq-g; kennedy-behr et al., 2013 reported available by rihtman et al., 2015 meachon et al., 2022 n/a greek ellinoudis et al., 2011 n/a n/ab n/a n/a n/a italian zoia et al., 2019 n/a caravale et al., 2015 n/a n/a n/a maltese n/a n/a camilleri et al., 2020 n/a n/a n/a norwegian holm et al., 2013 n/a n/a n/a n/a n/a polish n/a n/a dcdq’07-pl; nowak, 2016 n/a n/a n/a slovenian reported available by blank et al., 2019 n/a tercon et al., 2015 reported available by rihtman et al., 2015 n/a n/a spanish age band 1: niñocruz et al., 2019 for 4-7 years old children: serrano-gómez & correabautista, 2015 salamanca et al., 2012 reported available by rihtman et al., 2015 n/a delgado-lobete et al., 2021 swedish reported available by blank et al., 2019 n/a iwar, 2015 n/a n/a n/a dcd: relevance to clinical psychologists 6 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ language motor screening tests questionnaires for children questionnaires for adults mabc-2 (ages 3 to 16) bot-2 (ages 4-21) dcd-q (ages 5-15) little dcd-q (ages 3-4) adc (ages 17 42) aac-q (ages 16-35) other relevant languages hebrew n/a n/a version 1: barilan traub et al., 2005 ldcd-q; rihtman et al., 2011a kirby et al., 2010a n/a portuguese (brazil) valentini et al., 2014; capistrano et al., 2015 okuda et al., 2019 prado et al., 2009 reported available by rihtman et al., 2015 n/a n/a turkish n/a n/a yildirim et al., 2019 n/a n/a n/a note. mabc-2: movement assessment battery for children 2nd edition; bot-2: bruininks-osteretsky test of motor proficiency; dcd-q: developmental coordination disorder questionnaire; adc: adult developmental coordination disorders/dyspraxia checklist; aac-q: adolescents and adults coordination questionnaire; n/a indicates tool is not yet available in the listed language. adenotes original version. blisted in dcdq administration manual, but not elsewhere. clinical presentation and secondary psychosocial consequences dcd has a lifetime prognosis with major symptoms including difficulties with planning and execution of fine motor (e.g., sketching) and gross motor coordination (e.g., riding a bicycle). as described in the dsm 5, individuals with dcd can appear to be generally clumsy, and often have delays in reaching motor milestones compared to their peers (american psychiatric association, 2013). examples of this can be very evident, such as having to spend longer than other children in learning how to hold a pencil, or subtler, such as having more trouble learning to play a musical instrument in school than other children. notably, research in the last decade has provided increasing evidence that symptoms of dcd extend beyond motor coordination. more specifically, impaired execu­ tive functions (i.e., inhibition, cognitive control, working memory, and related processes such as attention) can be recognized as a prominent feature of dcd (bernardi et al., 2018; leonard & hill, 2015; sartori et al., 2020). however, neither the dsm-5 nor the icd-11 consider these as potential symptoms of dcd (purcell et al., 2015; see table 1). furthermore, the specific symptom profiles and the extent to which executive function impairments in dcd can be attributed to co-occurring conditions (e.g., attention and inhibition difficulties typical to adhd) remains unclear (blank et al., 2019). a combination of executive functioning and motor coordination difficulties may re­ sult in a plethora of consequences and challenges for individuals with dcd in all stages of life. recent research has suggested core symptoms of dcd likely entail secondary psychological problems, such as decreased quality of life, lower self-esteem, impaired social relationships compared to typically developing peers (e.g., tal saban & kirby, meachon, zemp, & alpers 7 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ 2018; zwicker et al., 2018). internalizing symptoms in the form of secondary anxiety and depression may often occur as a consequence of dcd (draghi et al., 2020; kirby et al., 2013; mancini et al., 2019; omer et al., 2019; rigoli & piek, 2016), which should be of concern in psychotherapy. more research is needed to understand the specificity of these features as they are known in similar conditions (e.g., adhd). consequences of dcd also include a risk for obesity, cardiovascular problems, reduced fitness ability, and worse self-reported general health compared to typically developing peers (cairney et al., 2017; joshi et al., 2015; kirby et al., 2013). existing evidence of dcd prevalence and etiology despite the often stated dcd prevalence rate of 5% (blank et al., 2012; blank et al., 2019), prevalence in some in many countries is not clear. among existing estimates is that 1-19% of school-aged children in the uk suffer from dcd (zwicker et al., 2012), but more recent estimates are around 10% in samples from the us and 24% from brazil based on a study children in these regions (valentini et al., 2017). while the prevalence rate in adults is not known, dcd is estimated to persist into adulthood in 30-70% of cases (tal saban & kirby, 2018). in addition, a recent cross-sectional analysis of children in spain estimates the prevalence of high risk for dcd is about 12% (delgado-lobete et al., 2019). differences in prevalence estimates still vary greatly between existing studies, possibly due to a variance in identification of dcd. previous research has estimated that dcd occurs three to seven times more often in males than females (zwicker et al., 2012), with recent evidence of a more equal gender ratio in a brazilian sample (valentini et al., 2017). however, these gender differences are not necessarily universal, as some recent research has found a more equal ratio between gender in brazil (valentini et al., 2017). these gender differences may also be a consequence of bias in detection of symptoms or referral bias, as has occurred for similar neurodevelopmental disorders such as adhd (young et al., 2020). beyond gender differ­ ences, recent research found that left-handedness is nearly twice as prevalent among those with dcd as it is for typically developing controls (darvik et al., 2018). further research has yet to explore the underlying mechanisms in this phenomenon. relatively little is known about the causes of dcd. compelling evidence for a 70% heritability estimate for dcd was calculated with a population of swedish twin pairs (lichtenstein et al., 2010). low birth weight and premature birth are also predictors of dcd, particularly among males (spittle et al., 2021; zwicker et al., 2012). while little is known about risk factors for dcd aside from being male and preterm (van hoorn et al., 2021), some research on neurodevelopmental disorders in general suggests there may be additional links to family income in addition to low birthweight and premature birth (e.g., carlsson et al., 2021). dcd: relevance to clinical psychologists 8 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ dcd with co-occurring adhd or autism spectrum disorder among the various challenges in the diagnosis and detection of dcd are its co-occurring conditions (cleaton & kirby, 2018). for instance, dcd and attention-deficit/hyperactiv­ ity disorder (adhd) have a particularly high co-occurrence of about 50% (blank et al., 2019). given the symptomatic overlaps, including motor impairments in adhd (kaiser et al., 2015), and attention, inhibition, and hyperactivity sometimes observed in dcd (harrowell et al., 2018; wilson et al., 2020), some have speculated whether dcd might be a subtype of adhd. while concrete evidence for this assumption remains limited to date, more research speaks for a unique pathology in dcd (e.g., in the genetic pro­ file, pearsall-jones et al., 2009; physiological responding, goulardins et al., 2015; neural mechanisms, meachon et al., 2021). this has also been supported by findings for unique functional pathways in co-occurring dcd and adhd as opposed to just one disorder (mcleod et al., 2014). it is important that this co-occurrence receives more scientific attention in the future to identify not only the extent to which the clinical symptoms but also their endophenotypes overlap (e.g., conzelmann et al., 2009). this may help to prevent misdiagnosis, given the many similarities between dcd and adhd. one simple step researchers and clinicians can take to work toward this goal is to screen for dcd when working with patients who have adhd (lange, 2018), and vice versa. another common co-occurrence is autism spectrum disorder (asd; caçola et al., 2017). asd can be diagnosed as a co-occurring disorder of dcd since the dsm-5, and researchers are just beginning to explore the co-occurring diagnosis. unlike adhd, existing literature clearly supports that the difficulties sourcing from dcd or asd are unique (paquet et al., 2019). for example, a systematic review of dcd and asd behavio­ ral outcomes primarily found clear differences between dcd and asd (caçola et al., 2017). thus, it can be assumed that co-occurring cases of dcd and asd present a much more complex symptom profile than dcd or asd alone available screening tools for dcd in european languages in the screening and diagnostic process for dcd, the current best practice is to ensure all four major dsm-5 criteria for diagnosis are met. there are various tests and screening tools which european clinicians can use to identify if a diagnosis of dcd should be con­ sidered. the most common tools relevant to european psychologists will be highlighted in this section. motor skill assessment is crucial to establish meeting the first criterion for a dcd diagnosis in the dsm-5: that motor skills are below the expected development compared to same-age peers. while there are many tools which can be used to assess motor skills (see cancer et al., 2020 for an overview of other motor screening tools for children), two of the most common screening tools used to assess risk for dcd are the movement assessment battery for children (mabc-2; henderson et al., 2007) and the bruininks-oser­ meachon, zemp, & alpers 9 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ etsky test of motor proficiency (bot-2; bruininks & bruininks, 2005). the mabc-2 was developed in english to identify probable dcd in children aged 3 to 16, and is available in dutch (schoemaker et al., 2012), german (petermann, 2008), italian (zoia et al., 2019), greek (ellinoudis et al., 2011), norwegian (holm et al., 2013), and spanish (age band 1 validated by niño-cruz et al., 2019; see table 2). in addition, some researchers have reported using the mabc-2 but do not reference a validated translation or test of the psychometric properties of the reported language used (e.g., danish, slovenian, swedish; blank et al., 2019). the bot-2 was designed in english as a motor competency test for broader popula­ tions among children from 4 to young adults of 21 years old, and available in german (blank et al., 2014), and spanish (validated for 4-7 years old children by serrano-gómez and correa-bautista, 2015). the bot-2 can reportedly be used to diagnose individuals of any language group, because it uses motor-skill games independent of language (baharudin et al., 2020), however, its norms should be extended beyond what is now exclusively based on us norms. for example, recent research on the ecological validity of the german bot-2 showed it strongly relates to other relevant fine motor skills and some gross motor skills, however subtests for bilateral coordination and balance do not have clear ecological validity (e.g., to sports and bike riding) among german children (vinçon et al., 2017). notably, the concerns of translation (i.e., for the mabc-2 checklist) and norms is also prevalent with mabc-2, which was developed with uk samples. some slight differences were observed between british norms and those of other nationalities tested on the mabc-2, suggesting the consideration norms for motor tests be adapted to specific countries, even within europe (barnett, 2014; zoia et al., 2019). given the age cutoffs, caution should be taken in the interpretation of scores for adolescents and adults, and should not outweigh assessment of the other diagnostic criteria for dcd. there are several questionnaires which can be used to assess the second and third dsm-5 criterion regarding persistent interruptions of symptoms and presence of symp­ toms in childhood. for children, the developmental coordination disorder questionnaire is a popular parent-report measure of dcd symptoms developed in english (wilson et al., 2009). the dcd-q has been translated and validated into many languages spoken in europe (see table 2, including german, (dcdq-g; kennedy-behr et al., 2013), dutch (dcdq-nl; schoemaker et al., 2006), italian (caravale et al., 2015), spanish (salamanca et al., 2012), danish (milidou et al., 2015), and french-european (dcdq-fe: ray-kaeser et al., 2019). in addition, a version to indicate dcd in young children (ages 3-4) exists, known as the little developmental coordination disorder questionnaire developed in hebrew (ldcd-q; rihtman et al., 2011) and translated into english (ldcdq-ca; wilson et al., 2015) and dutch (ldcdq-nl; cantell et al., 2019). the ldcdq was also translated into many european languages (rihtman et al., 2015; see table 1), however validation studies to confirm these translations have not yet been published. notably, in adolescent populations, parents were less accurate in identifying motor competencies than their dcd: relevance to clinical psychologists 10 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ adolescent children’s self-reports (timler et al., 2018), but to our knowledge, there is no evidence if this is the same in children versus parent-reports. therefore, parent-reports should be used with caution in older children, and should be accompanied by in-depth assessment of the adolescents themselves. to gain better insight into the daily life interruptions in adulthood, the self-report adult developmental co-ordination disorders/dyspraxia checklist (adc) was developed and validated in english and hebrew to detect probable cases of dcd in individuals 16 years and older (kirby et al., 2010). the adc was also recently translated into german (meachon et al., 2022) and reevaluated for potential to screen for motor and executive functioning parameters of dcd (meachon et al., 2022). in addition to the adc, tal saban et al. (2012) developed the adolescents and adults coordination questionnaire (aac-q) as a shorter-form self-report tool to screen for dcd compared to the adc. the aac-q was developed in english (tal saban et al., 2012) and recently translated into spanish (delgado-lobete et al., 2021). while retrospective diagnosis of dcd in adulthood is certainly possible, it must be on the premise that symptom experiences began in childhood. there is currently no gold standard motor assessment tool for screening in adults. in accordance with the final criterion of the dsm-5 for dcd, causes of clumsiness or differences in gait from other medical conditions or brain injury must be ruled out. con­ trary to the exclusion criteria of intellectual disorders listed in the dsm-5 and icd-10 (dsm-5; american psychiatric association, 2013; icd-10; world health organization, 2016), children with dcd may score lower than average on some or all domains of iq tests due to interruptions in motor processing and perception (jaščenoka & petermann, 2018). recent consensus established that iq score cutoffs should not prevent the diagno­ sis of dcd (blank et al., 2019). more research is needed to conclude if this is consistent across the development and into adulthood. dcd in adolescents and adults most of the existing research on dcd examines populations of affected children rather than adolescents and adults, even though a majority of adults with dcd continue to experience symptom-related difficulties in their daily lives (tal saban & kirby, 2018). this mirrors a pattern observed in adhd research, which primarily focuses on child and adolescent populations (targum & adler, 2014). the history of overlooking adult populations could be for strictly following diagnostic criteria for dcd (i.e., it must begin in childhood; american psychiatric association, 2013). other possibilities might include (1) the lack of assessment tools for adults, (2) the complex phenotype in adulthood (e.g., co-occurring conditions, symptom progression), and (3) the heterogeneous compensatory strategies adults develop to deal with their motor constraints. concerning the latter, compensatory strategies may mask symptoms for simple motor tasks (e.g., hand rotation meachon, zemp, & alpers 11 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ task; wilmut, 2017). this should be carefully considered in the diagnostic process for dcd, especially for adults with dcd who were not diagnosed in childhood. adults with dcd often struggle with difficulties in psychosocial domains, executive functioning, physical fitness, time management, and organization (e.g., kirby et al., 2013; kirby et al., 2011; tal saban & kirby, 2018). in general, underlying mechanisms of dcd are not likely change across the lifespan, however the context, experience of the individual, and compensation may change. for example, motor challenges and difficulty with distance estimation may manifest in adulthood as problems in learning to drive or even crossing the road compared to typical adults (kirby et al., 2010; wilmut & purcell, 2020). while the most relevant dcd symptoms for adults may vary interindividually, symptoms that are less easily detected or treated could become more problematic in adulthood. for example, executive functioning challenges were among the most com­ monly reported daily concerns for adults with suspected dcd (purcell et al., 2015), a concern that might not be addressed in traditional physical training to treat symptoms of dcd. there are also relationships between dcd and increased cognitive difficulties, fati­ gue, and somatic symptoms compared to a control group, albeit findings are based on cross-sectional data (thomas & christopher, 2018). because of the considerable overlaps between dcd and adhd that can also be present in adulthood, future research should work toward identifying the specific symptom profiles of dcd and adhd. despite considerable research gaps on adult populations with dcd, some recent research has investigated dcd in emerging adults between the ages of 16 to 25 (e.g., kirby et al., 2011). this group may still be dependent on their parents but are working toward independence and identity exploration (tal saban & kirby, 2018). due to the major life changes this age group commonly faces, it may be at risk for experiencing heightened difficulty in coping with dcd symptoms, and should be examined more in future research. multidisciplinary interventions for dcd there are several training programs frequently utilized for treating specific motor features of dcd used by occupational and physical therapists such as cognitive ori­ entation to daily occupational performance (co-op) and neuromotor task training (smits-engelsman, 2013; smits-engelsman et al., 2018). co-op and ntt are activity or task-oriented approaches which specifically target physical fitness and motor task-per­ formance (montgomery et al., 2018) and are historically effective for treating children with dcd (polatajko & mandich, 2004). these trainings, along with any other existing treatment, are not intended to cure dcd, and can substantially help the patient improve specific motor skills. however, the increasing evidence that dcd is more than just a disorder of motor functions qualifies that more psychological interventions should be comprehensively investigated (tamplain & miller, 2021). it is possible that psychological dcd: relevance to clinical psychologists 12 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ support may be equally important as physical treatment for some patients with dcd. this is especially relevant to reduce any risk for potential secondary psychosocial conse­ quences such as depression or anxiety (kirby et al., 2013). presently, an interdisciplinary approach along with occupational therapists and phys­ iotherapists (e.g., typical treatment: co-op; ntt for training specific motor skills) is recommended for effective intervention with dcd (blank et al., 2019; montgomery et al., 2018). it is also important that specific difficulties to the individual and the goals of the patient are considered in treatment, as this has led to reduced anxiety compared to preset large-group interventions in children (caçola et al., 2016). for example, one individual might find it most pertinent to practice typing on a keyboard for work or school, while another might want to reduce their anxiety participating in group sports. the role of motor concerns may be direct or indirect in treatment, but regardless, the patient’s preferences should determine the approach and prioritization of goals in their treatment plan. a recent review and meta-analysis of motor-based interventions for dcd also suggests that effective interventions are personalized for the patient and their specific goals, contexts, active involvement, functionality and support from peers (smits-engelsman et al., 2018). in sum, tailor-made treatments have potential to improve both motor and psychological outcomes, and psychological interventions for secondary problems and psychological consequences of dcd should be examined in great detail future research. discussion returning to the case of tanja, it is now clear the patient should be assessed for dcd, with consideration of potential co-occurring adhd. it is important in her case, to identify if her attentional difficulties are linked to motor activity, in which case she may just have dcd. in psychotherapy, screening for secondary anxiety and depression and working on stress-management would be important for immediate action. a psycho­ therapist should also consider referrals to a physical or occupational therapist to work on specific motor skills training relevant to her work and school activities (e.g., practicing typing). with a collaborative and patient-focused approach, there is hope for tanja to feel substantially less burdened by her motor and attentional difficulties. taken together, the recent research on dcd highlights several key areas of consid­ eration for clinical psychologists in europe. first, dcd is a complex disorder with motor-based symptoms, several probable secondary symptoms and psychological conse­ quences (e.g., executive functions; anxiety; depression). these secondary impairments of dcd should continue to be examined systematically in all age groups, and with the consideration of co-occurring disorders. more specifically, the prevalence of dcd should be examined more thoroughly across europe in adults and children to identify a more accurate prevalence rate that may exceed the presumed international rate of 5% (e.g., meachon, zemp, & alpers 13 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ delgado-lobete et al., 2019). this research may function in parallel with the necessary validation of dcd screening tools in additional languages. future research should also aim to identify if prevalence differs across genders, as well as the consistency of other links such as left-handedness (darvik et al., 2018) and links to motor integration. second, more attention should be devoted to the co-occurrences with dcd, especially between dcd and adhd. while some research has identified important differences between the two disorders (e.g., goulardins et al., 2015), there is still ambiguity in the extent to which symptoms overlap and how this might impact co-occurrence rates. it has been suggested that one way to increase detection of dcd could be to screen for it in all potential adhd cases, considering their high co-occurrence rate (lange, 2018). moreover, screening for dcd when at least one other neurodevelopmental condition is clearly present, especially adhd, should be consistently practiced. future research should also identify unique symptomatic profiles of dcd and adhd, and researchers examining dcd or adhd should consistently screen for the other disorder. third, additional attention should be given to the emerging adult and adult popula­ tions with dcd in research and practice. while it is possible to diagnose dcd in adults, there are few tools that can be used for the diagnostic process. furthermore, while there is evidence of psychosocial problems in adulthood (kirby et al., 2013) there is no research to explore the effects of psychotherapy among adults. while it is thought that the same core motor symptoms generally cross into adulthood (e.g., kirby et al., 2010; kirby et al., 2011), along with potential secondary psychological concerns (e.g., depression, anxiety; kirby et al., 2013), there is a paucity of evidence on the manifestation of these difficulties in new contexts (e.g., transitioning to news schools or jobs). future research should continue to build the evidence for symptom profiles and screening tools for adults, and more specifically, psychological interventions should be examined for effectiveness in all age groups. finally, evidence-based treatments for the primary symptoms and secondary prob­ lems are crucial to foster the improvement in quality of life for dcd patients. there is increasing evidence that the psychosocial sequelae of dcd can be addressed with elements of psychotherapy adjunct to motor therapies. thus, treatment should be collab­ oratively tailored toward the individual needs of each patient (e.g., smits-engelsman et al., 2018). it may also be worth considering if other therapies may be relevant to the treatment of dcd, such as a familial approach in treatment that is often used for adhd (weyers et al., 2019). future research should include a broader examination of the family and social system in the impact and treatment of dcd. conclusion overall, there are existing research gaps in the understanding of dcd, however, a recent increase in international attention to the condition is promising. we deem it relevant that more european psychological researchers and practitioners take note of this upsurge dcd: relevance to clinical psychologists 14 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ and integrate motor skill screenings into their work where possible. such inclusion is pertinent for more accurate symptom profiles, prevalence estimates, improved differen­ tial diagnosis, and effective treatment of the symptoms of dcd across all age groups. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. twitter accounts: @emeachon references american psychiatric association. 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(2018). developmental coordination disorder is more than a motor problem: children describe the impact of daily struggles on their quality of life. british journal of occupational therapy, 81(2), 65–73. https://doi.org/10.1177/0308022617735046 meachon, zemp, & alpers 23 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://doi.org/10.1080/01942630902784761 https://doi.org/10.3109/01942638.2014.980928 https://doi.org/10.1111/j.1365-2214.2012.01403.x https://doi.org/10.1111/dmcn.14646 https://icd.who.int/browse10/2016/en https://icd.who.int/ https://doi.org/10.1177/0031512518809161 https://doi.org/10.1186/s12888-020-02707-9 https://doi.org/10.1016/j.ridd.2018.04.013 https://doi.org/10.1016/j.ejpn.2012.05.005 https://doi.org/10.1177/0308022617735046 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. dcd: relevance to clinical psychologists 24 clinical psychology in europe 2022, vol. 4(2), article e4165 https://doi.org/10.32872/cpe.4165 https://www.psychopen.eu/ dcd: relevance to clinical psychologists (introduction) key aspects of developmental coordination disorder method clinical presentation and secondary psychosocial consequences existing evidence of dcd prevalence and etiology dcd with co-occurring adhd or autism spectrum disorder available screening tools for dcd in european languages dcd in adolescents and adults multidisciplinary interventions for dcd discussion conclusion (additional information) funding acknowledgments competing interests twitter accounts references meaningful and lasting change – psychotherapy in the light of evolutionary processes editorial meaningful and lasting change – psychotherapy in the light of evolutionary processes andrew t. gloster 1 , elisa haller 1 [1] division of clinical psychology and intervention science, faculty of psychology, university of basel, basel, switzerland. clinical psychology in europe, 2022, vol. 4(3), article e9859, https://doi.org/10.32872/cpe.9859 published (vor): 2022-09-30 corresponding author: andrew t. gloster, university of basel, department of psychology, division of clinical psychology and intervention science, missionsstrasse 62a, ch-4055 basel, switzerland. e-mail: andrew.gloster@unibas.ch keywords psychotherapy, evolution, processes of change highlights • psychotherapies can lead to meaningful and lasting change. • evolutionary theory is relevant for understanding psychotherapy. • process-based approaches to conceptualizing psychotherapy can help organize clinical knowledge. • process-based approaches may be more useful than competitions between psychotherapy schools. all psychotherapies aim to exact change. this basic tenant holds true as much for therapies that explicitly work with clients to alter the way they behave as it does for psychotherapies that try to help clients accept what is, stop trying to change, and thus manage to adapt. this much, we believe, is agreeable to all clients, practitioners, and researchers. all psychotherapies also aim to exact change that is useful in clients’ lives. whereas one can argue about how to define benefit (e.g., symptom reduction, increase in wellbe­ ing, social integration, behavioral performance, etc.), a plethora of empirical evidence across many types of psychotherapies demonstrates that psychotherapy “works” (e.g., gloster et al., 2020; hofmann et al., 2012). absent such data, it would nevertheless be logical that, by and large, clients must benefit in some way, lest they would not this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9859&domain=pdf&date_stamp=2022-09-30 https://orcid.org/0000-0002-3751-0878 https://orcid.org/0000-0002-4484-9992 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ come back and healthcare systems would not spend capital on and regulate access to psychotherapy without a return on investment. similarly, all psychotherapies aim to exact lasting change. that is, clients and psycho­ therapists are working to establish meaningful changes that last beyond the psychother­ apy itself. here, large differences exist across psychotherapies: some explicitly address maintenance and generalization, whereas others are silent as how to help achieved gains “stick”. nevertheless, research shows that change for many can be maintained for years following treatment. as such, we believe it is uncontroversial that the basic tenants of evolution can be brought to bear on all psychotherapies: variation (change), selection (utility), and retention (lasting change). developments in evolutionary science demonstrate that evo­ lutionary processes are not limited to genetics, that they include processes that shape behavior and symbolic language (the bread and butter of psychotherapy), and can play out in much faster time spans than previously believed (wilson et al., 2014). one such attempt to conceptualize and organize empirically verified change process­ es in psychotherapy around evolutionary concepts is the process-based approach to psychotherapy (hayes et al., 2019; hofmann et al., 2022). although its implications are not yet established, the theoretical groundwork is now ready to guide the next steps of empirical examination of candidate processes of change (hayes et al., 2022). we believe this type of thinking is more promising than our fields’ history of fighting about which psychotherapy is better. it is also closer to clinical reality of the multi-method and multi-dimensional approach of most clinicians. the upshot here is that with concerted effort, clinical wisdom could be organized around evolutionary concepts (e.g., “meaning­ ful variation was achieved for this client using the empirically established procedure of x”, etc.). furthermore, this perspective is egalitarian and open to all psychotherapies, theories, and even our field’s favorite animal, the dodo bird. it may take time before the field concludes that nothing in psychotherapy makes sense except in the light of evolution – to borrow a famous phrase – but such a step could be meaningful change in itself. funding: this work was funded in part by the swiss national science foundation (grants: pp00p1_190082 & pp00p1_163716/1) awarded to the first author. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. twitter accounts: @cpis_lab meaningful and lasting change 2 clinical psychology in europe 2022, vol. 4(3), article e9859 https://doi.org/10.32872/cpe.9859 https://twitter.com/cpis_lab https://www.psychopen.eu/ references gloster, a. t., walder, n., levin, m. e., twohig, m. p., & karekla, m. (2020). the empirical status of acceptance and commitment therapy: a review of meta-analyses. journal of contextual behavioral science, 18, 181–192. https://doi.org/10.1016/j.jcbs.2020.09.009 hayes, s. c., ciarrochi, j., hofmann, s. g., chin, f., & sahdra, b. (2022). evolving an idionomic approach to processes of change: towards a unified personalized science of human improvement. behaviour research and therapy, 156, article 104155. https://doi.org/10.1016/j.brat.2022.104155 hayes, s. c., hofmann, s. g., stanton, c. e., carpenter, j. k., sanford, b. t., curtiss, j. e., & ciarrochi, j. (2019). the role of the individual in the coming era of process-based therapy. behaviour research and therapy, 117, 40–53. https://doi.org/10.1016/j.brat.2018.10.005 hofmann, s. g., asnaani, a., vonk, i. j., sawyer, a. t., & fang, a. (2012). the efficacy of cognitive behavioral therapy: a review of meta-analyses. cognitive therapy and research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1 hofmann, s. g., barber, j. p., salkovskis, p., wampold, b. e., rief, w., ewen, a.-c. i., & schäfer, l. n. (2022). what is the common ground for modern psychotherapy? a discussion paper based on eaclipt’s 1st webinar. clinical psychology in europe, 4(1), article e8403. https://doi.org/10.32872/cpe.8403 wilson, d. s., hayes, s. c., biglan, a., & embry, d. d. (2014). evolving the future: toward a science of intentional change. behavioral and brain sciences, 37(4), 395–416. https://doi.org/10.1017/s0140525x13001593 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. gloster & haller 3 clinical psychology in europe 2022, vol. 4(3), article e9859 https://doi.org/10.32872/cpe.9859 https://doi.org/10.1016/j.jcbs.2020.09.009 https://doi.org/10.1016/j.brat.2022.104155 https://doi.org/10.1016/j.brat.2018.10.005 https://doi.org/10.1007/s10608-012-9476-1 https://doi.org/10.32872/cpe.8403 https://doi.org/10.1017/s0140525x13001593 https://www.psychopen.eu/ title of “ambassador of clinical psychology and psychological treatment” awarded to peter fonagy letter to the editor, commentary title of “ambassador of clinical psychology and psychological treatment” awarded to peter fonagy martin debbané 1,2 [1] faculty of psychology and educational sciences, university of geneva, geneva, switzerland. [2] department of clinical, educational, and health psychology, university college london, london, united kingdom. clinical psychology in europe, 2022, vol. 4(1), article e7781, https://doi.org/10.32872/cpe.7781 published (vor): 2022-03-31 corresponding author: martin debbané, university of geneva fpse, boulevard du pont d'arve 40, 1205 geneva, switzerland. e-mail: martin.debbane@unige.ch professor peter fonagy (obe) leads a career in clinical psychology that epitomizes an integrative approach to the psychological care for children, adolescents and adults, with a continued determination to alleviate mental pain in those suffering from often chronic psychological distress. driven by the ambition of increasing access to quality care for the vulnerable, he has occupied a number of key national leadership positions in the uk, including chair of the outcomes measurement reference group at the department of health, chair of two nice guideline development groups, chair of the strategy group for national occupational standards for psychological therapies and co-chaired the department of health's expert reference group on vulnerable children. his clinical interests centre on issues of early attachment relationships, resilience, social cog­ nition, borderline personality disorder and vi­ olence. drawing from psychoanalysis, develop­ mental psychology, attachment theory as well as cognitive and affective neuroscience, peter fona­ gy puts forward a clinical approach based on evidence as well as best practice, closely articula­ ted to the most recent developments in research on psychopathology and psychotherapy. a ma­ jor focus of his contribution has been an innova­ tive research-based psychodynamic therapeutic approach, mentalization-based treatment, which was developed in collaboration with a number of clinical sites in the uk and usa. he has peter fonagy (2013) this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7781&domain=pdf&date_stamp=2022-03-31 https://orcid.org/0000-0002-4677-8753 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ published over 500 scientific papers, 260 chapters and has authored or co-authored 19 books. embracing communication and collaboration over competition and hostility be­ tween different theoretical frameworks in psychotherapy, his most popular books include “what works for whom” and “affect regulation, mentalization and the development of the self”, which collectively have attracted over ten thousand citations. his recognition as a scientist include fellow of the british academy, the academy of medical sciences, the academy of social sciences and the american association for psychological science, and he was elected to honorary fellowship by the american college of psychiatrists. he has received lifetime achievement awards from several national and international professional associations including the british psychological society, the international society for the study of personality disorder, the british and irish group for the study of personality disorder, the world association for infant mental health and was in 2015 the first uk recipient of the wiley prize of the british academy for outstanding achievements in psychology by an international scholar. peter fonagy’s academic achievements are recognized not only in the uk and in europe, but also at the international level. he is currently head of the division of psychology and language sciences at university college london; chief executive of the anna freud national centre for children and families, london; consultant to the child and family programme at the menninger department of psychiatry and behavioural sciences at baylor college of medicine; and holds visiting professorships at yale and harvard medical schools. most importantly perhaps, peter fonagy’s work influences hundreds of clinical psy­ chologists across many different theoretical approaches to reflect on the common factors leading to salutogenesis, that is, the psychological mechanisms which sustain mental health in the face of the regular and more impactful challenges individuals face across the lifespan. beyond individual and group psychotherapy, peter fonagy advocates for a social and political approach to mental health, and his work underlines the responsibili­ ties we carry as families, communities and political entities to strive to care for each other and be kind to one another. profound humanism can be experienced from peter fonagy’s approach to clinical psychology. he has agreed to share and defend these values as a dedicated ambassador to the european association for clinical psychology and allied disciplines. details on his life and professional trajectories in the media • https://www.theguardian.com/society/2019/apr/27/peter-fonagy-refugee-childpsychologist-anna-freud-centre • https://www.bbc.co.uk/sounds/play/m000dpj2 ambassador of clinical psychology and psychological treatment: peter fonagy 2 clinical psychology in europe 2022, vol. 4(1), article e7781 https://doi.org/10.32872/cpe.7781 https://www.theguardian.com/society/2019/apr/27/peter-fonagy-refugee-child-psychologist-anna-freud-centre https://www.theguardian.com/society/2019/apr/27/peter-fonagy-refugee-child-psychologist-anna-freud-centre https://www.bbc.co.uk/sounds/play/m000dpj2 https://www.psychopen.eu/ citation from an interview with e. l. jurist (2010, p. 7) p. f.: (…) when we understand the mechanism of a disorder at the level of biology, at the level of neuroscience, we will also understand (…) that the only way to alter those things will be psychological. they will be much more targeted, better targeted, but they will be psychological interventions. e. l. j.: so there’s something ineradicable about the role of psychology. p. f.: we are here for the duration. funding: the author has no funding to report. acknowledgments: the author has no additional (i.e., non-financial) support to report. competing interests: the author has declared that no competing interests exist. references jurist, e. l. (2010). elliot jurist interviews peter fonagy. psychoanalytic psychology, 27(1), 2–7. https://doi.org/10.1037/a0018636 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. debbané 3 clinical psychology in europe 2022, vol. 4(1), article e7781 https://doi.org/10.32872/cpe.7781 https://doi.org/10.1037/a0018636 https://www.psychopen.eu/ external locus of control but not self-esteem predicts increasing social anxiety among bullied children research articles external locus of control but not self-esteem predicts increasing social anxiety among bullied children belinda graham 1,2 , lucy bowes 1 , anke ehlers 1,2 [1] department of experimental psychology, university of oxford, oxford, united kingdom. [2] oxford health nhs foundation trust, oxford, united kingdom. clinical psychology in europe, 2022, vol. 4(2), article e3809, https://doi.org/10.32872/cpe.3809 received: 2020-06-01 • accepted: 2022-01-20 • published (vor): 2022-06-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: belinda graham, oxford centre for anxiety disorders and trauma, department of experimental psychology, the old rectory, paradise square, ox1 1tw, u.k. e-mail: belinda.graham@psy.ox.ac.uk abstract background: elevated social anxiety is more likely among bullied children than those who have not been bullied but it is not inevitable and may be influenced by cognitive factors. lower selfesteem and more external locus of control are associated with bullying and social anxiety but the impact of these factors over time among bullied children is less clear. method: children from the uk avon longitudinal study of parents and children (alspac) reported bullying experiences at age 8 (n = 6,704) and were categorized according to level of bullying exposure. the impact of self-esteem and locus of control on social anxiety was assessed up to age 13 across the bullying exposure groups using multi-group latent growth curve analysis. complete data was available for 3,333 participants. results: more external locus of control was associated with a steeper increase in social anxiety among severely bullied children [b = .249, p = .025]. although self-esteem at age 8 was associated with existing social anxiety it did not predict later increases in social anxiety. conclusion: these results indicate that beliefs about lack of personal control among severely bullied children may contribute to increasing social anxiety over time. exploring related cognitions may be helpful in this potentially vulnerable group. keywords alspac, bullying, social anxiety, locus of control this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.3809&domain=pdf&date_stamp=2022-06-30 https://orcid.org/0000-0002-3073-617x https://orcid.org/0000-0001-5645-3875 https://orcid.org/0000-0002-8742-0192 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • childhood bullying increases risk of social anxiety. • for severely bullied children this risk is exacerbated by external locus of control. • exploring beliefs around lack of personal control may be helpful. social anxiety is characterised by excessive fears of coming across badly or being judged harshly by others in social situations (american psychiatric association, 2013; world health organisation, 1992) and can lead to avoidance and poorer performance in school, work, and relationships (e.g., stein & kean, 2000; van ameringen et al., 2003). it is a chronic treatable condition (bruce et al., 2005) that is maintained by unhelpful cognitions (clark & wells, 1995). childhood bullying increases the risk of developing social anxiety (arseneault, 2018; pontillo et al., 2019) with higher risk conferred by more frequent exposure (copeland et al., 2013) but not all bullied children are socially anxious and identifying subgroups at risk may inform prevention and intervention. previous crosssectional research has identified locus of control (reknes et al., 2019) and self-esteem (wu et al., 2021) as modifiers of the relationship between bullying and mental health outcomes. in this longitudinal study, we evaluate the impact of locus of control and self-esteem on social anxiety over time among children with different levels of bullying exposure. better understanding factors that contribute to the unfolding of social anxiety symptoms in young people over time could inform targeted and developmentally appro­ priate approaches to treatment. bullying is generally understood to include aggressive interpersonal acts that are in­ tentional, repeated, and include a power imbalance between the victim and the aggressor (olweus, 1994). prevalence rates vary according to the measure of bullying used, setting and child age. one survey found rates of 8.7-14.4% for frequent bullying and 26.8-38.1% for occasional bullying over a 10-year period in england (chester et al., 2015). bullying experiences are classified as overt events like hitting, threatening or name calling, and relational events that use social power to inflict hurt by excluding, ignoring, gossiping or telling lies behind someone’s back. experiences like these can be socially traumatic (wild & clark, 2011) and contribute to the onset and maintenance of anxiety disorders (norton & abbott, 2017) including social anxiety (hackmann et al., 2000). of note, problematic social anxiety commonly arises during adolescence, with rates of onset peaking around age 13 (kessler et al., 2005). among adults with anxiety disorders, those suffering with social anxiety are particularly likely to report having been bullied or teased when they were younger (mccabe et al., 2003, 2010). increased risk of elevated long-term anxiety af­ ter bullying is evident from retrospective studies (gladstone et al., 2006) and prospective data (copeland et al., 2013; gladstone et al., 2006; sourander et al., 2007; stapinski et al., 2014). therefore, it is well established that bullying increases risk of social anxiety. however, mechanisms are less well understood. locus of control and social anxiety in bullied children 2 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ locus of control (nowicki & duke, 1974) refers to the extent to which someone believes the outcomes of events or behaviours to be under personal control (internal) or down to luck or chance (external). internal locus of control is associated with better wellbeing while external locus of control is associated with negative outcomes such as depression (zhang et al., 2014) and higher levels of ptsd, for example among survivors of combat (karstoft et al., 2015) and children exposed to stressful political life events (hallis & slone, 1999). it is possible that these outcomes are driven by associations with thinking and coping styles, such that internality is associated with positive thinking and help-seeking, while externality is associated with avoidance and helplessness (reknes et al., 2019). research has shown that adolescents who are victims of bullying generally have a more external locus of control compared with peers not involved in bullying (radliff et al., 2016) and among severely bullied adolescents those with more external locus of control also had higher risk of psychotic symptoms (fisher et al., 2013). of note, reknes et al. (2019) suggested that externality may contribute to a diminished sense of personal responsibility that is actually protective for adult victims of workplace bullying, as they may more readily attribute negative experiences externally. this may suggest a reduced risk of negative outcomes for bullied children who have a more external locus of control. however, no longitudinal studies have specifically investigated locus of control as a mechanism driving social anxiety among bullied children. low self-esteem refers to an unfavourable attitude towards the self (rosenberg, 1979) and may be informed by negative social interactions including experiences of bullying that are internalised (van geel et al., 2018). cross-sectional studies show that lower self-esteem is associated with bullying (brito & marluce, 2013; o’moore & kirkham, 2001) and cyberbullying (patchin & hinduja, 2010) but cannot speak to the direction of the effect, such that although bullying may contribute to reducing self-esteem it is also possible that children with lower self-esteem are more likely to be targeted (van geel et al., 2018). wu et al. (2021) found that self-esteem explained some of the cross-sec­ tional relationship between bullying and social anxiety among adolescents, but did not investigate causation due to the study design. in this study we investigate longitudinally whether lower self-esteem increases the risk of social anxiety among children who are bullied. cognitive models suggest that negative beliefs maintain social anxiety (clark & wells, 1995) and ptsd (ehlers & clark, 2000). for social anxiety, beliefs are commonly connected in meaning to past experiences of humiliation or rejection (wild et al., 2007) and include themes of personal capacity to perform adequately and appear acceptable to other people (e.g., “i am inadequate”). for ptsd, beliefs are commonly connected with the traumatic event and its sequelae and include themes about loss of control in terms of personal reactions (e.g., “i cannot handle stress”) and the environment more broadly (e.g., “the world is completely dangerous”). of note, these maintaining cognitions related to self and past or future events are not limited to explicit thoughts, but rather include imagery graham, bowes, & ehlers 3 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ and “felt sense” that is highly emotional (ehlers et al., 2004; hackmann et al., 2000). beliefs consistent with external locus of control and low self-esteem may be fruitful targets for cognitive interventions with bullied children if these factors negatively impact anxiety trajectories in this group. the current study assessed the moderating effects of locus of control and self-esteem on social anxiety among children using a three-wave longitudinal design over five-years, from age 7.5 to 13. the goal of this study was to assess whether externality of locus of control and self-esteem at age 8 influence the trajectory of social anxiety among children up to the age of 13, and whether the impact of these cognitive factors differs depending on bullying exposure. therefore, this study hypothesized that (1) social anxiety will increase from age 7.5 to 13; (2) children exposed to more severe peer victimisation will have higher initial social anxiety and steeper increase in social anxiety over time; (3) lower self-esteem, and (4) more external locus of control will predict higher initial social anxiety and steeper increase over time for those with more severe victimization experiences. method this sample was drawn from the avon longitudinal study of parents and children (alspac) which is a large prospective observational study of health and development in children. pregnant women resident in avon, uk during 1991-2 were invited to take part in the study. of 14,541 pregnancies initially enrolled, there was a total of 14,676 foetuses, resulting in 14,062 live births and 13,988 children who were alive at 1 year of age. when the oldest children were approximately 7 years of age, an attempt was made to bolster the initial sample with eligible cases who had failed to join the study originally. the number of new pregnancies not in the initial sample (known as phase i enrolment) is 913 (456, 262 and 195 recruited during phases ii, iii and iv respectively). the phases of enrolment are described in more detail in the cohort profile paper and its update (boyd et al., 2013; fraser et al., 2013). the total sample size is therefore 15,454 pregnancies, resulting in 15,589 foetuses, of whom 14,901 were alive at 1 year of age. this includes multiple births. participant flowchart shown in figure 1. informed consent for the use of data collected via questionnaires and clinics was obtained from participants following the recommendations of the alspac ethics and law committee at the time. please note that the study website contains details of all the data that is available through a fully searchable data dictionary and variable search tool (http://www.bristol.ac.uk/alspac/re­ searchers/our-data/). this project proposal received approval from alspac executive committee [b2804]. locus of control and social anxiety in bullied children 4 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 http://www.bristol.ac.uk/alspac/researchers/our-data/ http://www.bristol.ac.uk/alspac/researchers/our-data/ https://www.psychopen.eu/ figure 1 participant flowchart attended clinic at age 8 (i.e., eligible for this study), n = 7,278 complete information on all variables, n = 3,333 data available on peer victimisation at age 8, n = 6,704 complete information on bullying and social anxiety, n = 4,175 missing data on social anxiety, n = 2,529 enrolled in phases i, ii, iii, iv, n = 14,676 fetuses excluded, n = 7,679: died, n = 92 untraceable, n = 627 withdrawn, n = 505 multiple birth, n = 404 did not attend clinic at age 8, n = 6,069 miscarriages and still births, n = 614 fetuses liveborn children, n = 14,062 additional enrolments, n = 913 missing data on peer victimisation age 8, n = 574 missing data on one or more covariatesa, n = 842 aprior emotional problems (strengths and difficulties questionnaire), locus of control (nowicki-strickland internal-external scale), self-esteem (harter’s self-perception profile for children). data available at www.bristol.ac.uk/alspac/researchers/cohort-profile/ participants in total 7,278 participants attended clinic assessment at age 8 making them eligible for this study. of these, 6,704 provided data on bullying exposure, of whom 2,529 were missing data on social anxiety at one or more time points and 842 were missing data on one or more covariates. complete data was therefore available for 3,333 cases. the current sample includes singleton births only to reduce within family confounds. measures peer victimisation a modified version of the bullying and friendship interview (wolke et al., 2001) was used to determine the frequency that children had experienced nine different types of re­ lational and overt peer victimisation involving other children at school or to/from school in the past six months. specifically, four relational behaviours (others wouldn’t play with them to upset them, been made to do things didn’t want to do, had lies/nasty things said about them, had games spoilt) and five overt behaviours (had personal belongings taken, been threatened/blackmailed, been hit/beaten up, been tricked in a nasty way, graham, bowes, & ehlers 5 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ been called bad/nasty names). for each type, participants responded “no”, “yes sometimes” (less than four times), “yes repeatedly” (four or more times), or “yes very frequently” (at least once per week). fisher et al. (2013) established an index of bullying severity in the same sample comprising three levels of bullying severity at age 8, such that children who reported exposure to both overt and relational victimization at least 4 times each or at least once per week were classed as severely bullied, those who had experienced only one of these types at this frequency were classed as occasionally bullied, and all remaining children were classified as not bullied. internal reliability was acceptable (α = 0.73). locus of control an adapted version of the nowicki-strickland internal-external scale (nowicki & duke, 1974) suitable for use with children was completed during in-person assessment at age 8 years, comprising 12 items answered yes/no. a sum score was calculated (range 0-12), with higher scores indicating more external locus of control and lower scores indicating more internal locus of control. self-esteem the global self-worth subscale of harter’s self perception profile for children (harter, 1985) was completed during in-person assessments at age 8 years, comprising 6 items each split into two components reflecting high and low self-esteem (e.g., some children are often unhappy with themselves, other children are pretty pleased with themselves). each component was rated as “sort of true for me” or “really true for me” to produce a four-point scale for each item. a sum score was calculated (range 6 – 24), with higher scores indicating higher self-esteem. internal reliability was acceptable (α = 0.73). prior emotional problems parents rated their child’s emotional wellbeing using the relevant subscale from the strengths and difficulties questionnaire at age 6.75 years. a sum score was calculated (range 0 – 10) with higher scores indicating more emotional difficulties. this variable was included as a covariate in the model. social anxiety parents rated their child’s fear of new people, lots of people, and eating, speaking, reading, or writing in front of others over the last month as either “no”, “a little”, “a lot”, using the development and well-being assessment (goodman et al., 2000) six-item social fears subscale (dawba-sf) at age 7.5, 10, and 13. a total score was calculated (range 0 – 12), with higher scores indicating more severe social anxiety. internal reliability was good (α = 0.77 – 0.80). locus of control and social anxiety in bullied children 6 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ analytic approach first, the pattern of growth in social anxiety over time was modelled using a first-order latent growth curve model (lgcm), specifying initial severity (intercept) and shape of change (slope) using a repeated measure sum score of severity of social anxiety (dawba-sf). data was collected at three time points so linear shape was assumed and loadings for time were fixed at 0 (baseline, age 7.5), 2 (age 10), and 5 (age 13) in order to allow interpretation of the intercept as severity at age 7.5 and slope as linear change over time (hypothesis 1). intercepts and slopes were allowed to vary between individuals. good model fit was assessed using recommended indices (hooper et al., 2008), namely standardized root mean square residual (srmr) below 0.08, root mean square error of approximation (rmsea) below 0.05, comparative fit index (cfi) above 0.95, and tucker-lewis index (tli) above 0.90. models were run in mplus using the mlr estimator (maximum likelihood estimation with robust standard errors) to minimize bias associated with missing data from study attrition and to account for non-normality of observations. chi-square significance was not used to assess model fit as it is unreliable in large samples and is not estimated when using mlr. all measures were assumed to be influenced by random measurement error. second, to test the hypothesis that trajectory of social anxiety differs by level of exposure to victimisation (hypothesis 2), exposure to victimisation was tested as a predictor of social anxiety overall, and in addition initial level and slope was compared between not bullied (n = 4,037), occasionally bullied (n = 1,955), and severely bullied (n = 712) groups in a multi-group lgcm grouped by exposure to victimisation. presence of additional variance in social anxiety trajectory was also assessed within each victimi­ sation exposure group, with and without adjustment for prior emotional problems. third, to test the contribution of cognitive predictors (hypothesis 3, 4) locus of control and self-esteem were entered into the model to determine their ability to explain variance in initial level and slope in the full sample, in each bullying exposure group, and between bullying exposure groups (see figure 2). univariate anova suggested no evidence of a differential relationship between bully­ ing and social anxiety according to sex so analyses were conducted on the group as a whole. data was inspected in spss27 and analysed in mplus 8. graham, bowes, & ehlers 7 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ figure 2 diagram of multigroup latent growth curve model, grouped by bullying severity (“not”, “occasionally”, “severely”) prior emotional difficulties (age 6) locus of control (age 8) self-esteem (age 8) social anxiety (age 7.5) social anxiety (age 10) social anxiety (age 13) social anxiety intercept social anxiety slope results sample characteristics enrollment and participation flowchart is shown in figure 1. at age 8, over a third of participants (n = 2,667, 39.8%) reported exposure to either relational or overt victimiza­ tion at least four times over the last six months, and of these over a quarter (n = 712, 26.7%) experienced both types and were classified as severely bullied. severity of bullying exposure at age 8 was not associated with level of social anxiety but was associated with lower self-esteem and more external locus of control. those exposed to bullying also had higher prior emotional difficulties compared to those not exposed to bullying. characteristics are shown in table 1. missing data among the sample with data on bullying at age 8, missing data on social anxiety at age 13 was more likely among those who were severely bullied, χ2(2, n = 6,704) = 9.89, p = .007 and those whose parents had a lower socio-economic status, χ2(1, n = 5,601) = 29.84, p < .001. missingness did not differ by sex, χ2(1, n = 6,704) = 0.241, ns. locus of control and social anxiety in bullied children 8 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ trajectory of social anxiety a single linear growth curve model of social anxiety over time had a good fit for the data, cfi = .992, tli = .977, srmr = .010, rmsea = .037, 90% ci [0.018, 0.060]. across the sample, the social anxiety variable was highly positively skewed but mean levels increased slightly from age 7.5 (range 0 – 12, m = 0.83, sd = 1.51), to age 10 (range 0 – 12, m = 0.91, sd = 1.60), to age 13 (range 0 – 11, m = 1.15, sd = 1.79), confirmed by small but significant positive slope (m = 0.07, se = .005, p < .001). there was also significant variability in social anxiety intercept (m = 1.27, se = .090, p < .001) and slope (m = 0.55, se = .008, p < .001) indicating individual differences around the mean trajectory. model fit improved when level of prior emotional difficulties, which are expected to be associated with social anxiety at age 7.5, was included in the model, cfi = .996, tli = .987, srmr = .009, rmsea = .024, 90% ci [0.010, 0.040]. prior emotional difficulties predicted initial social anxiety (m = 0.39, se = .021, p < .001) but did not impact on the rate of subsequent change in social anxiety over time (m = -0.02, se = .030, ns). table 1 sample characteristics by severity of bullying victimisation at age 8 variable severity of bullying at age 8, m (sd) or n (%) not bullied (n = 4,037) occasional (n = 1,955) severe (n = 712) f, χ2 gender female (n, %) 2,136 (52.9) 910 (46.5) 341 (47.9) 17.68a social anxiety age 7.5 0.83 (1.50) 0.81 (1.44) 0.86 (1.67) 0.31 (ns) age 10 0.89 (1.57) 0.92 (1.62) 1.01 (1.76) 1.49 (ns) age 13 1.12 (1.75) 1.17 (1.80) 1.32 (1.97) 3.23a self-esteem 19.67 (3.18) 18.98 (3.51) 18.02 (3.72) 80.14b locus of control 5.71 (2.05) 6.21 (2.00) 6.67 (2.12) 78.69b prior emotional difficulties 1.43 (1.58) 1.57 (1.74) 1.59 (1.71) 5.06c note. self-reported severity of bullying victimisation using bullying and friendship interview and categorized following fisher et al. (2013); social anxiety = dawba social fears subscale (range 0 – 12; higher is more social anxiety); self-esteem = harter’s self perception profile for children: shortened form (range 6 – 24; higher is better self-esteem); external locus of control = nowicki-strickland internal external scale (range 0 – 12; higher is more external); prior emotional difficulties = relevant subscale from strengths and difficulties questionnaire age 6.75 (range 0 – 10; higher is more emotional difficulties). significant group difference between, a. “not bullied” and “severe”, p < .05, b. all groups, p < .01, c. “not bullied” and both bullied groups (p < .05). graham, bowes, & ehlers 9 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ trajectories of social anxiety by severity of bullying exposure when severity of bullying exposure at age 8 was added as a predictor of overall social anxiety trajectory alongside prior emotional problems, the expected effect of bullying on social anxiety was shown, such that higher bullying exposure at age 8 predicted a slightly steeper increase in social anxiety over time (m = 0.06, se = 0.02, p = .014). however, bullying exposure at age 8 was not associated with concurrent social anxiety (m = -0.01, se = 0.02, ns). in order to test the impact of cognitive factors on social anxiety in the context of differing bullying exposure, the sample was split following fisher et al. (2013) into three groups of bullying severity, namely “not bullied”, “occasional”, and “severe”. model fit for this grouped model was good, cfi = .995, tli = .986, srmr = .011, rmsea = .025, 90% ci [0.007, 0.042]. all three groups had significant positive slope indicating increasing social anxiety over time (“not bullied”: m = .063, se = 0.01, p < .001; “occasional”: m = .075, se = .01, p < .001; “severe”: m = .102, se = .02, p < .001) but hypothesis 2 was not supported as there were no significant differences in mean initial social anxiety severity or mean slope between bullying exposure groups. see figure 3. of note, there was significant variance in slope within each group indicating that other factors are responsible for explaining individual differences in trajectory. figure 3 estimated mean social anxiety (age 7.5 – 13) grouped by bullying exposure at age 8 0 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 age 7.5 age 10 age 13 se ve ri ty o f s oc ia l a nx ie ty not bullied occasionally bullied severely bullied note. grouped by self-reported level of bullying victimisation in bullying and friendship interview. social anxiety assessed at three time points (age 7.5, 10, 13) using dawba social fears subscale (range 0 – 12; higher is more social anxiety). at age 10, group differences in social anxiety are not significant. at age 13, social anxiety was significantly higher in the severe group compared with the not bullied group (p = .013) but not the occasionally bullied group (p = .090). locus of control and social anxiety in bullied children 10 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ cognitive predictors of social anxiety by severity of bullying exposure the final model including hypothesized predictors (locus of control, self-esteem, and prior emotional difficulties) had good model fit, cfi = .995, tli = .986, srmr = .010, rmsea = .019, 90% ci [0.004, 0.032]. contrary to hypothesis 3, lower self-esteem at age 8 was not independently associated with concurrent social anxiety or rate of change in social anxiety over time in any group. in contrast, while more external locus of control at age 8 was not associated with concurrent social anxiety in any group, it predicted a moderate increase in anxiety in the severely bullied group (b = .167, p = .011) with smaller effects for those who were never bullied (b = .095, p = .005) and occasionally bullied (b = .097, ns). prior emotional problems strongly predicted social anxiety at age 7.5 in all groups but did not impact the rate of change in social anxiety over time. see table 2. table 2 predictors of social anxiety trajectory from age 7.5 to 13 grouped by age 8 bullying exposure trajectory components and predictors not bullied, n = 4,037 occasional, n = 1,955 severe, n = 712 coefficient (se) p coefficient (se) p coefficient (se) p intercept (social anxiety age 7.5) 0.816 (.024) 0.810 (.035) 0.846 (.066) predictors of intercept self-esteem -0.041 (.023) ns -0.059 (.034) ns 0.009 (.055) ns locus of control 0.039 (.024) ns 0.038 (.034) ns 0.075 (.049) ns prior emotional problems 0.393 (.026) < .001 0.412 (.043) < .001 0.344 (.063) < .001 slope (social anxiety over time) 0.057 (.007) 0.073 (.010) 0.102 (.018) predictors of slope self-esteem -0.021 (.033) ns 0.027 (.048) ns -0.031 (.069) ns locus of control 0.095 (.034) < .05 0.097 (.051) ns 0.167 (.065) < .05 prior emotional problems -0.033 (.040) ns -0.013 (.057) ns -0.008 (.081) ns intercept x slope -0.061 (.023) -0.067 (.035) -0.081 (.070) note. cells contain unstandardized coefficients for intercept and slope estimated without predictors, standar­ dized coefficients for predictors, with standard errors (se) and probabilities (p; two-tailed). social anxiety = dawba social fears subscale; self-esteem = harter’s self perception profile for children: shortened form; locus of control = nowicki-strickland internal external scale; prior emotional problems = mother report relevant subscale from strengths and difficulties questionnaire. discussion children who were bullied at age 8 were more likely to have a more external locus of control than other children and higher externality among severely bullied children was associated with steeper increases in social anxiety up to the age of 13. of note, graham, bowes, & ehlers 11 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ exposure to bullying at age 8 was not associated with existing social anxiety at age 7.5 but was associated with subsequent increases social anxiety, and this increase was larger for those with external locus of control. this pattern was not observed in relation to self-esteem. this suggests that external locus of control in early childhood could be a risk factor for later anxiety among severely bullied children and is a potential target for intervention. external locus of control describes a tendency to consider events and experiences as outside personal control. in this sample, the effect of externality on negative outcomes was small overall but larger in the severely bullied group, such that external locus of control was associated with steeper increases in social anxiety for severely bullied children. beliefs around bullying that are consistent with external locus of control may include thoughts such as, “being picked on is inevitable”, or “others will always target me”. evidence from personal experiences that contradict these types of beliefs related to bullying may be accessible for those who are not bullied or bullied occasionally. in contrast, beliefs about lack of control over a threatening and unpredictable social environment may be strengthened by repeated confirmatory evidence for children who are severely bullied and therefore more likely to persist. in line with existing literature suggesting that external locus of control is a risk factor for psychopathology (hallis & slone, 1999; karstoft et al., 2015; zhang et al., 2014), there was some indication of a dose response relationship between external locus of control and social anxiety, but with only minimal effects among children who were never or occasionally bullied. reknes et al. (2019) suggested that external beliefs were protective against general psychological strain for adult victims of workplace bullying, enhancing acceptance and enabling external attribution of negative experiences towards negative characteristics of the perpetrator or bad luck instead of taking personal blame. however, the current study suggests that while external control beliefs do not confer additional risk of social anxiety for occasionally bullied children there is an additional risk for severely bullied children. for children who are severely bullied and have a tendency towards externality, promoting personal control beliefs may be one route towards encouraging more constructive coping strategies. the cognitive model of social anxiety disorder (clark & wells, 1995) posits that those suffering with social anxiety hold unhelpful beliefs about their ability to perform well in social situations that, when triggered in a social situation, lead to increased self-consciousness and self-monitoring. in an effort to mitigate the perceived risks, the person then engages in “safety-seeking” behaviors that are intended to keep them safe (e.g. looking down and avoiding eye contact). however, these behaviors can also have unintended consequences (e.g. looking unfriendly or disinterested) which negatively impact the social interaction. therefore, it is possible that excessive perception of threat may persist even in the absence of an ongoing objectively threatening environment and that perceiving threat may encourage children to act in ways that could inadvertently locus of control and social anxiety in bullied children 12 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ increase likelihood of ongoing bullying. in this analysis, social anxiety at age 7.5 was not associated with higher bullying exposure at age 8, so it is not necessarily the case that more fearful children were being targeted or perceived that they were being targeted. however, appraisals associated with external locus of control may contribute to excessive perceptions of ongoing social threat and to passive or unhelpful forms of coping that contribute to increasing social anxiety over time. it is interesting to note that early self-esteem did not influence the trajectory of social anxiety to age 13 among any bullying exposure group. as such, it is possible that early cognitive processes related to self-esteem could be less important in terms of predicting future anxiety (sowislo & orth, 2013) despite evidence of cooccurrence (lee & hankin, 2009). in fact, these results support cross-sectional associations between bullying, self-esteem and social anxiety (gómez-ortiz et al., 2018; núñez et al., 2021) but our findings suggest that children who are bullied and have low self-esteem are not necessarily at increased risk of social anxiety over time. similarly, although our analyses showed the expected association between prior emotional problems and social anxiety at age 7.5, there was no ongoing impact of early emotional problems on increasing social anxiety over time. this indicates that early emotional problems and self-esteem may be less important indicators of ongoing adjustment compared with external locus of control, a feature that has been largely overlooked in this domain but which may be an important clinical target for assessment and intervention. this study has important clinical implications. it is notable that long-term anxiety as­ sociated with bullying can persist even in the absence of current threat, that is, even after bullying has stopped. cognitive theories of anxiety after stressful experiences (clark & wells, 1995; ehlers & clark, 2000) suggest that cycles develop between unhelpful beliefs, particular memory characteristics, and behavioral and cognitive coping strategies to maintain anxiety. maladaptive beliefs associated with bullying may contribute to social anxiety that increases over time and children who have been bullied may be supported with cognitive behavioural approaches (pontillo et al., 2019). this study suggests that particularly among children who have been severely bullied, beliefs associated with external locus of control may be relevant to maintaining and exacerbating social anxiety. more specific investigation of these beliefs could inform targeted and developmentally appropriate approaches to treatment among young people. in addition, these findings underline the importance of repeated measurement of social anxiety during adolescence in order to recognize differential trajectories of change. it appears that the differentiated trajectories in social anxiety were not visible prior to age 10 and rather became apparent first between age 10 and 13. this underscores the importance of developmental models of psychopathology that can be linked to a developmental clinical approach. some limitations in this study should be kept in mind. the sample suffered from attrition but this is common in prospective studies of this duration. although higher exposure to bullying was associated with dropout, this would have if anything likely graham, bowes, & ehlers 13 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ attenuated findings rather than increased them, such that effect sizes may have been greater if these participants had been retained. small effect sizes indicate that substantial variance in the model remains unexplained, perhaps due to cognitive or social factors that were not measured, or due to biological or genetic factors. observed effects between bullying and social anxiety accounted for early internalizing problems, but these were measured after starting school (age 6), so the possibility that very early bullying trig­ gered anxiety cannot be ruled out. it is also possible that past or ongoing bullying may negatively impact self-esteem later, but this is not measured in this study. of note, the locus of control and self-esteem measures used in this study were not developed within the cognitive model framework but can provide a useful proxy for the meaning of the constructs within this model. future research should assess whether the observed effect of external locus of control on social anxiety is indeed replicated for cognitions that are consistent with this construct and tailored to perceptions of bullying experiences. overall, it is well known that bullying contributes to increased risk of anxiety among children. it is also known that this is a critical developmental stage for increasing social anxiety symptoms and onset of social anxiety disorder, a mental health problem with severe consequences which once chronic rarely abates in the absence of specific interventions. it is also widely recognized that cognitive factors are central to the onset and maintenance of anxiety disorders including social anxiety. the present study aimed to understand the impact of specific cognitive factors, namely locus of control and self-esteem, on trajectories of social anxiety among children aged 8 to 13. results suggest that children who are severely bullied at age 8 are particularly at risk of increasing social anxiety if they also hold an external locus of control. however, self-esteem does not appear to have the same moderating effect. it is possible that beliefs consistent with external locus of control contribute to further reduced perception of control over the environment in the context of bullying, which leads to more passive or ineffective coping strategies. the results of this study offer new insight into potentially modifiable factors that increase risk of social anxiety among bullied children and suggest that external control beliefs could be useful targets for cognitive interventions. locus of control and social anxiety in bullied children 14 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://www.psychopen.eu/ funding: the uk medical research council and wellcome trust [217065/z/19/z] and the university of bristol provide core support for alspac. a comprehensive list of grants funding is available on the alspac website (http://www.bristol.ac.uk/alspac/external/documents/grant-acknowledgements.pdf). this publication is the work of the authors belinda graham, anke ehlers and lucy bowes who serve as guarantors for the contents of this paper. their work was supported by the wellcome trust [205156, 200796], the nihr biomedical research centre at oxford university hospitals nhs trust, and the nihr oxford health biomedical research centre. also, the academy of medical sciences springboard award and nihr public health program for bullying intervention. acknowledgments: we are extremely grateful to all the families who took part in this study, the midwives for their help in recruiting them, and the whole alspac team, which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists and nurses. competing interests: the authors have declared that no competing interests exist. twitter accounts: @drbelindagraham data availability: conditions for accessing and using alspac data are described on the study website http://www.bristol.ac.uk/alspac/researchers/access/ references american psychiatric association. 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(2014). a longitudinal study of posttraumatic stress disorder symptoms and its relationship with coping skill and locus of control in adolescents after an earthquake in china. plos one, 9, article e88263. https://doi.org/10.1371/journal.pone.0088263 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. graham, bowes, & ehlers 19 clinical psychology in europe 2022, vol. 4(2), article e3809 https://doi.org/10.32872/cpe.3809 https://doi.org/10.1371/journal.pone.0088263 https://www.psychopen.eu/ locus of control and social anxiety in bullied children (introduction) method participants measures analytic approach results sample characteristics missing data trajectory of social anxiety trajectories of social anxiety by severity of bullying exposure cognitive predictors of social anxiety by severity of bullying exposure discussion (additional information) funding acknowledgments competing interests twitter accounts data availability references symptom perceptions in functional disorders, major health conditions, and healthy controls: a general population study research articles symptom perceptions in functional disorders, major health conditions, and healthy controls: a general population study angelika weigel 1,2 , thomas meinertz dantoft 3 , torben jørgensen 3,4,5 , tina carstensen 2,6 , bernd löwe 1 , john weinman 7 , lisbeth frostholm 2,6 [1] department of psychosomatic medicine and psychotherapy, university medical center hamburg-eppendorf, hamburg, germany. [2] the research clinic for functional disorders and psychosomatics, aarhus university hospital, aarhus, denmark. [3] center for clinical research and prevention, bispebjerg and frederiksberg hospital, capital region of denmark, denmark. [4] department of public health, faculty of medical sciences, university of copenhagen, copenhagen, denmark. [5] faculty of medicine, aalborg university, aalborg, denmark. [6] department of clinical medicine, aarhus university, aarhus, denmark. [7] school of cancer & pharmaceutical sciences, king's college london, london, united kingdom. clinical psychology in europe, 2022, vol. 4(4), article e7739, https://doi.org/10.32872/cpe.7739 received: 2021-10-28 • accepted: 2022-08-14 • published (vor): 2022-12-22 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: angelika weigel, university medical center hamburg-eppendorf, department of psychosomatic medicine and psychotherapy, martinistr. 52, 20246, hamburg, germany. phone: 0049 40 7410 52996. email: a.weigel@uke.de abstract background: the present study investigated differences in symptom perceptions between individuals with functional disorders (fd), major health conditions, and fds + major health conditions, respectively, and a group of healthy individuals. furthermore, it investigated the relevance of fds among other health-related and psychological correlates of symptom perceptions in the framework of the common sense model of self-regulation (cms). method: this cross-sectional study used epidemiological data from the danish study of functional disorders part two (n = 7,459 participants, 54% female, 51.99 ± 13.4 years). symptom perceptions were assessed using the brief illness perception questionnaire (b-ipq) and compared between the four health condition groups. multiple regression analyses were performed to examine associations between symptom perceptions, fds, and other health-related and psychological correlates from the cms framework. results: individuals with fds (n = 976) and those with fds + major health conditions (n = 162) reported less favorable symptom perceptions compared to the other two groups, particularly this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7739&domain=pdf&date_stamp=2022-12-22 https://orcid.org/0000-0001-6820-8316 https://orcid.org/0000-0001-7437-7052 https://orcid.org/0000-0001-9453-2830 https://orcid.org/0000-0001-5086-4331 https://orcid.org/0000-0003-4220-3378 https://orcid.org/0000-0002-6786-0166 https://orcid.org/0000-0002-9683-7416 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ regarding perceived consequences, timeline, and emotional representations (effect size range cohen’s d = 0.12-0.66). the presence of a fd was significantly associated with all b-ipq items, even in the context of 16 other relevant health-related and psychological correlates from the cms framework, whereas symptom presence last year or last week was not. conclusion: in the general population, symptom perceptions seem to play a more salient role in fd than in individuals with well-defined physical illness. symptom perceptions should therefore be targeted in both primary and secondary interventions for fds. keywords symptom perceptions, functional disorders, epidemiological study, quality of life, common-sense model of illness, personality traits highlights • symptom perceptions were poorest in individuals with functional disorders with and without co-occuring major health conditions. • functional disorders in oneself and in the family were associated with symptom perceptions. • symptom presence last year or last week was not associated with symptom perceptions. experiencing physical symptoms is a common everyday phenomenon in the general population (hinz et al., 2017). their perception and appraisal are results of multidimen­ sional processes that go beyond a recognition of peripheral bodily changes (petersen et al., 2011). in major health conditions (e.g., cancer, heart attack), the relationship between peripheral bodily dysfunctions and self-reported symptoms is weaker in chronic multisymptomatic than in acute monosymptomatic diseases (janssens et al., 2011). in functional disorders, i.e., bothersome physical conditions that are not better explained by physical diseases or mental disorders and are associated with reduced health-related quality of life, evidence suggests a weaker relation between physical parameters (e.g., respiratory changes after gradually increased ventilation) and symptom perceptions (e.g., perceived dyspnea) compared to healthy controls (bogaerts et al., 2010). these varying associations between peripheral bodily changes and symptom perceptions underline the relevance of cognitive and emotional processes in symptom perception and appraisal (van den bergh et al., 2017). symptom perceptions describe dynamic mental representations and personal ideas that individuals generate to make sense of and respond to their symptoms (broadbent et al., 2015). among numerous empirically tested theoretical models of symptom perception and appraisal (whitaker et al., 2015), the common-sense model of self regulation is particularly established (csm; leventhal et al., 2016). according to the csm, individuals’ mental models of experienced symptoms include cognitive representations of the symp­ symptom perceptions in functional disorders 2 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ tom identity (lay diagnosis), the coherence and the perceived timeline, the control over and consequences of the experienced symptoms as well as emotional representations of symptom concerns and emotional reactions. symptom perceptions thereby directly affect the coping efforts that may be more or less beneficial. individuals then appraise the effects of these coping efforts, which may result in changes to their cognitive representa­ tions and emotional responses in a feedback loop. however, while healthy individuals can form their symptom perceptions based on their experience that symptoms are usual­ ly non-threatening and short-lived everyday phenomena and individuals with chronic diseases usually receive a biomedical explanation of their symptoms and a diagnostic label with an associated treatment rational, individuals with functional disorders lack these aspects. instead, individuals with functional disorders are often confronted with inconclusive medical findings and receive no diagnostic label or external information about the possible course of the disease, which might negatively influence their symptom perceptions. symptom perceptions have an impact on health outcomes in both mental and somatic disorders (dempster et al., 2015; hagger et al., 2017). for example, one methodologically rigorous study that investigated illness perceptions in a primary healthcare sample with diverse new health complaints provided evidence for the impact of symptom perceptions on quality of life (frostholm et al., 2007). furthermore, there is a large body of litera­ ture on the influence of symptom perceptions in clearly defined medical conditions on various health outcomes (aalto et al., 2006; de gucht, 2015; o’donovan et al., 2016; tiemensma et al., 2016; timmers et al., 2008; tribbick et al., 2017; van erp et al., 2017; xiong et al., 2018). despite valuable insights into the relevance of symptom perceptions on health outcomes, previous studies have rarely investigated symptom perceptions in individuals with functional disorders with potential co-occuring medical conditions. research into this area is crucial as suggested by a dutch epidemiological study showing that the functional impairments associated with functional disorders are similar in se­ verity to those in major health conditions (joustra et al., 2015). in addition, more negative symptom perceptions have been observed in individuals with functional gastrointestinal disorders compared with patients with peptic ulcer or reflux esophagitis (xiong et al., 2018) and functional disorders might co-occur with medical conditions (halpin & ford, 2012). according to the csm, a number of contextual, health-related, and psychological fac­ tors may influence the formation of symptom perceptions. a recent systematic review on so-called modifiable correlates of symptom perceptions observed an association between higher symptom severity and less favorable symptom perceptions in different somatic conditions (arat et al., 2018). the same review highlighted a negative influence of de­ pression and anxiety on symptom perceptions, with the limitation that no differentiation was made between lifetime mental disorders and the current presence of symptoms. only few studies have considered other mental comorbidities than depression and anxi­ weigel, meinertz dantoft, jørgensen et al. 3 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ ety. two studies investigated the influence of post-traumatic stress disorder (ptsd) on symptom perceptions in patients with a myocardial infarction and observed significantly less favorable symptom perceptions in patients with ptsd symptomatology compared with those without (princip et al., 2018; sheldrick et al., 2006). in contrast, many studies have investigated coping and symptom perceptions. a meta-analysis by dempster and colleagues concluded that symptom perceptions and coping explain a valuable amount of variance in distress outcomes across a range of physical health conditions (dempster et al., 2015). one cross-sectional study investigated the association between type d personality and illness perceptions in colorectal cancer survivors and observed significantly less favorable symptom perceptions in those with high type d personality traits (mols et al., 2012). however, the concept of type d personality has been criticized in favor of the big five personality traits (neuroticism, extraversion, openness, agreeableness, conscientiousness; horwood & anglim, 2017). furthermore, there is evidence that per­ sonality traits are more relevant to symptom perceptions than current illness severity (goetzmann et al., 2005), and that symptom perceptions at least partially mediate the association between personality traits and coping (rassart et al., 2014). within this body of literature on correlates of symptom perceptions in the framework of the cms, the possible influence of functional disorders in a patient or his/her significant others has not yet been investigated. knowledge of symptom perceptions within the csm framework from a large repre­ sentative general population sample can help shed light on the possible differences in symptom perceptions in functional disorders and somatic diseases, respectively. such an investigation would increase the evidence base for the current theoretical understanding of the role of specific symptom perceptions in functional disorders. furthermore, it may pave the way for the identification of intervention components to improve symptom management and improve health outcomes as has been shown in patients with myocar­ dial infarction (petrie et al., 2002) and severe functional disorders (christensen et al., 2015). the first aim of the present epidemiological study was to compare symptom per­ ceptions in healthy individuals and individuals with either functional disorders, major health conditions or both. we hypothesized that there would be differences between the four health condition groups, with particularly less favorable symptom perceptions in individuals with functional disorders. the second aim was to examine whether the presence of a functional disorder in a participant or his/her significant others would explain meaningful variance in symptom perceptions besides a large number of other possible correlates of symptom perceptions from the cms framework by means of an exploratory approach. symptom perceptions in functional disorders 4 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ method study population data collection took place in the context of the “danish study of functional disorders” (danfund; dantoft et al., 2017). the complete danfund sample comprises a random sample of 9,656 participants aged between 18-76 years from the danish general popula­ tion living in the western part of greater copenhagen (participation rate 33.7%). recruit­ ment occurred in two cross-sectional waves with the same eligibility criteria: danfund part one from 2011 to 2012 (2,308 participants) and danfund part two from 2012 to 2015 (7,493 participants). all danfund participants completed a general health examination and a self-report questionnaire battery at the research centre for prevention and health, glostrup, denmark. the danfund part two self-report questionnaire battery included a questionnaire on symptom perceptions, and this cohort was therefore eligible for the present study. all participants gave their written informed consent prior to study participation. the study was approved by the ethical committee of copenhagen country (ka-2006-0011, h-3-2011-081, h-3-2012). measures symptom perceptions the danish version of the b-ipq was applied to assess symptom perceptions with eight numerous rating scales (range 1–10, for item wording see table 2, broadbent et al., 2006). the b-ipq uses a single-item scaling to measure symptom perceptions based on the csm with five items related to cognitive perceptions, two items to emotional aspects and one item to the understanding of an illness. participants were instructed only to fill out the b-ipq items if they had experienced symptoms during the last year according to the bds checklist (see below) or the last week (scl-90 somatization subscale). as symptom perceptions were assessed with respect to physical symptoms and not to a certain illness, the b-ipq item assessing illness identity was removed. items assessing personal control, treatment control and coherence were reversed to facilitate interpretation, i.e., that higher scores indicate less control and less coherence. four health condition groups the questionnaire set comprised a predefined 22-item list that covered diagnosed major health conditions, functional disorders and mental health disorders that were categorical­ ly answered (yes/no) to the question “has a doctor ever told you that you have/had…”. participants were asked to answer this 22-item list with regard to themselves and each family member (i.e., fathers, mothers, siblings). within this list, cancer, heart attack and thrombosis or embolism in the brain were operationalized as major health conditions. fibromyalgia, chronic fatigue, irritable bowel syndrome, whiplash syndrome, and multi­ weigel, meinertz dantoft, jørgensen et al. 5 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ ple chemical sensitivity were operationalized as functional disorders. lifetime depression and anxiety were operationalized as mental disorders. of note, the list did not include questions on mental disorders in the family. in each case, a major health condition, functional disorder, or mental disorder was evaluated as being present either in the patient or in the family if one of the respective items was answered positively. the four health condition groups were: functional disorders, major health conditions, functional disorders and major health conditions, and healthy (i.e., no major health condition or functional disorder). perceived symptoms the bodily distress syndrome (bds) checklist (budtz-lilly et al., 2015) uses a likert-scale to assess 25 symptoms related to the cardiopulmonary, gastrointestinal, musculoskaletal and general symptom clusters of the diagnostic concept of the bodily distress syndrome. the danish version of the bds checklist was applied to assess the presence of physical symptoms during the last year. as we focussed on the number of symptoms during the last year rather than the burden of each symptom, answers were dichotomized (0 = not at all; 1 = little to a lot) and summed up with higher values indicating a higher number of symptoms (range 0-32). likewise, physical symptoms during the last week were operationalized through the 12-item sum score of the scl-90 somatization subscale (range 0-12, cronbach’s alpha in this sample = 0.80; olsen et al., 2004). psychological factors current symptoms of depression and anxiety were assessed using the 8-item sum score of the scl-90 mental distress subscale (range 0-24, cronbach’s alpha in this sample = 0.87; fink et al., 2004). personality traits were operationalized based on the neo-five factor inventory that assesses the personality traits neuroticism, extraversion, agreeableness, openness, and conscientiousness through 60 likert-scaled items (subscale range 0-48 points; körner et al., 2002). the number of adverse life events was operationalized through the cumulative life­ time adversity measure (range 0-37, additional item to mention specific life adversaries). the questionnaire asks respondents whether they ever experienced one or more of 37 different negative life events (carstensen et al., 2020). the 10-item perceived stress scale with a likert-scaled answering format was used to assess current stress (sum score range 0-40 points, cronbach’s alpha in this sample = 0.87; cohen et al., 1983). the 10-item general self-efficacy scale with a likert-scaled answering format was applied to assess coping abilities (sum score range 0-30 points, cronbach’s alpha in this sample = 0.91; luszczynska et al., 2005). symptom perceptions in functional disorders 6 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ self-perceived health one likert-scaled item of the 12-item short form health survey (ware et al., 1996) was applied to assess self-perceived health as an indicator of health related quality of life. objective health measures body mass index (bmi = kg/m2) and waist-to-hip ratio were obtained. sociodemographic aspects age, sex and years of school education (≤10 years = “elementary school education” >10 years = “beyond elementary school education”) were included. statistical analyses participants with a minimum of four answered b-ipq items (i.e., completers) and those with zero to three answered items were compared with regard to sex, age, marital status, and school education to identify potential selection biases. the four health condition groups were compared with regard to sociodemographic and clinical characteristics us­ ing χ2-tests for categorical (sex, marital status, school education) and anova for metric variables (age, bmi, waist-to-hip ratio, self-perceived health). first study aim: b-ipq items were compared between each of the four health con­ dition groups applying an ancova with age and sex as covariates and bonferroni corrected post hoc tests. adjusted means, standard errors (se) and in case of significant differences effect sizes (cohen’s d) are reported. second study aim: seven multiple regression analyses with each including a total of 18 independent variables were applied to examine associations between the b-ipq items and functional disorders (own; in the family) as well as other health-related (own major health condition or in the family, symptom presence in the last year and the last week) and psychological correlates of symptom perceptions (own mental disorder, mental dis­ tress, perceived stress, coping ability, number of adverse life events, personality traits) and sociodemographic variables (i.e., sex, age,) in the framework of the cms. b-ipq items were log10 transformed due to skewness and linearity. no imputation procedure was applied on the study variables and the maximum avail­ able information was used in each analysis. ibm spss version 25 (spss inc., chicago, il, usa) was used for all analyses. the significance level was set at p < .05 with adjustments in case of multiple testing. results among the 7,459 participants, 7% affirmed on the predefined list that a doctor told them they had cancer, 2% a heart attack and 2% thrombosis or embolism in the brain. further weigel, meinertz dantoft, jørgensen et al. 7 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ 1% affirmed to have been told to have fibromyalgia, 1% chronic fatigue, 12% irritable bowel syndrome, 3% whiplash syndrome, and 2% multiple chemical sensitivity. sociode­ mographic and clinical characteristics differed significantly between healthy individuals and the other three health condition groups with regard to age, sex, marital status, bmi, and waist-to-hip ratio (see table 1). within this total sample, 2,135 did not answer any b-ipq items (84% healthy individuals, 9% major health conditions, 6% functional disorders, 1% both). an additional 107 answered one to three (76%, 10%, 6%, 3%,) and 5,217 participants answered ≥4 b-ipq items (71% of the cohort). table 1 sample characteristics of participants from the danfund part two study sample variable healthy n = 5524 major health condition n = 601 functional disorder n = 976 major health condition + functional disorder n = 162 statistics sex % (n) female 51 (2821) 52 (311) 69 (672) 67 (108) χ2 = 117.377, p < .001 age m (sd) 50.49 (13.50) 59.94 (9.19) 53.29 (12.68) 60.21 (8.37) f = 125.064, p < .001 marital status % (n) married 64 (3544) 72 (429) 66 (639) 67 (109) χ2 = 95.259, p < .001 school education % (n) > 10 years 56 (2972) 52 (303) 53 (496) 50 (80) χ2 = 9.103, p = .028 body mass index m (sd) 25.84 (4.53) 27.15 (4.57) 26.30 (5.06) 27.08 (4.60) f = 18.726, p < .001 waist-to-hip ratio m (sd) 0.88 (0.09) 0.91 (0.10) 0.87 (0.09) 0.90 (0.09) f = 22.888, p < .001 self-perceived healtha m (sd) 2.39 (0.76) 2.76 (0.80) 2.86 (0.83) 3.17 (0.79) f = 166.024, p < .001 note. m = mean; se = standard deviation; cancer, heart attack and thrombosis or embolism in the brain were operationalized as major health conditions from a predefined list of 22 diseases; fibromyalgia, chronic fatigue, irritable bowel syndrome, whiplash syndrome, and multiple chemical sensitivity were operationalized as functional disorders from the same list of diseases. aincreasing scores equal a worse self-perceived health. symptom perceptions in functional disorders 8 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ aim 1: comparison of symptom perceptions in the four health condition groups all health condition groups differed significantly from each other with regard to the b-ipq subscale items when controlling for age and sex (see figure 1, table 2 and appen­ dix). participants with major health conditions reported significantly less favorable consequences (cohen’s d = 0.20) and emotional representations (cohen’s d = 0.17) than healthy participants. participants with major health conditions also reported significant­ ly more favorable consequences (cohen’s d = 0.32), timeline (cohen’s d = 0.27), symptom concern (cohen’s d = 0.31), and emotional representations (cohen’s d = 0.45) as well as significantly less favorable treatment control (cohen’s d = 0.27) than participants with functional disorders. with the exception of treatment control, a similar picture occurred between participants with major health conditions and those with functional disorders and major health conditions (cohen’s d range = 0.30–0.37). figure 1 mean comparisons of symptom perceptions as assessed with the b-ipq in the four health condition groups adjusted for age and sex * * * * * * * * * * * * * * * * healthy major health conditions functional disorders major health conditions + functional disorders * * * * * note. x-axis = items of the brief illness perception questionnaire (b-ipq), y-axis = visual analog scale, range of 0-10. * = significant group difference. error bars represent standard errors. cancer, heart attack, and thrombosis or embolism in the brain were operationalized as major health conditions from a predefined list of 22 diseases; fibromyalgia, chronic fatigue, irritable bowel syndrome, whiplash syndrome, and multiple chemical sensitivity were operationalized as functional disorders from the same list of diseases. weigel, meinertz dantoft, jørgensen et al. 9 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ table 2 symptom perceptions as assessed with the b-ipq in four health condition groups adjusted for age and sex b-ipq item healthy n = 5524 major health conditions n = 601 functional disorders n = 976 major health condition + functional disorders n = 162 statistics consequences m (se) how much do your symptoms affect your life? 2.79 (0.03) 3.24 (0.10) 3.90 (0.07) 3.99 (0.17) f = 77.670, df = 3, p < .001 timeline m (se) how long do you think your symptoms will last? 5.13 (0.06) 5.64 (0.17) 6.64 (0.12) 6.89 (0.29) f = 50.959, df = 3, p < .001 personal controla m (se) how much control do you feel you have over your symptoms? 4.62 (0.05) 4.84 (0.15) 5.34 (0.10) 5.08 (0.25) f = 13.872, df = 3, p < .001 treatment controla m (se) how much do you think your treatment can help your symptoms? 5.50 (0.05) 5.80 (0.16) 4.95 (0.11) 5.18 (0.27) f = 10.959, df = 3, p < .001 symptom concern m (se) how concerned are you about your symptoms? 3.20 (0.04) 3.40 (0.12) 4.13 (0.08) 4.18 (0.20) f = 40.059, df = 3, p < .001 coherencea m (se) how well do you feel you understand your symptoms? 3.66 (0.04) 3.71 (0.13) 4.13 (0.09) 4.06 (0.23) f = 7.687, df = 3, p < .001 emotional representations m (se) how much do your symptoms affect your emotionally? (e.g. make you angry, scared, upset or depressed) 2.81 (0.04) 3.31 (0.12) 3.95 (0.08) 4.34 (0.20) f = 69.459, df = 3, p < .001 note. b-ipq = brief illness perception questionnaire; item wordings are in italics. m = mean; se = standard error. cancer, heart attack and thrombosis or embolism in the brain were operationalized as major health conditions from a predefined list of 22 diseases; fibromyalgia, chronic fatigue, irritable bowel syndrome, whiplash syndrome, and multiple chemical sensitivity were operationalized as functional disorders from the same list of diseases. areversed item, age groups comprise missing values. participants with functional disorders reported significantly less favorable symptom perceptions than healthy individuals on all but one b-ipq subscales (cohen’s d range = symptom perceptions in functional disorders 10 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ 0.16–0.56), i.e., treatment control was significantly more favorable in participants with functional disorders. participants with functional disorders and major health con­ ditions reported significantly less favorable consequences (cohen’s d = 0.32), timeline (cohen’s d = 0.58), symptom concern (cohen’s d = 0.42) and emotional representations (co­ hen’s d = 0.66) compared to healthy participants. notably, participants with functional disorders and those with both major health conditions and functional disorders reported comparable b-ipq subscale item scores. aim 2: correlation between functional disorders in oneself and significant others and symptom perceptions in the context of other possible correlates from the cms framework there was no evidence of multi-collinearity as assessed by tolerance values greater than 0.1 and vif between 1.056 and 3.298. there was indepence of residuals as indicated by durbin-watson values between 1.958 and 2.041. the assumption of normality was met as assessed by q-q plots. higher, i.e., more negative, perceived consequences were significantly associated with own and family functional disorders, own major health conditions, mental disorders, higher mental distress and perceived stress, and more adverse life events (for regression coefficients, standard errors, 95% confidence intervals and model summary, see table 3). higher, i.e., more negative, perceived timeline was significantly associated with own and family functional disorders, own major health conditions, higher levels of mental distress, more adverse life events, and lower levels of extraversion. higher, i.e. less, perceived personal control was significantly associated with own functional disorders, higher levels of mental distress, and perceived stress as well as a lower coping ability, lower levels of conscientiousness, and female sex. higher, i.e. less, perceived treatment control was significantly associated with, own functional disorders, the absence of functional disorders in the family, lower levels of extraversion and agreeableness, and younger age. higher, i.e. more negative, perceived symptom concerns were significantly associated with own and family functional disorders, higher mental distress and perceived stress and female sex. higher, i.e. less, coherence was significantly associated with own functional disorders, the absence of a mental disorder, higher levels of mental distress and perceived stress as well as a lower coping ability, higher levels of neuroticisms and lower levels of openness and agreeableness, younger age and female sex. higher, i.e. more negative, emotional representations were significantly associated with own and family functional disorders and major health conditions, mental disorders and higher levels mental distress, perceived stress, and neuroticism. weigel, meinertz dantoft, jørgensen et al. 11 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ ta bl e 3 su m m ar y of m ul tip le r eg re ss io n a na ly se s to p re di ct s ym pt om p er ce pt io ns in a d an is h po pu la tio nb as ed s am pl e va ri ab le c on se qu en ce s ti m el in e sy m pt om c on tr ol tr ea tm en t c on tr ol b se 95 % c i b se 95 % c i b se 95 % c i b se 95 % c i fu nc ti on al d is or de rs a nd m aj or h ea lt h co nd it io ns o w n fu nc tio na l d is or de rs 1. 26 ** 1. 02 [1 .1 5, 1 ,3 2] 1. 34 ** 1. 03 [1 .2 5, 1 .4 3] 1. 14 ** 1. 03 [1 .0 8, 1 .2 1] 1. 06 ** 1. 19 [0. 83 , 0. 95 ] fu nc tio na l d is or de rs in fa m ily 1. 05 ** 1. 02 [1 .2 0, 1 .1 0] 1. 06 * 1. 03 [1 .0 0, 1 .1 2] 1. 04 1. 03 [0. 99 , 1 .0 9] -0 .8 9* 1. 03 [0. 89 , 0. 99 ] o w n m aj or h ea lth c on di tio ns 1. 07 * 1. 03 [1 .0 1, 1 .1 4] 1. 09 * 1. 04 [1 .0 0, 1 .1 9] 0. 99 1. 04 [0. 92 , 1 .0 6] -0 .9 4 1. 03 [0. 96 , 1 .1 2] m aj or h ea lth c on di tio ns in fa m ily 1. 02 1. 03 [1. 01 , 1 .0 7] 1. 05 1. 04 [0 .9 8, 1 .1 3] 1. 00 1. 03 [0. 94 , 1 .0 7] -1 .0 4 1. 04 [0. 92 , 1 .0 6] sy m pt om s la st y ea r 1. 00 1. 00 [0. 97 , 1 .0 0] 1. 00 1. 00 [0. 99 , 1 .0 0] -1 .0 0 1. 00 [1. 00 , 1 .0 0] -0 .9 9 1. 04 [1. 00 , 1 .0 1] sy m pt om s la st w ee k 1. 00 1. 00 [0. 99 , 1 .1 0] -1 .0 0 1. 01 [0. 99 , 1 .0 1] -1 .0 0 1. 01 [0. 99 , 1 .0 1] -1 .0 0 1. 00 [0. 99 , 1 .0 1] ps yc ho lo gi ca l c or re la te s of s ym pt om p er ce pt io ns m en ta l d is or de rs 1. 06 * 1. 03 [0 .9 9, 1 .1 2] -1 .0 4 1. 04 [0. 96 , 1 .1 2] -0 .9 4 1. 03 [0. 88 , 1 .0 0] -1 .0 0 1. 01 [0. 88 , 1 .0 2] m en ta l d is tr es s 1. 03 ** 1. 00 [1 .0 0, 1 .0 3] 1. 02 ** 1. 00 [1. 01 , 1 .0 3] 1. 02 ** 1. 00 [1 .0 1, 1 .0 2] 0. 95 1. 04 [0. 99 , 0 .0 0] pe rc ei ve d st re ss 1. 01 ** 1. 00 [1 .0 2, 1 .0 2] 1. 00 1. 00 [1. 00 , 1 .0 1] 1. 02 ** 1. 00 [1 .0 1, 1 .0 2] 1. 00 1. 00 [0. 99 , 1 .0 1] c op in g ab ili ty 1. 00 1. 00 [1. 01 , 1 .0 1] 1. 00 1. 00 [1. 00 , 1 .0 1] -0 .9 9* * 1. 00 [0. 99 , 1. 00 ] -1 .0 0 1. 00 [0. 99 , 1 .0 0] a dv er se li fe e ve nt s 1. 01 ** 1. 00 [1 .0 0, 1 .0 2] 1. 02 ** 1. 00 [1 .0 1, 1 .0 3] 1. 01 1. 00 [1. 00 , 1 .0 2] -0 .9 9 1. 00 [0. 99 , 1 .0 0] n eu ro tic is m 1. 00 1. 00 [1. 01 , 1 .0 1] 1. 00 1. 00 [1. 00 , 1 .0 1] 1. 00 1. 00 [1 .0 0, 1 .0 1] -0 .9 9 1. 00 [0. 99 , 1 .0 0] ex tr av er si on 1. 00 1. 00 [1. 00 , 1 .0 0] -0 .9 9* * 1. 00 [0. 99 , 1. 00 ] -1 .0 0 1. 00 [0. 99 , 1 .0 0] -0 .9 9* * 1. 00 [0. 98 , 0. 99 ] o pe nn es s 1. 00 1. 00 [1. 00 , 1 .0 0] -1 .0 0 1. 00 [0. 99 , 1 .0 0] -1 .0 0 1. 00 [0. 99 , 1 .0 0] -0 .9 9 1. 00 [1. 00 , 1 .0 1] a gr ee ab le ne ss 1. 00 1. 00 [0. 99 , 1 .0 1] 1. 00 1. 00 [1. 00 , 1 .0 1] -1 .0 0 1. 00 [0. 99 , 1 .0 0] -1 .0 0* * 1. 00 [0. 99 , 1. 00 ] c on sc ie nt io us ne ss 1. 00 1. 00 [1. 00 , 1 .0 0] -1 .0 0 1. 00 [0. 99 , 1 .0 1] -0 .9 9* * 1. 00 [0. 99 , 1. 00 ] -0 .9 9 1. 00 [0. 99 , 1 .0 1] so ci od em og ra ph ic fa ct or s se x 1. 02 1. 02 [0. 99 , 1 .0 7] -0 .9 8 1. 03 [0. 92 , 1 .0 3] -0 .9 5* 1. 03 [0. 91 , 1. 00 ] -1 .0 0 1. 00 [0. 98 , 1 .0 9] a ge 1. 00 1. 00 [0. 98 , 1 .0 0] 1. 00 1. 00 [1. 00 , 1 .0 0] -1 .0 0 1. 00 [1. 00 , 1 .0 0] -1 .0 3* * 1. 03 [0. 99 , 1. 00 ] m od el s um m ar y f 1 8, 40 38 = 4 2. 22 8, p = < .0 01 ad j. r 2 = 0 .1 55 d ur bi nw at so n = 1. 98 8 v if m ax = 3 .2 90 (n eu ro tic is m ) f 1 8, 39 65 = 1 7. 37 7, p = < .0 01 ad j. r 2 = .0 69 d ur bi nw at so n = 1. 96 7 v if m ax = 3 .2 98 (n eu ro tic is m ) f 1 8, 3 98 6= 2 6. 89 4, p = < .0 01 ad j. r 2 = .1 04 d ur bi nw at so n = 2. 04 1 v if m ax = 3 .2 95 (n eu ro tic is m ) f 1 8, 3 97 1= 5 .3 75 , p = < .0 01 ad j. r 2 = .0 19 d ur bi nw at so n = 1. 95 8 v if m ax = 3 .2 77 (n eu ro tic is m ) symptom perceptions in functional disorders 12 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ ta bl e 3 [c on ti nu ed ] su m m ar y of m ul tip le r eg re ss io n a na ly se s to p re di ct s ym pt om p er ce pt io ns in a d an is h po pu la tio nb as ed s am pl e va ri ab le sy m pt om c on ce rn s c oh er en ce em ot io na l r ep re se nt at io ns b se 95 % c i b se 95 % c i b se 95 % c i fu nc ti on al d is or de rs a nd m aj or h ea lt h co nd it io ns o w n fu nc tio na l d is or de rs 0. 08 ** 1. 03 [1 .1 4, 1 .2 7] 1. 13 ** 1. 03 [1 .0 7, 1 .2 0] 1. 04 ** 1. 15 [1 .1 7, 1 .2 9] fu nc tio na l d is or de rs in fa m ily 1. 06 * 1. 02 [1 .0 1, 1 .1 1] 1. 02 1. 03 [0. 98 , 1 .0 8] 1. 23 ** 1. 03 [1 .0 2, 1 .1 2] o w n m aj or h ea lth c on di tio ns 1. 02 1. 04 [0 .9 5, 1 .1 0] -0 .9 7 1. 04 [0. 90 , 1 .0 5] 1. 07 ** 1. 02 [1 .0 4, 1 .1 8] m aj or h ea lth c on di tio ns in fa m ily 1. 03 1. 03 [0. 98 , 1 .1 0] 1. 03 1. 03 [0. 96 , 1 .0 9] 1. 11 1. 03 [0. 95 , 1 .0 6] sy m pt om s la st y ea r 1. 00 1. 00 [1. 00 , 1 .0 1] -1 .0 0 1. 00 [0. 99 , 1 .0 0] 1. 01 1. 03 [1. 00 , 1 .0 0] sy m pt om s la st w ee k 1. 00 1. 00 [0. 99 , 1 .0 1] 1. 00 1. 01 [0. 99 , 1 .0 2] 1. 00 1. 00 [0. 99 , 1 .0 1] ps yc ho lo gi ca l c or re la te s of s ym pt om p er ce pt io ns m en ta l d is or de rs -0 .9 8 1. 03 [0. 92 , 1 .0 4] -0 .9 1* 1. 03 [0. 86 , 0. 98 ] 1. 00 ** 1. 00 [1 .0 3, 1 .1 5] m en ta l d is tr es s 1. 04 ** 1. 00 [1 .0 3, 1 .0 5] 1. 01 ** 1. 00 [1 .0 1, 1 .0 2] 1. 09 ** 1. 03 [1 .0 4, 1 .0 6] pe rc ei ve d st re ss 1. 01 ** 1. 00 [1 .0 1, 1 .0 2] 1. 01 ** 1. 00 [1 .0 0, 1 .0 2] 1. 05 ** 1. 00 [1 .0 1, 1 .0 2] c op in g ab ili ty 1. 00 1. 00 [0. 99 , 1 .0 0] -0 .9 9* * 1. 00 [0. 98 , 0. 99 ] -1 .0 2 1. 00 [0. 99 , 1 .0 0] a dv er se li fe e ve nt s 1. 01 1. 00 [1. 00 , 1 .0 1] -0 .9 9 1. 00 [0. 99 , 1 .0 0] 1. 00 1. 00 [1. 00 , 1 .0 1] n eu ro tic is m 1. 00 1. 00 [1 .0 0, 1 .0 1] 1. 01 * 1. 00 [1 .0 0, 1 .0 1] 1. 00 ** 1. 00 [1 .0 1, 1 .0 2] ex tr av er si on 1. 00 1. 00 [1 .0 0, 1 .0 1] -1 .0 0 1. 00 [0. 99 , 1 .0 0] 1. 01 1. 00 [1. 00 , 1 .0 1] o pe nn es s 1. 00 1. 00 [0. 99 , 1 .0 0] -0 .9 9* * 1. 00 [0. 99 , 1. 00 ] -1 .0 0 1. 00 [0. 99 , 1 .0 0] a gr ee ab le ne ss 1. 00 1. 00 [1. 00 , 1 .0 0] -0 .9 9* * 1. 00 [0. 99 , 0. 99 ] -1 .0 0 1. 00 [1. 00 , 1 .0 0] c on sc ie nt io us ne ss 1. 00 1. 00 [0. 99 , 1 .0 0] -0 .9 9* 1. 00 [0. 99 , 1. 00 ] 1. 00 1. 00 [1. 00 , 1 .0 1] so ci od em og ra ph ic fa ct or s se x -0 .9 5* 1. 02 [0. 91 , 0. 99 ] -0 .9 5* 1. 03 [0. 90 , 1. 00 ] -1 .0 0 1. 00 [0. 96 , 1 .0 4] a ge 1. 00 1. 00 [1 .0 0, 1 .0 0] -1 .0 0* 1. 00 [1. 00 , 1. 00 ] 1. 00 1. 02 [1. 00 , 1 .0 0] m od el s um m ar y f 1 8, 4 00 6 = 3 9. 01 4, p = < .0 01 ad j. r 2 = .1 45 d ur bi nw at so n = 1. 98 6 v if m ax = 3 .2 71 (n eu ro tic is m ) f1 8, 3 99 3 = 25 .1 25 , p = < .0 01 ad j. r 2 = .0 98 d ur bi nw at so n = 1. 99 2 v if m ax = 3 .2 69 (n eu ro tic is m ) f1 8, 3 99 8 = 85 .3 96 , p = < .0 01 ad j. r 2 = .2 74 d ur bi nw at so n = 1. 99 6 v if m ax = 3 .3 02 (n eu ro tic is m ) weigel, meinertz dantoft, jørgensen et al. 13 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ discussion this large population-based study observed more negative symptom perceptions in indi­ viduals with functional disorders with and without co-occuring major health conditions than in those with major health conditions only or healthy individuals. more specifically, individuals with functional disorders judged their symptoms to affect their life and their emotional well-being more and to last longer than the other health condition groups. they expressed less symptom understanding, less treatment control, but higher personal control than those with major health conditions. these results have three important implications. firstly, the higher levels of neg­ ative cognitive representations and emotional reactions observed in individuals with functional disorders confirm previous research that perceptual, cognitive, and emotion regulation processes may play a more salient role in functional disorders as compared to well-defined physical illness (henningsen et al., 2018; okur güney et al., 2019). secondly, our results support previous findings from clinical samples that functional disorders in some cases are comorbid with major health conditions (duffield et al., 2018; halpin & ford, 2012). our results extend the existing evidence by showing that this comorbidity results in more negative symptom perceptions and more negative self-perceived health. thirdly, more research is needed to investigate the consequences of these more negative symptom perceptions in individuals with functional disorders on relevant outcomes such as symptom burden, symptom course, and individual symptom management. in terms of correlates of symptom perceptions from the cms framework, our results indicate that not only the presence of a functional disorder in oneself was associated with symptom perceptions but also functional disorders in family members, albeit to a lesser extent. interestingly, the presence of a major health condition in the family was not associated with more negative symptom perceptions. these results might indicate that the experience of an illness or symptoms in significant others does not in itself lead to a more negative evaluation of present symptoms but that particularly in functional disorders, learning of illness behavior, and beliefs within families seem to be crucial (brace et al., 2000; palermo et al., 2014). it is of note that the presence of a major health condition, but neither the number of symptoms in the last year, nor the number of symptoms during the last week, was associated with current symptom perceptions in the multivariate regression models. on the one hand, this result might be interpreted in light of former evidence on a weaker association between health states and symptom reports in chronic health conditions (janssens et al., 2011). on the other hand, the inclusion of functional disorders in the analyses might have erased the impact of symptom reports. with regard to personality traits, extraversion, openness, and agreeableness were all significantly associated with more favorable symptom perceptions, whereas neuroticism was (to a lesser extent) associated with more negative associations. notably, conscien­ tiousness was associated with lower personal control. one may speculate that persons symptom perceptions in functional disorders 14 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ with high conscientiousness may need a more controlled environment to feel in control and therefore be prone to appraise less control when experiencing symptoms. overall, interpretating these results from the perspective of a recent meta-analysis, extraversion, openness, and agreeableness might be regarded as resilience factors in the context of symptom perceptions (oshio et al., 2018). in line with the accumulating evidence from other research fields (anda et al., 2006), multiple experiences of adverse life events were associated with more negative symptom perceptions. additionally, our results indicate that current symptoms of depression and anxiety as well as perceived stress and coping abilities were psychological correlates of most symptom perceptions. this result was in line with evidence derived from a systematic review on so-called modifiable correlates of symptom perceptions in samples with somatic diseases (arat et al., 2018) and indicates that these variables might be considered as potential moderators or mediators in future studies. taken together, our results support the notion from the perspective of the csm that a range of biopsychosocial factors are involved in the formation of symptom perceptions (leventhal et al., 2016), i.e., broadly speaking, that a person's life experience is involved in how the person reacts to and copes with symptoms and illness. extending on previous evidence, the present study found significant associations between functional disorders in significant others and oneself for the formation of symptom perceptions. still, the emerging picture is somewhat complex, as it remains challenging to judge which factors might be of particular relevance, given that each b-ipq subscale displayed an individual pattern of significant biopsychosocial correlates. from a clinical perspective, screening for functional disorders in individuals with major health conditions may be a valuable approach to identify vulnerable patients that might be at risk for more complex illness trajectories and to personalize the given treatment rationale with psychosocial interventions to challenge symptom perceptions if needed. derived from the observed associations of symptom perceptions in the present cross-sectional study, these interventions should address present symptoms of depres­ sion, anxiety, and current stress and should aim at improving coping skills. the present study was to the best of our knowledge the first to investigate symptom perceptions and their correlates in a population-based sample. this approach enabled a sufficient sample size and high representativeness. however, the results of the present study should to be interpreted in light of the following limitations. firstly, the crosssectional design of the present study prevented us from making any causal/temporal interpretations of our results. secondly, the participation rate in the danfund study was rather low (30%), which is a challenge for all epidemiological studies (galea & tracy, 2007). further, there seemed to be a selection bias, which has also been observed in other epidemiological studies (keeble et al., 2015), with females and more educated indi­ viduals being more likely to participate. thirdly, the four health condition groups were operationalized through self-report with a predefined list of health conditions. in doing weigel, meinertz dantoft, jørgensen et al. 15 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ so, some participants may not have indicated a diagnosis of a functional disorder because they disagree with it. also, other major health conditions not included in this list might have explained some of the perceived symptoms. fourthly, the present study applied a crude measure of school education. therefore, the effect of educational level (i.e., vocational training) on the outcome measures has to be investigated in future studies. fifthly, the b-ipq uses a single scale approach, which does not allow the determination of internal validity and might be more prone to random measurement error than mul­ ti-item scales. additionally, a scale deviating from the original scale was used and the b-ipq was answered in terms of symptoms in general, so the item assessing symptom identity was removed. these aspects and large amounts of missing responses on the b-ipq items decrease the comparability with other studies. last, further major health conditions or functional disorders and treatment related variables, such as prior illnesses and treatment, symptom duration or severity might be further relevant correlates of symptom perceptions but were not included in the present study. conclusions researchers can benefit from the results of the present study with respect to expectable differences in symptom perceptions in healthy individuals and those with functional disorders and major health conditions. further, the present study identified potential moderators and mediators of symptom perceptions that might be worth further investi­ gation in experimental and treatment studies. clinicians and health policy makers can benefit from the results in that the present results could inform the future development of preventive interventions in the context of symptom perceptions. symptom perceptions in functional disorders 16 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ funding: this study was a part of the danfund study funded by trygfonden (grant number 7-11-0213), the lundbeck foundation (grant number r155-2013-14070) and the center for clinical research and prevention. the danfund scientific management group consists of professor, dmsci torben jørgensen (pi); professor, dmsci per fink; senior consultant, phd lene falgaard eplov; msc, phd susanne brix pedersen; md, phd michael benros; msc, phd betina heignsbæk thuesen, and danfund scientific officer msc, phd thomas m dantoft. the university medical center hamburg-eppendorf supported this study by funding a three-month research visit in 2018 for angelika weigel. acknowledgments: the authors would like to thank the participants in the health survey and the team behind the survey at the center for clinical research and prevention, the capital region of denmark, for their great work with collecting and assuring data of high quality. competing interests: the authors declare that they have no conflicts of interest. ethics statement: all study procedures were approved by the ethical committee of copenhagen country (ka-2006-0011, 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(2018). illness perception of patients with functional gastrointestinal disorders. frontiers in psychiatry, 9, article 122. https://doi.org/10.3389/fpsyt.2018.00122 weigel, meinertz dantoft, jørgensen et al. 21 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://doi.org/10.1348/135910705x71434 https://doi.org/10.2147/copd.s109227 https://doi.org/10.1080/14768320701246535 https://doi.org/10.1097/sga.0000000000000225 https://doi.org/10.1016/j.neubiorev.2017.01.015 https://doi.org/10.1007/s12529-016-9599-y https://doi.org/10.1097/00005650-199603000-00003 https://doi.org/10.1038/bjc.2015.39 https://doi.org/10.3389/fpsyt.2018.00122 https://www.psychopen.eu/ appendix ta bl e a .1 a dj us te d m ea n c om pa ri so ns o f b -i pq s ub sc al es b et w ee n th e fo ur h ea lth c on di tio n g ro up s bip q s ub sc al e h ea lt hy v s. m h c h ea lt hy v s. fd h ea lt hy v s. m h c + f d m h c v s. fd m h c v s. m h c + f c fd v s. m c h + f d m di ff 95 % c i d m di ff 95 % c i d m di ff [9 5% c i] d m di ff [9 5% c i] d m di ff [9 5% c i] d m di ff [9 5% c i] d c on se qu en ce s -0 .4 3* [0. 72 , 0. 16 ] 0. 20 -1 .1 1* [1. 31 , 0. 90 ] 0. 56 -1 .2 0* [ -1 .6 6, -0 .7 3] 0. 61 -0 .6 6* [0. 98 , 0. 34 ] 0. 32 -0 .7 5* [1. 27 , 0. 23 ] 0. 35 -0 .0 9 [0. 58 , 0 .4 0] t im el in e -0 .5 1 [0. 98 , 0. 03 ] -1 .5 1* [1. 86 , 1. 15 ] 0. 47 -1 .7 6* [2. 54 , 0. 97 ] 0. 58 -1 .0 0* [1. 55 , 0. 46 ] 0. 27 -1 .2 5* [2. 13 , 0. 37 ] 0. 37 -0 .2 5 [1. 08 , 0 .5 8] pe rs on al c on tr ol -0 .2 2 [0. 63 , 0 .1 9] -0 .7 3* [1. 03 , 0. 42 ] 0. 24 -0 .4 6 [1. 14 , 0 .2 1] 0. 51 [0. 98 , 0. 04 ] -0 .2 4 [1. 01 , 0 .5 2] 0. 26 [0. 45 , 0 .9 8] tr ea tm en t c on tr ol -0 .2 0 [0 .6 4, 0 .2 4] 0. 64 * [0 .3 2, 0 .9 7] 0. 21 0. 41 [0. 32 , 1 .1 4] 0. 85 * [0 .3 4, 1 .3 5] 0. 27 0. 62 [0. 20 , 1 .4 4] -0 .2 3 [1. 00 , 0 .5 4] sy m pt om c on ce rn -0 .2 0 [0. 52 , 0 .1 3] -0 .9 3* [1. 17 , 0. 69 ] 0. 40 -0 .9 8* [1. 52 , 0. 44 ] 0. 42 -0 .7 3* [1. 11 , 0. 36 ] 0. 31 -0 .7 8* [1. 40 , 0. 18 ] 0. 33 -0 .0 5 [0 .6 2, 0 .5 2] c oh er en ce -0 .0 5 [0. 42 , 0 .3 2] -0 .4 7* [0. 73 , 0. 20 ] 0. 16 -0 .4 0 [1. 01 , 0 .2 1] -0 .4 2 [0. 84 , 0 .0 0] -0 .3 5 [1. 03 , 0 .3 3] 0. 07 [0. 57 , 0 .7 1] em ot io na l re pr es en ta tio ns -0 .5 0* [0. 83 , 0. 18 ] 0. 17 -1 .1 5* [1. 38 , 0. 91 ] 0. 50 -0 .5 3* [2. 07 , 1. 00 ] 0. 66 -0 .6 5* [1. 01 , 0. 28 ] 0. 45 -1 .0 3* [1. 63 , 0. 43 ] 0. 30 -0 .3 9 [0. 95 , 0 .1 8] n ot e. m h c = m aj or e he al th c on di tio n, i. e. c an ce r, he ar t a tt ac k an d th ro m bo si s or e m bo lis m in th e br ai n; f d = fu nc tio na l d is or de rs , i .e . f ib ro m ya lg ia , c hr on ic fa tig ue , i rr ita bl e bo w el s yn dr om e, w hi pl as h sy nd ro m e, a nd m ul tip le c he m ic al s en si tiv ity ; d = c oh en ’s d e ff ec t s iz e of s ig ni fi ca nt d iff er en ce ; m di ff = m ea n di ff er en ce ; 9 5% c i = 9 5% c on fi de nc e in te rv al , r an ge o f b -i pq s ub sc al es = 1 -1 0. *s ig ni fi ca nt a t b on fe ro ni c or re ct ed p -v al ue fo r m ul tip le c om pa ri ss on s. symptom perceptions in functional disorders 22 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. weigel, meinertz dantoft, jørgensen et al. 23 clinical psychology in europe 2022, vol. 4(4), article e7739 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ symptom perceptions in functional disorders method study population measures statistical analyses results aim 1: comparison of symptom perceptions in the four health condition groups aim 2: correlation between functional disorders in oneself and significant others and symptom perceptions in the context of other possible correlates from the cms framework discussion conclusions (additional information) funding acknowledgments competing interests ethics statement data availability references appendix building an early warning system for depression: rationale, objectives, and methods of the warn-d study research articles building an early warning system for depression: rationale, objectives, and methods of the warn-d study eiko i. fried 1 , ricarda k. k. proppert 1 , carlotta l. rieble 1 [1] department of clinical psychology, leiden university, leiden, the netherlands. clinical psychology in europe, 2023, vol. 5(3), article e10075, https://doi.org/10.32872/cpe.10075 received: 2022-08-15 • accepted: 2023-07-02 • published (vor): 2023-09-29 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: eiko i. fried, leiden university, wassenaarseweg 52, 2333 ak leiden, the netherlands. email: eikofried@gmail.com supplementary materials: materials [see index of supplementary materials] abstract background: depression is common, debilitating, often chronic, and affects young people disproportionately. given that only 50% of patients improve under initial treatment, experts agree that prevention is the most effective way to change depression’s global disease burden. the biggest barrier to successful prevention is to identify individuals at risk for depression in the near future. to close this gap, this protocol paper introduces the warn-d study, our effort to build a personalized early warning system for depression. method: to develop the system, we follow around 2,000 students over 2 years. stage 1 comprises an extensive baseline assessment in which we collect a broad set of predictors for depression. stage 2 lasts 3 months and zooms into participants’ daily experiences that may predict depression; we use smartwatches to collect digital phenotype data such as sleep and activity, and we use a smartphone app to query participants about their experiences 4 times a day and once every sunday. in stage 3, we follow participants for 21 months, assessing transdiagnostic outcomes (including stress, functional impairment, anxiety, and depression) as well as additional predictors for future depression every 3 months. collected data will be utilized to build a personalized prediction model for depression onset. discussion: overall, warn-d will function similarly to a weather forecast, with the core difference that one can only seek shelter from a thunderstorm and clean up afterwards, while depression may be successfully prevented before it occurs. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10075&domain=pdf&date_stamp=2023-09-29 https://orcid.org/0000-0001-7469-594x https://orcid.org/0000-0002-4225-2439 https://orcid.org/0000-0002-4764-3906 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords ecological momentary assessment, digital health, student mental health, depression, prediction, early warning system, prevention highlights • prevention of depression in students may help prevent a lifetime of chronic illness. • but we do not currently know whom to target in prevention programs, and when exactly. • we introduce the protocol of the warn-d study, aimed at building an early warning system for depression in students. • to do so, we leverage advances in theory (complexity science), measurement (smartphone, smartwatch, and registry data), and statistical modelling (machine learning, network models). depressive disorders are prevalent, debilitating, and costly, and therefore among the most pressing health problems of modern living. they affect around 300 million people worldwide (arias-de la torre et al., 2021; ferrari et al., 2013; james et al., 2018), are the leading cause of disability in the world, and are among the leading causes of global disease burden (lopez et al., 2006; mathers & loncar, 2006). major depressive disorder (mdd) is the strongest predictor for suicide (berman, 2009), with 1 million lives lost annually (world health organization, 2019). being depressed worsens the impact of com­ mon diseases like cancer and cardiovascular disease (cuijpers et al., 2012), and about 60% of people living with depression report severe, long-lasting impairment of functioning, compromising the capacity for self-care and independent living (kessler, chiu, et al., 2005; mathers & loncar, 2006; murray & lopez, 1996). mdd is often chronic: over half of depressed patients will develop multiple episodes, and many will spend a considerable part of their lifetime in a state of emotional agony and despair (cuijpers et al., 2012). compared to progress in treating diseases like cancer (biemar & foti, 2013), break­ throughs for treating depression have lagged far behind. treatment effectiveness has remained stable over the last decades (khan & brown, 2015). around half of patients remain depressed following initial treatment with psychological therapies or pharma­ cotherapy (cuijpers et al., 2018; khan & brown, 2015), and treatments reduce only one-third of the disease burden (van zoonen et al., 2014). mechanisms underlying mdd remain largely opaque, despite considerable efforts and investments into trying to under­ stand biological underpinnings (kapur et al., 2012; rogers, 2017). it is for these reasons that experts agree that prevention—stopping depression before it occurs—is the most important way forward to make a real difference in people’s lives (cuijpers et al., 2012; muñoz et al., 2010). since 60-75% of all mental health problems develop before the age of 24, young people are an especially important group for preven­ tion (kessler, berglund, et al., 2005; solmi et al., 2022). while some progress has been warn-d protocol paper 2 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ made in developing and testing prevention programs that can effectively lower incidence rates by levels considered clinically relevant, improving prevention crucially relies on the reliable detection of specific individuals at risk for depression in the near future, which is currently not possible (cuijpers et al., 2012; muñoz et al., 2010; van zoonen et al., 2014). the study we describe here aims to tackle one of the largest barriers to implementing successful, tailored prevention programs: knowing when to intervene, and in which people. we address this problem by developing the personalized early warning system warn-d. in the following, we will introduce the guiding principles of warn-d; discuss the challenges of conceptualizing and measuring depression; describe the design, proce­ dure, and measures of warn-d; and conclude with strengths and challenges of the study. principles guiding the development of warn-d our study’s design, methods, and measures are guided by 6 primary goals and principles. first, our most ambitious goal is to identify at-risk individuals before they transition into depression. we hope that our efforts will result in the first personalized early warning system for depression. second, we will develop this system in and for students, because timely detection of depression onset in young people promises to enable prevention programs to alleviate a potential lifetime of suffering for many, given the often-chronic nature of mdd. students are at considerable risk for developing depression and comorbid mental health problems (auerbach et al., 2016; ebert et al., 2019), and the recent who world mental health surveys international college student project reported that of ~14,000 full time students across 9 countries, including the us, mexico, germany, belgium, and south africa, the 12-month prevalence for any mental health disorder was ~31% (auerbach et al., 2018). another reason we focus on students is because mdd is highly heterogeneous in terms of both etiology and the problems people experience (fried, flake, & robinaugh, 2022; kendler, 2012a; zimmerman et al., 2015), and efforts to understand and predict depression onset are more likely to succeed in more homogeneous populations (cai et al., 2015, 2020). moreover, prediction projects such as warn-d require large samples, which are feasible to recruit in student populations, and students have the skills to operate the smartphone and smartwatch applications required for remote participation. third, warn-d should be feasible for implementation in real-world settings. this precludes repeated lab visits and costly, time-intensive measurement such as brain scans and other biomarkers, which also do not appear to robustly predict depression onset (border et al., 2019; kennis et al., 2020; winter et al., 2022). we instead focus on types of data that can readily be collected in the daily lives of students, including self-report sur­ veys collected via smartphones, smartwatch data, and registry data. we will investigate fried, proppert, & rieble 3 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ the feasibility of our data collection protocol by querying participants about perceived burden of and barriers to participation. fourth, we aim to build a generic infrastructure that can be transferred and applied to many other disorders and target populations. if successful, warn-d may spawn a host of follow-up projects that use the same infrastructure to provide personalized prediction of e.g., ptsd in military personnel, burnout in at-risk teachers, or manic episodes in recovered patients with bipolar disorders at risk for relapse. this promises to answer important scientific questions about personalized prediction across a range of mental disorders, such as which risk factors are transdiagnostic, which risk factors are disorder-specific, and which risk factors are specific to people with certain (e.g., demographic) features. this, in turn, relates to the identification of potentially novel mechanisms of change to inform future prevention programs (nock, 2007). fifth, our study is guided by open scholarship principles. we are excited to make our design, measures, code, and data available to the research community. information on design and measures are available in the accompanying supplementary materials. all empirical papers will be accompanied by open code; and we are currently developing a data sharing protocol with all relevant stakeholders which will be ready in 2025/2026 by the time data collection is finished. see our warn-d project hub for all future updates and publications. the final principle driving our design, methods, and measures is to conceptualize depression consistent with what we have learned about the complexities of the construct in the last decades (fried, flake, & robinaugh, 2022). the next section is dedicated to this challenge. conceptualization of depression depression is a complex construct, and any study aiming to understand and predict mdd onset must grapple with these complexities. challenges include (1) the heterogeneity of mdd in terms of etiology and symptoms; (2) depression severity as a continuum; (3) inter-individual differences of people diagnosed with mdd; (4) and the dynamic nature of mdd. we discuss these one by one below, and address how we aim to tackle them in warn-d. heterogeneity of risk factors and symptoms mdd is highly multifactorial, with many identified risk factors, all of which explain comparably little variance in isolation (kendler, 2012a). depression is also highly multifaceted: common rating scales for depression encompass over 50 separate symptoms (fried, flake, & robinaugh, 2022), and there is increasing evidence that symptoms are not interchangeable (fried & nesse, 2015b). for example, specific individual symptoms warn-d protocol paper 4 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ feature differential relations to constructs including impairment (fried & nesse, 2014; tweed, 1993), biological markers (frank et al., 2021; fried et al., 2020; hilland et al., 2020; nagel et al., 2018; van eeden et al., 2020), life events (fried et al., 2015; keller et al., 2007; keller & nesse, 2005), and treatments (boschloo, bekhuis, et al., 2019; boschloo, cuijpers, et al., 2019; snippe et al., 2021). further, there is evidence that depression is not unidimensional, i.e., cannot be adequately described as one process (fried et al., 2016). together, this calls into question the practice of modeling depression as a single variable or process, and its etiology as driven by a small number of factors. instead, it suggests the study of a broad set of biological, psychological, and social risk factors, protective factors, as well as problems or symptoms participants experience nested under the umbrella of the depressive phenotype (engel, 1977). depression severity as a continuum case-control studies are commonplace in depression research, where 2 groups (healthy vs depressed) are compared. this is widely recognized as a fundamental barrier to insights (fried, flake, & robinaugh, 2022; hitchcock et al., 2022), and categorical concep­ tualizations ignore subclinical cases who have increased levels of functional impairment, socioeconomic burden, service use, suicide attempts, and worse prognosis (cuijpers & smit, 2004; gotlib et al., 1995; hetrick et al., 2008; judd et al., 1997). dimensional perspectives in which subclinical cases are not subsumed into the category of healthy individuals offer ways forward that conceptualize depression as a continuum between healthy and sick, and align with evidence that depression behaves as a continuum at the between-subjects level (conway et al., 2019; haslam, 2003; haslam et al., 2012), rather than a category or taxon. inter-individual differences within mdd people diagnosed with mdd often differ from each other in fundamental ways regarding symptoms and etiology, and subsuming them into one group can obfuscate pronounced inter-individual differences (fried, flake, & robinaugh, 2022; fried & nesse, 2015a; kendler, 2012b; zimmerman et al., 2015). two patients can have the same dsm-5 diagno­ sis of mdd without sharing a single symptom, and knowing that a person is diagnosed with mdd tells us little about the actual problems they face in daily life (mcwilliams, 2021; parker, 2005). longitudinal data combined with statistical approaches that can leverage such data efficiently (e.g., network models, machine learning models) allow researchers to disentangle group-level processes (i.e., the nomothetic) from personalized processes (i.e., the idiographic) in order to find out to which degree processes are shared across people (fisher et al., 2018). fried, proppert, & rieble 5 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ depression as a dynamic phenotype this leads to the next challenge: the dynamic nature of depression (hetrick et al., 2008; judd et al., 1998; wichers, 2014). there is sparse data on the nature of transitions into depression in the first place: are they largely categorical (i.e., a catastrophic transition), continuous (i.e., a process that unfolds slowly over weeks), or are there considerable inter-individual differences in how people transition into depression? further, compara­ bly little empirical work has been conducted on the depressive prodrome: what are the prominent features that could serve as early warning signals (ews) for upcoming transitions into depression? studies have identified a host of prodromal signs such as anxiety, sleep disturbances, worthlessness, sad mood, and concentration problems (fava & tossani, 2007; iacoviello et al., 2010; murphy et al., 2002), but results are inconsistent across studies, and prospective studies in large samples, including a long period of daily assessments, do not exist. one of the most comprehensive studies on the topic collected data every 6 weeks (iacoviello et al., 2010), but cannot provide insights into daily fluctua­ tions of problems. such dynamic challenges require dynamic data, including daily reports of experiences, affect states, problems, and contextual variables whose fluctuations may shed light on upcoming transitions (kuppens, 2015; van de leemput et al., 2014; wichers et al., 2016). warn-d embraces the complexity of depression in sum, depression is a complex, dynamic, heterogeneous phenotype. to embrace this complexity, warn-d is guided by the rationale of depression as emerging from a sys­ tem of biopsychosocial elements (fried, 2022), which we term the human mood system. we conceptualize this system broadly, including time-invariant (or very slow-moving) features such as personality; time-varying features such as a person’s thoughts, feelings, and behaviors; as well as the context in which experiences are made; a detailed list of all assessed features is provided later. understanding this human mood system and its development requires the study of a broad set of system elements as well as their interrelations (borsboom, 2017; olthof et al., 2023), which is why we use smartphones and smartwatches to gather dynamic data. conceptualizing complex processes as mul­ tivariate, multicausal systems has resulted in many breakthroughs in disciplines such as ecology, meteorology, medicine, public health, and social dynamics (barabási, 2012; castellano et al., 2009; luke & stamatakis, 2012; olde rikkert et al., 2016; quax et al., 2018). in clinical psychology and psychiatry, recent studies have demonstrated the potential utility of a systems approach for understanding mental health problems like depression (hayes & andrews, 2020; lutz et al., 2018; olthof et al., 2023; robinaugh et al., 2020; wichers, 2014). of particular interest are ews that have been uncovered in many different areas of research, showing that systems close to transitions into alternative states (e.g., from healthy states to disordered states) show particular behavior that can warn-d protocol paper 6 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ be leveraged to forecast upcoming transitions (olthof et al., 2020; van de leemput et al., 2014; wichers et al., 2016). warn-d hopes to identify such markers in the human mood system to predict individuals at risk for imminent system shifts into depression. in our communication with participants, we use weather forecasting and thunderstorms as a metaphor for this: thunderstorms are not best predicted by increases in thunderstorms, and in the same way, monitoring symptoms over time may not be the best way to predict depression onset. instead, thunderstorms are best predicted by monitoring features of the weather system, along with the dynamic relations among these features. together, these can provide evidence of upcoming changes in the system. the main difference between forecasting thunderstorms and depression is that in the former case, if we successfully anticipate an upcoming storm, all we can do is to accept the incoming storm, seek shelter, and try to clean up afterwards. for depression, successful prediction may allow us to prevent depression before it occurs in the first place. warn-d design, procedure, and measurement design we plan to follow 2,000 students from vocational schools, technical universities, and universities in the netherlands for ~2 years, using a multicohort design with 4 cohorts of 500 students each. the 4 cohorts start in november 2021, may 2022, november 2022, and may 2023, respectively. the timeline of the project is visualized in figure 1 and includes 4 stages. figure 1 overview of design and procedure of the warn-d study note. the study takes place in 4 cohorts with a target n = 500 per cohort, and each cohort runs for 2 years through stages 1, 2, and 3. starting times for cohorts are november 2021, may 2022, november 2022, and may 2023. for stage 4, the repetition of stage 2, we will re-invite all participants from cohorts 1 and 2. attribution of images: laptop, phone, and smartwatch by mello, rabi'ah al adawiyyah, and smashicons, respectively (noun project, cc by 3.0). fried, proppert, & rieble 7 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ after participants meet inclusion criteria based on a brief online screener, stage 1 con­ sists of a 75-minute online survey with the goal to assess risk factors for depression broadly. stage 2 collects daily smartwatch and smartphone data, obtaining detailed insights into students’ lives. stage 3 consists of 8 online surveys, every 3 months, to determine if changes in mental health have occurred, and to assess risk and resilience factors. the study officially terminates after stage 3, at which point we plan to re-invite all participants from cohorts 1 and 2 for stage 4, which is a repetition of stage 2, i.e., another 3 months of daily monitoring. study design, procedure, inclusion and exclusion criteria, and measurement are described in more detail in the supplementary materials. procedure the warn-d study is funded by the european research council under the european union’s horizon 2020 research and innovation program (no. 949059). the data collection was approved by the leiden university research ethics committee leiden (2021-09-06e.i.fried-v2-3406). the study was exempted from having to obtain ethics approval under the medical research involving human subjects act. although data collection is finished for some cohorts, it is still running for others; therefore, we will use present tense in the remainder of the procedure section. we advertise the study both online and offline, and partnered with several initiatives (e.g., caring universities) and educational institutions (e.g., mbo rijnland) to reach students. participants interested in participating receive a link to an online survey. upon signing up, they can choose their preferred language (dutch or english), and then read and sign the informed consent materials. after a screener on inclusion and exclusion criteria described below, participants are invited to stage 1 of the study; completing stage 1 is mandatory to be invited to stage 2. we pay participants up to 90€ for completing all surveys in stage 1 (7.50€), stage 2 (45€), and stage 3 (37.50€; 7.50€ for the 30-minute surveys at 12 and 24 months, and 3.75€ for the 15-minute surveys at 3, 6, 9, 15, 18, and 21 months). participation in stage 4 yields up to 45€. participants who complete the 1-year and 2-year follow-up surveys in stage 3 can participate in 500€ lotteries for each survey. further, participants completing stage 2 receive a personalized report of the self-report data collected via smartphones, based on our experiences in a recent study that this is of great interest to many participants (fried, papanikolaou, & epskamp, 2022). inclusion and exclusion criteria participants qualify for the study if they meet the following criteria: ≥18 years old; fluent in reading dutch or english; studying at a dutch educational institution pursuing an mbo (vocational school), hbo (higher vocational school), or wo (university) degree warn-d protocol paper 8 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ (no phd students); currently living in the netherlands, germany, or belgium (this is to ensure that smartwatches can be shipped in time); having a european bank account (for reimbursement purposes); and having a smartphone that runs on android or ios so that the apps required for stage 2 work without problems. participants are excluded if they meet any of the following 6 criteria. first, at least moderate levels of current depression, operationalized via a score of ≥2 on the 2-item patient health questionnaire (phq-2; kroenke et al., 2003) and then a score of ≥14 on the 9-item patient health questionnaire (phq-9; kroenke & spitzer, 2013). second, current mania, operationalized via the corresponding items on the american psychiatric association’s (apa) “dsm-5 self-rated level 1 cross-cutting symptom measure—adult” (narrow et al., 2013), from here on referred to as the level 1 screener, followed by apa’s recommended level 2 screener, the altman self-rating mania scale (altman et al., 1997); participants are excluded if they meet thresholds on both level 1 (≥2 on either of the 2 items) and level 2 (sum score ≥6) screeners. third, current thought disorders, operationalized via the level 1 screener (sum score ≥1). fourth, substance use disorder via the alcohol, smoking and substance involvement screening test (assist v3.0), using the cutoff of ≥27 for each substance (who assist working group, 2010). fourth, we exclude participants reporting that they are currently in treatment or waiting for treatment for the mental health problems described above. fifth, we exclude students with at least moderate current suicidal ideation, operationalized via a score of 2 on item 4 of the beck scale for suicide ideation (bss; beck et al., 1979), which has shown excellent psychometric properties to screen for suicidal ideation, including in a dutch sample (de beurs et al., 2014). finally, we exclude participants who indicate that they would find seeing an estimate of daily calories burned very stressful, given that the smartwatches worn in stage 2 provide such an estimate. measurement there are many tools to measure constructs in clinical psychology and psychiatry. for our baseline and follow-up assessments, we based our selection of measures on 5 guiding principles: 1. scales should assess constructs relevant to understanding the human mood system and predict changes of the system (e.g., protective and risk factors). 2. scales should be free to use and in the public domain. 3. scales should have adequate psychometric properties. 4. scales should be validated in both english and dutch. 5. scales should be short without sacrificing content validity. some of the measures had to be created, translated, or adapted. guiding principles for measure adaptation were: 1. adapt as little as possible. fried, proppert, & rieble 9 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ 2. minimize burden for participants. we did so by streamlining time periods (e.g., we adapted the perceived stress scale (cohen & williamson, 1988) from the last 4 weeks to the last 2 weeks, so it is aligned with all our other measures that capture 2 weeks); by shortening scales to remove items not of interest to our research; and by shortening repetitive instructions (e.g., many scales instruct participants to “read these items carefully”). 3. adapt measures to ensure they are adequate for most participants in a student sample in the netherlands. three examples are: we changed the unit “stone” to “kilogram” in the scoff scale (morgan et al., 1999); we removed the item “combat or exposure to a war-zone” from the life events checklist for dsm-5 (gray et al., 2004); and we replaced the examples “gardening”, “collecting”, and “sewing” with “playing computer games” in the leisure domain of the work and social adjustment scale (mundt et al., 2002). because our selection of constructs may miss important aspects of participants’ lives, every stage affords participants the opportunity to indicate further relevant information in open text fields. overall, we have made all questionnaires and codebooks for all measures available in the supplementary materials. stage 1: baseline stage 1 consists of a 75-minute qualtrics survey to collect research data. table 1 contains an overview of our measurement battery, resulting from a detailed literature review and several expert meetings, followed by a short delphi study with 12 clinicians and researchers from clinical psychology and psychiatry. in addition to this survey, we ask participants for permission to link their postal code to dutch registry data containing neighborhood information such as air pollution, green spaces, and traffic noise (see table 1); such data may be helpful as indicators for socioeconomic status, which in turn has been shown to be related to depression (platania, 2023). more information about registry data is available at gecco.nl; permission to link postal code to registry data is not necessary for participation in warn-d. stage 2: daily monitoring stage 2 aims to provide a detailed mapping of the biopsychosocial components of the human mood system. this includes the temporal dynamics of important variables like depression and anxiety symptoms, affect states, stress, functional impairment, activity, sleep, as well as contextual variables. to assess these data, we use ecological momentary assessment (ema) to follow participants in their daily lives via smartphones for 85 days (bos et al., 2019; larson & csikszentmihalyi, 1983; myin-germeys & kuppens, 2021). specifically, we use the ethica app to query people 4 times a day, between around 10 am and 9:30pm at intervals of around 225 minutes with a normally distributed 30-minute jitter for each survey; each warn-d protocol paper 10 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ survey expires after 20 minutes. all 4 surveys contain the same block of 18 questions and take about 1-2 minutes to complete. the morning survey contains 3 additional questions table 1 stage 1 (baseline) measurements in the warn-d study category examples demographics age, nationality, population group physical appearance height, weight and satisfaction therewith, satisfaction physical appearance sex and gender biological sex, gender identity and struggles, sexual orientation and struggles internationality time spent in the netherlands, integration into dutch society, international student status ses and finances subjective socioeconomic status, current work, income sources, income vs spending, satisfaction work and finances, parents’ and own highest education education current studies and satisfaction, academic standing and satisfaction living situation children, household composition, satisfaction living situation religion religious affiliation, connection to church, place of worship physical health global physical health and impairment rating last 2 weeks and last year, chronic health issues, pain, medication menstruation-related questions detailed menstruation information, pregnancy / breastfeeding, contraception covid-19 impact of pandemic on mental health, prior covid-19 diagnoses, covid-19 symptom severity, long covid-19 symptoms sleep habits chronotype, sleep schedule, sleep problems like nightmares, worry about sleep, impairment, satisfaction mental health family history, global mental health and impairment rating last 2 weeks and last year, lifetime emotional problems, current / prior problems and diagnoses, recent changes in mental health, current need for treatment, current / prior treatment, current and lifetime depression, current seasonal affective disorder / (hypo)mania / generalized anxiety disorder / social anxiety disorder / obsessive-compulsive disorder / eating disorder / borderline personality disorder, current and past suicidal ideation, prior suicide attempts, non-suicidal self-injury substance use current, past, and lifetime substance use problems wellbeing and stressors hedonic and eudaemonic wellbeing, general life satisfaction, current stress and stress domains, childhood and lifetime adversity, discrimination, bullying, feelings of safety, negative and positive life events social social network online / offline, social media use, positive / negative interpersonal experiences, satisfaction relationship with friends / family, relationship status and satisfaction, satisfaction sex life, satisfaction independence from parents, loneliness leisure and activity physical activity, sedentary behavior, time spent outside, leisure activities and satisfaction traits and tendencies attachment style, negative affect, big five personality traits, repetitive negative thinking, intolerance to uncertainty, pessimism, behavioral and cognitive emotional regulation strategies, affective lability, anger/irritability, perfectionism, workaholism, dependency/separation anxiety/insecurity, procrastination resilience perceived stress recovery, self-efficacy, self-esteem, locus of control meta motivation to participate, survey difficulty, attention paid while answering, feedback on survey registry data air pollution, educational facilities, green spaces, income, urbanization, traffic noise, poverty, value of houses note. for a full list of variables, phrasing, response options, translations, and bibliography of measurement instruments, see codebook in the supplementary materials. fried, proppert, & rieble 11 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ about the last night and outlook for the day, and the evening survey contains 18 addi­ tional questions about the day as a whole. in addition, we query people every sunday at noon for a 46-item survey that takes around 5-7 minutes to complete, expiring after 10 hours. table 2 summarizes ema measurement design and content. an example item is “how sad are you right now”, which we query using a 7-point likert scale from 1 (not at all) to 7 (very much). our measures are based on the literature, our prior work, currently ongoing projects, and discussions with ema experts. the number of prompts and items per prompt were chosen based on discussions with numerous experts as well as our own experience regarding the compliance rates of ema data in student populations, with the overarching goal to obtain insightful momentary data whilst ensuring that the ema protocol is feasible for students; for that reason, we also assess if participants experience the monitoring as burdensome. table 2 stage 2 measurements in the warn-d study category examples mental health stress and stress domains, mental health and interference with daily activities, depression and anxiety symptoms, bad dreams, non-suicidal self-injury positive and negative affect happy/cheerful, motivated, relaxed, stressed, sad, nervous/anxious, overwhelmed, annoyed/irritated satisfaction and wellbeing ability to concentrate, feeling productive, general satisfaction physical experiences physical health and interference with daily activities, pain/discomfort, sleep, substance use, menstruation, sleep and tiredness experiences best and worst experiences of the day and the week, category of experiences such as finances, education, and love life social experiences feeling connected to others, being able to rely on others for support, current social offline/online contact, social media use context current activity and enjoyment of activity, current location coping and appraisal being able to handle daily and weekly challenges, emotion regulation meta enjoying study participation, reasons for missing surveys garmin smartwatch heart rate (constant, daily resting), blood oxygen saturation monitor, energy monitor, stress, body battery, sleep, step counter note. for a full list of variables, phrasing, response options, and translations, see codebook in the supplementary materials. we also collect digital phenotype data via the garmin smartwatch vivosmart 4, including sleep phases and duration, activity, heart rate, and stress. stage 3: follow-up surveys stage 3 consists of 8 follow-up surveys. two of these (the yearly ones) last ~30 minutes, the others ~15 minutes; see table 3 for an overview of the assessed constructs. warn-d protocol paper 12 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ stage 4: repetition of stage 2 stage 4 is a repetition of stage 2. we aim to recruit ~500 participants from cohorts 1 and 2 who previously completed stage 2 to obtain insight into the temporal stability of the human mood system. strengths and challenges we hope to achieve our ambitious goal of building a personalized early warning system for depression by embracing the complexity of the human mood system (fried, 2022; olthof et al., 2023). a multi-disciplinary approach integrating advances from systems table 3 stage 3 (follow-up) measurements in the warn-d study category variables physical appearance height, weight and satisfaction therewith, satisfaction physical appearance sex and gender struggles with gender identify / sexual orientation internationality integration into dutch society ses and finances satisfaction work and finances, highest education education current studies and satisfaction living situation children, satisfaction living situation physical health global physical health and impairment rating last 2 weeks and last 3 months, medication menstruation-related questions pregnancy/breastfeeding, contraception covid-19 impact of pandemic on mental health, prior covid-19 diagnoses, covid-19 symptom severity, long covid-19 symptoms sleep habits sleep, nightmares, satisfaction mental health global mental health and impairment rating last 2 weeks and last 3 months, current emotional problems and diagnoses, recent changes in mental health, current need for treatment, current treatment, current depression, current generalized anxiety disorder, current/prior suicidal ideation, suicide attempts, non-suicidal self-injury substance use current substance use habits wellbeing and stressors hedonic and eudaemonic wellbeing, current stress and stress domains, negative and positive life events social social network online / offline, social media use, positive / negative interpersonal experiences, satisfaction relationship with friends / family, relationship status & satisfaction, satisfaction sex life, satisfaction independence from parents, loneliness leisure and activity physical activity, satisfaction leisure activities traits and tendencies neuroticism, behavioral and cognitive emotional regulation strategies, affective lability, perfectionism, dependency/separation anxiety/insecurity, procrastination resilience perceived stress recovery, perceived recent resilience, forecast resilience meta motivation to continue participation, feedback on survey note. for a full list of variables, phrasing, response options, translations, and bibliography of measurement instruments, see codebook in the supplementary materials. fried, proppert, & rieble 13 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ theory, multi-modal measurement, and statistical models will be crucial to achieve this aim. the project also faces several challenges, and many open questions remain. first, there is a large literature on ews in other disciplines such as ecology (dakos et al., 2012; scheffer et al., 2012), and the psychological literature is growing rapidly (e.g., adler et al., 2020; cabrieto et al., 2019; olthof et al., 2020). which ews may be predictive of depression remains to be seen, and we will focus on both data-driven and theory-driven ews by leveraging all collected data and using machine-learning models to analyze what particular features are predictive of an upcoming transition, but also by testing various ews proposed in the literature. one is critical slowing down, a feature that has been shown to predict transitions in systems such as lakes before they turn from clean to turbid states, non-linear physical systems such as earth’s climate, as well as the stock market (olde rikkert et al., 2016; quax et al., 2018; scheffer et al., 2012, 2018). slowing down is a marker that a system becomes more vulnerable for an upcoming transition, because vulnerable systems take longer to recover from perturbations, which goes together with changes in parameters of systems that can be observed. another ews is higher connectivity, defined as more and stronger relations among components in a system, which could confer vulnerability for future depression. this is because in a more strongly connected causal system of problems (e.g., sleep problems, sad mood, concentration problems, fatigue), activating one problem may lead to a cascade that activates others (cramer et al., 2016; schweren et al., 2018; van borkulo et al., 2015; van de leemput et al., 2014). a second challenge is that warn-d is focused on forecasting depression, a complex and fuzzy phenotype for which many defensible operationalizations exist. for this rea­ son, we will predict several outcome variables, rather than restricting ourselves to one arbitrary operationalization. outcomes include: stress, anxiety and depression severity, as well as probable mdd diagnosis; wellbeing and impairment of functioning; changes in any of these constructs over time (as observed by longitudinal data), as well as perceived changes in these outcomes over time as retrospectively reported by participants. further outcomes include self-report information participants provide on diagnoses by health care professionals, as well as starting psychological or pharmacological treatments for mdd or related conditions. a robust predictor is one that predicts a larger number of these operationalizations of significant mental health changes. third, attrition rates are a concern in ema studies and prospective studies. to mitigate attrition, we incentivize participants in various ways: we pay them per comple­ ted survey (up to 90€ in total); organize 500€ lotteries per cohort for completing the 1-year and 2-year surveys, respectively; provide participants with garmin vivosmart 4 smartwatches they can use freely in stage 2; and offer participants a personalized data report of their ema data after completing stage 2. we also continuously ask participants about their experience with warn-d to learn about participation barriers with the goal of minimizing attrition rates in future cohorts. warn-d protocol paper 14 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://www.psychopen.eu/ finally, warn-d is an observational study, since our primary goal is prediction of onset—interventions carried out by warn-d itself would stand in the way of accurate forecasting. however, one could argue that especially stage 2 (tracking people via smart­ phones and smartwatches) may itself be an intervention. fortunately, we hope that such effects are held constant across time. that is, after we have developed the warn-d app in a few years to predict onset, people using it will go through a very similar program as described here, tracking themselves via smartphones and smartwatches to collect data to enable prediction of future onset. the app will likely also support a functionality where users can view the data they provide, similar to the personalized data reports. in that sense, our observational validation cohort for warn-d, and the people using the app in the future, will receive similar self-tracking ‘interventions’, holding potential intervention effects constant in our prediction and validation samples. funding: eiko fried, ricarda proppert, and carlotta rieble are supported by funding from the european research council (erc) under the european union’s horizon 2020 research and innovation program, grant no. 949059. acknowledgments: we wholeheartedly thank all participants of warn-d; all prior and current warn-d team members; all members of the scientific advisory board of warn-d; and all experts who participated in the delphi study to inform our baseline measurement battery. competing interests: the authors have declared that no competing interests exist. author contributions: conceptualization, funding acquisition, project administration, visualization, writing – original draft: e.i.f. data curation, investigation, software, supervision, validation, writing – review & editing: e.i.f., r.p., and c.l.r. twitter accounts: @eikofried, @rproppert, @carlottarieble data availability: we are excited to make our design, measures, code, and data available to the research community. information on design and measures are available in the accompanying supplementary materials (fried, proppert, & rieble, 2023a). all empirical papers will be accompanied by open code; we are currently developing a data sharing protocol with all relevant stakeholders which will be ready in 2025/2026 by the time data collection is finished. see our warn-d project hub (fried, proppert, & rieble, 2023b) for all future updates and publications, and, eventually, data. supplementary materials supplementary materials are available online (fried, proppert, & rieble, 2023a), which contain further information regarding: 1. consent sheets and general information sheets for participants, inclusion and exclusion screener, codebook for the screener 2. design and procedures for all stages fried, proppert, & rieble 15 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://twitter.com/eikofried https://twitter.com/rproppert https://twitter.com/carlottarieble https://www.psychopen.eu/ 3. all questionnaires and codebooks in dutch and english for all stages 4. stage 1: data journey for participant data, mental health information package for participants, information on the delphi study, information on the registry data 5. stage 2: participant instruction materials and video for setting up smartphones and watches 6. procedures for the personalized data reports and an example report index of supplementary materials fried, e. i., proppert, r. k. k., & rieble, c. l. 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(2016). critical slowing down as a personalized early warning signal for depression. psychotherapy and psychosomatics, 85(2), 114–116. https://doi.org/10.1159/000441458 winter, n. r., leenings, r., ernsting, j., sarink, k., fisch, l., emden, d., blanke, j., goltermann, j., opel, n., barkhau, c., meinert, s., dohm, k., repple, j., mauritz, m., gruber, m., leehr, e. j., grotegerd, d., redlich, r., jansen, a., . . . hahn, t. (2022). more alike than different: warn-d protocol paper 24 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://doi.org/10.1016/j.jad.2021.04.097 https://doi.org/10.1038/s41380-021-01161-7 https://doi.org/10.1017/s0033291700028476 https://doi.org/10.1001/jamapsychiatry.2015.2079 https://doi.org/10.1073/pnas.1312114110 https://doi.org/10.1038/s41398-020-00920-4 https://doi.org/10.1093/ije/dyt175 https://doi.org/10.1017/s0033291713001979 https://doi.org/10.1159/000441458 https://www.psychopen.eu/ quantifying deviations of brain structure and function in major depressive disorder across neuroimaging modalities. jama psychiatry, 79(9), 879–888. https://doi.org/10.1001/jamapsychiatry.2022.1780 world health organization. (2019). depression (who factsheet). world health organization. http://www.who.int/news-room/factsheets/ detail/depression zimmerman, m., ellison, w., young, d., chelminski, i., & dalrymple, k. (2015). how many different ways do patients meet the diagnostic criteria for major depressive disorder? comprehensive psychiatry, 56, 29–34. https://doi.org/10.1016/j.comppsych.2014.09.007 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. fried, proppert, & rieble 25 clinical psychology in europe 2023, vol. 5(3), article e10075 https://doi.org/10.32872/cpe.10075 https://doi.org/10.1001/jamapsychiatry.2022.1780 http://www.who.int/news-room/factsheets/detail/depression https://doi.org/10.1016/j.comppsych.2014.09.007 https://www.psychopen.eu/ warn-d protocol paper (introduction) principles guiding the development of warn-d conceptualization of depression heterogeneity of risk factors and symptoms depression severity as a continuum inter-individual differences within mdd depression as a dynamic phenotype warn-d embraces the complexity of depression warn-d design, procedure, and measurement design procedure inclusion and exclusion criteria measurement strengths and challenges (additional information) funding acknowledgments competing interests author contributions twitter accounts data availability supplementary materials references do we need a novel framework for classifying psychopathology? a discussion paper systematic reviews and meta-analyses do we need a novel framework for classifying psychopathology? a discussion paper winfried rief 1 , stefan g. hofmann 2 , max berg 1 , miriam k. forbes 3 , diego a. pizzagalli 4 , johannes zimmermann 5 , eiko fried 6 , geoffrey m. reed 7 [1] clinical psychology and psychotherapy group, department of psychology, philipps-university of marburg, marburg, germany. [2] translational clinical psychology group, department of psychology, philipps-university of marburg, marburg, germany. [3] school of psychological sciences, australian hearing hub, macquarie university sydney, sydney, australia. [4] department of psychiatry, center for depression, anxiety and stress research & mclean imaging center, mclean hospital, harvard medical school, belmont, ma, usa. [5] department of psychology, university of kassel, kassel, germany. [6] clinical psychology group, department of psychology, leiden university, leiden, the netherlands. [7] department of psychiatry, columbia university vagelos college of physicians and surgeons, new york, ny, usa. clinical psychology in europe, 2023, vol. 5(4), article e11699, https://doi.org/10.32872/cpe.11699 received: 2023-04-04 • accepted: 2023-10-09 • published (vor): 2023-12-22 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: winfried rief, philipps-university of marburg, department of psychology, clinical psychology and psychotherapy group, gutenbergstraße 18, d-35032 marburg, germany. e-mail: rief@staff.unimarburg.de abstract introduction: the icd-11 and dsm-5 are the leading systems for the classification of mental disorders, and their relevance for clinical work and research, as well as their impact for policy making and legal questions, has increased considerably. in recent years, other frameworks have been proposed to supplement or even replace the icd and the dsm, raising many questions regarding clinical utility, scientific relevance, and, at the core, how best to conceptualize mental disorders. method: as examples of the new approaches that have emerged, here we introduce the hierarchical taxonomy of psychopathology (hitop), the research domain criteria (rdoc), systems and network approaches, process-based approaches, as well as a new approach to the classification of personality disorders. results and discussion: we highlight main distinctions between these classification frameworks, largely related to different priorities and goals, and discuss areas of overlap and potential this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11699&domain=pdf&date_stamp=2023-12-22 https://orcid.org/0000-0002-7019-2250 https://orcid.org/0000-0002-3548-9681 https://orcid.org/0000-0003-3060-7869 https://orcid.org/0000-0002-6954-3818 https://orcid.org/0000-0002-7772-1143 https://orcid.org/0000-0001-6975-2356 https://orcid.org/0000-0001-7469-594x https://orcid.org/0000-0002-6572-4785 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ compatibility. synergies among these systems may provide promising new avenues for research and clinical practice. keywords icd-11, dsm-5, hierarchical taxonomy of psychopathology hitop, research domain criteria rdoc, network theory, personality disorders, process-based therapy pbt highlights • the world health organization’s international classification of diseases (icd) and its latest revision icd-11 offer the worldwide leading system for classification of mental disorders. • important proposals for rethinking classification came from the us national institute of mental health’s research domain criteria (rdoc), the hierarchical taxonomy of psychopathology (hitop) initiative, and the systems/network approach to mental disorders. • more ideographic approaches such as process-based interventions have also been suggested. • we present different ideas for classification before we suggest ways in which these approaches can inform each other, while respecting the different purposes that motivated their development. the classification of psychopathology has been a topic of debate for decades, sometimes from a scientific perspective, sometimes more from the perspective of societal relevance, epidemiology of clinical conditions, or in terms of its general usefulness. however, the discussion about how best to classify mental disorders has been particularly intense during recent years. these are not new discussion, but they were further stimulated by insel’s assertion that the most widely used classification systems – the diagnostic and statistical manual of mental disorders (dsm) and the international classification of diseases (icd) – have not proven useful as a framework for research or in the devel­ opment of new treatments targeted to underlying pathophysiological mechanisms (insel et al., 2010). since then, alternative approaches or extensions of these highly influential classification systems have been proposed and elaborated. here, we will review various proposals for modifying the classification of mental disorders, including the most recent iteration of icd’s chapter on mental, behavioral and neurodevelopmental disorders (icd-11). we highlight similarities and differences between proposed alternatives and different frameworks of classification (i.e., rdoc; hitop; the revised classification of personality disorders, network approaches, process-based approaches), and explore their advantages and challenges. the worldwide leading systems for the classification of mental disorders are the world health organization’s (who’s) icd, currently in its eleventh revision (icd-11) (who, 2022) and the american psychiatric association’s dsm, currently in its fifth edi­ novel ways of classifying psychopathology 2 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ tion (dsm-5-tr; american psychiatric association, 2022). although they each have their own antecedents internationally, the icd and the dsm have converged and diverged throughout their histories. the mental disorders chapter of the icd-8 (who, 1967) and the dsm-ii (american psychiatric association, 1968) were nearly identical and organ­ ized into the same three broad categories: psychoses; neuroses, personality disorders, and other nonpsychotic mental disorders; and mental retardation. some of their basic concepts can be traced back to pinel in 1798 (postel & quétel, 1994), kraepelin (1893) and bleuler (1911). the long history of concepts such as psychosis, schizophrenia, and depression could be attributed to the robustness of these concepts, or the resistance of the classification systems to change. the concepts were highly influential and the basis of research and treatment evaluations, but they were also misused (e.g., during mass murder campaigns like the “euthanasia program” in nazi germany). dsm-ii integrated the numerical coding system of icd-8. the descriptive, symptom-based approach that largely continues to characterize both the icd-11 and the dsm was initially realized in the dsm-iii (american psychiatric association, 1980), although there had been some par­ allel international developments. the dsm-iii gained substantial international influence as a professional and commercial success, widely taken up by funders and researchers and selling a great many more copies than anticipated (blashfield et al., 2014). the icd-11 classification of mental, behavioral and neurodevelopmental disorders and the dsm-5 were developed during overlapping periods of time and with substantial interaction between the who and the american psychiatric association. intentional “harmonization” between the systems was most successful in terms of the overall organi­ zation of the classification, but the icd and the dsm are currently more similar to one another than they have been in more than 40 years (for a detailed discussion see: first et al., 2021). most criticisms of categorical classification systems apply to both. these include questionable validity of many categories, dichotomization of dimensional features, high rate of use of “unspecified” or “other specified residual categories, lack of treatment specificity, excessive complexity and overspecification (reed, 2010), reification (hyman, 2010) (treating diagnostic categories as real and given without considering alternative approaches), heterogeneity of psychopathology / symptoms within diagnoses (e.g., fried et al., 2016; fried & nesse, 2015; hayes, hofmann, & ciarrochi, 2020), and stigma (thornicroft et al., 2022), in addition to other issues that are explored in later sections of this article. some aspects of the icd-11 intended to address these issues and are explained in this article (e.g., secondary parenting, integration of dimensions, linkage to etiology, social and environmental determinants of health), and the solutions are based on the flexible digital infrastructure of the overall icd-11 classification of diseases. at present, the icd is more widely used in clinical systems around the world (reed et al., 2011), whereas the dsm has been predominant in research. rief, hofmann, berg et al. 3 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ the icd and dsm classification systems are not intended or used for a single purpose (e.g., scientific validity), but rather have to achieve multiple goals at once. in part, they represent a pragmatic compromise among multiple competing demands and constituencies (lilienfeld, 2014). from a clinical perspective, a key aim is to facilitate communication among clinicians and health system decision makers using the terms of the classification system. diagnoses are meant to describe identifiable and meaningful clinical populations, a function that is intended to support treatment selection and clinical management. from a public health and policy perspective, an important priority is to communicate about the mental health of a population, and to quantify the need for treatment and governments responsibility to provide it. economically, the definition of prevalence rates of specific syndromes and associated treatment costs, together with consideration of the disease burden and costs of untreated conditions, allow the proper allocation of limited financial resources. these policy and financial aims lead to highly influential decisions (e.g., allocation of financial budgets). and finally, the icd must be acceptable and applicable all over the world to enable uniform global health statistics and to support comparability and focused prevention and intervention planning in support of global public health. the dsm, in contrast, is somewhat more bound to western culture and in particular more influenced by the us legal and healthcare reimbursement systems. some experts now argue that the flaws inherent in these systems require a major shift in perspectives and principles for conceptualizing mental disorders. the research domain criteria (rdoc) (insel, 2014) advocates as a framework for research a focus on basic mechanisms of mental disorders that are based on scientifically well-defined psychological and neurobiological concepts. the hierarchical taxonomy of psychopa­ thology (hitop) (kotov et al., 2017; kotov et al., 2021) recommends using a more data-driven approach to define symptom clusters organised within broader dimensions. this approach has similarities to investigating the structure of personality traits, which resulted in the big five model (john et al., 2008). meanwhile, these quantitatively based concepts enter more and more into the classification systems; the icd-11’s classifica­ tion of personality disorder and related traits (swales, 2022; tyrer et al., 2015) and the dsm-5’s alternative model for personality disorders (ampd) (zimmermann, kerber, et al., 2019) are related examples. others reject these “nomothetic” classification approaches as they are predominantly oriented towards differences between persons, and instead highlight the importance of “ideographic” approaches studying processes within persons. this process-based ap­ proach not only advocates for a more individualized diagnostic process, but also a psychopathological understanding in the context of basic principles of evolutionary theo­ ry, focusing on aspects such as variation, selection and retention of psychological and social processes as typical and highly relevant adaptation strategies (hayes, hofmann, & ciarrochi, 2020). finally, and consistent with some of these frameworks, systems and network approaches view psychopathology as emerging from a complex system of novel ways of classifying psychopathology 4 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ biopsychosocial variables and processes (borsboom, 2017; mcnally, 2021), and treatment as effecting dynamic changes in these networks. dynamic network theory not only con­ siders the relation and centrality of symptoms, social and environmental influences and biological processes, but also the dynamics of change processes. this framework aspires to describe, understand, predict, and intervene on psychological processes of mental disorders, and also inspires work on bridging levels of analysis, such as connecting neurobiological to behavioral systems (blanken et al., 2021). these approaches raise important criticisms and offer important insights for potential paths forward, but the key question remains whether they are viable alternatives for meeting the uses and demands of existing classification systems, or parallel systems that can inform the icd and the dsm. how can they be integrated with the knowledge that is in the dsm and icd? or are these recommendations for innovations just scientific “l’art pour l’art”, without relevant implications for clinicians or for public health? in this article, we focus on these questions and hope to advance the scientific discus­ sion concerning conceptualization of mental disorders, recognizing that the purposes of the icd and dsm extend far beyond their use as a framework for research (international advisory group, 2011; who, 2019b). by bringing together authors working with very different theories and approaches, we introduce the background and rationales of these frameworks, starting with the reference system icd-11 as a worldwide classification system with a long history and with important recent innovations in the classification of mental, behavioral, and neurodevelopmental disorders (reed et al., 2022; reed et al., 2019). we will investigate whether and how these new frameworks offer opportunities for improving the classification of mental and behavioral problems currently and over time. international classification of diseases, 11th revision (icd-11) the who is a specialized, semi-autonomous agency of the united nations with primary responsibility for global health. its highest governance body is the world health assem­ bly, which comprises the ministers of health of who’s 194 member states (countries). the who constitution (who, 1948 reprinted in: who, 2020) provides a list of 22 specific responsibilities that were assigned to who at the time of its founding. two of these are 1) to establish and revise as necessary international nomenclatures of diseases, of causes of death and of public health practices; and 2) to standardize diagnostic proce­ dures as necessary. the eleventh revision of the icd, the icd-11 (who, 2019a), was approved by the world health assembly on 27 may 2019 (who, 2019b). the icd-11 represents the first major revision of the classification since the icd-10 was published almost 30 years before (who, 1992) and incorporates major advances in research, practice, and rief, hofmann, berg et al. 5 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ information and healthcare technology. the primary purpose of the icd is to serve as a framework for the collection and reporting of health information by its 194 member states. important statistical uses of data based on the icd include monitoring epidemics and other threats to public health, the calculation of disease burden, and the identifica­ tion of vulnerable or at-risk populations. after adoption of new versions of the icd, the new system is implemented by member states as a part of their administrative, clinical, and information systems over the subsequent several years. beyond meeting reporting requirements, many member states use the icd as a part of the framework for defining their obligations to provide fee or subsidized health care to their populations. a specific consequence of this is that, in most countries, having a particular diagnosis generally entitles the individual to receive a specific range of health care services (e.g., a particular medication, a surgical intervention, a course of psychotherapy) that would not be provided without a qualifying diagnosis. in this way, the icd is used by who member states as a framework for defining the universe of health conditions that are an appropriate basis for reimbursed health services by appropriately qualified professionals. because of the icd’s major im­ plications for their health and health information and reporting systems, the pragmatic and statistical priorities of member states have a substantial influence on the icd and its implementation. member states are also invested in continuity across versions, so as not to undermine the usefulness of longitudinal health data. the date of implementation of icd-11 will vary by country, as it involves integration with laws, policies, health services and health data systems that vary considerably in scope and complexity. for example, the icd-11 classification of mental disorders has been adopted clinically in scottish mental health systems as of november 2022. germany, on the other hand, intends to launch a fully integrated implementation covering both clinical and data systems in 2027. development of the icd-11 classification of mental disorders although validity was obviously a primary concern in evaluating the need for changes in the mental disorders chapter of icd-10 (first et al., 2015), developing the icd-11 was not purely a matter of attempting to capture as well as possible the scientific “truth” about the nature of mental disorders (international advisory group, 2011). in developing the icd-11 classification of mental disorders, the who department of mental health and substance use also placed substantial emphasis on clinical utility and global applicability, which were seen as critical to the department’s aim of reducing the global disease burden of these conditions (reed et al., 2019). detailed descriptions of different aspects of the development of the icd-11 classification of mental disorders, its extensive program of integrated field studies, and its differences from the icd-10 and from the dsm-5 have been provided elsewhere (first et al., 2021; first et al., 2015; keeley et al., 2016; reed et al., 2022; reed et al., 2019). novel ways of classifying psychopathology 6 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ in addition to the statistical version of the icd-11 for mortality and morbidity statis­ tics (mms) (who, 2023) the who department of mental health and substance use developed clinical descriptions and diagnostic requirements (cddr) for icd-11 men­ tal, behavioral and neurodevelopmental disorders. the cddr are available on who’s icd-11 website (https://icd.who.int/dev11/l-m/en) and will be published in book form in 2024. to enable mental health and other health professionals to understand and apply this part of the classification in their work with patients, the cddr describe the features clinicians can reasonably expect to see in all cases of a given disorder and how to differ­ entiate disorders from non-pathological expressions of human experience and from other disorders including medical conditions (first et al., 2015). the cddr describes additional clinical features that can assist in evaluating diagnoses across cultures, genders, and the lifespan. (see first et al., 2015 for additional information about the contents of the cddr and its development.) benefits and costs of including mental disorders in the icd the icd-6 (who, 1949) was the first version of the classification published by who, the first to include a classification of morbidity in addition to mortality, and the first to include a classification of mental disorders. (the icd had previously been a classification of causes of death maintained by an international consortium. see reed et al. (2016) for a historical perspective). the icd-6 was therefore a major milestone in the recognition of mental disorders as valid health conditions and important causes of morbidity. in conceptualizing its approach to the development of the mental disorders classification in icd-11, who’s international advisory group (2011) stated, the inclusion of mental and behavioral disorders alongside all other diagnostic entities in health care is an important feature of the icd, facilitating the search for related mechanisms of etiology, pathophysiology, and comorbidity of disease processes and providing a solid basis for the parity of psychopathology with the rest of the medical system for clinical, administrative, and financial functions in health care” (p. 87). at the same time, integration in the icd has brought with it certain limitations because the icd classification of mental disorders must follow the same structural and taxonomic rules as the rest of the classification of diseases. clark et al. (2017) explain that the icd-11 “remains structured as a categorical taxonomic system because this format is necessary for its application as the classification system for global health statistics and, to a large extent, for its use in clinical systems (e.g., in treatment selection and the determination of eligibility for health care services)” (p. 105). these requirements impose different and much stricter restrictions on the classification model than other models discussed in this article. nonetheless, the icd-11 has been able to introduce substantial innovations that move beyond a strictly categorical classification in in the direction of greater dimensionality, while at the same time respecting rules and conventions that rief, hofmann, berg et al. 7 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://icd.who.int/dev11/l-m/en https://www.psychopen.eu/ have deep historical roots and are well accepted as the basis for classification in other areas of medicine. the overall taxonomical rules inherent in the icd — as a categorical classification system (and also inherent in the dsm, which in this regard is equivalent to the icd) (clark et al., 2017) — go back hundreds of years (adriaens & de block, 2013; kendler, 2009) and have contributed to the reification or “essentialization” of mental disorder categories (hyman, 2010). specifically, it led to the illusion that icd categories refer to discrete and non-overlapping disorders or subtypes of well-established validity, an illusion that has been further reinforced by the american psychiatric association’s focus on increasingly precise operationalizations of diagnostic criteria as a part of the dsm. randomized controlled trials were based on these precisely defined patient populations, de-emphasizing areas of overlap and commonality that are highly relevant to real-world implementation (tucker & reed, 2008). another limitation is that, by definition, a classi­ fication of diseases or health conditions locates the pathology within the individual. moving past categorical classification in the icd-11 structural and coding innovations introduced in the icd-11, partly based on its fully electronic infrastructure, have made it possible to introduce classification innovations that expand beyond a strictly categorical approach to mental disorders. a core principle of taxonomic classification is that entities can be classified in one and only one place. icd-11 uses a mechanism called “secondary parenting” to allow categories to appear in multiple places in order to improve clinical utility without sacrificing statistical integrity. for instance, tourette syndrome is classified under movement disorders in the icd-11 chapter on diseases of the nervous system but is also cross-listed under both neurodeve­ lopmental disorders and obsessive-compulsive and related disorders in the chapter on mental, behavioral or neurodevelopmental disorders. moreover, the icd-11 has made substantial progress in integrating a dimensional approach to the classification of mental disorders in the context of a categorical system (bach et al., 2021; clark et al., 2017; gaebel, 2012; reed, 2018). classification entities were introduced that are not diagnoses on their own but can be appended to other diagnostic categories to characterize them by utilizing dimensional profiles. these in­ clude symptomatic manifestations of primary psychotic disorders (positive symptoms, negative symptoms, depressive mood symptoms, manic mood symptoms, psychomotor symptoms, and cognitive symptoms); prominent personality trait domains in personality disorders (negative affectivity, detachment, dissociality, disinhibition, and anankastia), and behavioral or psychological disturbances in dementia (psychotic symptoms, mood symptoms, anxiety symptoms, apathy, agitation or aggression, disinhibition, and wander­ ing). syndromal dementia diagnoses are rated for severity as well as these psychological and behavioral descriptors, and they are also linked to the presumptive underlying novel ways of classifying psychopathology 8 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ etiology (e.g., cerebrovascular disease, chronic use of alcohol, parkinson disease, hiv). this provides a multidimensional picture of the individual clinical presentation. how can insights from other models be integrated – incrementally – into the icd-11? the icd-11 is the first version of the classification that has been designed and built using a fully digital architecture. the coding system has changed from numeric (10 possible values per digit, i.e., 0 – 9) to alphanumeric (36 possible values per digit, i.e., 0 – 9 and a – z), exponentially expanding the capacity of the system to contain information. therefore, it is likely that the core architecture of the icd-11 system will be in use for some time. member states’ interests and priorities for health information are also unlikely to change dramatically in the immediate future. so, discarding the entire classifi­ cation of mental disorders and substituting a fundamentally different approach will not realistically be possible anytime soon. however, there is a well elaborated and already functioning system for making more incremental proposals for changes to the icd-11 based on emerging evidence. proposals can be made by anyone registered on the icd-11 maintenance platform at https://icd.who.int/dev11/l-m/en. there are different proposal forms to modify the name or definition or other descriptive properties of a category, to add or delete a category, or to alter the organization of categories within or among groupings. after triage to verify that they meet basic requirements, proposals are sent to the classification and statistics advisory committee (csac), which primarily comprises representatives of the health statistics agencies of who member states. when appropriate, csac requests consultation from the medical and scientific advisory committee (msac) to evaluate the scientific and clinical foundation of a proposal and make a recommendation to csac on that basis. for msac, important factors in the evaluation of proposals are: 1) the amount and quality of scientific and clinical evidence in support of the proposal; 2) the amount and quality of contradictory evidence; and 3) the extent to which the proposal represents an international and widespread professional consensus. if a goal of the developers or adherents to any of the models discussed in this paper is to influence the icd, the icd-11 maintenance platform provides the best way to do that. the change in question should be proposed at a point where sufficient supportive evidence has been developed and there is substantial agreement (e.g., among international scientific and professional societies) about the desirability of adopting the proposal. rief, hofmann, berg et al. 9 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://icd.who.int/dev11/l-m/en https://www.psychopen.eu/ a paradigm shift in classifying personality disorders (pd) a prime example of the advancement of icd-11 is the section on pd. research on pd has been at the forefront of challenging the validity of categorical classification systems in recent decades and has increasingly questioned their clinical utility (bornstein & natoli, 2019; krueger, 2013; widiger & trull, 2007). for the icd-11 pd working group, as well as for many other researchers in the field, the time was ripe for a radical change: devel­ oping a model that better represents the empirical evidence for the dimensional structure of pd (hopwood et al., 2018). although pragmatic concessions were made to certain stakeholders (e.g., by retaining the category of borderline pd), this goal was ultimately achieved (tyrer et al., 2019). in this respect, the icd-11 model for pd demonstrates that a paradigm shift within the established classification of mental disorders is indeed possible. an important point of reference for the revision process was the ampd, published in 2013 in dsm-5 section iii, which converges with some elements of the icd-11 pd model. these include, for example, a refinement and substantiation of the general criteria for pd. criterion a of the ampd states that impairments in specific functions of the self (e.g., identity, self-worth, capacity for self-direction) and interpersonal relationships (e.g., capacity for empathy, cooperation, and intimacy) constitute pd and distinguish it from the state of mental health and other mental disorders. this definition is based primarily on the integration of various theories of pd (livesley, 1998), but it is also compatible with the empirical finding that these features are particularly pure markers of the general factor of pd (e.g., sharp et al., 2015). furthermore, in the ampd, the severity of pd takes centre stage and is directly represented diagnostically via a five-point rating scale—the level of personality functioning scale (lpfs: zimmermann et al., 2023). the underlying evidence base included findings of the high predictive validity of severity with respect to future impairment, as well as its clinical usefulness in determining the amount of care required. a particularly relevant element of the ampd that converges with the icd-11 pd model is using a dimensional trait model for describing the specific characteristics of pd. here the goal was not to simply adopt an established model from personality psychology. the point was to adopt the predominant methodological approach of personality research by 1) aiming at efficient and precise description (rather than explanation), 2) collecting human judgments of hundreds of nuanced characteristics in thousands of self and other descriptions, and 3) conducting a comprehensive analysis of the covariation of those characteristics. such a research program has contributed to a considerable integration of personality research since the 1990s. most prominent examples are hierarchically structured personality models such as the big five (john et al., 2008) or hexaco (ashton & lee, 2020), which encompass few broad domains and many specific, narrow facets. in line with this approach, the dsm-5 pd working group collected and defined 37 clinically relevant personality facets, created eight short descriptions per facet, submitted novel ways of classifying psychopathology 10 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ the entire list of items to multiple samples in self-report format, and used factor analytic methods to develop the taxonomy so that individual items are organized according to their empirical covariation (krueger et al., 2012). the result is the ampd trait model, with the five superordinate domains negative affectivity, detachment, antagonism, disinhibition, and psychoticism, and 25 subordinate facets. the fact that many domains correspond to the domains of the big five model (e.g., negative affectivity can be con­ sidered as the opposite pole of emotional stability) is ultimately an empirical outcome of this methodological approach and not an arbitrary decision by experts. some have called pd the “vanguard of the post-dsm-5.0 era” (krueger, 2013). indeed, the ampd trait model has stimulated a large body of research over the past 10 years that tends to support its validity and clinical utility (zimmermann, kerber, et al., 2019, but also see: clark & watson, 2022), and the pd section in icd-11 features for the first time a similar dimensional model in the main part of a classification system (tyrer et al., 2019). importantly, both models are based on a methodological approach that provides the template for creating a map for the totality of mental disorders, organized as they jointly emerge in the description of human raters. in this respect, the hitop initiative (kotov et al., 2017) can be seen as an attempt to complete the work that has been started on revising the pd sections in dsm-5 and icd-11. hitop for a better classification of mental disorders the hierarchical taxonomy of psychopathology (hitop; kotov et al., 2022; kotov et al., 2017) represents a quantitative approach to the classification of psychopathology, extending the methodological approach of the ampd described above. it is a hierarchical model of data-driven dimensions of psychopathology that have emerged in research on the structure of maladaptive personality as well as common and uncommon adult mental disorders (see kotov et al., 2017 for the foundational review). the dimensions are based on patterns of co-occurrence or covariation among symptoms and disorders, and the hierarchy arranges these dimensions from individual signs and symptoms at the bottom all the way up to very broad dimensions at the top (e.g., a general factor of psychopathology, or p-factor; caspi et al., 2014; lahey et al., 2012). the model will be revised as the literature evolves and ultimately is intended to become a comprehensive framework articulating the empirical structure of all psychopathology (forbes et al., 2023). the current model (figure 1) is organised around six core spectra that largely mirror the personality domains described in the ampd and the icd-11 pd model. in this framework, diagnoses are not “present” or “absent”; individuals’ symptom profiles indicate severity to guide intervention at the level of components, syndromes, and/or spectra (ruggero et al., 2019). rief, hofmann, berg et al. 11 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ figure 1 the current official hitop framework illness anxiety disorder somatic symptom disorder homogeneous symptom components / maladaptive traits disorders and related constructs linked to subfactors and spectra subfactors spectra syndromes superspectra components conversion somatization malaise head pain gastro-intestinal cognitive somatoform general factor of psychopathology (p-factor) traits anxiousness emotional lability hostility perseveration (low) restricted affectivity separation insecurity submissive-ness identity problems negative relationships fragility ineptitude (low) invulnerability internalizing arousal difficulties low desire orgasmic dysfunction sexual pain sexual problems anorexia nervosa binge eating disorder bulimia nervosa eating pathology agoraphobia ocd panic disorder sad social phobia specific phobia components interactive anxiety performance anxiety public places enclosed spaces animal phobia situational phobia blood-injectioninjury physiological panic psychological panic cleaning rituals checking fear borderline pd dysthymia gad mdd ptsd components dysphoria lassitude anhedonia insomnia suicidality agitation retardation appetite loss appetite gain (low) wellbeing gad symptoms re-experiencing avoidance hyperarousal numbing dissociation irritability pure obsessions distress bipolar i & ii components euphoric activation hyper-active cognition reckless over-confidence mania mood disorders with psychosis paranoid pd schizophrenia spectrum schizoid pd schizotypal pd components psychotic disorganized inexpressivity avolition traits eccentricity cognitive/ perceptual dysregulation unusual beliefs and experiences fantasy proneness thought disorder avoidant pd (low) histrionic pd schizoid pd traits anhedonia depressivity intimacy avoidance suspicious-ness withdrawal interpersonal passivity disaffiliativeness (low) attention seeking detachment traits problematic impulsivity irresponsibility theft distractibility risk taking (low) rigid perfectionism (low) ruminative deliberation (low) workaholism disinhibited externalizing substancerelated disorders components alcohol use alcohol problems marijuana use marijuana problems drug use drug problems harmful substance use antisocial pd conduct disorder ied odd adhd components physical aggression destructive aggression relational aggression fraud traits impatient urgency (low) planful control (low) dependability alienation boredom proneness blame externalization (low) honesty rebelliousness (low) empathy excitement seeking antisocial behavior borderline pd histrionic pd narcissistic pd paranoid pd traits attention seeking callousness deceitfulness grandiosity manipulativeness rudeness egocentricity dominance flirtatiousness (low) timorousness antagonistic externalizing externalizing dimensional syndromes individual signs, symptoms, and maladaptive behaviorssymptoms official hitop figure. this figure depicts the full current official hitop framework. dashed lines indicate dimensions included as provisional aspects of the framework. abbreviations: adhd, attention-deficit/hyperactivity disorder; gad, generalized anxiety disorder; ied, intermittent explosive disorder; mdd, major depressive disorder; ocd, obsessive–compulsive disorder; odd, oppositional defiant disorder; pd, personality disorder; ptsd, posttraumatic stress disorder; sad, separation anxiety disorder.note. dashed lines indicate dimensions included as provisional aspects of the framework. abbreviations: adhd, attention-deficit/hyperactivity disorder; gad, generalized anxiety disorder; ied, intermittent explosive disorder; mdd, major depressive disorder; ocd, obsessive–compulsive disorder; odd, oppositional defiant disorder; pd, personality disorder; ptsd, posttraumatic stress disorder; sad, separation anxiety disorder. reprinted from forbes and wright (2023), utilizing a creative commons 4 licence. see also hitop-system.org. motives for hitop the primary aim of hitop is to provide reliable and valid description of the structure of psychopathology to overcome the limited reliability and validity of many traditional categorical diagnostic categories (kotov et al., 2017). hitop dimensions have already been found to outperform traditional diagnoses in predicting important outcomes in research and practice (e.g., impairment, treatment-seeking, and suicidality) (kotov et al., 2021) and can be used for a variety of purposes — spanning understanding individuals’ symptom profiles, mapping the effect of a treatment to a specific domain of psychopa­ thology, and quantifying risk factors that predict psychological ill-health and distress in the population (conway et al., 2019). further, the hierarchical nature of the framework provides a high degree of flexibility for researchers and clinicians to focus on the specific novel ways of classifying psychopathology 12 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.hitop-system.org/ https://www.psychopen.eu/ level of detail relevant to their research questions or clinical context without needing to compromise on breadth of assessment (ruggero et al., 2019). bridging the gap between clinical applications, basic psychology, neuroscience, and other sciences due to its flexibility and breadth, hitop can act as a framework for disentangling the shared and unique features, processes, mechanisms, and causes of psychopathology for work spanning clinical practice, basic research, neuroscience, and other fields related to the study of mental disorders (conway et al., 2023; kotov et al., 2022; kotov et al., 2021; latzman et al., 2020; perkins et al., 2020). using reliable and empirically based constructs to operationalize psychopathology can offer a way forward that frees research in these fields from the limitations of traditional diagnostic categories and may present new opportunities for progress in understanding the mechanisms that underlie psycho­ pathology, as well as for developing more effective treatments. while the official hitop measure is still in development (simms et al., 2022), hitop constructs can be assessed using existing measures and analytic frameworks, reducing barriers to immediate imple­ mentation (e.g., conway et al., 2019; jonas et al., 2022). potential for a world-wide, transcultural, and culture-sensitive approach an important limitation of the evidence base for the hitop framework is the predomi­ nance of studies in homogeneous white and western samples. there have been several large cross-cultural studies as well as some work on multi-group invariance by race, ethnicity, gender, age, and sexual minority status in us samples (rodriguez-seijas et al., 2023). however, these studies have typically been limited to examining the internalizing and externalizing spectra. ultimately, the goal will be to have a classification system that has utility and is robust across sociodemographic and cultural groups, while also sensitive to differences between these groups. with more comprehensive research in this area, meaningful differences between groups may well emerge such that a more nuanced framework will be required that goes beyond a single structure. this is ongoing work in both the diversity, equity, and inclusion workgroup and the revisions workgroup in the hitop consortium (forbes et al., 2023; rodriguez-seijas et al., 2023). increasing the acceptability and utility of hitop in practitioner groups recent research shows mixed results regarding the acceptability and utility of hitop among practitioner groups; indeed, these were not the major goals for the development of hitop. for example, balling et al. (2022) found that clinicians rated hitop as having better clinical utility than the dsm when applying both systems to a clinical vignette. rief, hofmann, berg et al. 13 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ raskin et al. (2022) also found support from psychologists for alternatives to the dsm-5 in principle, but in practice they were unfamiliar with hitop. there is substantial work underway to increase the acceptability and utility of the hitop framework for practitioner groups. for example, there is work documenting the mapping between hitop constructs and existing interventions (mullins-sweatt et al., 2020); transdiagnostic treatments can be selected to target a range of related symptoms (e.g., selective serotonin reuptake inhibitors / ssri or the unified protocol to treat symptoms across the internalizing spectrum; kotov et al., 2017) or targeted treatments can be used for narrow symptom domains (e.g., exposure therapy for phobic anxiety or sleep restriction for insomnia). a digital assessment and tracker (hitop-dat) has also been developed that assesses symptoms and traits across the framework as well as functional impairment (jonas et al., 2022). it can be used for scoring clients’ symptom profiles at intake with reference to population norms, treatment planning, tracking progress over time, and cross-walking elevated hitop domains to icd-10-cm codes for reimbursement and administrative purposes. other clinical tools—such as links to existing ‘hitop friendly measures’ and explanations of how to use hitop in practice— are available on the hitop clinical network website (hitop-system.org; see also hitop consortium, 2023) and field trials are underway at nine clinical sites to identify and address gaps in clinical utility (kotov et al., 2022). rdoc for a better conceptualization of mental disorders motives for rdoc launched in 2009 by the national institute of mental health (nimh) in the us, the research domain criteria (rdoc) represents a research framework – rather than a nosological system – developed to overcome serious limitations associated with symp­ tom-based diagnostic categories. among others, three problems inherent in categorical classification systems (e.g. dsm, icd) fuelled the development of rdoc (insel et al., 2010). first was the fact that dsm/icd diagnoses remain generally agnostic with respect to underlying pathophysiology and etiology. second was the amply documented observa­ tion that current diagnoses are characterised by a remarkable degree of clinical (and presumably, etiological and pathophysiological) heterogeneity and extensive comorbidi­ ty. and finally, a substantial body of evidence indicates that dsm/icd diagnoses are poor predictors of treatment response and clinical course. the rdoc research framework responded to these challenges by focusing on func­ tional dimensions divided into seven domains ranging from normal to abnormal. these dimensions include negative valence systems, positive valence systems, cognitive sys­ tems, systems for social processes, arousal/regulatory systems, and sensorimotor sys­ novel ways of classifying psychopathology 14 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.hitop-system.org/ https://www.psychopen.eu/ tems. the investigation of these dimensions occurs across seven units of analysis: genes ↔ molecules ↔ cells ↔ circuits ↔ physiology ↔ behavior ↔ self-reports. this approach fosters a multi-faceted assessment of mental disorders. additionally, the framework acknowledges that both neurodevelopment and environmental influences continuously shape and affect the domains and units of analysis. for more information about rdoc, see reviews by cuthbert (2020); morris et al. (2022). in contrast to descriptive approaches for the classification of psychopathology, rdoc was launched from the premise that disorder categories should better consider diagno­ sis-relevant mechanisms. the first incarnation of the rdoc framework relied on the assumption that mental disorders are brain disorders that originate from dysfunctional brain neural circuits (insel et al., 2010). a key underlying assumption was that such circuit-level abnormalities could be addressed by therapeutic interventions. one foundational tenet of the rdoc is that studying mental disorders from the perspective of dimensions of measurable behavior and related neurobiological mecha­ nisms could overcome some limitations of current nosological systems (cuthbert, 2022). accordingly, this approach starts from basic knowledge about functions (e.g., ability to learn from rewards, propensity to attend to threat, working memory abilities), which can be evaluated at neural, behavioral, or self-report levels of analysis, for example. within this conceptualization, mental disorders can be studied as disruptions in these functions resulting in abnormalities across levels of analyses (and with varying degrees of disruption) (morris et al., 2022). refinements, misconceptions and criticisms of rdoc partially due to early writings emphasising that mental disorders are fundamentally disorders of aberrant brain circuits (e.g., insel et al., 2010), a misconception quickly arose that neural circuitry was considered the “primary focus” for rdoc (or stated differently, that neural units of analysis should be prioritized). this misconception has been clearly refuted in later writings (e.g., kozak & cuthbert, 2016), which have emphasized that no unit of analysis should have precedence or preferential consideration. with five of the seven units of analysis being biological, the rdoc retains a strong focus on biologi­ cal mechanisms, but this should not be misconstrued as biological reductionism (since self-report and behavior are considered equally important). rather, the rdoc framework emphasizes an approach in which mental disorders are studied simultaneously through observable (and quantifiable) behaviors as well as neurobiological variables. since its launch in 2009, the rdoc initiative has been criticized for several reasons, including insufficient attention to social determinants such as poverty, social inequality, and other environmental factors (e.g., dean, 2019), particularly in earlier rdoc conceptu­ alizations. although an exhaustive discussion of such criticisms goes beyond the scope of the current review, a few selected key criticisms are discussed (dean, 2019; peterson, 2015; ross & margolis, 2019; weinberger et al., 2015). rief, hofmann, berg et al. 15 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ perhaps among the most important criticisms, which goes to the core of the rdoc, is that serious mental disorders are not merely extreme forms of a dimensional continuum (ross & margolis, 2019; weinberger et al., 2015), but rather qualitatively different states. accordingly, serious mental disorders are thought to arise due to pathological processes that fundamentally disrupt normal neurobiological function (ross & margolis, 2019). along similar lines, it has been argued that variables summarized in the rdoc matrix regulate normal brain function, rather than disease states. according to these views, rdoc’s top-down approach rooted in seven predefined domains of functioning holds little promise towards better treatments. instead, critics advocate for a bottom-up “dis­ ease model,” which starts with identification of etiological factors (e.g., genetic variants), which in turn informs pathophysiological investigations and ultimately leads to a revised nosological system and targeted treatments. a second important criticism is that, owing to the fact that knowledge about the brain is still limited, the rdoc matrix focuses on well-established pathways and thus neglects emerging neurobiological targets discov­ ered, for example, through recent gwas studies of mental disorders (ross & margolis, 2019). as an example, ross and margolis (2019) highlighted that, as of spring 2019, the rdoc matrix included 33 mentions of dopamine or serotonin, 36 mentions of gaba or glutamate, without any mention of molecules recently implicated in risk for major mental disorders. although both criticisms are legitimate, it is important to emphasize that one important misconception is that the rdoc matrix is a fixed and prescriptive structure, focusing only on a subset of mental disorders. however, the rdoc leadership has been clear that the rdoc should be conceptualized as “a set of dynamic principles with which the field can build a cumulating knowledge base about psychopathology” (cuthbert, 2020, p. 84). thus, it is expected that the rdoc matrix will continue to evolve as knowledge is discovered and replicated. to conclude, rdoc is an approach that bridges the gap between clinical applications, basic psychology, neuroscience, and other sciences. it has the potential of changing education and training programs for clinicians by moving the focus from diagnostic groups to mechanisms of change. however, at present, it has not yet developed to answer societal questions, health economic questions, or transcultural issues. a systems perspective on mental disorder research and practice five key insights are of particular relevance to the systems perspective. first, mental disorders are highly multifactorial, including biological, mental, social, and environmen­ tal determinants. this contrasts with oversimplistic, monocausal frameworks that have dominated our field. second, people with the same determinants can develop different problems (multifinality), and people with different determinants may develop the same problems (equifinality). this means it is difficult to predict how a person’s problems novel ways of classifying psychopathology 16 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ will develop over time. third, people with the same diagnoses can differ substantially in both the determinants and problems they experience. there are (next to) no simple homogeneous categories, and one-size-fits-all treatments have shown limited efficacy. fourth, the problems people experience are often causally related: for example, injury → pain → insomnia → decreased work performance → negative affect → relationship problems. importantly, problems may persist even after determinants have subsided (see figure 2). overall, this calls into question simple cause-effect relationships as well as the clear separation of risk factors and symptoms. fifth, mental disorders are dynamic: they rise and fall over time. unfortunately, our knowledge of these dynamics is limited, largely owed to cross-sectional, between-subjects research designs. figure 2 the development of mental disorders from a systems perspective according to borsboom (2017) s2 s1 s4 s3 e1 phase 1. dormant network in stable state s2 s1 s4 s3 e1 phase 2. network activation s2 s1 s4 s3 phase 3. symptom spread e1 s2 s1 s4 s3 phase 4. active network in stable state e1 note. s = symptoms; e = environmental influences. according to the systems perspective, mental disorders go through several phases of development. initially, there is an asymptomatic phase where the network is inactive (phase 1). then, an external event triggers some symptoms to manifest (phase 2), which in turn enable other connected symptoms (phase 3). if the network is highly interconnected, simply removing the external trigger does not result in recovery. this is because the network is self-sustaining and becomes trapped in an active, stable state (phase 4). figure reprinted with permission from wiley & sons ltd. a framework for description, prediction, explanation, and control these five insights have led some experts to conclude that rather than studying single, isolated disorders or components, we should study the systems from which mental disorders arise. the systems perspective (or network approach) to mental disorders proposes just that: to conceptualize mental disorders as complex systems, and to study rief, hofmann, berg et al. 17 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ the systems (defined as components and relations among components) that give rise to mental disorders. the perspective has gained prominence in the last decade, and primers on the framework are available elsewhere (borsboom, 2017; fried, 2022; olthof et al., 2023; robinaugh et al., 2022; roefs et al., 2022). this brief section serves as a summary of the core points and available resources. broadly speaking, the perspective offers new theories and methods that aim to facilitate 1) description, 2) prediction, 3) explanation, and 4) control (i.e., prevention and intervention) of psychological systems. description one of the first steps to gain a better understanding into complex systems is data description and visualization. researchers in the last decade have implemented network methods from systems sciences that help psychologists estimate and visualize the rela­ tions between variables in datasets. such methodological tools are available for crosssectional data, panel-data (e.g., multi-wave epidemiological data), and time-series data (e.g., ecological momentary assessment data collected multiple times a day for several weeks using smartphones, or digital phenotype data collected using smartwatches or other wearable devices). a recent primer paper provides an overview of these methods and discusses challenges (borsboom, deserno, et al., 2021), which was followed by fur­ ther discussion of methodological limitations (borsboom et al., 2022; neal et al., 2022). importantly, some network methods allow one to distinguish processes that can only be identified at the individual level from those that generalize at the group-level (beltz & gates, 2017). these types of network models can start to bridge the gap between withinperson and between-person perspectives, and highlight the importance of disentangling differences between and within persons. prediction recent work has suggested that studying the dynamic features of disorder systems over time may enable researchers to predict upcoming transitions into and out of mental disorders (olthof et al., 2020; van de leemput et al., 2014; wichers et al., 2016). system features that are predictive of upcoming phase transitions are called early warning signals. such signals have been widely and successfully studied in other literatures such as ecology, and one of the most commonly discussed early warning signals in the psychopathology literature is critical slowing down (van de leemput et al., 2014; wichers et al., 2016) – a feature that systems may exhibit before a phase transition occurs, such as from a healthy to a depressed state. importantly, there is some evidence that critical slowing and other early warning signals can be detected some time before the symptoms of a person change, offering potentially novel opportunities for the prevention of mental disorders (fried et al., 2023). novel ways of classifying psychopathology 18 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ control climate scientists conceptualize the global climate as a system, and variables of interest, such as the global temperature, emerge from interactions among system components. climate scientists can simulate interventions on the system by implementing control mechanisms (such as reducing co2 emissions) and studying the outcomes for global temperature. similarly, conceptualizing mental disorders as systems and quantifying components as well as relationships among components may afford our field novel tools to study interventions. researchers in this field recently developed a toolkit for system interventions by combining the two disciplines of network psychometrics and control theory — the former is concerned with the estimation of network estimation in psychological data, the latter with the question of how to optimally control systems to achieve desired outcomes, such as reducing global temperature or mental disorders (henry et al., 2022). explanation in the summer of 2022, there were considerable shortages of sparkling water in italy, and media also reported a potential beer production shortage in germany—both “because” of the ukraine war. this is the result of causal processes in a system: war → increas­ ing energy prices → decreased ammonia (fertilizer) production that is very energy intensive → decreased co2 production that is a byproduct of ammonia production → co2 shortage that affects production of sparkling water and beer. understanding these causal pathways helps with predicting future states of the system, as well as thinking of potential control operations (e.g., subsidizing ammonia production or finding alternative sources of co2). this also applies to psychological systems, where thorough descriptions of a system, along with theory building and testing, could help to properly map out components and relations within a system, and lead to a better understanding. using a complex systems approach, robinaugh and colleagues developed a theoretical model that aims to explain panic attacks and panic disorder (robinaugh et al., 2022). this model specifies all relevant components and their relations in mathematical form, and the paper discusses in some detail the value of formalizing theories as systems (see also: borsboom, van der maas, et al., 2021; haslbeck et al., 2022; robinaugh et al., 2021). process-based therapy as a new conceptualization of problems and treatments on an individual level the goal of a process-based approach: the individual perspective process-based therapy is a new approach to psychopathology and treatment (hayes, hofmann, & ciarrochi, 2020; hofmann & hayes, 2019; hofmann et al., 2021). from rief, hofmann, berg et al. 19 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ a process-based perspective, perhaps the most problematic approach of contemporary psychiatry and psychology is to study phenomena on a between-person level (group level), rather than on a within-person level (individual level), leaving idiographic issues buried in statistical variation (fisher et al., 2018). by studying psychological phenomena almost exclusively at a between-person level (e.g., diagnostic categories), we miss out on the meaningful individual processes that are the main focus in clinical practice and might lead us to the actual underlying processes of treatment change. a related problem, specifically related to psychotherapy, is the contemporary ap­ proach of studying treatment processes with traditional mediation analyses based on a cross-sectional view of group data, which assumes that treatment change is nomothetic (baron & kenny, 1986). again, this assumption makes findings difficult to apply to individuals and has little relevance to clinical practice. to model processes of change, clinically meaningful intervention research needs to focus on variables longitudinally, allowing them to vary between and within individuals. furthermore, the impact of therapy cannot reasonably be reduced to just one or a few mediators and moderators, nor by assuming that these variables are independent or that they form simple unidirec­ tional, linear relationships (hofmann et al., 2020). the process-based perspective instead posits that change processes can more accurately be described as patterns of multiple inter-related variables forming dynamic complex networks over time, in individuals. the process-based framework for these reasons, hofmann and colleagues have advocated for shifting towards processbased therapy, or pbt (e.g., hayes & hofmann, 2021; hayes et al., 2019; hofmann & hayes, 2019) with the aim of discovering what change processes underlie psychopatholo­ gy and its successful amelioration, and refining our understanding of these processes to facilitate treating individuals in a flexible, more precise way. in transitioning to a pbt framework, the focus in clinical psychology is shifting from determining "what treat­ ments work?" to exploring "how treatments work and why." the goal of pbt is to gain a comprehensive understanding of two aspects: 1) identifying the essential biopsychosocial processes to target in an individual based on their specific goals and stage of inter­ vention, and 2) determining the most effective methods for targeting these processes, utilizing functional analysis, complex network approaches, and identifying core change processes derived from evidence-based treatments (hayes & hofmann, 2018). pbt shares goals with classical functional analysis, including the consideration of context and the usefulness of specific behaviors. however, pbt encompasses a wider range of processes and is specifically designed to be applicable and beneficial for clinicians (hayes et al., 2019). pbt also highlights the importance of distinguishing between therapeutic procedures and processes. therapeutic procedures refer to the specific techniques employed by a therapist with the aim of helping a patient to achieve their individual treatment novel ways of classifying psychopathology 20 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ goals (hayes & hofmann, 2018). processes occur primarily within the client, but they also involve interactions between the client and therapist, the client and other individ­ uals, and even within the therapist themselves. these processes encompass dynamic, theory-based, progressive, and multi-level changes. pbt necessitates a comprehensive theoretical framework to encompass specific evidence-based therapeutic models, and it has adopted an extended evolutionary model to fulfill that requirement (hayes, hofmann, & wilson, 2020). pbt views psychopathology as maladaptations to a particular context. from an evolutionary perspective, these maladaptations stem from issues related to variation, selection, and/or retention of specific biopsychosocial dimensions within that context. within pbt, this framework is referred to as the extended evolutionary meta-model (eemm). the eemm serves as a tool for researchers and clinicians to identify, study, categorize, and address the processes involved in psychopathology. we have extensively described the key aspects of the eemm, including variation, selection, retention, and context, and have applied these concepts across various domains (hayes, hofmann, & ciarrochi, 2020). variation is the initial step toward adaptation (hayes & hofmann, 2018). it requires flexibility. healthy selection is the second critical step in the process of adaptation. even if there is healthy variation present, maladaptation can occur if beneficial psychological variants are not recognized and chosen. selection processes include reinforcement, as well as the pursuit of goals, values, and attachment. finally, retention involves intention­ ally developing and reinforcing adaptive patterns and habits to replace old maladaptive ones. many evidence-based therapy techniques, such as homework assignments, aim to strengthen this aspect of adaptation. often during the development of psychopathology, some behaviors and cognitive approaches tend to become habitual, resulting in a narrow­ er range of variation. thus, a dialectic relationship exists between variation and selective retention. context serves as a moderating factor in this dialectic relationship, encompass­ ing cultural, diversity, social support, and family factors. psychological domains are not restricted to behaviors, but also include emotions, cognition, attention, self-perception, and motivational tendencies. multilevel selection involves considering gene systems, be­ havioral classes, cognitive themes, physiological processes, and sociocultural influences. together, these factors constitute the extended evolutionary meta model of change processes, as represented in figure 3. treatment and research implications of the pbt approach in recent years, there has been a growing trend towards transdiagnostic approaches in the field. the process-based approach addresses the limitations of the latent-disease model present in current classification systems by (1) systematically incorporating treat­ ment processes from various therapy modalities and (2) viewing the treatment focus in pbt as the removal of unhelpful processes rather than a specified disorder. this approach has been developed to analyze individual-level change processes. pbt places rief, hofmann, berg et al. 21 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ emphasis on tracking the patient's progress over time, utilizing techniques such as ecological momentary assessment, wearables, and smartphones. by redefining symptoms as problems based on the patient's current experiences, the aim is to understand the processes that contribute to maintaining these problems and the functional relationship between them. ultimately, the goal is to intervene effectively and predict future experi­ ences. figure 3 extended evolutionary meta-model of change processes variation selection retention context affective cognitive attentional self motivational overt behavioral physiological social/cultural maladaptive adaptive extended evolutionary meta-model (eemm) 1 note. figure from hayes, hofmann, and ciarrochi (2020). for the meta-model, it was argued that variation, selection, retention, and context are constructs to explain whether adaptation processes to life challenges are successful or end up in psychopathological problems. the theory of evolution is used in all life sciences to explain complex living systems. it was argued by hayes, hofmann, and wilson (2020) that evolutionary ideas have been underutilized by behavioral science. to introduce evolutionary thinking into the discourse, the extended evolutionary meta-model applies key concepts of variation, selection, and retention in different contexts to answer questions about the function, mechanisms, developmental pathways, and history of mental disorders. six content dimensions, including affect, cognition, attention, motivation, self, and overt behavior, are discussed to specify adaptation processes, and to be essential for describing mental disorders. figure reprinted with permission. copyright s.c. hayes and s.g. hofmann. novel ways of classifying psychopathology 22 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ to understand the individual, pbt encourages us to study the individual in all its complexities. this approach may lead to exciting new avenues for psychotherapy research, both in terms of identifying processes with empirical support and new data analytic advancements (hofmann et al., 2016). further research is necessary to investi­ gate whether the utilization of a pbt approach truly results in enhanced effectiveness of psychological treatment. this is because the scientific evaluation of this conceptual framework is still in its early stages, involving initial single case studies (ong et al., 2022). discussion in this article, we have presented the different rationales and purposes of different approaches to the classification of mental disorders. after briefly summarizing these ap­ proaches, we will discuss how they can inform each other. it is clear that a major source of differences among the approaches presented relate to distinct goals and purposes. the primary aim of icd-11 is as a tool for improving global public health, emphasizing usability and worldwide applicability. given its foundational role in global health statis­ tics, it has relevance for global development, economic evaluations, policy campaigns, legislation, and legal decisions. currently, there is no real alternative that serves all these purposes. however, other approaches can stimulate changes and improvements that can either be integrated into the icd-11 or can be further developed as a complementary or, perhaps eventually, alternative system. hitop is an empirically-based proposal to organize symptoms according to a hier­ archical and dimensional model. hitop has the potential to inform international classi­ fication systems because of its proximity to existing psychopathological concepts, but there is still a need for further evaluations based on hitop. the data underpinning the current hitop working model is heavily influenced by the traditional diagnostic catego­ ries it aims to improve, and the model does not yet capture sufficiently the diversity of populations. further, previous research on hitop is largely focused on differences between persons, and such a nomothetic approach can suffer from limitations when being applied to individual cases (e.g., fisher et al., 2018). rdoc, at first glance, seems to be orthogonal to the classification approaches based on descriptive psychopathology. it follows the vision of identifiable, separable mecha­ nisms that contribute to the development and maintenance of psychopathology. if such a system of identifiable mechanisms is further validated by empirical data, it can provide a breakthrough for moving primarily descriptive, psychopathological systems to a classi­ fication system that is characterized by central processes of mental disorders. however, many promises of rdoc have not been fulfilled yet. the definition of endophenotypes or the identification of central brain circuits responsible for mental disorders are progress­ rief, hofmann, berg et al. 23 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ ing only slowly, and effect sizes of pharmacological treatments continue to be in a low to moderate range (cipriani et al., 2018). another critique on rdoc is the tendency to focus on single systems, functions and mechanisms. alternatives may include dynamic network models that take into con­ sideration that relevant processes are interdependent. dynamic network models can be applied to mental/psychopathological symptoms and processes as well as to neurobiolog­ ical circuitries. although not unique to network approaches, they allow for integration of machine learning techniques, for example to improve prediction of changes. however, so far, network approaches have been applied only in an initial series of studies. it remains to be seen whether this approach will lead to relevant new insights and to a profound change of our understanding of mental disorders. the process-based approach mainly points to the fact that most diagnostic and inter­ ventional procedures focus on the individual, although the knowledge they are based on is mainly derived from analyses of group differences (the nomothetic-idiographic dilemma). the pbt approach advocates the need to collect more data on an individual level, such as individual trajectories about symptom development and recovery with the goal to derive novel, homogeneous, and treatment-relevant groups (using an integration of nomothetic and idiographic approaches such as the group iterative multiple model estimation / gimme algorithm; gates and molenaar, 2012). while the pbt approach offers a novel perspective on mental disorders and employs innovative analytical techni­ ques, it currently lacks sufficient empirical validation. opportunities and barriers to between-framework integration hitop shares its methodological approach with the ampd and icd-11 trait models, resulting in high convergence between hitop spectra and extant trait domains (wright & simms, 2015). hitop is also similar to the icd-11 in its focus on signs and symptoms and its prioritization of description as a foundation for explanation, and there is potential for more purposeful integration of hitop into icd. one barrier will be the emphasis on pragmatism in the icd-11 to ensure utility in health reporting and structuring clinical care, and also icd’s worldwide perspective. additional dimensions of psychopathology could be integrated into icd-11 where sufficient evidence for higher order spectra, empirical syndromes and other dimensional constructs accrues. other dimensions or units of analysis such as those contemplated in rdoc (e.g., neg­ ative valence systems, arousal/regulatory systems, circuits) could also be incorporated into what is called the “foundation layer” of the icd-11 without changing the statistical version. for example, the msac is already considering how best to incorporate genomic information in the foundation layer. although this would not be a part of the statistical version, if specific genomic variables were already part of the foundation they could easily be moved into the statistical version as evidence accumulates and there is a strong clinical or public health rationale for doing that. novel ways of classifying psychopathology 24 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ to take another example, the systems approach (e.g., fried, 2022; fried & robinaugh, 2020) explicitly includes consideration of factors in the interpersonal, social, and physical environment, so a classification model that focuses solely on disturbances within the individual would initially appear to be a poor fit. however, the icd-11 includes an exten­ sive chapter on factors influencing health status and encounters with health services, which covers many of the important social and environmental determinants of health. these include finances, education, employment, drinking water and nutrition, social or cultural environment, and relationships, among other areas. proposals based on the systems perspective could potentially focus on refining these categories and organizing them in configurations shown to be useful by research. the increasing attention current­ ly being devoted to issues of health equity, with the goal of addressing the overwhelming evidence of serious and unequal problems with access to healthcare services, quality of care received, and unequal outcomes among minoritized groups across numerous health and psychological parameters (kelly, 2022; who, 2018) suggests that consideration of these issues as part of the predominant global classification system for health could be important and timely. integration of hitop and rdoc is also a potential natural progression for both systems. for example, michelini et al. (2021) worked on an interface linking rdoc and hitop dimensions to strengthen both systems: rdoc’s biobehavioral focus could improve research on the mechanisms and processes underpinning hitop constructs, and hitop constructs can be used as reliable phenotypes (clinical targets) to guide rdoc-informed studies. while reliable covariation does not necessarily indicate a shared cause among constructs, the flexibility of the hitop hierarchy can at least account for heterogeneity within traditional diagnostic categories and this integration of the two approaches offers a concrete path forward for determining whether and where biobeha­ vioral mechanisms and processes map onto specific symptoms, broader components, or larger transdiagnostic dimensions (see also tiego et al., 2023). despite the possibilities for integration between different frameworks, there are sig­ nificant difficulties for integrating hitop and the systems perspective. one hurdle seems to be that the current hitop working model focuses on between-person differences, while the systems approach focusses primarily on within-person differences. however, it should be noted that hitop's underlying methodological approach of analyzing covaria­ tion in descriptions is also applicable to intensive longitudinal designs. in fact, similar to research on the big five as states (borkenau & ostendorf, 1998), the structure of withinperson fluctuations in mental disorders is found to be largely compatible with the hitop spectra (wright et al., 2023; zimmermann, woods, et al., 2019). in this respect, the hitop spectra could also have a heuristic value for the systems approach or pbt (e.g., regarding the selection of target dimensions or measures; wright & zimmermann, 2019). however, there are substantial philosophical and methodological differences between hitop and systems perspective frameworks. hitop – by design – searches for higher order latent rief, hofmann, berg et al. 25 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ factors of psychopathology while the systems perspective takes a deflationary stance on the existence of latent factors as constituents of mental disorders and instead emphasizes e.g., the importance of contextual variables for the development and maintenance of mental disorders (e.g., borsboom, 2017). in systems approaches, mental disorders are a system of interacting problems without simple underlying latent causes. hitop, however, is hierarchical and models latent constructs (supraspectra, spectra and subfactors) with the use of dimension reducing techniques (e.g., conway, forbes, et al., 2022). ongoing methodological and philosophical discussions (e.g., borsboom et al., 2022; forbes et al., 2021) exemplify the considerable challenge in integrating the systems perspective on mental disorders, including pbt, and hitop. for rdoc, there is emerging evidence indicating that utilizing the framework in conjunction with categorical diagnoses, such as from dsm or icd systems, may improve treatment outcomes. in a recent multi-site study in mdd, ang et al. (2020) reported that behavioral (relatively better reward learning ability, as assessed by the probabilis­ tic reward task) and neural (relatively stronger resting state functional connectivity between the nucleus accumbens and the prefrontal cortex) reward-related markers pre­ dicted treatment response to the atypical antidepressant bupropion after failing 8 weeks treatment with the first-line treatment sertraline (an ssri). critically, without a priori incorporation of these measures (including of the rdoc subdomain of reward learning), identification of treatment-specific markers (moderators) of treatment response would not have been possible. this is consistent with the rdoc’s assumption that, by imple­ menting quantifiable and granular assessments of fundamental dimensions of behavior that map onto precise neural circuitries (and computational parameters), we might be able to identify biologically more homogenous subgroups of individuals who might preferentially benefit from a given treatment strategy. for an important example of discovery of different “biotypes” in a study that used cognitive and electrophysiological variables to parse heterogeneity among a large group of individuals with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder, see clementz et al. (2016). a systems perspective aims to identify shortcomings of traditional diagnoses, includ­ ing inter-individual differences of people with the same diagnosis, lack of reliability and validity of categorical diagnoses, and an over-reliance on symptoms compared to other important factors. generally, the systems perspective aligns well with pbt, given the explicit focus on studying networks of within-person processes. methods from systems science can help to describe such systems, to describe their dynamic changes, and also to study to what degree systems generalize across people (borsboom, deserno, et al., 2021; roefs et al., 2022). it also aligns with rdoc’s transdiagnostic focus on mechanisms, and much of the work done by rdoc can be framed as studying disorder / health components and their interrelationships. the systems perspective and pbt also share a focus on understanding mental disor­ ders as dynamic processes that are shaped by complex interactions among various fac­ novel ways of classifying psychopathology 26 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ tors (borsboom, 2017; hofmann et al., 2020; hofmann & hayes, 2019). both approaches emphasize the role of individual experiences and the importance of context in shaping the development and maintenance of mental disorders. pbt and the systems perspec­ tive share a goal of developing personalized and context-aware treatment approaches that consider the unique needs and circumstances of the individual (e.g., fried et al., 2023; ong et al., 2022). despite the similarities there are also differences between the approaches. pbt is primarily a treatment approach, while the systems perspective is a broader framework for understanding mental disorders. while pbt draws on the systems perspective to inform its understanding of mental disorders, it is primarily focused on developing and implementing novel interventions. the systems perspective, on the other hand, seeks to provide a comprehensive understanding of mental disorders that can inform the development of a wide range of future treatments. conclusion the field of diagnosis and classification of mental disorders is characterized by a rapidly developing discourse, the utilization of multiple novel frameworks, and efforts to effec­ tively incorporate empirical data into the development of these models. as previously discussed, the main distinctions among the approaches result from their differing priori­ ties and goals. however, many aspects of single frameworks can be integrated into one another, which could lead to promising new research programs and hopefully also spark ideas for effective psychological treatments along the way. rief, hofmann, berg et al. 27 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ funding: rief: winfried rief declares to have received speaker’s honorarium from boehringer ingelheim. his research is support by several unconditional public grants from the german research foundation dfg and the hessian ministry of science and art. he also receives shares from publishing scientific and clinical books. all views expressed are solely those of the author. berg: max berg’s post-doc position is funded by the hessian ministry of arts and science. no funding from this entity was used to support the current work, and all views expressed are solely those of the author. forbes: miriam k. forbes is funded by the australian national health and medical research council, receives consulting fees from the environmental protection authority victoria, and receives honoraria from the american psychological association for editorial work. no funding from these entities was used to support the current work, and all views expressed are solely those of the author. fried: eiko i. fried is supported by funding from the european research council (erc) under the european union’s horizon 2020 research and innovation programme, grant no. 949059. no funding from these entities was used to support the current work, and all views expressed are solely those of the author. hofmann: during the last 3 years, stefan g. hofmann has received financial support by the alexander von humboldt foundation (as part of the alexander von humboldt professur), the hessische ministerium für wissenschaft und kunst (as part of the loewe spitzenprofessur), nih/ nimh r01mh128377, nih/nimhu01mh108168, broderick foundation/mit, and the james s. mcdonnell foundation 21st century science initiative in understanding human cognition – special initiative. no funding from these entities was used to support the current work, and all views expressed are solely those of the author. pizzagalli: over the past 3 years, dr. pizzagalli has received consulting fees from albright stonebridge group, boehringer ingelheim, compass pathways, engrail therapeutics, neumora therapeutics (formerly blackthorn therapeutics), neurocrine biosciences, neuroscience software, otsuka, sunovion, and takeda; he has received honoraria from the psychonomic society and the american psychological association (for editorial work) and from alkermes; he has received research funding from the brain and behavior research foundation, the dana foundation, millennium pharmaceuticals, nimh, and wellcome leap; he has received stock options from compass pathways, engrail therapeutics, neumora therapeutics, and neuroscience software. no funding from these entities was used to support the current work, and all views expressed are solely those of the author. reed: geoffrey m. reed has received support from the world health organization and the national institute of psychiatry ramón de la fuente muñiz, mexico. he has received honoraria for the direction and teaching of courses on the icd-11 from the world psychiatric association, and a speaker’s honorarium from the california psychological association. no funding from these entities was used to support the current work, and all views expressed are solely those of the author. zimmermann: johannes zimmermann received honoraria from the society for personality assessment for editorial work. no funding from this entity was used to support the current work, and all views expressed are solely those of the author. acknowledgments: this manuscript was stimulated by a symposium in berlin on “the future of diagnostics and classification of mental disorders“ during the 1st german psychotherapy congress dpk, may 2022. this symposium was enabled by the psychange project, an initiative sponsored by a grant from the hessian ministry of science and art to prof. rief. competing interests: winfried rief is editor-in-chief for clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. novel ways of classifying psychopathology 28 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ references adriaens, p. r., & de block, a. 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(2023). the dsm-5 level of personality functioning scale. in r. f. krueger & p. h. blaney (eds.), oxford textbook of psychopathology (4th ed., pp. 579-603). oxford university press. https://doi.org/10.1093/med-psych/9780197542521.003.0025 zimmermann, j., kerber, a., rek, k., hopwood, c. j., & krueger, r. f. (2019). a brief but comprehensive review of research on the alternative dsm-5 model for personality disorders. current psychiatry reports, 21(9), article 92. https://doi.org/10.1007/s11920-019-1079-z zimmermann, j., woods, w. c., ritter, s., happel, m., masuhr, o., jaeger, u., spitzer, c., & wright, a. g. c. (2019). integrating structure and dynamics in personality assessment: first steps toward the development and validation of a personality dynamics diary. psychological assessment, 31(4), 516–531. https://doi.org/10.1037/pas0000625 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. rief, hofmann, berg et al. 39 clinical psychology in europe 2023, vol. 5(4), article e11699 https://doi.org/10.32872/cpe.11699 https://doi.org/10.1093/med-psych/9780197542521.003.0025 https://doi.org/10.1007/s11920-019-1079-z https://doi.org/10.1037/pas0000625 https://www.psychopen.eu/ novel ways of classifying psychopathology (introduction) international classification of diseases, 11th revision (icd-11) development of the icd-11 classification of mental disorders benefits and costs of including mental disorders in the icd moving past categorical classification in the icd-11 how can insights from other models be integrated – incrementally – into the icd-11? a paradigm shift in classifying personality disorders (pd) hitop for a better classification of mental disorders motives for hitop bridging the gap between clinical applications, basic psychology, neuroscience, and other sciences potential for a world-wide, transcultural, and culture-sensitive approach increasing the acceptability and utility of hitop in practitioner groups rdoc for a better conceptualization of mental disorders motives for rdoc refinements, misconceptions and criticisms of rdoc a systems perspective on mental disorder research and practice a framework for description, prediction, explanation, and control process-based therapy as a new conceptualization of problems and treatments on an individual level the goal of a process-based approach: the individual perspective the process-based framework treatment and research implications of the pbt approach discussion opportunities and barriers to between-framework integration conclusion (additional information) funding acknowledgments competing interests references skill improvement through learning in therapy (skilt): a study protocol for a randomized trial testing the direct effects of cognitive behavioral therapy skill acquisition and role of learning capacity in depression research articles skill improvement through learning in therapy (skilt): a study protocol for a randomized trial testing the direct effects of cognitive behavioral therapy skill acquisition and role of learning capacity in depression sanne j. e. bruijniks 1,2, ulrike frank 1, brunna tuschen-caffier 1, jessica werthmann 1, fritz renner 1 [1] department of psychology, clinical psychology and psychotherapy, university of freiburg, freiburg, germany. [2] department of clinical psychology, utrecht university, utrecht, the netherlands. clinical psychology in europe, 2023, vol. 5(1), article e8475, https://doi.org/10.32872/cpe.8475 received: 2022-03-02 • accepted: 2023-01-06 • published (vor): 2023-03-31 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: sanne j. e. bruijniks, albert-ludwigs university of freiburg, engelbergerstrasse 41, 79106, freiburg, germany. e-mail: s.j.e.bruijniks@uu.nl supplementary materials: materials [see index of supplementary materials] abstract background: to improve psychological treatments for major depressive disorder (mdd), a better understanding on how symptoms ameliorate during treatment is essential. in cognitive behavioral therapy (cbt), it is unclear whether procedures focused on the acquisition of cbt skills play a causal role in the improvement of cbt skills. in this randomized trial, we isolate a single cbt skill acquisition procedure (cbtsap) and test its direct effects on cbt skills and related therapy processes (i.e., change in (idiosyncratic) dysfunctional thinking and reward processing). we hypothesize that the cbtsap causes improvements in cbt skills and related therapy processes compared to an active control condition. in addition, we hypothesize that individual differences in attentional bias and memory functioning (defined as learning capacity) moderate the effects of cbtsap on outcomes and that using mental imagery as a cognitive support strategy to strengthen the effects of the cbtsap will be most beneficial for patients with low learning capacity. method: 150 patients with mdd will be randomized to one of three conditions: 1. an active control condition, 2. cbtsap, 2. cbtsap plus mental imagery, all consisting of three sessions. primary outcomes will be change in cbt skills, changes in (idiosyncratic) dysfunctional thoughts this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.8475&domain=pdf&date_stamp=2023-03-31 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ and behaviors, reward processing. depressive symptoms are a secondary outcome. measures of learning capacity will be conducted at baseline and tested as a potential moderator. discussion: knowing whether and for whom the acquisition of cbt skills leads to change in therapy processes and a subsequent reduction of depressive symptoms will inform on how to personalize and optimize psychotherapy outcomes for depression. trial registration: the trial is registered at the german clinical trial register (dktr; registration number: drks00024116). keywords major depressive disorder (mdd), cognitive-behavioral therapy (cbt), cognitive behavioral therapy skills, mental imagery, experiment highlights • study protocol for a randomized trial to test direct effects of a procedure focused on cbt skill acquisition in mdd. • outcomes are cbt skills, dysfunctional thinking, reward processing and depressive symptoms. • the role of learning capacity as a moderator will be investigated. • results will inform on the direct effects and individual differences in effects of cbt procedures. background current psychological treatments for depression are only effective for half of the patients (cuijpers et al., 2021). response to psychological treatments is limited and relapse rates are high (steinert et al., 2014; verduijn et al., 2017; vittengl et al., 2007). to improve and innovate psychological treatments, a better understanding of how symptoms improve during treatment is essential. psychotherapies aim to reduce depressive symptoms by mobilizing therapy processes that seem central to the development and maintenance of depressive symptoms. therapy processes can be defined as the mechanisms inside the mind of the patient that are activated by the therapeutic procedures delivered by the therapist with the intent of producing change (bruijniks et al., 2018). in cognitive behavioral therapy (cbt; beck et al., 1979), one of the most investigated treatments for depression, therapeutic procedures focus on three major therapy processes: dysfunctional thinking, behavioral activation and the acquisition of cbt skills (barber & derubeis, 1989; lorenzo-luaces et al., 2016). first, cognitive change procedures aim to change the process of dysfunctional thinking (garratt et al., 2007). dysfunctional thoughts can be organized into different levels, some thoughts seem to occur more on a superficial level (negative automatic thoughts), while other thoughts are derived from more deeply integrated dysfunctional mental represen­ tations, that can include rules, expectations, or assumptions (attitudes) and sometimes skill improvement through learning in therapy (skilt) 2 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ even originate from early experiences in the childhood (schemas) (dozois & beck, 2008). second, cbt includes procedures aimed at behavioral activation in order to improve deficits in reward processing (dimidjian et al., 2011), such as a reduced response to reward or an oversensitive response to negative feedback (chiu & deldin, 2007; eshel & roiser, 2010; smoski et al., 2009). the third therapy process, the acquisition of cbt skills, is related to both dysfunctional thinking and behavioral activation. cbt skills are defined as the ability to re-evaluate the accuracy of one's own dysfunctional beliefs (ct skills) and in this way change patterns of dysfunctional thinking and the ability to engage proactively in pleasurable activities as a way to target reward experience (bt skills) (strunk et al., 2007). the acquisition of cbt skills is maybe one of the most promising therapy processes of cbt for depression. in contrast to the procedures focused on cognitive change and behavioral activation, cbt skill acquisition is a therapy process that emphasizes the patients' ability to use these cognitive change and behavioral activation procedures themselves, outside the therapy sessions. in addition, successful use of cbt skills may protect the patient from developing new future episodes after successful treatments (strunk et al., 2007). research shows that after successful treatment, impairments such as dysfunctional mental representations (arntz, 2020; sheppard & teasdale, 2004), negative processing of information (elgersma et al., 2019; spinhoven et al., 2018; woody et al., 2017) or blunted reward processing (dichter et al., 2012; pechtel et al., 2013) may remain, thereby possibly increasing the risk of new depressive episodes. the acquisition of cbt skills might be essential to transfer learned content from the therapy session to daily life and to cope with dysfunctional therapy processes or symptoms in future scenarios outside the therapeutic context. however, although multiple studies have pointed out that the acquisition of cbt skills is associated with reduced depression (adler et al., 2015; forand et al., 2018; strunk et al., 2014; webb et al., 2019) and seems specific to cbt (bruijniks et al., 2022), it is still unknown whether cbt skill acquisition directly causes a reduction of symptoms of depression. in order to test the causal effects of a certain therapeutic procedure, it is necessary to isolate the procedure and investigate its direct effects on the hypothesized changes in therapy processes and outcome (bruijniks et al., 2018). two preliminary experiments that focused on the acquisition of ct skills already evaluated how a proce­ dure focused on the acquisition of ct skills could be isolated (bruijniks et al., 2018) and showed that a short cognitive skill acquisition procedure in the form of a group masterclass led to better ct skill acquisition compared to an active control procedure in a sample of distressed students (bruijniks, los, & huibers 2020). a next step towards the clinical application of this finding would be to evaluate how a procedure focused on cbt skill acquisition causally affects the acquisition of cbt skills and subsequent symptom reduction in a clinically depressed sample. bruijniks, frank, tuschen-caffier et al. 3 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ nevertheless, skill acquisition seems to be a multifaceted process that requires dif­ ferent cognitive and neurobiological resources (anderson et al., 2016, 2018; basak et al., 2011; vanlehn, 1996), which may be impaired in depressed patients. compared to healthy individuals, depressed individuals have biased attention towards negative rather than positive information (fu et al., 2008; liu et al., 2012; marchetti et al., 2018; roiser et al., 2012) and suffer from a variety of deficits related to executive functioning, such as inhibition, planning and working memory (snyder, 2013). recent studies supported the hypothesis that individual differences in cognitive or neurobiological impairments may interfere with the success of psychological treatments. in a systematic review, cognitive and neurobiological impairments showed to be associated with impairments in dysfunctional thinking and reward processing while depressed patients with better cognitive control, but more emotional bias, before start of cbt seemed to benefit more from cbt’s procedures (bruijniks, derubeis, et al., 2019). possibly, patients who show more emotional bias are better able to tolerate and therefore target emotions as part of the cbt (stange et al., 2017) while individuals with better cognitive capacities are more capable of integrating and implementing new information that was retrieved in the therapy session. cbt might help individuals with increased emotional bias, but limited cognitive capacity, to regain (emotional) control (siegle et al., 2006). a recent experiment supports this suggestion, as results indicated that in healthy participants who received a stress induction, executive control under stress, but not under non-stressful circum­ stances, predicted the ability to reappraise negative material to become less negative (quinn & joormann, 2020). investigating whether individual differences in cognitive or neurobiological impairments are associated with the success of a cbt skill acquisition procedure will provide insight in for whom cbt skill acquisition procedures will be more or less effective. if individual differences in cognitive or neurobiological impairments are related to the success of cbt skill acquisition, this also means that the success of cbt skill acquisition might be improved by increasing the patients' capacity to learn from these procedures. one way to address and improve cognitive and neurobiological processes during treatment is by providing cognitive support. examples are the use of memory strategies within sessions of cbt (harvey et al., 2014, 2017) or providing short retrieval tests between the sessions (bruijniks, sijbrandij, et al., 2020). the major hypothesis is that by enhancing recall for the session content, the success of psychotherapy outcomes for depression can be improved and some studies provided preliminary evidence for this hypothesis (dong, lee, et al., 2017). however, to improve psychotherapy it might not only be important to improve recall of the session content but also improve and develop the therapy process. yet, while current cognitive support strategies such as retrieval of newly learned information may improve recall of the session content, it might not be enough to improve cbt skill acquisition. according to theories on skill acquisition, the process of skill acquisition starts with learning new information (this can also be seen skill improvement through learning in therapy (skilt) 4 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ as the 'declarative' part of skill acquisition), but then repeated practice is necessary to turn it into a more procedural form in which the newly learned skill becomes more and more automatized over time (anderson et al., 2018; tenison & anderson, 2016; vanlehn, 1996). to increase skill acquisition, it might therefore be necessary to use a strategy that supports both the declarative and procedural parts of memory. one strategy that seems promising in affecting both declarative and procedural mem­ ory is mental imagery. mental imagery refers to perceptual experiences in the absence of sensory input and constitutes a non-verbal way of information processing, closely related to the experience of emotions (holmes & mathews, 2010). mental imagery allows us to simulate past and future experiences and because of this allows us to “try-out” different courses of actions and their emotional consequences (ji et al., 2016; moulton & kosslyn, 2009). given these properties of mental imagery, when applied to cbt skills, imagery could be used to simulate skill application (renner et al., 2021). mental imagery has been linked to improved acquisition of skills in non-clinical settings, such as tennis performance or the development of surgical skills (anton et al., 2017; dana & gozalzadeh, 2017; gregg et al., 2011; kim et al., 2017; kraeutner et al., 2016), but also to increased bt skills in a clinically depressed population (renner et al., 2017). additionally, mental imagery has been related to the improvement of cognitive functioning, such as recall of memories (dalgleish et al., 2013) and prospective memory (i.e., memorizing to execute a previously formed intention at some point in the future; mcfarland & glisky, 2012; mcfarland & vasterling, 2018). we suggest that simulating applying cbt skills using mental imagery might be a potential efficient way to increase skill acquisition during psychotherapy (renner et al., 2021). the aims of this randomized trial are two-fold. the first aim is to investigate and compare the direct effects of three procedures (active control, cbt skill acquisition (cbtsap), cbtsap + mental imagery) on changes in therapy processes (the acquisition of cbt skills, changes in idiosyncratic dysfunctional thoughts and behaviors, general dysfunctional thinking and reward processing) and depressive symptoms in a sample of patients with a diagnosis of major depressive disorder who do not currently receive other psychological treatment. we expect that compared to an active control procedure, the procedures focused on cbt skill acquisition (cbtsap and cbtsap + mental imagery) will lead to more improvement in the therapy processes and depressive symptoms. sec­ ond, we will investigate whether the effect of the therapeutic procedures is moderated by individual differences in learning capacity. learning capacity will be defined as the presence of memory functioning and emotional bias (i.e., where more emotional bias and better memory functioning are defined as better learning capacity). following earlier literature on the measurement of memory (unsworth, 2010; wilhelm et al., 2013), the measurement of memory functioning will be composed of both working memory and long-term memory tasks. we expect that, compared to the active control procedure, better learning capacity will be associated with larger improvements in the therapy bruijniks, frank, tuschen-caffier et al. 5 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ processes and depressive symptoms in both the cbtsap’s. in addition, we expect a difference between cbtsap with versus without mental imagery: patients with low learning capacity will have most benefit from mental imagery and lower learning capaci­ ty will therefore be associated with more improvement in the therapy processes and depressive symptoms in the cbtsap with mental imagery compared to the cbtsap without mental imagery condition. besides the two main aims of the study, additional secondary analyses will be con­ ducted. because earlier studies suggested that cognitive support might improve the effects of therapy by increasing memory of the session content (dong, lee, et al., 2017), we additionally included a measure of session recall in the study and will test whether session recall will differ between the procedures. hypotheses of these secondary analyses are in line with our hypotheses for the main study aims: we expect session recall to be larger in the cbtsap with mental imagery compared to the cbtsap without mental imagery. in further secondary analyses we will investigate whether the effect of the procedures on depressive symptoms is mediated through one of the therapy processes and/or session recall and whether these mediation effects are specific to the cbtsap's (compared to the active control procedure). a conceptual model for the proposed study can be found in figure 1. figure 1 conceptual model for the proposed study methods active control moderator therapy procedures mechanisms: change in therapy processes patients with mild to severe depression (n = 150) cbt skill acquisition + mental imagery cbt skill acquisition  cbt skills  idiosyncratic dysfunctional thoughts and behaviors,  dysfunctional thinking  reward processing  recall change in depressive symptoms learning capacity   skill improvement through learning in therapy (skilt) 6 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ method design between-subject experimental design with three parallel conditions, each having an equal length of 3 x 45-minute sessions: 1) active control procedure (n = 50), 2) cbt skill acquisition procedure (cbtsap) (n = 50), 3) cbtsap with mental imagery (n = 50). the ethic committee of freiburg university approved the study (registration number: 20-1022) and the trial is pre-registered at the german clinical trial register (dktr; registration number: drks00024116). participants we aim to include 150 patients with a primary diagnosis of a major depressive disorder (mdd) (excluding non-dysthymic persistent major depressive disorder) as indicated by structural clinical interview for dsm-5 disorders (scid-5-cv) and a score on beck’s depression inventory ii (bdi-ii) ≥ 14 to ensure sufficient symptom severity. patients should be aged between 18-65 and have sufficient knowledge of the german language (because therapy sessions will be held in german). to prevent any potential interference with the therapeutic procedures and/or measurement of learning capacity, patients with the presence of a previously stated diagnosis of attention-deficit/hyperactivity disorder or attention-deficit disorder, current drug or alcohol use disorder according to the struc­ tural clinical interview for dsm-5 (scid-5-cv) or a cluster a or b personality disorder known by admission to the treatment center are excluded. to ensure the effects are attributable to the current therapeutic procedures, patients who receive currently (other) psychological treatment or have received cbt focusing on a major depressive disorder in the previous year are excluded. to reduce risk of adverse events, patient who show a high risk of suicide according to the intake staff or a score > 1 on bdi_ii item 13 (suicidal thought or wishes) will be excluded. sample size based on a medium effect size, alpha = .05, power =.80, number of experimental condi­ tions = 3, number of repeated measurements = 2 to 4 (g*power (faul et al., 2007)), a total sample size of 102 to 120 participants would be needed to detect a main effect, and 42 to 57 participants to detect an interaction in a repeated measures anova. simulation studies suggest 80 to 100 participants to detect an interaction effect between three groups (shieh, 2019) while simulation studies on multilevel analyses suggest n = 80 participants to detect a medium effect size with power =.80 (aarts et al., 2014). taking into account 20% drop-out, we aim to include a total of 150 participants. bruijniks, frank, tuschen-caffier et al. 7 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ recruitment patients will be recruited in two different ways. first, patients will be recruited from the academic outpatient treatment center at the department of psychology, unit for clinical psychology and psychotherapy at the albert-ludwigs university of freiburg. patients with various mental health problems and with a large variety of socio-demo­ graphic backgrounds seek treatment at the clinic. patients can receive up to 80 sessions individual cbt at the clinic in accordance with the german national health insurance regulations. treatment seeking individuals with severe mental disorders (e.g. schizophre­ nia) or acute suicidality are referred to other specialized services outside the clinic or in-patient treatment if indicated. during the intake patients will be checked on inand exclusion criteria and receive the patient information letter if they are potentially eligible for study participation. after one week, patients will be called to check whether they are interested in participating in the study. the remaining inand exclusion criteria will be checked, and the structural clinical interview for dsm-5 clinical version (scid-5-cv) interview will be conducted by phone. the procedures will take place while the patient is on a waiting list for regular treatment at the outpatient clinic. second, individuals can sign up for the study independently of treatment in the academic outpatient treatment center. information about the study will be put online and distributed in local health care centers. if interested, individuals will be send the patient information letter, called after one week to check remaining inand exclusion criteria and a scid-5-cv will be planned. randomization and procedure patient who are eligible to participate in the study will complete a baseline measurement and an introduction session on different days. the baseline measurement will take place in the lab and includes a measurement of learning capacity. informed consent will be signed before the baseline measurement. the order of the measurements during the baseline measurement will be randomized for each participant in order to control for potential fatigue effects. the introduction session is conducted by the therapist and focuses on introducing the principles of cbt and completing the core belief interview (cbi; mcbride et al., 2007). after the introduction session, patients will be randomized into one of the three conditions using a computer script performing block randomization (1:1:1, block size = 15). block randomization will be done by a researcher who is not involved in the study measurements. randomization will be pre-stratified on severity of depression (mild [beck depression inventory-ii (bdi-ii) = 14-19] vs. moderate to severe [bdi-ii ≥ 20]). therapy sessions will be completed weekly and the total study procedure from baseline measurement to the post measurement will take a maximum of 5 weeks. the researchers who perform the study measurements are blind for the therapeutic procedures. the full study procedure is also presented in figure 2. participants do not receive financial incentives for participation in this study. skill improvement through learning in therapy (skilt) 8 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ figure 2 recruitment and study procedure   intake at outpatient clinic or sign up by email screening for inand exclusion criteria and scid-i by phone week 1 week 2-4 week 4-5 baseline measurement introduction session (session 1) randomization active control procedure (3 sessions + pre and post-session measurements) post-procedure measurement one-week follow-up measurement cbtsap (3 sessions + pre and post-session measurements) cbtsap + mental imagery (3 sessions + pre and postsession measurements) note. the exact time point of each measurement is given in table 1. bruijniks, frank, tuschen-caffier et al. 9 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ therapists the therapeutic procedures will be conducted by 5 licensed therapists who are working at the outpatient treatment center of the university of freiburg. all therapist involved in this study had completed a 3-year fulltime psychotherapist cbt training course required and strictly regulated in germany to obtain a license as clinical psychological psychotherapist. therapist have between 5 and 29 years therapy experience. before start of the study, the therapists received 8 hour training consisting of advanced training in cbt skills by dr. strunk (ohio state university), advanced mental imagery training conducted by dr. renner (university of freiburg) and elaborate training on the different protocols for each therapeutic procedure in the study. all therapists will be involved in the delivery of all different procedures. introduction session the introduction session will focus on introducing the principles of cbt (central focus will be on the relation between thoughts, behaviors and mood) and completing the cbi. during the cbi, the therapist and patient try to gain insight in the current three most relevant dysfunctional beliefs and current three most relevant dysfunctional behaviors for the patient. these beliefs and behaviors will be used in the subsequent sessions to discuss in relation with depressive symptoms (active control procedure) or to practice cbt skills (cbtsap and cbtsap + mental imagery condition). therapeutic procedures all therapeutic procedures use techniques from the protocol for cognitive behavioral therapy (cbt; beck et al., 1979) for depression and use agenda setting to structure the sessions. in addition, each procedure will focus on targeting the idiosyncratic beliefs and behaviors that were established during the cbi. however, the procedures differ in the number of active ingredients (see figure 3 and data supplement 1). during the active control procedure, the therapist and patient will focus on discussion of dysfunctional thoughts and behaviors only. therapists in this condition will be explicitly instructed to focus purely on exploring the relation between dysfunctional thinking and behavior and depressive symptoms, and not to engage in evaluating dysfunctional thinking or behav­ ioral activation. during the cbt skill acquisition procedure (cbtsap), the therapist and patient will choose one of the cognitive or behavioral skills from a predefined list of cbt skills (i.e., consisting of behavioral activation (behavioral therapy skill) and questions used for evaluating dysfunctional thoughts (cognitive therapy skill). subsequently, the therapist and patient will discuss how this skill could be or have been applied in past or future situations in which idiosyncratic beliefs and behaviors may (have) lead to negative mood. during the cbtsap plus mental imagery, the therapist and patient will not only discuss application of the skill but in addition, engage in a mental imagery exercise skill improvement through learning in therapy (skilt) 10 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ of skill application. the mental imagery exercise is based on a guided mental imagery procedure and has been shown to increase motivation for goal directed behaviors (heise et al., 2022; renner et al., 2019). during the mental imagery procedure, participants are instructed to imagine as vividly as possible and focusing on the positive aspects of the image. the procedure consists of the following steps: 1) imagine the contextual cues (e.g., place, date) of a future or past situation with depressive symptom(s), 2) engaging in multi-sensory imagery of applying the cbt skill in this situation, 3) imaging and experiencing the positive aspects related to successfully applying the cbt skill. all sessions will be videotaped for treatment fidelity checks. research intervision will take place regularly. the agenda for each therapeutic procedure and the list of cbt skills that can be chosen from and practiced in the cbtsap procedures is given in data supplement 1 and 2. figure 3 therapeutic elements per procedure   active control procedure cbt skill acquisition procedure cbt skill acquisition procedure plus mental imagery agenda setting agenda setting agenda setting control component explore relation of recent depressive symptoms with dysfunctional thoughts and/or behaviors active element 1 discuss skill application to target dysfunctional thoughts and/or behaviors active element 2 mental imagery of skill application active element 1 discuss skill application to target dysfunctional thoughts and/or behaviors note. detailed information on the session content can be found in data supplement 1 and 2. instruments an overview of all patient measurements is given in table 1. an overview of all measure­ ments completed by the therapists or third observers can be found in table 2. bruijniks, frank, tuschen-caffier et al. 11 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ ta bl e 1 o ve rv ie w o f p at ie nt in st ru m en ts p er t im e po in t m ea su re m en t i ns tr um en ts ba se lin e in tr od uc ti on se ss io n se ss io n 1 se ss io n 2 se ss io n 3 o ne d ay a ft er se ss io n 3 fo llo w -u p pr im ar y ou tc om es : t he ra py p ro ce ss es cb t s ki lls w ay s of r es po nd in g (w o r) x x be ha vi or al a ct iv at io n fo r d ep re ss io n sc al e – sh or t f or m (b a d ssf ) x x x x x x c og ni tiv e c ha ng e su st ai ne d c ha ng e (c c sc ) x x x x x x id ios yn cra tic th ou gh ts an d b eh av ior s c or e be lie f i nt er vi ew (c bi ) x x x x x x dy sfu nc tio na l t hi nk in g c og ni tio n c he ck lis t ( c c l) x x x re wa rd pr oc ess in g re w ar d pr ob ab ili ty in de x (r pi ) x x x te m po ra l e xp er ie nc e of p le as ur e (t ep s) x x x se co nd ar y ou tc om es : s ym pt om s de pr ess ion be ck d ep re ss io n in ve nt or y ii (b d iii ) x x x x x x sy mp tom s o th er th an de pr ess ion br ie f s ym pt om in ve nt or y (b si ) x x skill improvement through learning in therapy (skilt) 12 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ m ea su re m en t i ns tr um en ts ba se lin e in tr od uc ti on se ss io n se ss io n 1 se ss io n 2 se ss io n 3 o ne d ay a ft er se ss io n 3 fo llo w -u p po te nt ia l m od er at or s: l ea rn in g ca pa ci ty me mo ry fu nc tio ni ng ve rb al w or ki ng m em or y: n -b ac k ta sk x v is ua l w or ki ng m em or y: s in gl e pr ob e de te ct io n ta sk x lo ng -t er m m em or y pa ir ed as so ci at es ta sk x em oti on al bia s fr ee v ie w in g ey etr ac ki ng ta sk x x x o th er m ea su re s re ca ll pa tie nt r ec al l t es t ( pr t ) x x x x x di ag no sti cs sc id -5 -c v x de mo gr ap hi cs x tr ea tm en t e va lu at ion x ma ni pu lat ion ch eck x x x pr oc ed ur e c he ck x ex pe cte d s uc ces s x x n ot e. c bt sa p = c bt s ki ll a cq ui si tio n pr oc ed ur e; m i = m en ta l i m ag er y; s tr uc tu ra l c lin ic al in te rv ie w fo r d sm -v c lin ic al v er si on (s c id -5 -c v ). bruijniks, frank, tuschen-caffier et al. 13 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ table 2 overview of therapist/observer instruments per time point measurement instruments baseline introduction session session 1 session 2 session 3 postprocedure follow-up therapy processes therapist-rated recall x x x manipulation check therapy integrity x protocol deviations x x x primary outcome: therapy processes cbt skills — cbt skill acquisition will be measured in two different ways. first, before and one week after the therapeutic procedure patients will complete the ways of responding (wor; barber & derubeis, 1992). during the wor, cbt skills of the participants are tested by asking them to think about themselves in various situations and to tell what they would think and do in such situations. the wor will reflect the level of cbt skills demonstrated by the patient. patients will receive three scenarios before treatment and three different scenarios after treatment. answers to each scenario will be coded into 25 different categories (more categories per answer possible) and given a rating of the overall quality of the response (i.e., the raters’ judgment on how well the response would be in improving mood or adjusting to the individual’s needs, range = 1 (very negatively) to 7 (very positively)). the total score will be composed of the number of responses on positive categories (responses considered consistent with cbt) minus the number of responses on negative categories (depressotypic statements). interrater reliability showed to be high (ranging from α = .91 to α = .98) and discriminant and convergent validity have been supported (for example: the wor showed no correlation with a measure of self-control, but was correlated to self-report measure of cbt skills) (barber & derubeis, 2001; strunk et al., 2014). second, change in cbt skills during the procedures will be measured using the behavioral activation for depression scale – short form (bads-sf) (ba skills) and cognitive change sustained change (ccsc) (ct skills). the bads-sf consists of nine items, each rated on a 7-point likert scale and internal consistency (α = .81) and construct and predictive validity were supported (for example: the bads-sf was positively related to measures of reward, negatively related to measures of avoidance and predicted time spent in high and low rewarding behavior; manos et al., 2011). an example item from the bads-sf is: ‘there were certain things i needed to do that i didn’t do’. the ccsc consists of 9 items rated on a 7-point likert scale and internal consistency was supported (α = .93) and the scale showed convergent and discriminant validity by showing a relation with a self-report scale of cbt skills and no relation with a measure of attributional styles (schmidt et al., 2019). an example item from the ccsc is: ‘i noticed myself thinking less negatively.’ skill improvement through learning in therapy (skilt) 14 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ idiosyncratic thoughts and behaviors — idiosyncratic thoughts and behaviors will be measured with the core belief interview (cbi; mcbride et al., 2007). this interview will be completed by the therapist during the introduction session. together the therapist and patient will form an idiosyncratic top three of dysfunctional thoughts and top three of dysfunctional behaviors. note that the behaviors can both exist of the presence of un­ helpful behaviors or the absence of rewarding behaviors. based on the identified beliefs and behaviors, six idiosyncratic visual analogue scales (vas) (0-100) will be constructed for each patient (i.e., three dysfunctional beliefs, three dysfunctional behaviors). for the dysfunctional beliefs, credibility of the beliefs and strength of related emotions will be rated. presence, reward and pleasure related to the behaviors will be measured. the cbi has been used successfully before to establish idiosyncratic dysfunctional thoughts (bruijniks, los, & huibers, 2020; renner et al., 2018). the exact items of the cbi are given in data supplement 3. general dysfunctional thinking — general dysfunctional thinking will be measured using the cognition checklist (ccl; taylor et al., 1997). the ccl consists of 26 items rated on a 5-point likert scale and can be divided into two subscale measuring dysfunc­ tional thoughts related to depression versus anxiety. internal consistency (ranging from α = .91 to α = .93) and validity was supported in an outpatient sample (i.e. the depression subscale showed a higher relation to other depression measures compared to the anxiety subscale, and the same was shown in the reverse direction; steer et al., 1994). an example item of the ccl is: ‘when i am with a friend i think: i’ll never be as good as other people are.’ reward processing — reward processing will be measured using the reward probabil­ ity index (rpi; carvalho et al., 2011) and the temporal experience of pleasure scale (teps; gard et al., 2006). the rpi is a 20-item self-report instrument that measures the presence of environmental reward, while the teps is an 18-item self-report instrument that measures the ability to experience pleasure. reliability (rpi: α = .93, teps: α = .75) and discriminant and convergent validity have been supported for both instruments (for example: the rpi was related to another measures of reward, but not to measures of anxiety and support, and was related to experiencing rewarding behavior; the teps was relatable but also distinguishable from other measures of motivation and pleasure; carvalho et al., 2011; gard et al., 2006; simon et al., 2018). an example item of the rpi is: ‘i have many interests that bring me pleasure.’ (rpi). an example item of the teps is: ‘i enjoy taking a deep breath of fresh air when i walk outside’. secondary outcome: psychological symptoms depression — depression will be measured with the beck depression inventory-ii (bdiii; beck et al., 1996). the bdi-ii is a 21-item self-report instrument assessing depressive bruijniks, frank, tuschen-caffier et al. 15 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ symptoms during the last two weeks. the items are rated from 0 to 3, higher scores representing more symptom severity. a score 0–13 indicates minimal depression, 14–19 mild depression, 20–28 moderate depression and 29–63 severe depression. reliability and validity have been supported (i.e., test retest reliability between .73-.96, α = .85, convergent and discriminant validity; beck et al., 1988; wang & gorenstein, 2013). for the purpose of this study, the bdi-ii will be adjusted to assess depressive symptoms during the past week. general psychological distress — additional psychological symptoms will be meas­ ured using the brief symptom inventory (bsi; (derogatis & melisaratos, 1983). the bsi consist of 53 items rated on a 0 (not at all) to 4 (extremely) scale and includes the follow­ ing subscales: somatization, obsessives-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. reliability and validity of the scale have been supported (i.e., cronbach’s alpha of .85, concurrent and divergent validity was supported; de beurs & zitman, 2006; geisheim et al., 2002). potential moderators: learning capacity memory functioning: verbal working memory — verbal working memory will be measured using the n-back task (braver et al., 1997). the n-back task measures verbal working memory. during the n-back task participants will be asked if a letter on the screen matches a letter previously (1-back, 2back, 3-back) presented for 500 ms with an interval of 2000 ms. wm load increases as the task progresses from 1-back to 3-back. accuracy of responses (total of correct hits (% correctly identified n-backs) and correct no hits (% correctly identified no presence of a n-back)) are measured and will be used as an outcome measure. the n-back task has been considered as a valid measure of working memory (cronbach’s alpha = .92; schmiedek et al., 2014; wilhelm et al., 2013). memory functioning: visual working memory — visual working memory will be measured using the probe change detection task (pcdt; dai et al., 2019). the pcdt consists of the following steps: 1. participants are instructed by an arrow on their screen to focus on the left or right side of the screen (200 ms), 2. after a short break (300 ms) the screen is filled with colored squares on a gray background (100 ms). the squares are equally distributed between the left and right side of the screen. participants are instructed to remember only the squares on the side that was instructed under step 1, 3. after a second blank screen (900 ms), participants see again a field with colored squares (750 ms) and have to indicate whether the squares on the side of the screen are the same as under step 2. set sizes of the trial different between 8 to 12 colored squares in total. participants will receive a total of 300 trials. reliability and validity has been supported (i.e., test retest reliability between .52-.75; dai et al., 2019). skill improvement through learning in therapy (skilt) 16 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ memory functioning: long-term memory — long-term memory will be measured using the paired associates task (pat; unsworth et al., 2009). long-term memory can also be considered as 'secondary memory', i.e., the part of memory where information is stored when the primary memory, where new information is temporary maintained is full. during the pat, participants will be given three lists of 10 non-semantically related word pairs. all words are common nouns, and the word pairs will be presented vertically for 2 sec each. participants will be told that the cue would always be the word on top and that the target would be on bottom. after the presentation of the last word (which takes 20 seconds), participants will see the cue word and "???" in place of the target word. participants will be instructed to type in the target word from the current list that matches the cue. cues will be randomly mixed so that the corresponding target words are not recalled in the same order as that in which they had been presented (i.e., this means that the time between encoding and recall varies and lies between the 2 and 70 seconds). participants will have 5 sec to type in the corresponding word. a participant’s score is the proportion of items recalled correctly. words will be taken from the toronto word pool (friendly et al., 1982). the paired associates task has been considered a valid task of long-term memory (unsworth et al., 2009; wilhelm et al., 2013). emotional bias: sustained selective attention to emotional stimuli — selective attention will be measured using a free-viewing eye-tracking task (klawohn et al., 2020). participants will view two blocks of neutral and happy and neutral and sad faces in counterbalanced order while their gaze patterns are concurrently recorded as index of selective spatial attention. each block will take 30 trials that last 6 seconds. each trial will show 16 different faces and participants will be asked to freely view the trials. partic­ ipants’ gaze location and duration will be assessed using eyelink eye-tracker software (https://www.sr-research.com/). the present study will use the exact same task as was recently used and validated by klawohn and colleagues (2020). to maximize reliability of the task (macleod et al., 2019), it will be completed twice at baseline. to further investigate the predictive value of the task, an additional post procedure measurement (i.e., at one week follow-up) will be completed. other measures recall — patient recall will be measured using the patient recall test (prt; lee & harvey, 2015). the prt measures recall of the previous session content. following procedures of lee & harvey, the patient will be given 10 minutes to remember as much treatment points from the previous session as possible (past session recall). in addition, cumulative recall (i.e., what is remembered from all sessions) will be measured at the follow-up session. treatment points will be defined as remembering insights, skills and strategies of the cbt model. scores will be rated by two independent raters, inconsisten­ cies in scoring will be resolved by discussion. interrater reliability between raters will bruijniks, frank, tuschen-caffier et al. 17 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.sr-research.com/ https://www.psychopen.eu/ be computed. the prt showed good interrater reliability in previous studies (icc = .92; dong, zhao, et al., 2017). in addition to recall of the patient, therapists are also asked to give a rating of recall on a 1-10 vas scale (1 = patient has no memory of the previous session, 10 = patient remembers everything perfectly). manipulation check — to check if patients in the cbt skill acquisition + mental imagery condition engaged in vivid mental imagery, they will be asked to note how vivid the imagery of the skills practiced in this session was on a scale from 1 (not vivid at all) to 10 (extremely vivid). to check and potentially control for self-efficacy, motivation and anticipated reward in the analyses, participants in all conditions will complete questions on a 0-10 scale and asked to rate based on today's session how capable they feel in coping with their dysfunctional beliefs and behaviors, their motivation to use the content of today's session to do something different in the upcoming week and their anticipated reward of doing something different in the upcoming week based on today's session. in addition, expected success of the skilt study sessions in reducing depressive symptoms will be asked at baseline and after the first session. at the end of the study, patients will be asked to rate on a 0-10 scale to what degree the received sessions contributed to an improvement in depressive symptoms. adherence — protocol deviations. after each session, the therapist will complete a short questionnaire to check 1. how many skills and application of these skills were discussed, 2. how many mental imagery exercises were conducted, and 3. ask for the presence of deviations to the protocol in that session. procedure integrity. to ensure the procedures differ in the presence of active com­ ponents (i.e., cbt skill application and use of mental imagery) all sessions will be video-taped. a questionnaire will be developed that measures the presence and duration of the different components in the therapeutic procedures. this questionnaire will be completed by two independent raters. diagnosis — the scid-5-cv (first et al., 2019) will be completed by phone during the recruitment phase. data analyses all statistical tests will be two-tailed (significance level alpha .05). descriptives (means, standard deviations) for all measures will be provided for each condition. all analyses will be intention-to-treat and missing data will not be imputed. main analyses the main analyses will be conducted in stata. first, to test the direct effects of the different procedures on change in therapy processes and symptoms, differences on the skill improvement through learning in therapy (skilt) 18 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ primary and secondary outcomes between conditions (cbtsap versus active control; cbtsap versus cbtsap + mental imagery; active control versus cbtsap + mental imagery) will be tested using multilevel analysis with maximum likelihood estimation (measurements [level 1] nested within patients [level 2] nested within therapists [level 3]). because the wor is only measured at two time points, differences between condi­ tions on the wor will be tested using a repeated measures anova. second, to test whether the effect of the procedures is moderated by individual differences in learning capacity, learning capacity will be added as a moderator in the model. moderation will be tested by adding learning capacity as a main factor and the interaction between learning capacity and condition to the multilevel regression model. for the wor, the interaction will be added to the repeated measures anova. moderation of learning capacity will be tested separately for memory functioning and emotional bias. memory functioning will be tested separately for each component of memory functioning (i.e., verbal working memory, visual working memory, long-term memory), while controlling for type i error (p < .016). mediation analyses the potential role of therapy processes and session recall as mechanisms of change will be tested by testing mediation within latent difference score (lds) models. in separate lds models (i.e., a different model for each mediator), we will test the relation of the procedure (cbtsap's versus active control) on subsequent change in the mediator (i.e., therapy processes: cbt skills, idiosyncratic dysfunctional thinking and behaviors, gener­ al dysfunctional thinking, reward processing, and session recall) on subsequent change in the outcome (depressive symptoms). note that we will merge the two cbtsap's to test mediation of the active control versus the cbtsap's. lds models allow tests of mediation, include the temporality of the effects and are therefore capable of testing potential reverse causality (grimm et al., 2017; mcardle, 2009). discussion we presented a protocol for a randomized controlled study that isolates an often-used therapeutic procedure focused on the acquisition of cognitive behavioral therapy skills (cbtsap) to test its causal effects on psychotherapy outcomes. the cbtsap will be compared to an active control condition and cbtsap with mental imagery. we hypothe­ sized that, compared to an active control procedure, the cbtsap's would lead to direct improvement in cbt skills, related therapy processes (dysfunctional thinking and reward processing) and subsequent reduction of depressive symptoms. in addition, we suggested that individual differences in cognitive and neurological impairments (referred to as learning capacity) in depressed patients may interfere with the successful acquisition of bruijniks, frank, tuschen-caffier et al. 19 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ cbt skills and that especially the patients with low learning capacity will benefit from added mental imagery to the cbtsap. one major strength of the present study is that it will be the first to investigate the direct effects of an isolated procedure focused on the acquisition of cbt skills in a depressed sample. although the potential of investigating isolated procedures has been recognized (craske, 2016; macleod & grafton, 2016; teasdale & fennell, 1982), experimental studies that isolate therapeutic procedures in the field of depression have been scarce so far (bruijniks et al., 2018). in addition, by performing an experiment that informs us about which therapeutic procedure works best for whom, the proposed study taps into the field of personalized medicine (i.e., optimizing the effects of treatment by matching the treatment to the patient (cohen & derubeis, 2018)). by increasing insight in the direct effects of therapeutic procedures on how and for whom they reduce depres­ sion, the present study will not only contribute to the research field of personalized medicine, but has the potential to inform and improve clinical practice (i.e., informing on what technique might be helpful for whom). this study is also the first that elaborately assesses learning capacity at baseline to investigate the moderating role of learning capacity on the effects of isolated cbt proce­ dures. earlier studies have indicated that depressed patients with more emotional bias and more memory functioning might show better improvement during cbt (bruijniks, derubeis, et al., 2019), but these studies mostly investigated the role of learning ca­ pacity on the complete treatment package (i.e., a full cbt that includes multiple cbt procedures), primarily used neurobiological measures or where conducted in an elderly depressed population. the present study will be able to inform on the specific role of learning capacity in a key therapeutic procedure, the acquisition of cbt skills, in cbt for depression. in addition, a better understanding of the role of learning capacity and a cbt skill acquisition procedure on cbt outcomes might open up new avenues for future research on the role of skill acquisition and learning capacity in psychotherapy for depression in general. another strength of the study is the repeated measurement of therapy processes, which will allow us to investigate how learning capacity affects the hypothesized mechanisms underlying the success of a cbt skill acquisition procedure and also how the cbtsap might lead to reduction of depressive symptoms through these mechanisms. a final strength of the present study is that it includes a multimodal assessment, using not only self-report instruments but also a cbt skill test, idiosyncratic measures of therapy process change, behavioral tasks and eye-tracking. a limitation of the present study is that it is powered to find medium to large effects and will be underpowered to find small effects between the three treatment conditions. in conclusion, while there are a number of effective evidenced based treatments for depression, many patients do not improve in treatment and progress in treatment innovation has been slow. one way forward is to isolate specific therapeutic procedures and test their direct effects on therapy processes and outcomes. based on this experimen­ skill improvement through learning in therapy (skilt) 20 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ tal research framework we will conduct a randomized clinical study testing the direct effects of a key cbt procedure, cbt-skills, with or without a cognitive support strategy compared to an active control condition. the results of this study will contribute to a better understanding of individual differences in the effects of key cbt procedures. funding: this project is funded by a rubicon research grant granted to s. bruijniks by the dutch research council social sciences and humanities from nwo. fr and jw are supported by a sofja kovalevskaja award from the alexander von humboldt foundation and the german federal ministry for education and research. acknowledgments: the authors thank anna boehncke, stephanie heinrichs, max heise, capucine john, lisa krause, janina reus, svenja schmedding, adriana soyoung-steinborn and dr. lena zirn for their (ongoing) contribution to the study. competing interests: the authors have declared that no competing interests exist. author contributions: sb designed the study and wrote the manuscript. uf, btc, fr and sb are involved in the coordination of the recruitment of patients and data collection. jw is involved as an eye-tracking expert. all authors read, contributed to, and approved the final manuscript. twitter accounts: @sbruijniks data availability: data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. supplementary materials the supplementary materials contain more exact information on the different therapeutic proce­ dures and the outcomes of the core belief interview as these are used in the study (for access see index of supplementary materials below). index of supplementary materials bruijniks, s. j. e., frank, u., tuschen-caffier, b., werthmann, j., & renner, f. (2023). supplementary materials to "skill improvement through learning in therapy (skilt): a study protocol for a randomized trial testing the direct effects of cognitive behavioral therapy skill acquisition and role of learning capacity in depression" [additional information]. psychopen gold. https://doi.org/10.23668/psycharchives.12574 bruijniks, frank, tuschen-caffier et al. 21 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://twitter.com/sbruijniks https://doi.org/10.23668/psycharchives.12574 https://www.psychopen.eu/ references aarts, e., verhage, m., veenvliet, j. v., dolan, c. v., & van der sluis, s. (2014). a solution to dependency: using multilevel analysis to accommodate nested data. nature neuroscience, 17(4), 491–496. https://doi.org/10.1038/nn.3648 adler, a. d., strunk, d. r., & fazio, r. h. 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belief interview cbt – cognitive behavioral therapy cbtsap – cognitive behavioral therapy skill acquisition procedure ccsc – cognitive change sustained change ccl – cognition checklist pat – paired associates task pcdt – probe change detection task prt – patient recall test rpi – reward probability index lds – latent difference scores scid-5-cv – structural clinical interview for dsm-v teps – temporal experience of pleasure scale vas – visual analogue scale wor – ways of responding clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. skill improvement through learning in therapy (skilt) 30 clinical psychology in europe 2023, vol. 5(1), article e8475 https://doi.org/10.32872/cpe.8475 https://www.psychopen.eu/ skill improvement through learning in therapy (skilt) background method design participants sample size recruitment randomization and procedure therapists introduction session therapeutic procedures instruments data analyses discussion (additional information) funding acknowledgments competing interests author contributions twitter accounts data availability supplementary materials references appendix: list of abbreviations open-label placebo effects on psychological and physical well-being: a conceptual replication study research articles open-label placebo effects on psychological and physical well-being: a conceptual replication study anne-kathrin bräscher 1 , ioanna-evangelia ferti 1, michael witthöft 1 [1] department of clinical psychology, psychotherapy, and experimental psychopathology, johannes gutenberg university of mainz, mainz, germany. clinical psychology in europe, 2022, vol. 4(4), article e7679, https://doi.org/10.32872/cpe.7679 received: 2021-10-18 • accepted: 2022-01-19 • published (vor): 2022-12-22 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: anne-kathrin bräscher, department for clinical psychology, psychotherapy, and experimental psychopathology, johannes gutenberg-university of mainz, wallstr. 3, 55099 mainz, germany. phone: +49 6131 3939209. e-mail: abraesch@uni-mainz.de supplementary materials: materials [see index of supplementary materials] abstract background: contrary to traditional placebos, open-label placebos (olp) abstain from deception, i.e., participants are openly informed to receive an inert substance. studies in clinical and healthy samples evidence the efficacy of olps. this study aims to conceptually replicate and expand findings of a recent olp study in healthy participants while implementing a within-subject design and daily instead of retrospective assessments. additionally, the effect of a brand name on the medicine container is tested and possible predictors of the olp effects are explored. method: healthy participants (n = 75) received olp and no placebo for 5 days each (randomized sequence) and answered daily questionnaires on sleep quality, bodily symptoms, mental wellbeing, and psychological distress. the medicine container of half the participants had a brand name, the remaining did not. different personality traits and situational factors were assessed. results: mental and physical well-being did not differ between olp and control phase, i.e., overall, no olp effect emerged. contrast analysis indicated that an olp effect emerged for sleep quality and psychological distress when no brand name was present. further, an olp effect emerged in persons with higher expectations for bodily symptoms (r = .23, p = .046) and psychological distress (r = .24, p = .037). conclusions: methodological differences to the original study are discussed as an explanation for the failure to induce overall olp effects. future studies should continue to replicate previous findings and determine the exact conditions of successful implementation of olp effects in healthy as well as clinical samples. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7679&domain=pdf&date_stamp=2022-12-22 https://orcid.org/0000-0002-2621-5689 https://orcid.org/0000-0002-4928-4222 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords open-label placebo (olp) effect, expectation, brand name, personality traits, healthy sample highlights • the attempt to replicate an open-label placebo effect on well-being in healthy participants failed. • possibly, differences in the design and time-points of assessments explain the negative findings. • presence of a brand name on the medicine container and possible moderators were tested. due to deception, the application of traditional placebos (i.e., “interventions that, owing to their intrinsic properties, are ineffective for a particular condition or symptom(s), but which may be (…) administered (…) with the aim of eliciting placebo effects”, p. 18, blease & annoni, 2019) in patient care can go along with ethical and legal problems as well as with a loss of trust in the therapist-patient relationship (bundesärztekammer, 2010; miller et al., 2005). open-label placebos (olp) might solve these issues since patients are openly informed about the placebo treatment, rendering deception unneces­ sary. numerous studies evidence the efficacy of olp in different clinical contexts and two meta-analyses indicate large effect sizes (charlesworth et al., 2017; von wernsdorff et al., 2021). studies in healthy participants have been conducted less frequently, although they can 1) help to shed light on underlying mechanisms of olp effects that remain unclear to this point and 2) target primary endpoints as the improvement of well-being and physical or cognitive performance (kleine-borgmann et al., 2021; saito et al., 2020). along these lines, some studies in healthy samples explored olp effects in experimental­ ly induced pain (disley et al., 2021; kube et al., 2020; locher et al., 2017; schafer et al., 2015; schneider et al., 2020; wei et al., 2018). few studies focused on areas other than pain perception (el brihi et al., 2019; guevarra et al., 2020; kleine-borgmann et al., 2021). especially, el brihi and colleagues (2019) showed that the intake of placebo pills on five subsequent days compared to not taking placebo pills can reduce psychological distress and bodily symptoms and increase mental well-being and sleep quality in healthy partici­ pants. while the dose (i.e., taking one vs. four pills each day) did not influence the olp effects, positive expectations and adherence were significant predictors. the primary aim of the present study was to conceptually replicate the findings of el brihi et al. (2019) on physical and mental well-being in healthy participants. as a stricter test of the olp effect, a within-subject design was implemented (i.e., all participants pass through a control phase without taking placebos and a placebo phase), since a control group that does not receive olps might be disappointed and thus artificially boost olp open-label placebo effects on well-being 2 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://www.psychopen.eu/ effects. further, instead of a singular retrospective assessment of relevant constructs, assessments were collected daily to avoid potential memory biases. knowledge on situational and personality factors that moderate olp effects is scarce. dispositional optimism has shown to be associated with deceptive but not open-label placebo effects (locher et al., 2019). yet, studies on the impact of personality factors are rare even in the investigation of deceptive placebo effects, and results tend to be inconsistent (kern et al., 2020). beyond that, evidence shows the influence of aspects like price, appearance, branding, and labeling on deceptive placebos (meissner & linde, 2018), but studies in this realm focusing on olp effects are missing. expanding the conceptual replication, we aimed to additionally explore whether the presence of a brand name on the medicine container would influence the olp effect, as suggested by el brihi and colleagues (2019), who did not vary the brand name (“placibax”) in the original study. we hypothesized that healthy participants would show olp effects in physical and mental well-being, which would be further enhanced when the medicine container is equipped with a brand name instead of no label. further, we exploratively assessed a range of different psychological and situational factors to potentially identify predictors of the olp effect. method sample participants were recruited by notes on campus, social media, and e-mail distribution lists, already indicating that the study investigated the influence of placebos on well-be­ ing. in total n = 75 participants (n = 49 females, 65.3%; m = 32.00, sd = 12.75 years) were included in the study (for exclusion criteria and further information cf. appendix a, supplementary materials). all participants gave their written informed consent before commencing the study. all procedures were approved by the local ethics committee (2019-jgu-psychek-001). experimental procedure in the first part of the study, participants came to the lab and filled in several psycho­ metric questionnaires and a questionnaire on demographic information via the online platform soscisurvey (leiner, 2018). suggestibility was assessed with the creative imagi­ nation scale (cf. below). subsequently, participants watched a 10-minute animated video (generated with videoscribe; cf. appendix b, supplementary materials, for the narrative), addressing the four key aspects that are always communicated in olp studies (kaptchuk, 2018): remove the stigma of placebo effects; automatic nature of placebo responses; no requirement to believe; taking the pills is critical. the video also stressed that studies have shown beneficial effects on psychological and bodily well-being in healthy persons. bräscher, ferti, & witthöft 3 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://www.psychopen.eu/ after that, participant’s questions were answered and expected effects on sleep quality, bodily symptoms, mental well-being, and psychological distress were assessed using a scale from 0 (“i do not expect any effect at all”) to 10 (“i expect a very strong effect”), respectively. finally, participants received a closed envelope containing an amber glass with five placebo pills. half of the amber glasses (n = 37) had a label inscribed with “pharmacebo”, the other half of the amber glasses (n = 38) did not have a label (random­ ized; cf. figure 1). the experimenter was blind to the kind of amber glass, which the participant received. further, participants were informed when they should start taking the placebo pills. figure 1 picture of the medicine container note. medicine container with and without a label (left) and display of the label with the brand name (“pharmacebo”), including information on the size and weight of the pills as well as the expiration date. the second part of the study always started on the monday following the lab appoint­ ment, to avoid interference with weekend days. participants either started with the placebo phase and were instructed to take a placebo every morning for five consecutive days (monday to friday) and then switch to the control phase (again from monday to friday), or they started with the control phase and switched to the placebo phase the week after. the order of placebo and control phase was randomized (random.org). during those ten days, participants received an e-mail every evening containing the link to questionnaires they were asked to fill in to assess the olp effects as well as a question on adherence (“did you take the placebo pill at least 6 hours ago?” yes/no). on the last day of the placebo phase, they were additionally asked how many placebo pills they had to spare. further, on the day before the start of the placebo phase, the expected effects on all outcome measures were assessed again, using the expectancy scale. open-label placebo effects on well-being 4 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://www.psychopen.eu/ outcome measures the following questionnaires were filled in daily. the instructions were changed where necessary to refer to the current day (instead of a longer period). warwick-edinburgh mental well-being scale the questionnaire (tennant et al., 2007; german version, lang & bachinger, 2017) con­ tains 14 items and assesses general mental well-being (range [14-70]). it has shown good internal consistency (α = .89 to .91), content, convergent, and discriminant validity. the retest reliability is high (r = 0.83, tennant et al., 2007). the german version has shown good validity and reliability, as well (lang & bachinger, 2017). internal consistency in the current study ranged between α = .91 and α = .96. profile of mood state (poms) the questionnaire (mcnair et al., 1971; german short version, dalbert, 1992) assesses the current mood through 19 items. within the present work, the subscales sorrow, hope­ lessness, fatigue, and positive mood (reversely coded) are summoned to build the scale psychological distress (16 items; range [16-112]). the internal consistency is high and ranges between α = .83 and .94 for the different subscales (dalbert, 1992). the internal consistency of the scale psychological distress in the current study ranged between α = .93 and α = .96. subjective health complaints (shc) the shc lists 29 bodily symptoms, which can be rated on an intensity scale from 0 (not at all) to 3 (severe) (rang [0-87]). it has acceptable to good internal consistency (α = .75 to .82, eriksen et al., 1999) and is associated with healthcare utilization (filipkowski et al., 2010). the items have been translated by the authors. internal consistency in the current study ranged between α = .70 and α = .80. groningen sleep quality scale (gsqs) this questionnaire (leppämäki et al., 2003; mulder-hajonides van der meulen et al., 1980) contains 15 items, which can be answered with yes and no, assessing sleep quality of the previous night. larger scores indicate poorer sleep [range 0-14]. internal consis­ tency was α = .88 in a sample of depressed patients (current study: α between .15 and .55). measures of psychological factors during the lab appointment, participants filled in the following questionnaires to as­ sess different traits and psychological factors: state-trait inventory (stai-t), neo-five factor inventory, somatosensory amplification scale, patient health questionnaire-15 bräscher, ferti, & witthöft 5 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://www.psychopen.eu/ (phq-15), questionnaire on attitudes towards complementary medical treatment (qa­ cam). further information on the questionnaires can be found in appendix c, supplementary materials. creative imagination scale (cis) the cis (wilson & barber, 1978) assesses suggestibility using standardized descriptions of ten different situations on visual, auditive, kinesthetic, and olfactory perceptions. while the experimenter reads out the descriptions, the participant is asked to imagine the situation and afterward evaluate inasmuch their imagination matched the real expe­ rience using one item for each of the ten situations. the internal consistency in the current study was α = .89. statistical analysis changes between the first and second assessment in expected olp effects were tested using the wilcoxon-signed-rank-test due to non-normally distributed data. considering sleep quality, bodily symptoms, mental well-being, and psychological distress, respective­ ly, as outcome variables, mixed 2x5x2-anovas were performed to assess the olp-effect (within-factor “condition”) and the influence of time (within-factor “day”) as well as brand name (between-factor “brand name”). since the order of the phases (placebo intake or control phase in week one) did not significantly influence the results, this factor was not included in the reported analyses. holm-corrected post hoc-tests were applied were appropriate. contrast analyses were calculated to test the hypothesis that olp effects were larger with a brand name. as measures of effect size, η2 (η2 ≥ 0.01 small; η2 ≥ 0.06 medium; η2 ≥ 0.14 large) and cohen’s d (d ≥ 0.30 small, d ≥ 0.50 medium, d ≥ 0.80 large) are specified. as explorative analyses, to identify potential predictors of the olp effect, pearson correlations between psychological factors and the outcome measures (i.e., the difference between the average score during placebo and control phase) were calculated (r ≥ |.10| small; r ≥ |.30| medium, r ≥ |.50| large). the alpha level was set to 5%. analyses were calculated with jasp version 0.14.1 (jasp team, 2020). results expectation and adherence adherence (i.e., intake of the placebos as instructed) was excellent. in only two instances, participants reported to have forgotten the intake once, which was confirmed by the question at the end of the olp phase (“how many pills do you have to spare?”). expected effects of the olp effects were in the medium to low range of the scale and significantly decreased from the first to the second assessment (see table 1). open-label placebo effects on well-being 6 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://www.psychopen.eu/ table 1 expected open-label placebo effects outcome expectation after manipulation expectation before placebo phase test statistic for differences between both assessments m sd m sd w p rrb sleep quality 3.41 2.99 2.82 2.85 427.5 .040 0.33 bodily symptoms 3.73 2.95 2.88 2.76 928.00 < .001 0.58 mental well-being 4.41 3.12 3.34 2.95 1039.50 < .001 0.63 psychological distress 3.77 3.01 2.86 2.84 874.00 .008 0.43 note. expectations assessed at the first assessment directly after the open-label placebo manipulation and at the second assessment the day before the first intake of the open-label placebo and difference test. open-label placebo effects concerning sleep quality, placebo and control week did not differ significantly and this did not change over the five days, i.e., overall, no olp effect emerged (see table 2). neither the main effect of day nor that of brand name were significant. a significant interaction effect between condition and brand name emerged (see figure 2), but post hoc-tests were non-significant (all ps > .190). contrary to the hypothesis, the contrast analysis showed that the difference between scores of the placebo versus the no treat­ ment week was larger when no brand name was present, t(73) = -2.42, p = .009, indicating that a medicine container without a brand label led to an olp effect but a medicine container without a brand label did not. with regards to bodily symptoms, placebo and control week did not differ significant­ ly (see table 2). a significant interaction effect between condition and day emerged (see figure 2), but post hoc-tests were non-significant (all p > .240). the five days differed significantly for reported bodily symptoms and post-hoc tests indicated that bodily symptoms decreased when comparing day 1 to day 5, t(74) = 4.11, p < .001, d = 0.48, remaining post hoc-tests all p > .056. bodily symptoms did not differ significantly depending on the presence of a brand name and no significant interaction emerged between brand name and condition. the contrast analysis did not point to a differential effect depending on the presence of a brand name, t(73) = -0.03, p = .490. placebo and control week did not differ significantly concerning mental well-being (see table 1, figure 2) and this did not change over the five days, i.e., no overall olp effect emerged. neither the main effect of day nor of label, nor the interaction effect between label and condition reached significance. the contrast analysis did not point to a differential effect depending on the presence of a brand name, t(73) = -0.94, p = .175. for psychological distress, similarly, placebo and control week did not differ signifi­ cantly (see table 2, figure 2) and no significant interaction effect between condition and day emerged. no main effect of day and label reached significance. the interaction bräscher, ferti, & witthöft 7 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://www.psychopen.eu/ effect between brand name and condition just reached significance, but post hoc-tests were non-significant (all ps > .561). contrary to the hypothesis, the contrast analysis indicated that the difference between scores of the placebo versus the no treatment week was larger without the brand name, t(73) = -1.99, p = .025, indicating that a medicine container without a brand label led to an olp effect but a medicine container without a brand label did not. figure 2 open-label placebo effects note. average scores of psychological distress, mental well-being, bodily symptoms, and sleep quality across five days each in the olp (white) and control condition (black). error bars represent the standard error. open-label placebo effects on well-being 8 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://www.psychopen.eu/ identification of predictors expectation assessed the day before the placebo intake (2nd assessment) significantly cor­ related with the difference between scores taken in the placebo versus the no treatment week for the outcome measures bodily symptoms (r = .23, p = .046) and psychological distress (r = .24, p = .037), respectively. the effect sizes of the remaining correlations with other psychological factors were partly in the small range but did not reach significance (suppl. table 1 in appendix c, supplementary materials). table 2 results of anovas for the respective outcome measures outcome / factor df f p effect size η2 sleep quality condition 1 0.43 .512 < .001 day of the week 4 2.18 .071 .010 condition x day 3.48 2.32 .066 .008 label 1 0.95 .334 .004 condition x label 1 5.85 .018 .007 bodily symptoms condition 1 1.60 .210 .002 day of the week 3.46 4.61 .002 .006 condition x day 3.32 2.68 .042 .004 label 1 < 0.01 .979 < .001 condition x label 1 < 0.01 .979 < .001 mental well-being condition 1 0.13 .716 < .001 day of the week 3.27 1.21 .306 .002 condition x day 3.68 0.99 .408 .001 label 1 0.10 .749 .001 condition x label 1 0.89 .349 < .001 psychological distress condition 1 0.16 .693 < .001 day of the week 3.51 2.50 .051 .003 condition x day 3.68 0.71 .572 .001 label 1 0.01 .910 .001 condition x label 1 3.96 .050 .001 bräscher, ferti, & witthöft 9 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://www.psychopen.eu/ discussion this study aimed to conceptually replicate findings of a previous experiment (el brihi et al., 2019) that demonstrated small to medium olp effects (d = 0.28-0.50) on mental and physical well-being in healthy participants. using a within-subject design and daily assessed sleep quality, bodily symptoms, mental well-being, and psychological distress, overall no significant olp effect emerged in the present study. other than hypothesized, a brand name on the medicine container hindered olp effects in sleep quality and psychological distress. explorative analyses hinted at expectation as a possible predictor of the olp effects in bodily symptoms and psychological distress. several reasons might explain the failure to replicate the results of the original study. general issues refer to possible differences in the populations investigated (e.g., language, country, ethnicity, etc.). it is also possible that floor or ceiling effects prevented the development of olp effects in this healthy sample, yet a comparison to normative values is hardly possible due to altered instructions (referring to the last day instead or a week or else). further, the present study partly used other outcome measures than the original study (poms, gsqs). the two most important differences to the original study refer to the design of the studies and the time points of assessment. employing a within-subjects design has the advantage that every participant serves as their control group, i.e., no random differences will confound the effects of interest. this is especially important since concerns regarding the control group in olp studies have been voiced (blease et al., 2020). it can be speculated that the control group in the original study was less motivated or did not pay as much attention to the symptoms in question as the group that received placebos because they were neither reminded to attend to possible effects by taking a pill nor by filling in daily questionnaires, which might have artificially boosted olp effects. regarding the time points of assessment, the present study assessed symptoms daily, while the original study assessed symptoms once after five days of placebo intake or control phase. this retrospective assessment might have led to an overestimated olp effect due to memory biases (ebner-priemer & trull, 2009). another potential reason for the non-existent olp effects might be the mode of presen­ tation of the information concerning olp effects to the participants. to standardize this aspect of the study, participants watched an animated video that conveyed the relevant information. in other olp studies, this information is given in a conversation between the experimenter and the participant. research indicates that (open-label) placebo effects benefit from trustworthy, friendly and empathetic treatment providers (gaab et al., 2019; kube et al., 2021). possibly, the therapeutic alliance between treatment provider and participant was adversely affected by implementation of the video instead of personal communication in the present study. feasibly, participants in our study were not as attentive or engaged or the video just was less convincing than a personal conversation. along these lines, expected olp effects were somewhat lower in our study (range of m = 3.4 and m = 4.4) compared to the original study (m = 4.9). interestingly, a recent study open-label placebo effects on well-being 10 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://www.psychopen.eu/ (kube et al., 2021) failed to find olp effects in allergic rhinitis when information on olp was conveyed in an online setting. this result emphasizes the importance of the mode of presentation. although many previous studies evidence olp effects in clinical (carvalho et al., 2016; charlesworth et al., 2017; von wernsdorff et al., 2021) as well as healthy samples, including those on mental and physical well-being (el brihi et al., 2019; guevarra et al., 2020; kleine-borgmann et al., 2021), some studies were only partly successful (context of itch, meeuwis et al., 2019; meeuwis et al., 2018) or failed to induce olp effects, e.g., in chronic back pain (ikemoto et al., 2020), nausea (barnes et al., 2019), wound healing (mathur et al., 2018), and allergic rhinitis (kube et al., 2021). future studies should find out, whether olp effects can be reliably induced in healthy participants and which conditions are key. we hypothesized that a brand name on the medicine container would increase the olp effect because usually medication is labeled and in deceptive placebos, brand names lead to larger effects (meissner & linde, 2018). however, contrary to that, the difference in scores between placebo and control week tended to be increased when no brand name was present for two of the outcome measures, namely psychological distress and sleep quality, while the presence of a brand name did not influence the effects of the two re­ maining outcome measures. possibly, when reading the label “pharmacebo”, participants were reminded that they are about to take a placebo, which might have counteracted conditioned effects based on previous experiences with medication. it would be worth­ while to replicate the present findings and to investigate the effect of a brand name that does not hint at the placebo context in future studies. several possible predictors of olp effects were explored. suggestibility, neuroticism, extraversion, openness, conscientiousness, habitual anxiety, somatization, somatosensory amplification, and a positive attitude towards cam or conventional medicine were not significantly associated with the difference in scores of the placebo and control week. these findings are similar to those of a study on experimental heat pain in healthy participants that did not find associations of the olp effect with optimism, pessimism, openness, locus of control, and positive attitudes towards cam (locher et al., 2019). interestingly, relevant traits in the context of deceptive placebo effects do not necessarily play a role in olp effects (cf. optimism, locher et al., 2019). thus, more research is needed to identify facilitating personality traits of olp effects, should they exist. in line with our assumptions, expectations were a significant predictor for the olp effects in bodily symptoms and psychological distress. results of previous studies concerning the role of expectations are inconsistent; whereas some studies showed a relationship between olp effect and measures of expectation (el brihi et al., 2019, not for sleep quality, however; kleine-borgmann et al., 2021) other did not (guevarra et al., 2020; kube et al., 2021). possibly, the time point of assessment of the expectations is an important aspect to consider. in the present study, participants expressed higher expect­ bräscher, ferti, & witthöft 11 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://www.psychopen.eu/ ations directly after the information about olp effects and expectations significantly decreased in the second assessment before the placebo phase. yet, only expectations of the second assessment were significantly associated with the olp effects. therefore, possibilities should be explored that keep expectations stable for a longer period of time, for example sending patients written information on the open-label placebo effect to boost expectations right before the intake of the placebos. some limitations need to be mentioned for the present study. the animated video was meant to increase standardization when giving participants information about olp effects. it would have been helpful to validate the animated video in a pilot study, test whether the information was conveyed as desired and whether alliance would be affected. since the placebo and control phases of the study took place in the field instead of in a controlled lab environment, we cannot be sure whether participants took the placebos as prescribed. yet, this approach has higher ecological validity than most olp studies that comprise healthy participants, as it closely resembles realistic conditions (i.e., taking medication at home). further, besides asking about the intake of the placebo pills daily, we confirmed the participants’ statements by asking how many pills they had to spare at the end of the study. the employed brand name “pharmacebo” might have not been optimally chosen, since it includes the term “pharma” and thus could be misleading. yet, the results do not support this notion as participants whose medicine container did not have a label tended to benefit better from the placebos. it would be helpful to investigate the impact of different brand names and their connotations in a future study. finally, analyses were based solely on self-report data. assessing objective data, for example with the help of fitness watches tracking sleep parameters, could be a beneficial addition. to conclude, open-label placebo effects are a promising phenomenon that has the potential to improve patient care while respecting patients’ autonomy. similar to other recent investigations, this study failed to find overall olp effects in mental and physical well-being in healthy participants. it will be important to continue replicating previous findings and to determine the exact conditions of successful implementation of olp effects in healthy as well as clinical samples. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. twitter accounts: @annekbraescher, @witthoef open-label placebo effects on well-being 12 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://twitter.com/annekbraescher https://twitter.com/witthoef https://www.psychopen.eu/ supplementary materials the supplementary material contains further information on the sample, the manualized narrative provided in the animated video, further information on questionnaires assessed, and a supplemen­ tary table with correlations of the difference between scores taken in the placebo versus the no treatment week of the outcome measures with psychological factors (for access see index of supplementary materials below). index of supplementary materials bräscher, a., ferti, i., & witthöft, m. 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(2020). pain response to open label placebo in induced acute pain in healthy adult males. anesthesiology, 132(3), 571– 580. https://doi.org/10.1097/aln.0000000000003076 tennant, r., hiller, l., fishwick, r., platt, s., joseph, s., weich, s., parkinson, j., secker, j., & stewart-brown, s. (2007). the warwick-edinburgh mental well-being scale (wemwbs): development and uk validation. health and quality of life outcomes, 5, article 63. https://doi.org/10.1186/1477-7525-5-63 von wernsdorff, m., loef, m., tuschen-caffier, b., & schmidt, s. (2021). effects of open-label placebos in clinical trials: a systematic review and meta-analysis. scientific reports, 11(1), article 3855. https://doi.org/10.1038/s41598-021-83148-6 wei, h., zhou, l., zhang, h., chen, j., lu, x., & hu, l. (2018). the influence of expectation on nondeceptive placebo and nocebo effects. pain research & management, 2018, article 8459429. https://doi.org/10.1155/2018/8459429 wilson, s. c., & barber, t. x. (1978). the creative imagination scale as a measure of hypnotic responsiveness: applications to experimental and clinical hypnosis. the american journal of clinical hypnosis, 20(4), 235–249. https://doi.org/10.1080/00029157.1978.10403940 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. open-label placebo effects on well-being 16 clinical psychology in europe 2022, vol. 4(4), article e7679 https://doi.org/10.32872/cpe.7679 https://doi.org/10.1097/aln.0000000000003076 https://doi.org/10.1186/1477-7525-5-63 https://doi.org/10.1038/s41598-021-83148-6 https://doi.org/10.1155/2018/8459429 https://doi.org/10.1080/00029157.1978.10403940 https://www.psychopen.eu/ open-label placebo effects on well-being (introduction) method sample experimental procedure outcome measures measures of psychological factors statistical analysis results expectation and adherence open-label placebo effects identification of predictors discussion (additional information) funding acknowledgments competing interests twitter accounts supplementary materials references the cooperative revolution reaches clinical psychology and psychotherapy: an example from germany scientific update and overview the cooperative revolution reaches clinical psychology and psychotherapy: an example from germany jürgen margraf a , jürgen hoyer b, thomas fydrich c, tina in-albon d, tania lincoln e, wolfgang lutz f, angelika schlarb g, henning schöttke h, ulrike willutzki i, julia velten a [a] mental health research and treatment center, ruhr university bochum, bochum, germany. [b] clinical psychology and psychotherapy, technical university of dresden, dresden, germany. [c] department of psychology, humboldtuniversität zu berlin, berlin, germany. [d] clinical child and adolescent psychology and psychotherapy, university of koblenz-landau, landau, germany. [e] clinical psychology and psychotherapy, universität hamburg, hamburg, germany. [f] clinical psychology and psychotherapy, trier university, trier, germany. [g] clinic psychology and psychotherapy of children and adolescents, bielefeld university, bielefeld, germany. [h] clinical psychology and psychotherapy, osnabrück university, osnabrück, germany. [i] clinical psychology and psychotherapy, university witten/herdecke, witten, germany. clinical psychology in europe, 2021, vol. 3(1), article e4459, https://doi.org/10.32872/cpe.4459 received: 2020-09-25 • accepted: 2020-12-30 • published (vor): 2021-03-10 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: jürgen margraf, mental health research and treatment center, ruhr university bochum, massenbergstrasse 9-13, bochum, d-44787, germany. tel: +492343223169. fax: +492343203169. e-mail: juergen.margraf@rub.de supplementary materials: materials [see index of supplementary materials] abstract background: psychology is at the beginning of a cooperative revolution. traditionally, psychological research has been conducted by individual labs, limiting its scope in clinical samples and promoting replication problems. large-scale collaborations create new opportunities for highly powered studies in this resource-intensive research area. to present the current state of a germany-wide platform for coordinating research across university outpatient clinics for psychotherapy. method: since 1999, over 50 such clinics were created in germany. they represent a unique infrastructure for research, training, and clinical care. in 2013, a steering committee initiated a nationwide research platform for systematic coordination of research in these clinics (german abbreviation “kodap”). its main goal is to aggregate and analyze longitudinal treatment data – including patient, therapist, and treatment characteristics – across all participating clinics. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4459&domain=pdf&date_stamp=2021-03-10 https://orcid.org/0000-0001-5207-7016 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ results: an initial survey (100% response rate) yielded recommendations for improved integration of data collection. pilot data from 4,504 adult (16 clinics) and 568 child and adolescent patients (7 clinics) proved feasibility of data transfer and aggregation despite different data formats. affective, neurotic, stress, and somatoform (adults) and anxiety and behavioral (children and adolescents) disorders were most frequent; comorbidity was high. overcoming legal, methodological, and technical challenges, a common core assessment battery was developed, and data collection started in 2018. to date, 42 clinics have joined. conclusions: kodap shows that research collaboration across university outpatient clinics is feasible. fulfilling the need for stronger cumulative and cooperative research in clinical psychology will contribute to better knowledge about mental health, a core challenge to modern societies. keywords psychotherapy research, outpatient clinics, collaborative research, replication crisis highlights • data from 4,504 adult and 568 child and adolescent patients were successfully aggregated across 23 outpatient clinics. • affective, neurotic, stress, and somatoform (adults) and anxiety and behavioral (children and adolescents) disorders were most frequent; comorbidity was high. • legal, methodological, and technical challenges were overcome, and a common core assessment battery was developed. • 42 clinics have joined a germany-wide research platform for systematic coordination of research in these clinics. longitudinal data collection started in 2018. psychology and psychotherapy are at the beginning of a cooperative revolution (chartier et al., 2018; spellman, 2015). traditionally, research in these fields has been conducted by individual labs, limiting its scope in clinical samples and promoting replication problems. in response to the so-called “replication crisis” in medicine, psychology and related fields (camerer et al., 2018; dumas-mallet et al., 2017; ioannidis, 2005; open science collaboration, 2015; pashler & wagenmakers, 2012), the search for causes revealed meth­ odological issues including insufficient sample sizes (button et al., 2013; flint et al., 2015; rossi, 1990; simmons et al., 2011) and the “file drawer problem” (aka publication bias; kirsch et al., 2002; rosenthal, 1979; turner et al., 2008). these proximal causes are wors­ ened by misaligned incentives in a context of dwindling research funding and increasing pressure to publish or perish (margraf, 2015; spellman, 2015). in addition, basic aspects of our academic cultures may serve as major contributors to the crisis by accelerating a race that, under the motto "winner takes all", favors fundamentally undesirable developments (fang & casadevall, 2012b). these “cultural” aspects include an exaggerated cult of originality (fang & casadevall, 2012a) and the “toothbrush problem” (mischel, 2008): we collaborative psychotherapy research in germany 2 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ tend to treat other peoples’ theories like toothbrushes — every decent person uses one but no self-respecting person wants to use anyone else’s. if getting and keeping your job and status requires achieving “originality” by not building on anyone else’s work, it may directly undermine the goal of building a cumulative science (mischel, 2008). the conflict applies not only to theories but also to therapies: the field is full of overstated claims of originality and uniqueness, leading to ill-founded distinctions and misguided competition that impede fruitful cooperation. as a result of this “disconnect between what is good for scientists and what is good for science” (nosek et al., 2012, p. 616) we have a situation, where “most published research findings are false” (ioannidis, 2005) and “most clinical research is not useful” (ioannidis, 2016). we cannot, however, simply deplore external pressures and individual misconduct, we must also devote our critical attention to the cult of originality and priority and the overemphasis on individual contributions that underlie them. we need to pursue an academic community that works collectively, albeit competitively, to advance theory and therapy. this requires developing common shared tools and a more serious quest for ro­ bust, replicable and consequential findings (mischel, 2009). the importance of teamwork in science has never been greater (fang & casadevall, 2012a). teams increasingly domi­ nate science and are contributing the highest-impact and most reliable research. collabo­ rations, consortia and networks are essential for tackling many of the most important challenges in psychotherapy and psychosomatics. luckily, scientists in psychology and medicine recently have opened up much more to new forms of increased collaboration, allowing them to initiate projects at a scale previously unattained. perhaps the most visible hallmark of the cooperative revolution has been the rapid increase in large-scale collaborations such as manylabs, manybabies, open science collaboration, psychologi­ cal science accelerator, registered replication reports, and studyswap (chartier et al., 2018). our research questions as well as our often still inadequate measurement accuracy typically require very large samples (margraf, 2015). large joint projects and individual projects coordinated with them must complement each other, and the necessary infra­ structure must be developed. this should create new opportunities for highly powered studies even in resource-intensive areas such as psychotherapy research. the present article describes the example of an innovative approach to collaborative psychotherapy research from germany (hoyer et al., 2015; in-albon et al., 2019; velten et al., 2017, 2018). since germany established the legal basis for psychotherapy outpatient clinics at university departments of clinical psychology in 1999, over 50 such clinics devoted to research (i.e., research clinics) and to clinical training of psychotherapists (i.e., training clinics) were created. each year, many thousand patients across all age and clinical groups are treated under routine clinical conditions as well as in circumscribed research projects (in-albon et al., 2019; velten et al., 2018). together, they represent a unique infrastructure for research, training and clinical care that rapidly has proven to be an important facilitator of research in psychotherapy and mental health. the clinics margraf, hoyer, fydrich et al. 3 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ routinely gather a large amount of data on therapy outcomes as well as on patient and therapist characteristics (velten et al., 2017). high standards of quality assurance are achieved in these outpatient clinics through regular, standardized diagnostic assessments. these data can also be used for research, in particular psychotherapy research (e.g., ziem & hoyer, 2020). in spite of this remarkable track record, the full potential of synergetic gain from a systematic coordination of research at the clinics had until recently not yet been sufficiently exploited. the scientific evaluation of treatment data is particularly difficult for clinics with a smaller number of cases: patients and therapists often invest time and effort to answer questions about symptoms, the course of therapy or therapeu­ tic relationships without sufficiently large samples for quantitative analysis. up to now, the combination of the collected data with other clinics has been an exception that was limited to individual multicenter research projects (e.g., gloster et al., 2011; hoyer et al., 2016; lutz et al., 2009). nonetheless, the chances of an aggregation of research data across clinics are manifold. research coordination would involve a standardization in diagnostic documentation, a standardized reporting system and consequently the possibility of aggregating data from several or all outpatient clinics. proposals for practice research networks have already been discussed on various occasions (e.g., borkovec et al., 2001; castonguay, 2011). a collaborative approach offers a number of important advantages: with the aggregated basic data, research with a large number of cases can be carried out in a short time. if necessary, comparatively rare disorders or their variants (e.g., skin picking disorder, depersonalization/derealization disorder, sexual dysfunctions; balon, 2017; sierra & david, 2011; velten et al., 2021) even those not yet explicitly defined in classification systems (e.g. facebook addiction disorder; brailovskaia et al., 2018, 2019) can be investigated. in the case of more frequent disorders, the high number of cases allows subgroup comparisons and valid benchmark analyses to be carried out. current topics such as the investigation of therapist data, discontinuation rates, the hotly debated topic of failures and side effects (jacobi et al., 2011), transgenerational psychotherapy effects (schneider et al., 2013) or groundbreaking developments in basic research (such as in the area of therapygenetics; coleman et al., 2017; rayner et al., 2019; roberts et al., 2017, 2019; wannemüller et al., 2018a; wannemüller et al., 2018b) could be addressed more quickly with highly visible studies based on large clinical data sets. ultimately, the collaborative database provides a valuable starting point for applying for major projects. in 2013, an initiative group began to lay the groundwork for the systematic coordi­ nation of research in the german university outpatient clinics for psychotherapy in order to create a nationwide research platform for clinical psychology and psychothera­ py (german abbreviation “kodap” for “coordination of data acquisition at research clinics for psychotherapy”). this platform will allow the aggregation and analysis of longitudinal treatment data – including patient, therapist, and treatment characteristics – across all participating clinics for adults, children and adolescents. the short-term goal collaborative psychotherapy research in germany 4 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ of kodap was to establish the feasibility of large-scale coordinated research. medium to long-term goals of the project are the advancement of theory, practice, and dissemination of psychotherapy and clinical psychology. the present article describes the steps taken, the challenges that had to be overcome and four feasibility studies that were carried out. overview of feasibility studies immediate goals of study 1 (hoyer et al., 2015) were (a) to gather information on the core characteristics of the clinics and on this basis (b) to develop proposals for better integration of research efforts. in order to estimate the size and clinical composition of potential populations for future studies the number of patients initiating treatment in the participating kodap outpatient clinics in 2016 as well as their diagnoses and psychopathological complaints together with the database, research and administrative software used in the clinics were recorded. immediate goals of study 2 (velten et al., 2017) were (a) to develop a comprehensive catalogue of the considerable logistical, technical and legal data protection challenges facing the planned research collaboration, (b) to use this to examine the workability of cross-clinic collection of patient, therapist and therapy data and (c) to plan the third and fourth pilot studies. study 3 (velten et al., 2018) and study 4 (in-albon et al., 2019) aimed (a) to actually aggregate patient data across a pilot sample of clinics (study 3: adults, study 4: children and adolescents) treated in 2016 and use this (b) to test all the processes necessary for data preparation, transmission and aggregation at the cooperation partners and the central coordination center. the focus was on the frequency distribution of treatment diagnoses to answer the following research questions: which disorders are frequently treated, which are rarely? how high is the proportion of severely distressed patient groups with more than one disorder diagnosis, at least one personality disorder or severe symptoms? study 1 (hoyer et al., 2015) method a complete list of outpatient clinics at german university departments of clinical psy­ chology and psychotherapy for the psychotherapeutic treatment of adults, children and adolescents (referred to as “clinics” in the following) was compiled in 2014 (hoyer et al., 2015). this yielded 53 institutions whose scientific and managing directors were contacted by e-mail in may 2014 with the request to complete a short survey form. a questionnaire was developed by the initiative group to record the characteristics of the clinics. it asked for the diagnostic instruments, disorder-specific and general clinical questionnaires, as well as the patient and therapist variables of interest. in addition, the type, strengths and weaknesses of the clinical, research and administrative software used was assessed by open questions. finally, the clinics reported the annual number of pre margraf, hoyer, fydrich et al. 5 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ and post therapy datasets of all patients (i.e., defined as any person for whom a patient file was created) treated in 2013. case numbers for adults and children and adolescents were asked separately. results all 53 clinics contacted provided data on their institution by november 2014 (100% response rate). whereas some of the clinics were still in the planning or construction stage or could not provide reliable data on current patient numbers for technical reasons, 49 clinics were able to provide information on their annual number of patients. estimates (some of the clinics were able to provide only approximate data) for patients treated in 2013 yielded 8200 preand 5400 post-therapy data records for adults, and 2400 preand 1100 post-therapy data records for children and adolescents. there were clear overlaps in the methods used for the diagnosis of mental disorders as shown in table 1. given the large number of different mental disorders treated in the clinics, it is not surprising that more than 150 different disorder-specific instruments were identified by the survey. table 1 diagnostic assessments utilized routinely in outpatient clinics (instruments used by at least 15% of clinics). instrument % of clinics using instrument instruments used for icd/dsm diagnoses adults structured clinical interview for dsm-iva, scid 89.2 international diagnostic checklistb, idcl 21.6 diagnostic interview for mental disordersc, dips 16.2 children and adolescents diagnostic interview for mental disorders in childhood and adolescenced, kinder-dips 85.7 general clinical instruments adults brief symptom inventorye, bsi 62.2 symptom checklist 90-revisedf, scl 90-r 45.9 inventory of interpersonal problemsg, iip 27.0 clinical global impressions scaleh, cgi 24.3 children and adolescents child behavior checklisti, cbcl/6-18r 64.3 youth self-report of the child behavior checklisti, ysr/11-18r 57.1 teacher report formi, trf/6-18r 50.0 inventory for the assessment of life quality in children and adolescentsj, ilk 42.9 collaborative psychotherapy research in germany 6 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ instrument % of clinics using instrument disorder-specific instruments adults beck depression inventoryk, bdi i or bdi ii 89.2 body sensations questionnaire, agoraphobic cognitions questionnaire, mobility inventoryl 64.9 screening for somatoform symptoms 2m, soms 2 56.8 eating disorder inventory 2n, edi 2 48.6 social interaction anxiety scaleo, sias 48.6 hamburg obsessive/compulsive inventoryp, hzi 45.9 social phobia-scaleo, sps 43.2 posttraumatic stress diagnostic scaleq, psd 40.5 impact of event scaler, ies 35.1 eating inventorys, fev 29.7 borderline-symptom-list-23t, bsl-23 29.7 yale brown obsessive compulsive scaleu, y-bocs 27.0 children and adolescents children's depression inventoryv, dikj 64.3 fear survey schedule for children – revisedw, phoki 57.1 social phobia and anxiety inventory for childrenx, spaik 35.7 anxiety questionnaire for school studentsy, afs 35.7 awittchen et al., 1997. bhiller et al., 1997. cmargraf et al., 2017; schneider & margraf, 2011. dmargraf et al., 2017; schneider et al., 2009. ederogatis & spencer, 1993; franke, 1997. fderogatis, 1992; franke & derogatis, 1995. ghorowitz et al., 2000. hguy, 1976; kadouri et al., 2007. idöpfner et al., 2014. jmattejat & remschmidt, 2006. khautzinger et al., 2000, 2009. lehlers et al., 2001. mrief et al., 1997. npaul & thiel, 2004. ostangier et al., 1999. pzaworka et al., 2003. qgriesel et al., 2006. rmaercker & schützwohl, 1998. spudel & westenhöfer, 1989. twolf et al., 2009. uhand & büttner-westphal, 1991. vstiensmeier-pelster et al., 2014. wdöpfner et al., 2006. xmelfsen et al., 2001. ywieczerkowski et al., 1981. the systematic collection of essential patient characteristics such as age, gender and diagnosis (see table 2) is a standard in all participating clinics. in addition, most clin­ ics also record level of education, marital status and the number of therapy sessions. the documentation of therapist characteristics is limited to therapist gender, age and training status in most clinics. a large number of different software programs for patient data maintenance, room planning and billing as well as other administrative purposes are used by the clinics. these include programs from commercial providers as well as individual database solutions created in-house. the three most frequently cited software tools were psychoeq (psychoware software), ambos (therapy organization software) and self-developed spss or microsoft excel databases. the most frequently named strengths of the respective software solutions are their individual adaptability to the needs of the clinic, easy exportability of the data, simple operation and good support from the manufacturer. frequently mentioned weaknesses of the programs are the susceptibility to errors, the limitation of data export only via employees of the manu­ margraf, hoyer, fydrich et al. 7 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ facturer as well as the missing possibility to record specific variables such as therapist characteristics. table 2 patient and therapist characteristics reported in feasibility study 1 variable % of clinics giving information patient characteristics age 100 gender 100 diagnosis (icd-10) 100 level of education 95.9 marital status 93.9 number of treatment sessions 93.9 index diagnosis 89.8 therapist characteristics gender 77.6 age 69.4 training status (fully licensed vs. in training) 65.3 study 2 (velten et al., 2017) method the results of the first pilot study were evaluated by the initiative group1 in several face­ to-face meetings as well as in telephone and skype conferences in 2015 and 2016. two subgroups dealt with the variables for adults and for children/adolescents, respectively. this led to the following structure of the catalogue of logistical, technical and legal data protection challenges facing the planned research collaboration: (1) organizational framework conditions, (2) cooperation agreement, (3) steering group, (4) coordination center, (5) initial set of variables to be collected for adults and for children and adoles­ cents, (6) process to expand the dataset in the future, (7) data protection of transmitted information and ethical approval, (8) planning of the final feasibility study (velten et al., 2017). for each of these sections specific recommendations were formulated on the basis of unanimous decisions. in addition, the procedures for patient informed consent and ethical approval of the project had to be developed. 1) c. bennecke, m. berking, j. hoyer, t. in-albon, t. lincoln, w. lutz, j. margraf, a. schlarb, h. schöttke, u. willutzki. collaborative psychotherapy research in germany 8 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ results based on the results of study 1, the initiative group for the development of research cooperation derived recommendations regarding the catalogue of challenges for the cooperation project listed below. all recommendations were formulated on the basis of unanimous decisions by the initiative group. (1) organizational framework conditions — the planned research cooperation re­ quires a solid organizational basis that must be supported by a legal entity. on 20 march 2017, unith.ev began to serve as the organizing institution of the kodap project. unith.ev (the network of german university outpatient clinics for psychotherapy) is a registered non-profit association (the german “ev” stands for registered association, “unith” combines “university” and “therapy”). the sponsorship by a registered associa­ tion clarifies the continued legal responsibility, and the non-profit character underlines the non-commercial character of its research, which serves the common good. (2) cooperation agreement — in order to legally secure the ambitious project, a cooperation agreement was drafted which regulates the rights and obligations of all par­ ticipating clinics. it specifies the subject matter of the contract and provides the relevant information on the duration, confidentiality, liability and termination of membership in the project. in order to ensure the effective execution of the scientific and operational work of the research network, a steering group and a coordination center had to be established. their respective tasks are also defined in the cooperation agreement (in german language, available from the first author on request). (3) steering group — the tasks of the steering group include the development, sup­ port and conception of kodap's research activities. at present (mid-2020), the steering group consists of most members of the initiative group, which was formed in october 2013 at the annual meeting of german university professors of clinical psychology and psychotherapy. so far, the group met about three times a year, addressing the essential steps of the project, taking decisions by consensus. it currently consists of 8 members, representing 8 different universities. rules of procedure were adopted in january 2017 to govern the rights and duties of the steering group (in german language, available from the first author on request) and contain guidelines for publications based on kodap data. (4) coordination center — the main tasks of the coordination center are the collection, storage, quality control, aggregation and statistical analysis of the data obtained. the data sets which the participating clinics provide annually for the kodap project are aggregated and stored in the coordination center. this task was taken over by the mental health research and treatment center of ruhr university bochum. regular reports, margraf, hoyer, fydrich et al. 9 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ which serve to keep the partners continuously informed about the progress of work, are prepared by the coordination center. the rights and duties of the coordination center are set out in the cooperation agreement (in german language, available from the first author on request). (5) initial set of variables — the initial core data set defined is presented in table 3. table 3 initial core set of variables to be collected for adults and for children and adolescents patient characteristics all age (years) gender previous psychological or psychosocial treatments index and additional diagnoses (icd-10, before and after therapy) based on structured or standardized clinical interviews level of education clinicians global impression scalea, cgi adults marital status brief symptom inventoryb, bsi or symptom checklist 90-revisedc, scl 90-r beck depression inventoryd, bdi i or bdi ii children and adolescents child behavior checkliste, cbcl youth self-report of the child behavior checkliste, ysr 11-18r psychosocial stressors (max. 5) living situation parent variables: bsib or scl-90-rc, level of education, partnership status therapist characteristics gender age training status (fully licensed vs. still in training) treatment variables number of therapy sessions type of treatment performed current treatment status (ongoing, discontinued, regular termination) aguy, 1976; kadouri et al., 2007. bderogatis & spencer, 1993; franke, 1997. cderogatis, 1992; franke & derogatis, 1995. dhautzinger et al., 2000, 2009. edöpfner et al., 2014. collaborative psychotherapy research in germany 10 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ the aim of assessing only a limited number of variables was to minimize the additional burden of data collection for kodap and to allow clinics to continue using established assessments. since the psychometric instruments are given before and after treatment, it is possible to evaluate therapy outcome. all patient and therapist data are collected in pseudonymized form. special consider­ ation needs to be given to the problem of personal data, as is emphasized in article 26 of the basic eu data protection regulation (see regulation [eu] 2016/679; european parliament and council, 2016), which became effective in may 2018. kodap follows the recommendations of a task force of the german society of psychology. as a consequence, the kodap project does not collect data that are used in combination by a "person at his or her own discretion [...] to identify the natural person directly or indirectly" (article 26). in order to ensure that individual patients even those with rare disorders cannot be identified on the basis of personal characteristics such as occupation or date of birth, only basic characteristics (level of education, age in years, gender, preand post-therapy diagnoses) are to be collected in the kodap project. this procedure enables the storage of different data for a given patient over several years necessary for the longitudinal data collection, one of the central goals of kodap. the same considerations also apply to the selection of therapist variables; therefore only information on age, gender and training status are recorded. with respect to treatment variables, the current treatment status (ongoing, completed or discontinued therapy), number of sessions and type of psychotherapeutic procedure are stored. (6) process to expand the dataset in the future — since the success of kodap essentially depends on smooth and reliable data collection and combination, only a manageable number of patient, therapist and therapy variables should be transmitted at the start of the project. however, a particular strength of a large-scale collaborative project is that it allows the investigation of rare disorders or therapy phenomena as well as new survey instruments. an extension of the initial data set is therefore planned for the future. it is relatively easy to extend the data set with instruments or variables, of which we know from study 1 (hoyer et al., 2015) that the majority of clinics already use them (e.g., sps, sias, soms 2, edi 2). in the long term, the survey can be expanded by follow-up data through multiple measurements across the course of therapy as well as freely available psychometric instruments. similar to the british improving access to psychological therapies (iapt) (clark, 2018) program, kodap will also serve to develop and establish public domain instruments. in addition, all participating project partners are free to propose additional time-limited research questions. if an additional variable that is relevant for many patients is specifically collected over a clearly defined period (e.g., 3 or 6 months) in all clinics, large, clinically well-documented samples can be obtained in a very short time. margraf, hoyer, fydrich et al. 11 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ (7) data protection and ethical approval — as the variables to be collected in the clinic include sensitive treatment and health data special attention had to be given to data protection aspects in the run-up to the project as discussed in section (5) above. with regard to data transmission, various technical implementations were examined by the steering group. the solution needed to ensure longitudinal data collection, secure data transmission and storage, easy application by the clinic and low maintenance in the coordination center. in order not to delay the start of the project due to costly and time-consuming technology, we decided to merge the data records into one spss data record. a corresponding spss template (for adults or children and adolescents) is provided to all participating clinics at the start of the project, which will be sent back to the coordination center on encrypted data carriers at the end of the first project year. the data are stored in secured form on the server of the coordination center. in order to ensure that the transfer of patient data in kodap is ethically acceptable, an informed consent form was developed, which has to be signed by the patients before the start of treatment (in german language, available from the first author on request). before the start of the project, the ethics committee of the faculty of psychology at ruhr university bochum approved the project. the clinics are, however, free to additionally secure their participation in the project by submitting their own applications to their local ethics committees. (8) planning of the final feasibility studies — the first transmission of data, which form the basis for longitudinal analyses over several years, was planned to take place between the clinics and the coordination center in january 2019. at this point, the core data of those patients whose treatment started in 2018 were to be transmitted. before this, however, it was planned to pilot the processes necessary for data preparation, trans­ mission and aggregation at the cooperation partners and the coordination center. for this purpose, the clinics that joined the project by september 2017 provided the patients' core data sets from 2016 for two final (the third and fourth) feasibility studies. the benefits of these feasibility studies go far beyond the mere optimization of the project processes as descriptive statistics of patient data (e.g., distribution of diagnoses, age structure, type and number of co-morbidities and severity of treated disorders) are not yet available for german psychotherapy clinics. study 3 (velten et al., 2018) method as of june 2018, 32 clinics from 15 locations had joined the kodap project (26 for adults and 6 for children and adolescents). these were invited to contribute the initial core set for adult patients (see table 3). all patients treated in the participating clinics in 2016 as well as their therapists were to be included, no other inclusion or exclusion criteria applied. a total of 16 clinics for adults were able to provide data sets (velten et al., 2018). collaborative psychotherapy research in germany 12 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ reasons for non-participation were the lack of data due to the recent establishment of clinics and the missing approval by ethics committees for the transmission of data from 2016 because of a lack of coordinated consent forms. the participating clinics checked their internal data for completeness and compatibility and assessed the time and personnel required to process and transmit the data. in the coordination center data quality and ease of data transmission were tested. faulty data points were reported back to the clinics. in addition, study protocols with precise information on all variables were sent to the clinics, which were to be returned to the coordination center together with the quantitative data set. a qualitative evaluation of the study protocols was used to check the variables for conclusiveness and to identify difficulties in data collection. in order to prevent possible personal identification, some variables (e.g., occupa­ tion, exact time of treatment, transgenderness) were not collected. icd-10 f diagno­ ses (dilling, mombour, schmidt, & weltgesundheitsorganisation, 2005; world health organization, 1993) at the beginning of treatment were recorded separately for the initial or index diagnosis (defined as the main reason for presentation) and for additional diagnoses. reported diagnoses had to be derived from a standardized diagnostic tool or a structured interview according to icd-10, dsm-iv or dsm-5. in addition to the patient, therapist, and therapy variables listed in table 3, the average number of patients treated during the study period was computed. results of the 26 kodap adult clinics, 16 clinics (61.5%) from ten locations (humboldt-universi­ tät zu berlin, freie universität berlin, bochum, dresden, greifswald, hamburg, landau, mainz, trier, osnabrück) provided data on 4504 individuals treated in 2016 (start of treatment could have been in 2016 or earlier). the number of records transmitted per clinic ranged from 24 to 756. the completeness and quality of the data (e.g. with regard to the coding of the response options) were checked in the clinics. with the support of the coordination center, all clinics were able to adapt their internal data collection in such a way that all defined variables for the future longitudinal study could be transmitted in an adequate form. all participating clinics were able to provide the time and personnel resources needed for the preparation and transfer of the data records. all clinics transmitted the data sets to the coordination center in compliance with data protection regulations (velten et al., 2017). patient sociodemographic — the majority of the persons treated (mean age = 37.87; sd = 13.47; range = 15-86 years) were female (n = 2937, 65.3%) and currently in a partnership (n = 2383, 67.5%). marital status was reported as 49.4% (n = 1777) single, 29.4% (n = 1058) married and 9.2% (n = 332) divorced. the highest school degree attained was the german “abitur” (equivalent to a-level or international baccalaureate diploma) for 48.2% (n = 1518), intermediate school certificate (german “mittlere reife”) for 29.4% margraf, hoyer, fydrich et al. 13 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ (n = 926) and basic school certificate (german “hauptschulabschluss”) for 18.1% (n = 570). at the start of treatment, 68.7% (n = 803) of the patients were able to work. in addition to the 18.6% (n = 217) disabled patients, 5.5% (n = 64) received a retirement pension and 3.1% (n = 36) an invalidity pension. patient diagnoses — nearly all clinics stated that the diagnosis at the beginning of treatment was confirmed by structured or standardized interview procedures. only one outpatient clinic reported that an interview was not always used. a total of 7947 diagnoses were assigned to 4266 patients. neurotic, stress and somatoform disorders (f4) were the most common category, followed by affective disorders (f3). a recurrent depressive disorder, currently a moderate episode (f33.1), was diagnosed 844 times, making it the most common disorder. with 651 and 539 assigned diagnoses, social phobia and the moderate depressive episode were the second and third most common disorders. personality and behavioral disorders were diagnosed a total of 563 times. at least one personality disorder (f60 or f61) was present in 10.8% of all patients. the distribution of index diagnoses, which were defined as treatment causes in this study, differed from that of the overall distribution of all diagnoses assigned. although f4 diagnoses were the most frequently assigned, affective disorders (f3) were by far the most frequent index diagnoses with 39.4% (n = 1682). phobias (f40.-) and other anxiety disorders (f41.-) accounted for 14.2% (n = 607) of the initial diagnoses. also frequently given were index diagnoses in the area of somatoform disorders (f45.-) with 5.5% (n = 233), post-traumatic stress disorder (f43.1) with 4.5% (n = 190), adaptation disorders (f43.2) with 4.5% (n = 190), eating disorders (f50.-) with 4.4% (n = 186) and emotionally unstable personality disorder: borderline type (f60.31) with 2.6% (n = 113). however, patients with bipolar affective disorders (n = 42; 0.9%), schizophrenia (n = 44; 1.0%) and sexual dysfunction (n = 8; 0.2%) as index diagnoses were rarely treated. the average number of diagnoses given was 1.84 (sd = 0.99, range = 0-7). thus, multimorbidity was found in the majority of cases. 43.1% (n = 1865) had only one diagnosis, 33.4% (n = 1448) had two and 21.6% (n = 942) had three or more. only 1.7% (n = 74) had no diagnosis at the start of treatment or no diagnosis was recorded in the system. the most frequent comorbidity pattern was the co-occurrence of affective disorders (f3) and neurotic, stress and somatoform disor­ ders (f4). for example, 581 patients (13.7%) with f4 index diagnosis had an additional f3 diagnosis. the reverse pattern, f3 as first diagnosis and f4 as second and/or third diagnosis, applied to 546 patients (12.8%). figure 1 shows the proportion of patients treated in research and training clinics by index diagnosis (icd-10). collaborative psychotherapy research in germany 14 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ figure 1 proportion of patients treated in research and training clinics by index diagnosis (icd-10) f0: mental and behavioural disorders due to psychoactive substance use f1: schizophrenia, schizotypal and delusional disorders f3: mood (affective) disorders f4: neurotic, stress-related and somatoform disorders f5: behavioural syndroms associated with physiological disturbances and physical factors f6: disorders of adult personality and behaviour other f0 2% f1 1% f3 39% f4 44% f5 6% f6 7% other 1% f0 2% f1 8% f3 47% f4 30% f5 8% f6 5% other 0% training clinicsresearch clinics table s1 in the supplementary materials shows the 50 most frequently assigned diagno­ ses, broken down by main disorder categories. table s2 in the supplementary materials shows the 50 most frequently assigned index diagnoses, which were defined as treatment causes in this study. table s3 in the supplementary materials shows the most frequent diagnostic combinations or comorbidity patterns after icd-10-f disorder sections. patient psychopathological symptoms — four clinics (n = 844 patients) provided data on the severity of the impairment at the start of therapy as assessed by the cgi. according to their therapists, 0.1% of the patients were not ill at all, 1.1% were borderline cases of mental disorder, 5.9% were only mildly ill, 28.9% were moderately ill, 49.8% were markedly ill, 12.1% were severely ill and 0.7% were among the most extremely ill patients. table 4 shows the bsi and bdi values at the start of therapy. at the start of treatment, clinically relevant elevated bsi values (gsi > 0.61) were present in 76% (n = margraf, hoyer, fydrich et al. 15 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ 2823), clinically significant bdi values (total values in bdi-i or bdi-ii > 14) in 70% (n = 2298) of the treated persons. severe depression symptoms (total values in bdi-i or bdi-ii > 29) were reported by 24.3% (n = 797) of patients at the start of treatment. table 4 level of patients´ psychopathological symptoms at the beginning of treatment instrument n m sd brief symptom inventorya, bsi 3753 0.89 0.77 somatization 3757 1.47 0.87 obsession-compulsion 3758 1.44 1.00 interpersonal sensitivity 3760 1.36 0.93 depression 3754 1.14 0.83 anxiety 3760 0.96 0.76 hostility 3756 0.85 0.88 phobic anxiety 3760 1.10 0.88 paranoid ideation 3756 0.92 0.77 psychoticism 3763 1.12 0.67 beck depression inventoryb, bdi bdi-i 642 18.47 10.10 bdi-ii 640 22.08 11.73 aderogatis & spencer, 1993; franke, 1997. bhautzinger et al., 2000, 2009. psychotherapeutic treatments — in accordance with german psychotherapy regula­ tions, a limited number of sessions are reserved for diagnostic procedures including case history and indicative decisions (so called probatory sessions). an average of 4.77 probatory sessions (sd = 0.85; range = 0-13) were performed. an outlier analysis showed only 1.5% of the treatments involved more than five probatory sessions. the number of regular therapy sessions after the probatory sessions was 35.01 (sd = 22.28, range = 0-117). while 42.7% (n = 1371) of the therapies were terminated consensually by patient and therapist (mean duration 43.09 therapy sessions, sd = 17.09), 23.3% (n = 748) were still ongoing at the time of data retrieval and 32.9% (n = 1057) of patients had dropped out of treatment (mean duration 23.8 sessions, sd = 22.04). in all cases, cognitive behav­ ior therapy was used as therapeutic procedure. in the vast majority, only individual therapy sessions took place (90.9%, n = 2683), combined individual and group therapy were applied in 9.0% (n = 284) of the treatments. therapists — a total of 675 persons (mean age = 30.91 years, sd = 5.82, range = 22-58) were involved as therapists. most therapists were female (n = 502, 83.3%) and the majority (n = 427, 70.6%) in advanced psychotherapy training (not licensed yet). on average, therapists treated 6.67 patients (sd = 5.75, range = 1-54) during the study period. collaborative psychotherapy research in germany 16 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ an average of 5.19 (sd = 6.94, range = 1-43) patients per therapist were treated in the research clinics and 6.80 (sd = 5.29, range = 1-54) patients per therapist in the training clinics. an outlier analysis showed that 95% of therapists were responsible for less than 17 patients. study 4 (in-albon et al., 2019) method this study characterized the patient population treated in 2016 in seven university outpatient psychotherapy clinics for children and adolescents (in-albon et al., 2019). these submitted the initial core data set for children and adolescent patients (see table 3). completeness and quality of the data were checked in the clinics as well as in the coordination center as described in study 3. descriptive data on the diagnoses and comorbidity patterns of the patient population as well as sociodemographic information of their parents and therapists were analyzed. for the cbcl/6-18r and ysr/11-18r, t-values adapted for age and gender for a total, an externalizing and an internalizing score are reported. results study 4 characterized the patient population treated in 2016 in seven university outpa­ tient psychotherapy clinics for children and adolescents. for the year 2016, data from 568 children and adolescents between 3 and 20 years of age (m = 11.89, sd = 3.68; 46.6% female) were available. the most frequent diagnoses were anxiety disorders (f40, f41, f93; n = 317, 35.30%) followed by attention-deficit hyperactivity disorders and conduct disorders (f90, f91, f92; n = 195, 21.71%). in 45.6% of the patients, there was at least one additional comorbid diagnosis. the mean t-value of the cbcl/6-18r (mother reports) was 67.60 (sd = 9.94) for the total score, 67.03 (sd = 10.70) for internalizing problems, and 61.84 (sd = 12.01) for externalizing problems. the mean t-value of the ysr/11-18r was 61.35 (sd = 10.23) for the total score, 63.43 (sd = 12.75) for internalizing problems, and 54.88 (sd = 9.53) for externalizing problems. all of these are above the clinical cut-off (t > 60; based on german norms; döpfner et al., 2014). therapist cgi severity scores classified the vast majority of patients as mentally ill (15.1% mildly, 46.6% moderately, 28.8% markedly, and 5.5% severely) and only few patients as not at all (1.4%) or borderline mentally ill (2.7%). of the 126 therapists (83.1% female, mean 29.76 years, sd = 5.04), the majority (78.9%) were still in psychotherapy training (not licensed yet). each therapist was responsible for a mean of 4.51 patients (range 1-13). cognitive behavior therapy was used for all patients, and almost all treatments (99.3%) were conducted in an individual setting (combination of individual and group setting in 0.8%). an average of 6.93 probato­ ry sessions (sd = 1.59, range 1-13) were performed. most of the treatments (52.3%) had not yet been terminated. overall, this study indicated the feasibility of consolidating and margraf, hoyer, fydrich et al. 17 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ evaluating research data across university outpatient psychotherapy clinics for children and adolescents. discussion while other fields of research, such as physics, astronomy and genetics, have been practicing collaborative research on a large scale for some time, their value in the field of psychotherapy and mental health has only been increasingly recognized in recent years (margraf, 2015). with the establishment of university outpatient clinics at departments of clinical psychology and psychotherapy in germany in 1999, a unique infrastructure for research, training and clinical care became available, offering opportunities for a collaborative approach. since 2013, a steering committee works towards a systematic co­ ordination across clinics in order to create a nationwide research platform. this platform will allow to aggregate and analyze longitudinal treatment data for adults, children and adolescents across all participating clinics and thereby contribute to the advancement of theory, practice and dissemination of psychotherapy and mental health research. the feasibility of large-scale coordinated research was investigated in a series of four descriptive studies. an initial survey with 100% response rate (study 1) in 2014 identi­ fied the most relevant features of the then 53 clinics and led to recommendations for improved integration of data collection. already in 2014, the annual number of patients reported by the clinics surpassed 10,000 children, adolescents, and adults, with a strongly growing trend. based on these results, we defined a catalogue of challenges facing the planned research collaboration and gave unanimously derived recommendations (study 2). study 3 collected data on 4,504 patients from 16 clinics treated in 2016 allowing for the first time to systematically describe patients, therapists and treatments available for collaborative research in the german psychotherapy outpatient clinic network. finally, study 4 analyzed data of 568 child and adolescent patients from seven clinics starting treatment 2016 providing the first description of this patient population within kodap. adult patients diagnoses are based on evaluated, structured or standardized interviews whose validi­ ty and reliability exceed clinical judgment and other non-standardized diagnostic pro­ cedures (margraf et al., 2017). the most frequently treated diagnostic groups in the kodap clinics in 2016 were neurotic, stress and somatoform disorders (f4) and affective disorders (f3), the latter also yielding the most frequent index diagnoses and cause of treatment. this is in line with previous studies of psychotherapy outpatient clinics in germany and england (clark, 2018; jacobi et al., 2011; richter et al., 2013; victor et al., 2018). the majority of kodap patients (55%) had several mental disorders at the start of treatment. this is more than previously reported in non-university clinics (victor et al., collaborative psychotherapy research in germany 18 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ 2018), individual university clinics (peikert et al., 2014; richter et al., 2013) or routine care by practicing psychotherapists (köck, 2012). while patients with almost all diagnoses and degrees of severity are treated, severe disorders (e.g., severe depressive episode, bor­ derline disorder, chronic pain disorders, post-traumatic stress disorder) are very frequent. in addition, a sub-sample of four clinics showed that almost two thirds of the patients were rated by their therapists as markedly, severely or extremely ill. the fact, however, that psychotic disorders accounted only for one percent of treatment reasons (34th rank) calls for an increased proportion of this patient group in outpatient training settings (schlier et al., 2017). further investigation of the 7% of patients labeled by their therapists as borderline or only mildly ill may help to determine whether these patients may not have been in need of psychotherapy or whether some patient characteristics (e.g., certain diagnoses or symptoms, age, gender) may result in therapists’ underestimation of patient distress. while patients on average had a high level of education, a lack of comparative values prevented a direct comparison with earlier studies. the results for age and gender as well as the bsi and bdi scores show that the patient population in kodap clinics is largely comparable to other german outpatient clinics and routine care by fully licensed behavior therapists (jacobi et al., 2011; köck, 2012; lutz et al., 2013; richter et al., 2013; victor et al., 2018). child and adolescent patients the most frequently assigned diagnoses were anxiety disorders and behavioral disorders. this is in line with epidemiological studies, e.g. a meta-analysis (polanczyk et al., 2015) indicating a prevalence rate of 6.5% for anxiety disorders, 5.7% for disruptive disorders, and 3.4% for adhd. as in the adult clinics, the diagnoses are based on validated struc­ tured clinical interviews. the results of the questionnaires cbcl/6-18r and ysr/11-18r are comparable with a clinical control group of an outpatient sample in a child and ado­ lescent psychiatric clinic (walter et al., 2018). the categorical and dimensional diagnostic assessments as well as the comorbidity rate of almost 50% underline the clinical severity and the breadth of the problems treated in the participating child and adolescent clinics. the age range of 3 to 20 years reflects the legal restrictions for child and adolescent psychotherapists in germany who may treat patients up to the age of 21. in contrast to the adult patient samples where roughly two thirds of the patients were female, girls and boys were equally distributed in the child and adolescent clinics. therapists the high proportion of female therapists (83%) is comparable with that of non-university training institutes (victor et al., 2018) and somewhat higher than for practicing fully licensed psychotherapists in germany (74.4%), or psychologist in the usa (73%) (apa center for workspace studies, 2015). this reflects an ongoing international trend toward margraf, hoyer, fydrich et al. 19 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ more women entering psychotherapy training and practice (apa center for workspace studies, 2015). because most of the reported treatments took place in training clinics, the majority of the therapists were not yet fully licensed. the fact that therapists treated an average of seven patients in training clinics during the study period underlines the intensity and structure of psychotherapy training in the participating clinics. variability in number of patients treated per therapist in our data reflects the different training models (part-time vs. full-time training). treatments with an average of 43 treatment sessions for adults and 36 sessions for children and adolescents (regularly terminated therapies), the length of treatment is identical to that reported in other german outpatient clinics (victor et al., 2018). this duration, howev­ er, is higher than internationally reported as the optimal dose for routinely delivered psychological therapies (robinson et al., 2020). patients dropped out in about one third of the treatments. although this figure appears high, these values are comparable with termination rates reported in similar treatment settings (hiller et al., 2009). in order to record the proportion of quality-relevant (e.g. low therapeutic success) in comparison to non-quality-relevant drop-outs (e.g., change of residence, low level of suffering), the reasons for early termination or non-execution of approved sessions should be systemati­ cally and uniformly documented in the future. limitations although a large number of the clinics in question have already joined the kodap project and more than half of the current member clinics contributed data to the last two feasibility studies, it is unclear to what extent the clinics included in this study are representative of all german university outpatient clinics for psychotherapy. causes for non-participation of kodap clinics in this study or reasons for missing variables in the transmitted data sets were not systematically documented. a more detailed, quantitative analysis of feasibility aspects related to data processing in clinics was therefore not possible. in addition, this study did not examine the extent to which clinics differ in terms of process and structural quality. due to ethical and data protection considerations, only a limited number of personal variables of patients and therapists can be evaluated across clinics. a detailed analysis of the influence of specific personal variables, such as occupation or place of residence, is therefore not possible. instead, this study deliber­ ately focuses on a description of the patient population and treatment diagnoses at the beginning of treatment. the majority of clinics use the bdi-ii, while two clinics still use the bdi-i. the comparability of the pre-treatment depression values across clinics with different bdi versions is therefore limited. since the primary focus of this study was the estimation of feasibility aspects, the clinics were free to decide whether this first data collaborative psychotherapy research in germany 20 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ transmission included variables already collected at the end of therapy. the analysis of treatment outcomes is planned for the longitudinal data collection that has been ongoing since the beginning of 2018. opportunities and challenges the network provides a distinctive, unprecedented infrastructure for research, training and clinical care in psychotherapy and mental health. clinical research designs, field experiments, and multicentric randomized controlled trials can be implemented rapidly and with large samples (e.g., 20 clinics per condition, inclusion of 1,000-5,000 patients), hence systematically solving typical problems such as recruitment issues, the lack of standardized assessments, and replicability. challenges for the collaborative project include expanding the core data set (e.g., be­ havioral data, social and biological variables), agreeing on new questions (e.g., long-term follow-up, systematic causality testing of predictors with experimental designs), and last but not least, full-cost funding of the joint research. a transfer of the network into a national structure would be desirable; a first application for consideration in the planned future national research center for mental health has already been submitted. the proof of a successfully established patient flow and the smooth realization of the coop­ eration will also improve the chances of success for acquisition of further third-party funding. conclusions despite different data formats, data transfer and aggregation proved feasible. affective, neurotic, stress, and somatoform disorders accounted for most of the diagnoses within the adult patients and anxiety and behavioral disorders within the child and adolescent patients. in both groups, comorbidity was the rule rather than the exception. overcoming legal, methodological, and technical challenges, a common core assessment battery was developed and data collection for kodap started in 2018. as of today, 42 clinics have joined and 30 already have provided data. the compilation of selected core data from the participating clinics makes it possible to answer important scientific and technical questions. these include but are not limited to the provision of normative data on patient, therapist, parents (for the child sample) and treatment characteristics, the inter­ actions of such variables (e.g., success in specific subgroups, interaction of patient and therapist characteristics), treatment outcomes under routine conditions, dropout rates as well as failures and side effects in therapy, rare disorders, subgroup analyses of frequent disorders, special comorbidity patterns, specific age groups (e.g., preschool age, primary school or adolescent age; older patients) and high-powered studies for the development of new instruments and treatments. the first steps of kodap reported here show that research collaboration across university outpatient clinics is feasible, provided that clin­ margraf, hoyer, fydrich et al. 21 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://www.psychopen.eu/ ics invest time and effort for data collection, data checking and data transfer. fulfilling the need for stronger cumulative and cooperative research in psychotherapy and related fields will contribute to better knowledge about mental health, a core challenge to modern societies. funding: financial support was provided by unith.ev, kinderund jugendlichenpsychotherapie verhaltenstherapie e.v., the mental health research and treatment center at ruhr university bochum, the alexander von humboldtprofessorship awarded to the first author, the departments of clinical child and adolescent psychology and psychotherapy and clinical psychology and psychotherapy at the university of koblenz-landau. competing interests: all authors are employed by the universities listed in the affiliations. they have no conflicts of interest to declare. acknowledgments: the authors gratefully acknowledge the support by the participating clinic directors, therapists and patients. christian leson and amelie scupin of the mental health research and treatment center at ruhr university bochum helped with data transfer and aggregation and preparation of tables and supplementary materials. author contributions: jürgen margraf, thomas fydrich, jürgen hoyer, tina in-albon, tania lincoln, wolfgang lutz, angelika schlarb, henning schöttke, ulrike willutzki and julia velten jointly conceived the work described here. julia velten coordinated data collection and data transfer. jürgen margraf wrote the first draft of the manuscript. tina in-albon contributed the first draft of the sections on study 4. all authors read the manuscript, gave feedback and agreed to the final version of the manuscript. all authors except for the first, second, and last are listed in alphabetical order. statement of ethics: this research complies with the guidelines for human studies and was conducted ethically in accordance with the world medical association declaration of helsinki. all patients gave their written informed consent and that the study was approved by the ethics committee of the faculty of psychology at ruhr university bochum. twitter accounts: @psychojule, @fbzrub supplementary materials the supplementary materials include three tables listing the diagnoses of patients in study 3 (for access see index of supplementary materials below). index of supplementary materials margraf, j., hoyer, j., fydrich, t., in-albon, t., lincoln, t., lutz, w., & velten, j. 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(2018). effectiveness of outpatient cognitive-behavioral therapy for adolescents under routine care conditions on behavioral and emotional problems rated by parents and collaborative psychotherapy research in germany 28 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://doi.org/10.1159/000350448 https://doi.org/10.1016/j.concog.2010.10.018 https://doi.org/10.1177/0956797611417632 https://doi.org/10.1177/1745691615609918 https://doi.org/10.1026//0084-5345.28.1.28 https://doi.org/10.1056/nejmsa065779 https://doi.org/10.1026/1616-3443/a000490 https://doi.org/10.1026/1616-3443/a000431 https://doi.org/10.1007/s00278-017-0225-5 https://www.psychopen.eu/ patients: an observational study. european child & adolescent psychiatry, 27(1), 65-77. https://doi.org/10.1007/s00787-017-1021-z wannemüller, a., moser, d., kumsta, r., jöhren, h.-p., adolph, d., & margraf, j. (2018a). mechanisms, genes and treatment: experimental fear conditioning, the serotonin transporter gene, and the outcome of a highly standardized exposure-based fear treatment. behaviour research and therapy, 107, 117-126. https://doi.org/10.1016/j.brat.2018.06.003 wannemüller, a., moser, d., kumsta, r., jöhren, h.-p., & margraf, j. (2018b). the return of fear: variation of the serotonin transporter gene predicts outcome of a highly standardized exposure-based one-session fear treatment. psychotherapy and psychosomatics, 87(2), 95-104. https://doi.org/10.1159/000486100 wieczerkowski, w., nickel, h., janowski, a., fittkau, b., & rauer, w. (1981). angstfragebogen für schüler–handanweisung. braunschweig, germany: westermann. wittchen, h.-u., wunderlich, u., gruschwitz, s., & zaudig, m. (1997). skid i. strukturiertes klinisches interview für dsm-iv. achse i: psychische störungen. interviewheft und beurteilungsheft. eine deutschsprachige, erweiterte bearb. d. amerikanischen originalversion des skid i. göttingen, germany: hogrefe. wolf, m., limberger, m. f., kleindienst, n., stieglitz, r.-d., domsalla, m., philipsen, a., . . . bohus, m. (2009). kurzversion der borderline-symptom-liste (bsl-23): entwicklung und überprüfung der psychometrischen eigenschaften. psychotherapie, psychosomatik, medizinische psychologie, 59(8), 321-324. https://doi.org/10.1055/s-0028-1104598 zaworka, w., hand, i., jauernig, g., & lünenschloß, k. (2003). hamburger zwangsinventar. weinheim, germany: beltz. ziem, m., & hoyer, j. (2020). modest, yet progressive: effective therapists tend to rate therapeutic change less positively than their patients. psychotherapy research, 30(4), 433-446. https://doi.org/10.1080/10503307.2019.1631502 world health organization. (1993). the icd-10 classification of mental and behavioural disorders: diagnostic criteria for research. retrieved from https://apps.who.int/iris/handle/10665/37108 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. margraf, hoyer, fydrich et al. 29 clinical psychology in europe 2021, vol.3(1), article e4459 https://doi.org/10.32872/cpe.4459 https://doi.org/10.1007/s00787-017-1021-z https://doi.org/10.1016/j.brat.2018.06.003 https://doi.org/10.1159/000486100 https://doi.org/10.1055/s-0028-1104598 https://doi.org/10.1080/10503307.2019.1631502 https://apps.who.int/iris/handle/10665/37108 https://www.psychopen.eu/ collaborative psychotherapy research in germany (introduction) overview of feasibility studies study 1 (hoyer et al., 2015) study 2 (velten et al., 2017) study 3 (velten et al., 2018) study 4 (in-albon et al., 2019) discussion adult patients child and adolescent patients therapists treatments limitations opportunities and challenges conclusions (additional information) competing interests funding acknowledgments author contributions statement of ethics twitter accounts supplementary materials references shame on me? love me tender! inducing and reducing shame and fear in social anxiety in an analogous sample research articles shame on me? love me tender! inducing and reducing shame and fear in social anxiety in an analogous sample jakob fink-lamotte 1,2 , jürgen hoyer 3 , pauline platter 2, christian stierle 4, cornelia exner 2 [1] clinical psychology, university of potsdam, potsdam, germany. [2] clinical psychology and psychotherapy, university of leipzig, leipzig, germany. [3] clinical psychology and psychotherapy, technische universität dresden, dresden, germany. [4] hochschule fresenius für wirtschaft und medien, hamburg, germany. clinical psychology in europe, 2023, vol. 5(3), article e7895, https://doi.org/10.32872/cpe.7895 received: 2021-12-01 • accepted: 2023-06-28 • published (vor): 2023-09-29 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: jakob fink-lamotte, university of potsdam, clinical psychology, karl-liebknecht-str 24/25, 14476 potsdam, germany. phone: +49-331-9772115. e-mail: jakob.fink-lamotte@uni-potsdam.de supplementary materials: data, materials [see index of supplementary materials] abstract background: shame is considered an important factor in the development and maintenance of many psychological disorders, e.g., social anxiety disorder, and an interesting target point for therapeutic intervention. method: in the present experimental study, we used an online-adopted autobiographical emotional memory task (aemt) to induce shame and tested different micro-interventions (selfcompassion, cognitive reappraisal, and a control intervention) with respect to their potential to reduce shame intensity. one-hundred-and-fifteen healthy subjects participated in the study and completed a series of self-report questionnaires on self-compassion, shame, and social anxiety. results: the experimental shame induction was well accepted and successful (with significantly heightened feelings of shame); there were no study drop-outs. there was a significant time*condition interaction, which was due the self-compassion-based intervention resulting in a significantly larger reduction of shame than the control condition (counting fishes). in addition, the main effect of the factor experimental condition was further moderated (enhanced) by trait social anxiety and trait self-compassion. conclusion: the findings demonstrate the usefulness of online-adopted aemt for the experimental induction of shame. they suggest that especially self-compassion interventions can this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7895&domain=pdf&date_stamp=2023-09-29 https://orcid.org/0000-0002-4384-4903 https://orcid.org/0000-0002-1697-6732 https://orcid.org/0000-0001-5904-6511 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ be beneficial in alleviating intense shame experiences, which is in accordance with self-compassion theory. overall, the results are promising in the context of experimental shame research and its potential clinical impacts call for further replication. keywords social anxiety, shame, shame induction, self-compassion, reappraisal highlights • we targeted shame by testing micro-interventions to reduce shame intensity. • shame was successfully induced using an online autobiographical emotional memory task in an experimental design. • self-compassion is a significant intervention to reduce shame. • the results have promising clinical implications as well as for future research. shame can broadly be understood as a global devaluation of the self and is characterized by a critical, judgmental, and condemning self-verbalization (self-directed private speech; (lewis, 1971). as shame motivates people to view themselves critically, they behave in a more reserved and detached manner in social situations. fessler (2004) argues that the psychological function of this behavior (as a “defense mechanism”) might be to protect us from the rejection of others. as a state, shame feels like being unmasked, judged, and humiliated in a specific situation (tangney et al., 2005), while as a trait shame comprises the tendency to experience these feelings in a variety of different (social) situations. when a strong desire for positive reactions from others is combined with a high level of insecurity about it, people might feel exaggerated shame (schuster et al., 2021). this ambivalence of desire for recognition and interactional insecurity leads to constant self-critical monitoring, which can be an underlying mechanism of psychological disor­ ders. shame associated excessive self-attention and adopting an observer perspective (self-as-object) are central factors of clark and wells (1995) psychopathological model of social anxiety disorder (sad). subsequently, exaggerated shame is thought to be a particularly important maintaining factor for sad (gilbert & miles, 2000; hedman et al., 2013), although it further plays a crucial role in the development and maintenance of a variety of psychopathological disorders e.g. depression (for review: kim et al., 2011), eating disorders (nechita et al., 2021), post-traumatic stress disorder (saraiya & lopez-castro, 2016). in order to avoid experiencing such shame and the rejection of others, people who suffer from these disorders avoid social situations to varying extents. sad is not only a highly prevalent but also a highly debilitating disorder (fehm et al., 2005; kessler, 2003). several studies show a significant positive correlation between shame proneness and sad (fergus et al., 2010; gilbert & miles, 2000; hedman et al., 2013; schuster et al., 2021; swee et al., 2021), although research on interventions specifically focusing on reducing (or preventing) exaggerated shame in sad is scarce. furthermore, inducing and reducing shame and fear 2 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ there is a lack of experimental studies on the modification of shame to isolate theoret­ ically important change processes. this is supported by a review of goffnett et al. (2020), which only includes one study investigating interventions to change shame in the context of sad. nonetheless, the review also showed the promising effect of psychotherapeutic inter­ ventions with a significant reduction in shame in a post-test in 89% across a variety of contextual aspects (ptsd, body image, borderline personality disorder, etc.). most of these studies used interventions based on cognitive-behavioral therapy (cbt) and mindfulness, while four of them applied compassion-focused interventions. compassionfocused therapy (cft; gilbert, 2010) is not only a promising approach for treating sad, for example (blackie & kocovski, 2018; goldin & gross, 2010; koszycki et al., 2016). self-compassion is a central construct of cft, which can be understood as a friendly and understanding self-perspective in difficult situations characterized by an understanding that suffering is an inevitable part of human nature, while accepting it in a mindful manner (neff, 2003b). nonetheless, self-compassion is more than simply friendliness; rather, it is about awareness of pain that may be present and having the intention to try to alleviate it (gilbert, 2010). studies have shown that patients with sad have lower self-compassion than healthy individuals (werner et al., 2012) and an intervention based on self-compassion can effectively reduce shame (see review of goffnett et al. (2020). this preliminary evidence suggests that cft might be especially efficacious for the treat­ ment of exaggerated shame, quite in accordance with the underlying theory: whereas shame is associated with a global negative devaluation of the self, self-compassion clearly counteracts this tendency as it promotes a loving relationship with the self. while shame involves a severe and judgmental emotional relationship with the self, self-compassion teaches an empathic approach. however, as common factors in psychotherapy might mask the effects of specific interventions, head-to-head comparison studies disentangling the most effective compo­ nents of psychotherapy can only be successful when based on extremely large patient samples. as mulder et al. (2017) suggest, studies based on online-based interventions that aim at transdiagnostic processes (such as shame) are very promising. thus, it is hypothesized that process-level variance can be more accurately elucidated by holding therapist variance constant. further, hofmann and hayes (2019) suggested a paradigm switch to a process-based therapy approach where moderators and mediators of clinical change are at the center of clinical research. we would like to add the notion that experimental studies that use micro-interventions and isolate theoretically important change processes like trait social anxiety, trait self-compassion and trait shame could also help to transcend the common factors problem (do psychotherapies work primarily through the specific factors described in treatment manuals, or common factors such as therapeutic relationship, expectations, confronting problems, mastery, and attribution of the outcome?). fink-lamotte, hoyer, platter et al. 3 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ to test the specific effectiveness of cft for shame in the context of different levels of social anxiety symptoms, we compared its effects with those of another established evidence-based emotion-regulation condition, cognitive reappraisal (reap), which is one of the best-evaluated emotion-regulation strategies (ochsner & gross, 2007). gross and thompson (2007) defined reappraisal as changing “a situation’s meaning in a way that alters its emotional impact” (p. 20). there is evidence that reappraisal can be helpful in reducing symptoms of social anxiety (for a review, see dryman & heimberg, 2018). this study thus aimed to test whether a self-compassion micro-intervention (comp) is superior in reducing shame in subjects with different levels of sa symptoms compared to a reap intervention and a control micro-intervention (cont). in the present study, the autobiographical emotional memory task (aemt) (mills & d’mello, 2014; prkachin et al., 1999) was used, as a method that has been proven to successfully induce shame (de hooge et al., 2010; friis et al., 2017; houazene et al., 2021; keng & tan, 2017). in the aemt, participants are instructed to remember a recent em­ barrassing social situation and focus on the associated emotions and feelings associated. to induce shame in an online experiment, we modified the aemt by including more detailed audio instructions. therefore, a further aim of the present study was to first generate data on the validity of the online version of the aemt and subsequently to test for the shame-specificity of the aemt. we define the manipulation check as successful when a) state shame is efficiently induced in all three micro-intervention conditions and b) the increase of state shame is more pronounced compared to state fear. due to theoretical assumptions on the specific effects of self-compassion for shame, we expect that comp will reduce shame more effectively than the reap and the cont (h 1). we also expect that the experimental induction of shame should lead to a higher level of shame in subjects with higher rather than lower levels of social anxiety (h 2.1). we thus expect that reap and comp result in a stronger reduction of shame and fear compared to cont in subjects with lower compared to higher levels of social anxiety (h 2.2: interaction of condition and anxiety group). material and method participants the participants were recruited using a university of leipzig internal database. as compensation for their participation, they either took part in a lottery (five vouchers worth 10 €) or received course credit. one-hundred-and-forty-four non-clinical subjects volunteered to participate and all provided written informed consent. respondents had to actively tick whether the following inclusion and exclusion criteria applied. inclusion criteria: good language skills in german, aged between 18 and 65 years, being in a quite environment and having the ability to listen to audio files. inducing and reducing shame and fear 4 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ exclusion criteria: being pregnant, suffering from a severe mental disorder other than social phobia or a severe health impairment, or a neurological disease (e.g. traumatic brain injury, falls with unconsciousness, neurodegenerative diseases, strokes, tic disor­ ders), psychotropic substance abuse (except coffee and nicotine) or benzodiazepine or neuroleptic medication. subjects could not continue the experiment if they denied presence of one of the inclusion criteria or agreed with the presence of one of the exclusion criteria at the end of the experiment, all subjects were asked if “something unusual” hap­ pened during the experiment. based on the responses, n = 12 subjects were excluded due to self-reported distraction, n = 2 were excluded due to self-reported technical problems, n = 2 due to unreasonably long experiment durations, n = 3 because of a more than 2 sd variance in trait questionnaires and n = 10 subjects were excluded because they stated that they had not carried out the micro-interventions at all, had dropped out beforehand, or had not mentioned anything at all concerning the interventions whereby it was not ensured that these subjects heard the intervention at all. in total, one-hundred-and-fif­ teen subjects were included in the statistical analysis, of whom n = 39 had been randomly assigned to comp, n = 37 to reap, and n = 39 to the cont. measures trait shame: tangney´s test of self-conscious affect the level of shame proneness was assessed using the german version (rüsch et al., 2007) of tangney´s test of self-conscious affect (tosca-3; tangney et al., 2000). the tosca-3, presenting 11 scenes (“you have broken an object at work and then hide it.”) with four reactions (e.g. “you would think about resigning.”) rated from 1, “not likely", to 5, “very likely", has been reported to have a high internal consistency (cronbach’s α > .77, in this study α = .66). the tosca-3 results in sum-scores for shame-proneness between 11 (low shame proneness) and 55 (high shame proneness). social anxiety: social interaction anxiety scale the severity of social anxiety was assessed using the german version (stangier et al., 1999) of the social interaction anxiety scale (sias; mattick & clarke, 1998). the 20-item scale (e.g. “i have difficulty making eye contact with others”), rated from 0, “not applica­ ble at all", to 4, “very much applicable", has a high internal consistency (patients with sad; n = 66; α = .86; healthy controls; n = 50; α = .90, in this study α = .94). the sum-scores ranging from 0 to 80. in the study of stangier et al. (1999) the social anxiety group showed a mean sum-score of 40.8 (sd = 16.6), the non-clinical group showed a mean sum-score of 12.5 (sd = 5.7). fink-lamotte, hoyer, platter et al. 5 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ trait self-compassion: self-compassion scale the self-compassion scale (scs; neff, 2003a; german version scs-d; hupfeld & ruffieux, 2011) was applied to measure the trait of self-compassion. the 26-item scale (e.g. “i disapprove and condemn my own faults and weaknesses.”), rated from 1, “almost never", to 5, “almost always", has been reported to have a high internal consistency (cronbach’s α = .91, in this study α = .89). the scs results in mean-scores for self-compassion trait between 1 (low) and 5 (high). state-trait anxiety inventory for state anxiety the short version of the state-trait anxiety inventory for state anxiety (stai-skd; englert et al., 2011) was applied to measure the level of state fear. the 5-item german translation (e.g. “i am nervous”), rated from 1, “not at all", to 5, “very much", has a high internal consistency (cronbach’s α > .84, in this study α = .9). the stai-skd results in mean-scores for state anxiety between 1 (low) and 5 (high). state shame and guilt scale the state variable shame was assessed in questionnaire format using self-assessment via the five shame items (e.g. “i feel small and insignificant”), rated from 0, “not applicable at all", to 4, “very much applicable", of the state shame and guilt scale (ssgs; marschall et al., 1994). an example item for shame is “i want to sink into the ground and disappear.” the ssgs results in mean-scores for state shame between 1 (low) and 5 (high) and has a high internal consistency (this study: cronbach’s α = .93). experimental design the influence of self-compassion vs. cognitive reappraisal vs. control on shame and fear was tested in an online experiment using unipark with a mixed subject design. while the differences between the comp, reap, and cont were analyzed by a between-sub­ ject design, time was assessed in a within-subject design. therefore, three data points (baseline, t0; post-induction, t1; post-intervention, t2) were recorded for each participant. in the study documentation, we reported how we determined our sample size, all data exclusion (if any), and all manipulations and measures conducted. procedure the data was collected between june and november 2020. on average, one trial lasted 42.3 minutes (sd = 16.14 minutes) and all experimental conditions took the same time, f(2,109) = .104, p = .901, d = .002. the participants were first informed of the details of the study and the test subjects’ written consent to participate was obtained. the participants then had to fill out the questionnaires listed above and state fear and shame were assessed with ssgs and stai-skd (t0). thereafter, shame was induced using auditory inducing and reducing shame and fear 6 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ instructions transmitted via headphones (see section “shame induction”). in the next step, state fear and shame were assessed again (t1) before participants received their randomization result and performed one of the three experimental conditions (comp vs. reap vs. cont, see sections “experimental conditions”). audio instructions were given over headphones. then, shame was induced again, followed by the third assessment of state fear and shame (t2). finally, questions regarding the usability and effectiveness of the manipulation ended the trial (see section “manipulation check”), followed by a debriefing. the schema of the experimental trial is shown in figure 1. figure 1 illustration of the experimental procedure inducing and reducing shame and fear 10 the influence of self-compassion vs. cognitive reappraisal vs. control on shame and fear was tested in an online experiment using unipark© with a mixed subject design. while the differences between the comp, reap, and cont were analyzed by a between-subject design, time was assessed in a within-subject design. therefore, three data points (baseline, t0; postinduction, t1; post-intervention, t2) were recorded for each participant. in the study documentation, we reported how we determined our sample size, all data exclusion (if any), and all manipulations and measures conducted. figure 1. illustration of the experimental procedure. 2.4.procedure the data was collected between june and november 2020. on average, one trial lasted 42.3 minutes (sd = 16.14 minutes) and all experimental conditions took the same time, f(2,109) = .104, p = .901, d = .002. the participants were first informed of the details of the study and the test subjects’ written consent to participate was obtained. the participants then had to fill out the questionnaires listed above and state fear and shame were assessed with ssgs and staiskd (t0). thereafter, shame was induced using auditory instructions transmitted via headphones (see section 2.5.1). in the next step, state fear and shame were assessed again (t1) before participants received their randomization result and performed one of the three control comp selfcompassion intervention reap intervention cognitive reappraisal shame induction (short) trait questionnaires t0: shame and fear shame induction (long) t1: shame and fear t2: shame and fear ra nd om iz at io n (baseline) (post-induction) (post-intervention) shame induction shame was induced using an auditive autobiographical emotional memory task (mills & d’mello, 2014; prkachin et al., 1999). the participants were instructed to remember a humiliating social situation and to focus on the emotions and feelings associated with it. if they could not think of such a situation, they were given another auditive instruc­ tion (icd-10 sad diagnostic criteria: e.g., focusing attention towards oneself, feeling physiological exacerbation). overall, the manipulation took six minutes. to isolate the intervention’s core effect from mere time-effects, all participants received a 3-minute short version of the aemt after the intervention for reasons of comparison (appendix a, supplementary materials). experimental condition: self-compassion intervention (comp) in the self-compassion intervention (comp), the subjects received auditory training to enhance self-compassion (desmond, 2017; gilbert, 2013; neff, 2003b). in different sections, the participants were guided through an imagination exercise to increase mind­ fulness and acceptance, to feel human connectedness, and to build self-friendliness and wisdom. the training was adapted from a previously used intervention by fink-lamotte et al. (2022) to the context of social anxiety and the duration of the procedure was 8 mi­ fink-lamotte, hoyer, platter et al. 7 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ nutes in total. a transcript of the instructions is attached in appendix b, supplementary materials. experimental condition: cognitive reappraisal intervention (reap) in the cognitive reappraisal intervention (reap), the subjects received an audio instruc­ tion to reevaluate maladaptive cognitions in social situations based on a previously used intervention by fink et al. (2018). in the context of a guided imagination exercise, the intervention aimed to reflect on factual knowledge, decatastrophize, and strengthen selfefficacy as well as appraise an alternative and more positive and empowering perception of the social situation. the duration of the procedure was 6:49 minutes in total and a transcript of the instructions is attached in appendix c, supplementary materials. control condition: counting fishes (cont) in the control condition, the participants had to watch a video of an aquarium with moving fishes. they were instructed to count the number of times a yellow fish swam in and out of the picture. the duration of the procedure was 6:30 minutes in total and the experiment was adapted from fink et al. (2018) and fink and exner (2019). manipulation check to check if the manipulation induced shame and/or anxiety, the participants received a four-item questionnaire. similarly, four items assessed the subjective evaluation of the effectiveness of the instructions provided. in addition, we invited participants to describe their personal experiences and strategies during the intervention (see appendix d, supplementary materials, for all materials concerning the manipulation-check). af­ ter the intervention, the participants were also asked to name specific aspects of the intervention that they perceived as helpful or hindering (appendix e, supplementary materials). statistical analysis the software r (r development core team, 2020) and jasp (jasp team, 2020) were used for the statistical analysis. the statistical investigations were tested at the α = .05 (two-tailed) level of significance. to test the manipulation check, two repeated anovas investigating the effects of condition (comp/reap/cont) and anxiety group, dividing the sample by a median split into low and high socially anxious groups, between t0 (before induction) and t1 (after induction), with t0 as a covariate, were calculated. these anovas were run for both dependent variables shame and fear, specifically testing the within-subject factor time for induction (t0/t1) and intervention (t1/t2), and were followed by bonferroni-corrected post-hoc tests for significant main effects and interactions. we are aware, that the media-split increases the probability of type i errors (maxwell & delaney, 1993), so we additionally ran two general linear mixed model inducing and reducing shame and fear 8 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ (glmm), with the continuous variable trait anxiety (sensitive analysis), which led to comparable results. furthermore, two ancovas investigating the effects of condition and anxiety group for the difference t1 (after induction) – t2 (after intervention) as dependent variable for shame and fear, with t1 as a covariate, were calculated. the addition of t1 (t0) as a covariate is to ensure that any change observed is not artifactually due to high t1 (t0) values (regression to the mean). if the effect of the condition is significant, the ancova was repeated for the pairs of conditions (each intervention is compared separately with the control) to test whether a difference between the interventions is greater than chance as indicated by the change in the control condition, which in turn would be tested by the condition term in the ancova. an overall anova was not calculated, because we expected an independent induc­ tion and an independent intervention effect. the effect sizes were calculated using the r package “rstatix” (version 0.4.0; kassambara, 2019) whereby the adjusted partial eta-squares (ηp2) are reported. a shapiro wilk test for normality was conducted, and the normality assumption was violated for both dependent variables. however, due to the sample size, it is possible to assume an approximate asymptotic normal distribution for each of these variables (field, 2013). a levene test for the homogeneity of variance was conducted for the dependent variables across the time and the homogeneity of variance was not violated for shame and fear at any time point, p > .05. to exploratively test the effect of individual traits on shame and fear reduction, either an analysis of covariance (ancova) or correlational analyses (pearson’s product-moment correlations) was calculated, depending on whether the experimental conditions differed or not. results demographic characteristics the three conditions were not statistically different concerning age, sex, level of social anxiety (sias), level of shame (tosca-3), level of self-compassion, or any of the other demographic or clinical data (see table 1). the median-split resulted in a low socially anxious group (n = 56, sex: 51 females [91%], age = 29.86 [sd = 11.54]) and a high socially anxious group (n = 59, sex: 45 females [76%], age = 28.98 [sd = 8.77]). these two groups did not differ a priori concerning age, t(113) = .456, p = .647, d = .086, trait compassion, t(113) = .784, p = .435, d = .146, and trait shame, t(113) = .292, p = .771, d = .055, but did differ – as expected – concerning social anxiousness, t(113) = .14.01, p < .001, d = 2.61. fink-lamotte, hoyer, platter et al. 9 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ table 1 demographics and clinical characteristics by condition characteristics comp (n = 39) reap (n = 37) cont (n = 39) stats p ηp2m sd / % m sd / % m sd / % sex (% female) 33:6 86% 31:6 84% 32:7 82% x2(2) = .064 .969 age 28.49 8.019 31.76 12.23 28.10 9.935 f(2, 112) = 1.810 .168 .032 highest educationa 2.821 .644 2.757 .641 2.872 .409 f(2, 112) = 0.382 .683 .007 social anxiety 33.05 21.15 28.30 16.69 26.23 14.24 f(2, 112) = 1.535 .220 .027 shame 33.63 2.56 32.22 2.729 32.68 2.85 f(2, 112) = 2.674 .073 .046 compassionb 3.29 .32 3.17 .38 3.23 .38 f(2, 112) = 1.036 .358 .018 note. comp = participants with the self-compassion intervention; reap = participants with the cognitive reap­ praisal intervention; social anxiety (sias = social-interaction-anxiety-scale); shame (tosca-3 = tangney’s test of self-conscious affect) compassion (scs = self-compassion scale). aeducational level was recorded in four levels matching the german school system from 1 [= highest secondary school level achieved (abitur)] to 4 [= basic secondary school level achieved (hauptschule)]. bself-compassion level was the average of the scs-score without the self-criticism subscales (neff, 2003a). hypothesis testing manipulation check: induction between t0 and t1 a repeated-measured anova investigating the effects of condition and anxiety group between t0 (before induction) and t1 (after induction) for shame as dependent variable, with t0 as a covariate, shows a significant main effect of the covariate t0, f(1,108) = 116.935, p < .001, ηp2 = .73, a main significant effect of time, f(1,108) = 47.233, p < .001, ηp2 = .304, and a significant main effect of anxiety group, f(1,108) = 4.998, p = .027, ηp2 = .044, but no significant main effect for condition, nor any other significant interaction, p > .37, ηp2 < .01. the bonferroni-corrected post-hoc results, controlled for the covariate, show a stronger shame experience in t1 compared to t0, m = .767, t = 8.952, p < .001, d = .835. however according to the bonferroni-corrected post-hoc results, there was no significant stronger shame experience in the high socially anxious group, m = .09, t = -.859, p = .392, d = .08, compared to the low socially anxious group (see figure 2a). a repeated-measured anova investigating the effects of condition and anxiety group between t0 (before induction) and t1 (after induction) for fear as dependent variable, with t0 as a covariate, shows a main significant effect of the covariate t0, f(1,108) = 291.32, p < .001, ηp2 = .73, a main significant effect of time, f(1,108) = 18.607, p < .001, ηp2 = .147, and a significant main effect of anxiety group, f(1,108) = 4.44, p = .037, ηp2 = .039, but no significant main effect for condition, nor any other significant interaction, p > .41, ηp2 < .02. the bonferroni-corrected post-hoc results, controlled for the covariate, show a stronger fear experience in t1 compared to t0, m = .51, t = 7.247, p < .001, d = .676 as well inducing and reducing shame and fear 10 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ as a stronger fear experience in the high socially anxious group, m = .15, t = -2.39, p = .019, d = .22, compared to the low socially anxious group (see figure 2b). hypothesis 1 and 2: emotion regulation between t1 and t2 and the impact of group an ancova investigating the effects of condition and anxiety group for the difference t1 (after induction) – t2 (after intervention) as dependent variable for shame, with t1 as a covariate, shows a significant main effect of the covariate t1, f(1,108) = 43.323, p < .001, ηp2 = .267, a marginally significant main effect of condition, f(2,108) = 2.98, p = .055, ηp2 = .037, and a significant main effect of anxiety group, f(1,108) = 4.378, p = .039, ηp2 = .027, but no significant interaction effect of condition and anxiety group, p > .85, ηp2 < .01. the tukey-corrected post-hoc results, controlled for the covariate, show a stronger shame reduction in the comp compared to the cont condition, m = .395, t = -2.441, p = .043, d = .523, but no significant differences between comp and reap, m = .204, t = -1.253, p = .425, d = .24, and reap and comp, m = .191, t = -1.175, p = .471, d = .224, as well as a stronger shame reduction in the high socially anxious group, m = .311, t = -2.092, p = .039, d = .37, compared to the low socially anxious group. the other post-hoc comparisons became not significant, p > .42, d < .22 (see figure 2a). an ancova investigating the effects of condition and anxiety group for the differ­ ence t1 (after induction) – t2 (after intervention) as dependent variable for fear, with t1 as a covariate, shows a significant main effect of the covariate t1, f(1,108) = 28.24, p < .001, ηp2 = .19, but no significant main effects of condition and anxiety group, nor a significant interaction effect, p > .42, d < .22 (see figure 2b). figure 2 means and standard error bars of the shame and fear experience between t0 (baseline), t1 (post-induction), and t2 (post-intervention) across the three experimental conditions note. shame ratings (a) and fear ratings (b) were given on a scale between 1 and 4. fink-lamotte, hoyer, platter et al. 11 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ explorative analysis: effects of individual traits on changing shame effect of individual traits on shame induction while the factor anxiety group was unrelated to shame induction, we also calculated pearson’s product-moment correlations between the dependent variable shame induction between t0 and t1 and the individual traits. the correlations between trait social anxiety, trait self-compassion, trait shame and the shame induction were all insignificant (all r between .07 and -.07, all p > .45). effect of individual traits on shame reduction to examine the association between the trait variables and shame reduction in more detail, an ancova investigating the effect of the three conditions for the difference t1 – t2 for shame, with t1, trait social anxiety, trait self-compassion and trait shame as a covariates, was calculated. the covariates trait social anxiety, f(1, 108) = 6.56, p = .012, ηp2 = .038, and trait self-compassion are significantly related to experimental condition, f(2, 108) = 1.874, p = .047, ηp2 = .023, while trait shame is not a significant covariate (p > .29). controlling for the effect of trait social anxiety and trait self-compassion, the significant main effect of condition on shame reduction between t1 and t2 becomes significant, f(2, 108) = 3.854, p = .024, ηp2 = .045. discussion the aim of the present study was a) to test an online-adapted method for inducing shame and b) to pilot-test two self-help interventions against heightened shame experiences. the results of this study show that the shame-based autobiographical emotional memory task could successfully induce both shame and fear. furthermore, the results show that a micro-intervention based on self-compassion can reduce shame significantly better than the control condition although this effect could only be shown for shame and not for fear. an exploratory analysis also showed that trait social anxiety and trait self-compassion moderated this effect. almost across all measurement time points, more shame and more fear were reported in the high socially anxious group compared to the low socially anxious group. confirming the first part of the manipulation check, the autobiographical emotional memory task used in this study was successful in inducing shame and fear and, accord­ ingly, should be further applied in future experimental studies. contrary to the second part of the manipulation check, shame and fear were induced with a similar intensity, when comparing the effect sizes. accordingly, this induction procedure cannot be labeled as being shame-specific, which at least in part might be due to fear and shame being overlapping and highly correlated emotional states (gilbert et al., 1994). however, to inducing and reducing shame and fear 12 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ further validate the induction procedure, the introduction of a divergent variable, e.g., an emotion such as joy, is clearly recommendable. furthermore, an induction task which is known to elicit feelings of shame even more precisely would certainly be desirable. in future research, of course, experimenters should further take care for applying the induction with ethical sensibility, as aemt could lead to increased stress especially in samples with vulnerable individuals. even though there is a main effect of social anxiety group, which underlines the link between shame and social phobic symptoms (fergus et al., 2010; gilbert & miles, 2000; lutwak & ferrari, 1997), the post-hoc effect did not become significant. further, the results did not confirm the interaction effect hypothesized in h 2.1, which implies that the induction of shame elicit higher level of shame in subjects with higher compared to lower levels of social anxiety. this might in part be explainable by the non-clinical nature of the sample (with limited variance in social anxiety severity), but it seems more likely that there was a ceiling effect in the socially anxious group, with their initially higher shame experience scoring leaving virtually no room for further increase in shame experiences on the likert scale. in the future, it might be useful to develop an empirical valence scale for shame (lishner et al., 2008) that takes such ceiling effects into account. in addition to exploring induction methods, the focus of the present study was on interventions to change exaggerated shame. here, in line with h 1, the results show that the micro-intervention based on self-compassion (comp) reduced shame with a medium effect size and significantly more strongly compared to a control condition (cont). this finding supports previous ones showing that interventions based on self-compassion can be helpful in regulating shame (cândea & szentagotai-tătar, 2018). this is particularly noteworthy because the control condition was an active distraction task that was also capable of producing an emotion-regulating effect. moreover, the preliminary results show that trait social anxiety and trait self-compassion moderates this effect, and that these traits could thus influence the effectiveness of self-compassion strategies. however, this would need to be investigated in more detail in future studies. interestingly, the stronger effect of the comp condition specifically compared to cont applies only to shame (and not fear) and thus does not seem to simply reflect a non-specific arousal effect. as the main effect condition became only marginally significant across all three conditions, the results need to be further verified, with the direct comparison between comp and cont reaching significance. future studies should investigate whether any type of active emotion regulation conditions could be similarly effective. the results of the present study however suggest that comp has benefits compared to active avoid­ ance. not confirming to h 1, the comparison with the other active regulation intervention, cognitive reappraisal (reap), did not show a significantly superior shame reduction of the comp condition. reap did not show superiority in shame reduction over the cont condition either, thereby indirectly indicating that comp might be preferable fink-lamotte, hoyer, platter et al. 13 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ in reducing shame. also contrary to h 2.2, reap and comp resulted not in stronger reduction of shame or fear in comparison to the control condition in subjects with higher levels of social anxiety. at the same time, the more socially anxious group reported more shame reduction during the intervention. thus, this finding supports the proposition that using self-compassion can be a successful approach to regulate shame for individuals with higher social anxiety symptoms (cf. blackie & kocovski, 2018; goldin & gross, 2010; koszycki et al., 2016). these results are also promising, in view of the transdiagnostic sig­ nificance of shame in a number of other psychopathologies e.g. depression (for review: kim et al., 2011), eating disorders (nechita et al., 2021), post-traumatic stress disorder (saraiya & lopez-castro, 2016). limitations the present study has some limitations. firstly, as this was an online study it could not directly be observed what the subjects did during the experiment and with what level of personal involvement they participated. we tried to experimentally control this limitation from the beginning with a series of open-ended questions. by asking the questions at the end, we hoped that it could reduce the effects of social desirability. in addition, we included subjects in the study conservatively, excluding n = 32 subjects from the analyses. nevertheless, the duration and the demands of the study might have introduced some unknown bias. a second limitation of this study is the non-clinical pop­ ulation, although previous research (abramowitz et al., 2003) postulated that thoughts and behaviors in psychological disorders differ more in their quantitative rather than qualitative aspects to those observed in non-clinical individuals and that basic aspects of psychological disorders (e.g., emotion regulation) can be investigated on a continuum between non-clinical individuals and patients. yet, the sample shows on average relative­ ly high social anxiety scores and a relatively wide variation of scores. both aspects are favourable for investigating our research questions. thirdly, this was a feasibility study with a piloting character without a formal a priori power analysis, and the study was not preregistered. these aspects are of course inevitable preconditions for possible repli­ cation studies in the future. fourth, the results might have been influenced by responder bias because self-report questionnaires were used for measuring the dependent variable. however, the response tendencies affect all conditions equally and thus should have no influence on differences between the conditions, but rather increase the “noise” of the main effect time. even though questions concerning shame and fear were not directly posed, further less biased measures, e.g., physiological measures should be included in future studies. fifth, it cannot be definitively ruled out that the effect is artifactual due to scale effects, even though we controlled for the initial measurement (t0/t1). by scale effects we mean that details of the information are lost due to the small range and the upper and lower limits of the scale. in future studies it would be helpful to use longerlasting, potentially even more intense interventions and follow-up measurements. lastly, inducing and reducing shame and fear 14 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://www.psychopen.eu/ future experiments might consider recording the broader variable “gender” instead of “sex”. conclusions and implications for further research the study had two aims: first, to examine the extent to which the autobiographical emo­ tional memory task is a helpful approach to induce shame experimentally in an online setting, and second, to find experimental evidence for superior effects of self-compassion in reducing subclinical shame (when compared with active control conditions). the re­ sults show that shame could be effectively induced in an experimental online study with the autobiographical emotional memory task, but that the induction also elicited fear which is why the procedure should be further developed and validated in future studies. in addition, the results show that even a short micro-intervention of self-compassion, unlike cognitive reappraisal, was significantly more efficacious in in down-regulating shame – also in healthy individuals with higher social anxiety symptoms – than a control intervention. additionally, the traits of social anxiety and self-compassion seem to moderate this effect. these results support the importance of self-compassion in the treatment of shame-related disorders. funding: this research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. acknowledgments: we would like to thank the individuals who participated in this study. the authors also thank lena lämmerhirdt and martin schmieder for their assistance in conducting the study. competing interests: the authors declare that they have no conflict of interest. ethics statement: this study was performed in line with the principles of the declaration of helsinki. approval was granted by the local ethics committee (no. 2020.02.09). twitter accounts: @jaemaf data availability: data and non-copyrighted materials can be publicly accessed (fink-lamotte et al., 2021a, 2021b, 2023) or will be made available by the authors on reasonable request. supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • the research data for this study • the codebook for the dataframe • the online appendices for the article fink-lamotte, hoyer, platter et al. 15 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://twitter.com/jaemaf https://www.psychopen.eu/ index of supplementary materials fink-lamotte, j., hoyer, j., platter, p., stierle, c., & exner, c. (2021a). supplementary materials to "shame on me? love me tender! inducing and reducing shame and fear in social anxiety in an analogous sample" [research data]. osf. https://osf.io/ne48g fink-lamotte, j., hoyer, j., platter, p., stierle, c., & exner, c. (2021b). supplementary materials to "shame on me? love me tender! inducing and reducing shame and fear in social anxiety in an analogous sample" [codebook]. osf. https://osf.io/gkam8 fink-lamotte, j., hoyer, j., platter, p., stierle, c., & exner, c. (2023). supplementary materials to "shame on me? love me tender! inducing and reducing shame and fear in social anxiety in an analogous sample" [online appendices]. psychopen gold. https://doi.org/10.23668/psycharchives.13165 references abramowitz, j. s., franklin, m. e., schwartz, s. a., & furr, j. m. 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(2012). selfcompassion and social anxiety disorder. anxiety, stress, and coping, 25(5), 543–558. https://doi.org/10.1080/10615806.2011.608842 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. inducing and reducing shame and fear 20 clinical psychology in europe 2023, vol. 5(3), article e7895 https://doi.org/10.32872/cpe.7895 https://doi.org/10.1080/10615806.2011.608842 https://www.psychopen.eu/ inducing and reducing shame and fear (introduction) material and method participants measures experimental design procedure statistical analysis results demographic characteristics hypothesis testing explorative analysis: effects of individual traits on changing shame discussion limitations conclusions and implications for further research (additional information) funding acknowledgments competing interests ethics statement twitter accounts data availability supplementary materials references aetiological understanding of fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome and classificatory analogues: a systematic umbrella review systematic reviews and meta-analyses aetiological understanding of fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome and classificatory analogues: a systematic umbrella review maria kleinstäuber 1 § , andreas schröder 2 § , sarah daehler 1 , karen johanne pallesen 3 , charlotte u. rask 2,4 , mathias sanyer 1 , omer van den bergh 5 , marie weinreich petersen 2 , judith g. m. rosmalen 6 [1] department of psychology, emma eccles jones college of education and human services, utah state university, logan, ut, usa. [2] the research clinic for functional disorders and psychosomatics, aarhus university hospital, aarhus, denmark. [3] danish centre for mindfulness, aarhus university, aarhus, denmark. [4] department of child and adolescent psychiatry, psychiatry, aarhus university hospital, aarhus, denmark. [5] department of health psychology, university of leuven, leuven, belgium. [6] university medical centre groningen, university of groningen, groningen, the netherlands. §these authors contributed equally to this work. clinical psychology in europe, 2023, vol. 5(3), article e11179, https://doi.org/10.32872/cpe.11179 received: 2023-01-21 • accepted: 2023-08-27 • published (vor): 2023-09-29 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: maria kleinstäuber, department of psychology, emma eccles jones college of education and human services, utah state university, 2810 old main hill, logan, ut 84322, usa. phone: +1 435 797 1236. email: maria.kleinstaeuber@usu.edu supplementary materials: materials [see index of supplementary materials] abstract background: this umbrella review systematically assesses the variety and relative dominance of current aetiological views within the scientific literature for the three most investigated symptomdefined functional somatic syndromes (fss) and their classificatory analogues within psychiatry and psychology. method: an umbrella review of narrative and systematic reviews with and without meta-analyses based on a search of electronic databases (pubmed, web of science, embase, psychinfo) was conducted. eligible reviews were published in english, focused on research of any kind of aetiological factors in adults diagnosed with fibromyalgia syndrome (fms), irritable bowel this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11179&domain=pdf&date_stamp=2023-09-29 https://orcid.org/0000-0002-4453-507x https://orcid.org/0000-0001-5211-4702 https://orcid.org/0000-0002-0072-3706 https://orcid.org/0000-0001-7543-5891 https://orcid.org/0000-0002-7426-0353 https://orcid.org/0000-0002-4785-2054 https://orcid.org/0000-0001-6394-7363 https://orcid.org/0000-0001-8141-2792 https://orcid.org/0000-0002-6393-0032 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ syndrome (ibs), chronic fatigue syndrome/myalgic encephalomyelitis (cfs/me), and somatic symptom disorder (ssd)/somatoform disorder (sfd). results: we included 452 reviews (132 systematic reviews including meta-analyses, 133 systematic reviews, 197 narrative reviews), of which 132 (29%) focused on two or more of the investigated health conditions simultaneously. across diagnoses, biological factors were addressed in 90% (k = 405), psychological in 33% (k = 150), social in 12% (k = 54), and healthcare factors in 5% (k = 23) of the reviews. the methodological quality of the included systematic reviews (k = 255) was low (low/ critically low: 41% [k = 104]; moderate: 49% [k = 126]; high quality: 10% [k = 25]). the high-quality systematic reviews suggest that deficient conditioned pain modulation, genetic factors, changes in the immune, endocrinological, gastrointestinal, cardiovascular, and nervous system, and psychosocial factors such as sexual abuse and pain catastrophizing increase the risk for fss. conclusion: only very few systematic reviews have used comprehensive, biopsychosocial disease models to guide the selection of aetiological factors in fss research. future research should strive for higher scientific standards and broaden its perspective on these health conditions. keywords chronic fatigue syndrome, myalgic encephalomyelitis, aetiology, fibromyalgia, irritable bowel syndrome, functional somatic syndromes, systematic review highlights • this is an umbrella review of 452 reviews on the aetiology of fss. • biological factors were most commonly examined as correlates of fss. • in 90% of the included reviews the methodological quality was low to moderate. • high-quality reviews found genetic, immuno-endocrinologic, gi, and cv risk factors. • high-quality reviews found psychosocial risk factors: sexual abuse, catastrophizing. how physicians conceptualize disease determines their attitude towards their patients and the problems they present (engel, 1977). this is particularly relevant in case of the so-called functional somatic syndromes (fss) (henningsen et al., 2007; wessely et al., 1999). fss are characterised by somatic symptoms that currently cannot be attributed to reproducibly observable pathophysiological processes, described by the rather outdated but in the past very popular term of medically unexplained symptoms (mus). medicine has a long tradition of struggling with classifying and understanding fss within the traditional disease model, resulting in a large variety of diagnostic labels that reflect the socio-cultural characteristics of a particular decade (neurasthenia, dacosta syndrome, soldier’s heart syndrome, etc.) (barsky & borus, 1999). in recent decades, fss have typically been investigated within a biopsychosocial model (engel, 1977), but substantial differences exist between physicians in their belief about the relative importance of cer­ tain factors to understand these syndromes. physicians who adhere to a purely biomed­ ical model might consider these health problems as non-diseases, resulting in reduced scientific interest and neglect in patient care. in contrast, physicians’ overemphasis aetiological understanding of fss 2 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ on psychosocial explanations might influence how such health problems are perceived publicly and might induce stigma. epidemiological research suggests that fss are closely related and partly overlapping (donnachie et al., 2020; fink & schröder, 2010; janssens et al., 2015; wessely et al., 1999), although some syndrome-specific aetiological factors have been found (hamilton et al., 2009). nevertheless, a variety of diagnostic labels are used, each based on the presence of a selected set of symptoms (fink & schröder, 2010), leading to unwanted diversity in diagnostic practice and clinical management (budtz-lilly et al., 2015; creed, 2006; wolfe, 2009). diagnoses of fss that are common in general medical settings as well as in med­ ical specialties such as rheumatology, gastroenterology, or neurology are fibromyalgia syndrome (fms) (clauw, 2014), irritable bowel syndrome (ibs) (ford et al., 2018), or chronic fatigue syndrome/myalgic encephalomyelitis (cfs/me) (haney et al., 2015). whereas in psychiatry and in psychology the diagnostic label of somatoform disorders (sfd) was introduced in the 4th edition of the diagnostic and statistical manual for mental disor­ ders (dsm-iv; american psychiatric association, 2000). the diagnostic category of sfd which mainly focused on excluding a medical explanation of the somatic symptom(s) was replaced by the somatic symptom disorders (ssd) in the 5th edition of the dsm (dsm-5; american psychiatric association, 2013). ssd include syndromes of medically unexplained as well as syndromes of explained symptoms and – in comparison dsm-iv – rather emphasise the psychological distress associated with poor symptom manage­ ment and psychological features such as extensive anxiety, dysfunctional thoughts and behaviours associated with the somatic symptom. besides these diagnostic entities in dsm-iv and -5, several other concepts of mus were established. for example in research literature concepts of multiple mus such as the somatic symptom index-4/6 (escobar et al., 1989) were introduced. in this paper we will refer to single fss (including ibs, fms, cfs/me). we will summarise studies that include patients with multiple mus in a sense of somatoform disorders, or other syndromes of multiple mus under the umbrella term ssd. this variety of diagnostic labels reflects also different aetiological views (ford et al., 2018; haney et al., 2015; schröder & fink, 2011) with important consequences. for exam­ ple, compared to receiving a somatic diagnosis, a psychiatric diagnosis for fss-related symptoms importantly impacts the patient’s behaviour, the patient-physician interaction (budtz-lilly et al., 2015; wolfe, 2009), and is associated with more stigma. previous research has shown that if patients present their symptoms with a more somatic versus psychosocial focus, they are more likely to receive a somatic diagnosis (salmon et al., 2007). consequently, receiving a psychiatric vs. somatic diagnosis for the same problem might influence the availability of certain healthcare services for patients. fss are highly prevalent, up to 22% in primary care (de waal et al., 2004) and up to 66% in some medical specialties (nimnuan et al., 2001). associated functional limitations are as severe as in well-defined chronic physical diseases (joustra et al., 2015). direct kleinstäuber, schröder, daehler et al. 3 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ medical costs and indirect costs as a consequence of sick leave and disability are high (ford et al., 2018; rask et al., 2015). given this high prevalence and associated burden, a shared conceptualisation of fss is urgently needed in order to optimise clinical manage­ ment (murray et al., 2016; yon et al., 2015). facing this challenge, we systematically assessed the variety and relative dominance of current aetiological views – i.e., from genes to biochemistry, pathophysiology, indi­ vidual psychological features, and cultural and healthcare factors – as represented in the scientific reviews on these health conditions across different syndrome definitions. we selected the three most well-described fss (ibs, fms, cfs/me) and the somatic symptom disorders (ssd, focusing on individuals with syndromes of multiple medically unexplained symptoms or the precedingly used diagnostic label of somatoform disor­ ders). the objectives of this review were to identify the predominant aetiological factors and proposed illness mechanisms in existing research literature to explain fss and ssd, and to explore the level of evidence for aetiological factors and proposed illness mecha­ nisms according to systematic reviews and meta-analyses. the methodological quality of reviews for specific investigated aetiological factors across syndrome definitions was evaluated, and the few currently well-documented aetiological factors are discussed. finally, we provide implications for research. method literature search a literature search was performed in medline (pubmed) and embase (embase.com) in january 2016, in psycinfo (ovid) and web of science (clarivate analytics) in february 2016. the searches were updated in august 2017, february 2020, and january 2022. we included meta-analyses, systematic reviews, and narrative reviews, published in english between 1990 and the search dates, which focus on research of aetiological factors and/or illness mechanisms in functional somatic syndromes (fss) and somatic symptom disor­ ders (ssd) in adults. narrative reviews were included to give a comprehensive overview as they form a large part of the available reviews. more specifically, we included reviews on the three most investigated fss – chronic fatigue syndrome/myalgic encephalomyeli­ tis (cfs/me), irritable bowel syndrome (ibs), and fibromyalgia syndrome (fms) –, and on somatic symptom disorders (ssd) (focusing on individuals with syndromes of multi­ ple medically unexplained symptoms [mus] or the precedingly used diagnostic label of somatoform disorders and classificatory equivalents). the complete search strategy is available in the supplementary material 1 or from prospero 2017 crd420170535961. 1) https://www.crd.york.ac.uk/prosperofiles/53596_strategy_20170105.pdf aetiological understanding of fss 4 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.crd.york.ac.uk/prosperofiles/53596_strategy_20170105.pdf https://www.psychopen.eu/ data extraction titles, abstracts, and full texts of studies retrieved using the search strategy were en­ tered at the covidence platform2. subsequently, the title and abstract of each retrieved reference were screened online by two review team members independently to identify reviews that met the eligibility criteria. next, the full text of potentially eligible reviews was independently further assessed for inclusion by two review team members. two raters tried to solve disagreements by finding consensus, if necessary, by involving a third review author. a standardized, pilot tested form was entered at the redcap-platform (harris et al., 2009), hosted at aarhus university and utah state university, and was used to extract data from the finally included reviews (box 1, for details, see prospero protocol3). for each eligible review, two review authors extracted data independently, discrepancies were identified and resolved through consensus discussion, with a third author where necessary. we did not allow raters to extract data and score quality of reviews they had authored. box 1 data that were extracted by two independent researchers from each review • type of review: narrative vs. systematic with/without meta-analysis • diagnostic concept: broad diagnostic concept vs. specific diagnosis • diagnoses covered: ibs, fms, cfs/me, ssd, others • number of included studies • minimum and maximum number of participants in the included studies • type of sample: clinical vs. population-based • aetiological domains covered: biological, psychological, social, health care system • main finding, and magnitude of main finding(s) for meta-analyses • authors' interpretation of the main findings • methodological quality, based on amstar-2 methodological quality the methodological quality of each included review was assessed using the assessment of multiple systematic reviews (amstar) (shea et al., 2007). amstar was developed 2) https://www.covidence.org 3) see footnote 1. kleinstäuber, schröder, daehler et al. 5 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.covidence.org https://www.psychopen.eu/ for critically appraising systematic reviews of randomised clinical trials. we adjusted the tool for our purposes as described below. according to the instructions of amstar-2 (shea et al., 2017), critical domains of the quality of reviews have to be identified. for this purpose three authors (mk, cr, and jr) independently indicated which of the 11 items of the original amstar tool (shea et al., 2007) indicated critical flaws, with discrepancies solved by consensus. the resulting unanimous critical items were item 3 (was a comprehensive literature search performed?), item 6 (were the characteristics of the included studies provided?), and item 8 (was the scientific quality of the included studies used appropriately in formulating conclusions?). overall confidence in the results of the review was rated according to the amstar-2 guidance as high (zero or one non-critical weakness), moderate (more than one non-critical weakness but no critical flaws), low (one critical flaw with or without non-critical weaknesses), or critically low (more than one critical flaw with or without non-critical weaknesses). data synthesis and analysis first, we obtained descriptive statistics of the frequency of diagnoses studied in the inclu­ ded reviews (fms, ibs, cfs/me, ssd), and of the type of review (narrative, systematic, meta-analysis) according to the year of publication. we distinguished between reviews that were diagnosis-specific, i.e., explored only one fss diagnosis, and reviews that were based on a broad diagnostic concept, i.e., investigated at least two fss simultaneously, sfd, ssd, and classificatory equivalents. reviews that, for instance, investigated both fms and other pain syndromes simultaneously were regarded broad reviews, but only data on fms were extracted. second, we analysed the predominant aetiological approach per diagnostic category, i.e., the frequency with which each domain of aetiological factors (see box 1) was addressed. we defined reviews that assessed multiple aetiological factors from at least two aetiological domains simultaneously as those investigating a broad biopsychosocial model. third, we analysed the frequency of specific aetiological factors per diagnostic category. fourth, we assessed the methodological quality (high – moderate – low – critically low) for systematic reviews with or without meta-analysis per year of publication. fifth, we provide a detailed overview of the few high-quality systematic reviews and analysed the associations of the investigated aetiological factors with fss. patient and public involvement the central aim of our review was to systematically assess and analyse the variety and relative dominance of current aetiological views represented in systematic reviews of certain fss. this research question did not provide opportunities to involve patients in the design, conduct, or reporting of our review. however, we plan to involve patients in aetiological understanding of fss 6 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ disseminating our research findings (e.g., by presenting our results at meetings of patient interest and support groups). results search results and descriptive variables of included reviews we identified 5,605 reviews and assessed 980 full text articles for eligibility (see prisma checklist in the supplementary material 8 and prisma flow chart in supplementary material 10). we excluded 526 articles and included 454 articles (reporting on 452 reviews) in our descriptive analysis. lists of all excluded and included reviews are in the online supplementary material (supplementary material 2 and 3). supplementary material 4 provides characteristics of included systematic reviews with and without meta-analyses. characteristics of included narrative reviews are sum­ marised in supplementary material 5. figure 1 provides the frequency of diagnosis-specific reviews (a-c) and reviews with a broader diagnostic conceptualisation (d) per publication year since 1990, divided into narrative reviews (k = 197), systematic reviews without meta-analyses (k = 123), and with meta-analyses (k = 132). the majority of reviews (71%, 320/452) were diagnosis-specific and of these 51% (164/320) were done in ibs. focusing on systematic reviews with meta-analyses only, we found the same tendency: 74% (98/132) were diagnosis-specific and of these 62% (61/98) were ibs-specific. while the numbers of reviews on fms and cfs/me (from the pool of all included reviews) were comparable (88 and 68, respective­ ly), the number of systematic reviews with meta-analyses on fms (k = 26) was almost twofold compared with cfs/me (k = 11) (figure 1, a and c). we identified 17 reviews on ssd only, 3 narrative, 8 systematic without meta-analyses, and 6 systematic with meta-analyses. these are reviews summarised under reviews with a broader diagnostic concept in figure 1d. predominant aetiological approach in fms, ibs, cfs/me, and ssd figure 2 provides the frequency of reviews covering biological (a), psychological (b), social (c), and healthcare (d) aetiological factors per publication year since 1990, divided into narrative reviews, systematic reviews with and without meta-analyses. in total 90% (405/452) of all reviews proposed or investigated biological factors to explain fss, while 33% (150/452) proposed psychological, and 12% (54/452) social factors (figure 2a-c). several reviews included more than one group of aetiological factors (28%, 127/452), i.e., investigated aetiology on different levels simultaneously. healthcare factors were dis­ cussed in 5% of the reviews (23/452) only (figure 2d). the primary scientific interest was also pronounced in systematic reviews with meta-analyses: 88% (116/132) investigated biological factors, while only 20% (27/132) explored psychological, social, or healthcare kleinstäuber, schröder, daehler et al. 7 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ factors. there was no indication that this relative dominance of biologically oriented reviews and meta-analyses changed during the past 20 years. supplementary material 4 and 5 shows that only 19% (87/452) of the included reviews are published in journals that are categorised in the field of psychiatry or social sciences (e.g., psychology, behavioural sciences, multidisciplinary sciences, sport sciences, public/environmental/occupational figure 1 a-d. frequency of diagnosis-specific (a-c) and broad reviews (i.e., covering more than one fss diagnosis and ssd) (d) per year of publication since 1990, divided into narrative reviews, systematic reviews without and systematic reviews with meta-analyses note. reviews focusing on somatic symptom disorder are summarised under reviews with a broad diagnostic concept. fms = fibromyalgia syndrome; fss = functional somatic syndrome; ibs = irritable bowel syndrome; cfs / me = chronic fatigue syndrome / myalgic encephalomyelitis; ssd = somatic symptom disorder. aetiological understanding of fss 8 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ health), whereas the remaining reviews were mostly published in medical journals (e.g., gastroenterology, neurology, rheumatology) or journals in biology and pharmacology. figure 3 provides the aetiological domains covered in diagnosis-specific reviews of fms (a), ibs (b), cfs/me (c) and reviews with broad diagnostic concepts (more than one fss or ssd) (d). the dominance of a primarily biological approach (i.e., the attempt to describe the aetiology on a basic or “mechanistic” level only) was most evident in figure 2 a-d. frequency of reviews (regardless investigated diagnoses) covering biological (a), psychological (b), social (c) and healthcare (d) factors per year of publication since 1990, divided into narrative reviews, systematic reviews without and systematic reviews with meta-analyses note. one review may cover several factors, and hence appear in more than one of the figures a-d. kleinstäuber, schröder, daehler et al. 9 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ ibs-specific reviews: 96% (158/164) covered biological factors, while only 26% (42/164) covered psychological and 11% (18/164) social factors. a broad biopsychosocial model (i.e., acknowledging the interplay of aetiological factors) was proposed in 30% (49/164). the distribution of investigated domains of aetiological factors was similar in fms, with 92% (81/88) addressing biological factors, 31% (27/88) psychological factors, 5% (4/88) social factors, and 25% (22/88) a broad biopsychosocial model. regarding cfs/me, in 28% (19/68) of the reviews addressed psychological factors, 13% (9/68) social factors, and broad models were included in 24% (16/68). however, the proportion of reviews investigating biological factors was with 91% (62/68) also high for cfs/me. figure 4 displays the number of systematic reviews (with and without meta-analyses) that investigated specific biological or psychosocial aetiological factors for each fss diag­ nosis. investigated biological factors included nervous and autonomic nervous system, sleep, hypothalamus pituitary adrenal (hpa)-axis, immune system, infection, vitamins and minerals, intestinal structure and function, intestinal bacterial composition, diet figure 3 a-d. aetiological domains covered in diagnosis-specific reviews (a-c) and reviews applying a broad diagnostic concept (d) note. one review may propose or investigate more than one aetiological factor. 'multiple factor domains' indicates reviews that include two or more domains simultaneously. fms = fibromyalgia syndrome; fss = functional somatic syndrome; ibs = irritable bowel syndrome; cfs / me = chronic fatigue syndrome / myalgic encephalomyelitis; ssd = somatic symptom disorder. aetiological understanding of fss 10 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ and body mass index (bmi), physical exercise, tobacco and alcohol use, mitochondrial structure or function and metabolism, muscular and cardiorespiratory metabolism, repro­ ductive system, genetic polymorphisms and epigenetic changes, parental biological fac­ tors, comorbid fss or somatic illness, and prenatal or perinatal factors (supplementary material 6a). psychosocial factors also embraced a wide variety of aetiological theories, from developmental issues such as early trauma or impaired affect regulation, over learn­ ing processes such as attentional bias or conditioning, to specific illness behaviours or coping styles, and finally personality structure or interindividual (i.e., social or societal) factors (supplementary material 6b). methodological quality the figures in supplementary material 10 provide the number of systematic reviews per publication year within the four quality strata. in general, the quality of reviews was low. of the 255 included systematic reviews (with and without meta-analyses), the quality of 35 (14%) was critically low, 69 (27%) was low, 126 (49%) was moderate, and only 25 figure 4 frequency of specific investigated biological and psychosocial factors in systematic reviews, divided into reviews addressing irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and reviews covering somatic symptom disorder or more than one of the investigated diagnoses simultaneously kleinstäuber, schröder, daehler et al. 11 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ (10%) were considered of high quality. figures a-d in supplementary material 9 also display the median year of publication within each quality category, ranging from 2015 for reviews of critically low quality to 2019 for reviews of moderate quality. the median publication year of the 25 high quality reviews was 2019 (range 2007-2021). of these, 12 were ibs-specific, 3 fms-specific, 2 cfs/me-specific and the remaining 8 reviews were on individuals with multiple fss. currently well-documented aetiological factors the table in the supplementary material 7 provides a detailed overview of the content and findings of the 25 systematic reviews of high quality. moderate associations of previous gastrointestinal infections with ibs were reported in six reviews (klem et al., 2017; li et al., 2020; saha et al., 2022; schwille-kiuntke et al., 2015; svendsen et al., 2019; wang et al., 2023). limitations of these findings are high heterogeneity (klem et al., 2017), and potential publication bias (schwille-kiuntke et al., 2015). moreover, only a low number of reviews reported on specific pathogens and the results of the synthesis of data from these few reviews has to be interpreted with caution (svendsen et al., 2019). ibs was the most commonly examined fss regarding the previous infections as potential risk factor. there was only one study that examined relationship between a previous infection, a human herpes virus (hhv)-6 infection, and cfs (mozhgani et al., 2022). the meta-analysis showed a 1.7 times increased risk in individuals with cfs to have a previous hhv-6 infection compared to healthy controls. lactose intolerance, but not lactose maldigestion, was identified as risk factor of ibs in one review (varjú et al., 2019). differential analyses for ibs subtypes were done only in a small number of included studies (varjú et al., 2019). thus, conclusions of which subgroups are mostly affected by lactose intolerance cannot be drawn. included studies vary substantially regarding the diagnostic criteria of ibs and diagnostic threshold of the lactose intolerance test (varjú et al., 2019). gastrointestinal dysbiosis, measured as count of lactobacillus, bifidobacterium, e coli, and enterobacter, significantly deviated between individuals with ibs and healthy control subjects (wang et al., 2020). here again, the increased heterogeneity of the studies included to the review limits the interpretability of the findings. apart from lower vitamin e levels, no associations were found between vitamins or minerals and cfs or fms (joustra et al., 2017). the role of genetic factors, functional polymorphism in the gene encoding for activity of the serotonin transporter protein (sert-p), was examined in individuals with ibs in two reviews (van kerkhoven et al., 2007; zhu et al., 2018). results are mixed, one analysis showed an increased risk of ibs associated with a functional polymorphism in the sert-p gene (zhu et al., 2018), whereas the other review showed no association (van kerkhoven et al., 2007). two recent meta-analyses found low to moderate associations for parasympathetic nervous system activity as measured by means of high-frequency heart-rate variability (hrv) for ibs and fms (sadowski et al., 2021; tracy et al., 2016). however, these estimates are based on only three to four studies aetiological understanding of fss 12 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ per diagnosis, including a double publication on the same sample for fms (sadowski et al., 2021; tracy et al., 2016). additionally, one meta-analysis found changes in para­ sympathetic activity/hrv in a mixed group of cfs, fms, and ibs patients, although these differences disappeared after correction for publication bias (tak et al., 2009). a weak association between hypocortisolism (i.e. hpa dysfunction) and cfs/me was found (tak et al., 2011). one review examined the immune status in individuals with fms (andrés-rodríguez et al., 2020). compared to healthy controls, effect sizes indicated an increased level of different types of interleukins in subjects who are diagnosed with fms. another review showed a significantly decreased level of conditioned pain modulation in individuals with ibs compared to a healthy control sample (albusoda et al., 2018). amiri et al. (2021) demonstrated a significantly lower nociceptive flexion reflex threshold in patients with fms. the nociceptive flexion reflex is a physiological, polysynaptic reflex triggered by a nociceptive stimulus activating a withdrawal response (smith et al., 2017). a decreased nociceptive flexion reflex threshold has been discussed as a possible biomarker of central sensitization that may cause alteration of central nervous system processing in individuals with chronic musculoskeletal-related pain condition (smith et al., 2017). núñez-fuentes et al. (2021) examined in their meta-analysis an association between alterations in postural balance and fms. the authors demonstrated large effects indicating that patients with fms show significantly worse scores on a variety of differ­ ent measures of postural balance compared to healthy controls. the following psychological variables were examined in high-quality reviews: history of sexual abuse and pain catastrophising. moderate associations were reported for a history of sexual abuse and a lifetime diagnosis of ibs (paras et al., 2009). the association of sexual abuse with fms is less straightforward; it was only significant in a sensitivity analysis that was restricted to severe abuse, specifically rape (paras et al., 2009). limi­ tations include unexplained heterogeneity, methodological limitations, recall bias, and the unknown generalisability to men, since studies were mainly performed in women. finally, one review showed that pain catastrophising explains to a moderate extend variance of pain intensity and disability in individuals with a combination of fms and cfs/me (martinez-calderon et al., 2019). discussion statement of principal findings this systematic umbrella review assessed the variety and relative dominance of aetiolog­ ical factors in both narrative and systematic reviews of the three most acknowledged fss and ssd (focusing on individuals with syndromes of multiple medically unexplained symptoms [mus] or the precedingly used diagnostic label of somatoform disorders and classificatory equivalents). although the number of systematic reviews has been increas­ kleinstäuber, schröder, daehler et al. 13 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ ing substantially in recent years, the review quality has only marginally improved. almost three-quarter of the reviews was diagnosis-specific, with ibs being the most prominent syndrome. very few reviews have taken a broad view across diagnoses. this is remarkable given the substantial diagnostic overlap among syndromes. this means that most individuals who are included in a study of ibs, for example, may suffer from other, co-morbid fss – however, very few original studies on ibs distinguish between study participants who have ibs only, and those who have ibs with concomitant other fss. results of a recently published systematic review of cohort studies on predictors of the onset of persistent somatic symptoms confirm a similar focus on irritable bowel syndrome (kitselaar et al., 2023). it is important to note that the overlap between the medical and psychiatric diagnoses has been reduced in the most recent version of dsm (american psychiatric association, 2013). sfd were included in dsm-iii (american psychiatric association, 1980) and dsmiv (american psychiatric association, 2000), and these diagnoses were based on the presence of somatic symptoms for which there were no demonstrable organic findings or known physiologic mechanisms. dsm-5 (american psychiatric association, 2013) replaced this category, given that it was not considered appropriate to make a mental disorder diagnosis solely because a medical cause of the somatic symptoms cannot be demonstrated. the new diagnosis of ssd is made based on the presence of somatic symp­ toms, explained or unexplained, in combination with dysfunctional cognitions, emotions, or behaviours. this implies that the overlap in diagnostic criteria between fss and ssd is largely reduced. our umbrella review clearly showed a predominance of the biological perspective: biological factors were included in 90% of reviews, whereas 33% discussed psychological factors; only 28% discussed two or more domains of aetiological factors. only 5% and 12% discussed healthcare or societal factors, respectively. this biological predominance, i.e. interest on the most basic aetiological level seems to be common and has also been demonstrated in other recently published systematic reviews, for example a review on cohort studies on predictors of the onset of persistent somatic symptoms (kitselaar et al., 2023). it is in contrast with the views of many health care professionals and with current prevailing clinical management strategies that focus on doctor-patient communication, patients’ illness perceptions and illness behaviours, and other healthcare and psychoso­ cial factors (henningsen et al., 2007; henningsen, zipfel, et al., 2018). in other words, the predominant management strategies are not backed up by firm aetiological research. this discrepancy between theoretical assumptions guiding clinical practice and those directing the dominant research focus seems to rely on fundamentally different views on causality and explanatory mechanisms, thereby contributing to enduring controversy and heated debates about legitimisation and “epistemic justice” to patients with fss (bernstein, 2016; cohen, 2017; mikocka-walus et al., 2016; spandler & allen, 2018). aetiological understanding of fss 14 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ specific aetiological factors included both previous or trait factors as well as current or state factors. while predisposing or triggering risk factors may help to identify people at risk or to prevent the development of fss through control or even elimination of such factors, current or perpetuating factors may be of special interest, as these are potentially modifiable and therefore may be targets for intervention. the few high-quality reviews suggest that both biological (e.g., infection) and psychosocial (i.e., history of sexual abuse or pain catastrophising) factors can increase the risk of fss. this is in line with current illness models for fss (e.g., deary et al., 2007). four high quality reviews suggest involvement of the ans in painful fss (sadowski et al., 2021; tak et al., 2009; tracy et al., 2016) in painful fss and syndromes of fatigue and exhaustion (tak et al., 2011). these findings suggest that different symptom clusters may be associated with specific pathophysiological pathways, while a more general dysfunction in interoception may be generic and of relevance for all fss (henningsen, gündel, et al., 2018). in summary, these high quality reviews show that there is a multiplicity of factors associated with fss. this could be interpreted as an indicator of subgroups in a group of people diagnosed with a particular syndrome, who have different aetiological pathways. a recently published study (kendler et al., 2022) examined genetic risk patterns in fss such as ibs, cfs, and fms as well as in a prototypic mental health condition, such as depression, and a prototypic somatic condition, rheumathoid arthritis. the authors could demonstrate unique profiles of family genetic risk scores in individuals with specific single fss that were very different to major depression and rheumatoid arthritis. anoth­ er recently published study (creed, 2022b) examined risk factors in individuals with self-reported ibs. this study identified partly overlapping and partly unique patterns of risk factors for a subgroup of ibs patients with previous mental health conditions compared to individuals with ibs but no previous mental health problem. there is another important aspect that we have to consider when we interpret the high-quality reviews included in our umbrella review: we observe a relative infrequency of studies that measure several putative risk factors simultaneously. there are some sin­ gle examples, such as the rather “biological“ study of ibs by dunlop et al. (2003) which examined risk factors simultaneously. dunlop et al. (2003) found that both increased enterochromaffin cell counts and depression were equally important predictors of devel­ oping post-infectional ibs. however most studies of biological factors in our umbrella review fail to include a psychological or social measure in addition to the biological one. another example concerned fibromyalgia, for which numerous somatic symptoms are a risk factor (creed, 2022a). however, a study by creed (2022a) demonstrated that there are new onset cases of fms with only few somatic symptoms and that this subgroup of fms patients shows, compared to individuals with fms and numerous other somatic symp­ toms, a unique pattern of risk factors. these results are in accordance with kendler’s concerns that we finally have to withdraw from the dualistic or dichotomous thinking within psychiatry and have to acknowledge that biological, psychological, and social kleinstäuber, schröder, daehler et al. 15 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ cultural domains are inter-twined with each other in aetiological pathways (kendler, 2012). strength and weaknesses of the review our review has a few limitations. first, we only included the most common fss. other intensively investigated syndromes or symptoms, such as chronic low back pain, might have added other well-documented aetiological factors (vlaeyen et al., 2018). second, systematic reviews of chronic pain not always provided specific results for primary pain as opposed to mixed pain, or secondary pain, and it was often difficult to extract specific details for fms and ibs from those reviews. third, our quality rating was done using a tool that was constructed for the evaluation of reviews of intervention trials. fourth, we only included reviews, meaning that the most novel aetiological factors as investigated in empirical studies may not have been covered. finally, the reviews included in our umbrella review are mainly based on studies implementing cross-sectional designs. we did not include animal research that would allow experimental designs and conclusions about causal factors. our review has also important strengths. first, it is the first comprehensive overview that covers aetiological factors of the most well-known fss together. second, both med­ ical and psychiatric definitions of these syndromes were used, thereby avoiding bias. third, we restricted our analysis to reviews which are typically the primary sources for guidelines that affect daily clinical practice. finally, we were interested in aetiological factors on various levels. therefore, we regard this review a very first step to unravel the "dappled nature of causes" of these syndromes (kendler, 2012). implications for research and clinical management our results have important implications for future research: first, we showed that the fss are largely studied separately, with only a minority of reviews including more than one syndrome, despite the empirical overlap in symptoms and shared non-symptom characteristics of the patients (wessely et al., 1999) suggesting that they constitute a family of disorders (fink & schröder, 2010; janssens et al., 2015). future studies should investigate them together, since this could facilitate the identification of both syndromespecific and generic aetiological and pathogenic factors at different levels, which would critically inform the discussion between “splitters” and “lumpers” (fink, 2017). second, current explanatory models promote a biopsychosocial approach to diseases in general (rief & broadbent, 2007; witthöft & hiller, 2010). however, since the appear­ ance of ibs, fms and cfs/me as mesh terms in medline from 1989 onwards, very few systematic reviews have used comprehensive disease models to guide the selection of aetiological factors in fss research. the still widely acknowledged dualistic "hardware versus software" rationale likely has slowed down scientific progress and might continue aetiological understanding of fss 16 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ to do so (fink & schröder, 2010; rosmalen, 2010) until it is replaced by empirically based pluralism (kendler, 2012). it would be a major step forward if different groups of aetiological factors on different levels would be combined into one longitudinal, multidisciplinary study, in order to examine their interrelations (rosmalen, 2010). this is currently done in a number of large epidemiological studies, e.g., danfund (dantoft et al., 2017) and lifelines (scholtens et al., 2015). our review also has important implications for clinical management: the knowledge about aetiological factors that has been gained from our review has to be translated into explanatory models for single patients. for each individual case the contribution of biological, psychosocial, and healthcare factors has to be weighted, acknowledged, and negotiated with the patient. after all, it is the individual patient’s history of risk and protective factors as well as his/her/their needs and wishes that is the foundation on which personalised care is built, not the theoretical preferences of the clinician (gask, 2018). conclusions and future research in summary, our umbrella review reveals that the literature on aetiological factors in fss and ssd is predominantly characterised by a diagnosis-specific perspective with a focus on biological factors, based on a purely biomedical conceptualisation of fms, ibs and cfs/me as distinct disease entities. ssd, or the previously used diagnostic category somatoform disorders, is only sparsely investigated. the majority of reviews provide expert views rather than firm results, and overall the reviews are very often of low quality and mostly implement only cross-sectional designs. we however identified 25 systematic reviews, partly including meta-analyses, that provide information of a variety of biological factors and some psychological factors that function as potential mecha­ nisms. the information gained from these high-quality studies should be translated into explanatory models for patients. we believe that future research should strive for higher scientific standards and more interdisciplinary research collaboration. we recommend that more research work should focus on examining the different fss together. examining differences as well as similarities of specific fss could be reached by an approach that uses the same data set gained in the same population (monden et al., 2022). recognising these health conditions as closely related and including all relevant factors that potentially play a role may lead to distinguishing evidence-based subtypes or syndromes that may benefit from per­ son-centred approaches. it is our hope that this review contributes to the development of a commonly accepted and evidence-based conceptualisation of fss and ssd in both medicine and psychiatry. kleinstäuber, schröder, daehler et al. 17 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ funding: this research received no specific grant from any funding agency in the public, commercial or not-forprofit sectors. acknowledgments: we thank librarian helene sognstrup for literature search and import of references and papers, our web designers nicolaj knudsen and ruben engrob nielsen for assistance with redcap, our msc student linda jolink for extraction of data regarding biological mechanisms, and michael cathro and nathan nelson for helping us with the extraction of journal-related data. competing interests: omer van den bergh is a subject editor for clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. author contributions: as, jr, and mk invented the review. as, mk, jr and cur designed the final review, with contribution from ovdb and kjp. mk and as wrote the review protocol, with contribution from all authors. as and cur finalized the search protocols together with the librarian hs. hs conducted the searches. as choose technical platforms. all authors contributed to screening of titles, abstracts and full texts and to the extraction of data. as, mk, and jr did the analyses, with contribution of cur. as, mk, and mwp created the figures. all authors were involved in the interpretation of data. as, mk and jr drafted the manuscript, and all authors critically reviewed, edited and approved the final manuscript. data availability: data are available on reasonable request from the corresponding author. supplementary materials the supplementary materials (kleinstäuber et al., 2023) contain the following items: • supplementary material 1. results of the search of electronic literature database • supplementary material 2. references of included reviews (k = 452) • supplementary material 3. references of reviews excluded after fulltext review (k = 526) • supplementary material 4. characteristics of included systematic reviews without metaanalysis (k = 123) and systematic reviews with meta-analyses (k = 132) • supplementary material 5. characteristics of included narrative reviews (k = 197) • supplementary material 6a. specific biological factors investigated in diagnosis-specific systematic reviews (fms, ibs, cfs/me and ssd) or systematic reviews that investigated at least two of these diagnoses simultaneously (combinations of fss/ssd) • supplementary material 6b. specific psychosocial factors investigated in diagnosis-specific systematic reviews (fms, ibs, cfs/me and ssd) or systematic reviews that investigated at least two of these diagnoses simultaneously (combinations of fss/ssd) • supplementary material 7. characteristics of systematic reviews with meta-analysis with an overall rating ‘high’ of confidence in the results of the review according to amstar-2 (k = 25) • supplementary material 8. prisma checklist • supplementary material 9. study selection process (prisma flow chart) • supplementary material 10. frequency of systematic reviews per year of publication since 1990, divided into reviews of critically low, low, moderate and high quality, according to the aetiological understanding of fss 18 clinical psychology in europe 2023, vol. 5(3), article e11179 https://doi.org/10.32872/cpe.11179 https://www.psychopen.eu/ assessment of multiple systematic reviews (amstar-2). the grey vertical lines indicate the median (md) publication year within each quality stratum. index of supplementary materials kleinstäuber, m., schröder, a., daehler, s., pallesen, k. j., rask, c. u., sanyer, m., van den bergh, o., weinreich petersen, m., & rosmalen, j. g. m. 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[2] center of mental health, university of würzburg, würzburg, germany. clinical psychology in europe, 2021, vol. 3(2), article e4221, https://doi.org/10.32872/cpe.4221 received: 2020-09-05 • accepted: 2021-03-22 • published (vor): 2021-06-18 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: andre pittig, department of psychology i, university of würzburg, marcusstrasse 9-11, 97070 würzburg, germany. e-mail: andre.pittig@uni-wuerzburg.de abstract background: increases in emotional distress in response to the global outbreak of the sarscov-2 (covid-19) pandemic have been reported. so far, little is known about how anxiety responses in specific everyday public life situations have been affected. method: self-reported anxiety in selected public situations, which are relevant in the covid-19 pandemic, was investigated in non-representative samples from the community (n = 352) and patients undergoing psychotherapy (n = 228). situational anxiety in each situation was rated on a 5-point likert scale (0 = no anxiety at all to 4 = very strong anxiety). situational anxiety during the pandemic was compared with retrospectively reported situational anxiety before the pandemic (direct change) and with anxiety levels in a matched sample assessed before the pandemic (n = 100; indirect change). results: in the community and patient sample, indirect and direct change analyses demonstrated an increase in anxiety in relevant public situations but not in control situations. average anxiety levels during the pandemic were moderate, but 5-28% of participants reported high to very high levels of anxiety in specific situations. interestingly, the direct increase in anxiety levels was higher in the community sample: patients reported higher anxiety levels than the community sample before, but not during the pandemic. finally, a higher increase in situational anxiety was associated with a higher perceived danger of covid-19, a higher perceived likelihood of contracting covid-19, and stronger symptoms of general anxiety and stress. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4221&domain=pdf&date_stamp=2021-06-18 https://orcid.org/0000-0003-3787-9576 https://orcid.org/0000-0002-7316-1652 https://orcid.org/0000-0002-2607-912x https://orcid.org/0000-0003-2227-0231 https://orcid.org/0000-0003-1618-4935 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusions: preliminary findings demonstrate an increase in anxiety in public situations during the covid-19 pandemic in a community and a patient sample. moderate anxiety may facilitate compliance with public safety measures. however, high anxiety levels may result in persistent impairments and should be monitored during the pandemic. keywords anxiety, covid-19, emotional distress, public situations highlights • anxiety in public situations has increased in germany in response to the covid-19 pandemic. • average anxiety levels were moderate, but 5-28% of participants reported high to very high levels of anxiety. • a stronger increase of anxiety was linked to a higher perceived likelihood and dangerousness of a covid-19 infection. • large-scale representative studies monitoring the development of persistent anxiety are needed. emotional distress has increased in response to the global outbreak of the sars-cov-2 (covid-19) pandemic. moderate to severe increases in distress have been reported inter­ nationally, for example, in china, the usa, canada, iran, and europe (e.g., asmundson et al., 2020; mazza et al., 2020; moghanibashi-mansourieh, 2020; pierce et al., 2020; salari et al., 2020; torales et al., 2020; wang et al., 2020). while early reports focused on the general increase in emotional distress, more recent studies specifically reported increases in symptoms of anxiety, depression, and stress (asmundson et al., 2020; taylor et al., 2020; torales et al., 2020). to date, little is known about emotional responses in specific public situations that are characterized by an increased threat of covid-19 infection. these specific emotional responses are, however, important to fully understand emotional responses to the covid-19 pandemic and how they may influence our daily life. public policy measures (i.e., behavioral recommendations or restrictions) to reduce the spread of covid-19 vary internationally. in germany, public life was largely “shut down” for approximately four weeks at the beginning of the covid-19 pandemic (i.e., from mid-march 2020 to mid-april 2020). after covid-19 infection numbers declined, some restrictions were revoked, but others were continued as the pandemic was ongoing (for german policy measures, see steinmetz et al., 2020). especially physical distancing, the use of disinfectant, and wearing face masks were recommended in most public situa­ tions (see robert koch institute, 2020). relevant public situations for covid-19 related restrictions concerned public transport, restaurants and supermarkets, and effectively every crowded public area. as had been communicated to the general public, these anxiety of public situations during covid-19 2 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ public situations are especially salient for covid-19 related threats. the resulting threat salience may be linked to elevated situational anxiety in these public situations. in the ongoing pandemic, moderate situational anxiety levels may indeed be adaptive as they may support safety behaviors to prevent covid-19-related harm (e.g., arnaudova et al., 2017; pittig et al., 2020). however, high anxiety levels may also lead to severe distress without additionally supporting safety behaviors and may even persist in the absence of threat (pittig et al., 2020). preliminary evidence showed that patients with anxiety-re­ lated and mood disorders exhibited stronger covid-related stress responses than a healthy sample (asmundson et al., 2020), suggesting that individuals with mental health conditions are prone to experiencing covid-related anxiety. it is therefore important to explore the potential increase of situational anxiety in public situations during the covid-19 pandemic, in both general community and clinical samples. methodologically, an increase in situational anxiety can be assessed by direct and indirect change measures (stieglitz & baumann, 2001). as a measure of direct change, current anxiety levels, which are assessed during the pandemic, can be compared with retrospectively assessed anxiety levels before the pandemic. retrospective self-reports pose a risk of recall biases (van den bergh & walentynowicz, 2016), whereby recall inaccuracies of affective states might differ between clinical and general community samples (ben-zeev, young, & madsen, 2009). nevertheless, this direct approach reflects perceived individual increases in anxiety, i.e., whether individuals feel that their anxiety has increased in response to the pandemic. as an indirect change measure, current anxi­ ety levels, which are assessed during the pandemic, can be compared with anxiety levels assessed before the pandemic, optimally within the same sample. the indirect approach is unbiased by retrospective recall but requires repeated measurements. the fast onset of the covid-19 pandemic prohibited the arrangement of such controlled longitudinal designs. alternatively, indirect change can be measured by comparing anxiety levels in a sample surveyed during the pandemic with anxiety levels in a different sample assessed before the pandemic. potential biases caused by differences in certain characteristics between the two samples (e.g., differences in age or biological sex distribution) can be prevented by matching the samples based on these characteristics. the current study examined both direct and indirect changes in situational anxiety in public situations, which are relevant to the covid-19 pandemic, in a non-representa­ tive community sample and a patient sample. in an online survey, individuals reported their anxiety levels for ten relevant public situations (e.g., taking the bus, going to the supermarket, or being at a crowded public place) and three control situations (e.g., being outdoors alone). we assessed retrospective anxiety levels (i.e., before the pandemic) and current anxiety levels in the previous two weeks (i.e., during the pandemic). besides comparing these ratings (direct change), situational anxiety during the pandemic was compared with a matched sample that was surveyed before the pandemic (indirect change). to highlight the clinical relevance (i.e., high levels of anxiety may result in pittig, glück, boschet et al. 3 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ impairments), we complemented these analyses by calculating the proportion of individ­ uals who reported high or very high anxiety levels in these situations. we hypothesized that both the community and the patient sample show an increase in situational anxi­ ety during the covid-19 pandemic, with a stronger increase in the patient sample (asmundson et al., 2020). furthermore, we explored the association between increased situational anxiety and symptoms of anxiety, depression, stress, the perceived likelihood of contracting covid-19, and the perceived dangerousness of a covid-19 infection. we expected that these clinical symptoms and perceived threat of covid-19 are positively associated with situational anxiety. method and materials participants and recruitment the study was approved by the local ethics committee (gzek 2020-31). three samples of participants anonymously completed an online survey. participants had to be ≥ 18 years of age. the pre-covid sample was recruited from the general community before the pandemic (february to april 2019) as part of the validation of an online survey (n = 100, age: m = 27.73, sd = 10.47, females: 69.8%). the community sample (n = 352, age: m = 35.90, sd = 14.09, females: 69.9%) and the patient sample (n = 228, age: m = 39.07, sd = 14.50, females: 60.5%) were recruited during the covid-19 pandemic (mid of may to mid of july 2020). as present restrictions may influence situational anxiety, we briefly report restrictions that were continuously active across the recruitment period (steinmetz et al., 2020): most public situations, e.g., going to supermarkets and shops, using public transport as well as attending religious meetings and demonstrations, were accessible on the condition that specific regulations were followed (e.g., physical distanc­ ing, face masks, a limited number of people). restaurants and entertainment venues (e.g., theaters and cinemas) re-opened stepwise starting between mid of may and mid of june (regionally depending). meetings of persons from more than two different households were permitted in germany as from mid of june, but group size was mostly still limited, e.g., to a maximum of ten people. major public events remained prohibited during the whole recruitment period. both the pre-covid and the community sample were recruited from the general community in germany via identical online recruitment pathways (e.g., via a german internet platform for online surveys, german local social media groups, and the partici­ pant management tool of the university of würzburg). the patient sample was recruited via the outpatient clinic for psychotherapy at the university of würzburg. 109 out of 689 participants completed opt-in informed consent but discontinued the survey before providing anxiety ratings for at least one situation and were thus excluded (15.8%). the remaining 580 participants in the community and patient sample completed all anxiety of public situations during covid-19 4 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ situational anxiety ratings, i.e., there were no missing data for the variables of interest, as the completion of sociodemographic data, trait anxiety, and symptom measures was required before answering the situational anxiety ratings. all patients had provided writ­ ten informed consent to be contacted for research purposes prior to the study and were currently undergoing psychotherapeutic treatment. a total of 496 patients was invited to participate in the study (response rate = 46.0%). the distribution of main primary diagnoses within the invited patients was 33.4% affective disorders, 23.7% anxiety disor­ ders, 15.3% adjustment disorder, 7.4% somatoform disorders, 5.0% obsessive-compulsive disorder, 3.9% posttraumatic stress disorder, 2.9% eating disorders. online survey the online survey measured self-reported anxiety in selected public situations, trait anxiety, symptoms of emotional distress, and basic demographic data (i.e., age, sex, em­ ployment status). trait anxiety was assessed with the anxiety subscale of the neo-pi-r (n1 subscale; costa & mccrae, 1992). symptoms of anxiety, depression, and stress over the previous week were assessed with the german short version of the depression anxiety stress scales (dass-21; lovibond & lovibond, 1995; nilges & essau, 2015). all participants, including the pre-covid sample, completed these two questionnaires. the community and patient sample additionally rated the perceived dangerousness of covid-19 (5-point likert-scale from very harmless to very dangerous) and the subjective likelihood of contracting covid-19 (5-point likert-scale from very unlikely to very likely). self-reported anxiety was assessed for 13 selected public situations, mostly taken from a well-established questionnaire for agoraphobia (mobility inventory; chambless et al., 1985). ten of these situations were regarded as highly relevant in the covid-19 pandemic: taking the bus, taking the train, going to the supermarket, going to the cinema/theater, shopping mall, restaurant, waiting in line, talking to others, and being at an outdoor or indoor public area with people. three additional situations were used to control whether general changes in anxiety occurred in situations that are unrelated to covid-19 but may still provoke some anxiety, i.e., being alone in an unknown area. all participants were instructed to rate their anxiety level for each situation during the previous two weeks (5-point likert scale; 0 = no anxiety at all to 4 = very strong anxiety). the community and patient samples retrospectively rated each situation regarding how anxious they were before the covid-19 outbreak. if participants had not approached a particular situation in the previous two weeks, they were asked to imagine being in the situation and rate the anxiety level accordingly. pittig, glück, boschet et al. 5 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ statistical analysis the main research aim was to examine changes in self-reported anxiety in public situations during the covid-19 pandemic. to this end, we calculated the direct and indirect change in self-reported anxiety. direct change was analyzed by comparing anxiety ratings for the 13 selected public situations during the previous two weeks with retrospectively reported anxiety for these situations before the pandemic (with­ in-subjects comparison). therefore, we conducted repeated measures anovas for each situation with group (community vs. patient sample) as between-subjects factor and time (previous two weeks vs. before covid-19) as within-subjects factor, including all participants from both samples recruited during the covid-19 pandemic. indirect change was analyzed by comparing anxiety ratings in the previous two weeks in the community and patient sample separately with anxiety ratings for the same situations in the matched pre-covid sample (between-subjects comparison). as these indirect change analyses may be biased due to different sample characteristics, we aimed to reduce sample bias by matching participants. precisely, we matched the three samples on age, sex, and employment status using nearest neighbor matching (ho et al., 2011). as the smallest sample (i.e., the pre-covid sample) included 100 participants, we selec­ ted the closest neighbors in the other samples, respectively. as a result, the indirect change analyses were conducted with 100 participants per sample. analyses with the complete, but unmatched samples yielded the same pattern of results. indirect change was analyzed using a manova with anxiety ratings in the previous two weeks in the 13 situations as dependent variables, followed by one-way anovas for each situation with the between-subjects factor group (pre-covid, community, patient). bonferroni-holm correction was applied in all analyses. cohen’s d and eta-squared are reported as effect sizes. to highlight the clinical relevance of these analyses, we aimed to provide descriptive data on the frequency of high anxiety levels in public situations in response to the cov­ id-19 pandemic. for each situation, we calculated the relative number of participants from the complete sample who indicated “strong” or “very strong” anxiety. finally, we exploratorily examined the associations between the increase in self-reported anxiety (difference score: anxiety during covid-19 – anxiety before covid-19) and clinical variables (trait anxiety, symptoms of depression, stress, and anxiety) as well as covid-19 related variables (perceived dangerousness and likelihood of contracting covid-19) in the unmatched community and patient samples. to this end, robust winsorized correla­ tions (trim = 0.2) were calculated using the wrs2 package (mair & wilcox, 2020) in r (r core team, 2020). anxiety of public situations during covid-19 6 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ results increased anxiety of public situations direct change for all situations, there was an increase in self-reported anxiety during the covid-19 pandemic (see figure 1a and table 1). for the control situations, this increase was relatively small and there were no significant effects involving group. for most cov­ id-relevant situations, repeated measures anovas yielded a significant interaction of group and time. post-hoc wilcoxon tests indicated that anxiety increased in all situa­ tions in the patient sample, ps < .001, rs = .86 to 1.00, and in the community sample, ps < .001, rs = .81 to 1.00. the patient compared to the community sample reported higher retrospective anxiety before the covid-19 pandemic in most situations, us > 42606.0, ps < .020, rs = .06 to .25, except for “being alone in an unknown area”, u = 39955.0, p = .924, r = .04. interestingly, the groups did not differ in anxiety during the covid-19 pandemic, us < 42858.0, ps > .077, rs = -.05 to .07. this overall pattern differed only for the situations “waiting in line” and “talking to others”. for both, anxiety was higher during than before the pandemic (table 1), and the patient sample reported higher anxiety. however, there was no significant interaction between group and time. in sum, direct change analyses indicated a slight increase in self-reported anxiety in the control situations and a larger increase in all covid-relevant public situations. interestingly, the latter increase was higher in the community sample compared with the patient sample, as indicated by patients’ higher anxiety levels before but not during the pandemic in most public situations. indirect change for the matched samples, the significant manova, pillais’ trace = .33, f(26, 572) = 4.27, p < .001, was followed up by one-way anovas for each situation, comparing self-reported anxiety levels during the previous two weeks between the three samples. as expected, no significant differences were found for the three control situations (see figure 1b and table 1). in all covid-relevant public situations, self-reported anxiety during the previous two weeks differed between groups. for almost all situations, anxi­ ety ratings did not differ between the community and the patient sample, ts < 1.58, ps > .116, ds = -0.19 to 0.05, but were higher than in the pre-covid sample, respectively, ts > 4.61, ps < .001, ds = 0.68 to 1.20. this pattern only differed for the situation “talking to others”: while the patient sample again reported higher anxiety than the pre-covid sample, t = 3.48, p = .002, d = 0.48, the community sample did not differ from the other two samples, ts < 2.03, ps > .087, ds < 0.30. in sum, indirect change analyses of the matched samples indicated higher self-reported anxiety levels during the previous two weeks than before the covid-19 pandemic in all relevant public situations. pittig, glück, boschet et al. 7 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ figure 1 average self-reported anxiety in selected public situations before and during the covid-19 pandemic (with standard error of the mean) note. situational anxiety was rated for each situation on a 5-point likert scale (0 = no anxiety at all to 4 = very strong anxiety). a: direct change as indicated by comparing anxiety ratings during the previous two weeks (during the pandemic) with retrospectively reported anxiety before the pandemic (within-subject comparison; community sample: n = 352, patient sample: n = 228). b: indirect change as analyzed by comparing anxiety ratings for the previous two weeks in a matched community and patient sample with anxiety ratings in the matched pre-covid sample (between-subject comparison, n = 100 for each subsample). anxiety of public situations during covid-19 8 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ table 1 overview of statistical results for direct and indirect change direct change indirect change situation / effect f p η2 effect f p η2 outdoor public area w/o people time 41.32 < .001 .011 group 0.34 .710 .002group 1.43 .232 .002 time*group 2.80 .095 < .001 indoor public area w/o people time 72.25 < .001 .024 group 0.02 .997 < .001group 6.12 .014 .008 time*group 0.88 .349 < .001 being alone in unknown area time 37.33 < .001 .003 group 0.32 .729 .002group 0.10 .755 < .001 time*group 0.67 .413 < .001 taking bus time 408.01 < .001 .188 group 28.32 < .001 .160group 7.80 .005 .007 time*group 4.79 .029 .002 taking train time 342.30 < .001 .174 group 19.30 < .001 .115group 8.17 .004 .007 time*group 4.80 .029 .002 supermarkets time 352.66 < .001 .173 group 22.33 < .001 .131group 6.20 .013 .006 time*group 4.64 .032 .002 cinema/theater time 390.67 < .001 .194 group 32.62 < .001 .180group 4.71 .030 .004 time*group 12.86 < .001 .006 shopping mall time 357.68 < .001 .170 group 25.31 < .001 .146group 6.10 .014 .006 time*group 9.39 .002 .004 restaurant time 364.73 < .001 .197 group 20.82 < .001 .123group 1.49 .223 .001 time*group 9.45 .002 .005 pittig, glück, boschet et al. 9 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ direct change indirect change situation / effect f p η2 effect f p η2 waiting in line time 311.01 < .001 .149 group 18.66 < .001 .112group 10.23 .001 .010 time*group 0.68 .409 < .001 talking to others time 222.51 < .001 .071 group 6.12 .002 .040group 15.43 < .001 .019 time*group 0.03 .865 < .001 outdoor public area w/o people time 283.91 < .001 .106 group 15.37 < .001 .094group 16.99 < .001 .019 time*group 8.17 .004 .003 indoor public area w/o people time 398.88 < .001 .167 group 22.48 < .001 .131group 15.08 < .001 .015 time*group 8.28 .004 .003 note. the factor time refers to the within-subject factor for ratings before (retrospective) vs. during pandemic. the factor group refers to community vs. patient sample (direct change) or pre-covid vs. community vs. patient sample (indirect change). frequency of high and very high anxiety in public situations the proportion of individuals indicating high or very high anxiety levels is displayed in table 2. overall, the frequency of high or very high anxiety increased by approximately 10%. in the community sample, the average increase was 8% (indirect) to 10% (direct). in the patient sample, the average increase was 11% (direct) to 12% (indirect). associations between anxiety increase, symptoms, and covid-19 related variables robust winsorized correlations within the patient and the community samples are shown in table 3. most correlations were similar in both samples. a stronger increase in self-re­ ported anxiety (i.e., a higher direct change score) was associated with a higher perceived dangerousness and a higher perceived likelihood of contracting covid-19 (the latter two correlated positively in the patient sample, r = .41, p < .001, and in the community sample, r = .33, p = .003). moreover, a stronger increase in self-reported anxiety was associated with stronger symptoms of anxiety and stress, but not with symptoms of depression, or with trait anxiety. anxiety of public situations during covid-19 10 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ table 3 associations between direct increase of anxiety in public situations and covid-19 variables, clinical, and demographic data sample covid-19 variable clinical variable danger likelihood contraction trait anxiety anxiety stress depression community sample .25* .19 .16 .21* .23* .03 patient sample .26* .26* .12 .21* .28* .14 note. zero-order robust winsorized correlations (trim = 0.2) with direct change score (anxiety during covid-19 minus before covid-19). *p < .05. table 2 relative frequency of high or very high anxiety to distinct public situations public situation community sample (n = 352) patient sample (n = 228) pre-covid sample (n = 100) duringa (before)b duringa (before)b beforea outdoor public place w/o people 0.9% (0.3%) 1.8% (0.9%) 0.0% indoor public place w/o people 2.3% (0.6%) 1.8% (1.3%) 2.0% being alone in unknown area 8.5% (7.1%) 10.5% (7.5%) 18.0% taking bus 15.1% (1.4%) 19.3% (4.8%) 4.0% taking train 15.1% (1.1%) 18.9% (5.3%) 2.0% supermarkets 7.7% (0.6%) 11.0% (2.6%) 4.0% cinema/theater 15.6% (1.4%) 20.6% (6.1%) 0.0% shopping mall 10.5% (0.9%) 11.0% (3.9%) 4.0% restaurants 13.1% (0.9%) 12.7% (3.5%) 6.0% waiting in line 5.7% (1.1%) 11.8% (3.1%) 2.0% talking to others 5.1% (1.1%) 9.2% (3.9%) 2.0% outdoor public area w/ people 8.8% (1.1%) 15.8% (6.6%) 8.0% indoor public area w/ people 20.5% (3.1%) 27.6% (7.9%) 6.0% note. proportion of participants responding with “strong anxiety” or “very strong anxiety” in the different public situations. aanxiety during the previous two weeks. bretrospective anxiety before the covid-19 pandemic. pittig, glück, boschet et al. 11 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ discussion the current study investigated changes in anxiety in public situations in response to the covid-19 pandemic. in all relevant public situations, anxiety increased strongly, both in a community sample and in a clinical sample of patients affected by mental disorders. in both samples, evidence for increased anxiety was supported by direct and indirect change analyses. for direct change, levels of situational anxiety during the pandemic were higher than retrospective anxiety levels of the same individuals before the pandem­ ic. for indirect change, situational anxiety during the pandemic was higher than anxiety in the same situations assessed before the pandemic in a matched community sample. thus, the present findings expand previous reports concerning an increase in general emotional distress during the covid-19 pandemic (e.g., asmundson et al., 2020; taylor et al., 2020), as the current results highlight a distinct increase in self-reported anxiety in covid-relevant public situations. the increase in situational anxiety in response to the pandemic was not driven by outdoor situations per se. no strong increase in anxiety was found in situations that do not involve potential physical contact with others (e.g., being alone in a public area). in these control situations, self-reported anxiety during the pandemic was only slightly higher than retrospectively reported anxiety. also, anxiety levels in these control situations before the pandemic and during the pandemic did not differ. thus, increased situational anxiety was linked to physical closeness to other individuals, presumably due to the associated risk of contracting covid-19. in support, a higher perceived likelihood of contracting covid-19 and a higher perceived danger of covid-19 infections were associated with a stronger increase in situational anxiety. in sum, increased anxiety of public situations likely resulted from a higher perceived threat of contracting covid-19. average situational anxiety levels during the pandemic were moderate. as the ongo­ ing pandemic represents a realistic threat to the individual and the society, moderate lev­ els of anxiety in situations that pose a higher risk of contraction can be seen as adaptive responses. anxiety activates the defensive network and facilitates defensive behaviors such as avoidance or safety behavior (pittig et al., 2018, 2020). in this regard, moderate anxiety levels could promote compliance with safety measures. however, extremely high anxiety levels may not entail additional benefits for preventing infections but may lead to severe distress and impairments. on average, there was an increase of 8-12% in individuals who reported high to very high anxiety in public situations. up to 20-28% of participants indicated high or very high anxiety when being in an indoor public area with others during the pandemic. importantly, high anxiety levels may result in avoidance of relevant situations, which may persist even in the absence of threat (pittig et al., 2020). it therefore seems important to identify individuals with high anxiety and to monitor the development of persistent maladaptive anxiety and potential avoidance. notably, individuals who perceived covid-19 as being more dangerous and perceived the likelihood of contracting covid-19 as being higher showed a stronger increase in anxiety of public situations during covid-19 12 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ situational anxiety. moreover, a stronger increase in situational anxiety has been linked to stronger general symptoms of stress and anxiety. these findings suggest that caution should be placed on these individuals, given that they are more likely to experience a higher level of psychological distress and detrimental effects on their overall well-being (kang et al., 2020; torales et al., 2020). interestingly, there were some expected, but also unexpected, differences between the community and the patient sample. as expected, patients reported higher levels of retrospective anxiety than participants of the community sample. these heightened anxiety levels before the covid-19 outbreak may reflect higher perceived threat in these situations due to relevant psychopathologies (e.g., agoraphobia, social anxiety). howev­ er, no group differences in situational anxiety during the pandemic were observed. in other words, both samples showed similar anxiety levels in public situations during the covid-19 pandemic. importantly, the lack of group differences was not due to a ceiling effect, considering that the average self-reported anxiety was moderate in both samples. these results are not in line with previous findings of higher levels of covid-19-related distress in clinical samples than in the general population (asmundson et al., 2020). there may be multiple explanations. first, whereas previous studies assessed general emotional distress, the present study examined anxiety in specific public situations. the higher levels of general distress found in previous studies may be caused by factors different from anxious responding in covid-relevant situations (e.g., troubles coping with self-isolation, general worries about the future, or the socio-economic impact of covid-19; see asmundson et al., 2020). second, the patient sample consisted of patients with mental disorders undergoing cognitive-behavioral treatment. the ongoing treatment may have buffered negative effects of the pandemic and facilitated adaptive coping strategies. third, patients and non-patients may have applied diverging scaling in covid-related anxiety ratings (e.g., patients who have frequently experienced highly anxious states may classify levels of anxiety as “moderate” when non-patients may classify similar levels as “high”). finally, the lack of differences between the patient and community sample under realistic threat is in line with findings from experimental fear learning research. specifically, a meta-analysis found no differences in learning novel fear responses to a stimulus signaling threat between healthy individuals and patients with anxiety disorders (duits et al., 2015). however, patients showed elevated responses to a safety signal and ongoing fear responses in the absence of threat. thus, patients seemingly do not show elevated responses to stimuli and situations signaling realistic threat but rather show a bias to stimuli and situations signaling safety or the absence of previous threat. therefore, it is important to monitor increased anxiety responses in patients when the risk for contraction of covid-19 decreases. moreover, the present study did neither assess the effects of psychotherapy on the negative psychological effects of the covid-19 pandemic, nor did it assess potential increases in anxiety in currently untreated clinical samples. thus, additional research is warranted. pittig, glück, boschet et al. 13 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://www.psychopen.eu/ the present results are limited by the non-representative samples, which were re­ cruited from a german-speaking population. the generalizability to other populations requires further research. the current findings may only represent a subset of the popu­ lation but provide the insight that at least in this portion of the german population, an increase in covid-19-related situational anxiety occurred. as no data about the current place of the participants’ residence were collected, the potential influence of regional variances in covid-19 incidence values and, relatedly, official regulations at the time of the survey on situational anxiety cannot be ruled out. however, incidences were generally low in germany and did not exceed 25 per 100,000 population in any german state at the period of the survey (robert koch institute, 2021) and official restrictions did not differ substantially between german regions (see steinmetz et al., 2020). the study’s results may also be used to generate more elaborate hypotheses on the associations between covid-19-related and clinical variables on the one side and an increase in situational anxiety on the other side. as outlined above, monitoring general and situa­ tion-specific anxiety levels and identifying individuals at risk for developing persistent anxiety and impairments is important for understanding and potentially preventing pan­ demic-related psychological distress. public policymakers should facilitate appropriate large-scale, long-term studies. another limitation is the missing assessment whether participants experienced the public situations during the previous two weeks or whether they imagined being in the situations. future research may disentangle these potentially diverging responses. finally, the patient sample was diagnosed with heterogeneous men­ tal disorders, which could not be matched to situational anxiety changes. thus, we could not evaluate whether there were any differences between different mental disorders or whether a specific disorder may be linked to a higher recall bias. in conclusion, the current study provides preliminary evidence for an increase in situational anxiety in public situations in a community and a patient sample during the covid-19 pandemic. both groups showed similar levels of moderate situational anxiety, which may facilitate compliance with public safety recommendations and restrictions for preventing covid-19 contractions. however, some individuals display high levels of anxiety, which should be monitored during and after the pandemic. funding: the authors have no funding to report. acknowledgments: the authors thank kristina schneider, julian koch and naja kärcher for their help with data collection. competing interests: the authors have declared that no competing interests exist. twitter accounts: @andrepittig, @gluckvalentina, @julianeboschet, @psycalexwong, @engelkepaula anxiety of public situations during covid-19 14 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://twitter.com/andrepittig https://twitter.com/gluckvalentina https://twitter.com/julianeboschet https://twitter.com/psycalexwong https://twitter.com/engelkepaula https://www.psychopen.eu/ references arnaudova, i., kindt, m., fanselow, m., & beckers, t. 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(2020). the outbreak of covid-19 coronavirus and its impact on global mental health. the international journal of social psychiatry, 66(4), 317-320. https://doi.org/10.1177/0020764020915212 van den bergh, o., & walentynowicz, m. (2016). accuracy and bias in retrospective symptom reporting. current opinion in psychiatry, 29(5), 302-308. https://doi.org/10.1097/yco.0000000000000267 wang, c., pan, r., wan, x., tan, y., xu, l., ho, c. s., & ho, r. c. (2020). immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china. international journal of environmental research and public health, 17(5), article 1729. https://doi.org/10.3390/ijerph17051729 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. pittig, glück, boschet et al. 17 clinical psychology in europe 2021, vol. 3(2), article e4221 https://doi.org/10.32872/cpe.4221 https://doi.org/10.1177/0020764020915212 https://doi.org/10.1097/yco.0000000000000267 https://doi.org/10.3390/ijerph17051729 https://www.psychopen.eu/ anxiety of public situations during covid-19 (introduction) method and materials participants and recruitment online survey statistical analysis results increased anxiety of public situations frequency of high and very high anxiety in public situations associations between anxiety increase, symptoms, and covid-19 related variables discussion (additional information) funding acknowledgments competing interests twitter accounts references the icd-11 diagnoses in the mental health field – an innovative mixture editorial the icd-11 diagnoses in the mental health field – an innovative mixture andreas maercker 1 [1] department of psychology, division of psychopathology and clinical intervention, university of zurich, zurich, switzerland. clinical psychology in europe, 2022, vol. 4(special issue), article e10647, https://doi.org/10.32872/cpe.10647 published (vor): 2022-12-15 corresponding author: andreas maercker, university of zurich, division of psychopathology and clinical intervention, department of psychology; binzmühlestrasse 14/17, 8050 zürich, switzerland. e-mail: maercker@psychologie.uzh.ch related: this article is part of the cpe special issue “innovations in icd-11”, guest editor: andreas maercker, clinical psychology in europe, 4(special issue), https://doi.org/10.32872/10.32872/cpe.v4.si the development of icd-11 in the mental health field has been innovative in several ways. perhaps most notable is that it has become equally relevant to clinicians and re­ searchers. before discussing these two aspects in more detail, it should be mentioned that the processes by which the icd-11 was created were also innovative and, moreover, that clinical psychologists and psychiatrists were equally involved at several crucial points in the icd-11 development. this began with dr. geoffrey reed, a us clinical and medical psychologist, as the responsible who senior project officer for new developments in the mental health field and who set important impulses at all stages of the process (e.g., reed, 2010). from the beginning, the lebanese psychologist brigitte khoury and the mexican psy­ chologist maria elena medina-mora served on the international advisory group for this field. both have published on important milestones and outcomes of regional meetings (khoury et al., 2011; medina-mora et al., 2019). furthermore, the author of this editorial, in his capacity as a psychologist, was one of the working group leaders of the icd-11 development (maercker et al., 2013). this new way of composing decision-making bodies represented an important step in the development of the international mental and be­ havioral disorder classification. this was further supported by the inclusion of clinicians and researchers from the fields of clinical social work and psychiatric nursing sciences in the committees. thus, the whole icd-11 development relied on a very multidisciplinary process. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10647&domain=pdf&date_stamp=2022-12-15 https://orcid.org/0000-0001-6925-3266 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ what, then, were the innovations for clinicians worldwide? from the very start, the aim was that “clinical usability” should be the focus of development (first et al., 2015). the rationale for this was that global applicability should be ensured both in countries with few and with ample health system resources. the intention was to avoid creating complex and costly diagnostic algorithms that would be unrealistic for the time and human resources available in some regions of the world. regarding clinical usability, the arguments were also based on the limited memory capacity for information elements known from general psychology, which typically does not allow for an overly complex diagnostic decision process without the loss of information. here, experts distinguished their approach from highly complex diagnostic algorithms in the dsm (diagnostic and statistical manual of mental disorders), which, for example, had different minimum numbers of required symptoms for several symptom groups. in addition, the dsm in its various versions contained lists of symptoms and criteria that grew longer and were almost unmanageable in each new version (dsm-iii, dsm-iii-r, dsm-iv, dsm-iv-tr). therefore, the international advisory group made a preliminary decision to follow a prototype approach to disorder definitions. this meant that a few symptoms define the core of a diagnosis (core symptoms or essential features), with a number of other associated symptoms (accessory symptoms or additional clinical features), which must not all be present to assign a diagnosis. the international advisory group also made the decision to omit subtypes from the diagnoses as much as possible, which was later widely adopted in the icd-11 development. further means of increasing clinical usability was the introduction of new sections in the definition texts: e.g., boundary with normality, developmental presentations, culture-related features, sexand/or gender-related features, boundaries with other disorders and conditions (differential diagnosis). these helpful new sections of icd-11 are discussed in most of the articles in this special issue. these sections are, in fact, included as standard in the central internet publication of icd-11 as so-called clinical descriptions and diagnostic recommendations (cddr) and, as with all material from the who, are also available free of charge. how about the scientific innovations? it is impossible to list all innovations in the present context. in terms of methodology, innovations were based on the serious consideration of and alignment with the customer orientation. customers of a classifi­ cation system include the global clinicians or practitioners, as well as the patients or clients in the health care system – both of these groups were involved throughout the entire process. furthermore, survey studies were conducted with the world associations of psychologists and psychiatrists to ask about previous diagnostic habits, as well as missing, problematic, and stigmatizing diagnoses (robles et al., 2014). the results of these studies were implemented whenever possible. for example, 12% of these studies (of over 3200 clinicians from 13 countries across six continents) indicated a need for a diagnosis that went beyond "classic" ptsd to include more complex trauma sequelae. the icd-11 diagnoses in the mental health field – an innovative mixture 2 clinical psychology in europe 2022, vol. 4(special issue), article e10647 https://doi.org/10.32872/cpe.10647 https://www.psychopen.eu/ this finding informed the development of the diagnosis of complex ptsd that now exists in icd-11 (see the paper in this special issue). moreover, the patients or people affected by the disorders were also involved in the feedback process of the icd-11 development (hackmann et al., 2019). for the subsequent steps of icd-11 finalization, the global clinical practice network (https://gcp.network) handled the involvement of global clinicians and practitioners. this network operates in nine world languages (including six european languages) and comprises approximately 10,000 people to date (operating in collaboration with columbia university, new york). beta versions of the new diagnostic proposals were submitted to this network in 2015, and for more recent surveys, the revised diagnoses were also submitted for further review. it is noteworthy to mention that one can also enroll in online continuing education courses in this network. it is impossible to provide an overview of the various innovations and their details here, as they are too extensive for an overview. this special edition of clinical psycholo­ gy in europe (cpe) is very pleased to present five very different topic areas: the autism spectrum disorder (which belongs to the neurodevelopmental disorders), the disorders specifically associated with stress (a separate subchapter), the personality disorders (also a separate subchapter), the disorders of substance use (with the emphasis here on alcohol use and a smaller focus on addictive behaviors), as well as chronic pain (a separate, overarching subchapter). it is very fortunate that our journal clinical psychology in europe is addressing the topic of icd-11 diagnoses, and as mentioned earlier, that many other regions of the world have already highlighted it as an area of particular prominence and innovation. it is interesting to note that the majority of international research activities on the individ­ ual disorders of icd-11 come from outside the united states, with european research activities playing a prominent role. not incidentally, these activities merge closely with who-sponsored programs on culturally appropriate interventions for global application (heim & kohrt, 2019; heim et al., 2021). however, in recent years, there has also been an incipient trend of an increasing number of us studies being devoted to icd-11 (e.g., cloitre et al., 2019). cpe will certainly continue to have a focus on contributions related to this global classification system, which is equally useful for both clinicians and researchers. funding: the author has no funding to report. acknowledgments: the author has no additional (i.e., non-financial) support to report. competing interests: the author has declared that no competing interests exist. maercker 3 clinical psychology in europe 2022, vol. 4(special issue), article e10647 https://doi.org/10.32872/cpe.10647 https://www.psychopen.eu/ references cloitre, m., hyland, p., bisson, j. i., brewin, c. r., roberts, n. p., karatzias, t., & shevlin, m. 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(2014). problematic, absent and stigmatizing diagnoses in current mental disorders classifications: the icd-11 diagnoses in the mental health field – an innovative mixture 4 clinical psychology in europe 2022, vol. 4(special issue), article e10647 https://doi.org/10.32872/cpe.10647 https://doi.org/10.1002/jts.22454 https://doi.org/10.1002/wps.20189 https://doi.org/10.1016/s2215-0366(19)30093-8 https://doi.org/10.32872/cpe.v1i4.37679 https://doi.org/10.32872/cpe.6351 https://doi.org/10.1002/wps.20057 https://doi.org/10.1016/j.ijchp.2018.09.003 https://doi.org/10.1037/a0021701 https://www.psychopen.eu/ results from the who-wpa and who-iupsys global surveys. international journal of clinical and health psychology, 14(3), 165–177. https://doi.org/10.1016/j.ijchp.2014.03.003 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. maercker 5 clinical psychology in europe 2022, vol. 4(special issue), article e10647 https://doi.org/10.32872/cpe.10647 https://doi.org/10.1016/j.ijchp.2014.03.003 https://www.psychopen.eu/ ambassadors of clinical psychology and psychological treatment letter to the editor, commentary ambassadors of clinical psychology and psychological treatment claudi bockting 1 , winfried rief 2 [1] department of psychiatry, amsterdam university medical centers, location amc, university of amsterdam, amsterdam, the netherlands. [2] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2022, vol. 4(1), article e8545, https://doi.org/10.32872/cpe.8545 published (vor): 2022-03-31 corresponding author: winfried rief, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, gutenbergstrasse 18, 35032 marburg, germany. e-mail: rief@unimarburg.de the european association of clinical psychology and psychological treatment (ea­ clipt) board has decided to nominate ambassadors of clinical psychology and psycho­ logical treatment. ambassadors are selected according to their achievements for our field, but also according to the perspectives for further fostering the visibility and impact of clinical psychology. the typical profile of our ambassadors is the high quality of translational research. ambassadors commit to show their support for the association and its mission. we are proud that two extremely well-known colleagues confirmed to become am­ bassadors for eaclipt: paul emmelkamp and peter fonagy, and they will be introduced in this issue. we are extending this list and will announce it in future issues of cpe, and we promise to consider gender and diversity issues. congratulations to paul emmelkamp and to peter fonagy, and to all of us because we have tremendous personalities in our group. claudi bockting (president of eaclipt) winfried rief (editor of cpe) this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.8545&domain=pdf&date_stamp=2022-03-31 https://orcid.org/0000-0002-9220-9244 https://orcid.org/0000-0002-7019-2250 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. ambassadors of clinical psychology and psychological treatment 2 clinical psychology in europe 2022, vol. 4(1), article e8545 https://doi.org/10.32872/cpe.8545 https://www.psychopen.eu/ cognitive symptoms link anxiety and depression within a validation of the german state-trait inventory for cognitive and somatic anxiety (sticsa) research articles cognitive symptoms link anxiety and depression within a validation of the german state-trait inventory for cognitive and somatic anxiety (sticsa) rebecca overmeyer 1 , tanja endrass 1 [1] faculty of psychology, institute of clinical psychology and psychotherapy, chair for addiction research, technische universität dresden, dresden, germany. clinical psychology in europe, 2023, vol. 5(2), article e9753, https://doi.org/10.32872/cpe.9753 received: 2022-06-21 • accepted: 2023-05-07 • published (vor): 2023-06-29 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: rebecca overmeyer, technische universität dresden, institute of clinical psychology and psychotherapy, chair for addiction research, chemnitzer straße 46a, 01187 dresden, germany. tel.: +49 351 463 39720. e-mail: rebecca.overmeyer@tu-dresden.de supplementary materials: data, materials [see index of supplementary materials] abstract background: in the present study we aimed to develop a german version of the state-trait inventory for cognitive and somatic anxiety (sticsa) and evaluate the psychometric properties. associations of cognitive and somatic anxiety with other measures of anxiety, depression, and stress, elucidating possible underlying functional connections, were also examined, as symptoms of anxiety, depression and stress often overlap. method: two samples (n1 = 301; n2 = 303) were collected online and in the lab, respectively. dynamic connections between somatic and cognitive anxiety, other measures of anxiety, depression, and stress, were analyzed using a network approach. psychometric analyses were conducted using exploratory and confirmatory factor analyses. results: we replicated and validated the two-factorial structure of the sticsa with the german translation. network analyses revealed cognitive trait anxiety as the most central node, bridging anxiety and depression. somatic trait anxiety exhibited the highest discriminant validity for distinguishing anxiety from depression. conclusion: the central role of cognitive symptoms in these dynamic interactions suggests an overlap of these symptoms between anxiety and depression and that differential diagnostics should focus more on anxious somatic symptoms than on cognitive symptoms. the sticsa could therefore be useful in delineating differences between anxiety and depression and for differential this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9753&domain=pdf&date_stamp=2023-06-29 https://orcid.org/0000-0002-7336-7984 https://orcid.org/0000-0002-8845-8803 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ assessment of mood and anxiety symptoms. additional understanding of both cognitive and somatic aspects of anxiety might prove useful for therapeutic interventions. keywords questionnaire, anxiety, depression, somatic symptoms, cognitive symptoms highlights • cognitive symptoms link depression and anxiety within a network approach. • somatic symptoms exhibit high discriminant validity towards depression. • differentiating subcomponents of anxious symptoms may help differentiate anxiety and depression. • the german version of the sticsa is a reliable and valid measure of trait anxiety. anxiety disorders and depression are among the most prevalent mental disorders, are highly comorbid and cause a high burden of disease (bandelow & michaelis, 2015; leray et al., 2011; martin, 2003; michael et al., 2007). symptoms of anxiety, depression and stress often overlap (mineka et al., 1998) and identifying overlapping and distinctive fea­ tures of anxiety and depression is highly important (eysenck & fajkowska, 2018). anxi­ ety and depression are clearly not identical emotional states, but the high comorbidity rate and the diagnostic overlap point to common nonspecific features and mechanisms, that are also important for treatment (eysenck & fajkowska, 2018; marchetti et al., 2016). there is also evidence that anxiety and depression dynamically interact and may trigger each other (starr & davila, 2012a, 2012c). anxiety can be divided into state and trait anxiety (e.g. endler & kocovski, 2001). trait anxiety is a stable predisposition to experience anxiousness or to experience state anxiety frequently (spielberger, 1966). state anxiety is an anxiety experienced within a specific moment and varies significantly between individuals and is associated with the development of pathological anxiety when experienced more often and with high intensity (spielberger, 1966). many models describing anxiety emphasize the multidimen­ sionality of anxiety. this is particularly important when aiming for comprehensive assessment of anxiety and distinguishing anxiety from depression. dimensions include cognitive, physiological and behavioral aspects of anxiety (elwood et al., 2012). so far, established measures of anxiety rarely distinguish between cognitive and somatic dimen­ sions of anxiety. the cognitive somatic anxiety questionnaire (delmonte & ryan, 1983; schwartz et al., 1978) and the endler multidimensional anxiety scales (endler et al., 1991) both include scales on cognitive and somatic symptoms but exclusively focus on trait assessment. distinguishing between anxiety and depression requires examining the complex and multilayered facets of both syndromes (eysenck & fajkowska, 2018). several approaches examine anxiety and depression in a common theoretical framework. one approach cognitive symptoms link anxiety and depression 2 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ suggests that anxiety focuses on the future and depression on the past resulting in respective cognitive biases (eysenck et al., 2006; pomerantz & rose, 2014). however, there is evidence that worry and rumination differ in their effects on behavioral and physiological responses to every day events and stressors, and that there is not a specific link between anxiety and worry, or depression and rumination (kircanski et al., 2017; lewis et al., 2018). beck’s content-specificity hypothesis suggests that anxiety is marked by a focus on danger, and in depression by self-deprecation (beck, 1976; beck et al., 1987). lastly, the tripartite model of anxiety and depression posits that anxiety and depression share a component of underlying negative affectivity or distress but anxiety is additionally marked by physiological hyperarousal, whereas depression is additionally marked by low positive affectivity (clark, 2009; clark & watson, 1991). however, none of these approaches can fully capture the complexity of how anxiety and depression overlap, how they differ, and how they interact (eysenck & fajkowska, 2018). in addition, some of the established instruments for the assessment of anxiety exhibit low discriminant validity regarding depressive symptoms. for instance, the state-trait anxiety inventory (stai; spielberger et al., 1983) is almost exclusively used to assess state and trait anxiety, but recent findings suggest that the stai also assesses depressive symptoms alongside anxiety. anxiety and depressive symptom severity are similarly correlated with the stai trait and state score, and individuals with depressive disorders score significantly higher on average than individuals with anxiety disorders (kennedy et al., 2001; knowles & olatunji, 2020). both anxiety and depression appear to share a component of negative affect (e.g. anderson & hope, 2008; balon, 2005; bieling et al., 1998; caci et al., 2003). in clinical research and practice, it is important to assess distinct aspects of anxiety, rather than just negative affectivity. therefore, an instrument is needed that validly as­ sesses anxiety, separately from depressive symptoms. in contrast to other questionnaires, the state-trait inventory for cognitive and somatic anxiety (sticsa; ree et al., 2008) aims to measure anxiety without including negative affectivity. the sticsa has 21 items for the state and trait scales, respectively, and has been shown to be a reliable instrument for the assessment of anxiety. the sticsa considers the multidimensionality of anxiety, as well as the need to differentiate it from depressive symptoms (elwood et al., 2012; grös et al., 2007; ree et al., 2008). while the two-factorial structure of cognitive and somatic anxiety has been validated for the state and trait scale of the sticsa, other factorial solutions have also been proposed. factor solutions for all items of the sticsa state and trait version revealed a four-factor model, as well as a higher-order model with a global anxiety factor and four first-order factors (sticsa trait cognitive subscale, stic­ sa trait somatic subscale, sticsa state cognitive subscale, and sticsa state somatic subscale). aside from the two-factor solutions for the trait and state scale, respectively, utilized by ree et al. (2008), these four-factor solutions have also been validated (carlucci et al., 2018; roberts et al., 2016). superior concurrent and divergent validity has been overmeyer & endrass 3 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ shown compared to the stai (tindall et al., 2021). so far, the sticsa was not available in a german version. the aim of the present study was to develop and validate a german version of the sticsa. to this end, the sticsa was translated into german and assessed in two independent samples (online and in the lab). we expected to replicate the two-factorial structure of the questionnaire. we examined associations with other scales assessing anxiety, as well as depressive symptoms and stress, to establish discriminant validity and parse different components of anxiety and depression. we expected that the sticsa would be positively associated with depressive symptoms, anxiety and stress. we also expected the sticsa to better distinguish between anxiety and depressive symptoms, possibly with the somatic subscale being less influential in the dynamic interactions between anxious and depressive symptoms. materials and method samples sample size estimation minimum sample size for factor analysis was estimated based on simulation studies by gagne and hancock (2006), who proposed a method that bases sample size estimation on measurement model quality or reliability, which can both be derived from the number of indicators per factor and the factor loadings of each indicator. therefore, taking into account the number of indicators per factor (n = 10 and n = 11, respectively) and the factor loadings of the original questionnaire, we estimated a minimum sample size of n = 250. sample 1 complete data from 510 individuals were collected online using the internet platform limesurvey (limesurvey project team, 2015) and participants’ identity remained anony­ mous to the research team. all participants were above 18 years of age and were native speakers of german. 209 participants were excluded due to either false responding to the control items (n = 17), no fluency in german (n = 7), the presence of current or past self-reported mental disorders other than anxiety disorders or depression (n = 95), or neurological disorders (n = 90). other mental and neurological disorders were excluded to distinctly examine anxious and depressive symptoms, and avoid confounding effects (e.g. bulloch et al., 2015). the final sample included 301 participants (mean age 26.6 years ± 8.8 standard deviation (sd), range 18-62 years; 67.1% female and 0.1% diverse; 96.7% had completed advanced education degrees; 19.9% self-reported diagnoses of anxiety and/or depressive disorders). participants could take part in a lottery to win 10 euro. cognitive symptoms link anxiety and depression 4 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ sample 2 complete data from 311 individuals were collected using the internet platform limesur­ vey (limesurvey project team, 2015) during a session in the lab as part of another research project. all participants were above 18 years of age, native speakers of german and had no neurological disorders. 8 participants were excluded due to the presence of current or past self-reported mental disorders other than anxiety disorders or depression. the final sample included 303 participants (mean age 24.9 years ± 5.2 standard deviation (sd), range 18-45 years; 48.8% female; 93.4% had completed advanced education degrees; 7.6% self-reported diagnoses of anxiety and/or depressive disorders). participants were compensated for their participation with 10 euro per hour. the ethics committee at the technische universität dresden approved all study procedures (ek 330082018) and study procedures for sample 2 (ek 372092017, and ek 585122019). measures the assessment for sample 1 included both the sticsa state and trait (ree et al., 2008), the stai (laux et al., 1981; spielberger et al., 1983), the depression anxiety stress scales (dass-21; henry & crawford, 2005; nilges & essau, 2015), and the beck depression inventory ii (bdi; beck et al., 1996; kühner et al., 2007). for more information on these measures see the supplementary materials. we also obtained information about gender, age, education level, presence of mental and neurological disorders, and native language. two control items to check for attention were included (meade & craig, 2012). the order of the questionnaires was randomized across participants. the assessment for sample 2 included the sticsa trait (ree et al., 2008) as well as information about gender, age, education level, and native language. bilingual psychologists translated the sticsa into german and back into english. the retranslated questionnaire was compared to the original version. differing items were discussed and adapted. data analysis to validate the german version of the sticsa trait, we first performed exploratory factor analysis (efa) with oblique rotation (oblimin) and maximum likelihood estimation on sample 1. due to non-normality of the data, as assessed by mardia’s test (mardia, 1970), the analysis was conducted on a polychoric correlation matrix (holgado–tello et al., 2010). to extract the number of factors or components, we used techniques with comparably high accuracy rates (ruscio & roche, 2012): parallel analysis for component extraction (pa), minimum average partial procedure (map), optimal coordinates (oc), acceleration factor (af) and comparison data (cd). to validate the factorial structure of the sticsa trait, we performed a confirmatory factor analysis (cfa), also based on a polychoric correlation matrix, on sample 2. we used the diagonally weighted least overmeyer & endrass 5 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ squares (wlsmv) estimator, which is specifically designed for ordinal data (li, 2016). reliability was assessed using mcdonald’s omega and cronbach’s alpha (cronbach, 1951; mcdonald, 2013; revelle & zinbarg, 2009). convergent and discriminant validity were examined using kendall’s tau correlations (kendall, 1938) with measures of individual traits that have been linked to anxiety, within sample 1. kendall’s tau has been shown to be a better estimate of the correlation in the population if the data is distributed non-normally (howell, 2012). a validation of the sticsa state can be found within the supplementary materials. to analyze the dynamic connections between the assessed traits, we used a network approach and estimated a standardized gaussian graphical model (ggm) using the graphical lasso as a regularization method; the tuning parameter was selected according to the extended bayesian information criterion (chen & chen, 2008; foygel & drton, 2010; friedman et al., 2008; lauritzen, 1996). the analysis was performed based on polychoric correlations within sample 1 (epskamp & fried, 2018). edge weight, or corre­ lation accuracy and stability of node centrality indices as measures of node importance were assessed using bootstrapping (see epskamp et al., 2018). an alternative model for comparison of network estimation was also estimated, see supplementary materials. data and code are available at osf (overmeyer & endrass, 2023a). all analyses were carried out with r (r core team, 2018), for used packages see supplementary materials. results exploratory factor analysis (sample 1) assumptions for efa were met (see supplementary materials). an initial analysis was conducted to extract the number of factors to retain. pa extracted two components, map, cd and af extracted 2 factors and oc extracted five factors. we analyzed the data using five and two factors. compared to the two-factor solution, the five-factor solution yielded more cross loadings and did not seem to adhere to meaningful constructs (see supplementary materials). due to the more convincing results from the two-factor solu­ tion, two factors were retained in the analysis (for analysis choice recommendations see costello & osborne, 2005; fabrigar et al., 1999). table 1 displays the factor loadings after rotation. item clustering replicated the factors from the original sticsa cognitive and somatic factors. factors were correlated, ϕ = 0.61, 95% ci [0.50, 0.66]. cognitive symptoms link anxiety and depression 6 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ table 1 oblimin rotated standardized loadings (pattern matrix) based upon polychoric correlation matrix item no. sticsa cognitive sticsa somatic item 3 0.72 0.17 item 4 0.59 0.02 item 5 0.41 0.19 item 9 0.80 -0.01 item 10 0.87 -0.07 item 13 0.76 0.04 item 16 0.64 0.01 item 17 0.61 0.08 item 19 0.78 -0.02 item 11 0.22 0.13 item 1 -0.01 0.57 item 2 -0.15 0.77 item 6 0.31 0.49 item 7 0.24 0.56 item 8 0.09 0.67 item 12 -0.07 0.62 item 14 0.08 0.63 item 15 -0.01 0.55 item 18 0.17 0.69 item 20 0.21 0.51 item 21 -0.19 0.64 note. sticsa cognitive and sticsa somatic = state-trait inventory for cognitive and somatic anxiety, cognitive and somatic symptoms subscales (sticsa trait). confirmatory factor analysis (sample 2) as a second analysis, we performed a cfa, also on a polychoric correlation matrix. goodness of fit for the proposed model was tested via root mean square error of ap­ proximation, rmsearobust = 0.04, 95% ci [0.03, 0.05], and tucker lewis index of factoring reliability (tlirobust = 0.95), values of rmsea close to 0.06 and tli close to 0.95 indicate acceptable fit (hu & bentler, 1999). additionally, the rmsea test of close fit (χ2 = 247, df = 188, p = .998) indicates close fit, and the rmsea test of not-close fit (χ2 = 247, df = 188, p < .001) indicates the model does not fit poorly (maccallum et al., 1996; steiger, 2007). the χ2 test of model fit (χ2 robust = 291, df = 188), however, was significant (probust < .001), providing evidence against perfect model fit. the standardized factor loadings (λ), their corresponding confidence intervals (ci) and standard errors (se) are presented in table 2. all factor loading estimates were significant and were of satisfactory magnitude. as expected, the two factors sticsa overmeyer & endrass 7 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ cognitive and somatic highly covaried in cfa (cov = 0.70; p < .001; 95% ci [0.61, 0.78]; se = 0.04). for a visualization of the sticsa structure see figure 1. table 2 standardized factor loadings (λ) based on polychoric correlations and estimated using diagonally weighted least squares item λ ci sell ul sticsa cognitive 3 0.75 0.68 0.83 0.04 4 0.57 0.46 0.68 0.06 5 0.54 0.44 0.64 0.05 9 0.71 0.63 0.78 0.04 10 0.75 0.67 0.82 0.04 11 0.27 0.15 0.40 0.06 13 0.72 0.63 0.80 0.05 16 0.69 0.60 0.77 0.05 17 0.63 0.53 0.73 0.05 19 0.72 0.63 0.81 0.05 sticsa somatic 1 0.55 0.44 0.66 0.05 2 0.55 0.45 0.65 0.05 6 0.73 0.62 0.85 0.04 7 0.62 0.49 0.76 0.04 8 0.62 0.50 0.75 0.04 12 0.55 0.43 0.67 0.06 14 0.76 0.61 0.91 0.06 15 0.47 0.32 0.61 0.06 18 0.64 0.51 0.61 0.04 20 0.67 0.57 0.77 0.04 21 0.28 0.15 0.42 0.07 note. ci = confidence interval; se = standard error; all loadings were significant. sticsa cognitive and sticsa somatic = state-trait inventory for cognitive and somatic anxiety, cognitive and somatic symptoms subscales (sticsa trait). cognitive symptoms link anxiety and depression 8 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ figure 1 path diagram of the sticsa trait (ree et al., 2008) results, including all items with their respective standardized factor loadings on the subscales as well as the correlation between the two subscales reliability mcdonald’s omega and cronbach’s alpha suggested satisfactory reliability for the stic­ sa in general (sample 1: ω = 0.89, 95% ci [0.86, 0.92], α = 0.89, 95% ci [0.86, 0.91]; sample 2: ω = 0.85, 95% ci [0.81, 0.88], α = 0.84, 95% ci [0.81, 0.87]), as well as for the subscales (sample 1: ωcog = 0.86, 95% ci [0.84, 0.89], ωsom = 0.81, 95% ci [0.76, 0.85], αcog = 0.86, 95% ci [0.83, 0.88], αsom = 0.81, 95% ci [0.76, 0.85]; sample 2: ωcog = 0.81, 95% ci [0.77, 0.84], ωsom = 0.73, 95% ci [0.67, 0.78], αcog = 0.81, 95% ci [0.77, 0.84], αsom = 0.73, 95% ci [0.67, 0.78]). overmeyer & endrass 9 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ validity and network dynamics we examined the validity of the sticsa and its subscales in sample 1, see table 3 for results. correlations were moderate to large in magnitude. it is important to note that the tau statistic has a different metric from other correlation coefficients (see gilpin, 1993). table 3 kendall’s tau correlations and their respective p-value between the two subscales of the sticsa and measures of anxiety, depression and stress within sample 1 measure 1 2 3 4 5 6 7 τ p τ p τ p τ p τ p τ p 1. sticsa cognitive – – 2. sticsa somatic 0.38 .001 – – 3. stai 0.38 .001 0.24 .001 – – 4. dass anx 0.44 .001 0.40 .001 0.33 .001 – – 5. dass stress 0.51 .001 0.34 .001 0.32 .001 0.41 .001 – – 6. dass depr 0.51 .001 0.19 .001 0.30 .001 0.31 .001 0.50 .001 – – 7. bdi 0.47 .001 0.21 .001 0.54 .001 0.37 .001 0.49 .001 0.54 .001 – note. sticsa cognitive and sticsa somatic = state-trait inventory for cognitive and somatic anxiety, cogni­ tive and somatic symptoms subscale scores (sticsa trait); stai = state-trait anxiety inventory-trait sum score; dass anx = depression anxiety stress scales sum score of anxiety subscale; dass stress = depression anxiety stress scales sum score of stress subscale; dass depr = depression anxiety stress scales sum score of depression subscale; bdi = beck depression inventory ii sum score. the connections between the nodes, or edge weights, within the network model calcu­ lated for sample 1 (for a visualization see figure 2) can be interpreted as partial correla­ tions. they therefore represent the connection between the different measures, control­ led for the presence of all other variables in the network (borsboom & cramer, 2013). the strongest connections were the connections between dass anxiety and sticsa somatic (pr = 0.33), between sticsa somatic and sticsa cognitive (pr = 0.28), between bdi and dass depression (pr = 0.39), between dass depression and dass stress (pr = 0.28) – and interestingly between sticsa cognitive and dass depression (pr = 0.30). the connection between sticsa somatic and dass depression was negative but small (pr = -0.14). sticsa cognitive appeared to be the most central node. it showed the highest values for node strength, closeness and expected influence, which indicate how strongly the node is connected to other nodes – directly as well as indirectly (epskamp et al., 2018). the z-standardized raw values of centrality indices of the ggm are visualized in the supplementary materials. in contrast, sticsa somatic has stronger links to dass anxiety and fewer or even negative connections with depression. results are supported within the alternative model (see supplementary materials). cognitive symptoms link anxiety and depression 10 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ figure 2 between-subject graphical lasso network with tuning parameter selected using the extended bayesian information criterion note. nodes represent the examined self-report measures or their respective subscales for depression, stress and anxiety. edges (connections) can be interpreted as partial correlation coefficients. red (dashed) lines represent negative edges, green (solid) lines positive edges. sticsatcog = sticsa trait (ree et al., 2008) cognitive subscale sum score, sticsatsom = sticsa trait (ree et al., 2008) somatic subscale sum score, stai = statetrait anxiety inventory (stai, spielberger et al., 1983) sum score, dassanx = depression anxiety stress scales (dass-21, henry & crawford, 2005) anxiety subscale sum score, dassstress = depression anxiety stress scales (dass-21, henry & crawford, 2005) stress subscale sum score, dassdepr = depression anxiety stress scales (dass-21, henry & crawford, 2005) depression subscale sum score, bdi = beck depression inventory ii (bdi, beck et al., 1996) sum score. overmeyer & endrass 11 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ discussion this study investigated the psychometric properties of a german version of the sticsa and dynamic associations with depressive symptoms, stress and negative affectivity. the two-factorial structure of the original version was replicated and validated for both the trait and state version of the questionnaire (see supplementary materials for results for the state version). all items consistently loaded on the expected factors. the somatic and cognitive anxiety factors were moderately correlated, as expected. the subscales were differentially associated with measures of anxiety and negative affectivity, depression, and stress. the cognitive subscale of the sticsa was shown to be the most central node within the network, and therefore may influence the connections between all other measures. results show that not only is the german version of the sticsa a reliable and valid instrument, but that it also helps to distinguish the common and distinct facets of depression and anxiety. dynamic interactions between psychological constructs can be conceptualized within network analyses (costantini et al., 2019). our results suggest that cognitive symptoms, as assessed by the sticsa are at the centre of a network intertwining depressive, anxious and stress-related symptoms, with evidence that cognitive symptoms are the most influential node. interestingly, the stai exhibited a large correlation with the bdi, but not in the presence of other anxiety measures and stress measures. within the net­ work, the stai and measures of depression only exhibited an indirect connection, with the connecting node being the cognitive symptoms of the sticsa. this fits well with research suggesting that anxiety and depressive symptoms can be differentiated using the bdi and the beck anxiety inventory (beck et al., 1988), particularly using items of the cognitive domain in depression and those from the physical domain in anxiety (lee et al., 2018). a study using questionnaires as well as ecological momentary assessment found that overlapping symptoms between depression and generalized anxiety disorder bridged other symptoms across the diagnostic boundary, while cognitive and somatic symptoms still more strongly clustered within disorders (shin, 2020). another study identified “worrying about past” and “worrying about future” as the most prominent symptoms connecting individual depression and anxiety symptoms and “feeling unhap­ py” and “feeling lonely” as the most prominent disorder bridging symptoms among depression symptoms, with associations possibly explaining comorbidities (konac et al., 2021). when integrating the approach of worry symptoms bridging disorders with the tripartite model, the finding that the cognitive symptom of worrying links depression and anxiety seems fitting: as rumination increases, the association between anxious and depressed mood is strengthened (starr & davila, 2012b). the insufficient focus on differences in content between anxiety and depression within the tripartite model has been criticized before (eysenck & fajkowska, 2018), as has the failure of the different versions of the classification systems to delineate the blurred (diagnostic) line between anxiety and depression: demyttenaere and heirman (2020) proposed a more phenomeno­ cognitive symptoms link anxiety and depression 12 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ logical or psychopathological approach to better understand the differences between expressions of anxiety and depression. it has been suggested that the negative affectivity component can be subdivided into “worry or apprehension anxiety” and “dysthymia or valence depression” (eysenck & fajkowska, 2018; fajkowska et al., 2018; renner et al., 2018). interestingly, there is evidence the arousal or somatic symptoms component most strongly relates to fear as measured by the positive and negative affective schedule and that the reactive and regulative functions of affect are related to the structure and function of anxiety and depression components (domaradzka & fajkowska, 2018). this may also explain the central role of the cognitive subscale of the sticsa within our analysis – most of the items are focused on general cognitive aspects and the subscale does not differentiate between aspects of worry vs. dysthymia. within the network model, the somatic subscale was only indirectly associated with the bdi, and was even negatively associated with the dass depression subscale. these findings align with previous research indicating that the somatic anxiety subscale was less correlated with measures of depression (tindall et al., 2021). another study found that the somatic subscale was related to differences in both subjective and psychophysio­ logical responses to emotional stimuli between groups of high vs. low anxiety (barros et al., 2022). thus, the somatic subscale of the sticsa may be useful in differentiating between anxiety and depression. however, it is essential to continuously evaluate the sticsa for future conceptualizations of anxiety. especially research on dynamic interac­ tions between anxiety and depression, indicating that symptoms reinforce each other, potentially explaining the high levels of comorbidity (mcelroy et al., 2018), and that anxiety can worsen the severity of depression in late-life (an et al., 2019). future research into the delineation of depression and anxiety may benefit from examining these interac­ tions. limitations of the current study include the relatively small sample sizes and the high homogeneity of the samples pertaining education. not all items may be optimal for the subscales. for items 1, 7, 8 and 14 the highest step of the likert scale was not used. additionally, items 11 and 21 showed low factor loadings (λ ≈ 0.30) on their respective subscales, and it may be discussed if it is statistically meaningful to include these items (tabachnick et al., 2007). while the sticsa appears to clearly distinguish between cognitive and somatic aspects of anxiety, and acknowledges the multidimensionality of anxiety, it does not assess the behavioral dimension of anxiety as described by elwood et al. (2012). this might prove an oversight, as anxiety is often marked by fearful avoidance, which may be useful as a discriminant symptom – however, it has been shown that the presence of depressive symptoms exacerbates fearful avoidance behavior (seekatz et al., 2016). also, cultural context might change the importance of somatic symptoms in the interaction between anxiety and depression (escovar et al., 2018; kim et al., 2019; park & kim, 2020). despite the compelling findings on discriminant validity, there has been a study that reported evidence that the cognitive and somatic scales of the sticsa are not overmeyer & endrass 13 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://www.psychopen.eu/ equally robust, with the authors concluding that the items appear to measure a mixture of both latent cognitive and somatic anxiety (styck et al., 2022). however, styck et al. (2022) did assess the presence of mental or neurological disorders which could influence responses for somatic symptoms (bulloch et al., 2015) – future studies should evaluate the sticsa scales in other disorders. conclusion the german version of the sticsa appears to be a reliable and valid measure of trait and state anxiety, providing the ability to discriminate between the subscales of somatic and cognitive anxiety. as the subscales assess different facets of anxiety, it is not surprising they appear to differ in their discriminant validity and their associations to depressive symptoms and stress. somatic symptoms of anxiety appear to most reliably assess symptoms primarily associated with anxiety, whereas cognitive symptoms seem to link anxious and depressive symptoms. the central role of cognitive symptoms in these dynamic interactions suggests that differential diagnostics should focus more on anxious somatic symptoms than on cognitive symptoms. information gathered using the sticsa could be useful in differential diagnosis of mood and anxiety disorders, and additional understanding of both cognitive and somatic aspects of anxiety might prove useful for therapeutic interventions. funding: this work was funded by the deutsche forschungsgemeinschaft (dfg, german research foundation), grant number sfb 940, project c6. acknowledgments: the authors would like to thank tyler bassett and julia hartl for the translation of the questionnaire; and michael höfler and john venz for helpful discussion on data analysis. the authors express their gratitude to all participants for their time and cooperation. competing interests: the authors have declared that no competing interests exist. ethics statement: the authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the helsinki declaration of 1975, as revised in 2008. the ethics committee at the technische universität dresden approved all study procedures (ek 330082018) and study procedures for sample 2 (ek 372092017, and ek 585122019). twitter accounts: @r__overmeyer, @tendrass data availability: the data that support the findings of this study are openly available at the open science framework (osf) (overmeyer & endrass, 2023a). cognitive symptoms link anxiety and depression 14 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://twitter.com/r__overmeyer https://twitter.com/tendrass https://www.psychopen.eu/ supplementary materials the supplementary materials for this article contain the following items (for access see index of supplementary materials below): 1. the data that support the findings of this study 2. additional information on the analysis of the sticsa trait: • on methods • on the exploratory factor analysis, with alternative factor solutions • on the network analysis 3. additional information on the analysis of the sticsa state: • on methods • on the exploratory factor analysis, with alternative factor solutions • on the confirmatory factor analysis 4. the german version of the sticsa trait and sticsa state index of supplementary materials overmeyer, r., & endrass, t. 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(2021). dimensionality and measurement invariance of the state-trait inventory for cognitive and somatic anxiety (sticsa) and validity comparison with measures of negative emotionality. frontiers in psychology, 12, article 644889. https://doi.org/10.3389/fpsyg.2021.644889 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. overmeyer & endrass 21 clinical psychology in europe 2023, vol. 5(2), article e9753 https://doi.org/10.32872/cpe.9753 https://doi.org/10.1080/13548506.2015.1111392 https://doi.org/10.1007/s10608-011-9434-3 https://doi.org/10.1007/s10608-011-9363-1 https://doi.org/10.1016/j.brat.2011.11.005 https://doi.org/10.1016/j.paid.2006.09.017 https://doi.org/10.1177/1073191120953628 https://doi.org/10.3389/fpsyg.2021.644889 https://www.psychopen.eu/ cognitive symptoms link anxiety and depression (introduction) materials and method samples measures data analysis results exploratory factor analysis (sample 1) confirmatory factor analysis (sample 2) reliability validity and network dynamics discussion conclusion (additional information) funding acknowledgments competing interests ethics statement twitter accounts data availability supplementary materials references the possible role of internet-delivered psychological interventions in relation to the covid-19 pandemic editorial the possible role of internet-delivered psychological interventions in relation to the covid-19 pandemic gerhard andersson a, matilda berg a, heleen riper bc, jonathan d. huppert d, nicolai titov ef [a] department of behaviorial sciences and learning, linköping university, linköping, sweden. [b] department of clinical, neuro and developmental psychology, vrije universiteit, amsterdam, the netherlands. [c] department of research and innovation, ggz in geest/amsterdam university medical center, vu university medical center, amsterdam, the netherlands. [d] the hebrew university of jerusalem, mount scopus, jerusalem, israel. [e] mindspot clinic, macquarie university, sydney, australia. [f] ecentreclinic, department of psychology, macquarie university, sydney, australia. clinical psychology in europe, 2020, vol. 2(3), article e3941, https://doi.org/10.32872/cpe.v2i3.3941 published (vor): 2020-09-30 corresponding author: gerhard andersson, department of behavioural sciences and learning, linköping university, se-581 83 linköping, sweden. tel: ++46 13 28 587 40. fax: ++46 13 28 21 45. e-mail: gerhard.andersson@liu.se the consequences of the covid-19 pandemic are moving targets, making it hard to estimate the societal burden in terms of not only physical but also mental health (holmes et al., 2020). it is clear that mental health problems will increase as a consequence of the pandemic. however, the specific problems across countries will reflect their response to the pandemic with mental health problems including the effects of social isolation (physical distancing), loss followed by disrupted grief ceremonies, loss or disruption to vocational, economic or educational opportunities, fear of a second outbreak of cov‐ id-19 and future post-corona mental health consequences (holmes et al., 2020). recent studies indicate that service demands for psychiatric assessments and interventions have increased (titov et al., 2020), while at the same time in person psychiatric visits for mild to moderate conditions have been advised against. there are many new challenges and possibilities raised by the pandemic. it is likely that we will see new problems and new groups of clients not seen before. mental health problems among health care workers is one example, and loneliness or relationship distress caused by social distancing is another example. a third example could be coping with loss: death of loved ones with little opportunity for social support, loss of employ‐ ment and monetary loss, and loss or disruption to education. to our knowledge, with the this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v2i3.3941&domain=pdf&date_stamp=2020-09-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ possible exception of problem-solving therapy and interpersonal psychotherapy focused on bereavement and role change, few psychological treatment studies have targeted financial concerns and mental health problems in association with such changes. the lesson for researchers is to document and adapt according to the new situation. provision of evidence-based psychological treatments that not only are cost-effective but also safe to deliver from a pandemic perspective would have relied solely on tele‐ phone contacts before the advent of modern information technology (wind, rijkeboer, andersson, & riper, 2020). since the late 1990s, a wide range of evidence-based internet interventions have been developed for a range of psychiatric diagnoses (for example major depression, anxiety and substance use disorders), and also psychological problems like loneliness, insomnia and stress (andersson, titov, dear, rozental, & carlbring, 2019). internet interventions often include instructions on how to perform tasks in real life. for example, exposure to feared social situations are performed in real life, and virtual reality and attention training may be used to augment or facilitate real life activities (miloff, lindner, & carlbring, 2020). this leads to one immediate challenge in the era of covid-19: homework assignments must be adapted to the current regulations and restrictions in each jurisdiction. real-time video conferencing is a further alternative to deliver evidence-based psychological treatments (varker, brand, ward, terhaag, & phelps, 2019). however, it is important to note that few studies have evaluated this treatment format and that it is more costly than internet interventions that involve minor therapist input. in spite of the many advantages of internet interventions there are additional limita‐ tions that are specifically relevant in view of the pandemic: first, internet interventions are rarely used for clients with severe mental health problems (e.g., psychosis and acute suicidal intent) and therefore cannot be a total solution in providing remote access to mental health care. second, with the covid-19 pandemic there has been an increase in the use of video consultations. while it is likely that video therapy works as well as face-to-face therapy, this has not been tested in empirical studies to the same extent as internet interventions in the form of guided self-help (varker et al., 2019). third, although a decreasing proportion of the population continue to experience the digital di‐ vide, still far from all people in the world have access to reliable internet. now, a majority have access, but it is still the case that there are groups who are not able to use comput‐ ers or smartphones, including frail, older persons, persons with intellectual disabilities, or those socio-economically disadvantaged. as a fourth limitation we raise the risk of not performing proper diagnostic assessments as is standard practice in most clinical settings (e.g., primary care and also some clinics providing internet interventions), where patients are screened for general health. in other words, internet interventions benefit from a well-functioning health care in order to maintain not only good quality treatment but also ethical standards when referral is needed. for example, if a cardiac problem is editorial 2 clinical psychology in europe 2020, vol.2(3), article e3941 https://doi.org/10.32872/cpe.v2i3.3941 https://www.psychopen.eu/ suspected in a telephone interview it may be more difficult to refer the client to regular health care. despite these limitations, internet interventions research has the advantage that treatments can be adapted rapidly and tested more quickly than is the case in regular psychotherapy research (and also medical research). there are several previous examples of this with treatments being developed for problems like loneliness, procrastination and perfectionism, but also adapting treatments for different age groups (e.g., adolescents, adults and older adults). furthermore, one striking advantage of internet interventions is translation and cultural adaption of interventions that would be very hard to deliver using a translator or expensive when training therapists in new settings (andersson et al., 2019). there are now studies on internet treatments in many languages including arabic, mandarin, and hebrew just to give a few examples. given the limited resources in many places and the risk of even worse economic circumstances, there is need and opportunity to develop and test interventions that are accessible regardless of where the person resides. of course, it is crucial that the medico-legal and clinical aspects are carefully managed, but this is a likely development in the future. in conclusion, the current covid-19 pandemic situation does not allow us to wait. internet-delivered psychological interventions should be offered and in particular evi‐ dence-based internet interventions that allow privacy and can be adapted for different problems and languages. specific interventions for psychological problems related to covid-19 should be developed. this could help reduce the societal burden caused by the pandemic. funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: the authors have no support to report. references andersson, g., titov, n., dear, b. f., rozental, a., & carlbring, p. (2019). internet-delivered psychological treatments: from innovation to implementation. world psychiatry, 18, 20-28. https://doi.org/10.1002/wps.20610 holmes, e. a., o’connor, r. c., perry, v. h., tracey, i., wessely, s., arseneault, l., . . . bullmore, e. (2020). multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science. the lancet: psychiatry, 7, 547-560. https://doi.org/10.1016/s2215-0366(20)30168-1 andersson, berg, riper et al. 3 clinical psychology in europe 2020, vol.2(3), article e3941 https://doi.org/10.32872/cpe.v2i3.3941 https://doi.org/10.1002/wps.20610 https://doi.org/10.1016/s2215-0366(20)30168-1 https://www.psychopen.eu/ miloff, a., lindner, p., & carlbring, p. (2020). the future of virtual reality therapy for phobias: beyond simple exposures. clinical psychology in europe, 2(2), article e2913. https://doi.org/10.32872/cpe.v2i2.2913 titov, n., staples, l., kayrouz, r., cross, s., karin, e., ryan, k., . . . nielssen, o. (2020). rapid report: early demand, profiles and concerns of mental health users during the coronavirus (covid-19) pandemic. internet interventions, 21, article 100327. https://doi.org/10.1016/j.invent.2020.100327 varker, t., brand, r. m., ward, j., terhaag, s., & phelps, a. (2019). efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder, and adjustment disorder: a rapid evidence assessment. psychological services, 16, 621-635. https://doi.org/10.1037/ser0000239 wind, t. r., rijkeboer, m., andersson, g., & riper, h. (2020). the covid-19 pandemic: the ‘black swan’ for mental health care and a turning point for e-health. internet interventions, 20, article 100317. https://doi.org/10.1016/j.invent.2020.100317 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology information (zpid), germany. editorial 4 clinical psychology in europe 2020, vol.2(3), article e3941 https://doi.org/10.32872/cpe.v2i3.3941 https://doi.org/10.32872/cpe.v2i2.2913 https://doi.org/10.1016/j.invent.2020.100327 https://doi.org/10.1037/ser0000239 https://doi.org/10.1016/j.invent.2020.100317 https://www.psychopen.eu/ imagery rescripting versus cognitive restructuring for social anxiety: treatment effects and working mechanisms research articles imagery rescripting versus cognitive restructuring for social anxiety: treatment effects and working mechanisms miriam strohm 1, marena siegesleitner 1, anna e. kunze 1 , thomas ehring 1 , charlotte e. wittekind 1 [1] department of psychology, lmu munich, munich, germany. clinical psychology in europe, 2021, vol. 3(3), article e5303, https://doi.org/10.32872/cpe.5303 received: 2020-11-29 • accepted: 2021-07-16 • published (vor): 2021-09-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: charlotte e. wittekind, department of psychology, lmu munich, leopoldstraße 13, 80802 munich, germany. tel.: +49 (0)89 2180 5196. e-mail: charlotte.wittekind@psy.lmu.de supplementary materials: materials [see index of supplementary materials] abstract background: negative mental images in social anxiety are often linked to memories of distressing social experiences. imagery rescripting (imrs) has been found to be a promising intervention to target aversive memories, but mechanisms underlying imrs are largely unknown. the present study aimed (a) to investigate the effects of imrs compared to cognitive restructuring (cr) on social anxiety symptoms and (b) to extend previous research by examining whether imrs works by fostering reappraisal of negative emotional self-beliefs. method: highly socially anxious individuals (n = 77) were randomly allocated to imrs, cr, or no intervention control (nic). a speech task was performed at baseline and at 1-week follow-up. results: only cr significantly reduced social anxiety symptoms from baseline to follow-up. decreases in negative appraisals and emotional distress in response to the speech task did not differ between conditions. regarding working mechanisms, imrs led to stronger increases in positive emotions than cr and nic. both cr and imrs yielded short-term reductions in emotionally anchored idiosyncratic self-beliefs, but cr was superior to imrs at follow-up. conclusions: the present study provides evidence for the efficacy of a single-session of cr for social anxiety symptoms. as one specific version of imrs was applied, it is conceivable that other or optimized versions of imrs might be more effective. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.5303&domain=pdf&date_stamp=2021-09-30 https://orcid.org/0000-0002-7021-6144 https://orcid.org/0000-0001-9502-6868 https://orcid.org/0000-0002-5841-0067 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords imagery rescripting, cognitive restructuring, social anxiety, mental imagery, working mechanisms, autobiographical memories highlights • cr was more effective than imrs and no intervention to reduce social anxiety symptoms. • cr more effectively reduced dysfunctional beliefs. • imrs led to strongest increase of positive emotions. cognitive models of social anxiety disorder (sad) suggest that negative mental images of the self are a key maintaining factor of the disorder (clark & wells, 1995; hofmann, 2007; rapee & heimberg, 1997). image content is often linked to former aversive social experi­ ences (hackmann et al., 2000). therefore, specifically targeting these aversive memories during treatment might improve therapeutic outcomes (norton & abbott, 2017; wild & clark, 2011). imagery rescripting (imrs) is an imagery-based intervention for aversive memories that has increasingly been incorporated in cognitive behavioral therapy (cbt) for sad (e.g., mcevoy et al., 2020; mcevoy & saulsman, 2014; wild & clark, 2011). during imrs, patients are instructed to visualize an aversive memory and to change it in imagination according to their emotional needs. imrs aims to update the meaning of memories thereby reducing associated negative (self-)images, beliefs, and emotions (arntz, 2012). imrs may be an efficacious treatment for different disorders including sad (morina et al., 2017). several studies have found that one session of imrs significantly improved social anxiety symptoms (lee & kwon, 2013; wild et al., 2007, 2008), also when delivered as a stand-alone intervention and without prior cognitive restructuring (cr; nilsson et al., 2012; norton & abbott, 2016; reimer & moscovitch, 2015). while imrs yields promis­ ing treatment results, a better understanding of its underlying working mechanisms is needed to eventually optimize treatment efficacy. it has been proposed that imrs might work by changing the idiosyncratic meaning of aversive experiences (arntz, 2012) and, more specifically, by leading to emotionally anchored reappraisal of core beliefs (nilsson et al., 2012; norton & abbott, 2016; wild et al., 2008). during imrs, positive meanings are offered in the form of images. based on evidence that mental imagery elicits stronger emotions than verbal thinking (holmes & mathews, 2010), it is conceivable that generating images with alternative meanings during imrs is associated with stronger emotional activation than questioning maladap­ tive beliefs verbally (holmes et al., 2009). consequently, alternative meanings offered in the form of images might be more emotionally anchored, more believable, and more likely to lead to changes in behavior than meanings exclusively generated as verbal representations (holmes & mathews, 2010). this assumption is in line with the idea that imrs vs. cognitive restructuring in social anxiety 2 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ one can distinguish between different levels of meaning representations (e.g., barnard & teasdale, 1991; but see power & dalgleish, 1999). according to the model of interacting cognitive subsystems (ics; barnard & teasdale, 1991), intellectual beliefs (propositional level) can be distinguished from emotional beliefs (implicational level). intellectual beliefs are described as knowing something “with the head”, whereas emotional beliefs corre­ spond to an implicit sense of knowing “with the heart” or “having a gut feeling” (barnard & teasdale, 1991). cognitive treatments can be expected to change beliefs primarily on a propositional level. imrs as an experientially oriented intervention invokes different sensory modalities thereby addressing the implicational meaning level, which is sugges­ ted to be necessary to then change emotional beliefs (see arntz, 2012; wild et al., 2008). although emotionally anchored reappraisal (i.e., changing emotional beliefs) has often been discussed as a mechanism underlying imrs, empirical evidence is largely missing. one study with a sample of bulimia nervosa patients has investigated effects of imrs on emotional vs. intellectual beliefs (cooper et al., 2007). imrs was found to be more effective than a control intervention in reducing emotional self-beliefs. a recent study investigated the effects of imrs (vs. imaginal exposure [ie] and supportive counselling [sc]) on memory processes in patients with social anxiety disorder (romano et al., 2020). there were no differences between conditions regarding memory appraisal, but a higher proportion of patients receiving imrs updated their negative core belief compared to sc (no differences emerged compared to ie). given the limited number of studies on working mechanisms of imrs, the aim of the present study was to investigate whether imrs works by reducing maladaptive emotional beliefs. the present study aimed to (1) investigate the effects of stand-alone imrs and cr on social anxiety symptoms, and (2) extend previous research by exploring mechanisms underlying imrs. our procedure was based on the study by norton and abbott (2016). highly socially anxious individuals were randomly allocated to either one session of imrs, one session of cr, or a no-intervention control condition (nic). outcomes were assessed at baseline and at 1-week follow-up. a speech task was included to examine intervention effects to a social stressor. in line with previous findings, we hypothesized that imrs and cr would yield greater decreases in social anxiety symptoms than nic. we expected imrs and cr to reduce negative appraisals and emotional responses (sub­ jective arousal and distress) to the speech task more strongly than nic. regarding mechanisms, we hypothesized that imrs would lead to stronger emotional activation than cr. while we expected both imrs and cr to decrease the maladaptive intellectual self-beliefs, we assumed that imrs would yield stronger reductions of maladaptive emo­ tional self-beliefs. we additionally explored the relationship between the hypothesized mechanisms and symptomatic change. strohm, siegesleitner, kunze et al. 3 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ method participants highly socially anxious individuals were recruited via advertisements on university cam­ pus and social media. to be included, participants had to score ≥ 30 (clinical cut-off) on the german version of the social interaction anxiety scale (sias; stangier et al., 1999). results of a sample-size calculation (two-tailed, α = .05, power = .80, run with g*power 3.1; faul et al., 2007) with medium to large effect sizes (d = .70; morina et al., 2017) showed that a sample size of 76 was required to detect significant differences between active treatments (imrs + cr) versus nic. during the first session, eligible participants were administered the mini interna­ tional neuropsychiatric interview (m.i.n.i. 5.0.0; sheehan et al., 1998; german version: ackenheil et al., 1999) to screen for exclusion criteria: (1) current diagnosis of major depressive disorder, (2) current and/or lifetime diagnosis of posttraumatic stress disor­ der/psychotic disorder/bipolar disorder, (3) substance dependence during the past 12 months, (4) acute suicidal tendencies. further exclusion criteria were: (5) age < 18 or > 35 years, (6) current psychological treatment, (7) pregnancy, (8) severe physical illness. the restricted age range was applied to obtain a more homogenous sample regarding age. participants had to meet the following inclusion criteria: (1) negative mental self-im­ age(s) in feared social situations, (2) aversive social experience related to the image, and (3) maladaptive self-belief (see section "imagery interview"). a total of 96 participants attended session 1 of whom 16 had to be excluded (n = 10 current/lifetime diagnosis of mental disorders specified above; n = 4 no negative mental self-image; n = 2 no maladaptive self-belief). three participants did not attend the follow-up session, leaving a final sample of 77 participants (81% female; age: m = 22.46, sd = 3.88). all participants gave written informed consent and were reimbursed by receiving partial course credit or 20€. the study was approved by the research ethics committee of the faculty of psychology and educational sciences at lmu munich. clinical interviews the m.i.n.i. (sheehan et al., 1998; german version: ackenheil et al., 1999) was ad­ ministered to assess current diagnoses according to dsm-iv (american psychiatric association [apa], 2000). additionally, the sad module of the structured clinical inter­ view for dsm-iv (scid-i; first et al., 2002; german version: wittchen et al., 1997) was administered. imagery interview the imagery interview was based on the waterloo images and memories interview (wimi; moscovitch et al., 2011) and on the interview used by norton and abbott (2016). imrs vs. cognitive restructuring in social anxiety 4 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ the semi-structured interview assessed negative self-imagery, aversive memories, and maladaptive self-beliefs. participants were asked to define their most anxiety-provoking social situation and to imagine themselves being in such a situation. they were instruc­ ted to become aware of whether there was a mental image that comes to their mind in this kind of situation and to describe the mental image in detail. participants were then asked when they first felt the way they did in the image and to visualize and describe the respective event. this was used to determine whether there was an early aversive memory related to the mental image. in order to specify the idiosyncratic self-belief derived from the negative mental image and the aversive memory, participants were asked: “what do the image and the memory tell about you as a person?”. participants were instructed to summarize the meaning in form of a short statement. speech task in order to measure reactions to a social stressor, participants were asked to give a 3 min video-recorded impromptu speech (norton & abbott, 2016) on a given political topic in both sessions (the order of two topics was counterbalanced). symptom measures the 20-item sias (mattick & clarke, 1998; german version: stangier et al., 1999) was used to assess social interaction anxiety during the past seven days on a 5-point scale (0 = not at all to 4 = extremely). the 12-item brief fear of negative evaluation scale-re­ vised (bfne-r; carleton et al., 2006; german version: reichenberger et al., 2016) was administered to measure fear of negative evaluation by others on a 5-point scale (1 = not at all characteristic of me to 5 = extremely characteristic of me). in order to test for baseline group differences in depressive symptoms, the patient health questionnaire-9 item (phq-9; krönke et al., 2001; german version: löwe et al., 2002) was administered. speech task measures in order to verify the relevance of the speech task as a stressor we asked participants to indicate how anxious they had felt or would have felt when giving a speech/presentation during the last week (0 = not at all anxious to 3 = extremely anxious). the probability and consequences questionnaire (pcq; rapee & abbott, 2007) asks participants to rate their appraisal of the likelihood (7 items) and cost (7 items) of negative evaluation of their speech on a 5-point scale (0 = not at all likely/bad to 4 = extremely likely/bad). subjective­ ly experienced levels of distress were assessed using subjective units of distress (sud, 0 = not at all distressed to 100 = extremely distressed). self-assessment manikins (sam; bradley & lang, 1994) were used to assess self-reported physiological arousal (1 = very calm to 9 = very aroused). strohm, siegesleitner, kunze et al. 5 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ measures of underlying mechanisms emotional activation the positive and negative affect schedule-extended (panas-x; watson & clark, 1994; german version: grühn et al., 2010) was administered to assess changes in positive and negative emotions from preto post-intervention. participants were instructed to indicate how they felt at this very moment. we included the general dimensions “positive affect” (pa) and “negative affect” (na) as well as the subscales “fear”, “hostility”, “guilt”, “sadness”, “joviality”, “self-assurance”, and “attentiveness”. scales range from 1 (very slightly or not at all) to 5 (extremely). intellectual and emotional beliefs the maladaptive self-belief was identified during the imagery interview. participants were asked to rate intellectually and emotionally how much they felt that this belief was true (see cooper et al., 2007). for the intellectual rating, participants were asked to indicate how much they would rationally agree to their belief (0 = i do not agree at all to 100 = i completely agree). for the emotional rating, participants were asked how much they felt the belief was true, regardless of what they were thinking rationally (0 = feels not true at all to 100 = feels completely true). interventions imagery rescripting the imrs procedure was based on protocols by arntz and weertman (1999) and wild and clark (2011). stage 1 of imrs started with participants closing their eyes and vividly imagining the aversive memory from the perspective of their younger-self. participants were instructed to describe the situation in the first person, present tense, and to include all sensory modalities. stage 2 of imrs was initiated by instructing participants to imag­ ine the scene from the perspective of their current adult-self who is witnessing the events as a bystander. participants were asked to describe what they see is happening to their younger-self and were then encouraged to intervene in any way they wished. when the adult-self felt fully satisfied, stage 3 was initiated by asking participants to relive the memory again from the perspective of their younger-self, experiencing the in­ terventions of their adult-self. additionally, the younger-self was encouraged to express further unmet needs. the imrs procedure was concluded by asking participants to dwell on the final positive image. as we wanted to elucidate the underlying mechanisms of imrs (vs. cr) on symptom change, we used “pure” interventions and tested imrs in isolation. consequently, imrs was not preceded by cognitive restructuring and we did not explicitly refer to the maladaptive self-belief during imrs. the mean duration of imrs was 22.35 min (sd = 6.20). imrs vs. cognitive restructuring in social anxiety 6 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ cognitive restructuring the cr procedure was based on the protocol by wild and clark (2011). participants were first asked to outline evidence for their maladaptive self-belief and were then encouraged to challenge the self-belief by collecting evidence against it. to support this process we asked participants to consider alternative explanations for their experiences (including the early aversive memory), and to think of experiences contradicting the self-belief. all evidence for and against the negative self-belief was written down on a worksheet. finally, participants were instructed to rephrase the original self-belief into a more helpful statement. the mean duration of cr was 23.74 min (sd = 4.40). no-intervention control condition participants in nic were provided neutral magazines and were instructed to wait for 30 min in the laboratory. they were asked not to use any electronic device. procedure the study comprised two sessions, which were one week apart. two experimenters carried out different parts of the procedure so that the speech task and intervention were not administered by the same experimenter. during session 1, experimenter 1 administered the clinical interviews and baseline measurements (t0: sociodemograph­ ic data, sias, bfne-r, public speaking anxiety, suis, erq), followed by pre-speech measures (sud, sam, pcq) and the speech task. experimenter 2 then conducted the imagery interview and administered pre-treatment questionnaires (t1: intellectual and emotional belief, panas-x). then, participants were randomly allocated to imrs (n = 25), cr (n = 27), or nic (n = 25). the allocation sequence was computer-generated and experimenter 2 was blinded until the beginning of the interventions, experimenter 1 was blinded during the entire study. immediately after the interventions or the waiting period, participants completed post-treatment measures (t2: intellectual and emotional belief, panas-x). during session 2, which took place one week later, experimenter 1 administered the follow-up questionnaire (t3: sias, bfne-r, intellectual and emotional belief) and the second speech task, again including speech task measures administered prior to the speech task (sud, sam, pcq). finally, participants were fully debriefed. statistical analyses a series of 2(time) x 3(condition) repeated measures anovas were carried out for so­ cial anxiety symptoms (t0; t3), for speech task measures (pre-speech1; pre-speech2), and for positive and negative emotions (t1; t2). to follow up significant interactions, planned contrasts on change scores were conducted (imrs+cr vs. nic; imrs vs. cr). effects on intellectual and emotional self-beliefs were tested with 3(time) x 3(condition) repeated measures anovas. significant interactions were followed up using planned contrasts strohm, siegesleitner, kunze et al. 7 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ (imrs+cr vs. nic; imrs vs. cr). for imrs, pearson correlations were computed between mechanisms and symptomatic change. a significance level of α = .05 (two-tailed) was used for all analyses. partial eta squared (ηp2) or cohen’s d were used as effect sizes. results participant characteristics and baseline comparisons no significant baseline differences between conditions emerged (see table 1). mean age at time of the aversive event was 12.86 years (sd = 4.55; range 3-27), with significant differences between groups1 (imrs: m = 13.88, sd = 4.90; cr: m = 13.76, sd = 4.60; nic: m = 10.88, sd = 3.55), f(2, 74) = 3.78, p = .027. table 1 demographic variables and pre-treatment characteristics demographics and pretreatment characteristics overall sample (n = 77) imrs (n = 25) cr (n = 27) nic (n = 25) statistics demographics gender (female/male), n 62/15 21/4 20/7 21/4 χ2(2) = 1.10, p = .577 age in years, m (sd) 22.36 (3.88) 22.64 (3.82) 22.59 (3.92) 21.84 (4.01) f(2,74) = 0.33, p = .718 social anxiety symptoms, m (sd) sias 40.29 (12.55) 40.84 (13.21) 37.93 (12.06) 42.28 (12.49) f(2,74) = 0.81, p = .447 bfne-r 40.48 (10.39) 40.20 (11.00) 39.44 (10.36) 41.88 (10.07) f(2,74) = 0.36, p = .696 sad criteria met, n (%) 21 (27) 8 (32) 8 (30) 5 (20) χ2(2) = 1.02, p = .599 comorbidity (yes/no), n 7/70 3/22 3/24 1/24 generalized anxiety disorder, n 2 0 1 1 dysthymia 3 1 2 0 anorexia nervosa 1 1 0 0 bulimia nervosa 1 1 0 0 public speaking anxiety, m (sd) 1.94 (0.85) 1.92 (0.95) 1.93 (0.96) 1.96 (0.61) f(2,74) = 0.02, p = .984 note. imrs = imagery rescripting; cr = cognitive restructuring; nic = no-intervention control; sias = social interaction anxiety scale; bfne-r = brief fear of negative evaluation scale-revised; sad = social anxiety disorder. 1) we tested whether age of the aversive memory (i.e., time that had passed since the event) had an influence on our main symptomatic outcomes. however, results remained unchanged when including age of the memory as a covariate. note that age of the aversive memory was not significantly different in the two active treatment conditions (imrs and cr). imrs vs. cognitive restructuring in social anxiety 8 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ social anxiety symptoms social interaction anxiety for sias scores (see figure 1), there was no main effect of condition, f(2, 74) = 1.97, p = .147, ηp2 = .05, but a significant effect of time, f(1, 74) = 17.94, p < .001, ηp2 = .20, and a significant interaction, f(2, 74) = 3.22, p = .046, ηp2 = .08. planned contrasts revealed no difference between the active treatment groups compared to nic in reducing social interaction anxiety, t(74) = 1.05, p = .298, d = 0.26. however, cr led to stronger decreases than imrs, t(74) = 2.29, p = .025, d = 0.64. figure 1 effects of imrs vs. cr vs. nic on (a) social interaction anxiety (sias), and (b) fear of negative evaluation (bfner) note. error bars represent sem. fear of negative evaluation results for bfne-r revealed a significant main effect of time, f(1, 74) = 5.70, p = .020, ηp2 = .07, but neither a significant effect of condition, f(2, 74) = 1.09, p = .342, ηp2 = .03, nor a significant interaction, f(2, 74) = 2.90, p = .061, ηp2 = .07., see figure 1. speech task measures for both subscales of the pcq2, there were significant main effects of time, fs(1, 71) > 9.74, ps < .003, ηp2s ≥ .12, but no significant interactions, fs(2, 71) < 2.28, ps > .110, ηp2s ≤ .06. the main effect of condition was significant for probability, f(2, 71) = 3.13, p = .050, ηp2 = .08, but not for cost of negative evaluation, f(2, 71) = 1.13, p = .330, ηp2 = .03. imrs and cr did not yield significantly greater reductions of appraisals of negative evaluation than nic (see table 2). for distress (sud), a significant effect of time emerged, f(1, 70) = 17.41, p < .001, ηp2 = .20, but neither the main effect of condition nor the interaction were significant, fs(2, 70) < 2.12, ps > .128, ηp2s < .06 (see table 2). 2) in some participants, speech-related questionnaires were erroneously not administered (pcq: n = 3; sud: n = 4; sam: n = 2) and these participants were excluded from the respective analyses. strohm, siegesleitner, kunze et al. 9 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ results for arousal (sam) revealed a significant effect of time, f(1, 72) = 11.35, p = .001, ηp2 = .14, but neither a significant main effect of condition nor a significant interaction, fs(2, 72) < 1.05, p > .354, ηp2 < .03 (see table 2). table 2 means and standard deviations for speech task measures before (speech 1) and after (speech 2) intervention: means (sd) group speech 1 speech 2 m (sd) m (sd) negative evaluation: probabilitya imrs 15.46 (4.25) 14.79 (4.66) cr 13.04 (5.62) 10.27 (5.45) nic 14.25 (5.93) 13.33 (5.93) negative evaluation: costa imrs 13.50 (5.87) 12.25 (6.10) cr 12.46 (6.71) 9.27 (4.64) nic 13.79 (5.98) 12.29 (6.52) distress (sud)b imrs 66.50 (29.77) 57.42 (27.33) cr 75.12 (22.01) 55.35 (28.42) nic 72.17 (23.10) 65.65 (24.33) arousal (sam)c imrs 6.67 (1.61) 5.79 (1.35) cr 6.62 (1.50) 5.65 (1.67) nic 6.28 (1.67) 6.00 (1.61) note. imrs = imagery rescripting; cr = cognitive restructuring; nic = no-intervention control; sud = subjective units of distress; sam = self-assessment manikins. an = 74. bn = 73. cn = 75. mechanisms activation of positive and negative emotions for panas-pa and na (see table 3) there were significant effects of time, fs(1, 74) > 35.10, ps < .001, ηp2s ≥ .32, but no significant effects of condition, fs(2, 74) < 2.17, ps > .121, ηp2s ≤ .06. no significant interaction was found for panas-na, f(2, 74) = 0.57, p = .570, ηp2 = .02. a significant interaction emerged for panas-pa, f(2, 74) = 9.29, p < .001, ηp2 = .20. planned contrasts revealed that active treatments increased positive emotions more strongly than nic (mdiff = -0.52, sd = 4.48), t(60.89) = 3.97, p < .001, d = 0.97, with imrs (mdiff = -7.36, sd = 6.81) leading to stronger increases than cr (mdiff = imrs vs. cognitive restructuring in social anxiety 10 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ -3.52, sd = 5.35), t(45.54) = 2.25, p = .029, d = 0.62. results for the remaining subscales of panas-x are provided in the supplementary materials (table s1). table 3 symptom measures and mechanism variables before the interventions (t0/t1), after the interventions (t2) and at follow-up (t3): means (sd) group t0/t1 t2 t3 m (sd) m (sd) m (sd) panas-pa imrs 23.12 (5.20) 30.48 (8.21) cr 22.89 (6.79) 26.41 (7.12) nic 22.92 (6.13) 23.44 (6.89) panas-na imrs 19.04 (6.77) 13.92 (3.64) cr 18.19 (6.29) 14.41 (5.37) nic 18.60 (5.58) 13.48 (3.12) intellectual belief imrs 51.60 (27.53) 39.40 (26.91) 48.80 (26.55) cr 64.74 (29.83) 40.37 (25.79) 42.52 (29.49) nic 57.8 (33.32) 55.48 (32.32) 57.24 (29.63) emotional belief imrs 90.40 (10.88) 62.52 (19.71) 73.80 (18.10) cr 84.07 (16.82) 56.11 (29.00) 52.78 (27.92) nic 83.08 (20.92) 81.36 (21.90) 79.60 (20.74) note. imrs = imagery rescripting; cr = cognitive restructuring; nic = no-intervention control; sias = social interaction anxiety scale; bfne-r = brief fear of negative evaluation scale-revised; panas = positive and negative affect schedule; pa = positive affect; na = negative affect. intellectual and emotional beliefs to check whether participants were able to distinguish between the intellectual and the emotional belief, a correlation between the two measures was computed. the moderate correlation of rs = .387, p = .001, suggests that the two measures have some overlap but are not identical. for intellectual beliefs, there was no significant effect of condition, f(2, 74) = 1.00, p = .373, ηp2 = .03, but a significant effect of time and a significant interaction, fs(1.81, 134.19 / 3.63, 134.19) > 6.12, ps < .001, ηp2s ≥ .14 (see table 3). planned contrasts revealed that active treatments led to stronger reductions in intellectual beliefs from preto post-intervention than nic, t(55.43) = 4.58, p < .001, d = 1.12, and from pre to follow-up, t(74) = 2.13, p = .036, d = 0.52. cr led to stronger reductions than imrs from preto post-intervention, t(35.93) = 2.03, p = .050, d = 0.49, and from pre to follow-up, t(74) = 3.04, p = .003, d = 0.84. strohm, siegesleitner, kunze et al. 11 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ for emotional beliefs, there were significant effects of time and condition, fs(2, 148/2, 74) > 5.37, ps ≤ .006, ηp2s ≥ .13, and a significant interaction, f(4, 148) = 13.94, p < .001, ηp2 = .27. planned contrasts revealed that the active treatments reduced emotional beliefs more strongly than nic from preto post-intervention, t(60.66) = 8.51, p < .001, d = 2.07, and from pre to follow-up, t(69.14) = 5.62, p < .001, d = 1.37. cr and imrs decreased emotional beliefs from preto post-intervention equally effective, t(49.78) = -0.16, p = .878, d = 0.04, but cr led to stronger reductions than imrs from pre to follow-up, t(48.13) = 2.67, p = .010, d = 0.74. correlations between mechanisms and symptomatic change within the imrs group, symptomatic change was not significantly correlated with changes in emotions (pa x sias: r = -.08; pa x bfne-r: r = .26; na x sias: r = -.35; na x bfne-r: r = .11; ps ≥ .085) nor with pre-post changes in emotional beliefs and symptomatic change (sias: r = -.39; bfne-r: r = -.15; all ps ≥ .055). the same non-signif­ icant pattern emerged in the cr group (pa x sias: r = -.25; pa x bfne: r = .07; na x sias: r = -.13; na x bfne: r = -.12; rational belief x sias: r = .14; rational belief x bfne: r = .09, ps ≥ .217). discussion the present study examined the effects of single-session imrs vs. cr for socially anxious individuals compared to nic. effects on social anxiety symptoms contrary to hypothesis, we found that one session of cognitive restructuring (cr) is more effective than one session of imagery rescripting (imrs) and no intervention con­ trol (nic) in reducing social interaction anxiety. no significant differences between groups emerged for fear of negative evaluation. when confronted with the speech task, participants in all conditions demonstrated equal reductions in distress, arousal, and negative appraisals suggesting that if cr and imrs are administered as very brief interventions no beneficial effects emerge over and above mere exposure to the speech. the speech task represents a strength of the study, but our findings suggest that the speech task may be susceptible to exposure effects, thereby reducing its ability to capture between-group differences in anxiety across time. taken together, we could not replicate previous findings regarding the effects of the interventions on responses to a social stres­ sor (norton & abbott, 2016). our findings support previous evidence that one session of cr exerts positive effects on social anxiety symptoms (e.g., norton & abbott, 2016; shikatani et al., 2014). contrary to expectations, we were not able to replicate earlier findings on the benefits of stand-alone imrs (nilsson et al., 2012; norton & abbott, 2016; imrs vs. cognitive restructuring in social anxiety 12 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ reimer & moscovitch, 2015) on social anxiety symptoms. this result is surprising given the similarities between studies (i.e., one session of imrs, no cognitive preparation); however, a sub-clinical sample was included in our study whereas participants were diagnosed with sad in previous research (nilsson et al., 2012; norton & abbott, 2016; reimer & moscovitch, 2015). although the severity of self-reported interaction anxiety in our study was comparable to previous studies (ø40 [this study]; ø37 [nilsson et al, 2012]; ø44 [norton & abbott, 2016]), the low rate of diagnoses in the present sample could indicate that the impairment caused by the social anxiety symptoms was not sufficient to fulfill diagnostic criteria and that participants are able to cope with their negative mental images. as our imrs procedure closely followed the procedure of norton and abbott (2016), it seems rather unlikely that procedural differences explain the inconsistent findings. alternatively, imrs as used in this study might need to be optimized. first, imrs might not have been optimally delivered (e.g., insufficient reactivation of emotions or the hot­ spot; short duration of imrs [ø 22min in the present study]). second, we do not know to what extent participants were able to put themselves in their younger self´s perspective. third, in order to ensure internal validity we used a highly standardized imrs protocol whereas other studies administered imrs in a more individualized way and with a more active therapist/ experimenter (e.g., norton & abbott, 2016). fourth, participants were instructed to introduce changes themselves in the present study. finally, as dysfunctional self-beliefs were not explicitly addressed during imrs it cannot be ruled out that the rescripting did not show a good enough match with the dysfunctional self-beliefs in the sense of providing corrective information and experiences to modify this belief. this may provide another explanation why imrs was not associated with long-term effects in our study. therefore, as the imrs protocol used in the present study represents only one specific implementation of imrs, it is conceivable that other versions of imrs might have yielded more stable effects. for example, in accordance with the protocol by wild and clark (2011), a combination of imrs with cr (lee & kwon, 2013; wild et al., 2008) might yield more stable treatment effects. different imrs techniques have been applied in both research and clinical practice; however, it remains an open question how imrs is best realized (e.g., with or without cognitive preparation; active vs. passive role of patient/therapist), therefore, future research is clearly needed to identify the most effective implementation of imrs. mechanisms underlying imagery rescripting in line with our hypothesis and with previous evidence (holmes & mathews, 2010), a single session of imrs led to stronger increases of positive emotions than cr and nic. in contrast, negative emotions significantly decreased across time with no differences between conditions. imrs and cr more strongly reduced maladaptive intellectual and emotional beliefs from preto post-intervention compared to nic, but only for cr strohm, siegesleitner, kunze et al. 13 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ reductions remained stable across time. in imrs, neither changes in positive emotions nor in emotional beliefs correlated with symptomatic outcomes. although our results indicate that brief imrs led to beneficial (short-term) effects, it remains to be tested whether the aforementioned mechanisms play a role in producing symptomatic change, as imrs did not yield improvements on symptom measures in the present study. moreover, our results challenge the notion that emotionally anchored reappraisal is a mechanism specific to imrs. in fact, brief cr seems to be more effective in targeting maladaptive emotional beliefs in the longer-term, counter to the theoretical idea that cognitive treatment strategies primarily change intellectual meaning levels (i.e., propositional level). however, after a single session of cr mean levels of emotional beliefs were still high at follow-up and more systematic research is needed to test whether emotional beliefs can be further reduced with multiple treatment sessions. limitations imrs and cr were delivered as very brief interventions within a non-therapeutic setting. thus, the interventions deviate from treatment as used in clinical practice limiting its generalizability. however, laboratory-based studies in healthy or subclinical samples are a valuable means to investigate mechanisms involved in psychological treatments under highly controlled and standardized conditions (e.g., van den hout et al., 2017). although we inquired about the meaning of the mental image, we did not assess how distressing and how relevant the image was regarding participants´ social anxiety symptoms. the distress/impairment caused by the image should be inquired in future studies as it is conceivable that only the modification of distressing images might be associated with long-term effects on social anxiety symptoms. moreover, it remains unclear whether participants adhered to the imrs instructions and how distressed they were during imrs as distress during imrs was not assessed. therefore, we cannot verify the correct implementation of imrs and that emotional activation was sufficient. emotional beliefs were rated on a one-item vas, which might reduce reliability. conclusion the present study compared the effects of imrs vs. cr as stand-alone single-session interventions in socially anxious individuals and aimed to examine mechanisms underly­ ing symptomatic change. results indicate that a single session of cr effectively reduces social anxiety symptoms. the present study raises the question how imrs for socially anxious individuals should optimally be implemented in order to yield symptomatic change. we propose that more individualized imrs protocols, higher treatment intensity, cognitive preparation, and/or directly targeting dysfunctional self-beliefs might be neces­ sary to yield therapeutic effects. imrs vs. cognitive restructuring in social anxiety 14 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ funding: this research did not receive any grant funding from the public, commercial, or not-for-profit sectors. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: all authors declare that they have no conflict of interest. ethics statement: all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. the study was approved by the research ethics committee of the faculty of psychology and educational sciences at lmu munich (67_strohm_b). author note: this paper was part of miriam strohm´s ph.d. project (strohm, 2019). supplementary materials the supplementary material contains a table containing the means and standard deviations of the positive and negative emotions as well as the results of the statistical analyses (for access see index of supplementary materials below). index of supplementary materials strohm, m., siegesleitner, m., kunze, a. e., ehring, t., & wittekind, c. e. 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(1997). skid – strukturiertes klinisches interview für dsm-iv: achse i und ii. göttingen, germany: hogrefe. imrs vs. cognitive restructuring in social anxiety 18 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://doi.org/10.1026/0012-1924/a000148 https://doi.org/10.1016/j.brat.2015.10.007 https://doi.org/10.1016/j.janxdis.2019.102169 https://doi.org/10.1016/j.janxdis.2014.05.012 https://doi.org/10.1026//0084-5345.28.1.28 https://edoc.ub.uni-muenchen.de/25436/1/strohm_miriam.pdf https://doi.org/10.5127/pr.045115 https://doi.org/10.1016/j.cbpra.2011.03.002 https://doi.org/10.1016/j.jbtep.2007.07.003 https://doi.org/10.1016/j.beth.2007.04.003 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. strohm, siegesleitner, kunze et al. 19 clinical psychology in europe 2021, vol. 3(3), article e5303 https://doi.org/10.32872/cpe.5303 https://www.psychopen.eu/ imrs vs. cognitive restructuring in social anxiety (introduction) method participants clinical interviews imagery interview speech task symptom measures speech task measures measures of underlying mechanisms interventions procedure statistical analyses results participant characteristics and baseline comparisons social anxiety symptoms speech task measures mechanisms discussion effects on social anxiety symptoms mechanisms underlying imagery rescripting limitations conclusion (additional information) funding acknowledgments competing interests ethics statement author note supplementary materials references impulsive buying and deferment of gratification among adults with adhd research articles impulsive buying and deferment of gratification among adults with adhd sverrir björn einarsson 1 , baldur heiðar sigurðsson 1,2 , sigurlín hrund kjartansdóttir 3 , páll magnússon †, jón friðrik sigurðsson 1,4 [1] department of psychology, reykjavík university, reykjavík, iceland. [2] landspítali – the national university hospital of iceland, reykjavík, iceland. [3] the health institute of east iceland, egilsstaðir, iceland. [4] faculty of medicine, university of iceland, reykjavík, iceland. †author deceased prior to publication of this paper. clinical psychology in europe, 2024, vol. 6(3), article e9339, https://doi.org/10.32872/cpe.9339 received: 2022-04-20 • accepted: 2024-04-22 • published (vor): 2024-09-30 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: jón friðrik sigurðsson, reykjavik university, menntavegi 1, 102 reykjavik, iceland. tel.: +354 8206277. e-mail: jonfsig@ru.is abstract background: impulsivity symptoms have been studied thoroughly in adults with adhd, including hasty actions and decisions without considering possible consequences. the objective of our study was to investigate impulsive buying and deferment of gratification among adults with adhd and a comparison group. method: the participants were 225 adults with adhd and 121 university students who completed the buying impulsiveness scale (bis), the deferment of gratification questionnaire (dogq), the adult adhd rating scale—iv (adhd-rs), as well as background questions. results: significant differences were found between the two groups on the three scales, the adhd group showing more adhd symptoms, more frequent impulsive buying behaviour and less ability to defer gratification. mediation analyses yielded significant indirect effects in both samples, which suggests that the relationship between adhd symptoms and impulsive buying is mediated by the ability to defer gratification. conclusion: the results suggest that placing emphasis on improving the capacity of adults with adhd to defer gratification might be beneficial in treatment. keywords adhd, impulsivity, impulsive buying, deferment of gratification, mediation analysis this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9339&domain=pdf&date_stamp=2024-09-30 https://orcid.org/0000-0002-2191-0009 https://orcid.org/0000-0001-9041-8942 https://orcid.org/0000-0003-3582-8521 https://orcid.org/0000-0001-6873-8157 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • adults with adhd symptoms are more likely to show impulsive buying behavior and lesser ability to defer gratification than those without adhd symptoms. • the relationship between adhd symptoms and impulsive buying is mediated by the ability to defer gratification. • improving capacity to defer gratification should be considered in treatment of adults with adhd. • more research on impulsive buying in adhd is warranted. future research might examine online impulsive buying among adults with adhd. adhd (attention deficit hyperactivity disorder) is a developmental disorder character­ ized by inattention, hyperactivity and impulsivity, that is inconsistent with the develop­ ment and age of the adult (american psychiatric association [apa], 2013). the preva­ lence rate of adhd is around 5% amongst children and 2.5% in adults when diagnoses are made according to the diagnostic and statistical manual of mental disorders, fifth edition (dsm-5) (apa, 2013). several twin studies indicate a strong genetic component in 70-95% of cases (comings, 2001). impulsivity, a core symptom of adhd, has been conceptualized as: (a) decreased sensitivity to negative outcomes of behaviour, (b) rapid, unplanned, reactions to stimuli before complete processing of information, and (c), lack of regard for long-term conse­ quences (moeller et al., 2001). impulsivity symptoms have been extensively studied in adults with adhd and among them are hasty actions and decisions without considering possible effects or consequences (apa, 2013; barkley, 1997). symptoms of impulsivity and hyperactivity are expected to decrease during adolescence and early adulthood (biederman et al., 2000), but some studies have shown that impulsivity persists into adulthood and may be a core factor of many behavioural dysfunctions seen in adults with adhd (asherson et al., 2016; babinski et al., 1999). impulsive buying has been conceptualized as “a sudden, often powerful and persis­ tent urge to buy something immediately” (rook, 1987), and studies indicate that impul­ sive buying tendencies derive from problems with executive functions such as problem solving, planning skills, reactivity, inattention and inflexibility (arican & kafadar, 2022). it has also been suggested that motor and non-planning impulsivity or lack of self-con­ trol are important aspects of impulsive buying (baumeister, 2002; sokić & korkut, 2020). deferment of gratification is a component of self-control and is based upon resisting the urge to receive an immediate reward in the hope of receiving a more valuable reward in the future (mischel et al., 1989). the ability to defer gratification is fundamental to effec­ tive self-control as studies suggest that consumers with greater self-regulatory resources are more likely to resist impulsive buying and there are indications that impulsive buying is motivated by immediate gratification (badgaiyan et al., 2016; roberts & manolis, 2012; sun et al., 2004; vohs & faber, 2007). impulsive buying among adults with adhd 2 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.psychopen.eu/ as of yet, no studies have demonstrated the relationship between adhd symptoms and impulsive buying among those with adhd, although a few studies indicate that adhd symptoms affect personal finances. bangma et al. (2019) explored problems in multiple domains of everyday life, including financial decision-making, among adults diagnosed with adhd. the results show that compared with healthy controls, those di­ agnosed with adhd reported a poorer financial situation, more debt, a lower incidence of having a savings account and a greater tendency to buy on impulse. a recent study by koerts et al. (2021) explored financial judgment among adults with adhd. they found that adults with adhd had lower financial competence scores than those with­ out adhd on appreciation, reasoning, understanding and communication. in addition, barkley et al. (2006) found that compared with controls, adults with adhd had more difficulties in allocating funds, i.e., problems with saving money, paying bills on time and a greater tendency for recklessness and impulsive buying. the same study found that growing up with adhd is a risk factor for financial problems in adulthood, regardless of whether adhd symptoms persist into adulthood although the risk was even greater in those cases where the symptoms did persist into adulthood. adults who are highly impulsive buyers tend to be more emotionally attracted to the item they are buying and more likely to desire immediate gratification (hoch & loewenstein, 1991). jackson and mackillop’s (2016) meta-analysis on the relationship between adhd and defer discounting indicates that people with adhd have a greater tendency to choose immediate and less valuable rewards instead of later rewards with more value, compared with people without the disorder. the aim of this study was to investigate impulsive buying as a function of adhd symptoms and the ability to delay gratification. of particular interest are the possible mediating effects of defer of gratification on the relationship between adhd and impul­ sive buying. three predictions were made: 1) adults diagnosed with adhd will have higher levels of impulsive buying than a sample of normal controls, 2) adults diagnosed with adhd will have more difficulty to defer gratification than normal controls, and 3) the link between adhd and impulsive buying is mediated by the ability to defer gratification. method participants the participants consisted of two groups: (1) a sample of 226 adults diagnosed with adhd and (2) a comparison sample (non-adhd group) of 134 university students at reykjavik university. inclusion criteria for both groups were: (a) age between 18 and 65 years, (b) reporting if and where the adhd diagnosis was made. in the student sample, 12 participants responded with “yes” to the question about adhd diagnosis and were einarsson, sigurðsson, kjartansdóttir et al. 3 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.psychopen.eu/ therefore eliminated from the sample, leaving a student sample of 122. after screening for outliers and influential cases (see below) two statistical outliers were identified and eliminated from the dataset, one from each sample, leaving a student sample of 121 participants and a clinical sample of 225 for the final analysis. the adhd sample had a mean age of 35.72 (sd = 9.80) and consisted of 162 (72.00%) females (mean age 35.09, sd = 9.08) and 63 (28.00%) males (mean age 37.33, sd = 11.37). one-hundred-fifty-five (68.89%) claimed to have graduated from upper secondary school and 187 (83.11%) being employed or studying at the time of the study. a majority (81.78%) of the adhd group reported having received their diagnoses from psychologists or psychiatrists in private practice, 10.22% from the adhd team at landspítali – the national university hospital of iceland, 4.00% from institutes of child mental health and developmental surveillance, and 4.00% from educational psychologists. it is worth men­ tioning that the diagnostic process of adhd in private practice in iceland is common, and that psychiatrists and psychologists are expected to follow clinical guidelines issued by the directorate of health (baldursson et al., 2012). the non-adhd sample had a mean age of 24.57 (sd = 5.33) and consisted of 82 (68.33%) females (mean age 25.00, sd = 6.07) and 38 (31.67%) males (mean age 23.54, sd = 2.96). one participant in the comparison group did not specify gender. the majority (119; 98.35%) claimed they had graduated from upper secondary school and all of them were university students at the time of the study. measures the buying impulsiveness scale (bis) the bis (rook & fisher, 1995) was designed to measure impulsive buying behaviour and contains nine statements such as, “i often buy things without thinking,” and “i carefully plan most of my purchases.” the participant indicates how much he or she agrees with these statements on a 5-point likert scale (1 = strongly disagree to 5 = strongly agree). the score of one item was reversed. higher scores indicate more impulsive buying tendencies. the scale has shown high levels of reliability (α = .88) (rook & fisher, 1995). it was translated to icelandic especially for this study using accepted methods, i.e. three independent forward translations which then were compared and semantic differences resolved arriving at the single translation which then was back-translated and amended accordingly (gudmundsson, 2009). the deferment of gratification questionnaire (dogq) the dogq (ray & najman, 1986) was designed to measure deferment of gratification in relation to financial planning and contains 12 questions such as “are you good at saving your money because you have had to wait for it and plan for it?” and “do you like to spend your money as soon as you get it?” the participant indicates how much he or she agrees with these statements on a 7-point likert scale (1 = very strongly impulsive buying among adults with adhd 4 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.psychopen.eu/ disagree, 4 = sometimes, 7 = very strongly agree). the scores of six items were reversed. lower scores indicate more difficulty in deferring gratification. the original scale has acceptable internal consistency (α = .72) (ray & najman, 1986). the scale was translated specifically for this study using three independent forward translations which were compared and semantic differences resolved arriving at the single translation which then was back-translated and amended accordingly (gudmundsson, 2009). the adult adhd rating scale—iv (adhd-rs) the adhd-rs (magnússon et al., 2006), was designed to measure the symptoms of attention-deficit/hyperactivity disorder (adhd). it contains 18 statements, nine items of inattention, five of hyperactivity, and four of impulsivity symptoms. the frequency and severity of each item is rated for the past six months on a 4-point likert scale (0 = never or rarely, 1 = sometimes, 2 = often, 3 = very often). a higher score indicates more adhd symptoms. the total score consists of 18 items, the scores of two subscales, the inattentive subscale (adhd-i) and the hyperactivity/impulsivity subscale (adhd-h/i). the scale has shown good reliability and validity and strong correlation with informal ratings of symptoms and interview-based diagnoses in childhood and adulthood. the scale was translated into icelandic by one of the authors of this paper and its validity and reliability turned out to be satisfactory (magnússon et al., 2006). the background information questionnaire the questionnaire developed by the adhd clinic at landspítali – the national univer­ sity hospital of iceland, consists of questions about gender, age, education, employment and adhd diagnosis. procedure a link to a survey (surveymonkey), was emailed by the icelandic adhd organisation, association of the adhd community in iceland, to all of its members and posted on its official facebook page (https://www.facebook.com/adhdsamtokin/?locale=is_is). for the comparison group, the survey was administered on paper in class in computer science, law, business and sports science at reykjavik university. participation of both groups was anonymous and voluntary and filling out the survey was considered as an informed consent for both groups as they had previously received written information about the study. the study was approved by reykjavik university and the icelandic bioethics com­ mittee (no. 18-0-51). einarsson, sigurðsson, kjartansdóttir et al. 5 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.facebook.com/adhdsamtokin/?locale=is_is https://www.psychopen.eu/ statistical analysis the data were analysed using the spss (v. 28.0). descriptive statistics were calculated on the measures used in the main analysis and t-tests were carried out to see if the adhd sample differed from the student sample on those variables. to adjust for the inflated type i error rate associated with multiple testing, bonferroni correction was employed resulting in an alpha level of 0.016 instead of 0.05. in the main analyses hayes’s spss process macro v. 4.2 (hayes, 2018) model 4 was used to carry out three identical mediation analyses: one for the total sample and one for each of the subsamples. this was done to examine whether the assumed effect of adhd on impulsive buying was mediated by the ability to defer gratification. the method relies on a series of regression analyses outlined by baron and kenny (1986). the total effect of the predictor (in this study adhd-rs) on the outcome variable (bis) is first assessed while leaving other variables out of the model. this is then fol­ lowed by examining the same relationship while controlling for the presumed mediator (dogq), taking into account the relationship between the predictor and the mediator. according to baron and kenny, if an originally significant total effect becomes insig­ nificant when controlling for the mediator, mediation is said to have occurred, i.e. the predictor operates through the mediator to affect the outcome. mediation is considered partial if some measurable, albeit insignificant relationship is left to account for, but if it reduces to zero when controlling for the mediator, the relationship between the predictor and the outcome is said to be completely mediated. the total effect (path c in figure 1) is thus broken down into a direct effect (path c´, the effect not accounted for by the relationship between the predictor and the mediator) and an indirect effect (paths a and b through the mediator, the effect accounted for by the relationship between the predictor and the mediator, or the mediated effect). these two regression analyses were, as mediation was originally defined, considered enough to calculate the indirect effect simply by subtracting the direct effect from the total effect. this, however, assumes the predictor and the mediator do not interact to affect the outcome. to account for a possible interaction effect, the indirect effect was therefor soon defined as the product of a) the first order relationship between the predictor and the mediator and b) the relationship between the mediator and the outcome when controlling for the predictor. in case of no interaction, these two methods (c-c´, and axb) yield the same result. therefore, for a complete mediation analysis, three regression analyses are needed to calculate the indirect effect. first, to assess the total effect (path c), the outcome is regressed on the predictor. second, to assess the direct effect of the predictor (path c´), the outcome is regressed on both the predictor and the presumed mediator. the direct effect is thus the regression coefficient of the predictor when controlling for the mediator. in this second regression analysis, we also get the first term needed to calculate the indirect effect, namely the effect of the mediator on the outcome when controlling impulsive buying among adults with adhd 6 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.psychopen.eu/ for the predictor (path b). finally, to calculate the second term needed for the indirect effect (path a), the presumed mediator is regressed on the predictor. figure 1 a conceptual model of mediation predictor mediator outcome a b predictor outcome c´ c note. c represents the total effect, c´ represents the direct, unmediated portion of the total effect and a and b, through the mediator represents the indirect, mediated portion of the total effect. as mentioned above, baron and kenny (1986) conceptualised mediation as an originally significant effect of a predictor on an outcome becoming insignificant (or zero) when controlling for a mediating variable. more recently these requirements of (non-)signifi­ cance of relationships have come under scrutiny. for instance, zhao et al. (2010) argue that indirect effects are interpretable and meaningful regardless of the significance of the relationships between the predictor and outcome. we therefor focus on the indirect effect but present the whole model as it needs to be considered when interpreting the meaning of the indirect effect. various methods of testing the significance of the indirect effect have been proposed. in this study the significance was examined by using bootstrapping procedures (5,000 bootstrap samples) to apply 95% bias corrected accelerated confidence intervals (95% bca ci) around the estimate of the indirect effect. if the 95% bca ci contains zero, the indirect effect is insignificant, and mediation cannot be assumed. finally, standardized indirect effects were calculated to give an impression of the sizes of the indirect effects. in all three analyses the adhd-rs was the predictor variable, the bis the outcome variable and the dogq the mediating variable. before any analyses were conducted the dataset was screened for outliers using ma­ halanobis’s distance (critical value at alpha level 0.001), cook’s distance (critical value = 1) and centred leverage values (critical value at 2(k+1)/n). these values were obtained by running a regression analysis in each of the samples separately with both the predictor and the mediator in the model. participants who reached the critical values on two of these measures were considered statistical outliers and were eliminated from the sample. einarsson, sigurðsson, kjartansdóttir et al. 7 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.psychopen.eu/ results group differences in symptom severity, ability to defer gratification and impulsive buying table 1 shows descriptive statistics for the measures used in the mediation analyses as well as their reliabilities. all the measures have acceptable to excellent reliabilities. the means differ significantly between the two groups in the predicted directions, the adhd group having a lower mean on the dogq, t(334) = -18.34, p < .001, and higher means on the adhd-rs, t(341.39) = 32.97, p < .001, and bis, t(295.86) = 13.28, p < .001. table 1 descriptive statistics and cronbach’s alpha for the adhd-rs, the dogq and the bis for the adhd and the nonadhd groups measures n m 95% ci sd cronbach’s alphall ul adhd-rs non-adhd 121 7.88 7.00 8.76 4.89 adhd 224 31.59 30.48 32.70 8.46 total 345 23.27 21.84 24.71 13.53 0.95 dogq non-adhd 117 58.03 56.37 59.69 9.07 adhd 219 38.21 36.93 39.49 9.62 total 336 45.11 43.68 46.54 13.35 0.84 bis non-adhd 120 19.57 18.35 20.79 6.75 adhd 221 30.78 29.64 31.91 8.57 total 341 26.83 25.81 27.86 9.61 0.93 note. ci = confidence interval; adhd-rs = the adult adhd rating scale; dogq = deferment of gratifica­ tion questionnaire; bis = buying impulsiveness scale. mediation analyses as shown in figure 2 the same pattern emerges in all three mediation models, where there is a substantial drop from the total effect to the direct effect, although neither effect is statistically significant in the non-adhd sample. in the other two samples the total effect of adhd is significant but becomes insignificant when controlled for the ability to defer gratification. all three 95% bca cis indicate significant indirect effects, suggesting a mediating effect of the ability to defer gratification. the fit of the models were assessed by calculating r 2 when both the predictor and the mediator are included. in the total sample r 2 = 0.60, in the adhd sample 0.45 and non-adhd sample 0.36. impulsive buying among adults with adhd 8 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.psychopen.eu/ figure 2 model for the mediation of the association between adhd symptoms and impulsive buying behaviors through the ability to defer gratification adhdrs dogq bis total effect: b = 0.41, 95% ci [0.35, 0.48] direct effect: b = 0.04, 95% ci [-0.03, 0.11] indirect effect: b = 0.37, 95% bca ci [0.31, 0.43] standardized indirect effect: b’ = 0.52, 95% bca ci [0.44, 0.59] a: b = -0.70 95% ci [-0.78, -0.62] b: b = -0.53 95% ci [-0.60, -0.46] total sample (n = 330) adhdrs dogq bis total effect: b = 0.27, 95% ci [0.14, 0.41] direct effect: b = 0.08, 95% ci [-0.03, 0.19] indirect effect: b = 0.19, 95% bca ci [0.11, 0.28] standardized indirect effect: b’ = 0.19, 95% bca ci [0.11, 0.28] a: b = -0.34 95% ci [-0.48, -0.19] b: b = -0.57 95% ci [-0.67, -0.48] adhd (n = 214) adhdrs dogq bis total effect: b = 0.10, 95% ci [-0.17, 0.37] direct effect: b = -0.17, 95% ci [-0.40, 0.06] indirect effect: b = 0.27, 95% bca ci [0.09, 0.49] standardized indirect effect: b’ = 0.18, 95% bca ci [0.06, 0.31] a: b = -0.57 95% ci [-0.92, -0.23] b: b = -0.47 95% ci [-0.59, -0.35] non-adhd (n = 116) note. ci = confidence interval; bca ci = bias corrected and accelerated confidence interval; adhd-rs = the adult adhd rating scale iv; dogq = deferment of gratification questionnaire; bis = buying impulsiveness scale. einarsson, sigurðsson, kjartansdóttir et al. 9 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.psychopen.eu/ discussion impulsivity symptoms in adhd have been extensively studied (barkley, 1997) and re­ search has shown the disorder to be linked to various financial problems. it is therefore noteworthy that to date, there are to our knowledge no studies on the relationship between adhd and impulsive buying, a type of impulsive behaviour that could clearly contribute to claimed financial problems. there is, however, research indicating that self-regulation and the ability to defer gratification may bolster against such impulsive buying in the general population (badgaiyan et al., 2016; roberts & manolis, 2012; sun et al., 2004). in this study we compared a group of people diagnosed with adhd to a student sample, predicting higher levels of impulsive buying and less ability to defer gratification among the adhd sample. our main analysis, however, tested a mediational model where it was hypothesised that this link between adhd and impulsive buying would be mediated by the ability to defer gratification. as predicted, significant differences were found between the two groups on measures of adhd symptoms, deferment of gratification and impulsive buying, with the adhd group showing more adhd symptoms, more frequent impulsive buying behaviour and less ability to defer gratification. previous studies reported in jackson and mackillop’s (2016) meta-analysis suggest that those with adhd have a greater tendency to choose immediate and less valuable rewards instead of later rewards, while other studies indi­ cate that deficits in self-regulation among non-adhd adults can increase the risk of impulsive buying (roberts & manolis, 2012; vohs & faber, 2007). however, our main findings from the mediation analyses indicate an indirect rela­ tionship between adhd symptoms and impulsive buying mediated by deferring gratifi­ cation, suggesting that the ability to defer gratification may be an important mechanism through which adhd exerts its effect on impulsive buying. moreover, in the total sample and the adhd sample, the total relationship between adhd symptoms and impulsive buying was completely eliminated when the relationship between adhd and the ability to defer gratification was accounted for, suggesting that no other mediators are needed to account for the effect of adhd on impulsive buying. in the student sample however, neither the total relationship nor the direct relation­ ship was significant. this makes the significant indirect relationship somewhat difficult to interpret, although the results could be due to low power as the sample was substan­ tially smaller than the adhd sample and a larger sample might yield either a significant total effect, direct effect, or both. in that case, and assuming the same trends, the seami­ ngly paradoxically negative direct relationship between adhd symptoms and impulsive buying in the student sample (meaning that more symptoms is related to less impulsive buying) could possibly be understood if we assume that the impaired ability to defer gratification is a stronger force in an adhd population than in a healthy population due to impairment in executive functions, commonly associated with adhd. it would impulsive buying among adults with adhd 10 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.psychopen.eu/ therefore be interesting to repeat this study with a larger normal sample to get more clarity regarding the meaning of the mediation through the ability to defer gratification. these results add to the results of sun et al. (2004), which reported that impulsive buying behaviour is motivated by immediate gratification. the results suggest that improved ability to defer gratification may be beneficial for people in general (just as re-evaluation of negative thoughts can benefit people in general, not only people with emotional problems) and for people with adhd in particular, for whom impulsive buying may be a serious problem. there are some limitations to the current study. as the participants in the adhd sample were recruited via the internet and email, the accuracy of their adhd diagnoses could not be clinically ascertained. also, the groups were different in age, education level and employment, the comparison group being significantly younger on average and with smaller age variation, and the non-adhd group reporting higher educational level and being more actively studying or working than the adhd group. a final limitation is that although mediational models assume causality with a specified causal direction, the design of the study does not allow any causal inferences. it would therefore be of interest to conduct an experiment to see if a treatment intervention targeting the ability to defer gratification would in turn also affect overall adhd symptoms. such an experiment might help to establish causality. the study has several strengths. among them is a large sample size, increasing both reliability and generalizability of the results. the relationship between adhd symptoms and impulsive buying, mediated by deferment of gratification, has to our knowledge not been investigated before so our findings are an important addition to the existing literature on the relationship between adhd and impulsive buying. future research should examine online impulsive buying among adults with adhd as products and services are increasingly becoming more accessible and cost-saving through online shopping, which may trigger impulsive buying among consumers (saha et al., 2020; sun & wu, 2011). einarsson, sigurðsson, kjartansdóttir et al. 11 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: we would like to thank the participants for taking time to fill in the questions and questionnaire. we would also like to thank the adhd association in iceland for introducing the study to its members and e-mail the survey. one of the authors, páll magnússon, died on the 10th october 2021, when we had started writing up the paper. páll was a good man and a professional, a pioneer and a leading authority in adhd research in iceland. he will be sorely missed. competing interests: the authors have declared that no competing interests exist. ethics statement: the study was anonymous and approved by reykjavik university and the icelandic bioethics committee (no. 18-0-51). social media accounts: @sverrirbjorn, @fri_jonfsig reporting guidelines: the publication manual of the american psychological association. preregistration: the study was not pre-registered but approved by the relevant authorities and the icelandic bioethics committee (no. 18-0-51). data availability: the data are not available for open access. references american psychiatric association. 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(2010). reconsidering baron and kenny: myths and truths about mediation analysis. journal of consumer research, 37(2), 197–206. https://doi.org/10.1086/651257 impulsive buying among adults with adhd 14 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://doi.org/10.1177/1087054705283650 https://doi.org/10.1126/science.2658056 https://doi.org/10.1176/appi.ajp.158.11.1783 https://doi.org/10.1080/00224545.1986.9713578 https://doi.org/10.2753/mtp1069-6679200204 https://doi.org/10.1086/209105 https://doi.org/10.1086/209452 https://doi.org/10.3390/su12031121 https://doi.org/10.2753/mtp1069-6679190307 https://doi.org/10.1086/510228 https://doi.org/10.1086/651257 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. einarsson, sigurðsson, kjartansdóttir et al. 15 clinical psychology in europe 2024, vol. 6(3), article e9339 https://doi.org/10.32872/cpe.9339 https://www.psychopen.eu/ impulsive buying among adults with adhd (introduction) method participants measures procedure statistical analysis results group differences in symptom severity, ability to defer gratification and impulsive buying mediation analyses discussion (additional information) funding acknowledgments competing interests ethics statement social media accounts reporting guidelines preregistration data availability references shame mediates the relationship between negative trauma attributions and posttraumatic stress disorder (ptsd) symptoms in a trauma exposed sample research articles shame mediates the relationship between negative trauma attributions and posttraumatic stress disorder (ptsd) symptoms in a trauma exposed sample rebecca seah 1 , david berle 1,2 [1] graduate school of health, university of technology sydney, sydney, australia. [2] school of psychiatry, university of new south wales, sydney, australia. clinical psychology in europe, 2022, vol. 4(3), article e7801, https://doi.org/10.32872/cpe.7801 received: 2021-11-09 • accepted: 2022-07-29 • published (vor): 2022-09-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: david berle, discipline of clinical psychology, graduate school of health, university of technology sydney, po box 123, broadway, nsw 2007, australia. p: +61 2 9514 4278. e-mail: david.berle@uts.edu.au supplementary materials: materials [see index of supplementary materials] abstract background: theoretical models of self-conscious emotions indicate that shame is elicited through internal, stable, and global causal attributions of the precipitating event. the current study aimed to investigate whether these negative attributions are related to trauma-related shame and ptsd symptom severity. method: a total of 658 participants aged 18 to 89 (m = 33.42; sd = 12.17) with a history of trauma exposure completed a range of self-report measures assessing trauma exposure, negative traumarelated attributions, shame, and ptsd symptoms. results: higher levels of internal, stable, and global trauma-related attributions were significantly associated with shame and ptsd. shame mediated the association between trauma-related attributions and ptsd symptom severity, even after controlling for the effects of number of trauma exposures, worst index trauma and depression. conclusions: the present results suggest that negative attributions are a critical cognitive component related to shame and in turn, ptsd symptom severity. future research should aim to replicate these findings in a clinical sample and extend these findings using prospective designs. keywords shame, posttraumatic stress disorder, ptsd, negative attributions, trauma this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7801&domain=pdf&date_stamp=2022-09-30 https://orcid.org/0000-0003-4724-1568 https://orcid.org/0000-0002-4861-2220 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • cognitive antecedents of shame were investigated in a large trauma-exposed sample. • internal, stable, and global trauma attributions were associated with shame severity. • trauma-related shame mediated the association between trauma-related attributions and ptsd symptoms. • specific attributions may be an important predictor of trauma-related shame. the exposure to a potentially traumatic event (pte) often elicits a myriad of emotional responses that intensify traumatic stress reactions. moreover, these reactions are thought to contribute to the development and maintenance of current threat characteristic of posttraumatic stress disorder (ptsd). recently, there has been a growing interest in the role of shame as an important emotional trauma sequalae linked to poorer adjustment and maladaptive coping and predictive of the development of ptsd symptoms (e.g., intrusive recollections, hyperarousal and avoidance) (saraiya & lopez-castro, 2016). the cognitive model of ptsd offers a framework for understanding how shame may emerge following exposure to ptes (ehlers & clark, 2000; elwood et al., 2009). according to the model, the nature of the emotional responses in persistent ptsd varies according to appraisals of the trauma and its sequalae (ehlers & clark, 2000). for example, the mod­ el posits that appraisals concerning attributions of responsibility and perceived violation of internal and societal standards may evoke feelings of shame. in line with this, theoretical models of shame classify it as a self-conscious emotion, as it arises when the self is implicated by a negative and aversive event that violates internal and/or external standards and evokes judgement from others (gilbert, 1997; lewis, 1971; tangney & dearing, 2002). specifically, shame is said to arise through a cog­ nitive-evaluative process, where the eliciting event is attributed to internal, stable, and global attributions; causes that relate to aspects of the individual that are present across all situations and likely to affect situations across one’s life (e.g., one’s character) (lewis, 1971; tangney & dearing, 2002; tracy & robins, 2004). guilt, which also arises from internal attributions, is distinct from shame in that the attribution pertains to a specific action (unstable) which does not affect all situations (specific) (e.g., one’s behaviour). this subtle difference in cognitive attributions is important as guilt and shame prompt distinct responses. the phenomenological experience of shame is the desire to withdraw and hide due to perceived judgement from others and threat of being exposed (gilbert, 2000). in contrast, guilt tends to prompt behavioural responses that are motivated by reparative efforts. indeed, higher levels of internal, stable and global attributions has been associated with higher levels of ptsd. while, these studies have focused on negative attributional style, which is the tendency to attribute events to internal, stable and global causes to common negative and/or hypothetical life events (elwood et al., 2009), ptes can be attributions, shame and ptsd 2 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ considered phenomenologically distinct to general negative life events and exert greater influence on current ptsd symptoms (gray & lombardo, 2004; reiland et al., 2014). following exposure to a traumatic event, posttraumatic shame may arise through this appraisal process, where the individual erroneously blames themselves for having caused the event. consequently, the self is implicated in an unwanted event, and the trauma and its effects are appraised as having occurred due to the individual being inadequate or worthless in some way. even in the absence of an external threat, the individual may still feel a sense of impending threat due to fear of rejection and stigmatisation but also an internal threat due to ongoing negative self-evaluation. consequently, feelings of trauma related shame are likely to be painful, prompting avoidance that inhibits trauma processing, which impedes recovery (leonard et al., 2020). for example, in their conceptual model of shame and adjustment in child sexual abuse survivors, feiring et al. (1996) proposed that shame arises from sexual abuse through the mediation of cognitive attributions and that such shame in turn leads to poorer overall adjustment. a number of studies of child sexual abuse survivors have reported findings consistent with this model as well as the possibility that shame may mediate the relationship between negative attributions and ptsd symptom severity (alix et al., 2017; feiring et al., 2002; uji et al., 2007). although promising, these studies utilised abuse specific attributions and shame measures which limit their generalisability to other trauma exposed populations. further, the attribution measure did not explicitly assess the dimensions of internal, stable and global attributions which is considered a necessary component of the attribution-emo­ tion link to shame (lewis, 1971; tangney & dearing, 2002; tracy & robins, 2004). although negative attributions are purported to be a cognitive antecedent to shame, there are several trauma characteristics that may impact the severity of posttraumatic cognitions and emotions. firstly, although trauma exposure is insufficient to elicit trau­ ma related shame, the nature of the traumatic event may function as a diathesis toward making more negative appraisals and higher levels of shame. for example, individuals with interpersonal trauma exposure, defined as an event that involves deliberate perpe­ tration of harm to another individual (e.g., sexual assault, armed robbery, physical threats etc.) (forbes et al., 2014) have reported increased levels of shame and ptsd (la bash & papa, 2014). in a recent study, zerach and levi-belz (2018) found that experiencing a morally injurious event may contribute to an increased tendency to make internal, stable and global attributions, trauma related shame and more severe posttraumatic stress symptoms (ptss). their findings indicate that it is possible that certain trauma types may increase one’s tendency to make negative attributions, subsequently eliciting higher levels of shame. secondly, routine self-report ptsd screening measures require a single designated trauma event to be used in assessing the severity of symptoms. however, the exposure to multiple potentially traumatic events can be considered a rule not the exception. there is robust evidence indicating that, with an increased number of pte exposures, ptsd seah & berle 3 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ risk increases in a dose-dependent manner (tortella-feliu et al., 2019). also, the severity of ptsd symptoms increases when participants are asked to rate symptoms across their trauma history (simpson et al., 2011). furthermore, the potential effect of time elapsed since the indexed trauma event may also impact endorsement of self-conscious cognitions and emotions (bryant et al., 2017). thus, consideration of the cumulative impacts of ptes along with time since trauma exposure is pertinent. regardless of overall trauma exposure, it is expected that individuals will seek to assign meaning and provide causal attributions to explain their experiences. thus, the current study sought to extend previous findings in two ways. firstly, it aimed to inves­ tigate the relationships between trauma specific negative attributions (higher internal, stable, and global attributions) shame and ptsd symptom severity in a broad sample of trauma exposed survivors. based on previous findings, it was hypothesised there would be significant associations between negative attributions, shame, and ptsd symptoms. secondly, it explored whether trauma-related shame would mediate the relationship between higher levels of internal, stable, and global attributions on the one hand, and ptsd symptoms on the other. to examine the unique contributions of trauma related attributions and shame in relation to ptsd, the current study controlled for the effects of the various trauma characteristics mentioned. this included cumulative lifetime exposure to ptes, reference trauma type (interpersonal vs. non-interpersonal) and time elapsed since reference trau­ ma. symptoms of depression were also controlled for due to depression’s significant comorbidity with ptsd (flory & yehuda, 2015). it was hypothesised that even after controlling for these covariates, trauma-related shame would mediate the relationship between attributions and ptsd symptom severity. method participants six hundred and sixty-seven participants consented to participate in the study, however nine participants failed the attention checks, and were excluded from the analyses. the final sample consisted of 658 participants between the ages of 18 to 89 (m = 33.42; sd = 12.17) who consented to participate in the study. a majority (n = 257; 39.1%) of the sample resided in the united states, with a similar proportion from the united kingdom (n = 249; 37.8%). the sample consisted of 346 women (52.6%), 300 men (45.6%) and 12 (1.9%) preferring to self-describe. just over half the participants (n = 371; 56.4%) reported being in a relationship or were married, 258 (39.2%) had never been married and 29 (4.4%) were either separated or divorced. slightly under half (n = 206; 31.3%) of participants disclosed at least one mental health disorder diagnosis from a professional. among those who chose to specify, 223 (n = 33.9%) reported a current diagnosis of depression and/or attributions, shame and ptsd 4 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ anxiety. 80 participants reported currently seeking mental health support from a health­ care professional. just over half of participants’ (58.7%) self-reported ptsd symptoms placed them within the clinical range for a provisional ptsd diagnosis (pcl-5 total scores ≥ 31) (bovin et al., 2016). participants endorsed exposure to an average of 6.3 (sd = 2.2) potentially traumatic events (pte) across their lifetime. in terms of type of trauma exposure, transportation accidents (n = 406; 61.7%), severe life-threatening illnesses (n = 227; 34.5%), and unwan­ ted/uncomfortable sexual experiences, including sexual assault (n = 209; 31.8%) were the most common trauma categories endorsed. the most common reference trauma endorsed was some form of direct exposure (personally experienced and/or witnessed it happening to a close family member/friend) to an interpersonal trauma (e.g., physical and/or sexual assault and psychological abuse) (n = 219; 33.3%), followed by some form of transport accident (n = 154; 23%), and various forms of illnesses and/or physical injury (n = 109; 16.7%). the mean elapsed time since the reference trauma was 11.6 years (sd = 10.7). measures the lifetime events checklist (lec) the lec (weathers, blake, et al., 2013b) is a 17-item self-report measure used to screen for exposure to potentially traumatic events (pte) in a respondent’s lifetime. it consists of 16 known events and an additional item assessing any stressful life events not listed. respondents indicate their level of exposure for each pte on a 6-point nominal scale. following this, participants are asked to identify and briefly describe the worst event they experienced, specifically the event that they classify as the most distressing. this event was used as the reference trauma for assessing current symptoms of ptsd. the lec does not yield a total composite score. the lec demonstrated adequate psychomet­ ric properties as a stand-alone measure for trauma exposure (gray et al., 2004). in the current study, a total lifetime trauma load was calculated by summing the number of traumatic experiences across each type of trauma endorsed by the individual. the ptsd checklist for dsm-5 (pcl-5) the pcl-5 (weathers, litz, et al., 2013) a 20-item self-report questionnaire which was administered to assess ptsd symptoms. participants endorse the extent to which they were bothered by ptsd symptoms in relation to their reference trauma in the past month (e.g., “repeated disturbing and unwanted memories of the stressful experience”) on a 5-point likert scale, 0 (not at all) to 4 (extremely). a total symptom severity score was obtained by summing each item, with a score higher than 31 indicating the presence of probable ptsd (bovin et al., 2016). the pcl-5 has demonstrated strong reliability and validity and is psychometrically sound instrument for quantifying ptsd symptom severity (bovin et al., 2016). seah & berle 5 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ the expanded attributional style questionnaire trauma (easq-t) the easq (peterson & villanova, 1988) is a measure used to assess a respondent’s tendency to generate specific attributions for hypothetical aversive events. participants are asked to rate the cause of each event. on this scale, respondents are asked to rate the cause of each event on 7-point likert scale for three dimensions; 1) internal or external (“is the cause something about you or about other people and/or circumstances”), 2) stable or unstable (“in the future, will this cause be present?”) and 3) specific or global (“is this cause something that affects just this type of situation or does it influence other aspects of your life?”). the easq has previously demonstrated adequate to good internal consistencies (peterson & villanova, 1988). the easq was adapted by reiland et al. (2014) to assess trauma related attributions. on the easq-trauma, participants rate the cause of each traumatic event they were exposed to according to the lec (weathers, blake, et al., 2013b) on the easq dimensions of internal-external, stable-unstable and specific-global. the score on each attribution dimension ranged between 1 and 7. an overall attribution score or negative trauma score was calculated by averaging the sum of each dimension. higher overall scores on the scale indicate higher levels of internal, stable and global attributions. the trauma related shame inventory (trsi) the trsi (øktedalen et al., 2014) is a 24-item measure of trauma related shame. respond­ ents rate the extent that they experience thoughts and feelings associated with shame in relation to their traumatic experiences over the past week on a 4-point likert scale, 0 (not true of me) to 4 (completely true of me). sample items include “because of what happened, i am disgusted with myself”, “if others knew what happened to me, they would be ashamed”. a total trauma-related shame score was computed by summing all items on the trsi. the trsi has demonstrated strong content and construct validity and discriminate validity from the trauma related guilt inventory (kubany et al., 1996). the depression anxiety and stress short form scale (dass-21) the dass-21 (lovibond & lovibond, 1995) is a widely used screening measure of distress in both clinical and non-clinical settings. it consists of 21 items comprised of three self-report scales of depression, anxiety, and stress symptoms. in the current study, only the 7-item depression subscale was used to yield a total depression score. respondents endorse the extent to which they experienced symptoms over the past week on a 4-point likert scale, 0 (did not apply to me at all) to 4 (applied to me very much, or most of the time). a total depression score was computed by summing all the items on the depression subscale. the dass-21 has demonstrated good discriminant validity relative to other depression measures and high internal consistency (henry & crawford, 2005). attributions, shame and ptsd 6 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ procedure participants were recruited from australia, canada, ireland, the united kingdom and united states via prolific academic (proa), an online crowdsourcing platform. only participants over the age of 18 and who endorsed being exposed to at least one potential­ ly traumatic event (pte) within their lifetime according to the lec (weathers, blake, et al., 2013b) were included in the study. participants were administered a battery of self-report questionnaires which assessed their lifetime exposure to ptes, along with their attributions for these events, trauma related shame, ptsd symptoms and symptoms of depression and anxiety. statistical analyses spearman’s rank order correlations were calculated given the non-normal positively skewed distributions of depression, ptsd, and trauma-related shame. bootstrapping (5,000) iterations were performed to test the indirect effects of shame and negative attributions in relation to ptsd symptom severity using conditional process analysis (hayes, 2017). trauma exposure, depression symptoms, worst reference trauma type, and time since worst reference trauma were entered as covariates. the use of bootstrapping, a non-parametric resampling method offers an advantage over the traditional sobel test as it does not require the assumption of normality to be met for the product of co-efficients. further, the resampling methods minimises bias that arises from non-normal sampling distributions (hayes, 2017). indirect effects are significant when the 95% confidence interval (ci) does not contain zero. results univariate and bivariate statistics mean, standard deviation and range of all self-reported measures are reported in table 1. the internal consistency for all scales was excellent. all measures were significantly and positively correlated with each other and small to moderate in magnitude (table 2). mediation analysis figure 1 reports the results of the bootstrapped mediation analysis. together, after con­ trolling for lifetime trauma exposure, depression symptoms, worst trauma type, and time since worst trauma, negative attributions and trauma-related shame accounted for significant variance in ptsd symptom severity, f(6,652) = 107.53, r 2 = .50, p < .001. trauma related negative attributions exhibited significant direct effects on shame, b = 1.47, p < .001, 95% ci [.56, 2.38], and shame also had a significant direct effect on ptsd seah & berle 7 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ symptoms, b = .57, p < .001, 95% ci [.48, .66]. trauma related attributions exhibited a significant indirect effect on ptsd symptoms via shame, 95% ci [.35, 1.34]. table 1 means, standard deviations, and reliability of measures variable m sd range cronbach’s α exposure (lec) 6.31 2.16 2-16 – depression (dass-21) 6.67 6.26 0-21 .94 internal attributions (easq-t internal) 2.45 1.43 1-7 – stable attributions (easq-t stable) 3.73 1.63 1-7 – global attributions (easq-t global) 3.34 1.56 1-7 – attributions (easq-t total) 3.17 1.07 1-6.58 – shame (trsi) 14.33 15.94 0-70 .97 ptsd (pcl-5) 27.78 19.59 0-80 .95 note. exposure = total lifetime trauma exposure to distinct trauma types; depression = depression symptoms; internal, stable and global = internal, stable and global trauma-related attributions; attributions = total trauma related attributions; shame = trauma related shame; ptsd = ptsd symptoms. table 2 spearman’s rank order correlations between trauma exposure, depression symptoms trauma-related attributions, trauma related shame, ptsd symptoms variable 1 2 3 4 5 6 7 8 1. exposure – .16** .10** .10** .08 .13** .30** .19** 2. depression – .27** .16** .14** .31** .59** .56** 3. attributions – .54** .73** .79** .27** .29** 4. internal – .04 .23** .25** .20** 5. stable – .42** .04 .08* 6. global – .35** .37** 7. shame – .66** 8. ptsd – note. n = 587. exposure = total lifetime trauma exposure to distinct trauma types (lec); depression = depression symptoms (dass-21); attributions = total trauma related attributions (easq-t total); internal, stable, and global = internal, stable and global trauma-related attributions (easq-t subscales); shame = trauma related shame (trsi); ptsd = ptsd symptoms (pcl-5). *p < .05. **p < .01. attributions, shame and ptsd 8 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ figure 1 the relationship between trauma-related attributions and ptsd symptom severity mediated by trauma-related shame trauma-related attributions ptsd symptom severity trauma related shame b: b =.57, β =.46, se = .05, 95% ci [.48, .66] c: b = 2.62, β = .140, se =.60, 95% ci [1.45, 3.79] c’: b = 1.78, β = .10, se = .54, 95% ci [.72, 2.84] a: b = 1.47, β = .10, se = .46, 95% ci [.56, 2.38] note. c = total effect; c’ = direct effect; b = non-standardised regression coefficient; β = standardised regression coefficient; se = standard error; ci = confidence interval. indirect effect = 95% ci = [.35 to 1.34]. figure 1 the relationship between trauma-related attributions and ptsd symptom severity mediated by trauma-related shame. note. c = total effect; c’ = direct effect; b = non-standardised regression coefficient; β = standardised regression coefficient; se = standard error; ci = confidence interval. indirect effect = 95% ci = [.35, 1.34]. however, when trauma related shame was included in the model, the direct effect of trauma-related attributions remained significant, b = 1.78, p < .001, 95% ci [.72, 2.84], indicating that trauma-related shame partially explains the relationship between traumarelated casual attributions. thus, it is likely that there are additional mediators that could contribute to the understanding the effect of negative trauma attributions and ptsd symptoms. as a secondary exploratory analysis, we repeated the mediation analyses for each separate attribution dimension. the results of these are presented in figures 1-3 in the supplementary materials. in brief, both internal, 95% ci [.53, 1.30] and global, 95% ci [.32, 1.10] attributions exhibited significant indirect effects on ptsd symptoms via shame. in contrast, there was no significant indirect effect for stable attributions, 95% ci [-.65, .03]. discussion to our knowledge, this is the first study that examines the role of internal, stable and global trauma-related attributions in relation to shame and ptsd symptoms in a broad trauma exposed sample. the purpose of the study was two-fold. firstly, it aimed to inves­ tigate the relationship between negative attributions (higher levels of internal, stable, and global attributions), trauma-related shame and ptsd. secondly, it investigated whether seah & berle 9 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ trauma-related shame would mediate the relationship between negative trauma-related attributions and ptsd symptoms. as predicted, negative attributions, that is, higher levels of internal, stable, and glob­ al attributions and trauma-related shame both had significant direct effects on ptsd symptom severity. interestingly, although cumulative trauma exposure is an important risk factor for ptsd (tortella-feliu et al., 2019), correlation analysis of the present data indicated that the relationship between trauma load and ptsd is negligible. these find­ ings are consistent with both empirical and theoretical evidence implicating maladaptive cognitive appraisals and subsequent emotional reactions as important predictors of ptsd beyond trauma exposure (cromer & smyth, 2010; ehlers & clark, 2000). the finding that internal, stable and global attributions are significantly associated with higher levels of ptsd is consistent with previous research indicating strong associ­ ations between negative causal attributions and ptsd symptoms (gómez de la cuesta et al., 2019). the attribution that one’s experiences are due to internal causes that are unchanging, and pervasive in all domains of life is likely to increase expectancy that future events would reoccur and engender feelings of helplessness and loss of control over life events and one’s future (mikulincer & solomon, 1988). indeed, a sense of helplessness has been associated with a perception of ongoing threat and perceived lack of safety among domestic violence survivors (salcioglu et al., 2017). moreover, findings from neuroimaging studies have indicated that cognitive distortions are linked to ptsd through intense re-experiencing of the trauma memory elicited by trauma related cues (berman et al., 2018; daniels et al., 2011). as our findings indicate, negative attributions of the traumatic event were associated with higher levels of trauma-related shame which in turn, were associated with more severe ptsd symptoms. thus, the appraisal that negative events are due to internal, stable and global attributions may lead to the focus of evaluation being directed inward where the self and its entirety is judged negatively, prompting feelings of intense shame. the cross-sectional nature of our study precludes causal inferences; however, further prospective studies of these variables should seek to confirm this possibility. the phenomenological experience of shame is painful, motivating the desire to withdraw and hide due to the fear of rejection or stigmatisation. in this way, feelings of shame may increase the intensity of ptsd symptoms through responses such as avoidance (feiring et al., 2002; leonard et al., 2020), a core symptom of ptsd that maintains overgeneralised fear and inhibits new learning (craske et al., 2008). indeed, a recent study indicates that experiential avoidance may be one of the key mechanisms that explains the relationship between shame and ptsd symptoms (leonard et al., 2020). however, future research will be needed to bolster such findings. in addition, current theoretical models of shame indicate that feelings of shame are also avoided due to their association with the event and trauma related cues (lee et al., 2001; wilson et al., 2006). attributions, shame and ptsd 10 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ consequently, the inability to process shame is likely to intensify these feelings where, in the absence of physical danger, feelings of shame become a source of internal threat. although the current results support our second hypothesis, there may be other var­ iables that influence and explain the relationship between shame and ptsd. following trauma exposure, shame is typically accompanied by other emotional responses such as fear, guilt, alienation, and betrayal that also promote avoidance and intense reliving of trauma memories (dewey et al., 2014; held et al., 2015). moreover, there may be other attributional processes such as perceived controllability and importance of events (tracy & robins, 2006) that may be relevant to shame worth investigating. overall, the findings support the assertion that individual variability in trauma attri­ butions and reactions are linked to not only an increase in ptsd symptom severity, but this relationship can also be explained by emotional and behavioural reactions associated with shame related to one’s traumatic experiences. some limitations of the current study should be noted as avenues for future research. first, the use of a cross-sectional design precludes any causal inferences. it is likely that both negative appraisals and trauma related shame have a bi-directional relationship, however the extent to which they reinforce each other remains an empirical question. thus, longitudinal research is needed to assess the directionality of these constructs. second, although the use of self-report questionnaires is common in clinical psychology research, responses may be influenced by participants’ introspective ability and other response biases. third, additional demographic data was not obtained with respect to ethnicity, or employment status which may be important risk factors for ptsd (tortellafeliu et al., 2019). also, not all participants in our sample were in the clinical range for ptsd, limiting the generalizability of our results to clinical populations. fourth, the construct validity of the “global” dimension of the easq may be im­ perfect in that the global dimension items appeared to assess attributions about the perceived consequences of traumas, rather than attributions about the cause itself (“is this cause something that affects just this type of situation, or does it also influence other areas of your life”). this may have contributed to the relatively stronger associa­ tions observed between global attributions and ptsd symptoms when compared with the internal-external and stable-variable dimensions. future studies should ideally use interviewer-based approaches to allow careful distinctions between attributions about the causes versus the consequences of trauma events. further, although the pcl-5 is widely accepted and utilised within trauma research as a ptsd symptom screening tool, it does not examine trauma relatedness of symptoms and significant overlap between ptsd and other psychiatric symptoms may inadvertent­ ly inflate ptsd symptom severity scores (monson et al., 2008). it is worth noting that an individual can make multiple attributions for a single event, especially when the event consists of multiple, closely related events. in the attempt to account for multiple lifetime exposures, we assessed attributions for all pte exposures. however, an individual can seah & berle 11 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ have multiple exposures to the same type of traumatic event, complicating the identifica­ tion of the particular event that a given attribution corresponds to. thus, assessment of the index trauma event to assess event specific attributions using a clinician adminis­ tered diagnostic assessment tool is warranted. for example, the clinician-administered ptsd scale for dsm-5 (caps5; weathers, blake, et al., 2013a) could be used to identify the index trauma and assess specific attributions in accordance with the event. further, the use of a diagnostic interview can provide a more accurate diagnostic picture of ptsd symptoms and increase the generalizability of current findings to clinical samples. although specific attribution dimensions may exert greater influence on shame and ptsd symptoms than others, the results indicate that, together, internal, stable and global attributions for lifetime exposure to ptes functions as a potential cognitive vul­ nerability toward trauma related shame. thus, targeting these cognitions may constitute an important mechanism for trauma recovery. cognitive based interventions that utilise attribution retraining such as cognitive processing therapy (cpt; resick & schnicke, 1992) has been found to be useful in modifying self-blaming attributions and ptsd (resick et al., 2002). moreover, there is some indication that gradual exposure to and pro­ cessing of trauma memories can significantly reduce shame based cognitive distortions (cohen et al., 2004). more recently, there has been increasing interest and empirical support for the use of compassion-based therapies are a potential adjunct to existing cognitive interventions for ptsd in facilitating the effectiveness of cognitive reappraisal strategies (au et al., 2017). overall, the present study indicates that following exposure to a pte, negative attributions are associated with shame, which in turn is associated with higher levels of ptsd symptoms. the findings underscore the potential clinical utility of assessing negative attributions as a potential antecedent of shame. in doing so, clinicians can seek to target these processes and potentially change the trajectory of shame responses and reduce the emotional impact of the trauma and the severity of ptsd symptoms. funding: the authors have no relevant financial or non-financial interests, and no conflicts or competing interests to disclose. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. data availability: participants in the present study did not consent for their data to be shared publicly, so supporting data for the present study is not available. attributions, shame and ptsd 12 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 https://www.psychopen.eu/ supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • figure 1 – the relationship between internal attributions and ptsd symptom severity mediated by trauma-related shame. • figure 2 – the relationship between stable attributions and ptsd symptom severity mediated by trauma-related shame. • figure 3 – the relationship between global attributions and ptsd symptom severity mediated by trauma-related shame. index of supplementary materials seah, r., & berle, d. 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(2018). moral injury process and its psychological consequences among israeli combat veterans. journal of clinical psychology, 74(9), 1526–1544. https://doi.org/10.1002/jclp.22598 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. seah & berle 17 clinical psychology in europe 2022, vol. 4(3), article e7801 https://doi.org/10.32872/cpe.7801 http://www.ptsd.va.gov http://www.ptsd.va.gov http://www.ptsd.va.gov https://doi.org/10.1177/1524838005285914 https://doi.org/10.1002/jclp.22598 https://www.psychopen.eu/ attributions, shame and ptsd (introduction) method participants measures procedure statistical analyses results univariate and bivariate statistics mediation analysis discussion (additional information) funding acknowledgments competing interests data availability supplementary materials references how and why the choice of success criteria can impact therapy service delivery: a worked example from a psychological therapy service for anxiety and depression research articles how and why the choice of success criteria can impact therapy service delivery: a worked example from a psychological therapy service for anxiety and depression mark h. wheeler 1, sheina orbell 1 , tim rakow 2 [1] department of psychology, university of essex, colchester, united kingdom. [2] department of psychology, institute of psychiatry, psychology and neuroscience, king’s college london, london, united kingdom. clinical psychology in europe, 2023, vol. 5(4), article e10237, https://doi.org/10.32872/cpe.10237 received: 2022-09-08 • accepted: 2023-10-18 • published (vor): 2023-12-22 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: tim rakow, department of psychology, addison house (floor 2), guy’s campus, king’s college london, london, se1 1ul, united kingdom. e-mail: tim.rakow@kcl.ac.uk supplementary materials: materials [see index of supplementary materials] abstract background: well-defined measures of therapeutic benefit are essential for evaluating therapies and services. however, there is no single gold standard for defining ‘successful’ outcomes. we therefore examined the potential impact of adopting different success criteria. method: we analysed data for 7,064 patients undergoing psychological therapy in a single uk iapt (increasing access to psychological therapy) service, each patient being assessed for depression (phq-9) and anxiety (gad-7) both at the start and end of treatment. predictors of successful outcomes based on these measures were analysed separately for three different success criteria: based either on assessing clinically significant change, or reliable change, in depression and anxiety. results: the choice of criteria had little bearing on which variables predicted successful outcomes. however, the direction of the relationship between initial phq-9 or gad-7 score and outcome success reverses when the criteria used to judge success are changed: successful outcomes are less probable under clinically significant change criteria for patients entering the service with more severe depression and/or anxiety but are more probable for such patients under reliable change criteria. conclusion: relevant for clinicians, researchers, and policymakers, the choice of success criteria adopted can substantially change the incentives for patient selection into a therapy service. our this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10237&domain=pdf&date_stamp=2023-12-22 https://orcid.org/0000-0002-8665-3541 https://orcid.org/0000-0002-7127-8793 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ analysis highlights how the methods used to evaluate treatment outcomes could impact the priorities and organisation of therapeutic services, which could then impact on who is offered treatment. we recommend further investigations of success criteria in other conditions or treatments to determine the reproducibility of the effects we found. keywords increasing access to psychological therapy (iapt), therapy outcomes, clinically significant change, reliable change, payment by results, anxiety, depression highlights • changing the criteria for judging therapy success alters treatment incentives. • the choice of success criteria changes which cases are likely to have successful outcomes. • incentives to treat a patient group are substantially affected by the success criteria chosen. incentives in healthcare systems incentives abound in healthcare systems. of course, the primary incentive is shaped by the goal of achieving good outcomes for patients. however, incentives can be created in numerous ways, and their (sometimes unintended) consequences are diverse. for example, one might expect that insurance-based systems and/or a culture of malpractice litigation encourage excessive use of diagnostic tests (e.g., additional testing with limited incremental predictive value) because the costs of testing are easily covered (by insur­ ance companies) and extensive testing provides concrete evidence of due diligence in diagnosis (a defence against litigation). in the – mainly publicly funded – uk health sys­ tem, ‘payment by results’ has become increasingly common (e.g., nhs england and nhs improvement, 2017a) with the laudable goal of incentivising best practice to improve services and clinical outcomes, while also increasing efficiency (horton, 2007; taunt et al., 2015). however, anecdotes of weaknesses in such target-driven approaches are commonplace. these include removing wheels from trolleys to create ‘beds’ that meet targets designed to reduce patients’ waiting-times on trolleys (bevan & hood, 2006) and having patients wait outside a hospital in ambulances to meet a maximum 4-hour waiting target in accident and emergency departments (watts & donnelly, 2012). nonetheless, there is no a priori reason why well-designed financial incentives should not be used to improve the treatment that patients receive. in 2017, nhs england and nhs improvement issued detailed guidance to support service commissioners and providers to implement an outcomes-based payment ap­ proach for the uk’s flagship (publicly funded) iapt service (increasing access to psycho­ logical therapy; nhs england and nhs improvement, 2017b). this mandated the use of an outcomes-based payment model for iapt services from 1 april 2018 onwards, why success criteria matter 2 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ consisting of both a basic service price component reflecting activity and an outcomes payment component based on quality indicators and patient outcomes. the analysis presented in this paper primarily relates to the clinical outcomes element that comprises 50% of the outcomes payment component (with the other half of this component being based on performance against nine other quality and outcome measures). note, however, that the application our analysis is not restricted to situations where payment by results is applied; but rather, to any situation where one clinical outcome measure is chosen in place of another or is given priority over another measure when outcomes are evaluated. to illuminate the potential impact of the incentive structure created by the choice of clinical outcome measures, we analyse the clinical outcomes for both depression and generalised anxiety disorder from an iapt service prior to the introduction of payment by results (pbr). to assess depression, iapt services routinely use the patient health questionnaire phq-9 (kroenke et al., 2001) and for generalised anxiety disorder the seven question gad-7 measure (spitzer et al., 2006). a quantitative assessment of the outcome of treatment is based on comparing preand post-therapy scores on the relevant clinical scale. however, there are different ways that this can be done in order to define a ‘successful’ treatment outcome (e.g., see richards & borglin, 2011). by considering three possible success criteria, and examining what predicts successful treatment outcomes according to each criteria in several thousand patients, we illustrate how the choice of success criteria could affect the incentives for patient selection for treatment. this is important because when incentives change, behaviour often changes – though not necessarily as hoped for by those creating the incentive structure (gneezy & rustichini, 2000). success criteria in psychological therapy jacobsen and colleagues (jacobson et al., 1984; jacobson & revenstorf, 1988; jacobson & truax, 1991) proposed two criteria to ascertain whether or not the change experienced by a patient/client is meaningful: clinically significant change (csc) and reliable change (rc). the notion of clinical significance (as distinct from statistical significance) in therapy has been conceptualised in various ways, including: the practical value of the effect of an intervention (risley, 1970); an improvement in the client’s everyday functioning (kazdin & wilson, 1978); a return to normal levels of functioning (kendall et al., 1999; nietzel & trull, 1988) which is indistinguishable from that of their peer group (kazdin, 1977). operationalizing such considerations via standardised clinical assessments, jacobson and colleagues proposed that clinical significance can be determined by the client’s score at post-treatment falling within the range for the functional population as opposed to the dysfunctional one (at pre-treatment). however, this criterion does not take account of measurement error, which may therefore give rise to misinterpretation due to regres­ sion to the mean; and there can also be difficulties determining what cut-off score(s) wheeler, orbell, & rakow 3 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ should divide the functional and dysfunctional populations (tingey et al., 1996a, 1996b; wampold & jenson, 1986) measurement error is better dealt with in measures of (statistically) reliable change, which seek to determine whether a change is large enough to be considered meaningful. such measures assess pre-post changes in scores on a clinical assessment relative to the standard error of that assessment tool (reflecting its reliability and the variability of scores in the normal/functional population). a reliable change can be said to have occurred if the pre-post change represents a statistically reliable improvement (or de­ terioration). thus, the size of change, rather than whether change takes the patient across a threshold (as with csc) is what determines success. this has the advantage of recognising improvements in symptoms even if the patient’s scores remain within the dysfunctional range (lunnen & ogles, 1998). in our analysis of treatment outcomes, we follow the implementations of csc and rc used by richards and borglin (2011) for the phq-9 and gad-7 measures (the tools for assessing depression and anxiety used by iapt, and reflected in the clinical outcomes element of the iapt pbr system). additionally, we examine outcomes according to an iapt recovery criteria. this is a variant of the csc approach but specifies different threshold (cut-off) scores to those for richards and borglin’s csc implementation. the cut-off scores for this iapt recovery criteria match the guidance given to general prac­ titioners (gps) regarding who to refer to an iapt service (clark et al., 2009) and are therefore important for determining which patients enter the iapt service, how long they remain in it, and when they leave. this guidance dated from the set-up of the first iapt services, and therefore precedes the introduction of pbr to iapt by several years. method data the anonymous dataset analysed (n = 7,064) comprised all patient cases undergoing therapy in a single iapt service between 01 january 2009 and 14 february 2012 for whom both initial (start-of-treatment) and final (end-of-treatment) scores were available for both the phq-9 and gad-7 measures. the data were provided by the iapt service in question. scores for phq-9 and gad-7 were used to categorise each case according to the three success criteria under consideration: iapt recovery, clinically significant change and reliable change criteria. application of success criteria to the data it made little sense to analyse successful outcomes for patients who, because of their pre-treatment scores, could not achieve a criterion for ‘success’. therefore, for each of the three success criteria that we considered (table 1) a subset of the data was created why success criteria matter 4 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ containing only those patients that could (in principle) have a successful outcome to their treatment. the process of creating these three subsets is described below. iapt recovery criteria iapt services were set up to provide psychological therapy primarily for patients with anxiety disorders and/or depression that is at least moderate (clark et al., 2009). there­ fore, ‘recovery’ is classified as moving a service user from a score (at first appointment) that would identify them as suitable for gp-referral (phq-9 > 9 or gad-7 > 7) to a score (at last appointment) that is too low to trigger gp-referral to the service (phq-9 < 10 and gad-7 < 8). thus, when a patient’s initial score is close to the threshold specified by the iapt criteria, a small reduction in their score is sufficient for a ‘recovery’ classification, e.g., from 10 to 9 for phq-9, and from 8 to 7 for gad-7. however, much larger changes are required for a recovery classification when a patient’s initial score is high (e.g., severe depression with phq-9 of 21) because for this classification the final score must fall below the specified threshold. consequently, for the iapt recovery criteria, we analysed cases with initial phq-9 scores above 9, or initial gad-7 scores above 7 because these were the patients (n = 6,338) who could ‘recover’ on these criteria. clinically significant change (csc) criteria following the definition from richards and borglin (2011), a success under the csc criteria for depression is when phq-9 is above 8 pre-treatment and then is below 9 post-treatment. gad-7 scores were required to be above 9 at pre-treatment and below 10 post-treatment. thus, the minimum changes for a ‘success’ classification on the csc criteria are from 9 to 8 for phq-9, and from 10 to 9 for gad-7. this means that ‘success’ cannot be defined by the csc criteria when a patient’s initial score is already below the specified threshold (i.e., phq-9 below 9, gad-7 below 10). therefore, for csc, we analysed cases with initial phq-9 scores above 8, or initial gad-7 scores above 9 (n = 6,127). reliable change (rc) criteria for an outcome to be defined as showing reliable improvement, richards and borglin (2011) calculated that the phq-9 had to improve by 6 points or more and the gad-7 by 5 points or more. because the phq-9 and gad-7 scales start at zero, a reliable change cannot be observed when a patient’s initial score is smaller than the size of change specified by the rc criteria. therefore, for the rc criteria, we analysed cases with an initial phq-9 score above 5 or an initial gad-7 score above 4. for our joint analysis of success according to reliable change on both measures, reported below, only cases above both cut-offs (simultaneously) are included (n = 6,218). wheeler, orbell, & rakow 5 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ table 1 criteria applied for the analyses of outcomes defined by phq-9 and gad-7 scores (analyses are reported in tables 2-4) success criteria starting criteriaa criteria to achieve a successful intervention number of cases analysed [available]b iapt recovery case has either a phq-9 > 9 or a gad-7 > 7 must record final scores of phq-9 < 10 and gad-7 < 8 6,293 [6,338] clinically significant change (csc) case has either a phq-9 > 8 or a gad-7 > 9 must record final scores of phq-9 < 9 and gad-7 < 10 6,184 [6,229] reliable change (rc) case has both a phq-9 > 5 and a gad-7 > 4 must improve phq-9 score by 6 points or more and improve the gad-7 score by 5 points or more 6,170 [6,218] astarting criteria represent the minimum score(s) needed to allow for the possibility of success; if scores fall below the specified cut-offs it is impossible to achieve a successful outcome with these criteria. bsome cases with complete data for phq-9 and gad-7 scores could not be included in the regression analysis of predictors of success due to missing data for predictor variables. missing data are for deprivation, age or gender. for all three of the assessment methods, we used the success on both affect scales considered in combination as criteria for being an overall success for the patient (table 1). data analysis within each data subset, each patient’s outcome was coded for success (no vs. yes) according to the criteria for iapt recovery, csc and rc. next, using spss software, three analyses were conducted using binary logistic regression, one for each data subset. each analysis used the same set of 10 predictor variables (see table 2, 3, or 4) to determine the independent predictors of success (for each success criteria in turn). these variables are ones that had previously been found to predict engagement with treatment and/or final scores for phq-9 or gad-7 within this patient cohort (wheeler, 2018). for simplicity and transparency of reporting, phq-9 scores were re-coded into one of five categories: minimal (scores of 0-4), mild (5-9), moderate (10-14), moderately severe (15-19) and severe (20-27). four categories were used for the gad-7: minimal (0-4), mild (5-10), moderate (11-15) and severe (16-21). non-dichotomous categorical variables were dummy coded. for these variables, the reference category (i.e., ‘baseline category’, coded why success criteria matter 6 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ ‘0’) is shown in tables 2, 3, and 4, together with the other category (coded ‘1’) for each dummy variable. table 2 successful outcomes for iapt recovery criteria by patient category, and logistic regression with successful outcome as the dependent variable predictor variable (level) baseline characteristic % patients in category % success within category pa adjusted odds ratio (or) df 99% ci for adjusted or (lower and upper limits) gender male 33.4 39.0 – – – – female 66.6 38.9 .297 1.069 1 0.907 – 1.260 age in bands 16-24 15.9 33.3 – – – – age 25-34 years 21.9 38.2 .516 1.066 1 0.827 – 1.374 age 35-44 years 23.8 37.9 .677 1.042 1 0.810 – 1.340 age 45-59 years 26.9 39.1 .309 1.102 1 0.861 – 1.411 age ≥ 60 years 11.6 49.8 .020 1.348 1 0.967 – 1.878 deprivation decileb decile 1-2 9.9 33.0 – – – – decile 3-4 11.0 38.4 .218 1.172 1 0.841 – 1.635 decile 5-6 32.5 38.6 .535 1.069 1 0.810 – 1.413 decile 7-8 27.3 41.7 .080 1.213 1 0.913 – 1.610 decile 9-10 19.4 38.6 .326 0.891 1 0.660 – 1.205 employmentc in work 33.1 46.2 – – – – unemployed seeking 17.0 42.1 .014 0.812 1 0.652 – 1.011 students 20.8 25.8 < .001 0.490 1 0.393 – 0.611 long term sick 7.8 28.9 < .001 0.535 1 0.391 – 0.733 not actively seeking 19.5 42.5 .001 0.726 1 0.566 – 0.930 retired 1.0 43.1 .304 0.754 1 0.372 – 1.530 not known/stated 0.8 18.4 .005 0.317 1 0.109 – 0.919 referral sourcec gp 53.2 38.9 – – – – self (i.e., patient) 41.0 40.7 .728 1.021 1 0.873 – 1.196 secondary care 2.3 28.1 .056 0.675 1 0.398 – 1.146 other source 3.6 25.3 < .001 0.535 1 0.340 – 0.843 referral history new referral 79.8 39.9 – – – – re-referral 20.2 34.9 .381 .936 1 0.771 – 1.136 psychotropic medication not prescribed 5.9 39.0 – – – – prescribed, not taking 50.8 36.0 .853 1.024 1 0.740 – 1.416 prescribed, taking 40.1 42.3 .596 1.070 1 0.771 – 1.484 unknown/declined to say 3.3 44.2 .150 1.327 1 0.800 – 2.202 initial phq-9c minimal 2.4 68.4 < .001 4.923 1 2.923 – 8.260 mild 10.9 61.5 < .001 3.763 1 2.834 – 4.995 moderate 26.7 48.6 < .001 2.322 1 1.859 – 2.901 moderately severe 32.0 35.3 < .001 1.591 1 1.591 – 1.955 severe 29.0 22.9 – – – – wheeler, orbell, & rakow 7 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ predictor variable (level) baseline characteristic % patients in category % success within category pa adjusted odds ratio (or) df 99% ci for adjusted or (lower and upper limits) initial gad-7c minimal 1.6 58.0 < .001 3.075 1 1.710 – 5.528 mild 20.4 55.7 < .001 2.229 1 1.796 – 2.766 moderate 35.8 41.9 < .001 1.448 1 1.211 – 1.730 severe 42.3 27.6 – – – – engagementc less than 25% 4.1 14.8 – – – – 26 – 50% 31.2 22.9 .007 1.681 1 1.027 – 2.750 51 – 75% 39.2 42.0 < .001 4.462 1 2.749 – 7.244 76 – 100% 25.5 57.5 < .001 8.563 1 5.228 – 14.025 note. n = 6,293 patients with initial phq-9 > 9 or initial gad-7 > 7, as defined by the iapt recovery starting criteria. ci = confidence interval. model fit: -2ll = 7135.5, nagelkerke r 2 = .249, χ2(32, n = 6,293) = 1273.9, p < .001. ap-values for significant differences (α = .01) from the baseline category are shown in bold face type. bpredictor variable is significant, p < .01. cpredictor variable is significant, p < .001. table 3 successful outcomes for clinically significant change (csc) criteria by patient category, and logistic regression with successful outcome as the dependent variable predictor variable (level) baseline characteristic % patients in category % success within category pa adjusted odds ratio (or) df 99% ci for adjusted or (lower and upper limits) gender male 33.5 40.2 – – – – female 66.5 39.5 .621 1.032 1 0.875 – 1.217 age in bands 16-24 16.0 35.3 – – – – age 25-34 years 21.8 38.9 .990 0.999 1 0.776 – 1.286 age 35-44 years 23.8 38.8 .809 0.977 1 0.760 – 1.256 age 45-59 years 27.0 39.4 .978 1.003 1 0.784 – 1.283 age ≥ 60 years 11.4 50.3 .057 1.279 1 0.916 – 1.784 deprivation decile decile 1-2 10.0 34.8 – – – – decile 3-4 10.9 39.1 .297 1.144 1 0.821 – 1.593 decile 5-6 32.4 39.0 .804 1.027 1 0.779 – 1.354 decile 7-8 27.3 42.3 .163 1.164 1 0.879 – 1.542 decile 9-10 19.3 40.2 .464 0.918 1 0.681 – 1.239 employmentb in work 33.1 47.8 – – – – unemployed seeking 16.9 41.9 .001 0.745 1   0.597 – 0.929 students 21.0 27.0 < .001 0.485 1 0.389 – 0.603 long term sick 7.8 28.3 < .001 0.473 1 0.345 – 0.649 not seeking 19.3 43.0 < .001 0.704 1 0.549 – 0.903 retired 1.0 42.9 .170 0.684 1 0.335 – 1.396 not known/stated 0.8 22.0 .012 0.380 1 0.141 – 1.024 why success criteria matter 8 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ predictor variable (level) baseline characteristic % patients in category % success within category pa adjusted odds ratio (or) df 99% ci for adjusted or (lower and upper limits) referral sourceb gp 53.2 39.9 – – – – self (i.e., patient) 40.8 41.3 .949 1.004 1 0.857 – 1.176 secondary care 2.4 26.5 .007 0.571 1 0.335 – 0.972 other source 3.6 27.4 .002 0.591 1 0.380 – 0.919 referral history new referral 79.7 40.8 – – – – re-referral 20.3 35.5 .415 0.940 1 0.775 – 1.142 psychotropic medication not prescribed 5.9 38.4 – – – – prescribed, not taking 51.1 36.4 .437 1.104 1 0.796 – 1.531 prescribed, taking 39.7 43.7 .140 1.208 1 0.868 – 1.681 unknown/declined to say 3.3 47.3 .012 1.638 1 0.985 – 2.723 initial phq-9b minimal 1.6 68.6 < .001 5.678 1 3.085 – 10.449 mild 10.1 63.5 < .001 4.333 1 3.243 – 5.790 moderate 27.1 49.8 < .001 2.552 1 2.044 – 3.185 moderately severe 31.6 37.4 < .001 1.770 1 1.443 – 2.171 severe 29.5 23.2 – – – – initial gad-7b minimal 1.9 60.2 < .001 2.510 1 1.447 – 4.354 mild 18.7 53.0 < .001 1.806 1 1.451 – 2.248 moderate 36.4 44.0 < .001 1.377 1 1.154 – 1.643 severe 43.0 29.5 – – – – engagementb less than 25% 4.1 15.0 – – – – 26 – 50% 31.2 23.6 .003 1.762 1 1.079 – 2.880 51 – 75% 39.4 43.0 < .001 4.657 1 2.872 – 7.552 76 – 100% 25.4 58.4 < .001 8.912 1 5.445 – 14.587 note. n = 6,184 patients with initial phq-9 > 8 or initial gad-7 > 9, as defined by the csc starting criteria. ci = confidence interval. model fit: -2ll = 7083.0, nagelkerke r 2 = .243, χ2(32, n = 6,184) = 1226.4, p < .001 ap-values for significant differences (α = .01) from the baseline category are shown in bold face type. bpredictor variable is significant, p < .001. alpha was set to .01 to reduce the risk of capitalising on chance relationships (given the relatively large number of effects examined by each analysis), and as a conservative correction for the fact that there may be some dependence of observations that we could not remove from, or control for, in our anonymised dataset (e.g., two lines of data for a single individual representing two separate referral/treatment episodes; patients referred from the same gp surgery where we cannot rule out effects due to surgery-specific referral practices). missing data were rare. if data were missing for variables included in an analysis, the case was excluded from that analysis. these exclusions never exceeded 0.8% of cases (see table 1). to determine whether the conclusions are affected by our decision to analyse successful outcomes defined jointly by phq-9 and gad-7 scores, we also conducted separate analyses for each affect scale using each of the three success cri­ wheeler, orbell, & rakow 9 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ teria. for the sake of brevity, these six analyses are reported in supplementary materials (tables s1-s6). table 4 successful outcomes for reliable change (rc) criteria by patient category, and logistic regression with successful outcome as the dependent variable predictor variable (level) baseline characteristic % patients in category % success within category pa adjusted odds ratio (or) df 99% ci for adjusted or (lower and upper limits) gender male 33.8 36.3 – – – – female 66.2 36.6 .329 1.063 1 0.904 – 1.250 age in bands 16-24 15.9 31.7 – – – – age 25-34 years 22.1 36.1 .519 1.065 1 0.829 – 1.367 age 35-44 years 23.6 37.3 .732 1.034 1 0.806 – 1.325 age 45-59 years 27.1 37.2 .903 0.989 1 0.775 – 1.261 age ≥ 60 years 11.2 41.1 .148 1.205 1 0.865 – 1.678 deprivation decile decile 1-2 10.1 33.2 – – – – decile 3-4 11.1 37.7 .187 1.178 1 0.855 – 1.623 decile 5-6 32.6 36.6 .583 1.059 1 0.809 – 1.385 decile 7-8 27.0 37.6 .358 1.103 1 0.838 – 1.452 decile 9-10 19.2 35.7 .484 0.924 1 0.690 – 1.237 employmentb in work 33.2 42.6 – – – – unemployed seeking 17.2 36.0 < .001 0.737 1   0.591 – 0.918 students 20.9 29.8 < .001 0.500 1 0.404 – 0.620 long term sick 7.9 29.2 < .001 0.560 1 0.412 – 0.762 not seeking 19.1 37.5 < .001 0.712 1 0.557 – 0.912 retired 1.0 41.9 .594 0.864 1 0.426 – 1.751 not known/stated 0.8 16.3 .004 0.312 1 0.109 – 0.892 referral source gp 53.5 36.6 – – – – self (i.e., patient) 40.6 37.6 .396 1.053 1 0.901 – 1.230 secondary care 2.4 34.7 .558 0.894 1 0.547 – 1.461 other source 3.5 25.5 .003 0.594 1 0.379 – 0.928 referral historyb new referral 79.8 36.7 – – – – re-referral 20.2 32.2 .003 0.802 1 0.662 – 0.972 psychotropic medication not prescribed 5.8 40.2 – – – – prescribed, not taking 51.1 36.2 .115 0.822 1 0.596 – 1.133 prescribed, taking 39.8 35.9 .179 0.844 1 0.609 – 1.168 unknown/declined to say 3.3 43.3 .381 1.185 1 0.720 – 1.950 initial phq-9b mildc 13.2 21.1 < .001 0.395 1 0.294 – 0.530 moderate 26.3 34.4 .014 0.814 1 0.656 – 1.010 moderately severe 31.2 41.1 .640 1.035 1 0.856 – 1.252 severe 29.3 40.6 – – – – why success criteria matter 10 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ predictor variable (level) baseline characteristic % patients in category % success within category pa adjusted odds ratio (or) df 99% ci for adjusted or (lower and upper limits) initial gad-7b mildc 22.5 23.2 < .001 0.456 1 0.364 – 0.572 moderate 34.8 38.2 .038 0.870 1 0.733 – 1.034 severe 42.7 42.2 – – – – engagementb less than 25% 4.1 13.4 – – – – 26 – 50% 31.2 21.4 .001 1.896 1 1.146 – 3.136 51 – 75% 39.3 40.0 < .001 4.898 1 2.985 – 8.035 76 – 100% 25.4 53.5 < .001 8.740 1 5.284 – 14.454 note. n = 6170 patients with both initial phq-9 > 5 and initial gad-7 > 4, as constrained by the minimum size of rc. model fit: -2ll = 7234.9, nagelkerke r 2 = .178, χ2(30, n = 6170) = 859.7, p < .001 ap-values for significant differences from the baseline category are shown in bold face type, though only when the overall effect for the variable is also significant (α = .01). bpredictor variable is significant, p < .001. cmild was the lowest category analysed for phq-9 depression and gad-7 anxiety because a successful outcome on the rc criteria cannot be achieved for patients with minimal depression or anxiety. this is because any initial score in the minimal category is already too low to allow for the size of reduction that the rc criteria require for a successful outcome. results and discussion tables 2, 3 and 4 summarise each analysis of the predictors of success for the iapt, csc and rc success criteria, respectively, together with descriptive statistics for the distribution of patient characteristics and rates of successful outcomes across the levels of each predictor. these analyses suggest that there is ‘nothing unusual’ about the patient population that we have analysed. consistent with other analyses of iapt service populations, women outnumber men by a ratio of 2-to-1, and uptake rates are not particularly high among older individuals (clark, 2018). also consistent with previous analyses (e.g., gyani et al., 2013) those who attend a higher proportion of the treatment sessions that they are offered have substantially better outcomes (see the ‘engagement’ predictor in tables 2, 3, and 4). perhaps unsurprisingly, some groups not in employment (e.g., long-term sick) are less likely to have a successful outcome, as is also the case in some analyses for those whose referral to the service did not originate from primary or community healthcare services. importantly, each of tables 2, 3 and 4 show that both initial phq-9 scores (for depres­ sion) and initial gad-7 scores (for anxiety) significantly predict successful outcomes. this is true for each of the three success criteria. however, as seen by comparing treatment success rates for each level of depression or anxiety across tables 2, 3, and 4, the direction of effect is not the same for all three criteria. figure 1 illustrates this pattern of effects. for the iapt recovery criteria, success rates are progressively lower for more severe levels of depression or anxiety: effects that are large, statistically significant, and wheeler, orbell, & rakow 11 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ follow approximately linear progressions across different levels of phq-9 and gad-7 (table 2). an equivalent pattern and similar size of effect is seen for the csc criteria: with the lowest rates of success found among those with severe depression and severe anxiety (table 3). in contrast, this pattern is reversed when success is defined by rc: success rates are highest for those with severe depression or anxiety and lowest for those with mild depression or anxiety (table 4). these effects are not so large as the equivalent ones for the iapt recovery and csc criteria. nonetheless, the effects are statistically significant, both for depression and anxiety, and reveal that the recovery rate approximately doubles between the mild and severe categories on either the phq-9 or gad-7. figure 1 success rate by diagnostic category for each of three success criteria, for (a) depression [left] and (b) anxiety [right] note. minimal category not included because it is not examined in the analysis of the reliable change criteria. the analyses reported in the supplementary materials confirm that initial scores for the affect measures also predict successful outcome when these outcomes are analysed separately for depression and anxiety. the direction of these effects reported in the supplementary materials (tables s1-s6) match those described in the previous para­ graph. thus, consistent with the conclusions drawn from the analyses reported in tables 2, 3, and 4 and illustrated in figure 1, higher initial phq-9 scores are associated with a lower chance of successful outcome for depression when assessed on the iapt recovery or csc criteria, but a higher chance of successful outcomes for depression when assessed via rc criteria (tables s1-s3). likewise, the chances of a successful outcome for anxiety on the iapt recovery or csc criteria reduce as initial gad-7 scores increase, but increase for the rc criteria as initial gad-7 scores increase (tables s4-s6). moreover, the effects reported in the supplementary materials are always descriptively stronger than the cor­ responding effects reported in tables 2, 3, and 4. that is, when predicting treatment why success criteria matter 12 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ success for depression (tables s1-s3) the odds ratios (ors) for each level of the phq-9 are further from 1 (i.e., ‘no effect’) than the corresponding ors reported for the phq-9 in tables 2, 3 and 4. and likewise, when predicting treatment success for anxiety (tables s4-s6) the ors for each level of the gad-7 are further from 1 than the corresponding ors reported for the gad-7 in tables 2, 3 and 4. from this we infer that the findings reported in tables 2, 3, and 4 are not an artefact of analysing success criteria based jointly on outcomes for depression and anxiety. indeed, reporting analyses based on such joint criteria may have resulted in a conservative illustration of the general patterns that we find. we assume that the implications of these findings are clear with respect to the incen­ tives for which patients are prioritised for treatment, irrespective of whether those incen­ tives are created by the goals that the service sets for itself, or derive from another source such as via payment by results (pbr). the choice of success criteria could impact on which patients are most worthwhile treating. when success is defined by the principles of clinically significant change (iapt recovery and csc criteria) the chances of success are better for those whose depression and/or anxiety is not so severe. if these criteria are adopted, the service is incentivised to treat the less severe cases and to encourage those with more severe depression and/or anxiety to seek treatment outside the service. when success is defined according to the principles of statistically reliable change, the chances of success are better for those whose condition is severe. if such criteria are adopted, this incentivises treatment of more severe cases, and therefore dis-incentivises taking the relatively less severe cases into the service. it is not necessary for service providers to be consciously aware of this incentive structure for the incentives to have this effect: changes in patterns of referral, acceptance into the service, and extension of treatment provision for those most likely to achieve ‘success’ (however defined) can all happen gradually (perhaps imperceptibly so) following a simple ‘trial-and-improvement’ or stimulus-reward mechanism. to illustrate how such a mechanism might play out in a specific context, we consider one of the changes to service funding that occurred subsequent to the period in which our data were recorded. the guidance from nhs england and nhs improvement (2017b) for outcomes-related payments to iapt services (which came into effect on 01 april 2018) gave precedence to statistically reliable change in payments to iapt services for the clinical outcomes component. payment that rewards the clinical outcome for a patient was only made if there was statistically reliable improvement. there was, however, some regard for the principles of clinically significant change in these payments because the full payment was only made if the patient’s score drops below the cut-off for the iapt recovery criteria. failing that, payment was proportional to the degree of movement towards recovery. given our analysis reported in this paper, such a pbr structure that emphasises reliable change seems to provide an incentive to prioritise treatment for those with more severe levels of depression and anxiety.1 wheeler, orbell, & rakow 13 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ such incentives may be entirely reasonable: prioritising intervention for those whose conditions are most severe may bring the greatest reduction in the ‘global burden’ (for individuals, on their families, and to the economy) associated with mental ill health; and financial rewards to a service for treating these patients may offset the costs of treating these patients who are likely to have longer-than-average programmes of treatment. that said, we note that the iapt programme was set up to provide a readily accessible service to those with at least moderate depression and/or anxiety disorders – and not necessarily to treat the most severe cases of these conditions (clark et al., 2009). what our analysis illustrates is that the choice of success criteria – for whatever reason they are adopted – can be important for which patients a service targets and therefore treats. it is, of course, a limitation that our analyses use a single dataset and focussed on only two clinical measures for two mental health conditions. we conjecture that the patterns we find arise from the principles that differentiate csc from rc criteria, and should be apparent in other contexts. nonetheless, further investigations should examine the reproducibility of our findings in other mental health conditions and for implementations of csc and rc in clinical measures other than the phq-9 and gad-7. another area for future research is to examine whether and how patients’ individual therapy goals map onto csc or rc criteria. for example, can patients’ goals be expressed in terms of changes or thresholds on clinical measures, how do those goals vary with a patient’s starting point, and by what process do patients set their goals? when considering how our findings relate to the academic literature on pbr in mental health services, it surprised us how small that body of literature seems to be. to illustrate, a search of the pubmed database for “payment by results” [in article] and “mental health” [in title/abstract] yielded only 13 articles2. as best we could determine, all 13 articles had pbr in uk mental health services as their main focus. however, mason et al. (2011) also examined what the uk nhs could learn from the experience of the small number of countries in which pbr for mental health services had been explored (australia, canada, new zealand) or implemented (the netherlands, usa). a few other articles also reflected on pbr in mental health in some of those countries (e.g., tulloch, 2012) usually by drawing on mason et al. (2011). however, important for the analyses that we report, the ‘results’ in these pbr schemes were service activity not clinical outcomes. these pbr schemes set price tariffs for mental health services contingent on the features of the clinical populations being treated. higher prices are set for patients whose treatment is judged likely to be cost­ 1) additionally, the third largest component of the payment model, reducing disability and improved wellbeing (10% weighting), also has payments linked to statistically reliable improvement. 2) we are grateful to a reviewer for pointing us towards this literature. our search, conducted in july 2023, identified one further article. however, this article was on homelessness, not mental health services, and its single reference to payment by results did not refer to mental health. why success criteria matter 14 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://www.psychopen.eu/ ly (e.g., because their diagnosis means treatment will probably be resource-intensive). though rather different to the outcome-based pbr that we have focussed on in this article, our findings may point to a potential additional complexity associated with activ­ ity-based pbr. if treatment stops when a ‘successful’ outcome is achieved, but otherwise may continue, the choice of success criteria should impact what resources are allocated to a given patient. this is because – as our analyses show – the choice of success criteria impacts how condition severity relates to a ‘successful’ treatment outcome. under csc criteria, the chances of success are better for patients whose condition is less severe, and therefore these are the patients least likely to receive extended (costly) treatment. conversely, a service that aims for ‘success’ under rc criteria will likely deploy more resources to treat these same patients because it will be more difficult (and therefore take longer) to achieve a successful outcome for their patients whose condition is less severe. thus, when designing an activity-based pbr scheme, assuming one success criteria or another could (perhaps should) impact what price tariffs are set. and when operating under an established activity-based pbr scheme, the success criteria that a service adopts (explicitly or implicitly) in its clinical practice could affect whether or not service funding reflects service costs. as a general point of application, our analyses illustrate that the question ‘which type of patients respond best to this treatment?’ is not a context free question. crucially, the answer to that question can depend on what criteria are used to measure a ‘success­ ful’ response to treatment. specifically, whether a successful outcome is determined according to a threshold for a clinical outcome measure (e.g., csc) or according to the extent of improvement in such a clinical outcome (e.g., rc) can determine whether it appears that treatment is more successful for patients with less severe, or more severe, symptoms. our goal is not to argue that one success criterion is best, or that another is inappropriate. rather, we offer this analysis to emphasise that because incentives affect behaviour, success criteria must be chosen carefully if a therapy service is to operate according to its stated goals. funding: this research was funded by the university of essex (colchester, uk) and health in mind. acknowledgments: we thank doug hiscock and sam lane for assistance. competing interests: the authors have declared that no competing interests exist. twitter accounts: @icarpcic data availability: data are not publicly available due to the privacy policy of the service in relation to patient data. for questions about the data or its analysis, please contact the corresponding author. wheeler, orbell, & rakow 15 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://twitter.com/icarpcic https://www.psychopen.eu/ supplementary materials the supplementary materials (see wheeler et al., 2023) report analysis of the predictors of a successful treatment outcome, separately for each affect scale (phq-9 and gad-7), and separately for each of the three success criteria. these six analyses, using logistic regression, serve as a 'check' on the conclusions from the three analyses that are reported in the article. index of supplementary materials wheeler, m. h., orbell, s., & rakow, t. 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(2012, october 27). don’t leave patients in ambulances to hit a & e targets, hospitals told. daily telegraph. https://www.telegraph.co.uk/news/9637865/dont-leave-patients-in-ambulances-to-hit-aandetargets-hospitals-told.html wheeler, m. h. (2018). managing common mental disorders and ptsd in the community [doctoral thesis, university of essex]. university of essex research repository. https://repository.essex.ac.uk/23629 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. why success criteria matter 18 clinical psychology in europe 2023, vol. 5(4), article e10237 https://doi.org/10.32872/cpe.10237 https://doi.org/10.1016/s0005-7894(86)80059-4 https://www.telegraph.co.uk/news/9637865/dont-leave-patients-in-ambulances-to-hit-aande-targets-hospitals-told.html https://www.telegraph.co.uk/news/9637865/dont-leave-patients-in-ambulances-to-hit-aande-targets-hospitals-told.html https://repository.essex.ac.uk/23629 https://www.psychopen.eu/ why success criteria matter (introduction) incentives in healthcare systems success criteria in psychological therapy method data application of success criteria to the data data analysis results and discussion (additional information) funding acknowledgments competing interests twitter accounts data availability supplementary materials references argentinian mental health during the covid-19 pandemic: a screening study of the general population during two periods of quarantine research articles argentinian mental health during the covid-19 pandemic: a screening study of the general population during two periods of quarantine martín juan etchevers a , cristian javier garay a , natalia inés putrino a , natalia helmich a , gabriela lunansky b [a] faculty of psychology, university of buenos aires, buenos aires, argentina. [b] faculty of psychology, university of amsterdam, amsterdam, the netherlands. clinical psychology in europe, 2021, vol. 3(1), article e4519, https://doi.org/10.32872/cpe.4519 received: 2020-10-05 • accepted: 2021-01-03 • published (vor): 2021-03-10 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: cristian javier garay, pacheco de melo 2549 2c (c1425auc) ciudad autónoma de buenos aires, argentina. e-mail: cristiangaray@psi.uba.ar abstract background: due to the covid-19 pandemic, argentina has been under mandatory quarantine. we have aimed to investigate the state of mental health of the argentine population and the behaviours adopted to cope with mental distress during quarantine. method: an online survey was conducted using a probabilistic sampling technique and stratified according to the geographic regions of the country. the survey covered days 7-11 (n = 2,631) and days 50-55 (n = 2,068) after compulsory quarantine. the psychological impact was measured using the 27-item symptom checklist (scl-27), which provides a global severity index (gsi). an ad hoc questionnaire registered problematic, healthy and other behaviours. two network models were estimated using a mixed graphical model. data from the two periods were compared and analysed. outcomes: higher gsi scores and greater risk of experiencing mental disorder were found in period 2 as compared with period 1. the lowest gsi scores were associated with physical activity in both periods, and meditation and yoga in period 1. drug users reported the highest gsi scores in both periods. the network comparison test confirmed a significant change in symptomatology structure over the two quarantine periods. conclusion: this study showed that psychological symptoms and the risk of experiencing mental disorder increased significantly from period 1 to period 2. network analysis suggested that the quarantine might have brought about changes in the relationships between symptoms. overall this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.4519&domain=pdf&date_stamp=2021-03-10 https://orcid.org/0000-0003-2798-7178 https://orcid.org/0000-0003-4082-8876 https://orcid.org/0000-0001-8205-9070 https://orcid.org/0000-0001-5483-9387 https://orcid.org/0000-0001-6226-2258 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ results revealed the relevance of mental health and the need to take mental health actions upon imposing quarantine during the current covid-19 pandemic. keywords covid-19 pandemic, mental health, argentina, quarantine highlights • the length of the quarantine is associated with increased psychological symptoms. • the youngest, the ones with a low income and females reported the most symptoms. • physical activity is less associated with psychological symptoms. • access to mental health assistance is crucial to minimize the psychological impact of quarantine. pandemics are epidemics on a large scale which affect people in multiple countries and which sometimes, as is the case of the current covid-19 pandemic, can spread globally (world health organization [who], 2010). there is a long history of fighting epidemics and pandemics (huremovic, 2019). it is pertinent to highlight that, in the absence of adequate biomedical treatments, behavioural methods such as good hygiene practices and social distancing have been frequently implemented to reduce morbidity and mortality (taylor, 2019). quarantine is the restriction of movement of people who have been exposed to an infectious disease to determine if they have been infected and thus, reduce the risk of spreading the disease. isolation, on the other hand, is the separation of people who have been diagnosed with an infectious disease from those who have not (centers for disease control and prevention [cdc], 2017; hurtado & fríes, 2010). recently, quarantine has been implemented against the coronavirus disease 2019 (covid-19) outbreak. on march 3, argentina confirmed its first covid-19 case. school classes were suspended on march 16 with a strong non-mandatory recommendation for social iso­ lation and, as of march 20, the mandatory quarantine came into effect; exemption was secured for health professionals, security and defence personnel, journalists and media professionals, and the food industry (decreto necesidad y urgencia [emergency decree, argentina], 2020). at the beginning of the quarantine, 30 cases and 3 deaths by covid-19 were confirmed in argentina (ministerio de salud [ministery of health, argentina], 2020). the quarantine was enforced through police controls; city and town limits and provincial borders were closed, resulting in a 54.78% reduction in public transport usage (reaching 86%) (google, 2020). the psychological effects of quarantine have been studied in different past occasions and countries. from previous epidemic and pandemic studies, it appears that the longest quarantine studied was a 21-day quarantine instituted in 2015 in liberia, a country in argentinian mental health during the covid-19 pandemic 2 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ west africa, on account of an ebola virus outbreak. three studies showed that prolonged quarantine was associated with symptoms of post-traumatic stress, avoidance behaviours and anger, among the most prevalent (brooks et al., 2020). also, an association between higher levels of psychological symptoms and low income, job and financial insecurity, and healthcare workers was also established (holmes et al., 2020). studies of recent and dramatic experiences with covid-19 show similar or more serious results. (de girolamo et al., 2020; wang et al., 2020; williams, armitage, tampe, & dienes, 2020). although mental health aspects of the covid-19 crisis play an important role in managing the pandemic, there is a pre-existing lack of mental health research studies in argentina. given factors such as quarantine duration, culture, politics and economic situation are unique to this study. this study, which aims to determine the psychological impact of these factors on the argentine population, was carried out 55 days after imposition of mandatory quarantine and 72 days after the first confirmed covid-19 case. more specifically, it intends to establish the impact of the pandemic and quarantine on psychological symptomatology in the argentine population, and its relationship with certain behaviours, defined as healthy, problematic and others. we also aim to establish whether quarantine duration is related to symptom severity. apart from investigating changes in symptom severity, we are likewise interested in the changes in symptomatol­ ogy structure as well as in the relationships between symptoms and reported healthy and problematic behaviours as the quarantine period is extended. network models are used for studying unique relationships between individual symptoms and the reported behav­ iours (borsboom, 2017; borsboom & cramer, 2013). furthermore, symptom network models show the unique associations between behaviours and symptoms, elucidating the possible pathways via which healthy or problematic behaviours can (negatively or positively) influence specific symptom development (isvoranu, borsboom, van os, & guloksuz, 2016). to this means, we will attempt to identify changes in symptomatology structure and symptom-behaviour relationships between the early and later quarantine phases by constructing a network model of psychological symptoms and behavioural variables. method study design and participants we adopted a survey design to assess the impact of covid-19 and quarantine by using an anonymous online questionnaire. the sample was probabilistic and stratified according to geographic regions of argentina and its population distribution (see table 1 and table 2). the online survey was conducted on days 7-11 (from march 27 to 31, 2020) and days 50-55 (may 8 to 12, 2020) of the compulsory quarantine. etchevers, garay, putrino et al. 3 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ table 1 sample characteristics of the period 1 (days 7-11 of quarantine) and 2 (days 50-55 of quarantine) participants’ characteristics period 1 (n = 2631) period 2 (n = 2068) n % n % age 18-20 113 4 119 6 21-29 472 18 321 15 30-39 750 28 439 21 40-49 469 18 661 32 50-59 450 17 280 14 > 60 377 14 248 12 gender women 1210 46 1056 51 men 1421 54 1012 49 educational level primary 143 5 80 4 secondary 1056 40 777 37 vocational 708 28 594 29 higher 724 27 617 30 income low 1201 45 843 41 middle 1281 49 1072 52 high 149 5.5 153 7 table 2 samples’ geographic distribution of the period 1 (days 7-11 of quarantine) and 2 (days 50-55 of quarantine) region period 1 (n = 2631) period 2 (n = 2068) n % n % buenos aires metropolitan area 1159 44 1011 49 buenos aires province 409 16 257 12 córdoba 322 12 257 11 rosario 269 10 178 9 mendoza 246 9 157 8 tucumán 226 9 111 5 neuquén – 132 6 argentinian mental health during the covid-19 pandemic 4 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ psychological symptomatology the psychological impact of covid-19 was measured using the 27-item symptom check­ list (scl-27; hardt & gerbershagen, 2001). the scl-27 has been adapted and well-vali­ dated to the argentine population (castro solano & góngora, 2018). two indexes were calculated: 1) the global severity index (gsi -27), which is the total item mean scores; and 2) the risk of mental disorder index, which included participants who answered over 50% of the items (14 or more out of the 27 items in this instrument) with the options "quite" or "much”; these participants being thus regarded as at risk of developing mental disorders. problematic, healthy and other behaviours through an ad hoc questionnaire, problematic behaviours (alcohol, illegal drug and tobacco abuse), healthy behaviours (sports and physical activity, sex life and religious practice) and other behaviours (use of over-the-counter and prescription drugs, yoga or meditation practice) were registered. associations with these behaviours and their changes during mandatory quarantine were analysed with gsi-27 indicators and the "risk of mental disorder" index provided by scl-27. procedures after completing the informed consent process, participants filled an online question­ naire sent through a social network. it contained a socio-demographic section, the scl-27 (castro solano & góngora, 2018), and an ad hoc questionnaire on healthy, problematic and other behaviours mentioned below. statistical analysis in order to compare the gsi-27 between the two periods, we conducted a paired-samples t-test. in addition, we compared risk of mental disorder and suicidal thoughts in the two periods through the z-test for population proportions. in order to compare the effects of sex, age, and income on gsi in each period, we performed a one-way between-subjects anova. for the purpose of comparing the effects of problematic behaviours (tobacco, drug, and alcohol use), healthy behaviours (sports and physical activity, sex life and religious practice), and other behaviours (medication use, yoga or meditation practice) on gsi in each period, we carried out an independent-samples t-test. in an attempt to examine the relation between yoga practice and the risk of mental disorder, we performed a chi-square test of independence. data were analysed using the statistical package for the social sciences (spss), version 18.0. the network model was estimated with a mixed graphical model (mgm), using the “mgm” implementation in the “bootnet” package in r (epskamp, borsboom, & fried, etchevers, garay, putrino et al. 5 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ 2018; haslbeck & waldorp, 2020). this model combined the use of categorical and gaussian variables which allowed us to combine behaviours and symptoms into one network model. the mgm is not yet available for ordinal data, so we used the “gaussian” option for the 5-point likert scale symptom data, as suggested by haslbeck and waldorp (2020). relationships between variables were statistically estimated based on conditional dependencies of the data. in order to test if symptomatology structure significantly changed from period 1 to period 2, we conducted the network comparison test (nct; van borkulo et al., 2021) by using the “nct” software package in r (van borkulo, epskamp, & millner, 2016). the nct compared the symptom networks from the two periods based on their structure and overall connectivity (i.e., the strength of statistical associations between symptoms). this test cannot be performed on mixed data, which is why we conducted it on symptom networks only containing the scl-27 symptom data (i.e., without behaviours). results 2631 participants completed the online survey in period 1 and 2068 participants comple­ ted it in period 2. psychological symptomatology firstly, it was evaluated if the psychological symptoms differed between period 1 and period 2. in addition, the risk of experiencing a mental disorder and suicidal ideation in both periods was estimated. a significant difference was observed in gsi scores, t(2067) = -50.664, p < .001, between the two periods; period 2 yielding the highest score. we also identified a significant difference between the two population proportions according to the mental health risk index, z = 3.48, p < .01. during period 1, 4.86% of participants were at risk of mental health disorder, while during period 2, 7.2% of participants were at risk. an independent-sample t-test comparing gsi values of individuals with suicidal thoughts and individuals without suicidal thoughts showed a significant difference in period 1, t(2629) = 18.16, p < .001, (individuals with suicidal thoughts [m = 1.9, sd = 0.82] and individuals without suicidal thoughts [m = 0.81, sd = 0.61]). important differ­ ences were also detected in period 2, t(2066) =18.03, p < .001, (individuals with suicidal thoughts [m = 2.96, sd = 0.71] and individuals without suicidal thoughts [m = 1.9, sd = 0.66]). a z-test for population proportions was performed between the two periods for suicidal thoughts (ad hoc question). significant differences were found; period 2 yielding the highest score (z = 3.28, p < .01, period 1 = 4.22%; period 2 = 6.53%). regarding sleep disturbances, period 1 showed that 73.7% of the sample had sleep related problems. in period 2, 76.06% of the sample reported sleep disorders. concerning argentinian mental health during the covid-19 pandemic 6 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ sex life, 43.97% in period 1 and 44.39% in period 2 reported sexual dissatisfaction. no significant differences were observed. see table 3. table 3 screening symptomatology comparing samples of the period 1 (days 7-11 of quarantine) and 2 (days 50-55 of quarantine) measure, index and symptomatology period 1 (n = 2631) period 2 (n = 2068) p mean gsi-27 (sd) 0.85 (0.66) 1.96 (0.71) < .001b scl-27 mental disorder risk 128/2631 (4.86%) 149/2,068 (7.2%) < .01a suicidal thoughts 111/2,631 (4.22%) 135/2,068 (6.53%) < .01a sleep disturbance 1,572/2,631 (73.7%) 1,939/2,068 (76.02%) ns sexual life dissatisfaction 1,157/2,631 (43.97%) 918/2,068 (44.39%) ns note. gsi-27 = global severity index of scl-27; scl-27 = symptom check list-27. scl-27 mental disorder risk = participants who choose score 3 or 4 in at least 50% of the items; ns = not significant. az-test. bt-test. age, sex and income we compared gsi values with socio-demographic characteristics (i.e., age, sex, and in­ come). the lowest gsi values corresponded to the eldest participants in the sample, in both periods, f(5, 2625) = 31.322, p < .001, and f(5, 12.88) = 26.67, p < .001. the highest scores corresponded to women, also in both periods: period 1, t(2618) = 10.77, p < .001, and period 2, t(2055) = 8.91, p < .001. lowest income participants reported the highest gsi scores as compared to middle and highincome participants in both periods: period 1, f(2, 2349) = 29.65, p < .001, and period 2, f(2, 6.82) = 13.45, p < .001). see table 4 for post hoc analysis and descriptive results. etchevers, garay, putrino et al. 7 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ table 4 gsi post hoc comparisons using hsd test on age, sex and income, in period 1 and 2 participants’ characteristics period 1: gsi-27 period 2: gsi-27 m sd m sd age 18-20 1.05 0.06 2.41 0.80 21-29 1.02 0.03 2.18 0.73 30-29 0.96 0.02 2.01 0.74 40-49 0.85 0.03 1.90 0.66 50-59 0.69 0.03 1.84 0.67 60 or more 0.58 0.03 1.68 0.71 sex men 0.77 0.58 1.80 0.66 women 1.00 0.71 2.10 0.73 income low 0.98 0.71 2.06 0.69 middle 0.75 0.59 1.90 0.69 high 0.74 0.59 1.87 0.66 note. in period 1, post hoc comparisons using the tukey hsd test indicated that the mean score for the 18-20 and 21-29 years old subgroups had significantly more symptoms than the 40-49, 50-59, and 60 plus years old subgroups. also, the 40-49 years old subgroups had a higher gsi than the 50-59 and 60 plus years old subgroups. in period 2, the 18-20 years old subgroup had significantly more symptoms than 21-29, 30-39, 40-49, 50-59 and 60 plus years old subgroups. the 21-29 subgroup had significantly more symptoms than 30-39, 40-49, 50-59 and 60 plus years old subgroups. also, the 30-39 years old subgroup had a higher gsi than the 50-59 and 60 plus years old subgroups. the 40-49 years old subgroup had more symptoms than the 60 plus subgroup. in period 1, post hoc comparisons using the tukey hsd test indicated that the mean score for the low-income participants had a significant difference with the middle and high-income participants. in period 2, the low-in­ come participants reported the highest gsi score. low-income participants had a significant difference with the middle and high-income participants. problematic, healthy and other behaviours with respect to problematic, healthy and other behaviours, lower gsi scores were found in individuals who did physical activity both in period 1, t(2629) = -6.63, p < .001, and in period 2, t(2066) = -6.46, p < .001. in a similar manner, lower gsi scores were found in those who practiced meditation in period 1, t(2629) = -3.19, p = .001). again in period 1, lower proportions of participants in the risk of mental health index were associated with the practice of yoga, χ2(1, n = 2630) = 9.94, p < .01. regarding religious practice, we did not find considerable differences. drug users reported the highest gsi scores in period 1, t(2601) = 4.93, p < .001, and period 2, t(2033) = 3.54, p < .001. tobacco users showed higher gsi scores during period 1, t(2629) = -3.76, p < .001). argentinian mental health during the covid-19 pandemic 8 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ alcohol was consumed by 37.51% of participants (n = 987) in period 1 and 41.15% of participants (n = 851) in period 2. 27.43% (n = 271/988) of participants in period 1 and 33.73% (287/851) in period 2 referred that their alcohol consumption had increased. differences were not significant. over-the-counter and prescription drugs were used by 33.33% (n = 877) of partici­ pants in period 1 and 33.12% (n = 686) in period 2. differences were not significant. more participants used prescription drugs for coping with distress (anxiety, “nerves”, relaxation, sleep) in period 2 than in period 1, but we did not find a marked difference. considering mental health care, in period 2, 14.02% (n = 290) of participants were in psychological treatment and 37.55% (n = 668) of responders that were not receiving mental health care considered that they needed treatment but pointed to difficulties in accessing mental health care systems. network analysis figure 1 and figure 2 show the estimated network models for both periods. figure 1 estimated network model – period 1 sports religion meditation yoga sexual medication tobacco alcohol drugs scl1 scl2 scl3 scl4 scl5 scl6 scl7 scl8 scl9 scl10 scl11 scl12 scl13 scl14 scl15 scl16 scl17 scl18 scl19 scl20 scl21 scl22 scl23 scl24 scl25 scl26 scl27 problematic behaviors tobacco: tobacco use alcohol: alcohol use drugs: illicit drugs use healthy behaviors sports: physical/sports activity religion: religious practice sexual: sexual life satisfaction other behaviors meditation: practice of meditation yoga: practice of yoga medication: medication use scl−27 : social phobia scl1: feeling very self−conscious with others scl8: feeling that people are unfriendly or dislike you scl21: feeling inferior to others scl23: feeling uneasy when people are watching or talking about you scl−27 : depression scl2: feeling blue scl5: thoughts of death or dying scl15: feeling hopeless about the future scl22: thoughts of ending your life scl−27 : agoraphobia scl3: feeling afraid to go out of your house alone scl4: feeling fearful scl20: feeling afraid you will faint in public scl25: having to avoid certain things, places or activities that frighten you scl27: feeling afraid in open spaces or on the streets scl−27 : dysthymia scl6: your mind going blank scl7: trouble remembering things scl9: feeling low in energy or slowed down scl24: trouble concentrating scl−27 : vegetative scl10: nausea or upset stomach scl11: hot or cold spells scl13: faintness or dizziness scl16: a lump in your throat scl18: heart pounding or racing scl26: trouble getting your breath scl−27 : mistrust scl12: others not giving you proper credit for your achievements scl14: feeling that people will take advances of you if you let them scl17: feeling that most people cannot be trusted scl19: having ideas or beliefs that others do not share note. the estimated network model includes the scl-27 variables and behavioural variables for quarantine period 1. the nodes in the figure represent the variables, and the lines between the nodes represent the edges, which encode the statistical associations between variables. the colour etchevers, garay, putrino et al. 9 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ of the edges represents the nature of this association: blue edges represent positive associations; red edges represent negative associations. thickness of edges represents the strength of associations. regarding the structure of symptom network models, the network model for period 1 shows that symptoms cluster together according to their domain: this means that the items designed to measure the same domain have indeed strong positive associations amongst each other. figure 2 estimated network model – period 2 sports religion meditation yoga sexual medication tobacco alcohol drugs scl1 scl2 scl3 scl4scl5 scl6 scl7 scl8 scl9 scl10 scl11 scl12 scl13 scl14 scl15 scl16 scl17 scl18 scl19 scl20 scl21 scl22 scl23 scl24 scl25 scl26scl27 problematic behaviors tobacco: tobacco use alcohol: alcohol use drugs: illicit drugs use healthy behaviors sports: physical/sports activity religion: religious practice sexual: sexual life satisfaction other behaviors meditation: practice of meditation yoga: practice of yoga medication: medication use scl−27 : social phobia scl1: feeling very self−conscious with others scl8: feeling that people are unfriendly or dislike you scl21: feeling inferior to others scl23: feeling uneasy when people are watching or talking about you scl−27 : depression scl2: feeling blue scl5: thoughts of death or dying scl15: feeling hopeless about the future scl22: thoughts of ending your life scl−27 : agoraphobia scl3: feeling afraid to go out of your house alone scl4: feeling fearful scl20: feeling afraid you will faint in public scl25: having to avoid certain things, places or activities that frighten you scl27: feeling afraid in open spaces or on the streets scl−27 : dysthymia scl6: your mind going blank scl7: trouble remembering things scl9: feeling low in energy or slowed down scl24: trouble concentrating scl−27 : vegetative scl10: nausea or upset stomach scl11: hot or cold spells scl13: faintness or dizziness scl16: a lump in your throat scl18: heart pounding or racing scl26: trouble getting your breath scl−27 : mistrust scl12: others not giving you proper credit for your achievements scl14: feeling that people will take advances of you if you let them scl17: feeling that most people cannot be trusted scl19: having ideas or beliefs that others do not share note. the estimated network model includes the scl-27 variables and behavioural variables for quarantine period 2. however, this does not apply to the network model for period 2. here, symptoms no lon­ ger cluster together according to their domain and symptom relations are interchanged. results from the nct confirm the change in symptom structure: the structure of the symptom networks changed substantially over the two quarantine periods (p < .01). however, the global connectivity of the symptom networks was not altered (p = .98). this argentinian mental health during the covid-19 pandemic 10 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ means that associations between different symptoms changed significantly over the two periods, but overall associations between symptoms did not increase or decrease. discussion this study is limited in the sense that participants were recruited through a social network and completed an online survey; therefore, individuals lacking access to the internet or an electronic device, or presenting more severe symptoms, have not been in­ cluded in the sample (pierce et al., 2020). this is particularly important in argentina, as it is a country with high poverty rates (instituto nacional de estadísticas y censos [indec, 2019]). however, the number of registered cell phone users in argentina exceeds its total population. nevertheless, this study is a contribution to the understanding of the mental health impact of covid-19 pandemic and its subsequent mandatory quarantine. this study showed that symptom indicators notably increased as the quarantine was extended. in addition, there is an indication that the risk of mental health disorders is al­ so increased. whereas diffuse symptoms may require lower intensity interventions, deep seated psychological problems call for more complex interventions by mental health professionals. individuals with mental disorders were identified as the most vulnerable group, and the literature endorses the need to approach this group with a more compre­ hensive evaluation (duan & zhu, 2020). the percentage of participants having suicidal thoughts increased greatly from period 1 to 2. this surge is correlated with the increase in clinical psychological symptoms and risk of mental disorder mentioned above. although certain symptoms are expected to increase in such extraordinary circumstances, there is concomitant risk that increased mental disorders lead to pathological behaviours such as self-harm, suicide and domestic violence (holmes et al., 2020). a recent us study on covid-19 and suicide mortality reported the highest rates since 1941 (reger, stanley, & joiner, 2020). preventing suicide risk is a priority which requires immediate interventions and actions (gunnell et al., 2020). in regard to participant’s sex life, our findings were consistent with evidence in the scientific literature which reports higher levels of overall prevalence of psychological symptoms in women compared to men (mazza et al., 2020). in addition to biology-based roles, women in latin america exhibit greater levels of stress on account of the number of tasks they perform and the social pressure to which they are subjected, as well as their exposure to gender discrimination and violence (economic commission for latin america and the caribbean [eclac], 2020). in both periods, younger women reported more symptoms than older women. in argentina, 35.5% of the general population and 42.5% of its youth live below the poverty line (indec, 2020). young people are therefore more vulnerable, have greater job instability, and fewer resources in general. the pre­ existing argentine economic recession has been exacerbated by the adverse economic etchevers, garay, putrino et al. 11 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ effects of the quarantine on the entire population. indeed, our study confirmed that lower income sectors experienced higher risk of mental disorder. this population is more exposed to labour, housing and economic uncertainty, factors that can impede quarantine compliance. hence, the official slogan "stay at home" was adapted to the reality of these vulnerable areas and became: "stay in your neighbourhood". for the middle class sector, monthly rent fees became an additional stressor in the face of financial uncertainty and, in fact, during the quarantine, the argentine government issued a controversial decree for the suspension of payment of rental fees and yet another decree which prohibited dismissals. higher income sectors presented less symptoms possibly resulting from its access to greater resources to face the mandatory restrictive measures for the quarantine period and the loss of income during the pandemic. besides, this social sector has access to health insurance or prepaid health coverage, which can prove crucial during the covid-19 crisis. according to our findings, more than half of the population did not engage in the healthy behaviours considered. furthermore, as quarantine duration kept getting moved, a tendency to dismiss them was observed. it should be borne in mind that the mandatory quarantine during the period studied only allowed people to go outside their homes to get food and medicines. in addition, given that sport facilities and recreational areas remained closed, the population was forced to seek more restrictive alternatives such as video tutorials, online learning and workout classes in small spaces at home. despite the fact that healthy behaviours could decrease the emotional impact of quarantine (e.g., those who did physical activity showed less psychological symptomatology in both periods), only a small percentage of the population resorted to these protective conducts, and this became accentuated as the quarantine progressed. furthermore, the decrease in healthy activities can also be explained as a consequence of the changes in psychological symptomatology. the network analysis conducted provided an insight into the specific relationships between symptoms and behaviours. domain-specific symptoms clustered together during the first period, but were significantly interchanged during the second period. this means that quarantine might have changed the symptom rela­ tionships which govern the specific symptomatology from which participants might suffer. although there was no significant increase in global connectivity (i.e., associations between the symptoms of the network as a whole did not increase), this change in symptomatology structure, where the symptoms decreased in their domain-specific clus­ tering, might indicate a worsening in symptomatology. decrease in model fit regarding underlying symptom clusters has been related to a worsening of depression symptoms (elhai et al., 2013). however, future research should focus on the implications of change in symptomatology network structure on symptom severity. sleep disturbances affected about 75% of participants in both periods of this study. sleep problems are highly prevalent in both anxiety disorders and depression. decreased physical activity and low exposure to sunlight in large cities alter sleep cycles. over­ argentinian mental health during the covid-19 pandemic 12 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ sleeping was the most frequent sleep disturbance recorded in period 1 of the study, while insomnia predominated in period 2. regarding sex life satisfaction, almost 45% of participants in the present research reported that their sex life worsened during both period 1 and 2. in comparison to the previous year, 35% considered that their sex life had deteriorated (etchevers, garay, castro solano, & fernández liporace, 2019). sexuality is regarded as a healthy behaviour, together with physical activity and social life. diminished sex life is associated with discomfort rates and widespread social restriction. mandatory quarantine hinders sexual encounters for single or divorced / separated persons. it is to be expected that once the quarantine is over, these bonding difficulties will persist out of fear of contagion. even in consolidated couples, human sexuality can be explained in the tension between presence and absence, which increases fantasy and desire. however, this item should be regarded with caution, because the great majority of respondents preferred not to provide an answer. our results showed that alcohol consumption increased as the quarantine progressed. the same was not observed with respect to tobacco or illegal drugs. consumption of sub­ stances constituted one of the problematic behaviours adopted to deal with psychological distress. although they provide relief by altering the effects of neurotransmitters, thus producing feelings of pleasure or sedation, prolonged use eventually results in general health deterioration. about 40% of participants reported the need for mental health treatment but poin­ ted out to barriers to access mental health care. among the reasons for this, they stressed personal financial problems together with a set of barriers associated with lack of medical coverage and lack of response from nearby health centres. additionally, partial closure of mental health services, which provided only emergency consultations, together with the fact that clinical psychologists have not yet been authorized to resume face-to-face therapy sessions, made it even more difficult for the population to get access to psychological care. to the best of our knowledge, like it was discussed (andersson, berg, riper, huppert, & titov, 2020), the problems that can be effectively addressed through distance modality (i.e., tele-psychiatry or tele-psychology) and there is evidence that digital psychological interventions are moderately effective in low-income and middle-income countries according to a recent meta-analysis (fu, burger, arjadi, & bockting, 2020). although the number of professionals adequately trained in this modali­ ty in argentina have yet to be determined. the percentage of the population having the digital resources to access these approaches has not been established either. improving the population's access to mental health care is a priority at this point in the quarantine. our findings emphasize the need to improve monitoring of the psychological impact of the quarantine and pandemic, and to evaluate crisis interventions or approaches and face-to-face and non-face-to-face treatments in order to identify and implement optimal models. likewise, it is essential to identify the degree of psychological support required etchevers, garay, putrino et al. 13 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://www.psychopen.eu/ by health care workers on the front line and its accessibility since this population is at greater risk of suffering psychological consequences. the general results of this study show the relevance of mental health and the need to take action to protect it when implementing mandatory quarantine measures during the covid-19 pandemic. increased psychological symptomatology and the risk of mental disorder can in turn increase alcohol consumption or other risky behaviours for oneself or others, and medium-term quarantine compliance depends on the level of understand­ ing and emotion regulation ability of the quarantined population. as the covid 19 pan­ demic continues to sweep the world and mandatory quarantine in argentina is extended, more methodologically rigorous studies need to be conducted in order to determine how to reduce their impact on mental health. funding: the authors have no funding to report. competing interests: the authors have declared that no competing interests exist. acknowledgments: we appreciate the generous help provided by jorge biglieri, alejandro castro solano, and mercedes fernández liporace. we also express our thanks to gustavo gonzález, edgardo etchezahar, and joaquín ungaretti. references andersson, g., berg, m., riper, h., huppert, j. d., & titov, n. 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(2021). comparing network structures on three aspects: a permutation test. manuscript submitted for publication. argentinian mental health during the covid-19 pandemic 16 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://doi.org/10.1016/s2215-0366(20)30168-1 https://doi.org/10.1007/978-3-030-15346-5_2 https://www.indec.gob.ar/uploads/informesdeprensa/eph_pobreza_01_19422f5fc20a.pdf https://doi.org/10.1093/schbul/sbw049 https://doi.org/10.3390/ijerph17093165 https://www.argentina.gob.ar/salud/coronavirus-covid-19/sala-situacion https://doi.org/10.1016/s2215-0366(20)30237-6 https://doi.org/10.1001/jamapsychiatry.2020.1060 https://www.psychopen.eu/ wang, c., pan, r., wan, x., tan, y., xu, l., ho, c., & ho, r. (2020). immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china. international journal of environmental research and public health, 17(5), article 1729. https://doi.org/10.3390/ijerph17051729 williams, s., armitage, c. j., tampe, t., & dienes, k. (2020). public perceptions and experiences of social distancing and social isolation during the covid-19 pandemic: a uk-based focus group study. bmj open, 10(7), article e039334. https://doi.org/10.1136/bmjopen-2020-039334 world health organization. (2010). what is a pandemic? retrieved from https://www.who.int/csr/disease/swineflu/frequently_asked_questions/pandemic/en/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. etchevers, garay, putrino et al. 17 clinical psychology in europe 2021, vol.3(1), article e4519 https://doi.org/10.32872/cpe.4519 https://doi.org/10.3390/ijerph17051729 https://doi.org/10.1136/bmjopen-2020-039334 https://www.who.int/csr/disease/swineflu/frequently_asked_questions/pandemic/en/ https://www.psychopen.eu/ argentinian mental health during the covid-19 pandemic (introduction) method study design and participants psychological symptomatology problematic, healthy and other behaviours procedures statistical analysis results psychological symptomatology age, sex and income problematic, healthy and other behaviours network analysis discussion (additional information) funding competing interests acknowledgments references innovations of the icd-11 in the field of autism spectrum disorder: a psychological approach scientific update and overview innovations of the icd-11 in the field of autism spectrum disorder: a psychological approach kirstin greaves-lord 1,2 , david skuse 3,4 , william mandy 4 [1] department of psychology, clinical psychology and experimental psychopathology unit, university of groningen, groningen, the netherlands. [2] autism team north-netherlands, jonx, lentis psychiatric institute, groningen, the netherlands. [3] great ormond street institute of child health, university college london, london, united kingdom. [4] research department of clinical, educational, & health psychology, university college london, london, united kingdom. clinical psychology in europe, 2022, vol. 4(special issue), article e10005, https://doi.org/10.32872/cpe.10005 received: 2022-08-01 • accepted: 2022-11-03 • published (vor): 2022-12-15 handling editor: andreas maercker, university of zurich, zurich, switzerland corresponding author: kirstin greaves-lord, department of psychology, clinical psychology and experimental psychopathology unit, university of groningen, grote kruisstraat 2/1 9712 ts groningen, the netherlands. e-mail: k.greaves-lord@rug.nl related: this article is part of the cpe special issue “innovations in icd-11”, guest editor: andreas maercker, clinical psychology in europe, 4(special issue), https://doi.org/10.32872/10.32872/cpe.v4.si abstract background: this article aims to explain and elaborate upon the recently released icd-11 criteria for autism spectrum disorder (asd, world health organization), which endorse a medical model. method: we integrate insights from several disciplines (e.g., psychology, linguistics, sociology and lived experiences) to reflect the scientific and ethical insights derived from the biopsychosocial, neurodiversity perspective on autism. results: first, we describe the core domains of asd’s behavioural characteristics and then the lifetime, developmental perspective on the manifestations of these behaviours. subsequently, we discuss potential underlying neuropsychology, related behaviours (i.e. associated features/ conditions) and we consider some similarities and differences with the diagnostic and statistical manual of mental disorders fifth edition (dsm 5, american psychological association). conclusions: recommendations for clinical application are provided. for instance, diagnostic classification in clinical practise should be a means to provide proper, suitable care, and therefore all diagnostic assessments should be used to tailor interventions and/or care to the capacities and genuine needs of the people that ask for professional help. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10005&domain=pdf&date_stamp=2022-12-15 https://orcid.org/0000-0001-7229-7139 https://orcid.org/0000-0002-7891-5732 https://orcid.org/0000-0002-3564-5808 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords autism spectrum disorder, icd-11, diagnostic process policies highlights • atypical responses to sensory stimuli are included as part of the diagnostic requirements in icd-11, in contrast to icd-10, where unusual sensory processing was not yet considered a core (diagnostic) feature. • in icd-11 it is recognized that some individuals with autism spectrum disorder start to experience distress, impairment and overt social challenges once societal demands increase (e.g., during adolescence or adulthood). • unlike dsm-5, icd-11 does not emphasize the criteria related to disorders of intellectual development (id; such as flipping objects, strong attachment or preoccupation with unusual objects, excessive smelling or touching of objects, echolalia, stimming). current icd-11 definition, criteria and conceptualisations of autism spectrum disorder according to the current international system for the classification of diseases 11th revision (icd-11) diagnostic requirements, in order to receive a classification of autism spectrum disorder (asd), a person’s behaviour should be characterised by three essen­ tial features. first, “persistent deficits in the ability to initiate and sustain reciprocal so­ cial interaction and social communication” (world health organization, 2019a). second, by “a range of restricted, repetitive, and inflexible patterns of behaviour, interests or activities that are clearly atypical or excessive for the individual’s age and sociocultural context”. atypical responses to sensory stimuli are now included in this domain, unlike icd-10, where unusual sensory processing was not considered a core (diagnostic) fea­ ture. third, “symptoms should result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning” and, as in previous definitions, the onset should have been during early development. yet, some individuals with asd can function in many contexts through exceptional effort, such that their autistic characteristics are not apparent to others during childhood. icd-11 recognises that overt symptoms are sometimes only fully manifest later, in adolescence or even adulthood, when social demands exceed capacities. consequently, the condition can present clinically at all ages. asd is a “lifelong condition, of which the manifestations and impact are likely to vary according to age [developmental stage], intellectual and language abilities, co-occurring conditions and environmental context”. the icd-11 is an international system for the classification of diseases. as such, it endorses a medical model, conceptualising autism spectrum disorder as a medical condition with an inborn, for a substantial part, genetically inherited nature, while asd in icd-11: a psychological approach 2 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ acknowledging that gene-environment interactions also play a pivotal role in neurode­ velopment (classifying this category in the over-arching category of neurodevelopmental disorders). although most people agree with this conceptualisation of neuro-biological aetiology, amongst a variety of stakeholders, the preference for a biopsychosocial model with more emphasis on how social factors affect functioning and wellbeing, is increasing (bolis et al., 2017; greaves-lord et al., 2022). in such integrative accounts of asd, an au­ tistic person’s difficulties are not seen as simply caused by individual deficits; but rather are understood as arising from a poor fit between, on the one hand, the individual’s characteristics and, on the other hand, the demands placed on them by their environment (mandy, 2022). according to this perspective, autistic symptoms are seen as a form of neurodiversity, and emphasis is placed on promoting functioning and wellbeing via environmental modifications that can improve person-environment fit. in this article, we were invited to describe and reflect upon the recently released icd-11 criteria, therefore, this will be the focus of the paper. yet, in doing so, we will try to integrate insights from several disciplines (e.g., medical, psychological, linguistic, sociological and lived experiences), to reflect the scientific and ethical insights derived from the biopsychosocial, neurodiversity perspective on autism. we will first go into the core domains of asd’s behavioural characteristics. then we will emphasize the lifetime, developmental perspective on the manifestations of these core behaviours. subsequently, we briefly discuss theories on the underlying neuropsychological mechanisms driving the core behaviours. finally, we discuss related behaviours (i.e. associated features/condi­ tions), consider similarities and differences with the diagnostic and statistical manual of mental disorders fifth edition (dsm 5, american psychiatric association, 2013) and make some final remarks for clinical application. social communication individuals on the autism spectrum display the full range of intellectual functioning and language abilities; nowadays, especially in high-income countries, an asd diagnostic classification is increasingly made in individuals who have normal-range verbal and non-verbal intellectual abilities (e.g., lord et al., 2022; zeidan et al., 2022). the key features of an asd comprise persistent deviations from the norms of social behaviour shown by most non-autistic people, including difficulties with initiating and sustaining social communication and reciprocal social interactions, and responding in a manner considered typical (conventional). whilst there is a normal distribution of such abilities in the general population, people with an asd are “outside the expected range of typical functioning”, when an individual’s age and level of intellectual development are considered (world health organization, 2019a). “specific manifestations will vary according to the individual’s chronological age, verbal and intellectual ability”, and the overall profile of their autistic characteristics (world health organization, 2019a). greaves-lord, skuse, & mandy 3 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ there are, however, a number of key characteristics of interpersonal behaviour that are the essence of the condition. first and foremost, is the difficulty of spontaneously understanding the verbal or non-verbal social communications of other people, together with the tendency not to respond typically (conventionally) to those communications. it should be noted that autistic people and professionals are increasingly aware that many of the social difficulties ascribed to autistic people as simply reflecting their impairments, are better understood as reflecting the challenges of ‘cross-neurotype’ interactions (chen et al., 2021). autistic people may struggle to understand non-autistic people, but also, non-autistic people frequently struggle to empathise with autistic people. people with an asd diagnosis vary in terms of their social motivation, although icd-11 states that there is a tendency for them, compared to non-autistic people, to show less interest in social interactions, and be less likely to pay attention to other people’s verbal and non-verbal social cues. an important nuance to make here, is that although some autistic people show less involvement in social interaction, this might not necessarily be the result of lower social motivation, but rather it may be a consequence of exhaustion from trying to emulate a typical non-autistic style of interaction, known sometimes as camouflaging (e.g., cook et al., 2021; livingston et al., 2019). moreover, there is a critical role of early communicative experiences in the development of individuals’ attention towards other people’s verbal and non-verbal social communication cues (vernetti et al., 2018). “children vary widely in the age at which they first acquire spoken language and the pace at which their speech and language become firmly established” (world health organization, 2019a). most children with early language delay eventually acquire similar language skills to their same-aged peers. early language delay alone is not strongly indicative of asd, unless there is also evidence of limited motivation to engage in social communication and of atypical social interaction skills (world health organization, 2019a). an essential feature of asd is persistent atypicality in how language is used and understood for social communication. people with an asd typically do not follow non-autistic norms (conventions) in how they integrate their spoken language with complementary non-verbal cues, such as (considered) appropriate eye-contact, gestures, facial expressions, nodding in agreement, or other demonstrations of acknowledgement. compared to non-autistic people, they are less likely to use body language to share a perspective, such as pointing to express interest in a distant object, or sharing attention in some external event or object. there is usually reduced tendency to initiate, join, or to sustain a conventional back-and-forth social conversation, which has its origins in early childhood. in general, people with an asd have difficulty understanding and using language in social contexts that are dominated by non-autistic people, and are less likely to initiate and sustain reciprocal, purely social conversations (especially ‘chat’). the pragmatic language difficulties that are typical of asd can manifest as misunderstand­ ings of others’ language due to literal interpretations, together with speech that lacks asd in icd-11: a psychological approach 4 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ ‘normal’ (i.e., non-autistic) prosody and emotional expressiveness, sometimes with a distinctly monotonous tone of voice, or contrastingly, with exaggerative expressiveness. some autistic people are unaware that, to non-autistic people, their use of language sounds atypical, and may talk with such precision that it is considered pedantic, together with the use of an arcane vocabulary. in isolation, atypical language of this nature is only indicative; the diagnostic classification of an asd requires there to be broad range of additional social reciprocity difficulties, as well as tendency towards inflexible behaviour and sensory sensitivities (see below). in the context of social relationships with non-autistic people, especially with unfa­ miliar individuals, there can be limited social awareness, which can lead to behaviour that is not appropriately modulated according to the social context. although people with asd are often characterised as ‘lacking empathy’, the evidence for diminished empathic capacity in typical asd is not strong. some research shows altered affective empathy (e.g., mazza et al., 2014), but, especially in cognitively able individuals, cognitive empathy can usually be present, although there may be an altered processing speed (i.e. due to a local rather than a global processing style, information is processed somewhat slower, but in more detail; bölte et al., 2007). according to clinical observations of autistic adults, the empathic response may be over-developed (i.e., the tendency to expe­ rience high levels of emotional contagion). moreover, whilst someone with asd may not obviously be conventionally responsive to a non-autistic person’s feelings, autistic adults often explain their atypical reaction reflects a state of anxious confusion and/or indecision, rather than unawareness or disinterest. compared to non-autistic people, those with asd are less likely to spontaneously share their interests with others, and may assume that others do spontaneously share their own interests and point of view (without the need to explicitly ask them). given that in social life, non-autistic people are often highly intolerant of even small devia­ tions from social norms, this can lead to challenges making and sustaining typical peer relationships. the impact of such peer problems changes from early childhood to adoles­ cence. intimate friendships with peers become more significant during adolescence, and difficulties building such relationships often become more overt at that time (e.g., mandy, 2022). isolation from or rejection by peers will usually have secondary consequences in terms of impaired mental health (e.g. social anxiety, depression or even trauma). genuine pervasive lack of interest in making peer relationships is rare. clinically, it is important to be aware that a young person’s withdrawal from social interactions may reflect social anxiety, and could be the result of persistent lack of acceptance by a peer majority non-autistic group. furthermore, peer victimisation is a common experience for autistic people, and clinical assessment should always explore whether bullying is occurring, how it can be stopped, and its impact on the individual. also, non-autistic individuals “vary in the pace and extent to which they acquire and master skills of reciprocal social interaction and social communication” (world health greaves-lord, skuse, & mandy 5 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ organization, 2019a). a diagnosis of asd should only be considered if there is marked and persistent difference from the expected range of abilities and behaviours in these domains given the individual’s age, level of intellectual functioning, and sociocultural context. some individuals may exhibit limited/altered social interaction due to shyness (i.e., feelings of awkwardness or fear in new situations or with unfamiliar people, due to anxiety about negative social judgement), behavioural inhibition (i.e., being slow to approach or to ‘warm up’ to new people and situations) or behavioural disinhibition (i.e. impulsiveness). limited social interactions in shy or behaviourally (dis)inhibited children, adolescents, or adults are not indicative of asd. shyness is differentiated from asd by evidence of typical, non-autistic social communication behaviours in familiar situations (world health organization, 2019a). repetitive, stereotyped behaviours and sensory interests “many children go through phases of repetitive play and highly focused interests as a part of typical development. unless there is also evidence of impaired reciprocal social interaction and social communication, patterns of behaviour characterized by repetition, routine, or restricted interests are not by themselves indicative of autism spectrum disorder” (world health organization, 2019a). clinically significant evidence requires persistent “restricted, repetitive, and inflexible patterns of behaviour, interests, or activ­ ities that are clearly atypical and excessive for the individual’s age and sociocultural context” (world health organization, 2019a). typically, children with asd are slower and/or less able to adapt to new experiences and circumstances. strong reactions (often one of acute anxiety, distress and/or anger) can be evoked by changes to a familiar environment that, to non-autistic people, seem trivial, or in response to unanticipated events. characteristic of the response to such unwelcome change and uncertainty is extreme discomfort which manifests in childhood as acute distress. this resistance to change also commonly manifests as the tendency to strongly adhere to particular routines. these may be geographic, such as the need to follow familiar routes, or may require precise timing, such as during mealtimes or when travelling. the tendency to engage in restricted and repetitive behaviours persists over time, although its frequency and overtness may diminish during adolescence. in contrast, insistence on ‘sameness’, can become more prominent in later life. other aspects of this underlying need for consistency and predictability can be observed in terms of unusually strong adherence to rules (e.g., when playing games), as well as marked “and persistent ritualized patterns of behaviour (e.g., a preoccupation with lining up or sorting objects in a particular way” (world health organization, 2019a) or analysing/systemizing all sorts of information). historically, such behaviours have been dismissed by non-autistic people as serving no apparent external purpose, but recent qualitative research with verbally asd in icd-11: a psychological approach 6 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ fluent autistic individuals has revealed that the actions of organizing and systemizing can serve to regulate arousal. thus, as their internal tension builds up, (e.g., in response to increasing social demands) an autistic person might start organizing or performing some systemic routine, in order to calm down (greaves-lord et al., 2022). specific repetitive or stereotyped behaviours will differ according to the developmen­ tal stage of the individual, but the tendency is usually life-long. in contrast, “repetitive and stereotyped motor movements, such as whole-body movements (e.g., rocking), atyp­ ical gait (e.g., walking on tiptoes), unusual hand or finger movements and posturing” (world health organization, 2019a), are more likely to be observed during childhood and are seen in situations of distress and excitement (i.e. hyperaoursal, see below). such behaviours can also persist into adulthood, especially in autistic people with a co-occurring intellectual disability (abbreviated: id). many individuals with an asd develop fascinations with specific topics, objects or activities. in icd-11, these are characterised as persistent preoccupations “with one or more special interests, parts of objects, or specific types of stimuli (including media), or an unusually strong attachment to particular objects (excluding typical comforters)” (world health organization, 2019a). the range of special interests is wide, and they may change from time to time during development. a key feature of the intensity of the special interests that are typical of asd, is their pervasiveness and the fact that they disrupt an individual’s ability to conform to conventional norms within a social setting, to some extent. for example, everyday life may be adversely influenced by the need to pursue those interests. in childhood, this could have a negative impact on the family, as could the intense attachment to favoured objects (e.g., because of the distress engendered by their being left behind or lost). nevertheless, it is important to recognise that these fascinations often enrich autistic peoples’ lives, with positive effects on identity and mood. furthermore, such fascinations can engender skill and expertise that is valued in wider society. the most recent addition to the diagnostic rubric of asd symptoms (i.e., a change from icd 10 to icd 11) is the presence of lifelong strong and persistent hypersensitivi­ ty and/or hyposensitivity to sensory stimuli. sensory sensitivities can include unusual interests in certain sensory stimuli, which may include sounds, light, textures (especially clothing and food), odours and tastes. although a strong interest in spinning objects is often illustrated in assessment tool as characteristic of asd, this clear exemplar of autistic behaviour is mainly observed in individuals with id and delayed social-emotion­ al development. a positive interest in sensory stimuli is less common than negative reactions to such stimuli, but a strong negative reaction to everyday sensory stimuli can be upsetting for the autistic person and also disruptive of family life. these typically include sensitivities to sounds, especially white noise such as hand dryers or vacuum cleaners. the sounds may not be especially loud; these reactions are most frequently observed in childhood. other negative reactions can be observed to bright lights, certain greaves-lord, skuse, & mandy 7 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ clothing textures including labels, and especially food textures. negative reactions to textures in food typically include the avoidance of mixed textures, requiring strict food separation. although such behaviours are not exclusively observed in asd, their severity and persistence, together with the consequent impact on everyday life, are more typical of asd. life-course perspective and advice on assessment when individuals with suspected asd present in adolescence or in adulthood, it is essential to perform an interview on developmental history, and not to rely exclusive­ ly on self-report or observations of current behaviour, however well-structured the observation. this is because one prerequisite for the diagnostic classification (although deliberately formulated in a nuanced way) is evidence that the onset of the atypical behaviours occurred during the early developmental period, typically toddlerhood/child­ hood (i.e., pre-school/primary school). in contrast to icd-10, in icd-11 there is no longer the requirement of history of delayed onset of language, or clear evidence of autistic symptoms before/around the age of four to five years. this change reflects in part the fact that asperger syndrome has been discontinued as a valid diagnosis; typically, individuals with normal-range verbal intelligence do not have delayed onset of language and they have been subsumed into the asd diagnostic rubric. also, it is now recognized that some individuals with asd start to experience distress, impairment and overt social challenges once societal demands increase (during adolescence or adulthood). late onset symptoms of asd and their differential diagnosis from personality disor­ ders in adulthood are still a complex and controversial issue. difficulties in inter-personal functioning (i.e., with understanding others’ perspectives, intimacy and self-regulation) are also characteristic of personality disorders. as we do not conventionally diagnose personality disorder in childhood, clear history of early (preschool) social communica­ tion difficulties, could be a differentiating feature. enquiries should attempt to define exactly when the atypical social behaviours started to occur, but more importantly, under what circumstances. early signs and predictors of later manifest asd, such as a lack of/altered attention to eyes (jones & klin, 2013) and limited facial recognition (eussen et al., 2015)/limited use of facial expressions, should be investigated. at the time our conventional diagnostic instruments were developed, most clinically recognised children with autism were also experiencing generalized developmental delay (i.e., id). plateauing of social communication and language skills and lack of progress in their development characterises many such children. yet the minority had a period of normal development (sometimes including age-typical language skills), but then lost their previously acquired skills, often in the second year of life. such regression can be asd in icd-11: a psychological approach 8 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ rapid, over a period of days or weeks, and usually leads to impaired language and social responsiveness. “loss of previously acquired skills is rarely (spontaneously) observed after 3 years of age” (world health organization, 2019a), but can occur in acquired conditions such as encephalitis. if it occurs after age 3, it is more likely to involve a more generalized loss of cognitive and adaptive skills (including the loss of bowel and bladder control, and impaired sleep), as well as regression of language and social abilities (world health organization, 2019a). in rare cases of spontaneous regression, recovery takes place. this is usually slow (over months or years), and usually requires intensive interdisciplinary care that focusses on restoring the lost skills, including support for the development of speech/conversational, adaptive and regulatory skills. asking and clarifying concrete examples of atypical development is therefore key when performing an interview on developmental history, and especially challenging when done only once the individual and caregivers involved are already older. therefore, training such interviewing skills is essential when educating mental health professionals. in preschool children, indicators of an asd “often include avoidance of mutual eye contact, resistance to (conventional expressions of) physical affection, lack of social imaginary play, language that is delayed in onset, or is precocious” (world health organization, 2019a), but not used for conventional back-and-forth social conversation; social withdrawal, marked fascinations with topics that are sometimes notably unusu­ al, and lack of age-typical social interaction with non-autistic peers, characterized by parallel play or apparent disinterest. “sensory sensitivities to everyday sounds, or to foods, may overshadow the underlying social communication deficits” (world health organization, 2019a). these social characteristics are often first reported by a nursery or other preschool placement where the child’s behaviour is observed to differ significantly from the majority. therefore, obtaining information from such sources (e.g., reports from infant care agencies/pre-school) can be of important additional value when charting the developmental history, especially in older cases. in children with asd without a disorder of intellectual development (or general developmental delay), "social adjustment difficulties outside the home may not be detec­ ted until school entry or adolescence", when atypical social communication all-too-com­ monly leads to peer rejection, bullying and social isolation (world health organization, 2019a). "resistance to engage in unfamiliar experiences and marked reactions to even minor change in routines is typical" (world health organization, 2019a). furthermore, a strikingly strong "focus on detail as well as rigidity of behaviour and thinking" may be present. secondary mental health problems are common, and symptoms of anxiety (i.e. social/specific phobia; e.g. verheij et al., 2015) may become evident at this stage of development (world health organization, 2019a). by adolescence, the capacity to cope with increasing social complexity in peer relationships at a period of ever-more demanding academic expectations is often over­ whelmed. in some autistic individuals, their underlying social communication difficulties greaves-lord, skuse, & mandy 9 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ may be overshadowed by the symptoms of co-occurring mental and behavioural disor­ ders. depressive or anxiety symptoms are often a presenting feature (world health organization, 2019a), and restrictive eating disorders (including anorexia nervosa) be­ come increasingly common in autistic girls at this age. thus, clinicians should be aware of potential underlying asd when performing diagnostic assessment in mental health settings. in adulthood, the capacity for those with asd to cope with complex and fluid cross-neurotype “social relationships can become increasingly challenged, and clinical presentation may occur when social demands overwhelm the capacity to compensate. presenting problems in adulthood may represent reactions to (victimisation and) social isolation” (world health organization, 2019a). also, they may reflect the challenges of planning and organising one’s professional and personal life, and regulating emo­ tions, with less support than was received in childhood and adolescence. compensation strategies may be sufficient to sustain dyadic relationships, but usually come under ex­ cessive strain in more complex group situations. “special interests, and focused attention, may benefit some individuals in education and employment. work environments may have to be tailored to the capacities (and sensitivities) of the individual. a first diagnosis in adulthood may be precipitated by a breakdown in domestic or work relationships” (world health organization, 2019a). as mentioned, if the individual is autistic, there is always history of at least some atypical signs in early childhood social communication and relationships, although this may only become apparent, or interpreted as such, in retrospect. because it is now recognised that asd represents a more intense manifestation of the wide range of behaviours that are observed in the general population, it is critical to consider the impact of those symptoms on everyday life, before making a diagnosis. diagnostic criteria, as outlined above, stipulate that autistic characteristics should “result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning” (world health organization, 2019a; e.g., emotional/phys­ ical wellbeing). some individuals with asd can function well in many contexts, often through exceptional effort on their part, such that their autistic characteristics are ‘cam­ ouflaged’ and are not apparent to others. a diagnosis of asd is still appropriate in such cases, especially when such exceptional effort is no longer achievable due to aging or changing social circumstances, during which the autistic characteristics might become more apparent to others over time. camouflaging is commonly described by autistic people as exhausting and is associated with elevated risk for anxiety, depression and suicidality (cook et al., 2021). asd in icd-11: a psychological approach 10 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ hypothesised neuropsychological mechanisms driving the core behaviours defining asd although asd is defined based on behavioural features, several theories exist on the neuropsychological mechanisms hypothetically underlying these behaviours. classically, three main theoretical frameworks explaining underlying neuropsychological function­ ing were presented; theory of mind (tom; e.g., andreou & skrimpa, 2020), executive functioning (ef; e.g., demetriou et al., 2019) and central coherence (cc; e.g., lópez et al., 2008). over time, nuances were made on how these theories each explain particular behavioural aspects of autism (e.g., happé et al., 2006). more recently, theories have been proposed that combine, integrate and extend these theories, e.g. the predictive coding account (pc; e.g., van de cruys et al., 2014) and the polyvagal theory (pt; e.g., brown, 2020). given the scope of this article, we cannot go into detail on all these accounts, nor can we mention the abundant literature. however, we will briefly explain these theories and illustrate them with examples of behaviours seen in autistic people, so that clinical psychologists can a) better understand what mechanisms might be driving certain behaviours, and b) use this to increase the understanding of autistic people they support. firstly, tom refers to the ability to formulate hypotheses on how other people feel, think and thus behave; i.e. mentalizing. autistic people might sometimes respond differ­ ently than conventionally would be expected. such responses can however be better understood, when being aware that depending on the circumstances the response might be either mostly to the verbal information that was primarily processed, or to the visual information that was mainly processed (e.g., chung et al., 2014). secondly, ef refers to a set of capacities used to consciously plan ahead, meet goals, display self-control, etc. speculatively, more unconscious, automatically driven cognitive distortions might appear in case of cognitive overload in autistic people (e.g., autistica, 2021). sometimes, autistic people show the tendency to categorize things or people as all good or all bad, all right or all wrong (sometimes referred to as 'dichotomous thinking'), rather than at that instance being able to consciously notice the possibilities in between, sometimes referred to dichotomous thinking. weak cc refers to difficulties in ‘seeing the bigger picture’, but rather an associative, non-linear thinking style in autistic people (e.g., grandin, 2009). simply put, some people might mainly have a global (bigger picture) processing style, while other (autistic) people might mainly have a local (detail-focussed) processing style (bölte et al., 2007). the idea of cc was taken further in pc theory. this theory of brain function stipulates that the brain is constantly generating and updating a mental model of the environment (e.g., pellicano & burr, 2012). this model is used to generate predictions of sensory input that are compared to actual sensory input. this comparison results in prediction errors that are then used to update and revise the mental model. an autistic person might be focussed more on the actual sensory input and their brain might be con­ greaves-lord, skuse, & mandy 11 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ stantly working to minimize the gap between the prediction and actual sensory input. as such, this theory might explain why some autistic people have more intolerance of uncertainty, given the larger prediction errors and the cognitive resources it takes to try and solve these. finally, although the pt (porges, 1995) is not yet well substantiated empirically, it’s popularity is growing amongst some clinical practitioners and autistic people, as it is relatable. therefore, we discuss it briefly. polyvagal theory takes its name from the vagus, a cranial nerve that is the primary component of the parasympathetic nervous system. the autonomic nervous system (ans) has two parts; the sympathetic nervous system, which is mostly activating (“fight or flight”), and the parasympathetic nervous system, which exists of two distinct branches: a "ventral vagal system" which supports social engagement, and a "dorsal vagal system" which supports immobilisation behaviours, both “rest and digest” and defensive immobilisation or “shutdown”. behav­ ioural responses that derive from the hybrid state of activation and calming are key to the ability to adaptively socially engage. it is speculated that in autistic people, the ans might (at times) be dysregulated, which could explain emotional melt downs or shut downs in autistic people. again, we emphasize that in this section we did not provide an extensive explanation of all neuropsychological concepts. rather, we illustrated some behaviours seen in autistic people and tried to stimulate readers to think about their assumed neurobiological origins. in clinical practice, for most autistic people it is key to connect abstract, neuropsychological concepts to very concrete day-to-day personal experiences, to ‘digest’ these explanations fully (e.g., gordon et al., 2015). thus, in psy­ cho-education, it is essential to help autistic people make these translational connections. further features and disorders some individuals with an asd experience delay in the development of their intellectual abilities, and qualify for a diagnosis of id. in countries with well-established facilities for the assessment of autistic symptoms, and with experience in the manifestations of the condition among individuals with good verbal skills, individuals with id are a minority of those diagnosed with asd. by contrast, in more under-served areas, those with id constitute the majority people diagnosed with asd. “if present, a separate diagnosis of disorder of intellectual development should be assigned, using the appropriate category to designate severity (i.e., mild, moderate, severe, profound, provisional). because social difficulties are a core feature of autism spectrum disorder, the assessment of adaptive behaviour as a part of the diagnosis of a co-occurring disorder of intellectual devel­ opment should place greater emphasis on the intellectual, conceptual, and practical do­ mains of adaptive functioning than on social skills” (world health organization, 2019a). self-injurious behaviours (e.g., hitting one’s face, head banging) occur more often in autistic people with co-occurring disorder of intellectual development, perhaps because asd in icd-11: a psychological approach 12 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ they represent attempts to express and communicate painful feelings, in the absence of verbal means. even among individuals with normal-range intellectual abilities, profiles of specific cognitive skills in asd as measured by standardized assessments, may show striking and unusual patterns of strengths and weaknesses that are highly variable from individual to individual. clinical experience teaches that such a ‘spikey profile’ of cognitive strengths and difficulties can affect learning and adaptive functioning to greater extent than would be predicted from the overall scores on measures of verbal and non-verbal intelligence, yet more research on this matter is needed to substantiate such clinical claims. isolated difficulties in intellectual functioning that are associated with asd include slow/different processing speed/style (bölte et al., 2007) and limited verbal or non-verbal working memory, which may occur in the presence of strong verbal and/or visuospatial skills in other domains. "the degree of impairment in functional language (spoken or signed) should be designated with a second qualifier. functional language refers to the capacity of the individual to use language for instrumental purposes (e.g., to express personal needs and desires). this qualifier is intended to reflect primarily the verbal and non-verbal expressive language [difficulties] present in some individuals with autism spectrum disorder” (world health organization, 2019a), and not the atypical pragmatic language that is a core feature of the condition. icd-11 requires the assessment of whether the individual has a degree of functional language impairment (spoken or signed) relative to their age in the following terms: i) with mild or no impairment of functional language; ii) with impaired functional language (i.e., not able to use more than single words or simple phrases); iii) with complete, or almost complete, absence of functional language (world health organization, 2019a). it is important to note that the observable manifestation of asd will be different at different developmental stages (as discussed above), as well as in different groups (e.g., males versus females versus gender-diverse individuals, or those with and without id). for instance, parental or caregiver concerns about intellectual or other develop­ mental delays (e.g., problems in language and motor coordination) often characterise the presentation in young children during the preschool period. when there is no significant impairment of intellectual functioning, the presentation to clinical services is often prompted by staff at nursery school, who have observed unusual social or other behaviour. in middle childhood, there may be prominent symptoms of anxiety, including social anxiety disorder, school refusal, and specific phobia (verheij et al., 2015). during adolescence and adulthood, depressive disorders are a common presenting feature. for women, a restrictive eating disorder can drive engagement with mental health services, with their underlying asd and/or associated social trauma only being identified later (bentz et al., 2022). across all ages, there is strong co-occurrence with attention defi­ cit/hyperactivity disorder, and in males impulsive and disruptive behaviour often prompt greaves-lord, skuse, & mandy 13 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ referral (especially in middle childhood), although in females the symptoms are more likely to be related to attention difficulties, rather than impulsivity or hyperactivity. consequently, it is important to be aware that asd commonly co-occurs with other mental, behavioural or neurodevelopmental disorders across the lifespan. in a substantial proportion of cases, particularly in adolescence and adulthood, it is the co-occurring disorder that first brings the autistic individual to clinical attention. some people with asd are capable of functioning even in environments that are poorly adapted to accom­ modate them, by making an exceptional effort to compensate for their symptoms during childhood, adolescence or adulthood (i.e., ‘camouflaging’). such camouflaging requires sustained effort, is more typical of females (although it is common in all genders), and can have deleterious impact on mental health and well-being (cook et al., 2021). “some young individuals with autism spectrum disorder, especially those with a cooccurring disorder of intellectual development, develop epilepsy or seizures during early childhood with a second increase in prevalence during adolescence. catatonic states have also been described. a number of medical disorders such as tuberous sclerosis, chromosomal abnormalities including fragile x syndrome, cerebral palsy, early onset epileptic encephalopathies, and neurofibromatosis” are associated with an asd diagnosis (world health organization, 2019a), with or without a co-occurring disorder of intellec­ tual development. genomic deletions, duplications and other genetic abnormalities are increasingly described in individuals with asd, some of which may be important for genetic counselling. prenatal exposure to valproate is also associated with an increased risk of asd (world health organization, 2019a). recently, there is growing recognition of the fact that people with asd more fre­ quently develop more severe physical illnesses, in the worst case resulting in relatively early death, as compared to other people from the general population. potentially, this might reflect the fact that autistic people experience high levels of stress, due to having to live in environments that are poorly designed to accommodate them, with consequent elevated levels of mental health, suicidality and substance use problems. poor physical health outcomes could reflect a combination of two underlying causes. first, autistic people might have a limited capacity to sense and recognize early physical symptoms. this might be due to limited interoception, i.e. hypo-sensitivity or a limited inclination to direct their attention towards internal stimuli of the body (e.g. garfinkel et al., 2016). secondly, they might be reluctant to communicate any concerns they have about their physical health to professionals. this might result in their initially not seeking access to medical services, as well as limiting their action in following up any subsequent referral to medical specialists. research on this topic is still ongoing. nevertheless, it is important that mental health professionals are aware that there is potentially limited somatic awareness in autistic clients. they should therefore pro-actively bring up the topic of their client’s physical health. psychologists should consider referral to a medical specialist when an autistic client complains about somatic symptoms, and should be asd in icd-11: a psychological approach 14 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ aware of their potential professional biases. faced with an autistic client who has somatic symptoms they should not automatically assume a psychological explanation, but be aware that an alternative physical condition could be present, and that condition should be adequately investigated. the prevalence of premature mortality affecting people on the autism spectrum, which is excessive, could be attributable at least in part from these risk factors. comparison between icd-11 and dsm-5 both systems of diagnosis differ substantially from previous versions (icd-10 and dsmiv and dsm iv tr). there are differences in their conceptualization of asd as a broad category comprising many different conditions (not yet identified, the 'autisms'), and in terms of specific phenotype requirements. hence the agreed term asd, reflecting the heterogeneity of those conditions. both systems recognize that asd is a set of symptoms that exist on a continuum that blends into normal variation, and they also consider the fact that at one extreme end there is a subset of conditions that are associated with identifiable biological substrates (largely genetic, but also some environmentally induced risks). the greatest difference between the icd-11 and dsm 5 diagnostic systems is not in the social communication aspects of the condition, but in the patterns of restrictive, repetitive, and inflexible patterns of behaviour that are regarded as atypical. the blurry boundaries between id and asd bedevils research. experts who are look­ ing at genetic risk factors continue to have a heated debate about whether certain genetic anomalies increase risk for asd or id or both. icd-11 criteria are cognizant of the fact that nowadays most diagnoses of asd are made in individuals who are of normal-range intelligence. accordingly, b-scale symptoms are defined in a way that reflects behaviours that are seen in those individuals (more broadly ranging than is discussed in dsm-5). unlike dsm-5, icd-11 does not emphasize the id-related criteria (such as flipping objects, strong attachment or preoccupation with unusual objects, excessive smelling or touching of objects, echolalia, stimming; who, 2019b). the associated limited enquiry about symptoms of repetitive, restricted and stereotyped behaviour (rrsb) is one of the reasons why there was, under the former dsm-iv tr criteria, such high prevalence of pervasive developmental disorder – not otherwise specified ('pdd-nos'). by broaden­ ing the criteria and introducing concepts such as 'lack of adaptability to new experiences and circumstances...' icd-11 has aimed to reduce the perceived lack of sensitivity of the dsm-5 criteria to cognitively able and older individuals. intellectual disability is conceptualized as a homogeneous condition in dsm-5. it is said that asd may be difficult to differentiate from id in very young children (under the heading differential diagnosis), but this statement exemplifies the problem that in the usa the terms are much closer aligned than the developers of icd-11 considered to be appropriate. dsm-5 does not make distinctions between levels of intellectual impairment. greaves-lord, skuse, & mandy 15 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ in icd-11, as discussed, there is the possibility to record an associated disorder of intellectual development, and this should be assigned a degree of severity. dsm-5 criteria state that, to make an asd diagnosis, the atypical social communi­ cation should be more marked than would be anticipated from the individual's develop­ mental level when any associated id is considered. in icd-11 a similar statement is made. both diagnostic systems acknowledge that it is important to distinguish the lack of adaptive behaviours that are indicative of generalized learning disabilities from the specific difficulties that are experienced by individuals with asd. the difference in emphasis between the systems reflects the expectation in the us that it is important to identify asd symptomatology in those with id, whereas in icd-11 the emphasis is on the importance of identifying intellectual impairment in those with a primary diagnosis of asd. in dsm-5 a differential diagnosis is made between asd and social (pragmatic) com­ munication disorder, a condition that does not exist in icd-11. the developers of icd-11 criteria were not convinced that a specific disorder of this nature could be differentiated clearly from atypical social communication that is associated with asd, nor from vari­ eties of specific language impairment (mandy et al., 2017). icd-11 records the degree of impairment of functional language at three levels, but this distinction is not treated as a differential diagnosis. that decision, to record three levels of impairment appears to be similar, but more structured, than the dsm-5 stipulation to use the specifier 'with or without accompanying language impairment' with an injunction to assess the current level of language and describe it. the choice of three levels reflected the need to be more explicit for clinical purposes, and the icd-11 developer’s estimate that this distinction could be made reliably. both systems of diagnosis require the recording of loss of skills. in icd-11 there is a qualifier that records whether there is loss of previously acquired skills, or not. dsm-5 discusses loss of skills in the context of development and course and distinguishes social from loss of other skills (such as toileting or motor skills). icd-11 acknowledges that the pattern of skill loss will be different at different stages of development. dsm-5 has a section on differential diagnosis which implies that it is possible that asd could be confused with other diagnoses, such as selective mutism or adhd. icd-11 has taken a different approach, recognizing that these conditions can (and frequently do) co-occur. hence, in icd-11 they are included in a section that uses the term 'boundaries with other disorders and conditions’. the guidelines in icd-11 provide greater detail than dsm-5 about the distinction between conditions that may present with an autismlike phenotype. asd in icd-11: a psychological approach 16 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ towards intervention to improve quality of life and functioning in our view, the diagnostic classification of asd should always inform and serve proper, suitable interventions and support aimed at improving the wellbeing and functioning of the autistic person. thus, clinical psychologists should remain aware that diagnostic classification is not a purpose in itself. therefore, as part of the diagnostic assessment process, clinicians should perform assessments with a purpose in mind. if the goal is to primarily acquire new insights for scientific/applied research and/or related mental health care innovations, that purpose of potential additional assessments should be transparently communicated to all involved. diagnostic classification in clinical practise should be a means to provide proper, suitable care, and therefore all diagnostic assess­ ments should be used to tailor the interventions and/or care to the capacities and genuine needs of the people that ask for professional help. even though asd is concep­ tualized as predominantly inborn, so genetically determined condition, the interaction with social factors is more and more recognized both in society as well as in research. as such, interventions to help autistic people should not simply focus on effecting change in the individual, but should also include steps to improve person-environment fit by making adaptations to the environment. furthermore, intervention targets should be identified collaboratively with the client and their family, and will often concern improv­ ing wellbeing, mental health and societal functioning. whilst practice may need to be adapted to promote access and inclusion for autistic clients, mental health care providers are in a good position to use their clinical skills to offer effective help. there is growing evidence-base for psychological treatment procedures and social support interventions. recommendations regarding suitable methods for treatment and support with sufficient evidence as well as preference base will be provided in a future follow up article. funding: the authors have no funding to report. acknowledgments: we want to thank gillian baird and graccielle rodrigues da cunha who were involved in writing a related book chapter. also, gratitude goes out to annemiek landlust, inge van balkom and sigrid piening who at the autism team north-netherlands provide an excellent environment in which much can be learned about asd, conceptually as well as practically. finally, a large thank you to all members of the academic workplace autism, the volante workgroup and autism europe who enlarged our perception and conception of what asd entails when experienced at a daily basis. competing interests: all authors were involved in the development and evaluation of the developmental, dimensional and diagnostic interview (3di), a semi-structured interview that can be used to clarify the developmental history as part of the diagnostic assessment process concerning autism spectrum disorder. greaves-lord, skuse, & mandy 17 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://www.psychopen.eu/ references american psychiatric association. 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(2019a). 6a02 autism spectrum disorder. in international statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/437815624 world health organization. (2019b). 6a00 disorders of intellectual development. in international statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/605267007 zeidan, j., fombonne, e., scorah, j., ibrahim, a., durkin, m. s., saxena, s., yusuf, a., shih, a., & elsabbagh, m. (2022). global prevalence of autism: a systematic review update. autism research, 15(5), 778–790. https://doi.org/10.1002/aur.2696 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. asd in icd-11: a psychological approach 20 clinical psychology in europe 2022, vol. 4(special issue), article e10005 https://doi.org/10.32872/cpe.10005 https://doi.org/10.1037/a0037665 https://doi.org/10.1007/s10803-015-2592-5 https://doi.org/10.1016/j.dcn.2018.05.007 https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/437815624 https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/605267007 https://doi.org/10.1002/aur.2696 https://www.psychopen.eu/ asd in icd-11: a psychological approach current icd-11 definition, criteria and conceptualisations of autism spectrum disorder social communication repetitive, stereotyped behaviours and sensory interests life-course perspective and advice on assessment hypothesised neuropsychological mechanisms driving the core behaviours defining asd further features and disorders comparison between icd-11 and dsm-5 towards intervention to improve quality of life and functioning (additional information) funding acknowledgments competing interests references is singing under the christmas tree psychologically recommended? a scientific evaluation editorial is singing under the christmas tree psychologically recommended? a scientific evaluation philipp kanske 1, winfried rief 2 [1] clinical psychology and behavioral neuroscience, faculty of psychology, technische universität dresden, dresden, germany. [2] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2022, vol. 4(4), article e10841, https://doi.org/10.32872/cpe.10841 published (vor): 2022-12-22 corresponding author: philipp kanske, technische universität dresden, faculty of psychology, clinical psychology and behavioral neuroscience, chemnitzer str. 46, 01062 dresden, germany. phone +49 (0)351 463-42225. e-mail: philipp.kanske@tu-dresden.de clinical psychology in europe cpe wants to present latest scientific findings, but also highlight their societal impact, and practical relevance. following the tradition of our first three years, we integrate these aims in a special christmas editorial, that can be taken seriously, but there is no need to be overly serious with it. many european families build a christmas tree into a living room, although this room was kept clean and proper for the other times of the year, and no dirt from outside was allowed. this surprising activity for inside decoration follows old egyptian, chinese, jewish and northern tribal traditions to put some green into buildings during cold winter days. however, it is unique that these trees seem to trigger some urgent need to sing along, preferably together in families. we will analyze whether, from a psychological perspective, it can be recommended to follow this urgent need, or whether we should give priority to stop this tradition. it is not easy to find someone who does not know at least one christmas carol. why is that? if anything, it suggests that singing under the christmas tree is not particularly aversive. in fact, for most people singing is surprisingly fun; using a preto post-design to evaluate singing, your mood seems to improve (schladt et al., 2017). and it is not the same if you just listen to music, singing yourself is what seems to do the trick (kreutz et al., 2004). so, dig up all those christmas carols from memory and sing to your heart’s content? now there is one further ingredient that may make the festive singing so pleasurable. the positive mood effect is considerably increased by singing together with others this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10841&domain=pdf&date_stamp=2022-12-22 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ (schladt et al., 2017). this could be due to a whole range of social effects of joint singing. singing with others seems to have an “ice-breaker effect”. faster than other group activities like crafting, it will increase social bonding and felt closeness (pearce et al., 2015), potentially because performing music together, requires a considerable amount of social coordination. in order to really sing together, you need to anticipate the sounds produced by others, divide attention between yourself and others and constantly adjust your timing to that of the group (keller, 2008). this social attentiveness and adaptation increases group cohesion and accordingly, group singing even promotes feelings of social inclusion (welch et al., 2014). christmas is the feast of charity. according to christian tradition, jesus was born in a stable and the big churches take the occasion of christmas to collect money for people in need. singing could actually benefit such altruistic behavior. it enhances empa­ thy, the capacity to share others’ suffering, and also compassionate feelings for others (mcdonald et al., 2022). these social emotions, in turn, increase people’s willingness to help, especially when the other is in need (lehmann et al., 2022). maybe this is a reason why churches of different traditions also encourage to sing along. you probably learned the songs that you are singing already as a child. and this is part of the reason why christmas carols may have a particular magic about them. in contrast to music that we encountered later in life, the songs we were exposed to as children have a special potential to calm us in the face of stress and act as emotional regulators (gabard-durnam et al., 2018). already at six months of age, we seem to prefer our mother singing to us compared to her speaking (nakata & trehub, 2004). and sing­ ing with others leads to spontaneous cooperative and helpful behavior in four-year-olds (kirschner & tomasello, 2010). so take some time to sing with your kids. it will not only improve your mood, but also help in creating some peace and harmony in the family. this could be a helpful game changer if other education attempts have failed. even on a bodily level, music in general and singing in groups in particular have astonishing effects. it increases secretory immunoglobulin a, a marker of immune com­ petence that can only be helpful at the height of the latest flu wave when winter really hits and in the late outbreaks of the covid pandemic (kreutz et al., 2004). the broad positive effects of singing have led to the development of a number of clinical interventions making use of mainly group singing for diverse health conditions ranging from somatic (e.g. reagon et al., 2017) to neurodegenerative (baird, 2018) and mental health conditions (williams et al., 2018). among others, depression could be shown to be reduced during an eight weeks group singing intervention (petchkovsky et al., 2013). meta-analytically, group singing effects for mental health conditions reach moderate to large effect sizes in wellbeing and mental health improvements, mainly attributable to improved emotional states, sense of belonging and self-confidence in patients (williams et al., 2018). is singing under the christmas tree psychologically recommended? 2 clinical psychology in europe 2022, vol. 4(4), article e10841 https://doi.org/10.32872/cpe.10841 https://www.psychopen.eu/ there seems to be little to no downside to singing and given that almost everyone knows a christmas carol, christmas might really be the one occasion to actually do it, for yourself, your family, your children and their children, since it is the early songs we learn that we will never forget. therefore, the conclusion of this scientific evaluation is quite straight forward: just do it, let’s sing together. on behalf of the whole cpe editorial board, we wish you a relaxing time of the year, and a happy and peaceful new year 2023. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references baird, a. (2018). group singing enhances positive affect in people with parkinson’s disease. music and medicine, 10(1), 13–17. https://doi.org/10.47513/mmd.v10i1.570 gabard-durnam, l. j., hensch, t. k., & tottenham, n. (2018). music reveals medial prefrontal cortex sensitive period in childhood. biorxiv, 412007. https://doi.org/10.1101/412007 keller, p. e. (2008). joint action in music performance. in f. morganti, a. carassa, & g. riva (eds.), enacting intersubjectivity: a cognitive and social perspective on the study of interactions (pp. 205– 221). ios press. kirschner, s., & tomasello, m. (2010). joint music making promotes prosocial behavior in 4-yearold children. evolution and human behavior, 31(5), 354–364. https://doi.org/10.1016/j.evolhumbehav.2010.04.004 kreutz, g., bongard, s., rohrmann, s., hodapp, v., & grebe, d. (2004). effects of choir singing or listening on secretory immunoglobulin a, cortisol, and emotional state. journal of behavioral medicine, 27(6), 623–635. https://doi.org/10.1007/s10865-004-0006-9 lehmann, k., böckler, a., klimecki, o., müller-liebmann, c., & kanske, p. (2022). empathy and correct mental state inferences both promote prosociality. scientific reports, 12(1), article 16979. https://doi.org/10.1038/s41598-022-20855-8 mcdonald, b., böckler, a., & kanske, p. (2022). soundtrack to the social world: emotional music enhances empathy, compassion, and prosocial decisions but not theory of mind. emotion, 22(1), 19–29. https://doi.org/10.1037/emo0001036 nakata, t., & trehub, s. e. (2004). infants’ responsiveness to maternal speech and singing. infant behavior and development, 27(4), 455–464. https://doi.org/10.1016/j.infbeh.2004.03.002 pearce, e., launay, j., & dunbar, r. i. (2015). the ice-breaker effect: singing mediates fast social bonding. royal society open science, 2(10), article 150221. https://doi.org/10.1098/rsos.150221 kanske & rief 3 clinical psychology in europe 2022, vol. 4(4), article e10841 https://doi.org/10.32872/cpe.10841 https://doi.org/10.47513/mmd.v10i1.570 https://doi.org/10.1101/412007 https://doi.org/10.1016/j.evolhumbehav.2010.04.004 https://doi.org/10.1007/s10865-004-0006-9 https://doi.org/10.1038/s41598-022-20855-8 https://doi.org/10.1037/emo0001036 https://doi.org/10.1016/j.infbeh.2004.03.002 https://doi.org/10.1098/rsos.150221 https://www.psychopen.eu/ petchkovsky, l., robertson-gillam, k., kropotov, j., & petchkovsky, m. (2013). using qeeg parameters (asymmetry, coherence, and p3a novelty response) to track improvement in depression after choir therapy. advances in mental health, 11(3), 257–267. https://doi.org/10.5172/jamh.2013.11.3.257 reagon, c., gale, n., dow, r., lewis, i., & van deursen, r. (2017). choir singing and health status in people affected by cancer. european journal of cancer care, 26(5), article e12568. https://doi.org/10.1111/ecc.12568 schladt, t. m., nordmann, g. c., emilius, r., kudielka, b. m., de jong, t. r., & neumann, i. d. (2017). choir versus solo singing: effects on mood, and salivary oxytocin and cortisol concentrations. frontiers in human neuroscience, 11, article 430. https://doi.org/10.3389/fnhum.2017.00430 welch, g. f., himonides, e., saunders, j., papageorgi, i., & sarazin, m. (2014). singing and social inclusion. frontiers in psychology, 5, article 803. https://doi.org/10.3389/fpsyg.2014.00803 williams, e., dingle, g. a., & clift, s. (2018). a systematic review of mental health and wellbeing outcomes of group singing for adults with a mental health condition. european journal of public health, 28(6), 1035–1042. https://doi.org/10.1093/eurpub/cky115 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. is singing under the christmas tree psychologically recommended? 4 clinical psychology in europe 2022, vol. 4(4), article e10841 https://doi.org/10.32872/cpe.10841 https://doi.org/10.5172/jamh.2013.11.3.257 https://doi.org/10.1111/ecc.12568 https://doi.org/10.3389/fnhum.2017.00430 https://doi.org/10.3389/fpsyg.2014.00803 https://doi.org/10.1093/eurpub/cky115 https://www.psychopen.eu/ disorders specifically associated with stress in icd-11 scientific update and overview disorders specifically associated with stress in icd-11 andreas maercker 1 , david j. eberle 1 [1] department of psychology, division of psychopathology and clinical intervention, university of zurich, zurich, switzerland. clinical psychology in europe, 2022, vol. 4(special issue), article e9711, https://doi.org/10.32872/cpe.9711 received: 2022-06-15 • accepted: 2022-10-12 • published (vor): 2022-12-15 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: andreas maercker, university of zurich, division of psychopathology and clinical intervention, department of psychology; binzmühlestrasse 14/17, 8050 zürich, switzerland. e-mail: maercker@psychologie.uzh.ch related: this article is part of the cpe special issue “innovations in icd-11”, guest editor: andreas maercker, clinical psychology in europe, 4(special issue), https://doi.org/10.32872/10.32872/cpe.v4.si abstract background: after almost three decades of icd-10 use for diagnostic purposes, the world health organization has conducted a systematic and elaborate evaluation to revise the classification of mental disorders in this system. this revision resulted in the 11th version (icd-11), introduced in 2022. as one new feature, the icd-11 forms a new grouping of mental disorders specifically associated with stress. method: the current review presents an overview of the diagnostic features and cultural specifications of disorders specifically associated with stress. this grouping includes posttraumatic stress disorder and complex posttraumatic stress disorder, prolonged grief disorder, adjustment disorder, as well as two diagnoses for children, reactive attachment disorder and disinhibited social engagement disorder. results: overall, there is evidence for the improved clinical utility and applicability of these disorders. the disorders have been defined in a parsimonious way by few features, but they suffice for scientific purposes as well. conclusion: however, more research is needed to evaluate assessments for the diagnoses and diagnostic features in the icd-11. keywords disorders specifically associated with stress, icd-11, posttraumatic stress disorder, complex posttraumatic stress disorder, prolonged grief disorder, adjustment disorder this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9711&domain=pdf&date_stamp=2022-12-15 https://orcid.org/0000-0001-6925-3266 https://orcid.org/0000-0002-9578-667x https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • in the area of trauma and stress, there are two newly specified diagnoses and further redefinitions of the content of the existing diagnoses. • the icd-11 features a new grouping of disorders specifically associated with stress. for almost 30 years, the 10th version of the international classification of diseases (icd-10) was the standard in diagnosing physical diseases as well as mental disorders around the globe. on 1 january 2022, the world health organization (who) introduced the 11th revision of this diagnostic system and set a new milestone in the classification of mental disorders. back in 2011, the who had appointed several international working groups for revising the section on mental disorders in the icd-10. one of these working groups was commissioned to create the grouping of diagnoses specifically associated with stress (dsas). for the development of the 11th revision of the icd, the icd-11, the who placed particular emphasis on improving the clinical utility and applicability of the diagnoses. for dsas, several methodological preparations for the general revision of the icd-11 were particularly important. for instance, several global mental health surveys were conducted to assess the needs of psychologists and psychiatrists regarding mental health diagnoses (evans et al., 2013; reed et al., 2011, 2013). these preliminary mental health surveys concluded that there is a considerable need among health care professionals to create scientifically based diagnoses for stress-related phenomena like complex trauma and pathological grief reactions (robles et al., 2014). the advisory board of the who therefore expected the international working group on dsas to further evaluate these stress-related phenomena. researchers and clinicians with a broad global distribution took part in the working group for dsas, from africa (lynne m. jones, ashraf kagee), america (marylene cloitre, cecile rousseau), asia and australia (asma humayan, daya somasundaram, yuriko suzuki, richard bryant), and europe (chris brewin, andreas maercker, simon wessely), as well as members from global organizations such as the who (michael b. first, mark van ommeren, geoffrey reed) and the international committee of the red cross (renato souza). this composition of experts was chosen to ensure a global applicability of the diagnostic criteria for the new disorders in consideration. for the proposed mental disorders of the icd-11 and specifically for dsas, a compre­ hensive clinical evaluation was conducted. between the start of the working group and the final implementation of the icd-11, several evaluation steps were implemented: • diagnostic propositions of the working group for disorders specifically associated with stress were published and discussed in scientific journals (e.g., maercker et al., 2013) and in the global clinical practice network1. disorders specifically associated with stress 2 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://www.psychopen.eu/ • for the entire icd-11 section of mental disorders, approximately 20 working groups worked on different disorder groupings as well as cross-sectional features. each working group developed clinical best practices, organized regional meetings with health care professionals, and consulted local patient representatives for a comprehensive validation of the working groups’ proposals. • 13 different research centres across the globe implemented clinical case studies to finalize the new disorder and symptom characterizations (reed et al., 2018). • more detailed clinical descriptions and diagnostic recommendations (cddr) for individual disorders were developed. for the cddr, the who pursued an open access approach. complementary to the frozen release of diagnostic features, the who published open access descriptions to implement future diagnostic changes2. as a major aspect of all revisions, the complexity of mental disorder’s characteristics was reduced. for this purpose, previous disorder subtypes were erased or limited (see reed, 2010). furthermore, only symptoms with a particular sensitivity and specificity were implemented as diagnostic features. as a consequence, the clinical utility and ap­ plicability of icd-11 diagnoses was significantly improved. regarding dsas, the expert group also discussed the inclusion of diagnoses such as embitterment disorder, burnout, continuous trauma disorder, and a more pronounced relation to – or even inclusion of – dissociative disorders. however, these proposals were not realized in the icd-11. furthermore, the diagnosis of an acute stress reaction was moved to the icd-11 section ‘factors influencing health status’, as such reactions are considered to be normal and are expected to be resolved within a short period after experiencing an aversive life event. disorders specifically associated with stress in adults table 1 presents an overview of disorders specifically associated with stress in the icd-11 and the corresponding stress-related disorders in the icd-10 and the dsm-5 (apa, 2013). the diagnostic features of the icd-11 diagnoses will be outlined in the following sections. 1) https://gcp.network 2) https://icd.who.int/dev11/l-m/en#/ maercker & eberle 3 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://gcp.network https://icd.who.int/dev11/l-m/en#/ https://www.psychopen.eu/ table 1 disorders related to stress and trauma according to the icd-11, the icd-10, and the dsm-5 icd-11 icd-10 dsm-5 6b40: posttraumatic stress disorder f43.1: posttraumatic stress disorder 309.81: posttraumatic stress disorder 6b41: complex posttraumatic stress disorder f62.0: enduring personality change after catastrophic experience – 6b42: prolonged grief disorder – – 6b43: adjustment disorder f43.2x: adjustment disorders 309.x: adjustment disorders 6b4y & 6b4z: other specified or unspecified disorders specifically associated with stress f43.8 & f43.9: other specified or unspecified reactions to severe stress 309.89 & 309.9: other specified or unspecified trauma and stressor-related disorders qe84: acute stress reaction (in subchapter 24 – no longer a diagnostic entity but a ‘factor influencing health status’) f43.0: acute stress reaction 308.3: acute stress disorder posttraumatic stress disorder for this category, there was essentially a revision and tightening up of the previous definition. posttraumatic stress disorder (ptsd) may develop after experiencing an ex­ tremely distressing or life-threatening event or series of events, such as sexual abuse or a serious accident (who, 2022). a core symptom of ptsd is the re-experiencing of the aversive life event in vivid memories. in most cases, such intrusive re-experiencing manifests as flashbacks or nightmares. however, intrusive symptoms can also involve other modalities or body-related re-experiencing, so that odours, sentiments, or other sensations from the traumatic event may be experienced again. intrusive re-experiencing typically occurs in combination with strong and overwhelming emotions such as fear or horror (see bar-haim et al., 2021). in the icd-11, repetitive or burdensome thinking of the experienced traumatic event is no longer considered to be a manifestation of intrusive re-experiencing as part of a ptsd. repetitive thoughts have also been found to be characteristic of resilient trauma survivors. even though remembering the traumatic event might be distressing for these individuals, such thoughts are not specifically associ­ ated with ptsd. the second symptom feature of ptsd is avoidance of memories, activities, situations, or people related to the traumatic event. importantly, this avoidance behaviour is de­ liberately produced by the affected individuals. in past conceptualizations, ptsd has sometimes been associated with amnesia as an unconscious avoidance strategy. such phenomena are no longer part of the avoidance symptoms in the icd-11, as they rarely disorders specifically associated with stress 4 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://www.psychopen.eu/ occur and are not consciously reflected by affected individuals. in addition, symptoms such as numbing, diminished interest, and emotional alienation have been removed from avoidance definitions, as they are understood as manifestations of comorbid depressive symptoms. the third symptom group of ptsd consists of persistent perceptions of current heightened threat. such perceptions may manifest as hypervigilance or enhanced startled reactions to stimuli such as unexpected noises. due to their unspecific relation to ptsd, hyperarousal phenomena such as disturbed sleep, concentration problems, and increased irritability are no longer listed as ptsd symptoms in the icd-11. as for all disorders specifically associated with stress, ptsd is characterized by a significant impairment in personal, social, educational, occupational, or other important areas of functioning. however, some affected individuals are able to maintain a normal level of functioning, which is only possible through considerable psychological and phys­ ical effort. importantly, clinicians need to account for such compensatory behaviours in the diagnostic process to adequately assess the impairment level of an individual (see also rodriguez et al., 2012). ptsd typically emerges within several weeks after experiencing the traumatic life event, but it is possible for ptsd symptoms to emerge many months or years after the traumatic life experience. the icd-11 includes the possibility of delayed onset of ptsd symptoms, without specifying this phenomenon as a subtype. however, no time limit is introduced for this feature because specific time limits do not accurately reflect psychological processes (see reed et al., 2018). furthermore, the icd-11 no longer defines specific stressor characteristics of the traumatic life event, as it has been shown that the type of trauma is not particularly decisive for the subsequent psychopathology. there is empirical evidence showing that the described pattern of ptsd symptoms only occurs in traumatized individuals, thus allowing a reliable differentiation of individuals with and without ptsd (berntsen et al., 2003; brewin et al., 2009). it can therefore be strongly assumed that the symptom pattern in the icd-11 sufficiently describes the phenomenology of ptsd without the inclusion of stressor types. the icd-11 features a particular focus on the cultural characteristics of mental disor­ ders. in the case of ptsd, the icd-11 states that symptoms such as increased anger, headaches, intensified nightmares, or somatic symptoms might occur with different prevalence in certain cultural groups. the icd-11 also specifies that intrusive re-experi­ encing is not considered as something unusual in all cultures; rather, it might be seen as an intense but normal way of remembering a critical life event. furthermore, certain symptoms can also trigger dysfunctional health beliefs. for instance, anxiety-related symptoms such as persistent perceptions of heightened current threat might be interpre­ ted as a lifelong condition of weak nerves or a weak heart, as is sometimes observed in latin american countries or in cambodia. all these aspects need to be considered when working with individuals from different cultural groups. maercker & eberle 5 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://www.psychopen.eu/ complex posttraumatic stress disorder complex posttraumatic stress disorder (cptsd) may develop after experiencing a trau­ matic life event that is particularly horrific or threatening (who, 2022). in most cases, the stressor consists of a series of traumatic situations or an ongoing event, such as slavery or repeated abuse. many psychosocial stressors with an extremely threatening nature have the potential to cause cptsd. however, as is the case for ptsd, the diagno­ sis mainly depends on symptomatic presentation instead of specific event characteristics (maercker et al., 2022). regarding the psychopathological features of cptsd, all symptom requirements of ptsd need to be met, including intrusive re-experiencing, avoidance, and persistent perceptions of heightened current threat. in addition, cptsd is characterized by distur­ bances in self-organization (dso), which is indicated by several symptom patterns. first, dso features problems in affect regulation, which might manifest as frequent excitability, anger, rage, or an increased self-harming behaviour. second, individuals with cptsd exhibit beliefs about the self as worthless, defeated, or diminished, which is often accompanied by feelings of guilt, shame, or failure related to the stressful life event. the third feature of dso constitutes interpersonal problems. the inability to trust, a suscept­ ibility to hyperbolic views, and difficulties in partnership interactions are particularly characteristic for this symptom group. individuals with cptsd also show an increased tendency for dissociation (see also hyland et al., 2020), which includes depersonalization experiences, clouding of consciousness, and amnesia. contrary to the dso symptoms, however, dissociation is not a diagnostic requirement for cptsd. the introduction of cptsd as a new disorder in the icd-11 generated significant criticism. for instance, one criticism is that cptsd only represents a comorbidity between ptsd and borderline personality disorder, which makes an introduction of a new disorder redundant (resick et al., 2012, see maercker, 2021). however, empirical findings demonstrated that cptsd possesses a distinct, reliable, and useful symptom profile (brewin et al., 2017; kazlauskas et al., 2018), which finally led to the inclusion of cptsd in the icd-11. in the icd-10, cptsd was classified as an enduring personality change after catastrophic experiences. however, continuous research showed that the related symptomatic features were part of a posttraumatic syndrome, which is why this psychopathological type has been reallocated to disorders specifically associated with stress. according to the icd-11, cptsd also exhibits an important cultural variation. in particular, dissociative and somatic symptoms are believed to increasingly emerge in certain cultural groups. furthermore, migrants across the globe are of particular concern in trauma sequelae. as they are frequently and often repeatedly confronted with severely stressful life events, migrants have a highly increased prevalence of suffering from cptsd. when migrating to countries with a different cultural background, cptsd might be triggered and intensified by the ongoing stressors experienced related to migration. disorders specifically associated with stress 6 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://www.psychopen.eu/ as refugees are sometimes faced with continuous violence or discrimination in host countries, they represent a group that is particularly vulnerable to severe disorders specifically associated with stress. even though research has not yet identified a distinct set of cultural properties of cptsd, recent publications have started to shed light on these characteristics (see heim et al., 2022). prolonged grief disorder compared to other disorders specifically associated with stress, stressors leading to a prolonged grief disorder (pgd) are defined more precisely. pgd might develop after the death of a loved person, such as a partner, parent, child, other family member, or another person close to the bereaved (who, 2022). importantly, animals are not included in this definition. the event of loss causes an intense and long-lasting grief reaction, which can take on many individually different manifestations. however, in terms of common symptoms, pgd is defined by intensive yearning and longing for the deceased, as well as by intrusive preoccupation with the death of the loved person or the implications of this event. in addition to these core symptoms, the icd-11 defines several accessory symptoms, including guilt, sadness, denial, anger, blame, difficulty accepting the loss, an inability to be in a positive mood, numbness, and a diminished interest in activities. however, the icd-11 does not define the number of accessory symptoms needed for a pgd diagnosis. more cultural characteristics are specified for pgd than for other mental disorders. cultural practices and attitudes towards bereavement strongly differ across the globe. ideas and concepts of the afterlife manifest a broad range of clinical presentations and behaviours related to bereavement, which may also increase the chance for a prolonga­ tion of grief. for instance, the icd-11 states that in some religions, death is regarded as an important step in the transition to the afterlife. cultural beliefs focusing on rebirth, but also on karma, heaven, or hell, can have an enormous impact on a bereaved person. pgd might therefore be additionally triggered by concerns about the afterlife of the deceased. according to some religious beliefs, such as those common in southern europe, an encounter with the spirit of a deceased person – which may be regarded as a symptom of re-experience – is not considered as an abnormal event and may even be perceived as a positive experience. another culturally diverse feature in relation to pgd is the duration of grief, as there are different norms across the globe concerning mourn­ ing periods. in some countries, a one-year mourning period is considered as normal, whereas in other cultures, mourning periods are considered to trigger negative emotions and are therefore kept relatively short. due to these various cultural manifestations, the icd-11 states that for the diagnosis of pgd, the cultural background of patients needs to be evaluated thoroughly. the diagnosis of pgd should only be made if the grief reaction clearly exceeds the respec­ tive cultural norms of the individual. in general, the icd-11 states that pgd may be maercker & eberle 7 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://www.psychopen.eu/ diagnosed no earlier than six months after the death of the loved person. however, due to the cultural variations outlined before, the duration of grief should correspond to the cultural background when considering a pgd diagnosis. long-lasting grief reactions that are still within a cultural norm are classified as a normal grief reaction and not as pgd. the extent to which different cultures affect the expression of symptoms remains the subject of further research. there were also some objections to the introduction of pgd as a new idc-11 diagno­ sis. for instance, one criticism was that the introduction of pgd as a new diagnosis represents disease mongering and that grief should always be classified as a natural process of life. however, it should be noted that in the past, prolonged grief has mostly been falsely diagnosed as depression, ptsd, or adjustment disorder, even for the small number of those it affects. such diagnoses are not only clinically inaccurate but can also cause inadequate treatment. for individuals affected by mental disorders, a diagnosis can be helpful to understand and address psychological problems, presupposing that the underlying problems are correctly identified in the first place. adjustment disorder another disorder specifically associated with stress is adjustment disorder (ajd). this disorder may develop after one or several critical life event(s), such as involuntary job loss, severe illness, or a relationship breakup (who, 2022). on a symptomatic level, ajd is characterized by an intrusive preoccupation with the aversive life event or its implications, which mainly manifests as repetitive and distressing thoughts of the event. failure to adapt constitutes a further ajd symptom, which may take the form of sleep and concentration problems or an inability to recuperate. due to the high levels of distress that individuals with ajd experience, suicidal tendencies are not uncommon as part of the disorder. importantly, the diagnosis of ajd specifies that disorder-related symptoms persist no longer than six months after the aversive life event. however, in the case of a prolonged exposure to a stressor, such as an ongoing illness, ajd may also be diagnosed for longer than six months. in general, all aversive life events have the potential to trigger ajd, which makes it particularly difficult to differentiate such experiences from traumatic events and seque­ lae. however, a great majority of individuals diagnosed with ptsd and cptsd have been confronted with life-threatening experiences, whereas events leading to ajd are not particularly overwhelming in most cases. even though stressors like a divorce might be extremely stressful for those affected, such events are usually not associated with a threat to one’s core identity and basic tenets of life during exposure to the stressor and therefore do not cause typical posttraumatic symptoms (brewin, 2014; eberle & maercker, 2022). the manifestation of ajd varies across the lifespan. according to the icd-11, chil­ dren with ajd may typically exhibit increased disruptive or oppositional behaviour, disorders specifically associated with stress 8 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://www.psychopen.eu/ hyperactivity, irritability, concentration problems, increased clinginess, tantrums, regres­ sion, sleep disturbances, or bedwetting. in contrast to children, adolescents may manifest an intensification of substance use as well as increased behaviours of acting out or risk taking. children and adolescents with ajd often fail to verbalize their emotions related to the stressful experience. therefore, it is important to account for this interactive inhibition in the diagnostic process and relate reports of critical life events to changed behaviour patterns. meanwhile, older adults diagnosed with ajd increasingly manifest psychosomatic symptoms as a reaction to critical life events. consequently, in this age group, the core ajd symptom of preoccupation is especially focused on their own health (for more age-specific information, see also mulligan, 2018; who, 2022). the icd-11 states that in some cultural groups, ajd might intensify significantly in the case of lacking family or community support. furthermore, local idioms of distress and concepts of suffering can play a significant role in the manifestation of ajd. for example, exposure to aversive life events may result in particularly strong anxiety reac­ tions, as it has been observed in individuals from central america. additional disorders for children in the icd-11, diagnoses for children and adolescents are no longer separately coded but are rather implemented in the disorder group of the appropriate life-span diagnoses. this means that the grouping of disorders specifically associated with stress also features two diagnoses for children and adolescents: disinhibited social engagement disorder and reac­ tive attachment disorder (who, 2022). one childhood-specific stress-related diagnosis listed in the icd-10 has not been transferred to the icd-11. due to the phenomenological overlap, autism spectrum disorder is an important exclusion criterion for both childhood disorders specifically associated with stress in the icd-11. disinhibited social engagement disorder develops as a consequence of grossly inade­ quate childcare, such as institutional deprivation, severe neglect of the child’s physical or emotional needs, a constant change of primary caregivers, parenting in inadequate settings, and child abuse (see also zeanah et al., 2016). according to the icd-11, children with disinhibited social engagement disorder are characterized by an indiscriminate approaching of adults, a lack of restraint to approaching, an overly familiar behaviour towards strangers, and a willingness to go away with unfamiliar adults. disinhibited social engagement disorder is relatively rare and has been found to develop only in a small proportion of children who have experienced inadequate care. reactive attachment disorder, as the second child-specific stress-related disorder in the icd-11, is also characterized by highly inadequate childcare. the disorder features an inhibited attachment behaviour of the child. according to the icd-11, this may manifest as an unwillingness to return to the primary caregiver for nurture, comfort, or support, even though an adequate caregiver is available. furthermore, the child does not respond maercker & eberle 9 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://www.psychopen.eu/ when comfort is offered and rarely displays security-seeking behaviours towards any adult (zeanah et al., 2016). questionnaires and clinical interviews with its revised diagnostic features for mental disorders, the icd-11 also requires an adaptation in the assessment of these disorders. in recent years, new measurement instruments for dsas have been developed. for the development of these diagnostic assessment tools, a european-american consortium has been founded: the international trauma consortium3, which offers freely available diagnostic instruments in numerous languages. while english versions of the developed scales are already fully validated, the validation processes for other languages, such as german or arabic, are not yet completed. the icd-11 in clinical practice the new icd-11 diagnoses have been repeatedly evaluated. for instance, various disor­ ders have been cross-compared with mental health conceptualizations from the icd-10 and the dsm-5, as will be shown in the following paragraphs. however, with regard to prevalence studies, data sets based on epidemiological and high-risk samples often cover individuals who are not in treatment. therefore, studies with patients undergoing actual treatment are most relevant for an evaluation of the icd-11 in clinical practice. in addition, many previous studies have not assessed the diagnostic features of impair­ ment in personal, family, social, educational, occupational, or other important areas of functioning, even though this feature is a critical diagnostic element. these limitations need to be kept in mind when diagnostic findings are compared. regarding childhood disorders, studies have not yet managed to replicate the prevalence numbers of the disor­ ders, which is why the following section will not evaluate disinhibited social engagement disorder and reactive attachment disorder. ptsd and cptsd regarding ptsd, the first study to evaluate different diagnostic systems involving the icd-11 was conducted as part of the world mental health surveys (stein et al., 2014). the assessment applying the icd-11 indicated that 3.2% of screened individuals met the diagnostic criteria for ptsd. in comparison, a prevalence of 4.4% was found with the icd-10 and a prevalence of 3.0% was found with the dsm-5. among all individuals 3) www.traumameasuresglobal.com disorders specifically associated with stress 10 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 http://www.traumameasuresglobal.com https://www.psychopen.eu/ who received a ptsd diagnosis with the icd-11, the icd-10, or the dsm-5, 75% were diagnosed accordingly in all three classification systems. another study including a high-risk sample of older adults found a ptsd prevalence of 10.3% when diagnosed with the icd-11. in comparison, according to the icd-10, 15% of individuals met all diagnostic features of ptsd (glück et al., 2016). prevalence numbers differ for more specific populations, such as members of the military. wisco et al. (2016) found that, in a high-risk sample of us military personnel, 34% were diagnosed with ptsd according to the icd-11, while 45% were diagnosed with the icd-10 and 34% with the dsm-5. the diagnostic overlap between the icd-11 and the dsm-5 was 89%. a similar study has been conducted in the german military: kuester et al. (2017) found ptsd rates of 48% for the icd-11, 30% for the icd-10, and 56% for the dsm-5. the diagnostic overlap between the icd-11 and the dsm-5 was 84%. however, both of these studies only used validated dsm instruments for their assessment, which were adapted to also capture icd diagnoses. furthermore, møller et al. (2020) investiga­ ted ptsd and cptsd in a patient sample. of the patients who received a ptsd diagnosis according to the icd-10, 46% were also diagnosed with ptsd according to the icd-11, 28% were diagnosed with cptsd, and 26% were diagnosed with another mental disorder. in summary, empirical studies show that the diagnostic overlap between different classification systems must be estimated at roughly 60–90%. in clinical practice, this means that even though a patient might receive a ptsd diagnosis according to the icd-10 or the dsm-5, a ptsd diagnosis may no longer be assigned when using the icd-11. such empirical findings might seem upsetting, as all diagnostic systems are supposed to ensure valid diagnostic results. however, it must be considered that diag­ nostic tools are always subject to a minimal level of uncertainty, which may lead to different results. furthermore, the theoretical background for diagnostic characteristics have changed between different classification systems. for instance, symptoms of re-ex­ perience have been laid out more strictly in the icd-11. if an individual exhibits distress­ ing repetitive thoughts of a trauma but no vivid flashbacks or severe nightmares, the diagnosis of ptsd is no longer indicated by the icd-11. ajd and pgd prevalence numbers for both ajd and pgd are not yet conclusively determined due to sparse research activity and changing disorder definitions over the last years. a diagnostic evaluation based on the icd-10 found that across different countries, ajd exhibits a prevalence of approximately 1% (ayuso-mateos et al., 2001). this finding was replicated in a german study by maercker et al. (2012), which found an ajd prevalence of 0.9% by implementing icd-11 features. therefore, in contrast to other disorders spe­ cifically associated with stress, ajd appears to show little variability in the prevalence figures of the different diagnostic systems. since pgd was newly introduced in the icd-11, no comparison with broadly established conceptualizations of grief is possible. maercker & eberle 11 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://www.psychopen.eu/ however, the dsm-5 defines persistent complex grief disorder as a research diagnosis. maciejewski et al. (2016) compared this diagnosis with the icd-11 definition and found a kappa coefficient of 0.82, which indicates a big overlap between the two disorders. importantly, in the upcoming dsm-5-tr, pgd will be included as a regular disorder in the classification system (moran, 2021). hence, it is hoped that future research will be able to conduct thorough comparisons between classification systems and adequate prevalence estimations. conclusion disorders specifically associated with stress encompass a set of psychopathological sequelae emerging after exposure to a stressful life event. research shows that these revised disorders entail an increased clinical utility and applicability. however, more studies are needed to investigate the long-term benefits of the new dsas grouping of disorders. it is hoped that the icd-11, which will guide clinicians and their therapeutic actions over the next decades, proves to be beneficial for individuals suffering mental disorders from the kinds of external sources outlined here. we may see further steps towards convergence with the dsm-5 as well, such as with pgd, which was included in the dsm-5-tr (text revision) in 2022. funding: this contribution did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. acknowledgments: thanks go to the work group members at who icd-11 development, whose names are listed in the text. competing interests: am had been the chair of the icd-11 work group on disorders specifically associated with stress. he is the guest editor of this special issue of clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. both authors have no financial conflicts of interest to declare. references american psychiatric association. 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(2016). practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder and disinhibited social engagement disorder. journal of the american academy of child and adolescent psychiatry, 55(11), 990–1003. https://doi.org/10.1016/j.jaac.2016.08.004 maercker & eberle 15 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://doi.org/10.1002/jclp.22031 https://doi.org/10.1002/wps.20524 https://doi.org/10.1002/jts.21699 https://doi.org/10.1016/j.ijchp.2014.03.003 https://doi.org/10.1682/jrrd.2011.09.0162 https://doi.org/10.1002/da.22279 https://doi.org/10.1016/j.psychres.2016.04.043 https://icd.who.int/browse11/l-m/en https://doi.org/10.1016/j.jaac.2016.08.004 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. disorders specifically associated with stress 16 clinical psychology in europe 2022, vol. 4(special issue), article e9711 https://doi.org/10.32872/cpe.9711 https://www.psychopen.eu/ disorders specifically associated with stress (introduction) disorders specifically associated with stress in adults posttraumatic stress disorder complex posttraumatic stress disorder prolonged grief disorder adjustment disorder additional disorders for children questionnaires and clinical interviews the icd-11 in clinical practice ptsd and cptsd ajd and pgd conclusion (additional information) funding acknowledgments competing interests references interoception and premonitory urges in children and adolescents with tic disorders research articles interoception and premonitory urges in children and adolescents with tic disorders christina schütteler 1 , katrin woitecki 2, manfred döpfner 2,3 , alexander l. gerlach 1 [1] department of psychology, clinical psychology and psychotherapy, university of cologne, cologne, germany. [2] school of child and adolescent cognitive behavior therapy (akip), faculty of medicine and university hospital cologne, university of cologne, cologne, germany. [3] department of child and adolescent psychiatry, psychosomatics and psychotherapy, faculty of medicine and university hospital cologne, university of cologne, cologne, germany. clinical psychology in europe, 2023, vol. 5(1), article e8185, https://doi.org/10.32872/cpe.8185 received: 2022-01-20 • accepted: 2022-10-25 • published (vor): 2023-03-31 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: christina schütteler, department of psychology, clinical psychology and psychotherapy, university of cologne, pohligstr. 1, 50969 cologne, germany. tel.: 0221 470 5381. e-mail: c.schuetteler@uni-koeln.de supplementary materials: data, preregistration [see index of supplementary materials] abstract background: compared to healthy controls (hcs), adult tic disorder (td) patients exhibit a lower interoceptive accuracy (iacc) in heartbeat perception. since the lower iacc is not evident in children, the age at which tics develop, but in adults only (pile et al., 2018, https://doi.org/10.1007/ s10803-018-3608-8), lower iacc may reflect a pathological mechanism relevant with regard to tics, premonitory urges (pus) or the resulting impairment. although tics are a motor phenomenon, up to date, iacc has been assessed only with a heartbeat-counting task. this study aims at comparing cardiac and muscular iacc using two different paradigms and investigates how iacc is related to premonitory urges in youth. method: interoceptive measures (heartbeat-counting task, muscle tension paradigm) of 28 youth with td were compared to 23 control participants and related to self-rated premonitory urges and tic symptoms. results: td patients did not differ from hcs in any iacc measures. however, within td patients, iacc explained additional variance in pus when controlling for tic severity. muscular iacc in td patients is related to urges and tics, but the direction of this association is unclear. iacc is lower in td patients than in hcs, indicating imprecise sensory input which is more easily overcome by priors within the predictive coding framework. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.8185&domain=pdf&date_stamp=2023-03-31 https://orcid.org/0000-0003-4196-4503 https://orcid.org/0000-0002-7929-0463 https://orcid.org/0000-0001-6794-5349 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusions: muscle tension feedback tasks could extend interoceptive trainings aimed at improving iacc to improve accuracy of urge perception (more precise sensory input) to foster the ability to control tics via hrt. longitudinal studies could provide further insights in causal relationships between iacc, premonitory urges and tics. keywords heartbeat, muscle, emg, interoceptive accuracy, predictive coding highlights • a muscle tension paradigm assessed interoceptive accuracy. • patients with tics did not differ from healthy controls in interoceptive accuracy. • muscular interoceptive accuracy in patients relates to premonitory urges and tics. • muscular tension feedback tasks could improve treatment via habit reversal training. tics are sudden repetitive movements or vocalizations that occur in up to 21% of children (cubo et al., 2011; kurlan et al., 2001). in most cases tics disappear with increasing age and remain stable in only about 1% of people worldwide (robertson & cavanna, 2008). tics regularly are preceded by an unpleasant premonitory urge or sensation (pu). pus are often perceived as an urge to move, an impulse to move, inner tension or restlessness and mostly occur in the face, neck, shoulders, arms or hands (kwak et al., 2003). in psychotherapy, the perception of pus is both necessary and problematic. on the one hand, in line with habit reversal training, a precise perception of pus improves the ability to successfully suppress tics (mcguire et al., 2015). on the other hand, pus illicit tics, negatively reinforce tics and correlate with tic severity (li et al., 2019). the capability to perceive bodily signals (‘interoception’) entails several different facets: iacc is defined as the process of accurately detecting and tracking internal bodily sensations (garfinkel et al., 2015). interoceptive sensibility refers to the self-reported at­ tention given to and detection of interoceptive information. finally, interoceptive aware­ ness refer to the metacognitive correspondence between objective iacc and self-report of interoceptive information (garfinkel et al., 2015). in the following, we will only focus on iacc based on the notion that iacc may be an underlying dimension in pus, necessary to perceive interoceptive sensations. adult individuals suffering from a td exhibit a lower iacc in a heartbeat perception tasks whilst reporting a heightened perception of sensory stimuli (interoceptive sensibili­ ty) as compared to individuals without tics. however, this lower iacc is not evident in children but in adults only (pile et al., 2018). so far, iacc in individuals with tds has exclusively been assessed with a heartbeat-counting task (schandry, 1981). arguably, tic symptoms are muscle movements. thus, assessing iacc by looking at the ability of an individual to perceive heart activity may not be the best test of the possible involvement of iacc in td. consequently, this study plans to investigate whether iacc in a muscle interoception and urges in tics 2 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ tension perception paradigm is associated with pus in addition to or over the ability to perceive heart activity. according to a predictive coding account of bodily symptom perception, bodily changes such as heart activity or muscle tension often are weak and imprecise signals. against this background, a heightened interoceptive sensibility for tic related symptoms may be the result of overly precise interoceptive priors. specifically, in tds, an overac­ tive putamen and insula may lead to overly precise predictions at hierarchically higher levels, overriding the actual weak and imprecise sensory inputs. the resulting prediction error may be reduced by performing an ‚involuntary’ tic and/or be the basis for the perception of an unpleasant pu (rae et al., 2019). on the behavioral level, pus may represent a conditioned response to aversive exter­ nal stimuli such as criticism, offenses or social marginalization as result of tic execution. in the course of a td, tics may become associated with those negative emotional va­ lences that subsequently constitute the pu. after a tic is executed, the unpleasant pu dissolves and ticking is negatively reinforced, promoting maintenance of tics (o’connor, 2002). following the o’connor model, an attentional focus on pus and tics may, over time, enhance the overly precise prior even further. as a result, unpleasant pus are perceived even more, impairing patients’ quality of life. indeed, adult td patients with a long history of the experience of tics exhibit lower iacc (ganos et al., 2015; rae et al., 2019). simultaneously, in adults, physical sensations are self-reported more often (interoceptive sensibility) compared to individuals without tics (rae et al., 2019). since a lower iacc is not evident in children but in adults only (pile et al., 2018), lower iacc in adults may reflect a failure to develop, over time, a better iacc if individuals suffering from td, which is commonly found in healthy individuals (murphy et al., 2019). in consequence, given this overly precise prior, the experience of pus continues and may even be strengthened into adulthood. however, given that iacc, so far, has been assessed only with a heartbeat-counting task, it is important to additionally assess whether iacc in children with tds may be increased with regard to the perception of muscular activity, since muscles are involved in the execution of tics. we opted to assess facial muscle tension given that most td patients experience at least one tic in the face (mcguire et al., 2016). thus, in this study we wanted to test the hypotheses, that children and adolescents with pathological tics exhibit lower iacc with regard to both heart activity as well as facial muscle tone as compared to children and adolescents without tics. we also test the hypotheses, that variance in pus is explained by iacc scores. furthermore, we compare muscular to cardiac iacc, using two different paradigms. schütteler, woitecki, döpfner, & gerlach 3 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ method participants a total of 51 children and youth between 10 and 19 years old were recruited at the university hospital cologne (28 patients and 23 control participants) and surrounding schools. one patient fulfilled the criteria of a chronic td, 27 patients fulfilled the crite­ ria of tourette’s syndrome according to icd-10. inclusion criteria were a previously diagnosed tic disorder, age 10-21 years and fluency in german. exclusion criteria were insufficient german language skills and the absence of any tic during the last week. twenty of these 28 td patients (71%) were male (13 of 23 hcs, 57%). 7 td patients were diagnosed with a comorbid disorder via diagnostic checklists (5 adhd, 1 ocd, 1 conduct disorder, 1 trichotillomania). two td patients received anti-tic medication (aripiprazole, tiapride), three received medication targeting adhd (methylphenidate). td patients and hcs did not differ with respect to gender (χ2 = 1.229, p = .268) or age. cbcl total scores differed significantly between groups, but not ysr scores (table 1). procedure a two-group design compared td patients with control participants not suffering from a td (hc). td patients and their parents additionally completed questionnaires regarding tic symptomatology and other psychopathology measures. participation took between 70 to 90 minutes. the experimental paradigms measuring iacc were presented via computer screen. participants received an allowance of 8€ per hour. the current study was carried out according to the declaration of helsinki. the ethics commission of the university of cologne’s faculty of medicine approved the study (cshf0044) and the study was pre-registered (see supplementary materials). all participants and their legal guardians gave informed consent. the data that support the findings of this study are openly available in figshare (see supplementary materials). questionnaires the german version of the child behavior checklist (cbcl; döpfner et al., 2014) is a caregiver report and assesses a variety of psychopathological symptoms. in the current study, the internal consistency of the total score was excellent (α = 0.93). the german version of the youth self report (ysr; döpfner et al., 2014) aims at children and youth, is constructed equivalently to the cbcl, and assesses self-reports of a variety of psychopathological symptoms. the total score exhibited good internal consistency in the current study (α = 0.84). both cbcl and ysr consists of the subscales aggressive behavior, anxious/depressive symptoms, attention problems, rule-breaking behavior, somatic complaints, social problems, thought problems, and withdrawal/depression. interoception and urges in tics 4 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ the self-rated symptom checklist for tic disorders scl-tic-s (scl-tic-s) and scl-tic-p (parent-rated) are part of the disyps-iii diagnostic system (döpfner & görtzdorten, 2017). they each assess the number of tics. on a 5-point likert-type scale for each tic the respective intensity (very mild to severe, irritates others), frequency (a few times a week to constantly, every few minutes), and overall impairment (very low, hardly disturbs to extreme) is assessed. additionally, the scl-tic-s assesses overall controlla­ bility (very low to very high). a tic symptom score (range: 0 – 16) is calculated by multiplying intensity with frequency for each tic, summing up the results and dividing the sum by the number of tics (döpfner & görtz-dorten, 2017). internal consistency of the scl-tic total score in the current study was excellent (α = 0.91 for scl-tic-s, α = 0.92 for scl-tic-p). the premonitory urge to tic scale (puts) consists of 10 items and assesses pus (woods et al., 2005). we used the german translation (rössner et al., 2010). the 10th item asks about tic controllability and is usually excluded or interpreted separately to sustain internal consistency (woods et al., 2005). puts’ internal consistency in the current study was acceptable (α = .75 for puts-9, α = .71 for puts-10). experimental measures the mental tracking paradigm (schandry, 1981) was employed to assess iacc based on cardiac sensibility. participants were instructed to concentrate on their heartbeats for three randomly presented time intervals (à 25s, 35s and 45s) and silently count the perceived heartbeats. they were instructed to only count heartbeats that they felt (koch & pollatos, 2014). after a trial run, ecg-electrodes assessed the participant’s ecg (sample rate: 512 hz) and heart beats were assessed online using the software uvariotest (gerhard mutz, cologne, compare meyerholz et al., 2019). a sound signal indicated begin and end of each time interval. participants were not allowed to measure their pulse or time and were not informed about their average heart rate nor the length of each time interval. the mental tracking paradigm is applicable for children and youth at least 10 years old (koch & pollatos, 2014). in the current study, internal consistency of the iacc score for heart activity (hiacc) based on the scores of the three time intervals was good (α = 0.94). facial emg was assessed by skin electrodes placed on the masseter and corrugator supercilii on the left side of each participant’s face. emg placement followed the emg guidelines by (fridlund & cacioppo, 1986). muscle tension iacc was assessed with a paradigm originally developed by flor et al. (1992). reported muscle tension and emg measures were correlated to form an iacc score for the masseter (miacc) and corrugator supercilii (ciacc), respectively. we opted for two facial muscles that have previously been used in muscle discrimination tasks, because most td patients display facial tics (flor et al., 1992). during the task, participants looked at a screen that represented their muscle tension as measured by emg. muscle tension was visualized by a soccer ball schütteler, woitecki, döpfner, & gerlach 5 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ that moves along a line colored in red, green and yellow. participants were instructed to keep the soccer ball in the green target zone for 2.5 seconds by tensing their facial muscles accordingly. a sound signal indicated the successful completion of the task. af­ ter regulating the respective muscle, participants reported the degree of muscle tension they believed the task required on a likert-type scale ranging from 1 to 5. since the axis of the colored line changed with the task (i.e., the green zone represented different intensities of muscle tension), participants needed to rely on interoceptive information only. overall, participants went through 16 tasks as described above for each muscle. the required muscle tension levels varied in equal parts between 15%, 30%, 45% and 60% of the maximal achievable tension level for each participant. this maximal achievable tension level for each participant had been measured directly before the perception task by asking participants to tense the respective muscle as much as possible. data analysis the correlation between perceived and via emg measured muscle tension represent masseter and corrugator iacc scores, respectively. the heartbeat perception accuracy score (hiacc) indicated the ability to perceive one’s own heartbeat accurately and was calculated by employing the following formula with i = time intervals (25s, 35s, 45s) and no = measured heartbeats ns = counted heartbeats: hiacc = 1 3 ∑ i = 1 3 1 − noi − nsi noi the resulting scores ranged between 0 to 1 with higher scores indicating higher cardiac accuracy. independent samples two-tailed t-tests or chi2-tests were used to compare clinical between group measures and group differences in iacc scores. effect sizes are indicated by cohen’s d. all statistical tests are two-sided with p < .05. pearson-productmoment-correlations and multiple regressions determined the relation between iacc scores and tics or pus, respectively. we used spss for these calculations. results interoception in youth with tic disorders does not differ from healthy controls when investigating iacc scores, n = 2 masseter datasets, n = 5 corrugator datasets and n = 1 hiacc dataset needed to be excluded due to technical failure. on average m = 13.18 corrugator trials (range from 2 to 16 trials) and m = 14.92 masseter trials (range from 10 to 16 trials) were valid and could be included. interoception and urges in tics 6 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ table 1 displays descriptive statistics for each group and group comparisons between td patients and hcs. td patients’ and hc’s masseter and corrugator iacc scores are shown in table 1. masseter and corrugator iacc scores did not significantly differ be­ tween td patients and hcs. td patients and hcs did not significantly differ in any of the three iacc measures, even when td patients with comorbidities were excluded and the analysis was repeated (hiacc: t = -0.414, df = 49, p = .68; miacc: t = -1.795, df = 38, p = .08; ciacc: t = -1.309, df = 40, p = .20). table 1 group differences variable td patients healthy controls t (df) p cohen's dn m (sd) n m (sd) age 28 12.65 (2.21) 23 12.86 (2.47) t = -0.324 (df = 49) .75 -0.09 cbcl total score 27 32.19 (17.13) 21 11.24 (7.84) t = 5.188 (df = 46) < .001*** 1.51 ysr total score 26 49.96 (18.50) 23 45.26 (10.62) t = 1.072 (df = 47) .29 0.31 interoceptive accuracy scores hiacc 27 0.59 (0.28) 23 0.61 (0.29) t = -0.244 (df = 48) .81 -0.07 miacc 26 0.42 (0.32) 23 0.53 (0.33) t = -1.115 (df = 47) .27 -0.32 ciacc 26 0.26 (0.36) 20 0.43 (0.34) t = -1.614 (df = 44) .11 -0.48 note. cbcl = child behavior checklist; ysr = youth self report; hiacc = heartbeat perception accuracy score; miacc = masseter interoceptive accuracy score; ciacc = corrugator interoceptive accuracy score. ***p < .001. iacc in a proprioceptive perception task explains variance in premonitory urges in youth scl-tic-s score was m = 5.54 (sd = 2.98, n = 26), mean scl-tic-p score was m = 6.22 (sd = 3.33, n = 27). the mean puts total score for 9 items was m = 18.14 (sd = 5.02, n = 28). ciacc and miacc correlated substantially with each other indicating internal validity, while not correlating significantly with hiacc. table 2 gives an overview over correlations between interoception scores and tic symptoms including pus. table 2 pearson correlations variable 1 2 3 4 5 6 1. puts-9 r – .14 .47 -.06 .39 .24 p .50 .01 .77 .05 .22 n (27) (26) (26) (26) (27) schütteler, woitecki, döpfner, & gerlach 7 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ variable 1 2 3 4 5 6 2. scl-tic-p r – .34 .06 .11 .00 p .08 .77 .59 .99 n (27) (26) (25) (27) 3. scl-tic-s r – .12 .36 .07 p .57 .08 .73 n (26) (25) (27) 4. ciacc r – .58** -.30 p .00 .14 n (25) (26) 5. miacc r – -.23 p .27 n (25) 6. hiacc – note. puts-9 = premonitory urge to tic scale (9 items); scl-tic-s = self-rated symptom-checklist for tic disorders; scl-tic-p = parent-rated symptom-checklist for tic disorders; ciacc = corrugator interoceptive accuracy score; miacc = masseter interoceptive accuracy score; hiacc = heartbeat perception accuracy score. *p < .05. **p < .01. table 3 linear model of predictors of puts-9 total scores with confidence intervals reported in parentheses predictors b 95% ci se b β p zero-order correlation partial correlationll ul step 1 constant 13.45 9.39 17.50 1.96 < .001** scl-tic-s 0.78 0.13 1.42 0.31 .46 .02* .462 .462 step 2 constant 9.70 4.00 15.40 2.73 .002* scl-tic-s 0.50 -0.15 1.14 0.31 .30 .12 .462 .340 hiacc 5.14 -1.51 11.79 3.19 .29 .12 .279 .339 ciacc -4.40 -10.62 1.82 2.98 -.31 .16 -.059 -.313 miacc 8.09 0.88 15.31 3.46 .52 .03* .378 .464 note. r 2 = .21 (p = .020) for step 1, δr2 = .22 (p = .08) and r = .43 (p = .02) for step 2. puts-9 = premonitory urge to tic scale (9 items); scl-tic-s = self-rated symptom-checklist for tic disorders; scl-tic-p = parentrated symptom-checklist for tic disorders; ciacc = corrugator interoceptive accuracy score; miacc = masseter interoceptive accuracy score; hiacc = heartbeat perception accuracy score. *p < .05. **p < .01. interoception and urges in tics 8 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ in youth, tic symptoms vary substantially with age parallel to pus, so tic severity should be accounted for when investigating pus. multiple regression analysis was used to investigate how iacc relates to pus. with puts total score as the dependent variable, self-reported tic total score was entered in step 1 to control for tic severity. hiacc and ciacc and miacc scores were entered in step 2. adding the iacc scores in step 2 led only to a marginally significant change in r 2. note, however, that the miacc score explained significant variance in pus in addition to tic severity in model 2 (compare table 3). discussion in the present sample of children and adolescents with and without tics, we found that neither hiacc nor proprioceptive iacc scores differed between these groups. these results are in line with recent studies that also did not find any difference in interocep­ tive accuracy (iacc) in children with td (pile et al., 2018). our study extends those findings to the perception of muscle tension. although iacc scores were numerically lower in participants with td, these differences did not reach significance (d = -.07 – .43). whereas lower hiacc compared to hcs has been established in adult td patients, we were not able to demonstrate such differences in our sample of children and adolescents. however, such differences in ia may evolve with increasing age of the td, equal to increasing duration of a childhood-onset td and may be compared to a model of altered interoception in children with chronic pain: top-down processes, such as expectations of uncontrollably ticcing, and bottom-up processes, such as a stressed bodily state, may lead to altered interoception over time (hechler, 2021). it would consequently be highly interesting to assess a sample of adult individuals with td using our muscle tension paradigm. within td patients, recent studies found iacc to be positively correlated with pus in adults (ganos et al., 2015; rae et al., 2019). our findings corroborate this assumption. adding iacc scores (miacc, ciacc and hiacc) to tic severity scores when predicting pus, a substantial (δr 2 = .22) additional amount of variance in pus was explained. note, that neither masseter nor corrugator ia scores were significantly correlated with hiacc. consequently, these different measures of interoceptive ability may cover different facets indicating that different body domains may matter when assessing ia. when taking a closer look at the results, the miacc (r = .39) correlated more strongly with the puts than the ciacc (r = -.06), which even correlated negatively with the puts. in contrast to the corrugator supercilii, the masseter is more frequently contracted deliberately and thus might it be easier to control and it might be easier to estimate its tension. arguably, this may result in a more reliable measure. however, the corrugator supercilii is linked with emotional expression (tan et al., 2012) and, arguably, the location of the corrugator supercilii overlaps with locations most frequently affected by tics (mcguire et al., 2016). schütteler, woitecki, döpfner, & gerlach 9 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ we therefore recommend that future studies nonetheless continue to assess both facial muscles when looking at ia with regard to muscular tension. herbert et al. (2012) compared interoceptive accuracy in eating disorders across two bodily domains – cardiac and gastric –and showed them to be inversely correlated. similarly, we found cardiac and muscular iacc to be inversely correlated in td (rciacc = -.30, rmiacc = -.23), although not reaching significance. following the interpretation by herbert et al., trying to control muscles that feel uncontrollably at times, might increase activation in the sympathetic nervous system which in turn might increase cardiac iacc. in line with flack et al. (2017), activation in the sympathetic nervous system might as well be the result of heightened levels of fear when focusing on muscles associated with unpleasant tic execution. hiacc score did marginally significantly correlate with the puts in our sample of children and adolescents. children have smaller hearts and a lower stroke volume, associated with a higher heart rate which influences heartbeat detection positively (knapp-kline & kline, 2005). in light of this it may be concluded that increased hiacc promotes the perception of pus in children. in summary, these results on the association between ia and pu provide an ambigu­ ous picture. on the one hand, ia clearly is associated with pu, but the direction of this association remains unclear. following our hypotheses, we would have assumed that ia should be negatively associated with pu, as was the case for corrugator perception. in contrast, we find a clear positive association between the perception of cardiac activity as well as tension of the masseter and pu. obviously, more research is needed here. note that the findings linking interoception and pus rely on the puts to represent pus. however, the puts is a self-report measure that more likely represents interocep­ tive sensibility. interoceptive sensibility is known to be altered in children and adults with td (owens et al., 2011; rae et al., 2019) and the measure is challenged by the usual problems associated with self-reports. the relative relationship of interoceptive accuracy, interoceptive sensibility und interoceptive awareness constitute pus’ presence and cognitive, emotional and clinical consequences (garfinkel et al., 2015). we find it especially intriguing to interpret our findings within the predictive coding framework (ainley et al., 2016; friston, 2010; khalsa et al., 2018; rae et al., 2019). in this framework, a difference between sensory input and prior expectation results in a prediction error. following bayesian inference, the prediction error may be resolved by updating the prior expectation or executing a movement to change sensory input. in td patients, in hierarchical higher brain structures, an over-precise interoceptive prior might predict movements. if the weak bottom-up sensory input does not correspond with this prediction, the insula has to resolve the resulting interoceptive prediction error. the anterior insula is hypothesised to update predictions to reduce prediction errors (seth, 2013; seth et al., 2012) and is known to show functional abnormalities in td patients. due to the prior’s over-precision and weight, imprecise sensory input may be interoception and urges in tics 10 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ overcome by the prediction and the prediction error is being ‘explained away’ by the anterior insula as a premonitory sensation (urge to move). in adults, lower iacc is found which, arguably, indeed indicates weaker priors. however, in line with previous research in adults (ganos et al., 2015), we found that lower ia (heart activity and tension of the masseter) is correlated with lower pus. assuming that good ia, over time, leads to weaker priors, a smaller prediction error may result in less pu. in contrast, ia for the tension of the corrugator, was negatively correlated with pu. following this finding, one could argue that the worse the perception of actual physical sensations in areas in which tics occur the more top-down predictions will overshadow interoceptive sensations and result in the perception of pus (perceptual inference). there are a number of limitations to the current study that offer opportunities for fu­ ture research. studies investigating the perception of muscle tension in adult td patients are yet to be conducted to gain further insights on the development of pus over the life span. since the current cross-sectional study allows correlative interpretations only, the longitudinal comparison of chronological changes in hiacc, miacc and ciacc scores, puts and urge thermometers over the lifespan would provide further information on their etiological meanings. in addition, the exploratory findings on ia in child and adolescent td patients need to be replicated, preferably in larger samples. our study exclusively focused on iacc in youth with td. future studies may extend our findings to interoceptive sensibility to disentangle the influence of interoceptive sensibility and iacc on the self-reported perception on premonitory urges. altogether, our sample size was relatively small, compromising statistical power to some degree. td patients usually differ from hcs not only with regard to tics but also with regard to comorbidities such as adhd or ocd, depression or anxiety. when comparing td patients to typically developing children, our study cannot account for the impact of comorbidities such as adhd or ocd due to the relatively small sample size. therefore, the relationship between interoception and tics and pus in td patients with multiple comorbid diagnoses is hard to disentangle. panic and somatic ratings, for example, were found to correlate with higher hiacc in adults in children (eley et al., 2007). comparing td patients with a control group exhibiting matching comorbidities could help to disentangle the complex influences of comorbidities on iacc and pus. in line with pile et al. (2018), additional instructions could be added to muscle tension perception tasks to reduce effects of inattention, a frequent comorbid symptom in td patients, and task-misunderstanding. the puts measures pus as a whole but does not differentiate between contextand time-dependent urges as a state and the pu as a general trait. it is yet to be examined how contextand time-dependent urges, measured by urge thermometers, vary in rela­ tion with changes in pus as a trait and changes in iacc. similar to the puts that measures pus as a general trait, the scl-tic-s and scltic-p measure selfand parent-reported mean tic severity over the course of a week. it schütteler, woitecki, döpfner, & gerlach 11 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ is not clear how accurate self-assessed tic frequency reflects actual tic expression. on the one hand, both child and adult patients underestimate their tic expression (müller-vahl et al., 2014; pappert et al., 2003). on the other hand, parent-reports cannot be accurate either. at least adolescent patients are not observed by their parents most of the day and tic frequency highly depends on context. another study compared children’s self-re­ ported account of tic frequency to objective video ratings of tic frequency in various experimental situations. self-reported tic frequency related to objective measures depen­ ded on the situation. interestingly, the higher children scored on the puts, the better their self-report predicted objective tic-frequency (barnea et al., 2016). this implies that self-reported tic frequency depends on pus and probably iacc. still, as our multiple re­ gression analysis showed, ia explains variance in addition to self-reported tic frequency. the moderate correlation with parent-reported tic-frequency (r = .34) further validates self-reported tic-frequency. the current study holds clinical implications. interoceptive trainings specifically targeting interoceptive domains that are impaired in td may be more beneficial than multisystem interventions (khalsa et al., 2018), so research on the impact of interoceptive trainings aimed at improving heartbeat perception (schaefer et al., 2014) could be expan­ ded by adding muscle tension biofeedback tasks to improve accuracy of urge perception to foster the ability to control tics via hrt. observations from intervention studies examining muscle tension biofeedback in td would provide further insights in causal relationships between iacc, pus and tics. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: christina schütteler reports no conflict of interest. katrin woitecki received royalties from treatment manuals published by hogrefe. manfred döpfner received consulting income and research support from lilly, medice, takeda, and eyelevel gmbh and research support from the german research foundation, german ministry of education and research, german ministry of health, and innovation fund. he received income as head, supervisor, and lecturer of the school of child and adolescent cognitive behaviour therapy at the university hospital cologne and as consultant for child behaviour therapy at the national association of statutory health insurance physicians (kassenärztliche bundesvereinigung). he also received royalties from treatment manuals, books and psychological tests published by beltz, elsevier, enke, guilford, hogrefe, huber, kohlhammer, schattauer, springer, wiley. alexander l. gerlach reports no conflict of interest. data availability: for this article, a data set is freely available (schütteler, woitecki, döpfner, & gerlach, 2020). interoception and urges in tics 12 clinical psychology in europe 2023, vol. 5(1), article e8185 https://doi.org/10.32872/cpe.8185 https://www.psychopen.eu/ supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • pre-registration protocol • research data index of supplementary materials schütteler, c., woitecki, k., döpfner, m., & gerlach, a. l. (2020). supplementary materials to "interoception and premonitory urges in children and adolescents with tic disorders" [preregistration protocol]. osf registries. https://doi.org/10.17605/osf.io/v3zky schütteler, c., woitecki, k., döpfner, m., & gerlach, a. l. (2021). supplementary materials to "interoception and premonitory urges in children and adolescents with tic disorders" [research data]. figshare. https://doi.org/10.6084/m9.figshare.17121632 references ainley, v., apps, m. a. j., fotopoulou, a., & tsakiris, m. (2016). ‘bodily precision’: a predictive coding account of individual differences in interoceptive accuracy. , philosophical transactions of the royal society: b. biological sciences, 371(1708), article 20160003. https://doi.org/10.1098/rstb.2016.0003 barnea, m., benaroya-milshtein, n., gilboa-sechtman, e., woods, d. w., piacentini, j., fennig, s., apter, a., & steinberg, t. 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participants procedure questionnaires experimental measures data analysis results interoception in youth with tic disorders does not differ from healthy controls iacc in a proprioceptive perception task explains variance in premonitory urges in youth discussion (additional information) funding acknowledgments competing interests data availability supplementary materials references implicit attitudes toward psychotherapy and explicit barriers to accessing psychotherapy in youths and parent–youth dyads research articles implicit attitudes toward psychotherapy and explicit barriers to accessing psychotherapy in youths and parent–youth dyads simone pfeiffer 1 , ashley huffer 1, anna feil 1, tina in-albon 1 [1] department of clinical child and adolescent psychology and psychotherapy, university of koblenz-landau, landau, germany. clinical psychology in europe, 2022, vol. 4(3), article e7375, https://doi.org/10.32872/cpe.7375 received: 2021-08-23 • accepted: 2022-06-14 • published (vor): 2022-09-30 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: simone pfeiffer, clinical child and adolescent psychology and psychotherapy, university of koblenz-landau, ostbahnstraße 12, 76829 landau, germany. phone: +49 6341 280 35615. e-mail: pfeiffer-s@unilandau.de abstract background: few studies have investigated implicit and explicit attitudes toward psychotherapy in youths (study 1), although information about attitudes would improve interventions that aim to decrease barriers to accessing psychotherapy including parents (study 2), who facilitate the helpseeking process of youths. method: the study 1 sample comprised 96 youths (14–21 years) and the study 2 sample 38 parent–youth dyads. differences in implicit attitudes regarding psychotherapy and a medical treatment were measured with the implicit association test, and psychotherapy knowledge and self-reported barriers to psychotherapy were assessed with questionnaires. the actor-partner interdependence model was used to test the dyadic effects of implicit attitudes on explicit attitudes in parents and youths. results: we did not find evidence for an implicit bias toward psychotherapy compared to a medical treatment, neither in youths, nor in parents. self-reported barriers were a predictor for lower help-seeking intentions. deficits in psychotherapy knowledge were more relevant in younger participants. having a prior or current experience with psychotherapy and having a friend or family member with a prior or current experience with psychotherapy were predictors for better psychotherapy knowledge, but was not for lower barriers to accessing psychotherapy. partner effects (degree to which the individual’s implicit attitudes are associated with explicit attitudes of the other dyad’s member) were not found. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7375&domain=pdf&date_stamp=2022-09-30 https://orcid.org/0000-0002-6866-8221 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: specific deficits in psychotherapy knowledge should be addressed in interventions to lower barriers accessing psychotherapy. parents should be included in interventions as a valuable resource to support youths in seeking psychotherapy for mental disorders. keywords implicit association test, psychotherapy, barriers, mental disorders, stigma, youths highlights • implicit attitudes toward psychotherapy were comparable with attitudes toward a medical treatment. • youths reported explicit barriers to accessing psychotherapy and exhibited deficits in psychotherapy knowledge. • interventions aiming to reduce barriers to accessing psychotherapy should address specific knowledge deficits in youths. • parents should be included in interventions as a valuable resource to support youths in seeking psychotherapy for mental health problems. stigmatizing attitudes toward people with mental disorders as a barrier of help-seeking have been widely studied (aguirre velasco et al., 2020; gulliver et al., 2010; radez et al., 2021), however, there is a lack of studies investigating attitudes toward mental health care, especially psychotherapy, in youths. in their mental illness stigma framework, fox and colleagues (2018) distinguish between experienced stigma and internalized stigma as a consequence of self-disclosure and anticipated stigma toward psychotherapy (the extent to which a person with a mental disorder expects to be the target of stereotypes, prejudice, or discrimination in the future), which is the focus of our study. in adult samples, negative attitudes toward mental health care use, especially the presence of stigma, low perceived efficacy of treatments, or the desire to handle the problem on their own, are the most common barriers to seek treatment for mental disorders (andrade et al., 2014; mojtabai et al., 2011; van voorhees et al., 2006). when asked specifically about psychotherapy, adults have reported mainly positive attitudes (petrowski et al., 2014) yet also that they would be ashamed if neighbors and friends knew about the use of psychotherapy (albani et al., 2013). most of those studies use explicit measures to assess attitudes toward mental health care, implicit measures however can elicit more spontaneous responses than explicit measures, whereas explicit measures are related to deliberative decisions about the con­ formation or rejection of attitudes. there is evidence that the assessment of implicit and explicit attitudes are distinct measures with a rather weak relationship and the need to consider (negative) attitudes as a multifaceted construct (brauer et al., 2000). the combination of implicit and explicit measures to assess barriers toward psychotherapy might be promising in capturing the complexity of attitudes toward psychotherapy. implicit and explicit attitudes toward psychotherapy 2 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ studies investigating implicit attitudes toward mental disorders using the implicit association test (iat) found that adults reported a more negative implicit attitude to­ ward people with mental disorders than toward people with a physical illness (gonzálezsanguino et al., 2020; teachman et al., 2006). o’driscoll et al. (2012) found higher stigmatization for a vignette describing an individual with depression compared to an individual with attention-deficit/hyperactivity disorder in boys, but not in girls. in a sample of young adults, depression was associated with more implicit, but not explicit, negative attitudes compared to a physical illness (monteith & pettit, 2011). little is known about the effects of implicit attitudes toward psychotherapy with regard to low treatment rates for mental disorders in youths and negative attitudes toward people with mental disorders. negative attitudes are influenced by gender, age, and personal experience with men­ tal disorders and help seeking. in men compared to women, there is evidence of lower help-seeking intentions for mental health problems (addis & mahalik, 2003; oliver et al., 2005; petrowski et al., 2014) and less mental health knowledge (farrer et al., 2008). boys compared to girls have reported higher mental health stigma and less willingness to use mental health services (calear et al., 2011; chandra & minkovitz, 2006; gonzalez et al., 2005). further, there is evidence that higher age is associated with higher mental health knowledge and a less stigmatizing attitude (farrer et al., 2008; swords et al., 2011) and more acceptance of peers with mental disorders (swords et al., 2011). a prior experience with a mental disorder or psychotherapy, or familiarity with someone who has a mental disorder, which is associated with less stigmatizing attitudes in children, youths, and adults (bellanca & pote, 2013; griffiths et al., 2008; sandhu et al., 2019) may be seen as protective factors for stigmatizing attitudes. the identification of possible risk factors (e.g., gender, specific age group) might enable to develop ageor gendertailored interventions to reduce barriers toward psychotherapy or interventions, which include contact to a person with a prior experience of psychotherapy. parental role in attitudes toward psychotherapy children and youths often prefer informal sources of help for mental disorders, such as parents (rickwood et al., 2005). when assessing attitudes toward psychotherapy in youths, it is important to include parental attitudes, as they are important key gatekeep­ ers to mental health care access and as they also report negative attitudes toward mental health care (reardon et al., 2017). despite youths’ growing autonomy, their decision to seek professional help for mental health problems is highly influenced by their parents (gulliver et al., 2012; rickwood et al., 2005; ryan et al., 2015), who are often the first to recognize mental health problems in their children and the need for help. in their model for a parent-mediated pathway to mental health services for adolescents, logan and king (2001) emphasized the important role of parent’s attitudes toward mental health care in the help-seeking process of their child. pfeiffer, huffer, feil, & in-albon 3 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ youths’ willingness to seek help is higher when they think their parents support the use of mental health services (chandra & minkovitz, 2006; wahlin & deane, 2012) and lower when they think their parents would be ashamed of them because of their mental health problems (moses, 2009). little is known about whether youths report similar attitudes toward mental health to those of their parents. there is evidence that youths seem to agree with their parents’ evaluation of the helpfulness of mental health services (jorm & wright, 2007) but that parents and youth differ in their knowledge and explicit attitudes toward mental disorders, with youths showing higher stigma scores and less mental health knowledge compared to their parents (lorona & miller-perrin, 2016). there is, however, a lack of research evaluating implicit and explicit attitudes toward psychotherapy and their relationship which each other in parent–youth dyads. aims of the study in study 1, the first aim was to compare implicit attitudes toward psychotherapy with attitudes toward a medical treatment using the iat (greenwald et al., 1998). we decided to contrast psychotherapy with a medical treatment to control for attitudes that are generally associated with help-seeking behavior for (mental) health problems (e.g., being confronted with symptoms of [psycho]pathology). in this study, we were particularly interested if attitudes differ about consulting a pediatrician or general practitioner for health-related symptoms versus a psychotherapist for mental health problems. the second aim was to assess explicit barriers to accessing psychotherapy as well as psy­ chotherapy knowledge in youths and their influence on help-seeking intentions, for which we used a self-report questionnaire. we hypothesized that higher positive implicit attitudes toward psychotherapy compared to a medical treatment, higher psychotherapy knowledge, and lower explicit barriers to accessing psychotherapy would be associated with higher help-seeking intentions. as there are gender and age differences in attitudes toward mental health care, we evaluated if male participants reported more negative attitudes toward psychotherapy than female participants and if negative attitudes toward psychotherapy decrease with age. the analysis of differences between different educa­ tion levels were analyzed exploratively. we further expected fewer barriers to accessing psychotherapy and better psychotherapy knowledge in participants with a prior or current experience with psychotherapy and in those who had a friend or family member involved in psychotherapy. in study 2, we investigated parents and youths’ implicit and explicit attitudes (barriers) toward psychotherapy and their relationship considering the dyadic structure of the data. implicit and explicit attitudes toward psychotherapy 4 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ study 1 method participants a total of 96 youths between the age of 14 and 21 years participated in this study (m = 18.4 years, sd = 2.1). in this sample, 68% self-identified as female and 32% as male. in terms of education, 69% attended a secondary school, 21% a university, and 10% a voca­ tional school. nineteen percent had a prior or current experience with psychotherapy and 72% rated the experience as positive. in all, 72% were familiar with someone having sought or seeking psychotherapy and 78% rated that person’s experience as positive. participants were recruited online via social media and in local secondary schools. the inclusion criterion to participate in the study was being between 14 and 21 years of age. we chose the age of 14 years because youth can participate in studies without a written parental consent and 21 years as this is the age limit for child and adolescent psychotherapy in germany. measures implicit association test (iat) — the iat (greenwald et al., 1998) is a computerized dichotomous categorization task measuring association strengths between concepts and attributes. the outcome measure is response time (milliseconds), with shorter latencies indicating stronger automatic associations of concepts with the stimulus group. the key iat assumption is that participants show faster reaction times when stimuli are paired in ways that are consistent versus inconsistent with well-learned automatic associations, that is, implicit biases. the iat is a relative assessment; that is, evaluations of one group are compared with evaluations of a second group (greenwald et al., 1998). regarding the concepts, psychotherapy and a medical treatment were compared using words as stimuli. psychotherapy was primed with words psychotherapist, psycho­ therapist’s practice, psychological conversation, psychology, and children’s and adolescents’ psychotherapist; medical treatment was primed with general practitioner, general practi­ tioner’s practice, medical exam, medicine, and pediatrician. we chose positive and negative attributes associated with psychotherapy (maier et al., 2014). positive attributes were pro­ fessional, effective, trustworthy, competent, and meaningful and negative attributes were unprofessional, ineffective, untrustworthy, incompetent, and meaningless. the categoriza­ tion of concepts and attributes was checked in advance with four youths that correctly assigned the priming words to the concepts and the attributes. in our pilot study, we evaluated time-differences for concepts and attributes and did not find differences between the concept “medical treatment” and “psychotherapy”, t(8)= 0.87, p = .38 or between the attributes “positive” and “negative”, t(8)= 0.29, p = .77. the iat was constructed with online-survey software, a valid and reliable approach (carpenter et al., 2019) using sosci-survey (leiner, 2019). the iat consists of seven pfeiffer, huffer, feil, & in-albon 5 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ “blocks” (sets of trials) and in each block, participants see a stimulus (word) on the screen. stimuli represent concepts (medical treatment or psychotherapy) or attributes (positive negative). when stimuli appear, the participant “sorts” the stimulus as rapidly as possible by pressing with either their left or right hands on the keyboard (the “e” an “i” keys). the sides with which one should press are indicated in the upper left and right corners of the screen. if the target word was a member of the category listed on the left side of the screen, the participants were to respond with the e key. if the target word was a member of the category listed on the right side of the screen, the participants were to respond with the i key. a correct response was required before continuing to the next slide and response latencies were recorded from the presentation of the stimulus to the correct response. the initial pairing of concepts and attributes was counterbalanced across participants. the interstimulus interval was 300 ms. block 1 is used to practice the two categories; participants distinguished between the target categories of medical treatment and psychotherapy. the priming words were presented in a random order and were distinguished by designated keys on the left or right side of the keyboard (e.g., left for medical treatment, right for psychotherapy). block 2 is used to practice the attributes (positive vs. negative); participants distinguished positive attributes from negative attributes presented on the screen. block 3 is the first pairing of categories and attributes; participants distinguished between medical treatment and positive attributes versus psychotherapy and negative attributes by pressing the designated keys. block 4 repeats the block 3 pairings. in block 5, responses to the positive attributes and negative attributes are reversed. both blocks 6 and 7 are test blocks that consist of the second category and attribute pairing; participants distinguished between medical treatment and negative attributes versus psychotherapy and positive attributes. the order in which each pairing was presented and associated with the key on the right or left side of the keyboard (blocks 3 and 4 vs. blocks 6 and 7) was randomized. barriers to accessing psychotherapy — to assess explicit barriers to accessing psy­ chotherapy, we developed a self-report questionnaire. first, we conducted a literature review on attitudes toward psychotherapy, from which we drew 13 statements (table 1). in a pilot study, youths (n = 9) rated the comprehensibility of the statements on a 6-point likert scale (1 = totally disagree, 6 = totally agree). to explore the factor structure, the 13 items were subjected to an exploratory analysis with oblique rotation. the kaiser–mey­ er–olkin (kmo) measure verified the sampling adequacy for the analysis (kmo = 0.85). bartlett’s test of sphericity, χ2(78) = 406.72, p < .001, indicated that the correlation struc­ ture was adequate for factor analysis. a maximum likelihood factor analysis with a cutoff point of .40 and kaiser’s criterion of eigenvalues greater than 1 yielded a one-factor solution as the best fit for the data, with the root mean square of residuals = 0.06, the root mean square error of approximation = 0.08, and the tucker–lewis index = 0.96, an acceptable value considering it is over 0.9. one item (“i would prefer other treatment implicit and explicit attitudes toward psychotherapy 6 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ options than psychotherapy”) did not load on the factor and was excluded from further analyses. internal consistency was good with mcdonald’s omega = 0.88. help-seeking intention and familiarity with psychotherapy — we asked partici­ pants to rate their anticipated probability of initiating psychotherapy in the event of serious mental health problems (0–100%) and to indicate if they had current or past experience with psychotherapy themselves, and if they had a friend or family member who had current or past experience with psychotherapy. they also rated whether the experience (or reported experience) was positive (1) or negative (0) using a dichotomous item. the items were taken from a previous study (pfeiffer & in-albon, 2022). psychotherapy knowledge — we assessed psychotherapy knowledge with a self-de­ veloped questionnaire with 11 statements based on a literature search (e.g., knowledge about the professional confidentiality, the nonpsychoanalytical setting, multifactorial causes of mental disorders), which are listed in table 3. six licensed psychotherapists rated the statements for correctness and we made adjustments in two steps. first, we used fleiss’s kappa to measure interrater reliability. we found κ = 1 (perfect agreement) for nine of the items and lower kappas for item 1 (κ = .5) and item 5 (κ = .33). these two items were then revised and rated again, resulting in perfect interrater agreement of κ = 1 for all items. participants were asked to indicate if the statements were true or false or to indicate that they did not know the answer (“i don’t know”). before conducting the pilot-study, we conducted a pretest with four youths who rated the statements for sufficient feasibility, which lead to the revision of one item because of the use of professional jargon. procedure the local ethics committee approved the study (reference number: lek_262). parents and youths were informed about the content and aims of the study. written consent in accordance with the declaration of helsinki from parents and youths was mandatory for participants. we conducted a pilot study in advance with n = 9 youths to test the feasibility of the study design. parents and youths received a link and a qr code to participate in the online study. study duration was 20-25 minutes. researcher were available to answer questions during the study. participants did not receive compensation. data processing and statistical analyses statistical analyses were conducted with r (version 4.03). for the evaluation of implicit attitudes, we used the improved d score (greenwald et al., 2003), which measures the strength and direction of the implicit association. we included all participants who pfeiffer, huffer, feil, & in-albon 7 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ completed the study. reaction times faster than 300ms and slower than 10 seconds were excluded from further evaluation (n = 1). positive improved d scores suggest a stronger association between medical treatment and positive attributes than psychotherapy and negative attributes. negative d scores suggest that the association between psychotherapy and positive attributes is higher compared to medical treatment and negative attributes. for psychotherapy knowledge, we calculated the total score using the number of correct answers (correct answer = 1; wrong answer or “i don’t know” = 0). exploratively, we examined if implicit attitudes toward psychotherapy and barriers to accessing psy­ chotherapy as well as psychotherapy knowledge varied with gender, age, or education using a multivariate analysis of variance and multiple regression analysis. an apriori power analysis was conducted with g*power (faul et al., 2007). for the manova a sample size of n = 84 is necessary to detect a small effect, f2 = 0.10, 1-ß = 0.95, α = 0.05. for the multiple regression analysis, a sample size of n = 70 is necessary to detect a small effect, f 2 = 0.10, 1-ß = 0.95, α = 0.05. multiple regressions were calculated to determine if implicit attitudes toward psychotherapy and barriers to accessing psychotherapy as well as psychotherapy knowledge predict higher help-seeking intentions. multiple regressions were also calculated to determine if a prior or current experience with psychotherapy or familiarity with someone seeking psychotherapy predicts fewer negative implicit attitudes toward psychotherapy, fewer barriers to accessing psychotherapy, and better psychotherapy knowledge. we used dummy variables with 1= prior or current experi­ ence and 0= the absence of a prior or current experience. results iat we did not find evidence for a stronger association neither for positive nor for negative attributes with psychotherapy compared to a medical treatment with an improved d score of m = 0.09 (sd = 0.41). barriers to accessing psychotherapy the descriptive statistics regarding explicit barriers to accessing psychotherapy indicate an overall moderate agreement with barriers (table 1). help-seeking intention and familiarity with psychotherapy the intention to seek psychotherapy in the event of mental health problems had a median of 60% (range 0–100%). multiple linear regressions indicated an overall effect for implicit attitudes, explicit barriers and psychotherapy-knowledge as predictors for helpseeking intentions, r 2 = .23, f(3, 91) = 8.91, p < .001, with a significant effect in explicit barriers to accessing psychotherapy as predictor for lower help-seeking intention, b = implicit and explicit attitudes toward psychotherapy 8 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ -1.20, ß = -0.45, ci 95% [-1.71, -0.69], se_b = 0.25, t(91) = -4.72, p < .001, whereas implicit attitudes, b = -0.43, ci 95% [-0.63, 1.49], ß = 0.08, se_b = 0.53, t(91) = 0.81, p =.42 and psychotherapy knowledge, b = 0.07, ci 95% [-0.11, 0.26], ß = 0.08, se_ b = 0.09, t(91) = 0.82, p = .41 were not associated with higher or lower help-seeking intentions. table 1 barriers to accessing psychotherapy in study 1 (youths) and study 2 (youth–parent dyads) item study 1 youths study 2 youths study 2 parents m (sd) m (sd) m (sd) 1. i would be afraid that psychotherapy would make my problems worse. 2.45 (1.18) 2.79 (1.42) 2.34 (1.28) 2. i would be concerned that my problems would not be treated confidentially. 3.03 (1.57) 2.29 (1.35) 2.26 (1.37) 3. i would think that starting psychotherapy costs money and is too expensive. 2.57 (1.50) 2.71 (1.56) 2.21 (1.18) 4. i would be afraid that the psychotherapist would judge me or think something bad about me. 2.50 (1.47) 2.05 (1.14) 1.63 (0.91) 5. i would be afraid that the psychotherapist would admit me to a psychiatric facility against my will. 3.23 (1.48) 2.84 (1.41) 2.26 (1.18) 6. i would think a psychotherapist doesn’t understand my problems. 2.95 (1.37) 3.45 (1.78) 3.63 (1.75) 7. i had negative previous experiences with psychologists/psychotherapists. 2.94 (1.51) 2.26 (1.41) 1.74 (0.95) 8. my parents/my environment would not support me in starting psychotherapy. 2.90 (1.41) 2.16 (1.20) 4.55 (1.35) 9. i would be concerned that starting psychotherapy would say something bad about my family. 3.28 (1.55) 2.58 (1.18) 2.34 (1.02) 10. i would be afraid of not knowing what happens during psychotherapy. 3.39 (1.52) 2.45 (1.25) 2.39 (1.20) 11. i would be afraid to talk about my problems with a psychotherapist. 3.06 (1.41) 3.05 (1.45) 3.05 (1.63) 12. i wouldn’t think psychotherapy would help. 2.58 (1.47) 3.47 (1.61) 4.34 (1.65) total score 2.60 (0.88) 2.67 (0.84) 2.94 (0.49) note. items were rated on a 6-point likert scale (1 = totally disagree, 6 = totally agree). multiple regression analysis were conducted to investigate if a prior or current experi­ ence of psychotherapy or familiarity with a person seeking psychotherapy are predictors of levels in implicit attitudes (model 1), r 2 = .00, f(2, 92) = 1.08, p = 0.34, barriers toward psychotherapy (model 2), r 2 = .00, f(2, 93) = 0.48, p = 0.61, and psychotherapy knowledge (model 3), r 2 = .22, f(2, 93) = 14.21, p < .001, and are reported in table 2. pfeiffer, huffer, feil, & in-albon 9 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ table 2 results from multiple regression analysis for prior or current experience of psychotherapy and familiarity with people seeking psychotherapy as predictors for implicit attitudes (model 1), explicit barriers (model 2), and psychotherapy knowledge (model 3) estimates b se beta (β) t p model 1 (implicit attitudes) intercept 0.14 0.08 0.00 1.75 .08 experience_pt 0.15 0.71 -0.14 -1.35 .18 familiarity -0.04 0.09 -0.04 -0.42 .67 model 2 (explicit attitudes] intercept 2.70 0.17 0.00 15.65 < .001 experience_pt -0.20 0.23 -0.09 -0.85 0.40 familiarity -0.08 0.20 -0.04 -0.38 0.70 model 3 (psychotherapy knowledge) intercept 4.33 0.43 0.00 9.98 < .001 experience_pt 2.00 0.59 0.31 3.40 < .001 familiarity 1.87 0.51 0.33 3.66 < .001 note. experience_pt = prior or current experience with psychotherapy. psychotherapy knowledge participants’ psychotherapy knowledge is reported in table 3. age, gender, and education differences in implicit attitudes, explicit barriers, and psychotherapy knowledge contrary to our expectations, we did not find gender differences, f(3, 93) = 2.09, p = .13, or differences between education levels, f(3, 93) = 0.15 p = .87, in implicit attitudes toward psychotherapy, explicit barriers to accessing psychotherapy, or psychotherapy knowledge as a result of a manova. we conducted a single predictor regression analysis to examine if age is associated with implicit attitudes, explicit barriers, and psychotherapy knowledge and found a significant overall effect, r 2 = .12, f(3, 91) = 3.99, p < .001. higher age was associated with higher psychotherapy knowledge, b = 0.29, ci 95% [0.12, 0.47], ß = 0.35, se_b = 0.09, t(91) = 3.42, p < .001, however age was not a predictor for implicit attitudes, b = 0.32, ci 95% [-0.68, 1.32], ß = 0.06, se_b = 0.50, t(91) = 0.63, p = .53, or explicit barriers seeking psychotherapy, b = 0.31, ci 95% [-0.17, 0.79], ß = 0.13, se_b = 0.24, t(91) = 1.30, p = .20. implicit and explicit attitudes toward psychotherapy 10 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ study 2 method participants in study 2, 38 parent–youth dyads participated. the youths (mage = 18.5 years, sd = 2.0, range: 14–21) had not participated in study 1. here, 68% identified themselves as female. in terms of education, 37% attended a secondary school, 57% a university, 6% a vocational school. the parent sample had an age range of 38–62 years (m = 49.6 b, sd = 5.7) and 76% identified themselves as female. twenty-nine percent had a prior or current experience table 3 percentages of correct, incorrect, and “i don’t know” answers for psychotherapy knowledge items item correct answer (%) incorrect answer (%) i don’t know (%) 1. the costs of psychotherapy are usually covered by health insurance. 47 13 41 2. during psychotherapy, the patient is usually lying on a couch. 77 5 18 3. in a psychotherapy patients take an active part in the decision making concerning the psychotherapy process. 58 7 34 4. mental illnesses often manifest as physical symptoms, e.g., abdominal pain and headaches. 67 14 20 5. over 40% of all people meet the criteria of a mental disorder during their lifetime. 49 7 44 6. the origin of mental disorders is exclusively genetic. 81 4 15 7. the effectiveness of psychotherapy is proven by scientific studies. 53 6 41 8. from the age of 15, i am allowed to start psychotherapy without the consent of my parents. 17 6 77 9. a psychotherapist is allowed to speak with my parents about the content of my psychotherapy without my consent. 72 7 21 10. health insurance pays for trial sessions to find out if i want to work with the therapist. 34 5 60 11. a therapist helps me become an expert on my own problems. 50 11 39 note. percentages do not sum up to 100% due to rounding. pfeiffer, huffer, feil, & in-albon 11 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ with psychotherapy and 64% of them rated the experience as positive. seventy-nine percent were familiar with people having sought or seeking psychotherapy, with 77% rating the reported experience as positive. measures the iat and explicit barriers measure were identical to those in study 1. regarding help seeking, youths were asked if they thought they would receive support from their parents, and parents were asked if they would seek support from their close network. procedure the procedure was identical to that in study 1. parents and youths were asked to create the same code to assign the parent-youth dyad. data processing and statistical analysis statistical analyses were conducted with r (version 4.03). the data treatment was iden­ tical to study 1. three participants were excluded from further analysis because their codes did not match with a corresponded code. descriptive statistics and welch sample t-tests for implicit attitudes and barriers toward psychotherapy between youths and parents were calculated. considering the dyadic structure of the data we conducted an actor-partner-interde­ pendence model (apim) using the lavaan package for structural equation modelling (sem). apims are useful for exploring the dynamic interplay between relational partners, in our case parents and youths (kenny, kashy, & cook, 2006). this model is based on the fact that the scores within the same dyad are not independent but instead are more similar than the scores of two individuals, who are not in the same dyad. the apim is useful to determine how parameters (explicit and implicit attitudes) among youth and parent are influenced by not only internal factors but also factors related to the other member of the dyad. structural equation modeling simultaneously examines both paths in the apim: two actor effects (i.e., each person’s implicit attitudes regressed on his or her own explicit attitudes) and two partner effects (i.e., each person’s implicit attitudes regressed on the other person’s explicit attitudes). results consistent with the results of study 1, we did not find evidence for a stronger association neither for positive nor for negative attributes with psychotherapy compared to a medi­ cal treatment with an improved d score of m = 0.04 (sd = 0.47) for youths and m = 0.12 (sd = 0.51). means and standard deviations for barriers toward psychotherapy are reported in table 2. analyzing mean scores, parents and youths did differ in explicit attitudes, t(44) = 2.88, p = .01, but not in their implicit attitudes, t(73) = 0.70, p = .46. implicit and explicit attitudes toward psychotherapy 12 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ the results of the apim analysis for explicit attitudes and implicit attitudes are set out in figure 1. the goodness of fit measures were good with χ2(n = 38, 6) = 18.68, p = .01, cfi = 1.00, tli = 1.00, rmsea = 0.00, srmr = 0.00 with except for the chi-square test, which is however sensitive to sample size. the actor effect for youths was significant with implicit attitudes being a predictor for explicit attitudes in youths, which has not been the case for the parent sample. there was no evidence for a partner effect. figure 1 path diagram of the actor-partner-interdependence model (apim) with implicit attitudes being a predictor for explicit attitudes implicit attitudes youth explicit attitudes youth implicit attitudes parent explicit attitudes parenta2-0.10 (0.08), p= 0.31 ci 95% [-0.30, -0.16] a1 0.97 (0.25), p<.001 ci 95% [0.42, -1.56] p21 0.01 (0.09), p= 0.90, ci 95% [-0.13, -0.12]) p12 0.03 (0.23), p= 0.87, ci 95% [-0.47 -0.36]) c1 0.03 (0.04), p= 0.46, ci 95% [-0.05 -0.10]) c2 0.05 (0.03), p= 0.08, ci 95% [-0.01 -0.11]) e1 e2 note. a1, a2 = actor effect; p12, p21 = partner effect; c1 = covariance of implicit attitudes between parent and youth; c2 = residual non-independence of explicit attitudes. ***p < .001. general discussion in contrast to the higher stigmatization of mental disorders when compared to physical illnesses (gonzález-sanguino et al., 2020; teachman et al., 2006), psychotherapy was not more stigmatized when evaluating implicit attitudes in comparison to a medical treatment. this result is in line with findings of mainly positive explicit attitudes toward psychotherapy in a general nonclinical adult sample (petrowski et al., 2014). the youth sample in the present study did, however, agree with explicit specific barriers to access­ ing psychotherapy, probably reflecting more negative attitudes when confronted with pfeiffer, huffer, feil, & in-albon 13 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ the idea of actual help seeking instead of psychotherapy in general, which is consistent with findings in adults (albani et al., 2013). higher barriers to accessing psychotherapy were also, as expected, associated with lower help-seeking intentions, which is consistent with findings in adult samples regarding attitudes toward mental health care (andrade et al., 2014; mojtabai et al., 2002; van voorhees et al., 2006). regarding psychotherapy knowledge, the results were mixed (see table 2) revealing deficits in psychotherapyknowledge. interventions aiming to increase mental health knowledge should include information about the setting and general framework of psychotherapy to facilitate the decision to access it. in our sample, higher psychotherapy knowledge was not associated with higher help-seeking intentions, but the interpretation of the results is limited by the high number of youths indicating knowledge deficits. we did not find gender differences for implicit attitudes toward psychotherapy, ex­ plicit barriers to accessing psychotherapy, or psychotherapy knowledge. in contrast to other studies that found gender differences for mental health knowledge and attitudes toward mental health care use (chandra & minkovitz, 2006; gonzalez et al., 2005), we focused specifically on psychotherapy, which might represent a different construct from mental health care in general that includes treatment in inpatient settings and psychopharmacotherapy. overall, there are few studies evaluating gender differences in this field of research in youths. the results indicate less psychotherapy knowledge in younger youths compared to participants with older youths, which is consistent with other findings (farrer et al., 2008; swords et al., 2011). barriers to accessing psychotherapy seemed to increase with age and were associated with lower help-seeking intentions. more research is necessary to determine age-related factors to improve interventions aiming to lower barriers to accessing psychotherapy in specific age groups. having a prior or current experience with psychotherapy and being familiar with someone with a prior or current experience with psychotherapy were predictors for higher psychotherapy-knowledge, but surprisingly not with fewer implicit and explicit attitudes toward psychotherapy. however, the interpretation of this result is limited, as we had only a small sample of those seeking psychotherapy and a lack of further information (e.g., number of sessions). when we analyzed the data from parent–youth dyads, we found evidence of similar implicit attitudes toward psychotherapy. comparable with study 1, psychotherapy was not more highly stigmatized than medical treatment in youths as well as in parents. the dyadic analyses for implicit and explicit attitudes based on the apim revealed an actor effect for youths with implicit attitudes being a predictor for explicit attitudes, meaning that higher improved-d scores (a stronger association between medical treatment and positive attributes than psychotherapy and negative attributes) were predictors for more negative explicit attitudes. this might be evidence for a higher congruency in youths implicit and explicit attitudes, whereas parents’ explicit attitudes were not predicted by implicit and explicit attitudes toward psychotherapy 14 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ their implicit attitudes. we did not find partner effects for parents’ implicit attitudes being a predictor for youths’ explicit attitudes and vice versa. the covariance between youths and parent implicit and explicit attitudes were also non-significant. to sum up, parental explicit and implicit attitudes toward psychotherapy seem to be independent from youths` explicit and implicit attitudes with youths reporting less explicit barriers than parents. this might be due to a higher awareness of mental disorders and their treatment by exposure to interventions (e.g., in schools) aiming to increase mental health knowledge and decrease stigmatizing attitudes toward people with mental disorders (reavley & jorm, 2012). these results also indicate that interventions aiming to decrease barriers of help-seeking for mental disorders are well invested in youths who build their attitudes more and more independently of their parent’s attitudes when transitioning into adulthood. however, these results also emphasize the need to include parents in interventions to lower barriers to seeking psychotherapy, as they play an important role in supporting their children during the professional help-seeking process (logan & king, 2001). lowering barriers to accessing psychotherapy in parents might increase recogni­ tion of their child’s need for help and encourage them to search for professional help in the event of mental health problems. in conclusion, the results suggest that interventions or campaigns promoting a positive image of psychotherapy might be less relevant than intervention focusing on the reduction of specific barriers toward psychotherapy and deficits in psychotherapy-knowledge. there is evidence that parents should be included in interventions as a valuable resource to support youths in the help-seeking process for a mental disorder. limitations there are some limitations with regard to the use of the iat to assess implicit attitudes toward psychotherapy (see meissner et al., 2019). we did not assess whether a negative evaluation of psychotherapy predicts actual help-seeking behavior, as we assessed only help-seeking intentions. we also chose to contrast psychotherapy with a medical treat­ ment, assessing the relative strength of the associations with the attributes. for this reason, we do not know if psychotherapy is perceived as positive, negative or neutral, the only knowledge we have is that psychotherapy is not perceived more negatively com­ pared to a medical treatment. future studies might choose different implicit measures, for example, a single iat (teige-mocigemba et al., 2008) to evaluate the association of psychotherapy with attributes independent of a reference to a medical treatment. the age differences might also pose problems as older participants may have very different needs and knowledge compared to younger participants. the gatekeeper role accessing mental health treatment might vary with age and further analyses are neces­ sary to determine to which extend parents are still important gatekeeper for youths in their transition to adulthood. although youths in emerging adulthood get more and more autonomous, parents still play an important role in their life might be an important pfeiffer, huffer, feil, & in-albon 15 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://www.psychopen.eu/ source to discuss sensitive topics (jiang et al., 2017), for example mental health problems and treatment use. in the parent sample, we had higher participation of mothers (76%) compared to fathers. the sample size was low for dyadic data analysis with an insuffi­ cient power of 0.7 to detect an actor effect in youths and a power of 0.05 to detect a partner effect for parents, whereas the power was good with 0.8 to detect an actor effect in parents and 1.00 to detect a partner effect in youths. therefore, analysis should be conducted with a larger sample size. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references addis, m. e., & mahalik, j. r. 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(2012). discrepancies between parentand adolescent-perceived problem severity and influences on help seeking from mental health services. the australian and new zealand journal of psychiatry, 46(6), 553–560. https://doi.org/10.1177/0004867412441929 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. implicit and explicit attitudes toward psychotherapy 20 clinical psychology in europe 2022, vol. 4(3), article e7375 https://doi.org/10.32872/cpe.7375 https://doi.org/10.1007/s00127-006-0091-x https://doi.org/10.1177/0004867412441929 https://www.psychopen.eu/ implicit and explicit attitudes toward psychotherapy (introduction) parental role in attitudes toward psychotherapy aims of the study study 1 method results study 2 method results general discussion limitations (additional information) funding acknowledgments competing interests references the relation between social anxiety and perceptions of likeability and friendship in adolescents research articles the relation between social anxiety and perceptions of likeability and friendship in adolescents jeanine m. d. baartmans 1,2,3 , bonny f. j. a. van steensel 4 , j. loes pouwels 5 , tessa a. m. lansu 5 , reinout w. h. j. wiers 2 , susan m. bögels 4 , anke m. klein 2,6 [1] uva minds: academic treatment centre, amsterdam, the netherlands. [2] developmental psychology, university of amsterdam, amsterdam, the netherlands. [3] education and child studies, leiden university, leiden, the netherlands. [4] child development and education, university of amsterdam, amsterdam, the netherlands. [5] behavioural science institute, radboud university nijmegen, nijmegen, the netherlands. [6] developmental and educational psychology, leiden university, leiden, the netherlands. clinical psychology in europe, 2024, vol. 6(4), article e10705, https://doi.org/10.32872/cpe.10705 received: 2022-11-20 • accepted: 2024-07-02 • published (vor): 2024-12-20 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: anke m. klein, wassenaarseweg 53, 2333 ak leiden, the netherlands. phone number: 0031 71 527 6673. e-mail: a.m.klein@fsw.leidenuniv.nl abstract background: this study investigated how different social anxiety symptoms (i.e., worrying about negative evaluation versus avoidance tendencies) in adolescents are related to the perception accuracy of likeability by peers and friendships with peers. method: a community sample of 263 adolescents between 12 and 15 years old reported on their social anxiety symptoms. in addition, they estimated how much their peers liked them, indicated how much they liked their peers, and who their friends were in their classroom. results: results showed that socially anxious adolescents who mainly worried about negative evaluations, underestimated their likeability by peers. adolescents with strong social avoidance tendencies had a more accurate perception of their likeability and friendships; they were less liked by their peers and had fewer friends. conclusion: the results emphasize the importance of treating avoidance behavior in social anxiety since avoidance tendencies may not only maintain the social anxiety symptoms but are also related to a more negative judgment by others. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10705&domain=pdf&date_stamp=2024-12-20 https://orcid.org/0000-0001-8063-1061 https://orcid.org/0000-0002-1782-3682 https://orcid.org/0000-0002-9586-392x https://orcid.org/0000-0003-2419-0315 https://orcid.org/0000-0002-4312-9766 https://orcid.org/0000-0003-0055-4620 https://orcid.org/0000-0002-0914-0996 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords social anxiety, adolescents, worry, avoidance, likeability, cognitive bias, friendship highlights • adolescents who worry about their social evaluation tend to underestimate their own likeability. • adolescents who tend to avoid social situations are less liked and have fewer friends. • it is important to be aware of different symptoms of social anxiety. background the beginning of adolescence is characterized by an increased sensitivity to others’ judgment. adolescents find it important to be liked by their peers and to be accepted in the peer group and often fear being rejected or negatively evaluated. therefore, fear of negative evaluation is part of normal development. still, it can become problematic when these fears hinder adolescents in their daily lives and development (american psychiatric association, 2013). several studies indeed found that a strong fear of negative evaluation peaks in early adolescence due to challenges in the peer context and social-cognitive development. this heightened fear of negative evaluation, one of the key cognitive symptoms of social anxiety, can amplify peer relationship stress (chavira & stein, 2005; erath et al., 2008; ranta et al., 2014). however, fear of negative evaluation is only one of the symptoms associated with social anxiety, with other symptoms including attentional, emotional, behavioral, and physical symptoms also being present in social anxiety. in this study we focused on cognitive symptoms (fear of negative evaluation) and behavioral symptoms (avoidance). with regards to cognitive symptoms, adolescents with social anxiety (disorder) have strong assumptions about being judged or rejected by others (american psychiatric association, 2013; bögels et al., 2010); they have fears of saying something 'wrong,' behaving 'inappropriate' or making a fool out of oneself in social situations. in addition, they expect that their social performances have disastrous consequences, and as a result, they are likely to avoid social situations (leigh & clark, 2018; ranta et al., 2014). thus, cognitive symptoms often lead to behavioral symptoms: i.e., avoidance of feared (social) situations and/or the use of safety behaviors to avoid the perceived anxious scenario from happening (e.g., extremely preparing and/or memorizing what to say prior to giving a presentation because the child believes this will prevent that other children will make fun of him). the avoidance of threatening stimuli results in a decrease in anxiety in the short term. however, in the long term, avoidance may maintain social anxiety by preventing habituation and by disconfirmation of biased perceptions (miers et al., 2014; rapee & spence, 2004). for social anxiety specifically, social avoidance may be reflected in withdrawal from peer interactions. the current study aims to examine the associations perceptions of likeability in adolescents 2 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ of (the subtypes of symptoms of) social anxiety with social functioning and (biased) perceptions of social functioning. there is a growing body of evidence showing that adults with social anxiety (disor­ der) also suffer from actual deficits in social interactions (e.g., voncken & bögels, 2008). in addition, social withdrawal has been associated with social anxiety in children and can be defined as abstaining from social activities in the presence of peers (erath et al., 2007). this withdrawn behavior prevents adolescents from practicing their social skills (blöte et al., 2014; clark & wells, 1995). however, instead of, or in addition to actual lesser social performance, individuals high in social anxiety might also underestimate their social performance. cognitive theories state that people with high levels of social anxiety or social anxiety disorder have a negatively biased perception of their social performance (e.g., clark & wells, 1995; hofmann & dibartolo, 2014; rapee & heimberg, 1997). as a result, it could be that the relation between social anxiety and worse social performance in self-report measures is affected by negative cognitive biases and might not be in line with others’ opinions. regarding youths, research shows considerable evidence for the relation between social anxiety, negative expectations of one’s own social performance, and negative ratings of one’s own social competence (kingery et al., 2010). in previous studies, we tested the association between social anxiety and the accuracy of being disliked by peers in children and adolescents (baartmans et al., 2019, 2020; klein et al., 2018). for example, baartmans and colleagues (2019) examined the extent to which children between 7 and 13 years old had an accurate or biased perception of their general likeability among classroom peers. results showed that in children, higher levels of social anxiety were associated with underestimating one’s likeability among classroom peers. in line with this study, baartmans and colleagues (2020) examined these questions in a different sample, using the same age group (7 to 13 years old) but investigated estimations of likeability among each peer individually instead of likeability among all classroom peers. results again showed that when children had higher levels of social anxiety, they more strongly underestimated their own likeability. in addition, it was found that older children with social anxiety symptoms were more likely to underestimate their likeability by peers than younger children (baartmans et al., 2020). finally, klein and colleagues (2018) followed a similar procedure to study adolescents aged between 12 and 19 with a mild intellectual disability. they also found that social anxiety symptoms were linked to a biased perception of likeability; adolescents with mild intellectual disability and with symptoms of social anxiety underestimated their likeabili­ ty by peers (klein et al., 2018). previous research thus showed preliminary evidence for a relation between social anxiety and a negatively biased perception of likeability. in order to be able to compare the findings of the current study to previous findings, the current study examines a group of typically developing adolescents with an age range in between the studies mentioned above (10-15 years). baartmans, van steensel, pouwels et al. 3 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ whereas we already have some insight into how social anxiety is related to youth’s (accuracy of the perception of) likeability among peers, we know less about their func­ tioning and particularly accuracy regarding friendships. in addition to likeability, friend­ ship plays a vital role in the lives of adolescents. although both constructs are closely related (cantin et al., 2019), they each tap into different components of social compe­ tence. whereas likeability reflects a relatively general affective evaluation, friendships, conversely, are dyadic relationships requiring mutuality (greco & morris, 2005). research on the relation between social anxiety and friendships in youth showed that social anxi­ ety negatively influences companionship and intimacy in friendships (vernberg et al., 1992) and that higher social anxiety is related to negative interactions in best friendships (la greca & harrison, 2005). studies that focused on the number of friends about social anxiety symptoms suggested that especially girls with high levels of social anxiety report fewer friendships and less intimacy and support within close friendships (la greca & lopez, 1998). socially anxious adolescents also indicate to have fewer friends, and they more often choose other socially anxious youth as their friends (van zalk et al., 2011; but see karkavandi et al., 2022, who find that socially anxious girls nominate as many friends as socially non-anxious girls). however, important to note is that most findings are based on self-report measures. this raises the question of to what extent these findings reflect actual friendship func­ tioning or are driven by negative cognitive biases related to social anxiety. there are some indications that socially anxious youth may indeed be less likely to be selected as a friend (karkavandi et al., 2022; van zalk et al., 2011) and that they have fewer recipro­ cated friendships (erath et al., 2010). however, it could also be the case that adolescents do not always recognize it when peers consider them to be friends (an underestimation of friendship). therefore, the second goal of this study was to investigate the association between social anxiety symptoms in adolescents and the accuracy of their estimations of friendships within the classroom. the present study the overall aim of this study was to examine the relations of social anxiety level with cognitive biases and social performance in the peer group among a large group of adoles­ cents (10-15 years old). we examined this aim in the context of likeability and friendships within a classroom setting. in addition, we paid special attention to the subcategories of social anxiety symptoms; i.e., cognitive symptoms (fear of negative evaluation) and behavioral symptoms (avoidance). to answer the first research question – how social anxiety symptoms in adolescents are related to self-perceived and peer-perceived likeability and the perception accuracy of likeability by peers we first studied how both self-perceived and peer-perceived likeability were related to social anxiety in adolescents (goal 1a). we expected that social anxiety would be negatively related to selfand peer-perceived likeability. regarding the perceptions of likeability in adolescents 4 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ subcategories of social anxiety, we expected that especially the behavioral symptoms (avoidance) would play an important role in actual likeability among peers because avoidance prevents adolescents from practicing their social skills, and adolescents with social skills deficits can be less likeable (blöte et al., 2012, 2014; clark & wells, 1995; miers et al., 2010, 2011). moreover, when socially anxious adolescents avoid social inter­ actions with peers, these peers are less likely to get to know them. they may, therefore, be less likely to develop a positive opinion about them. this is also in line with the find­ ings of henricks and colleagues (2021, 2023), who find a negative association between the behavioral social anxiety component ‘avoidance’ and likeability among peers, but not between the cognitive ‘fear of negative evaluation’ component and likeability. in goal 1b, we focused on the discrepancy between the two reporters and its relation with social anxiety symptoms in adolescents. based on previous research in children, we hypothesized that higher levels of (cognitive symptoms of) social anxiety in adolescents would be associated with stronger underestimations of likeability (la greca & lopez, 1998; van zalk et al., 2011). the second research question focused on how social anxiety symptoms in adolescents relate to selfand peer-reported friendships and the perception accuracy of friendships within the classroom. to answer this question, we first focused on the association of social anxiety with the number of self-nominated, peer-nominated, and reciprocal friends (goal 2a). we computed discrepancies between these three scores as indicators of under­ estimation and overestimation of the number of friendships. subsequently, we examined how these discrepancies were related to social anxiety symptoms (goal 2b). we expected that higher levels of social anxiety would be related to fewer self-reported friendships (la greca & lopez, 1998; van zalk et al., 2011), fewer peer-reported friendships, and fewer reciprocal friendships. we also expected that adolescents would underestimate the number of friendships (i.e., them ‘being blind’ to the friendship offered by others). with regards to the subcategories of social anxiety, we again expected that especially the behavioral symptoms (avoidance) would be associated with the number of self-reported and peer-reported friends. in contrast, the cognitive symptoms would be associated with underestimating the number of friendships. method participants and procedure a total of 263 adolescents (49.4% boys) between 10 and 15 years old from 12 classrooms in grades 7 and 8 from two secondary schools (m = 13.64, sd = 0.65) participated in the study. in total, 168 adolescents (63.9%) attended the school level ‘senior general secondary education / pre-university education,’ and 95 adolescents (36.1%) attended the school level ‘pre-vocational secondary education / senior general secondary education.’ baartmans, van steensel, pouwels et al. 5 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ the adolescents completed digital questionnaires in a classroom setting. tables were set up in a ‘test’ setting so that participants could not see each other’s answers. also, the project coordinator stressed that there were no right or wrong answers and that the individual results would not be shared with anyone. the study was part of a larger study on social development and bullying (henricks et al., 2021; pouwels et al., 2018, 2019). the ethical committee of the behavioural science institute of radboud university nijmegen, the netherlands, approved this study. materials social anxiety symptoms social anxiety symptoms were measured with the shortened version of the social anxiety scale for adolescents (sas-a; la greca & lopez, 1998; kärnä et al., 2010). this question­ naire consists of nine items divided into two subscales, ‘fear of negative evaluation’ (fne) and ‘social avoidance and distress’ (sad; derived from the original sad-general subscale of the sas-a). adolescents were asked to indicate to what extent the questions applied to them, ranging from 0 (never) to 4 (always). the shortened version of the sasa has a good internal consistency, α = .88 (kärnä et al., 2010). in our sample, the sas-a also had a good internal consistency, α = .88. the subscale fne had an excellent internal consistency, α = .93, and the subscale sad-general had a good internal consistency, α = .84. both the total scale and the two subscales were included in the analyses. likeability the adolescents were asked to answer on a likert scale (1 = not at all, 7 = a lot), “how much do you think your classmates like you?”. this score is indicated as like-self. all adolescents were also given a list of their classmates and asked to answer on a likert scale (1 = not liked at all, 7 = very much liked): “how much do you like classmate x?”. the average received score for each participating adolescent was computed and indicated as like-peer. discrepancy scores were used as a measure of perception bias. the discrepancy scores were computed by subtracting the like-peer-score from the like-self-score. this resulted in the like-discr-score. positive values correspond with overestimating one’s own likeability, and negative scores with underestimating one’s likeability. friendship first, adolescents were asked to name up to five best friends among their classmates. in a second question, adolescents were asked to name who were other good friends among their classmates. best-friend-scores were derived from the first question and total-friend-scores were derived by computing the sum of the first and second question. given-friend-scores were derived by computing the number of indicated best friend and perceptions of likeability in adolescents 6 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ good friend nominations by each participant. received-friend-scores were derived from the number of received nominations for each participant (i.e., how often a participant was indicated as a friend) from their classmates. furthermore, for both the best-friend and total-friend-scores the number of reciprocal nominations was determined by examin­ ing how often the participant and a classmate nominated each other as friends. this resulted in six friendship scores: best-friend-received, best-friend-given, best-friend-recipro­ cal, total-friend-received, total-friend-given, total-friend-reciprocal. overand underestimation scores were computed to obtain information on the extent to which adolescents’ self-indicated friendships were in line with the friendships indica­ ted by their classmates. these two types of scores were used as indicators for perception accuracy. the first type of perception bias indicator on friendship was the underestimatescores. underestimate-scores were computed by subtracting the reciprocal-scores from the received-friend-scores (nreceived – nreciprocal). these scores indicate to what extent an ado­ lescent recognizes the friendship-nominations that they receive. higher underestimatescores correspond with higher underestimation of the number of friends in the class. the second type of perception bias scores on friendship are the overestimate-scores. these were computed by subtracting the reciprocal-scores from the given-friend-scores (ngiven – nreciprocal). these scores indicate the extent to which peers indicate the same friendships as the participants themselves nominate. higher overestimate-scores correspond with higher levels of overestimation of the number of friends in the class. the overestimate and underestimate-scores were both computed for the number of best friends and the number of total friends. in total, this resulted in four friendship accuracy scores: overestbest-friend, underest-best-friend, overest-total-friend, and underest-total-friend. data analysis before answering the research question, a pearson correlation between the two subscales of the sas-a (fne and sad) was computed. in addition, we tested if the like-discr-score deviated significantly from zero with a one-sample t-test to test if the group of adoles­ cents overestimated or underestimated their likeability by peers on average. to answer the first research question – how social anxiety symptoms in adolescents relate to the perception accuracy of likeability by peers – partial correlations were com­ puted between social anxiety symptoms (sas-a) and like-self, like-peer, and like-discr, while controlling for gender and age. we controlled for age and gender in the analyses since previous studies found evidence for the relation between age, gender, social anxiety symptoms, and biased perceptions (baartmans et al., 2019, 2020). the partial correlation between the social anxiety symptoms and like-self and like-peer provides information about how the self-estimates and the opinions of peers about adolescents’ likeability are related to social anxiety symptoms. the partial correlation between like-discr and social anxiety symptoms indicates if adolescents with higher levels of social anxiety are more likely to underestimate their likeability by peers. baartmans, van steensel, pouwels et al. 7 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ to answer the second research question – how social anxiety symptoms in adoles­ cents relate to the perception accuracy of their friendships within the classroom – we first tested how social anxiety symptoms were related to the selfand peer-nominations of friendships within the class. therefore, partial correlations were computed between social anxiety symptoms and the best-friend-received, best-friend-given, best-friend-recip­ rocal, total-friend-received, total-friend-given, and total-friend-reciprocal-scores while con­ trolling for gender and age. in the next step, partial correlations were computed between social anxiety symptoms and overestimate-best-friend, underestimate-best-friend, overesti­ mate-total-friend, and underestimate-total-friend to test if social anxiety symptoms in adolescents were related to overand/or underestimation of the number of friendships, again while controlling for age and gender. in order to discriminate between sub-symptoms of social anxiety in their relation to perception accuracy of likeability and friendship – we conducted all analyses described above for the total social anxiety symptoms, as well as for the fneand sad-scale separately. results descriptives the pearson correlation between the fne and sad subscales was .35 (p < .001). the like-discr-score had a mean of 0, indicating that adolescents had, on average, an accurate perception of their own likeability as rated by their peers. however, the standard devi­ ation suggests that some adolescents underestimated or overestimated their likeability (see table 1). research question 1: social anxiety and likeability as expected, higher levels of social anxiety were significantly related to lower self-esti­ mates of likeability (see table 2). in addition, higher levels of total anxiety were also significantly related to being less likeable according to peers and an underestimation of likeability by peers. adolescents with higher levels of social anxiety thus were less liked by their peers and also indicated themselves that their peers liked them less (goal 1a). however, adolescents with higher social anxiety scores were, on average, too pessimistic about their low likeability, as indicated by a tendency to underestimate their actual likeability level (goal 1b). as expected, both higher levels of the subscales fear of negative evaluation and social avoidance and distress were significantly related to lower self-estimates of likeability. in accordance with our hypothesis, only the avoidance subscale was significantly related to lower peer ratings of likeability. this resulted in a significant negative relation between the negative evaluation scale and the discrepancy score but not between the avoidance subscale and the discrepancy score. these results perceptions of likeability in adolescents 8 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ suggest that a higher fear of negative evaluation was related to the underestimation of likeability by peers. in contrast, higher levels of social avoidance were related to both lower peerand self-ratings of likeability, resulting in unbiased perceptions of one’s likeability. table 1 means (m) and standard deviations (sd) of the social anxiety symptoms, likeability measures, and friendship measures variable m sd sas-total 1.46 0.67 sas-sad 1.78 0.85 sas-fne 1.07 0.75 like-self 4.34 0.81 like-peer 4.29 0.57 like-discr 0.00 1.28 best-friend-given 4.14 1.24 total-friend-given 7.98 3.98 best-friend-received 4.00 2.09 total-friend-received 7.68 3.18 best-friend-reciprocal 2.79 1.36 total-friends-reciprocal 5.62 2.63 overest-best-friend 1.35 1.36 overest-total-friend 2.36 2.80 underest-best-friend 1.21 1.31 underest-total-friend 2.06 1.95 note. sas-total = total anxiety symptoms; sas-sad = social avoidance and distress symptoms; sas-fne = fear of negative evaluation symptoms; like-self = self-perceived likeability; like-peer = peer rated likeability; like-discr = difference between selfand peer-perceived likeability; best-friend-given = self-nominated number of best friends; total-friend-given = self-nominated number of best and good friends; best-friend-received = peer-indicated nominations of best friend; total-friend-received = peer-indicated nominations of total friend; best-friend-reciprocal = reciprocal number of best friends; total-friend-reciprocal = reciprocal number of best and good friends; overest-best-friend = overestimation of number of best friends; overest-total-friend = overes­ timation of number of best and good friends; underest-best-friend = underestimation of number of best friends; underest-total-friend = underestimation of number of best and good friends. baartmans, van steensel, pouwels et al. 9 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ table 2 partial correlations between social anxiety symptoms (total, fne, and sad), the likeability measures, the friendship measures, and the perception bias measures on friendship while controlling for gender and age variable social anxiety symptoms total fne sad likeability like-self -.31*** -.22*** -.32*** like-peer -.14* -.04 -.23* like-discr -.13* -.14* -.07 friendship quantity best-friend-given -.19* -.14 -.18* total-friend-given -.11** -.07 -.13* best-friend-received -.16* -.04 -.25*** total-friend-received -.10 .02 -.22*** best-friend-reciprocal -.17* -.06 -.25*** total-friends-reciprocal -.17* -.06 -.24*** friendship accuracy overest-best-friend .00 -.07 .08 overest-total-friend .00 -.04 .04 underest-best-friend -.08 .00 -.14* underest-total-friend .07 .11** -.02 note. total = total anxiety symptoms; fne = fear of negative evaluation symptoms; sad = social avoidance and distress symptoms; like-self = self-perceived likeability; like-peer = peer rated likeability; like-discr = difference between selfand peer-perceived likeability; best-friend-given = self-nominated number of best friends; totalfriend-given = self-nominated number of best and good friends; best-friend-received = peer-indicated nomina­ tions of best friend; total-friend-received = peer-indicated nominations of total friend; best-friend-reciprocal = reciprocal number of best friends; total-friend-reciprocal = reciprocal number of best and good friends; over­ est-best-friend = overestimation of number of best friends; overest-total-friend = overestimation of number of best and good friends; underest-best-friend = underestimation of number of best friends; underest-total-friend = underestimation of number of best and good friends. *p < .05. **p < .01. ***p < .001. research question 2: social anxiety and friendship as expected, total social anxiety symptoms were significantly related to self-nominating fewer best friends, being less often nominated as best friends, and fewer reciprocal best friends and reciprocal total friend nominations (goal 2a). no significant relations existed between the fear of negative evaluation subscale and friendship quantity measures. in contrast, the social avoidance and distress subscale was significantly related to lower scores on all friendship quantity measures. thus, higher levels of avoidance and distress were related to less self-nominated, peer-nominated, and mutual best friends and total friends. in contrast, fear of negative evaluation was not (see table 2). perceptions of likeability in adolescents 10 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ the results of the partial correlations between the overand underestimation scores and social anxiety symptoms are displayed in table 2 (goal 2b). total social anxiety symptoms and fear of negative evaluation were not significantly related to overor underestimation of best friends and total friends. only the subscale of social avoidance and distress was negatively related to the underestimate-best-friend-score, which suggests that adolescents with high levels of social avoidance and distress were less likely to “miss” best friends they had within their class than adolescents with low levels of social avoidance and distress. in other words, when adolescents show higher levels of avoidance and distress, they are more likely to recognize a friendship. discussion the overall aim of the current study was to investigate how different symptoms of social anxiety in adolescents relate to adolescents’ perception accuracy of likeability by peers and friendships with their peers. the first goal was to examine how social anxiety symptoms in adolescents are related to self-perceived likeability, peer-perceived likeabil­ ity, and the perception accuracy in likeability. the second goal was to examine how social anxiety symptoms relate to self-perceived friendships, peer-perceived friendships, and perception accuracy of friendships within the classroom. as social anxiety can be divided into cognitive factors or symptoms (i.e., worry about negative evaluation) and behavioral symptoms (i.e., avoidance; american psychiatric association, 2013; chavira & stein, 2005; clark & wells, 1995; ranta et al., 2014), we differentiated between cognitive and behavioral anxiety symptoms in the examination of both research goals. social anxiety and likeability we first examined how overall levels of social anxiety were related to self-rated and peer-rated likeability (goal 1a). as hypothesized, adolescents with higher levels of social anxiety were less liked by their peers according to themselves and their classmates. this finding is in line with other studies that also found that higher social anxiety symptoms were related to lower peer-rated likeability (baartmans et al., 2020; verduin & kendall, 2008) and with studies finding that more social anxiety symptoms were related to decreased peer acceptance and victimization in adolescents (henricks et al., 2021; tillfors et al., 2012; verduin & kendall, 2008). we also examined the discrepancy between adolescents’ own likeability perception and the likeability perception of their peers (goal 1b). as expected, socially anxious adolescents tended to underestimate their likeability. these findings are in line with previous findings showing that social anxiety symptoms in pre-adolescents and adolescents with mild intellectual disability are related to the underestimation of likeability by peers (baartmans et al., 2019; klein et al., 2018). therefore, by studying a sample of 10to 15-year-old typically developing adolescents, baartmans, van steensel, pouwels et al. 11 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ the current study found that adolescents’ overall levels of anxiety were not only related to actual lower likeability according to peers but also to an underestimation of their likeability. an important note is that most previous studies did not discriminate between worry­ ing about negative judgment by others and the tendency to avoid social situations as subtypes of social anxiety when studying the accuracy of perceived likeability among peers. in order to overcome this limitation, we also examined how the cognitive and behavioral social anxiety symptoms were uniquely associated with self-perceived likea­ bility, peer-perceived likeability, and the accuracy of perceived likeability. as expected, a higher tendency to avoid social situations was associated with being less liked by peers and perceiving oneself as less liked. therefore, adolescents with a higher tendency to avoid social situations accurately perceive that their peers like them less than other classmates. in contrast, although adolescents with a tendency to worry about social situa­ tions (fear of negative evaluation) had the perception that they were less liked among their peers, their social anxiety symptoms were unrelated to their actual likeability among peers. adolescents with cognitive and social anxiety symptoms, therefore, have an inaccurate perception (i.e., underestimation) of one’s likeability among peers. like henricks and colleagues (2021, 2023), this study shows that especially avoiding social situations is associated with low likeability among peers. it is known that the innate need to belong becomes more important in adolescence and that adolescents might prefer peers with less strong avoidance tendencies (baumeister & leary, 1995; schoch et al., 2015). at the same time, avoidance tendencies become stronger and more influential in adolescence (miers et al., 2014), which could explain our finding that the tendency to avoid is related to less likeability by peers. in addition, worrying mainly plays a role in the mind, while others can notice avoidance tendencies, which may lead to lower ratings on likeability. social anxiety and friendships regarding friendships (goal 2), the results of the current study confirmed the hypothesis and previous research findings that social anxiety is related to fewer friendships (la greca & lopez, 1998; van zalk et al., 2011). we extended these findings by showing that like for likeability, these findings depend on the type of social anxiety symptoms. in line with our hypothesis, the tendency to avoid social situations and/or experiencing social distress was related to fewer (self-reported, peer-reported, and reciprocal) friendships. in contrast, worrying about negative judgment by others was unrelated to self-perceived and peer-perceived and reciprocal friendships. in contrast to the findings for likeability and the hypothesis, total levels of social anxiety symptoms were not significantly related to more overor underestimation of the number of best friends and total friends. thus, adolescents with higher levels of social anxiety did not seem to have a biased perception of the number of friendships within the perceptions of likeability in adolescents 12 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ class compared to adolescents with lower levels of social anxiety. surprisingly, a stronger tendency to avoid social situations and/or experiencing social distress was related to less underestimation of the number of best friends within the class, whereas worry was not associated with a biased friendship perception. based on theories about cognitive biases in social anxiety, we expected that social­ ly anxious adolescents might underestimate their number of friendships (hofmann & dibartolo, 2014; morrison & heimberg, 2013), but the results did not show this. the lack of a significant relation between social anxiety symptoms and underestimating the number of one’s friendships might be explained by the fact that friendship is a social construct that requires reciprocal liking and, for instance, engaging in joint activities (bukowski & hoza, 1989; demir & urberg, 2004). these requirements could make it easier and clearer for adolescents to be sure whether or not someone can be considered as a friend. thus, the fact that friendship quantity might be easier to perceive than liking could possibly explain why adolescents with higher levels of (cognitive) social anxiety seem to have more problems with accurately estimating a more general concept, such as their likeability, and not with a more concrete concept, such as friendship. strengths, limitations, and suggestions for future research a strength of the current study was the differentiation of the social anxiety symptoms into the subscales of fear of negative evaluation and the tendency to avoid social sit­ uations. this provides further information about the specific relation between social anxiety symptoms and social functioning measures. an additional strength was using a multiple-informant approach and including different measures of likeability and friend­ ship. limitations also need to be mentioned. a first limitation of the current study was that we included a typically developing community sample only and no clinical sample. even though the levels of social anxiety were comparable to other community sample studies (kärnä et al., 2010), the scores of social anxiety were relatively low. this limits the generalization of the results to children with high levels of social anxiety or clinical samples. clearly, more research is needed on children with high levels of social anxiety and clinical samples to draw more robust conclusions and to recommend implications for treatment. second, the current study used a cross-sectional design. therefore, no conclusions can be drawn about the causality or longitudinal effects of social anxiety symptoms and perception accuracy of social functioning. third, using self-reports in a classroom setting could have led to socially desirable answers. adolescents filled in the questionnaires in a ‘test setting’ so that others could not see their answers, and we stressed that there were no right or wrong answers and that the results would not be shared with anyone. still, we cannot rule out the fact that social desirability might have influenced our findings. fourth, there were some limitations regarding our friendship measures. we only measured friendships within the classrooms. therefore, we cannot generalize these results to friendships in baartmans, van steensel, pouwels et al. 13 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ general. it could, for instance, be that socially anxious adolescents have more friendships outside the classroom (e.g., friends from primary school or sports). the findings of the current study lead to some suggestions for future research. first, as we only included adolescents between the ages of 10-15 in the current study, little is known about how the associations between social anxiety, likeability, and friendships vary by age. a broader age range would allow drawing further conclusions regarding the relation between social anxiety symptoms and perceptions of social functioning across ages. second, the current study extended previous research using a multi-meth­ od approach using selfand peer-reported measures. this approach could be further strengthened by including measures of social anxiety and social functioning by other raters, like teachers and parents. third, a suggestion for future research would be to include measures to examine depression and externalizing problems. as depression and externalizing disorders are found to influence likeability and friendship and often co-occur with social anxiety disorder (mohammadi et al., 2020), it would be especially important to include both variables when testing the associations between social anxiety, likeability, and friendships, to get a better understanding of the complex constructs of likeability and friendships in relation to mental health. fourth, further research could be conducted to get more fine-grained insights into the accuracy of perceptions of adoles­ cents’ friendships. in this study, we determined overand underestimating friendships by studying discrepancies in nominations of friendships within the classroom. this differed from the likeability accuracy scores since we did not ask who the adolescent thought would indicate them as friends. this would have allowed us to distinguish adolescents not noticing others wanting to be friends with them from adolescents noticing a peer wanting to be friends with them but choosing not to engage in a friendship with that peer. including these measures in future research would allow for drawing more precise conclusions on the accuracy of estimations. practical implications the current study stresses the importance of targeting avoidance behavior in treating social anxiety symptoms. when adolescents with higher levels of social anxiety report the tendency to avoid, they are more likely to be disliked by peers, which could make their socially anxious thoughts about being negatively evaluated by others warranted. if replicated in a sample with high levels of social anxiety, these results might suggest that in addition to the cognitive training in cbt, encouraging socially anxious adolescents to approach and practice social situations rather than avoid them appears to be an impor­ tant aspect of treatment. in addition, following the extended process model (gross, 2015), it may be interesting to examine which of the five ways (situation selection, situation modification, attentional deployment, cognitive change, and/or response modulation) is the most relevant (or best) target for treating social anxiety. perceptions of likeability in adolescents 14 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://www.psychopen.eu/ conclusion in conclusion, the results of the current study provide evidence that even though social anxiety symptoms are related to both lower self-estimates and peer-estimates of likeabil­ ity, adolescents with higher levels of social anxiety still seem to underestimate their likeability among classroom peers. in addition, we found that adolescents who worried more about negative evaluations underestimated their likeability by peers; they think they are less liked than they are. no such effects occurred for worrying about negative evaluations and perceptions of friendship. further, adolescents with strong social avoid­ ance tendencies accurately perceived their likeability and friendship; they were less liked by their peers and had fewer friendships, and they also perceived their situation as such. even though these findings must be reviewed in light of the current study's limitations, these results highlight the possible importance of disentangling different subtypes of social anxiety and using multiple informants of likeability and friendships in future research and clinical practice. if replicated in a group of children with high (clinical) levels of social anxiety, these results emphasize the importance of explicitly treating avoidance behavior in social anxiety since this may not only maintain the social anxiety symptoms but were also found to be related to more negative judgments by others. funding: there are no significant sources of funding to declare. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: there are no financial or personal competing interests for any author in the making of the study. ethics statement: the authors confirm that they complied with the recognized ethical standards and local guidelines. all participants and parents were properly instructed and gave informed consent. the ethical committee of the behavioural science institute of radboud university nijmegen, the netherlands, approved this study. preregistration: there was no preregistration of the study. reporting guidelines: we followed apa7 reporting guidelines and jars-quant guidelines for writing the manuscript. social media accounts: @reinoutwiers, @susanbogels related versions: the manuscript was based on chapter 8 of the dissertation of the first author: baartmans, j. m. d. (2021). childhood social anxiety: what’s next? exploring the role of cognitions, depression, parents, and peers. university of amsterdam. url: https://pure.uva.nl/ws/files/54463245/thesis_complete_.pdf data availability: data from our study is available by contacting the corresponding author. baartmans, van steensel, pouwels et al. 15 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://x.com/reinoutwiers https://x.com/susanbogels https://pure.uva.nl/ws/files/54463245/thesis_complete_.pdf https://www.psychopen.eu/ references american psychiatric association. (2013). diagnostic and statistical manual of mental disorders (5th ed.). american psychiatric publishing. baartmans, j. m. d., rinck, m., hudson, j. l., lansu, t. a., van niekerk, r. e., bögels, s. m., & klein, a. m. 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(2011). social anxiety as a basis for friendship selection and socialization in adolescents’ social networks. journal of personality, 79(3), 499– 526. https://doi.org/10.1111/j.1467-6494.2011.00682.x clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. baartmans, van steensel, pouwels et al. 19 clinical psychology in europe 2024, vol. 6(4), article e10705 https://doi.org/10.32872/cpe.10705 https://doi.org/10.1007/s11031-015-9482-1 https://doi.org/10.1016/j.adolescence.2012.04.008 https://doi.org/10.1007/s10802-007-9192-6 https://doi.org/10.1207/s15374424jccp2102_11 https://doi.org/10.1016/j.janxdis.2008.02.001 https://doi.org/10.1111/j.1467-6494.2011.00682.x https://www.psychopen.eu/ perceptions of likeability in adolescents (introduction) background the present study method participants and procedure materials data analysis results descriptives research question 1: social anxiety and likeability research question 2: social anxiety and friendship discussion social anxiety and likeability social anxiety and friendships strengths, limitations, and suggestions for future research practical implications conclusion (additional information) funding acknowledgments competing interests ethics statement preregistration reporting guidelines social media accounts related versions data availability references chronic pain in the icd-11: new diagnoses that clinical psychologists should know about scientific update and overview chronic pain in the icd-11: new diagnoses that clinical psychologists should know about antonia barke 1 , beatrice korwisi 2 , winfried rief 2 [1] clinical psychology and psychological intervention, institute for psychology, university duisburg-essen, essen, germany. [2] department of psychology, clinical psychology and psychotherapy, philipps university of marburg, marburg, germany. clinical psychology in europe, 2022, vol. 4(special issue), article e9933, https://doi.org/10.32872/cpe.9933 received: 2022-07-18 • accepted: 2022-10-26 • published (vor): 2022-12-15 handling editor: andreas maercker, university of zurich, zurich, switzerland corresponding author: antonia barke, universität duisburg-essen, institut für psychologie, klinischpsychologische intervention, universitätsstr. 2, d-45141, essen, germany. e-mail: antonia.barke@uni-due.de related: this article is part of the cpe special issue “innovations in icd-11”, guest editor: andreas maercker, clinical psychology in europe, 4(special issue), https://doi.org/10.32872/10.32872/cpe.v4.si abstract background: in the 10th revision of the international classification of diseases and related health problems (icd-10), chronic pain was not represented adequately. pain was left undefined and not recognized as a biopsychosocial phenomenon. instead, a flawed dualism between psychological and somatic factors was implied. individual diagnoses were ill-defined and scattered randomly through different chapters. many patients received diagnoses in remainder categories devoid of meaningful clinical information. method: the international association for the study of pain launched a task force to improve the diagnoses for the 11th revision of the icd and this international expert team worked from 2013-2019 in cooperation with the who to develop a consensus based on available evidence and to improve the diagnoses. results: a new chapter on chronic pain was created with a biopsychosocial definition of pain. chronic pain was operationalized as pain that persists or recurs longer than three months and subdivided into seven categories: chronic primary pain and six types of chronic secondary pain. all diagnoses were based on explicit operationalized criteria. optional extension codes allow coding pain-related parameters and the presence of psychosocial aspects together with each pain diagnosis. conclusion: first empirical studies demonstrated the integrity of the categories, the reliability, clinical utility, international applicability and superiority over the icd-10. to improve reliability this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9933&domain=pdf&date_stamp=2022-12-15 https://orcid.org/0000-0002-6863-3213 https://orcid.org/0000-0003-1477-6742 https://orcid.org/0000-0002-7019-2250 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ and ease of diagnosis, a classification algorithm is available. clinical psychologists and other clinicians working with people with chronic pain should watch the national implementation strategies and advocate for multimodal and interdisciplinary treatments and adequate reimbursement for all providers involved. keywords icd-11, classification, biopsychosocial model of chronic pain, chronic primary pain, chronic secondary pain, implementation highlights • a systematic chapter on chronic pain in the icd-11 improves the representation of chronic pain. • chronic pain is pain that persists or recurs for more than three months. • chronic pain in the icd-11 is regarded as biopsychosocial. • icd-11 introduces chronic primary pain and distinguishes six types of chronic secondary pain. background what was wrong with the representation of chronic pain in the icd-10? in the previous version of the international classification of diseases and related health problems (icd), the icd-10, chronic pain was represented neither systematically nor adequately. the main shortcomings were: firstly, the icd-10 did not reflect the widely accepted biopsychosocial model of pain (rief et al., 2010; rief et al., 2008; treede et al., 2010), which is also a central aspect of the internationally widely accepted definition of pain by the international association for the study of pain (iasp) (raja et al., 2020). secondly, for many important types of chronic pain, no diagnoses were available at all: chronic neuropathic pain, chronic pain associated with cancer and its treatment, or chronic pain after surgery or accidents were missing in the icd-10 (rief et al., 2012). thirdly, even if a diagnosis was available in the icd-10, it often lacked clear definitions and criteria, e.g., “r52.2 other chronic pain”. in most cases, not even the information whether the pain was chronic or acute could be recorded (e.g., “m54.4 low back pain”) – despite agreement that highly relevant differences exist between acute and chronic pain (kröner-herwig, 2017; treede, 2019). as a result, one of the most frequently used diagnoses for chronic pain was the ill-defined residual category “r52.2 other chronic pain”, which held next to no information value for clinicians, patients or health statistics. fourthly, the diagnoses that were available in icd-10 were scattered rather arbitrarily among different chapters (rief et al., 2010; rief et al., 2012), depending upon the medical specialty that tended to treat them. for example, the diagnosis “m54.5 low back pain” was found in the chapter for diseases of the musculoskeletal system and connective chronic pain in the icd-11: new diagnoses 2 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://www.psychopen.eu/ tissue while different types of headache (“g43 migraine”) were listed among the diseases of the nervous system (world health organization, 2019). clinical psychologists are probably most familiar with the chronic pain diagnosis “f45.4 persistent somatoform pain disorder” available in the so-called “icd-10 f-chapter” for mental and behavioral disorders. this diagnosis recognizes the role of psychological factors in the development and maintenance of the chronic pain and gives a definition that specifies the chronic course of the pain (world health organization, 2019). however, the contribution of biological or physiological factors is excluded. by definition, the diagnosis f45.4 cannot be assigned if a patient has chronic pain associated with an underlying disease such as, for example, rheumatoid arthritis. this contributes to the artificial and problematic dichotomy of “psychological” vs. “somatic” chronic pain in the icd-10 (arnold et al., 2017; rief et al., 2008; treede et al., 2010). the german modifica­ tion of the icd-10 includes an additional chronic pain diagnosis, “f45.41 chronic pain with somatic and psychological factors” which, for the first time, recognized the contri­ bution of both biological and psychological factors to chronic pain (nilges & rief, 2010) thereby overcoming the dichotomy (arnold et al., 2017; treede et al., 2010). this was a great step forward and the frequency with which this diagnosis has since been used (häuser et al., 2013) shows it is well-accepted – probably because it offers a much-needed way of classifying chronic pain according to the biopsychosocial model. despite these advances, the diagnosis f45.41 had to compromise. its location in the chapter on mental and behavioral disorders was a theoretical compromise since chronic pain is neither. the fact that the diagnosis is only available in the german modification (icd-10-gm), is a practical compromise since it means that the diagnostic advance is geographically limited to countries that use this national version (world health organization, 2022b). what were the consequences of the deficient representation of chronic pain in icd-10? negative consequences arose from the inadequate representation of chronic pain in the icd-10 for patient treatment, research into chronic pain as well as health statistics and health policies. most importantly, the distinction of “psychological” chronic pain on the one hand and “somatic” chronic pain on the other, is not useful because chronic pain is always an interplay of psychological, biological, and social factors (raja et al., 2020; rief et al., 2008; treede et al., 2010). since in many healthcare systems, icd codes are relevant for treatment choice and treatment access (boerma et al., 2016; jakob, 2018a, 2018b), patients with chronic pain may be excluded from specific multimodal interdisciplinary pain treatment programs as well as from psychological treatment (nilges & rief, 2010; rief et al., 2009; rief et al., 2008), unless they also receive a diagnosis of a mental disorder, such as f45.4. on an individual level, this meant that many patients tended to receive multimodal therapies including psychological treatments at a very late stage, often only when treatment providers and patients felt they had exhausted the somatic barke, korwisi, & rief 3 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://www.psychopen.eu/ treatments without much progress. this made it unnecessarily hard for patients to accept the biopsychosocial model and engage with psychological treatments. individually, this may mean more distress and suffering. at a public health level, this translates into a larger societal burden of chronic pain and direct and indirect costs (blyth et al., 2019; blyth & huckel schneider, 2018). missing diagnoses meant that for treatment purposes, precise and appropriate codes for the chronic pain were lacking and clinicians chose various ways of expressing chron­ ic pain diagnoses, often with recourse to entities such as “chronic intractable pain” (r52.1). this led to numerous problems in communication with patients and health providers. considering the role of outcome expectations that have been shown for many areas (auer et al., 2016; di blasi et al., 2001; laferton et al., 2017) labeling a person’s pain as “intractable” may convey a nihilistic therapeutic attitude to clinician and patient alike. apart from problems of treatment and management of individual cases, the lack of diagnostic codes also rendered the different types of chronic pain and the associated burden invisible from the perspective of public health policy. the vague definitions and ambiguous diagnoses also presented difficulties for the communication between patients and healthcare providers as well as for the information exchange among healthcare professionals. on a larger scale, it impeded the formulation of fruitful research agendas. referring to a large variety of chronic pain syndromes as “non-cancer pain” or “non-specific pain” underestimated the differences between the syndromes – while researching only into very specific syndromes glossed over the commonalities. finally, in epidemiological and register studies based on inadequate representation, the true prevalence of chronic pain and its associated disease burden remained underestimated. such underestimation, in turn, was likely to influence health policy decisions and funding allocation (blyth et al., 2019; rice et al., 2016; treede et al., 2010). method developing a new set of chronic pain diagnoses for icd-11 to remedy the situation of chronic pain in the icd-10, the community of pain specialists had long worked together and argued for a classification better reflecting the empirical and theoretical advances. in 2012 the iasp formed an international and interdisciplinary task force and collaborated with the world health organization (who) to reform the classification of chronic pain for the next revision of the icd. the who demanded consensus and evidence in order to enter diagnoses into the icd-11 (world health organization, n.d.). the task force provided both by striving for a consensus among the professionals working with patients with chronic pain and publishing the results in a series of papers (aziz et al., 2019; bennett et al., 2019; benoliel et al., 2019; nicholas et al., chronic pain in the icd-11: new diagnoses 4 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://www.psychopen.eu/ 2019; nugraha et al., 2019; perrot et al., 2019; scholz et al., 2019; schug et al., 2019; smith et al., 2019; treede et al., 2019; treede et al., 2015). the development was accompanied by formative evaluations (barke et al., 2018; barke et al., 2022) and evaluative studies (hay et al., 2022; korwisi, garrido suarez, et al., 2022; korwisi et al., 2020; zinboonyahgoon et al., 2021). in 2019, the world health assembly endorsed the icd-11 with the new clas­ sification of chronic pain (world health assembly, 2019). the icd-11 came into effect on january 1st, 2022 for international mortality reporting (world health organization, 2022a). many countries are currently preparing the implementation of the icd-11 within their national healthcare systems. results: the new chronic pain diagnoses in icd-11 and how they address the problems in icd-10 an improved definition of chronic pain the chronic pain classification implemented in the icd-11 forms one structured chapter, which contains all chronic pain diagnoses in one logical order (for details see below), which are subdivisions of the clearly operationalized entity “chronic pain” (mg30, id: http://id.who.int/icd/entity/1581976053) the definition of chronic pain was aligned with the updated iasp diagnosis of pain (raja et al., 2020): “pain is an unpleasant sensory and emotional experience asso­ ciated with, or resembling that associated with, actual or potential tissue damage.” it continues to specify chronic pain as “pain that persists or recurs for longer than 3 months”, providing a clear operationalization of chronic pain. the defining sentence is immediately followed by the clause regarding the typical nature of chronic pain: “chronic pain is multifactorial: biological, psychological and social factors contribute to the pain syndrome.” this sentence expresses the biopsychosocial model for all types of chronic pain. it is open for variable weights of the respective factors in different chronic pain syndromes, but unequivocally affirms the general model for all subdiagnoses that characterize specific syndromes. here it is important to note that in the icd-11 the subordinate diagnoses (called “children”) inherit the characteristics of the higher-order diagnoses (called “parents”), without repeating all the features in each child diagnosis. throughout the whole chapter of chronic pain, chronic pain is defined as explained here. with this definition, the icd-11 addressed and remedied a major criticism leveled at the earlier editions, and now accurately reflects the widely accepted biopsychosocial model of pain. barke, korwisi, & rief 5 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 http://id.who.int/icd/entity/1581976053 https://www.psychopen.eu/ adding missing diagnoses the second major criticism was that for many important types of chronic pain, no diagnoses were available at all in the icd-10. diagnoses were missing for chronic neuropathic pain, chronic pain associated with cancer or its treatments, chronic pain after surgery and accidents, as well as many types of chronic orofacial pain. the icd-11 classification contains systematically ordered diagnoses in these fields. chronic pain has seven subdivisions: mg30.0 chronic primary pain (nicholas et al., 2019) mg30.1 chronic cancer related pain (bennett et al., 2019) mg30.2 chronic postsurgical or post traumatic pain (schug et al., 2019) mg30.3 chronic secondary musculoskeletal pain (perrot et al., 2019) mg30.4 chronic secondary visceral pain (aziz et al., 2019) mg30.5 chronic neuropathic pain (scholz et al., 2019) mg30.6 chronic secondary headache or orofacial pain (benoliel et al., 2019) the reasoning behind these subtypes and the diagnoses classified there have been ex­ plained and discussed in the dedicated papers for each subtype. here we can only give a brief resumé – for fuller details we recommend the specific articles. chronic primary pain chronic primary pain is defined as chronic pain in one or more anatomical regions that is associated with significant emotional distress and/or significant functional disability (nicholas et al., 2019). the diagnosis should be assigned unless the symptoms are better accounted for by another diagnosis in the section of chronic secondary pain. the definition of the new diagnosis of chronic primary pain is formulated to be ag­ nostic regarding the etiology of the pain syndrome and is purely descriptive. subsuming a diagnostic term here does not commit us to the claim that no somatic factors contribute to the diagnosis. neither does it commit us to the claim that psychosocial factors are the main contributors. this is true on the level of diagnostic entities: classifying fibro­ myalgia as a type of chronic primary pain does not imply the empirical judgement that central sensitization or other somatic processes do not play a part in the fibromyalgia syndrome. at the patient level, assigning a diagnosis of chronic primary back pain does not mean to deny that biological factors contribute to the chronic pain or to claim that psychological factors dominate. this descriptive nature is viewed as a distinct advantage. if another diagnosis accounts better for the chronic pain, one of the secondary diagnoses should be assigned, usually in combination with the respective underlying condition. note, however that – again – this does not imply that no psychosocial factors may be present or relevant regarding the pain. the biopsychosocial model of chronic pain applies to chronic primary and chronic secondary pain in exactly the same way and thus psychosocial factors may be relevant in both instances. the difference is that: chronic pain in the icd-11: new diagnoses 6 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://www.psychopen.eu/ a. for chronic primary pain significant distress or functional interference (or both) are required as part of the definition. b. for chronic secondary pain a clearly defined somatic factor as expressed in another icd-11 diagnosis is required and should be co-diagnosed. in the section on chronic primary pain several frequent pain syndromes are classified, including chronic pain often referred to as 'functional gastrointestinal disorders', as char­ acterized by the rome criteria (drossman & hasler, 2016). see table 1 for an overview. table 1 overview of chronic primary pain and its subdiagnoses in the icd-11 chronic primary pain in the mms linearization (mg 30.0) / subdiagnoses classified here foundation ida chronic primary visceral pain (mg30.00) 679352876 chronic primary chest pain syndrome 128474405 chronic primary epigastric pain syndrome 1983908934 chronic primary bladder pain syndrome 2093682836 chronic primary pelvic pain syndrome 1663013388 chronic primary abdominal pain syndrome 709631177 chronic widespread pain (mg30.01) 849253504 fibromyalgia syndrome 236601102 chronic primary musculoskeletal pain (mg30.02) 1236923870 chronic primary cervical pain 2014134682 chronic primary thoracic pain 642165115 chronic primary low back pain 1291385632 chronic primary limb pain 413174579 chronic primary headache or orofacial pain (mg30.03) 2104869000 chronic migraine 1336990680 burning mouth syndrome 618998878 chronic primary orofacial pain 1545281608 chronic primary temporomandibular disorder pains 975254799 chronic tension-type headache 107534985 complex regional pain syndrome (mg30.04) 1834504950 crps type i 2067142665 crps type ii 1415867395 ato locate the entities using their foundation id please use the icd-11 foundation browser (https://icd.who.int/dev11/f/en) and paste the id number in the search field. this is only required in case you would like to access the subdiagnoses that for technical reasons do not have an mg30 code. further details and explanations regarding these technical aspects can be found in (korwisi, barke, et al., 2022). barke, korwisi, & rief 7 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://icd.who.int/dev11/f/en https://www.psychopen.eu/ the terms chronic “primary” and chronic “secondary” were adapted from the headache classification (headache classification committee of the international headache society [ihs], 2018). they were chosen to express the fact that the chronic pain constitutes a health problem in its own right with high clinical priority for the patient and is not directly associated with another disease accounting for the pain. the term was preferred by the who and seen to have a number of advantages over other terms that might have been considered, such as “non-specific”, “functional” or “idiopathic”. chronic secondary pain chronic secondary pain is chronic pain that accompanies underlying diseases or health conditions that are coded elsewhere in the icd. in this section, chronic pain in connec­ tion with cancer or its treatment (bennett et al., 2019), chronic pain after surgery or accidents (schug et al., 2019), chronic musculoskeletal pain due to underlying conditions such as rheumatoid arthritis (perrot et al., 2019), chronic visceral pain due to persisting inflammation or mechanical causes (aziz et al., 2019), chronic neuropathic pain (scholz et al., 2019) and chronic secondary headache (benoliel et al., 2019) (including medication overuse headache) can be classified. it should again be noted that these diagnoses are also children of chronic pain, and thus inherit the fundamental biopsychosocial model. the diagnoses listed under chronic secondary pain address the criticism that many chronic pain conditions could not be diagnosed within icd-10. a typical case is chronic cancer-related pain. due to medical advances, many more people survive cancer (glare et al., 2022). in a significant number of cases, the cancer survivors suffer from chronic pain, either due to the cancer itself or due to the often aggressive treatments needed. for both types of chronic pain codes were created: the former can be coded as “chronic cancer pain” (mg30.10), the latter as “mg30.11 chronic post cancer treatment pain” (mg30.11). for the affected person and their families, the diagnosis can mean better understanding and acknowledgement of the chronic pain and improvements in the access to multimodal and interdisciplinary care. statistically, the chronic pain people suffer as a result of cancer and its therapies and the associated burden become visible and can be taken into account in health planning. the same is true for chronic neuropathic pain, chronic postsurgical pain and chronic pain after accidents. addressing unclear criteria and ambiguous diagnoses other diagnoses were part of the icd-10, but lacked clear criteria. this issue was ad­ dressed in the icd-11 by introducing operationalized diagnostic criteria, which at all levels state criteria that are individually necessary and jointly sufficient for the respec­ tive diagnosis. on average, each diagnosis relies on 4-7 explicit criteria. each diagnosis inherits the criteria of the diagnosis above and adds more specific criteria. in total, the diagnoses in the section on chronic pain are based on c. 200 explicit criteria. chronic pain in the icd-11: new diagnoses 8 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://www.psychopen.eu/ better representation of relevant factors and pain parameters given the centrality of the biopsychosocial model of chronic pain, it is justified to expect that biopsychosocial factors can be expressed better in the icd-11. indeed, there are several ways in which they can be coded alongside all chronic pain diagnoses, primary and secondary. the tools provided for this purpose are “extension codes”. with extension codes, information can be added to the categorical diagnoses. in the section of chronic pain, extension codes for “pain severity” and the “presence of psychosocial factors” allow the expression of psychosocially relevant information. a further extension code can be assigned to communicate “temporal features” of the pain (continuous, episodic or continuous with additional flare-ups). the pain severity specifier captures three important aspects of chronic pain: its inten­ sity (how much does it hurt? how intense is the pain?), the pain-related emotional distress experienced by the person (how much does the pain distress you?) and the pain-related interference with everyday life and functioning (how much does the pain interfere with your daily life?). all three aspects should be rated on a numerical rating scale from 0 – 10, or – if preferred – on a visual analogue scale by the patient (see box 1 for the exact wording as well as a case vignette showing their application). the numeric scores can be used for individual documentation. however, they can also be converted into severity codes of “none – mild – moderate – severe”, which can be included with any chronic pain diagnosis in icd-11, thereby providing a fuller picture of the chronic pain and how it affects the individual person. more specifically, the presence of psychosocial factors can be coded with the exten­ sion code “presence of psychosocial factors”. this code is designed to allow coding problematic cognitive (e.g., catastrophizing, excessive worry, eccleston & crombez, 2007; sullivan et al., 2001), emotional (e.g., fear, anger; thibodeau et al., 2013; trost et al., 2012), behavioral (e.g. avoidance, endurance; hasenbring & verbunt, 2010; vlaeyen & linton, 2012) and social factors (e.g. work-related and economic factors (haukka et al., 2011; rios & zautra, 2011)) that accompany the chronic pain. it is important to note that the extension code should be used only in cases in which there is positive evidence that psychosocial factors contribute to the cause, the maintenance or the exacerbation of the pain or the associated disability, or when the chronic pain results in negative psy­ chobehavioral consequences (e.g. demoralisation, hopelessness, avoidance, withdrawal). assigning the code requires ascertaining the psychosocial factors, e.g. by use of explo­ ration of the patient and / or psychometric questionnaires. the inference “no somatic cause of the pain can be found, therefore the pain must have a psychological cause” is flawed and cannot form the basis of a use of the extension code “with psychosocial factors”. assigning the code does not entail any specific causal path: the psychosocial factors can be the consequence of the burden of living with chronic pain just as much as a mechanism contributing to the experienced functional interference. the intended use of the code is communicative – the possible presence of psychosocial factors should be barke, korwisi, & rief 9 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://www.psychopen.eu/ box 1 case vignette: paul (55 years) history: paul works as a mechanic in the automotive industry. about 22 months ago, paul had been diagnosed with cancer of the prostate. he underwent surgery to remove the prostate. the surgery went well. after the initial shock of the diagnosis, he was glad that the surgery was over and he had very few side effects. on his doctor’s advice, he began a course of chemotherapy with docetaxel. during the chemotherapy, he developed neuropathic pain in the hands and feet. he was told that in many cases the pain resolves a while after the last dose, but in some cases, it does not. for paul, the pain did not remit. paul was on sick leave during the surgery and the subsequent recovery. afterwards, he went back to work, only pausing for a few days for each course of chemotherapy. when the neuropathic pain developed, he found his work harder and harder. hoping the pain would go away after the last treatment, he gritted his teeth and carried on working full hours despite the pain and the interference with his work. he is determined to continue in his present work schedule as a matter of pride. the family had bought a house a few years ago and there were a few years of mortgage payment left. paul worries a lot about his pain and how it affects his and his family’s life. he finds it difficult to fall asleep due to the pain and the worry. he feels exhausted and overstretched and often withdraws from activities he used to like. his family-life suffers from his dejected mood and irritability. on a scale from 0-10 he rates his pain in the last week as “7” (“how strong was your chronic pain in the last week [on average]?”) and the pain-related interference as “5” (“how much did the pain interfere with your activities in the last week [on average]?”), his pain-related distress he rates as a “7” (“how much pain-related distress did you experience in the last week because of your pain [on average]?”). diagnoses according to the icd-11 mg30.11 chronic post cancer treatment pain associated with: xs7g psychosocial factors present has severity: xs2e severe pain [pain intensity] has alternate severity 1: xs7n severe distress [pain-related distress] has alternate severity 2: xs2l moderate pain-related interference [pain-related interference] has causing condition: 2c82.y other specified malignant neoplasms of prostate final code: mg30.11&xs7g&xs5d&xs7c&xs5r/2c82 note. this code is optimized for machine readability and does not have to be memorized by humans – it is chosen via computer interface. however, it contains all of the above information. it could be augmented even further with information regarding the neoplasm itself (e.g. staging). chronic pain in the icd-11: new diagnoses 10 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://www.psychopen.eu/ discussed between patient and clinician, their presence recorded and communicated to other health providers with the diagnosis. ideally, they are used to point to a treatment relevance of the psychosocial factors. in the future, such a code should entitle the person to multimodal care including psychological treatments. discussion empirical support for the new chronic pain classification the classification of chronic pain in the icd-11 was developed with a view to the empir­ ical evidence accrued over many years. the classification and its implementation itself have also undergone first empirical evaluations. important targets of the revision process of the icd were clinical utility and international applicability of the new classification (jakob, 2018a; reed, 2010; üstün & jakob, 2005; üstün et al., 2007). clinical utility can be regarded as an approximation of validity and reflects how much a classification system offers a useful conceptualization of the diagnostic entities, enables selecting of adequate treatments, and is easy and feasible to use. high clinical utility allows application in rou­ tine practice, facilitates communication and documentation and – ideally – is predictive of treatment outcomes. (first et al., 2004; keeley et al., 2016) the integrity of the diagnostic categories is an important prerequisite for the utility of a classification. diagnostic categories should not overlap, but have clear boundaries (distinctness); together, the categories should cover the whole phenomenological space (exhaustiveness). these aspects were investigated in formative field tests (barke et al., 2018). in a sample of unselected patients, the categories demonstrated good distinctness and exhaustiveness: less than 3% could not be assigned one of the seven main categories of chronic pain, thus dramatically reducing the number of patients who received a diagnosis reflecting a non-descript remainder category. this favorable result has since been confirmed by a documentation-based retrospective coding study (zinboonyahgoon et al., 2021). as a further condition, clinical utility requires reliability of the code assignments. the who led extensive field tests of coding aspects of the icd-11. the results obtained for chronic pain showed that the icd-11 diagnoses outperformed icd-10 on all counts, including correct code assignments, ease of application, level of detail and fewer per­ ceived ambiguities (barke et al., 2022). a next step in reliability testing was testing the interrater-reliability of clinicians assigning diagnoses to real consecutive patients. in an international field testing study, consecutive patients were independently diagnosed by two clinicians and substantive kappa coefficients for interrater reliabilities reported (0.596 < κ < 0.783) (korwisi, garrido suarez, et al., 2022). the clinicians were asked to rate the clinical utility of the diagnoses and it was rated as high throughout all studies (barke et al., 2018; barke et al., 2022; korwisi, garrido barke, korwisi, & rief 11 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://www.psychopen.eu/ suarez, et al., 2022). in addition, preliminary results of a survey among people with the lived experience of chronic pain also showed that they judged the new diagnoses to be helpful for communicating with health professionals, their families and others (korwisi et al., 2019). the detailed categories increased the visibility of the chronic pain diagnoses when compared with icd-10 diagnoses (zinboonyahgoon et al., 2021). international applicability was addressed in a multi-country field testing study in india, cuba and new zealand. details of the testing are described in the study protocol (korwisi et al., 2020). clinicians in specialist pain centers in each country were intro­ duced to the icd-11 classification in training workshops and subsequently coded n = 353 consecutive patients with the icd-11 classification as well as their usual diagnostic system. they provided data for the interrater-reliability and rated the clinical utility of the icd-11 and the standardly used system, showing a clear preference for the icd-11 classification (korwisi, garrido suarez, et al., 2022). this study provides evidence that the classification is clinically useful in a range of international settings, including countries with limited resources. the relationship with the diagnoses in the chapter on mental and behavioural disorders the icd-10 chapter on mental and behavioural disorders includes the group of somato­ form disorders, with a subdiagnosis on somatoform pain disorder. this led to several critical comments. the mind-body-dualism seemed to be amplified with this somatoform pain diagnosis, because a psychological etiology of pain conditions was emphasized in its definition. however, the whole category of somatoform disorders was associated with various problems (creed, 2006). despite substantial prevalence rates of 9% and above in the general population (creed et al., 2012), in countries like the us, these diagnoses were rarely used (dimsdale et al., 2011). based on this critique, dsm-5 decided to revise this chapter substantially, and introduced the somatic symptom and associated disorders cat­ egory. the relevance of whether somatic symptoms are medically explained or not was completely abolished, while psychological factors that are associated with the suffering from these physical complaints play a major role for the diagnosis of a somatic symptom disorder (rief & martin, 2014). the icd-11 decided to introduce a new category on “disorders of bodily distress and bodily experience”, and its prototypic diagnosis is called “bodily distress disorder (bdd)”. bdd has a similar concept to somatic symptom disorder in dsm-5: it requires bodily symptoms that are persistent, and present on most days for at least several months. as a psychological criterion, excessive attention is directed toward the symp­ toms. while the description acknowledges that pain symptoms are among the most common symptoms of bdd, no pain subtype is defined yet. it remains unclear whether the german modification will stick to the current f45.41 diagnosis of chronic pain with psychological and somatic factors. therefore, at this stage, we recommend the chronic chronic pain in the icd-11: new diagnoses 12 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://www.psychopen.eu/ primary pain diagnoses if chronic pain is the leading somatic complaint, and the other criteria for chronic pain are fulfilled. future directions over the next 5-10 years, the icd-11 will be implemented in many european countries’ health systems (world health organization, 2022a). even in countries in which it is not the basis for health planning and reimbursement, governments will provide data based on icd-11 diagnostic categories to the who in fulfillment of treaty obligations for the reporting of health data. it is recommended that for pain research the new diagnoses are used to inform research programs and utilize the improved diagnostic criteria as well as the specifiers (barke et al., 2020; treede et al., 2019). implementing changes in classification entails changes in other areas, including adaptations in administration and information technology, reimbursement practices and student education. in addition, it requires thorough training for clinicians, administrative and coding staff. a helpful resource when beginning to familiarize oneself with the icd-11 and the new chronic pain diagnoses, may be a paper in which questions regarding the classification were collected systematically and answers provided (korwisi, barke, et al., 2022). to improve the diagnostic reliability further and facilitate the training, a classification algorithm (cal-cp) was developed (korwisi, hay, et al., 2021) that guides the users through the criteria and diagnoses with a binary decision tree. the user decides for each diagnostic criterion whether it is present in a given patient and then follows the respective “yes” or “no” arrow. the decision tree guides the user through all levels that are available for the new diagnoses. in some settings, a less specific diagnosis might be sufficient (e.g., mg30.0 chronic primary pain in primary care) while the most specific diagnoses will probably be required in pain research and specific pain treatment (e.g., mg30.02 chronic primary musculoskeletal pain: chronic primary low back pain). hence, the algorithm is a central tool to apply the new diagnoses in practice as well as in research. the clinicians participating in the international field test had used a pilot version of the algorithm and rated it favourably (korwisi, hay, et al., 2021). currently an authorized version (a pdf with active hyperlinks) is available as digital supplement to the original publication (http://links.lww.com/pain/b277). a large test using online virtual patients is underway and its results will provide the basis for a digitized version. a further aspect, which will have to be discussed and decided on a national level, will be the implications of the new diagnoses in terms of treatment authorization and reimbursement policies. since the new diagnoses are based on the biopsychosocial model and it is recommended that chronic pain is no longer classified as a somatoform disor­ der, in some health systems, political and professional negotiations may be required to allow multimodal and interdisciplinary treatments including psychological interventions to be offered and reimbursed by multidisciplinary teams. for instance, in germany, barke, korwisi, & rief 13 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 http://links.lww.com/pain/b277 https://www.psychopen.eu/ psychotherapists and psychosomatic hospitals are currently limited to treating disorders that are classified in the icd-10 chapter v (mental and behavioural disorders). clinical psychologists and other health professionals working with people with chronic pain need to be aware of these developments in their respective countries and should seek to advocate for state of the art multimodal treatments for patients with chronic pain delivered by those who are qualified practitioners. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: winfried rief is one of the editors-in-chief of clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. references arnold, b., lutz, j., nilges, p., pfingsten, m., rief, w., boger, a., brinkschmidt, t., casser, h. r., irnich, d., kaiser, u., klimczyk, k., sabatowski, r., schiltenwolf, m., & sollner, w. 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(n.d.). icd-11 reference guide. retrieved 30 june 2022 from https://icdcdn.who.int/icd11referenceguide/en/html/index.html zinboonyahgoon, n., luansritisakul, c., eiamtanasate, s., duangburong, s., sanansilp, v., korwisi, b., barke, a., rief, w., & treede, r. d. (2021). comparing the icd-11 chronic pain classification with icd-10: how can the new coding system make chronic pain visible? a study in a tertiary care pain clinic setting. pain, 162(7), 1995–2001. https://doi.org/10.1097/j.pain.0000000000002196 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. chronic pain in the icd-11: new diagnoses 20 clinical psychology in europe 2022, vol. 4(special issue), article e9933 https://doi.org/10.32872/cpe.9933 https://icdcdn.who.int/icd11referenceguide/en/html/index.html https://doi.org/10.1097/j.pain.0000000000002196 https://www.psychopen.eu/ chronic pain in the icd-11: new diagnoses (introduction) background method developing a new set of chronic pain diagnoses for icd-11 results: the new chronic pain diagnoses in icd-11 and how they address the problems in icd-10 an improved definition of chronic pain adding missing diagnoses addressing unclear criteria and ambiguous diagnoses better representation of relevant factors and pain parameters discussion empirical support for the new chronic pain classification the relationship with the diagnoses in the chapter on mental and behavioural disorders future directions (additional information) funding acknowledgments competing interests references personality disorder diagnoses in icd-11: transforming conceptualisations and practice scientific update and overview personality disorder diagnoses in icd-11: transforming conceptualisations and practice michaela a. swales 1 [1] north wales clinical psychology programme, bangor university, bangor, wales, united kingdom. clinical psychology in europe, 2022, vol. 4(special issue), article e9635, https://doi.org/10.32872/cpe.9635 received: 2022-06-04 • accepted: 2022-09-19 • published (vor): 2022-12-15 handling editor: andreas maercker, university of zurich, zurich, switzerland corresponding author: michaela a. swales, north wales clinical psychology programme, brigantia building, pen yr allt, bangor, ll57 2as, uk. e-mail: m.swales@bangor.ac.uk related: this article is part of the cpe special issue “innovations in icd-11”, guest editor: andreas maercker, clinical psychology in europe, 4(special issue), https://doi.org/10.32872/10.32872/cpe.v4.si abstract background: until the advent of the icd-11, classification of personality disorders was based on categorical prototypes with a long history. these prototypes, whilst familiar, were not based in the science of personality. prototypical classifications were also complex to administer in nonspecialist settings requiring knowledge of many signs and symptoms. method: this article introduces the new structure of icd-11 for personality disorders, describing the different severity levels and trait domain specifiers. case studies illustrate the main aspects of the classification. results: the new icd-11 system acknowledges the fundamentally dimensional nature of personality and its disturbances whilst requiring clinicians to make categorical decisions on the presence or absence of personality disorder and severity (mild, moderate or severe). the connection between normal personality functioning and personality disorder is established by identifying five trait domain specifiers to describe the pattern of a person’s personality disturbance (negative affectivity, detachment, dissociality, disinhibition, and anankastia) that connect to the big 5 personality traits established in the broader study of personality. conclusions: whilst new assessment measures have been and are in development, the success of the new system will rely on clinicians and researchers embracing the new system to conceptualise and describe personality disturbances and to utilise the classification in the investigation of treatment outcome. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9635&domain=pdf&date_stamp=2022-12-15 https://orcid.org/0000-0002-7603-1546 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords personality disorder, severity of personality disorder, icd-11, trait domains highlights • introduces the new structure of icd-11 for personality disorders. • describes the different severity levels and trait domain specifiers. • case studies illustrate the main aspects of the classification. • discusses the issue of stigmatization in clinical practise. problems with icd-10: the case for change personality disorder is perhaps the most stigmatising diagnosis to receive (bonnington & rose, 2014). we all have a personality and our personality is often central to how we perceive ourselves in the world. so, to be told that this part of ourselves – or indeed our whole self – is disordered is extremely stigmatising and potentially highly damaging. thus, for a clinician to make the diagnosis they must be sure that the benefits outweigh the costs. there are now a number of treatments developed for people who experience the problems that commonly are labelled personality disorder, particularly borderline personality disorder (storebø et al., 2020), and therefore the cost benefit ratio has changed. in this context, withholding the identification of problems for which there are effective interventions becomes a different ethical challenge, whether the diagnosis is stigmatising or not. how clinicians conceptualise personality disorder impacts their ensuing discussions with their clients and patients about the diagnosis. these discussions provide significant opportunities to mitigate stigma, especially as evidence indicates that it is often mental health professionals who hold the most stigmatising views of all (newton-howes et al., 2008; ring & lawn, 2019). icd-10 like the dsm, was based in clinically derived prototypes that were not based in scientific research that can, as tyrer and mulder (2022) argue, be traced back to the conceptualisations of schneider. each of the ten prototypes (personality disorders) had a substantial list of symptoms which meant that making a diagnosis required clinicians to be familiar with a long list of symptoms and how they related. often these symptoms overlapped. such complexity presented particular challenges in the many low and middle income countries using the classification where there are very few psychiatric specialists, much less personality disorder experts. this inherent structure of the classification resulted in two significant problems. firstly, rarely did clinicians use anything other than three of the diagnostic categories (emotionally unstable personality disorder; antisocial personality disorder; and personality disorder not otherwise specified), making the remainder of the classification effectively redun­ dant and also raising questions about its utility. secondly, often people met criteria for more than one, sometimes many more than one, personality disorder diagnosis resulting diagnosing personality disorder in icd-11 2 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ in multiple ‘comorbidities’ which were more apparent than real. consequently, some individuals were loaded up with diagnoses providing added stigma with no realistic prospect of benefit. in response to these not insignificant problems, icd-11 fundamen­ tally changes the way in which personality disorder diagnoses are conceptualised. it recognises that personality and personality disorder are continuous with each other, and although a categorical structure is maintained, the system recognises that the underlying structure is dimensional. the new system also establishes a connection between basic personality research and the diagnosis of personality disorder. in fundamentally changing the structure of personality diagnosis icd-11 provides the potential for a more compassionate framing of personality disorder in discussions between clinicians and the people who come to them requiring help. to mitigate stigma clinicians must root their discussions of personality and its disorders in a psychological understanding of the development of personality rather than within the terminology of psychiatric nosology. personality develops in the transaction between our biology and our early life experiences. personality characteristics have a strongly heritable com­ ponent (vukasović & bratko, 2015) and can be seen in early temperament, which has a high degree of stability across the life span (roberts & delvecchio, 2000). early trauma, however, can have a significant impact on the developing brain. these impacts may make a child more sensitive, or aggressive further prompting adverse experiences such as invalidation or punishment from caregivers which may increasingly impact the child’s neurobiology. thus, personality and personality disorder develop in the transaction between biology and environment and can be conceptualised as a person’s best efforts to function and cope with their familial and social environment given their biological heritage and early life experiences. conceptualising personality dysfunction as learned patterns of coping – which may have been functional in the person’s early context, and may continue to function in some environments – that have become problematic for the person, potentially provides a supportive and less stigmatising context in which to discuss personality and its disorders. icd-11’s new structure which is strongly connected to the study of human personality provides a context for furthering these initial discus­ sions with clients and patients. a study with health professionals of the respective utility of icd-10 versus icd-11 found that the new structure was more useful with respect to formulating interventions, communicating with clients, comprehensively describing a person’s difficulties and ease of use (hansen et al., 2019). whether clients themselves ex­ perience clinicians’ discussions using the new structure as less stigmatising will require systematic research. if this aspiration is to be realised, initial service user responses indicate that clinicians will need to be more adept at understanding internal distress and that patterns of behaviour were adaptive responses to early adversity (hackmann et al., 2019). swales 3 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ aims of the new classification simplification and greater utility are the primary aims of the new classification. the ini­ tial two step-process of diagnosing pd (do the person’s difficulties meet the threshold for disorder and, if they do, how severe are they) are much simpler than the previous system and therefore potentially more clinically useful, especially in non-specialist settings. the new system removes the artificial comorbidity of icd-10 and also significantly decreases the number of symptoms clinicians need to assess in determining the diagnosis thus potentially improving clinical utility. focusing on severity explicitly foregrounds risk, potentially improving the identification of risk in clinical settings. severity directly links to treatment intensity, frequency, setting and level of care required, thus, helping services to decide on the complexity of interventions required (bach & simonsen, 2021). whether the classification delivers on these aims will be a matter for subsequent research and implementation studies to decide. what follows is a description of the changes in icd-11, illustrated by three case studies, and a discussion of issues in assessment. description of the changes in sum, the new diagnostic classification requires two steps with two further optional steps if required. in the first step clinicians assess whether the person’s difficulties meet the general requirements for a personality disorder diagnosis. secondly, if these requirements are met, then clinicians further assess to determine the severity of the difficulties. the third and first optional step requires further assessment of the person’s personality trait domains to more comprehensively describe an individual’s personality disturbance. finally, and if applicable, a borderline pattern specifier can be applied. each of these steps will be considered in further detail. description of the core features of personality disorder the central features of personality disturbance in icd-11, as in dsm-5, are disturbances in aspects of both self and interpersonal functioning. for a diagnosis, these disturbances must be enduring – so present for a minimum of two years. self-dysfunction may manifest as persistent difficulties in maintaining a stable sense of identity, a pervasive sense of impoverished or highly over-valued self-worth, inaccuracies in self-perception or challenges in self-direction and decision making. persistent difficulties in making and sustaining close relationships or in the ability to understand other people’s perspectives are typical manifestations of the interpersonal dysfunction. managing conflict in rela­ tionships may also present significant challenges. these two main features will manifest in maladaptive patterns of cognition, emotional experience and expression and behaviour which must be evident across a range or personal and social situations. diagnosing personality disorder in icd-11 4 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ when considering the disturbance demonstrated or described by the person there are several important factors to consider. first, the disturbance must be present across a range of personal and social situations and not limited to single contexts, although, particular types of situation or common prompting events may elicit the same behaviour across contexts. for example, a person may become repeatedly aggressive when their views are contradicted and this pattern maybe evident with family, and in both social and work contexts. secondly, when working with young people the developmental con­ text must be considered. interpersonal difficulties and a degree of unstable self-identity are developmentally normative during the adolescent period. clinicians, therefore, must be certain that the behaviours reported or demonstrated are significantly different to be­ haviour of young people of that age and developmental stage within their specific cultur­ al context. clinicians must carefully assess whether the young person’s behaviours are normative responses to adverse environmental situations. for example, a young person may run away from home frequently, getting into fights, using drugs and self-harming because they are being physically and sexually abused at home. similar difficulties may arise in the situation of women subjected to coercive control and domestic violence and in both cases the person may have significant difficulties in alerting the assessor to the truth of the situation they find themselves in. a proper assessment of context, therefore, is required to ensure that presenting problems truly warrant a diagnosis of personality disorder. third, and following on from the previous point, the disturbance must not be explained primarily by social and cultural factors, including socio-political conflict. assessors must take especial care when assessing a person from a different culture or heritage to their own to guard against their own culturally defined assumptions about behaviour, thought and emotional expression. fourth, the disturbance must not be a direct effect of medication or of some other substance, including withdrawal effects. finally, the disturbance must be associated with substantial distress of significant impair­ ment in personal, family, social, educational, occupational or other important roles. severity ratings once a determination has been made that a person’s disturbance meets threshold for a personality disorder diagnosis, the severity of that disturbance (mild, moderate or severe1) needs to be considered. researchers recently have argued for the importance of severity from a conceptual and methodological perspective (pincus et al., 2020; sharp & wall, 2021). selecting this feature as the next required feature of diagnosis, however, relates to the strong relationship between severity and clinical outcomes (clark et al., 2018; crawford et al., 2011; yang et al., 2010). severity is determined by several factors: 1) sub-threshold difficulties which present problems in specific contexts (e.g. in effectively accessing healthcare) may be coded as personality difficulty, which can be found in the section of the icd-11 classification factors influencing health status or contacts with health services. swales 5 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ i. the degree and pervasiveness of disturbance in the person’s relationships and their sense of self ii. the intensity and breadth of the emotional, cognitive and behavioural manifestations of the person’s disturbance iii. the extent to which these patterns and problems cause distress or psychosocial impairment iv. the level of risk of harm to self and others. as personality disorder becomes more severe an increasing number of areas of a person’s life become affected by their difficulties and evidence of harm to self or others becomes more prevalent. for example, in mild personality disorder a smaller number of areas of a person’s life will be affected, for example, work and close friendships but perhaps not family or hobbies; or if the difficulties affect all of these areas, they will be mild in severity. severe personality disorder in contrast affects all areas of a person’s life, will be clearly evident to other people around them and will always entail harm to self or others. mild personality disorder the most notable aspect of mild personality disorder is that only some areas of personal­ ity function are affected. for example, a person might have difficulty making decisions or deciding on the direction of their career yet have a strong sense of self-worth and identity. problems in many interpersonal relationships or in the performance of social and occupational roles are evident but some relationships are maintained or social roles carried out. the manifestations of a person’s difficulties are generally mild and not typically associated with harm to the self or others. for example, they may struggle to recover from minor setbacks or criticisms when stressed or they may distort how they perceive situations or other people’s motives without losing total contact with reality. whilst the personality disturbance may be mild, the person may still experience substan­ tial distress and impairment. the distress and impairment are limited to a narrower range of functioning or, if the difficulties are across many areas, the difficulties are less intense. mr r (see text box 1) illustrates these features of mild personality disorder. mr r has sustained his work history for many years and indeed his personality traits, of which more later, have served him well. difficulties in the work context have only recently begun as a result of a change of demand necessitating more team working where his high standards have interfered with effective working relationships. his difficulties in close interpersonal relationships have been evident for many years within the family context, yet he is able to still maintain some social relationships and family connections. diagnosing personality disorder in icd-11 6 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ moderate personality disorder for moderate personality disorder, disturbance affects multiple areas of personality functioning such as identity, sense of self, formation and maintenance of intimate rela­ tionships, capacity to control and moderate behaviour. despite these difficulties, some areas of functioning may be relatively less affected. occasionally moderate personality disorder will be associated with harm to self or others. when this is present, typically, it will be of moderate severity. text box 1 mr r: mild personality disorder with negative affectivity and anankastia mr r is 54 years old and has been referred for assessment by his employer. he arrives at the appointment with his sister with whom he has lived for 15 years since the breakdown of his marriage. mr r describes how he was recently promoted to head up a team to run a major project. he was promoted because of his track record of delivering high quality work on time. for the first time he has been required to both lead and co-ordinate a team. his high standards and desires for perfection have caused difficulties with colleagues infuriated by mr r’s exacting standards and frequent requests for work to be re-done. previously when working alone coworkers have tolerated his style of working because it had minimal impact on them. mr r was previously married and has three children. he describes his former wife as exceptionally difficult to live with as she was ‘extremely untidy, disorganised and slovenly’. they disagreed about how to raise their children and he found his children’s ‘noise and chaos’ impossible. he laments that children are no longer ‘seen and not heard’. in a separate interview with his sister, she reports that mr r is extremely punctilious about household standards and she thinks that his wife was no untidier and more disorganised than most people. they live effectively together by having separate spaces in their old family home so that she is not impacted by his standards – except in the kitchen where she does not mind following his ‘rules’ about how things must be maintained. mr r now sees his children, now adults, relatively often. he says he is surprised how well they turned out given their ‘chaotic start’. mr r is the secretary for his local cricket club and the local church. his organisational skills are much appreciated, although, he occasionally argues with other members of these groups when they disagree about how things should be organised. swales 7 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ text box 2 ms t: moderate personality disorder with negative affectivity and disinhibition (borderline pattern specifier) ms t is a veterinary student, aged 26. her course tutor suggested that she seek assistance as her behaviour on her current programme of study is likely to lead to suspension of her studies if it does not change. this is not the first time that ms t has presented to services. she describes a history of suicidal thoughts and self-harm behaviours that began in her middle teenage years. whilst in her early twenties suicidal and self-harm behaviours were less common, they have increased in frequency following a series of break-ups of romantic relationships. ms t describes that she often feels that she can no longer cope with her life and her emotions and that considering suicide and self-harm provides a degree of relief from the intensity of these thoughts and feelings. ms t says that she believes she experiences emotions more intensely than other people. ms t describes intense and frequent mood changes that have worsened as a result of the interpersonal difficulties she has been experiencing. she describes intense emotions often in response to minor things. for example, her current presentation was prompted after she had yelled and thrown things during a meeting with her programme director and her other course mates where her next placement was being discussed and she had not got the placement that she had hoped for. she realised almost immediately that she had acted inappropriately and was extremely tearful and apologetic. incidents like these have resulted in her peers treading carefully around her or avoiding her altogether. she discovered recently that she had not been invited on an outing and she believes this is a consequence of her reactivity. ms t describes a history of frequent romantic relationships. she falls in love rapidly and intensely. recent relationships have ended as a result of the intensity of her attraction, her jealous rages and, when she believes her partner is unfaithful, she herself then initiates casual sexual contacts with other people. ms t’s parents were highly critical of her as she was growing up. academic achievement was extremely important to them. she was very close to her grandmother and spent much of her early teenage years living with her as her parents travelled extensively with their work. her grandmother suffered from a chronic illness and ms t cared for her during this time and was devastated when she died when ms t was 16. she describes her grandmother as the only supportive person in her life. after her grandmother’s death she would often run away from home for days at a time drinking heavily and initiating casual sexual encounters. despite this she maintained good grades at school as she wanted to be a vet – an ambition her grandmother also had but was unable to fulfil. diagnosing personality disorder in icd-11 8 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ marked problems in interpersonal relationships will be evident. relationships may be tumultuous, characterised by high levels of conflict and frequent ruptures. alternatively, a person may be conflict avoidant and withdraw from relationships or they may be highly dependent on one or two relationships being either submissive or dominant. ms t (see text box 2) fulfils the requirements for moderate personality disorder as a much greater number of areas of functioning are affected. there is also evidence of harm to self. her academic skill is well preserved, however, capitalising on her abilities in her chosen profession is compromised by her emotional regulation difficulties and their interpersonal consequences. her social relationships are also heavily impacted. severe personality disorder people with severe personality disorder have major disturbances in their sense of self functioning. for example, they may have no sense of who they are, experience intense numbness or report that what they believe and think changes dramatically from one context to another. some individuals may have a very rigid view of themselves and the world and have very regimented routines and approaches to situations. a person’s sense of self may be grandiose or highly eccentric or characterized by disgust and self-contempt. unsurprisingly, virtually all relationships in all contexts are adversely affected. often relationships are very one-sided, unstable or highly conflictual. there may even be a de­ gree of physical violence. family relationships are likely to be severely limited or highly conflictual. the person’s ability, and sometimes willingness, to fulfil social and occupa­ tional roles is severely impaired. so, for example, a person may be unwilling or unable to sustain regular work as a result of lack of interest, or effort, or poor performance. alternatively, the poor work performance may derive from interpersonal difficulties or inappropriate behaviour such as angry outbursts or insubordination. severe personality disorder is often associated with harm to the person or other people. severe impairment is evident in all areas of the person’s life. mr d (text box 3) presents with severe personality disorder. all areas of his life are affected. he has no meaningful relationships with family or friends and the only connections he has made are with his victims who he has exploited for personal gain. yet he seems unwilling or unable to appreciate the damage and harm that he has inflicted upon them. trait domain specifiers once the two obligatory steps for diagnosing pd are completed, there are two further optional steps both of which involve further describing the type of difficulties that a person presents with. in some jurisdictions the first two steps will be all that is required. in countries with more advanced systems in place for supporting people who receive a personality disorder diagnosis the first of these next two steps would be encouraged. as swales 9 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ is evident from the descriptions of severity above, the manifestations of severity vary significantly, and these expressions are in accordance with the trait domains of normal personality function. icd-11 describes five trait domain specifiers that are continuous with normal personality characteristics, consistent with the big 5 model of personality text box 3 mr d: severe personality disorder with detachment and dissociality mr d aged 34 has been referred for evaluation pending trial. he has been arrested on charges of befriending and then defrauding elderly people. over the last ten years he has befriended 5 different elderly people, all of whom lacked family nearby. he would begin the relationship by introducing himself as a representative of a local charity that supported elderly people in organising practical tasks about their home e.g arranging gardeners, decorators etc. he would then spend increasing amounts of time with his intended victim and then pour out a story about how his mother had a serious medical illness for which treatment was only available in the us and how distressed he was that he could not afford it. he would eventually accept funds from his victims after protesting for a short while that he could not possibly accept their generosity. his victim’s reported that his persistent refusal over a period of time was in part what was so convincing. mr d is confident that he will be found not guilty as he maintains that all of the money was given as ‘gifts’. he maintains that his victims were simply grateful to him for all the support and help that he offered them. his victims, in contrast, describe how he was initially helpful but latterly would easily become irritated and aggressive if they did not follow his advice and they found it hard to resist his suggestions. mr d in recent years has had no regular employment and has relied on the funds that he obtained from his victims to sustain himself. his family have severed all contact with him– including his motherbecause of his constant demands for money and his aggressive behaviour when his demands are not met. he has no reliable place to live, frequently being asked to leave where he is living because of non-payment of rent. mr d describes other people as a nuisance and as parasites and says that he can see no need of relationships or connections with others. mr d had difficulties originating in childhood. he described his father as an abusive man who frequently told him to stand up for himself. he often fought with other children and complained that he was constantly disrespected although he was often described as a bully. he left school with minimal qualifications and although he began a college course he was dismissed for a combination of non-completion of the course and aggressive behaviour towards other students. diagnosing personality disorder in icd-11 10 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ (mccrae & costa, 1987) and have been found in most if not all mental disorders. trait domain specifiers are not diagnostic categories rather they represent a set of dimensions corresponding to the underlying structure of personality in all people. factor analytic studies broadly speaking support the icd-11 five factor structure (bach et al., 2017; mulder et al., 2016), although some studies have found four factors rather than five, where one factor captures the two polar opposites of disinhibition versus anankastia (bach et al., 2020; oltmanns & widiger, 2018). as many trait domain specifiers can be applied as are appropriate to describe a person’s characteristics. individuals with more severe personality disturbance tend to have a greater number of prominent traits although it is possible to have severe personality disorder and manifest only one trait domain e.g. dissociality. each of the trait domain specifiers will now be considered in turn. negative affectivity tendency to experience a broad range of negative emotions forms the central element of negative affectivity. in people with a personality disorder diagnosis this typically means that they experience a broad range of negative emotions with a frequency and intensity that others judge as being out of proportion to the situation. nevertheless, given the person’s life experiences and genetic heritage their responses make sense in terms of their own learned experiences. common negative emotions include anxiety, worry, sadness, fear, anger, hostility, guilt and shame. the person often experiences emotional lability with accompanying difficulties in regulating their emotions. they are often easily distressed and it takes them longer than average for their emotions to return to their baseline levels. as a result of intense and frequent emotions, negative thoughts and attitudes com­ monly occur which, in turn, further fuel strong emotional reactions. hopeless thoughts are frequent and a tendency to assume that interventions or solutions suggested by friends, family and professionals will not help their situation. individuals often have low self-esteem and self-confidence which may result in avoiding situations or activities as they anticipate difficulty. often, they do find situations difficult, because of their emo­ tional sensitivity. they may become highly dependent on others for advice, reassurance, help and direction. at times, they may be understandably envious of other’s abilities and successes given their own challenges. in more severe cases they may experience intense feelings of worthlessness and suicidal ideation. negative affectivity may be very evident both in a person’s report and behaviour, as might be seen in the case of ms t or it may be heavily disguised and may not even be reported directly as is the case with mr r. interactions with other personality traits influence how negative affectivity manifests. in individuals with traits of greater disinhibition negative affectivity is more likely to be clearly evident and to present swales 11 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ earlier in life, whereas in those with detachment and anankastia it may present later, be less directly evident and may even not be reported. detachment detachment can be either social or emotional. social detachment in people with a personality disorder diagnosis consists of significant avoidance of social interactions and what they may consider unnecessary interpersonal contact. the person may often respond in ways that actively discourage social interaction. as a result, the person often lacks friends or even acquaintances, often avoiding intimacy of all kinds, including sexual intimacy. emotional detachment is evident in a reserved and aloof manner with limited emotional expression and experience, both verbally and non-verbally. in extreme cases a person may report a lack of emotional experience altogether; they may be unreactive to positive or negative events and both report and demonstrate a limited capacity for enjoyment. mr d shows evidence of both social and emotional detachment dissociality mr d also shows strong evidence of the dissociality trait specifier. disregard for the feelings and rights of others which includes self-centeredness and lack of empathy is at the centre of this trait domain. people with this trait may demonstrate a sense of entitle­ ment, expecting others to admire them. they may endeavour to attract the attention of others or to ensure that they are at the centre of other people’s attention. if others do not respond as they wish they may dramatically express their dissatisfaction. dissociality may lead to a disregard of the importance of others and the person may have a relentless focus on their own needs, desires and comfort. disinhibition impulsive action in response to immediate internal or environmental stimuli without consideration of longer-term consequences forms the basis of the disinhibition trait domain. people with this trait tend to act rashly without considering the impact of their actions on themselves or others in the longer term and this can include putting themselves or others at risk. difficulties delaying reward or satisfaction result in strong associations with such behaviours as substance use, gambling, and unplanned sexual activity. alongside impulsive action, appraisal of risk is impaired combined with an absence of an appropriate sense of caution resulting in, for example, reckless driving, dangerous sports and activities without appropriate training and preparation. ms. t shows elements of disinhibition in her reactions in romantic relationships and in her responses to her current placement. people with this trait are frequently distractible, becoming easily bored or frustrated with routine, difficult or tedious tasks and may often be seen scanning the environment for more pleasurable options. people with a personality disorder with this trait often diagnosing personality disorder in icd-11 12 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ demonstrate a lack of planning preferring spontaneous over planned activities with a focus on immediate emotions and sensations with little attention to long-, and sometimes even short-, term goals. consequently, they often fail to reach any of the goals that they set themselves. anankastia individuals high on anankastia have a very clear and detailed personal sense of perfec­ tion and imperfection that extends beyond the typical standards of their community. they believe strongly that everyone should follow all rules exactly and meet all obliga­ tions. like mr. r, individuals high on anankastia may redo the work of others because it does not meet their perfectionistic standards. individuals with this trait strongly believe in controlling themselves and situations to ensure that their perfectionistic standards are met. they have a preoccupation with social rules and obligations and what should be considered right and wrong. they focus intensely on detail and are highly systematic and organized to the point of being rigid. their intensity of focus on issues or orderliness, neatness and structure frequently leads to interpersonal difficulties because they expect these same high standards from everyone else. they may also have extreme difficulty making decisions as they are not sure that they have considered every aspect of the situation. applying the same rules of order to their emotional and behavioural expression such that they do not express emotions or only in a very minimal way is common manifestation of the trait. their extreme planfulness means that they are often incapable of spontaneity or of making changes to their schedule. they are very risk aware and so are highly unlikely to engage in any activity that would be likely to have a negative consequence. borderline pattern the original intention with the new icd-11 classification was to end after the identifi­ cation of trait domains. extensive concern was expressed by the clinical and academic community about the changes to the classification and in particular about continued access to treatments (herpertz et al., 2017). following discussions with representatives from concerned groups, a concession was agreed primarily to ensure that no one was disadvantaged by the removal of the ‘borderline’ / ‘emotionally unstable’ personality dis­ order diagnosis. in some jurisdictions without this diagnosis payment for some specialist treatments would be unavailable and so in order to limit this possibility a borderline pattern specifier was introduced which essentially has the same diagnostic features for bpd as in dsm. swales 13 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ the special case of adolescents one noteworthy feature of the icd-11 classification is the removal of any age specifica­ tion for the diagnosis. previously diagnosis was either forbidden in under 18s or strongly discouraged and reluctance to diagnose in clinicians was well documented (chanen et al., 2020). the reasons for this were primarily a concern about assigning a stigmatising diagnosis to a young person especially when their personality was still in development. whilst this concern is legitimate, it resulted in the paradoxical position that a disorder known to begin in adolescence could not be identified and addressed because of the re­ strictions on classification. with icd-11, clinicians can make a diagnosis and this opens up the opportunity for early intervention for young people whose behaviours may meet the essential requirements for a diagnosis and yet because of their youth these behav­ iours may be less entrenched and more open to change (chanen et al., 2020). caution is still required, however. as discussed earlier, young people may demonstrate concerning behaviours that may be better accounted for by other diagnostic descriptions e.g. what could be described as personality disorder with traits of detachment and anankastia may be much better accounted for by an autism spectrum diagnosis or their behaviour may be a response to adverse environmental circumstances. thorough assessment and consideration are required. assessment given the risks and potential harms of a personality disorder diagnosis careful assess­ ment is required. typically, clinicians utilise clinical interviews, observation and psycho­ metric assessment, although, the icd-11 system is designed to be used without use of formal psychometric measures and, in some non-specialist settings, this will be all that is available. robust assessment requires more than one meeting with the person and would also involve discussion with people who know the person well (with the consent of the person being assessed). a comprehensive clinical interview should begin with the person’s current functioning and its history paying particular attention to a developmental history, early adversity and trauma. throughout the clinician will seek to establish the breadth of areas which are impacted, considering functioning in social, educational, occupational and familial roles. sufficient duration of difficulties must be considered and, as discussed earlier, alternative explanations, diagnoses or contextual factors must be ruled out. newly developed measures are now available to measure both severity and trait do­ mains to augment clinical interview and observations. the icd-11 personality disorder severity scale (pds-icd-11; bach et al., 2021) is a 14-item measure that shows promise and provides a rapid assessment of the severity of personality dysfunction. bach et al. (2017) and sellbom et al. (2020) describe a method of scoring the icd-11 trait specifiers utilising the personality inventory for dsm-5. clark et al. (2021) have recently developed diagnosing personality disorder in icd-11 14 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ a self-report measure of both self and interpersonal functioning as well as the trait do­ mains. for clinicians interested in a more nuanced assessment of the facets that comprise the trait domains, oltmanns and widiger (2020) have developed a 121-item facet-level assessment of the icd-11 model. the recently modified pid5bf+ captures both icd-11 and dsm-5 trait domains using three facets per domain (bach et al., 2020). conclusion icd-11 personality disorder diagnosis moves away from a schneiderian typology that has governed personality disorder classification for almost a century and established the connection with the psychological study of ‘normal’ personality structure. in so doing icd-11 provides an opportunity to root our conceptualisations of a person’s established patterns of emotions, thoughts and behaviour within a psychological case formulation that understands these patterns as a person’s best attempts at functioning in often less than ideal environments. whilst transitioning away from well-understood and familiar concepts presents a challenge, the simplified structure of the classification opens up potential benefits in terms of simplicity and clinical utility, increased awareness of risk and better matching of resource intensive therapies to severe presentations. how far these benefits are realised will depend upon clinicians embracing the new classification, on researchers further developing measures to capture the new method of classifying and on treatment developers evaluating their treatments using the new structure. funding: the author has no funding to report. acknowledgments: thanks to my colleagues from the icd-11 working group on the classification of personality disorders: roger blashfield, lee-anna clark (dsm liaison), mike crawford, alireza farnam, andreas fossati, youl-ri kim, nestor koldobsky, dusica lecic‐tosevski, roger mulder and david ndetei enthusiastically led by peter tyrer, and geoff reed. thanks also to jared keeley for earlier version of the case vignettes. competing interests: the author was a member of the working party that developed the personality disorder guidelines reporting to the who. references bach, b., brown, t. a., mulder, r. t., newton‐howes, g., simonsen, e., & sellbom, m. 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(2010). personality pathology recorded by severity: national survey. the british journal of psychiatry, 197(3), 193–199. https://doi.org/10.1192/bjp.bp.110.078956 swales 17 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://doi.org/10.1037/0022-3514.52.1.81 https://doi.org/10.1002/pmh.1336 https://doi.org/10.1080/00048670802119739 https://doi.org/10.1037/pas0000459 https://doi.org/10.1037/pas0000763 https://doi.org/10.1159/000506313 https://doi.org/10.1080/09638237.2019.1581337 https://doi.org/10.1037/0033-2909.126.1.3 https://doi.org/10.1037/pas0000746 https://doi.org/10.1146/annurev-clinpsy-081219-105402 https://doi.org/10.1002/14651858.cd012955.pub2 https://doi.org/10.1037/bul0000017 https://doi.org/10.1192/bjp.bp.110.078956 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. diagnosing personality disorder in icd-11 18 clinical psychology in europe 2022, vol. 4(special issue), article e9635 https://doi.org/10.32872/cpe.9635 https://www.psychopen.eu/ diagnosing personality disorder in icd-11 problems with icd-10: the case for change aims of the new classification description of the changes description of the core features of personality disorder severity ratings trait domain specifiers assessment conclusion (additional information) funding acknowledgments competing interests references development and psychometric evaluation of the hope in medicine scale research articles development and psychometric evaluation of the hope in medicine scale lea balthasar 1 , anne-kathrin bräscher 2 , ted j. kaptchuk 3 , sarah k. ballou 3,4 , tobias kube 1,3 [1] pain and psychotherapy research lab, rptu kaiserslautern-landau, landau, germany. [2] department of clinical psychology, psychotherapy, and experimental psychopathology, johannes gutenberg university of mainz, mainz, germany. [3] program in placebo studies, beth israel deaconess medical center, harvard medical school, boston, ma, usa. [4] division of gastroenterology, beth israel deaconess medical center, harvard medical school, boston, ma, usa. clinical psychology in europe, 2024, vol. 6(1), article e12001, https://doi.org/10.32872/cpe.12001 received: 2023-05-21 • accepted: 2023-10-30 • published (vor): 2024-03-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: tobias kube, pain and psychotherapy research lab, rptu kaiserslautern-landau, ostbahnstr. 10, 76829 landau, germany. phone: +49 (0) 6341 280 35652. e-mail: tobias.kube@rptu.de supplementary materials: materials, preregistration [see index of supplementary materials] abstract background: hope is an integral, multi-dimensional part of seeking medical treatment. the aim of this study was to develop a self-report scale, the hope in medicine (him) scale, to measure different modes of hoping in relation to the course of symptoms, the effects of treatment, and supporting medical research. method: we examined the psychometric properties of the scale in a sample of 74 allergic rhinitis patients participating in a 2-week randomized-controlled trial comparing open-label placebos (olp) with treatment as usual (tau). results: the him scale had a cronbach’s α of .78. an exploratory factor analysis revealed four factors: realistic hope (i.e., hoping for specific positive outcomes such as improvement in symptoms), transcendent hope (i.e., non-directed hoping that things will turn out positively), utopian hope (i.e., hoping to contribute to greater knowledge), and technoscience hope (i.e., hoping for scientific breakthroughs). speaking to the convergent validity of the scale, realistic hope was moderately related to treatment expectancies (r = .54); transcendent hope was related to optimism (r = .50), treatment expectancies (r = .37), self-efficacy (r = .36), and inversely correlated with pessimism (r = -.43). hope subscales predicted neither course of symptoms nor impairment. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12001&domain=pdf&date_stamp=2024-03-28 https://orcid.org/0000-0002-6147-4424 https://orcid.org/0000-0002-2621-5689 https://orcid.org/0000-0002-2253-1940 https://orcid.org/0000-0002-6746-1958 https://orcid.org/0000-0002-5420-4506 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: the him scale is a questionnaire with adequate internal consistency allowing to assess four modes of hoping. preliminary results for its convergent validity are promising. yet, further validation is needed. keywords hope, placebo, questionnaire, self-report, allergic rhinitis highlights • the him scale was developed to assess hope specifically in relation to treatment. • the him scale allows to assess several modes of hoping. • the study shows promising results concerning internal consistency and convergent validity of the him scale. hope has been the subject of scrutiny across academic disciplines, including philosophy, psychology, and medicine. it is an integral aspect of human life (webb, 2007) and is often present in everyday life (e.g., hoping for a promotion or a general hopefulness for a bright future). when facing a serious illness, patients may hope for a remission of their symptoms and/or successful treatment outcomes. even terminally ill, patients often maintain hope, e.g., hoping to preserve a good quality of life (e.g. hagerty et al., 2005). defining hope although hope is a nearly ever-present phenomenon in human life, defining the con­ struct is difficult. in several scholarly disciplines, many theories and definitions of hope have been proposed (for an overview see kube et al., 2019; webb, 2007). according to most definitions, hope involves desiring a future event or outcome with a low or unknown probability of fulfillment (kube et al., 2019). although there is a certain over­ lap between hope and expectations, people can differentiate between these constructs (montgomery et al., 2003), with expectations relating to subjectively higher certainty of the desired outcome (kube et al., 2019; leung et al., 2009). hope also resembles optimism defined as “generalized expectations of the occurrence of good outcomes in one’s life” (scheier & carver, 1985, p. 239) and both involve positive affect towards the future (bruininks & malle, 2005). in contrast, pessimism describes anticipating bad outcomes (scheier & carver, 1985, p. 219) and is negatively correlated with optimism. however, people distinguish between hope and optimism: compared to optimism, hope is directed at more important outcomes, with a smaller subjective likelihood of occurring, and less perceived personal control over the obtaining of the outcome (bruininks & malle, 2005). webb (2007) integrated hope theories and definitions and developed a model with five modes of hoping assigned to the two superordinate dimensions “goal-directed hope” and “open-ended hope”. in a qualitative study, eaves et al. (2014) applied webb’s frame­ development of the him scale 2 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://www.psychopen.eu/ work to a medical context. chronic pain patients participating in a randomized-control­ led trial (rct) to evaluate traditional chinese medicine were interviewed before treat­ ment started and over the 18-month course of the rct. five modes of hoping emerged from the patients’ answers: realistic hope, wishful hope, utopian hope, technoscience hope, and transcendent hope. this modes-of-hoping framework will be the theoretical basis of our hope scale. definitions of the modes of hoping realistic hope describes “any hope that would be considered reasonable or probable based on current medical knowledge” (eaves et al., 2014, p. 228). it includes, for ex­ ample, hopes for minor symptom reductions, needing less medication or finding new techniques to manage pain (p. 229). there is a certain overlap between realistic hope and expectations, with realistic hope resembling the definition of the term “hope” in everyday language (e.g. “desire accompanied by expectation of or belief in fulfillment”, merriam-webster, n.d.). wishful hope comprises very high hopes which still can be fulfilled. for example, when patients expressed “hope for a cure” or hope “related to hearsay about miraculous outcomes experienced by others” (eaves et al., 2014, p. 229). although patients often considered these hopes to be unrealistic, they are in the realm of possibility and motivate chronically ill patients to seek further treatment. utopian hope contains hoping that collective action might lead to a better future. in the context of medical and psychological research, utopian hope means that patients hoped that their participation in a research study would contribute to greater overall knowledge about the disease and would help others in the future (eaves et al., 2014, p. 229). especially utopian hope and realistic hope show a certain overlap with self-efficacy, i.e., the belief that a certain behavior will produce the desired outcome (i.e., outcome expectancies) combined with the confidence in one’s ability to perform the required behavior, i.e., efficacy expectancies (bandura, 1977). however, in utopian hope it is a desire rather than an expectancy. realistic hope also includes outcomes independent from one’s own actions. technoscience hope refers to hope for unforeseeable medical or scientific break­ throughs concerning treatment or cure. it also includes faith in science and medicine (eaves et al., 2014, p. 229). an open, hopeful attitude not directed to a specific outcome or goal is classified as transcendent hope (eaves et al., 2014, p. 230). transcendent hope may also contain religious faith and openness to the future. measuring hope due to the variety of definitions, more than 30 measures exist to assess hope (schrank et al., 2008). they differ in the number of assessed dimensions, whether they assess hope as a trait vs. as a state or globally vs. in a specific context. although some widely used questionnaires have been developed for clinical settings and used in medical and balthasar, bräscher, kaptchuk et al. 3 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://www.psychopen.eu/ nursing research (e.g. the herth hope index by herth, 1992), none of them contains items to assess hope concerning the course of an illness, treatment success or quality of life. instead, they assess hope more globally, such as having goals or plans for the future, feeling connected to others, and spirituality. although these questionnaires might be valuable to assess a general hopefulness, possibly linked to positive health outcomes, they do not cover concrete hopes regarding illness or treatment. additionally, they do not account for hopes concerning participating in a research study. covering these aspects of hope is the main goal of the newly developed hope scale presented in this article, the hope in medicine (him) scale. aims of the present study in the present study, we aimed to preliminarily validate the him scale by examining its psychometric properties, i.e., its factorial structure, internal consistency and correlations with related constructs such as treatment expectancies, optimism, pessimism, and self-ef­ ficacy. we predicted the him scale to have an internal consistency of cronbach’s α ≥ .70. in terms of convergent validity, we predicted a moderate relationship (.3 ≥ r ≤ .7) of hope as assessed with the him scale with related constructs. we examined these aspects in a rct comparing the effects of open-label placebos + treatment as usual (subsequently referred to as “olp”) vs. treatment as usual (tau) in allergic rhinitis patients. the main results of this rct are reported elsewhere (kube et al., 2022). here, we focus on the validation of the scale that – in the context of the spe­ cific aforementioned rct – assessed hope concerning the effects of placebo treatment and the course of allergic symptoms. in terms of the modes-of-hoping framework, we assessed hope regarding symptom improvement (realistic hope), hope for full remission of symptoms and/or being cured from allergic rhinitis in the future (wishful hope), and hope that taking part in a research study would contribute to greater knowledge about allergic rhinitis and its treatment (utopian hope). furthermore, we assessed an open, hopeful attitude towards the future in general (transcendent hope) and hope for unforeseeable scientific breakthroughs concerning novel treatment options for allergic rhinitis (technoscience hope). in the olp literature there is a recent discussion whether hope might be a better explanatory mechanism for olp effects than expectations (e.g. kaptchuk, 2018). while positive expectations robustly predict effects in deceptive placebos (e.g. enck et al., 2013), expectations do not predict olp effects in most studies (e.g. kleine-borgmann et al., 2019; pan et al., 2020). in rcts, many participants do not report positive treatment expectations; instead, they often report hope (e.g. eaves et al., 2014; haas et al., 2022). therefore, we tested whether hope predicted course of symptoms and quality of life in olp and tau to examine criterion validity. development of the him scale 4 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://www.psychopen.eu/ materials and method scale development items were generated by reviewing literature, especially the framework by eaves et al. (2014, 2016), and by reviewing existing scales. kube et al. (2019) stated that participating in a research study to evaluate novel treatments could include utopian hope (increasing knowledge), transcendent hope (being open to see what happens), and technoscience hope (hoping for unforeseen medical/scientific breakthroughs). these considerations were also taken into account when developing the items. reviewing existing question­ naires assessing hope, we included two items (items no. 20, 21) of the perceived hope scale by krafft et al. (2019) in our questionnaire. additionally, our scale development was guided by participants’ answers in qualitative studies in which they were asked what they expected or hoped for prior to a new medical treatment (di blasi et al., 2005; eaves et al., 2014, 2015, 2016; kaptchuk et al., 2009). an initial item-pool of 22 items was developed by one of the authors (lb) in consultation with a second author (tk). based on the discussion with two further authors (tjk, skb), who have extensively addressed the concept of hope in both their scientific and clinical work, the wording of six items was slightly revised and five items were replaced entirely. as a result, the him scale consisted of 22 items (see table a1 in appendix a, supplementary materials) that were rated on a 6-point likert-type scale ranging from 1 = do not agree to 6 = completely agree. lower sum scores of the him scale indicate less hope. the scale was developed and administered in german (see table a2 in appendix a, supplementary materials), and it was translated into english for the present article. participants for the rct, we aimed to reach a sample size of 90 participants, f = .30; α = .05; 1-β = .80, as pre-registered: https://aspredicted.org/ss6ag.pdf (see kube et al., 2022). 96 participants were screened for study participation. inclusion criteria were: diagnosed allergic rhinitis, at least 18 years old, and sufficient german language skills. exclusion criteria were: diabetes, pregnancy, mental or neurological illnesses, and lactose intoler­ ance (as the placebo tablets contained lactose). the final study sample consisted of 74 participants (n = 54 female, 73%; m = 32.4, sd = 13.0 years) as detailed in the consort diagram (see figure 1). the sociodemographic characteristics are presented for the two treatment conditions separately in appendix b, supplementary materials. participants were recruited via email lists, social media, and newspaper announcements. data was collected between april and august 2021. participants received either 10 € or course credit for their participation. balthasar, bräscher, kaptchuk et al. 5 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://aspredicted.org/ss6ag.pdf https://www.psychopen.eu/ figure 1 consort diagram assessed for eligibilty (n = 96) randomized (n = 77) excluded (n = 19) • not meeting inclusion criteria (n = 13) • declined to participate (n = 1) • person unavailable (n = 5) allocated to intervention (n = 37) • received allocated intervention (n = 35) • did not receive allocated intervention (n = 2) • did not show up (n = 1) • declined to participate (n = 1) allocated to intervention (n = 40) • received allocated intervention (n = 39) • did not receive allocated intervention (n = 1) • person unavailable (n = 1) analyzed (n = 35) • excluded from analysis (n = 0) analyzed (n = 39) • excluded from analysis (n = 0) lost to follow-up (n = 1) person unavailable (n = 1) lost to follow-up (n = 1) person did not want to participate any longer (n = 1) enrollment allocation follow-up analysis olp tau figure 1 consort diagram procedure the rct included a pretest (t1) and a posttest (t2) with a virtual clinical encounter each time. at t1, a psychology master student spoke to the participants about their allergic rhinitis and informed them about potentially positive effects of placebos. afterwards, participants completed several questionnaires including the him scale. at the end of the pretest (i.e., after completing the questionnaires), participants were informed about their randomized treatment allocation to olp vs. tau. in the following 2 weeks, they took either olp (two placebo tablets per day) + tau or tau alone. participants in the tau group only took their regular antiallergic medication (if there was any). after 2 development of the him scale 6 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://www.psychopen.eu/ weeks, there was a second clinical encounter (t2), in which the same psychology master student asked the participants about the course of their allergic symptoms and potential treatment effects, in addition to the second completion of questionnaires. all data was collected online via the survey platform sosci survey (leiner, 2021). the study was approved by the local ethics committees of the university of koblenz-landau and the johannes gutenberg university of mainz. all participants gave informed consent. additional measures severity and frequency of allergic rhinitis symptoms were assessed with the combined symptom medication score (csms; pfaar et al., 2014) and a questionnaire by schaefer et al. (2016, 2018). allergy-related impairment of quality of life was assessed with the ger­ man version of the mini rhinoconjunctivitis quality of life questionnaire (minirqlq; juniper et al., 2000). treatment expectations were measured with the adapted version (kube et al., 2021) of the treatment expectancy scale by kube et al. (2020). self-efficacy, optimism, and pessimism were assessed with the fragebogen zu selbstwirksamkeit, opti­ mismus, pessimismus kurzform (swop-k9; questionnaire for self-efficacy, optimism, and pessimism; scholler et al., 1999). the instructions were adapted where necessary to refer to the last 2 weeks instead of the last week. these measures are detailed in appendix c, supplementary materials. statistical analyses two participants dropped out between pretest and posttest. therefore, we conducted an intention to treat analysis with expectation maximization using ibm spss statistics (version 27) to estimate missing values concerning symptom severity, symptom frequen­ cy, and quality of life at t2 of those two participants. power analyses were conducted in g*power (version 3.1.9.6, faul et al., 2007), and all other statistical analyses were performed in r (r core team, 2020). alpha error levels were set at 5%. we conducted an item analysis of the him scale and excluded items with a popularity index > 95 according to dahl (1971; kelava & moosbrugger, 2020; see appendix d, supplementary materials). to examine the factorial structure, an efa was performed with the remaining items. the number of empirically relevant factors was determined with a parallel analysis according to horn (1965) and an oblique rotation (promax) with these factors was performed as they were expected to be correlated. items either loading > .30 on more than one factor or not loading at least .30 on any of the extracted factors were excluded (boateng et al., 2018). internal consistency was determined by computing cronbach’s alpha. to determine the convergent validity, we computed correlations between hope and treatment expect­ ancies, optimism, pessimism, and self-efficacy. evaluating the criterion validity, three hierarchical regression analyses were conducted to test whether higher hopes at t1 were balthasar, bräscher, kaptchuk et al. 7 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://www.psychopen.eu/ associated with less symptom severity, frequency of symptoms, and impairment of quali­ ty of life after the 2-week intake of olp or tau. in the first step, the four hope subscales were included as predictors. in the second step, treatment condition (olp vs. tau) was added as an additional predictor. residuals were plotted to examine whether the preconditions of homoscedasticity, normal distribution of residuals, and correct model specification were met. results item analysis and exploratory factor analysis means, standard deviations, and item popularity according to dahl (1971) for all items are presented in appendix e, supplementary materials. items no. 4, 5, 10, and 11 were ex­ cluded from further analyses as they had a popularity index > 95. with the remaining 18 items, we performed an efa. the kaiser-meyer-olkin criterion was .65 and thus above the cutoff of .50 (kaiser & rice, 1974) and the bartlett test was significant (p < .001), both suggesting that conducting an efa is appropriate. a parallel analysis according to horn (1965) yielded a four-factor solution, explaining 49% of the variance. table 1 shows the factor loadings and communalities after oblique rotation. item no. 6 was excluded from further analyses as it loaded > .30 on more than one factor. items no. 14 and 22 did not load on any of the four extracted factors, thus they were also excluded. hence, the final him scale contains 15 items comprising four factors: realistic hope, transcendent hope, utopian hope, and technoscience hope. the assumed fifth factor wishful hope could not be confirmed. table 2 shows the intercorrelations of these factors. internal consistency and validity analyses cronbach’s α for the final 15-item him scale was .78. convergent validity table 3 shows the correlations of the four factors of the him scale with treatment expectancies, optimism, pessimism, and self-efficacy. means and standard deviations of the hope subscales and the scales used for validation can be found in appendix f, table f1, supplementary materials. criterion validity contrary to our assumptions, none of the hope subscales predicted symptom severity (see appendix f, table f2, supplementary materials) or symptom frequency at t2 (see appendix f, table f3, supplementary materials). taking bonferroni correction into account, none of the hope subscales predicted impairment of quality of life at t2 (see development of the him scale 8 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://www.psychopen.eu/ table 4). the power to detect a small effect of f2 = 0.02 (α = .05, n = 74) was very low, though, 1-β = .12. table 1 results from the exploratory factor analysis of the hope in medicine scale item factor loadings 1 2 3 4 h2 factor 1: realistic hope 1. i hope i will have less symptoms after taking the pills. .93 -.10 -.10 .19 .86 2. i hope that taking the pills will improve my quality of life. .86 -.05 -.09 .16 .74 3. i have hope that the pills will help me. .78 .06 -.08 .11 .63 7. i believe there is a small chance the placebos will make my symptoms go away completely. .39 .10 .09 -.06 .21 factor 2: transcendent hope 21. i am hopeful with regard to my life. -.02 .89 -.05 -.04 .75 19. i have the feeling that a lot of positive things await me in my future life. -.01 .85 .08 .00 .76 18. i have the feeling that my life will develop positively in the future. .10 .76 .00 -.03 .62 20. in my life hope outweighs anxiety. .05 .44 .23 -.17 .31 factor 3: utopian hope 8. i have hope that my participation in this study will contribute to a greater overall knowledge about the treatment of allergic rhinitis. -.29 .07 .96 .04 .89 9. i hope that my participation in this study will contribute to helping other people with allergic rhinitis in the future. -.15 .13 .82 -.21 .69 12. i do not believe that i will make an important contribution to the investigation of treatments for allergic rhinitis by participating in this study. (r) .14 -.09 .40 .07 .21 13. i think that studies like this can help us learn more about allergic rhinitis and its treatment. .03 -.05 .30 .26 .18 factor 4: technoscience hope 14. i hope that sooner or later an effective treatment for allergic rhinitis will be developed. -.02 -.04 .21 .82 .75 16. i hope for a scientific breakthrough in the treatment of allergic rhinitis. -.02 -.09 .02 .70 .48 17. i have hope that my allergic rhinitis will suddenly be cured someday. .13 .04 -.13 .43 .22 excluded items 6. i do not have specific expectations for the treatment with placebos but it is worth trying. -.55 -.01 .10 .32 .34 15. i believe science will be able to find a treatment for almost every illness. -.08 .23 -.12 .17 .09 22. i look hopelessly into the future. (r) .06 .08 .08 .06 .04 note. n = 74. extraction method: principal factor analysis with oblique rotation. factor loadings ≥ .30 are in bold. h2 = communalities. eigenvalue of factor 1 realistic hope = 3.20; eigenvalue of factor 2 transcendent hope = 1.91; eigenvalue of factor 3 utopian hope = 1.17; eigenvalue of factor 4 technoscience hope = 0.83. balthasar, bräscher, kaptchuk et al. 9 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://www.psychopen.eu/ table 2 intercorrelations of the four factors factor 1 2 3 4 1. realistic hope – .24 [-0.11, 0.54] .18 [-0.16, 0.49] .23 [-0.11, 0.52] 2. transcendent hope .24 [-0.11, 0.54] – .29 [-0.06, 0.58] .09 [-0.21, 0.38] 3. utopian hope .18 [-0.16, 0.49] .29 [-0.06, 0.58] – .12 [-0.20, 0.43] 4. technoscience hope .23 [-0.11, 0.52] .09 [-0.21, 0.38] .12 [-0.20, 0.43] – note. n = 74. 95% confidence intervals in square brackets using bonferroni-holm correction. table 3 correlations of the four factors of the hope in medicine scale with treatment expectancies, optimism, pessimism, and self-efficacy hope subscales treatment expectancies optimism pessimism self-efficacy realistic hope .54*** [0.23, 0.75] .13 [-0.20, 0.44] -.03 [-0.29, 0.23] .07 [-0.23, 0.35] transcendent hope .37* [0.03, 0.64] .50*** [0.18, 0.73] -.43*** [-0.68, -0.09] .36* [0.02, 0.63] utopian hope .25 [-0.10, 0.55] .10 [-0.21, 0.39] .03 [-0.25, 0.31] -.01 [-0.24, 0.22] technoscience hope .17 [-0.16, 0.47] .13 [-0.20, 0.43] .11 [-0.21, 0.41] .25 [-0.10, 0.54] note. n = 74. *p < .05. **p < .01. ***p < .001. p values and 95% confidence intervals in square brackets using bonferroni-holm correction. development of the him scale 10 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://www.psychopen.eu/ table 4 hierarchical regression analysis with impairment of quality of life at t2 as dependent variable predictor b se(b) β t p model 1 realistic hope -0.08 0.12 -.08 -0.66 .51 transcendent hope 0.01 0.15 .01 0.09 .93 utopian hope 0.43 0.18 .30 2.43 .02 technoscience hope 0.06 0.13 .06 0.49 .62 model 2 realistic hope -0.07 0.12 -.07 -0.59 .56 transcendent hope 0.01 0.15 .01 0.09 .93 utopian hope 0.41 0.18 .28 2.33 .02 technoscience hope 0.08 0.13 .08 0.64 .52 treatment condition 0.42 0.23 .21 1.84 .07 note. model 1: r 2 = .09, f(4, 69) = 1.74, p = .15. model 2: r 2 = .14, f(1, 68) = 2.12, p = .07. discussion we developed the hope in medicine (him) scale to assess hope specifically in a medical context and examined its psychometric properties in a 2-week rct comparing the effects of olp vs. tau on symptoms of allergic rhinitis. an exploratory factor analysis of the him scale yielded a four-factor solution with the factors “realistic hope”, “transcendent hope”, “utopian hope”, and “technoscience hope”. thus, we could extract 4 of the 5 modes of hoping suggested by eaves et al. (2014, 2016). however, we did not find a fifth factor relating to the mode “wishful hope”. it might be difficult to assess “wishful hope” in allergic rhinitis patients in general as there is a variety of promising treatment options and a wide range of treatment outcomes which can be considered realistic, including full remission. wishful hope might be more important in more desperate chronically ill patients with a lower likelihood of experiencing full remission. nonetheless, based on the current data, the him scale allows to assess four of the intended modes of hoping that are relevant especially in medical settings and prior to starting a new treatment, speaking to its validity. furthermore, the scale shows good internal consistency given the heterogeneity of the construct. analyses regarding the convergent validity of the him scale provided a mixed pattern of results. realistic hope correlated significantly with treatment expectancies, speaking to its convergent validity as the items assessing realistic hope also relate to desired improvements following placebo treatment which could be considered probable. transcendent hope was significantly correlated with treatment expectancies, optimism, and self-efficacy and inversely correlated with pessimism, suggesting convergent validity balthasar, bräscher, kaptchuk et al. 11 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://www.psychopen.eu/ as well. in contrast, the factors utopian hope and technoscience hope did not correlate with any of the assumed related constructs. however, this is not surprising because both utopian hope and technoscience hope are relatively specific aspects of hope. they neither refer to the general attitude towards the future (i.e., optimism, pessimism) nor to specific treatments outcomes (i.e., treatment expectancies). the swop-k9 assesses self-efficacy concerning mastering difficulties instead of a general confidence in being able to show a certain behavior to reach a specific outcome (bandura, 1977). this might explain why utopian hope did not correlate with self-efficacy in the present study, although it shares a certain overlap with self-efficacy defined by bandura (1977). future research may examine whether a more substantial association between utopian hope and self-efficacy can be found with other measures of self-efficacy. none of the hope subscales predicted symptom severity, symptom frequency or impairment of quality of life after the 2-week intake of olp or tau, questioning the predictive validity of the him scale. however, the statistical power in the present study was low due to the small sample size, possibly explaining the nonsignificant results. it is worth noting, though, that it is unclear so far whether hope is an explanatory mechanism for olp effects. only few studies, which show limitations concerning the assessment of hope, have examined the role of hope in olp rcts so far (haas et al., 2022; kube et al., 2020; pan et al., 2020). possibly, measurable hope does not matter in olp effects or the course of symptoms. instead, it might mainly instill the motivation to seek treatment. limitations and future directions the present study has several limitations: 1) the same sample was used for developing and validating the him scale. thus, further validation in another independent sample is recommended. 2) most items showed ceiling effects leading to limited variance which might explain some of the unexpected non-significant results concerning validation. the ceiling effects might be due to social desirability or a self-selection bias with only those patients expressing interest in the study who hoped to benefit from it. alternatively, giv­ ing information about possible positive effects of placebos during the clinical encounter might have instilled hope. 3) the present study focused on allergic rhinitis and baseline allergic symptoms and baseline impairment were rather low. we assume that the him scale can be applied to other medical conditions except for life threatening illnesses. however, the external validity of the present rct is rather limited. therefore, it would be valuable to examine the him scale’s validity in more severe or chronic diseases as hope might be more important in those cases, possibly leading to higher variance, increased explained variance, and higher correlations with measures of convergent valid­ ity. in future studies, criterion validity could be addressed by testing whether treatment conditions differ in certain hope subscales after treatment allocation. content validity could be tested by examining the relation of certain hope subscales and the big-5 traits development of the him scale 12 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://www.psychopen.eu/ (e.g., transcendent hope with openness). 4) the psychometric properties of the english version of the him scale should be tested, and larger sample sizes are recommended for future studies to increase statistical power. conclusions since there has been a lack of measures assessing hope specifically in relation to medical treatment and symptom course, the him scale may fill this gap as it covers several modes of hoping in the context of starting a new treatment and participating in a research study. as validated in a sample of patients with allergic rhinitis, the scale shows good internal consistency and the preliminary results for its convergent validity are promising. contrary to our hypotheses, however, hope was not related to greater symptom improvement following treatment. the current study is just a very first step into more systematically investigating the role of hope, which allows only some very cautious conclusions due to the small sample size and some other limitations. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. author contributions: lea balthasar, conceptualization, methodology, formal analysis, investigation, data curation, writing – original draft, writing – review and editing, visualization. anne-kathrin bräscher, resources, writing – review and editing, supervision, project administration. ted j. kaptchuk, writing – review and editing. sarah k. ballou, writing – review and editing. tobias kube, conceptualization, methodology, resources, writing – review and editing, supervision, project administration. ethics statement: this research was approved by the local ethics committees of the university of koblenz-landau and the johannes gutenberg university of mainz. informed consent was obtained from all participants included in the study. twitter accounts: @drsarahballou data availability: open data: the information needed to reproduce all of the reported results are not openly accessible. the data is available on request from the authors. code: code is not openly accessible. open materials: the information needed to reproduce all of the reported methodology is not openly accessible. supplementary materials the supplementary materials include the following items: balthasar, bräscher, kaptchuk et al. 13 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://twitter.com/drsarahballou https://www.psychopen.eu/ • the pre-registration protocol for the study. the rct was preregistered at aspredicted (see kube et al., 2021). the development and psychometric evaluation of the him scale was not preregistered. • online appendices (see balthasar et al., 2024) ◦ appendix a. table a1-2. table a1 shows the english translation of the instructions and items of the him scale. table a2 shows the german instructions and items of the him scale. ◦ appendix b. table b1. table b1 shows sociodemographic characteristics of the two treatment groups separately. ◦ appendix c. detailed description of additional measures. ◦ appendix d. formula to calculate the popularity index according to dahl (1971). ◦ appendix e. table e1. table e1 shows the results of the item analysis. ◦ appendix f. table f1-3. table f1 shows means and standard deviations of the hope scales, treatment expectancies, self-efficacy, optimism, and pessimism. table f2 shows the results of the hierarchical regression analysis with symptom severity as dependent variable. table f3 shows the results of the hierarchical regression analysis with symptom frequency as dependent variable. index of supplementary materials kube, t., kirsch, i., glombiewski, j. a., witthöft, m., & bräscher, a. 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(2007). modes of hoping. history of the human sciences, 20(3), 65–83. https://doi.org/10.1177/0952695107079335 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. balthasar, bräscher, kaptchuk et al. 17 clinical psychology in europe 2024, vol. 6(1), article e12001 https://doi.org/10.32872/cpe.12001 https://doi.org/10.1111/all.12383 https://www.r-project.org/ https://doi.org/10.1159/000447242 https://doi.org/10.1371/journal.pone.0192758 https://doi.org/10.1037/0278-6133.4.3.219 https://doi.org/10.23668/psycharchives.337 https://doi.org/10.1111/j.1600-0447.2008.01271.x https://doi.org/10.1177/0952695107079335 https://www.psychopen.eu/ development of the him scale (introduction) defining hope measuring hope aims of the present study materials and method scale development participants procedure additional measures statistical analyses results item analysis and exploratory factor analysis internal consistency and validity analyses discussion limitations and future directions conclusions (additional information) funding acknowledgments competing interests author contributions ethics statement twitter accounts data availability supplementary materials references worry intervention in an older adult with a persecutory delusion: a single case experimental design research articles worry intervention in an older adult with a persecutory delusion: a single case experimental design poppy brown 1 , anna crabtree 2 [1] oxford institute for clinical psychology training and research, oxford health nhs foundation trust and university of oxford, warneford hospital, oxford, united kingdom. [2] royal holloway university of london, egham hill, egham, united kingdom. clinical psychology in europe, 2023, vol. 5(3), article e11173, https://doi.org/10.32872/cpe.11173 received: 2023-01-21 • accepted: 2023-07-01 • published (vor): 2023-09-29 handling editor: tania lincoln, university of hamburg, hamburg, germany corresponding author: poppy brown, oxford institute for clinical psychology training and research, oxford health nhs foundation trust and university of oxford, warneford hospital warneford lane, oxford, uk, ox3 7jx. phone: +44 1865 225145. e-mail: poppy.brown@hmc.ox.ac.uk supplementary materials: materials [see index of supplementary materials] abstract background: this report presents the single case of jack, a 67-year-old referred to our older adult community mental health team (oa cmht) for his distressing persecutory delusion and high levels of worry. jack also reported learning difficulties and autistic traits, although neither were formally diagnosed. method: ten sessions of worry intervention taken from the feeling safe programme worry module were used to reduce jack’s time spent worrying and increase his engagement in meaningful activity. weekly face-to-face sessions were held, with jack’s brother acting as a cotherapist. adaptations to the intervention were made based on jack’s learning preferences. an ab single case experimental design was adopted to compare jack’s scores on measures of worry, paranoia and delusional conviction, and wellbeing and daily functioning before and after intervention. results: results demonstrate the worry intervention improved jack’s scores on all measures to a clinically significant degree. conclusions: this is the first known report of applying the worry intervention to an older adult. the results show the intervention can be of considerable benefit in terms of reducing worry and paranoia, in the context of both older age and suspected neurodiversity. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11173&domain=pdf&date_stamp=2023-09-29 https://orcid.org/0000-0003-3105-2420 https://orcid.org/0000-0002-5726-6876 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords worry, paranoia, persecutory delusion, older adult, single case experimental design highlights • the evidence base for treating persecutory delusions through cbt is growing, but we do not know if these treatments are acceptable to, and effective with, older adults. • this is the first known use of the worry module from the feeling safe programme with an older adult. • significant reductions in paranoia and worry and improvements in wellbeing and functioning were seen. • the intervention is brief and can be adapted to the learning needs of the individual. overview of the literature a persecutory delusion is a severe form of paranoia, where an individual holds a distress­ ing belief with high conviction (above 50% certainty) about being at risk of harm from others (freeman, 2016). persecutory delusions are one of the most common symptoms of psychosis and can have a severe impact on an individual’s life and wellbeing. half of those experiencing persecutory delusions report levels of psychological wellbeing in the lowest 2% of the general population (freeman et al., 2014). levels of anxious avoidance are often comparable to what is seen in agoraphobia, and levels of worry are comparable to generalised anxiety disorder (freeman, taylor, et al., 2019). a significant number of older adults are likely to be living with psychosis, including persecutory delusions, likely due to a combination of these symptoms being persistent over many years from first onset, and an estimated 2% of individuals experiencing a first episode of psychosis after the age of 65 (excluding psychotic experiences in the context of dementia) (mitford et al., 2010; vasiliadis et al., 2022). despite this, there is limited research looking at persecutory delusions in older adults and no separate nice guidance for treating psychosis in older adults. older adults also do not have the same access to assertive outreach, crisis, and early intervention in psychosis (eip) teams as working age adults. eip services, for example, typically only accept referrals of patients aged 15-65, despite guidance stating that these services do not exclude individuals based on their age (royal college of psychiatrists, 2018). nice guidance for treating psychosis in adults recommends oral anti-psychotic medi­ cation in conjunction with psychological intervention – family intervention or cbt. a recent meta-analysis concluded that cbt was more effective for both hallucinations and delusions when compared with any control (turner et al., 2020), and that the evidence base for its effectiveness is robust. furthermore, a number of randomised controlled trials tailoring aspects of cbt to treat persecutory delusions have shown very positive effects; for example, the worry intervention trial (freeman et al., 2015). compared with treating worry in an older adult with delusions 2 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ standard care, this eight-week worry intervention significantly reduced levels of worry and paranoia in 150 patients with persecutory delusions, adding to evidence that worry is a causal factor in the development and persistence of persecutory delusions that can be successfully ameliorated through intervention. the worry intervention now forms one of six modules within the feeling safe programme, a modular psychological therapy for persecutory delusions that targets mechanisms (such as worry), that are known to cause and maintain paranoia (freeman, emsley, et al., 2021). the feeling safe programme as a whole has demonstrated effect size improvements in delusions far above any previous intervention (cohen’s d = 1.2 versus cohen’s d = 0.3 for generic cbt for psychosis; bighelli et al., 2018; van der gaag et al., 2014) and training on this intervention is now being delivered to clinicians across england. in the recent trial of the intervention, patients typically completed two-to-three of the six modules in total, with the worry intervention most commonly being delivered first. given our ageing population, the number of older adults living with psychosis is like­ ly to increase. this could have major clinical, social, and economic implications (mitford et al., 2010). evidence suggests older adults typically have more positive help-seeking attitudes than younger adults, meaning their low use of mental health services may be better explained by lack of service provision and/or ageism within healthcare in some cases (mackenzie et al., 2008). to reduce ageism, provision must be based on need and appropriateness, rather than age. it is therefore important to assess whether current treatments used with adults of working age are also acceptable to, and effective, with older adults, with consideration given to the unique difficulties that older adults may more commonly face. this may include poor physical health, bereavement, and changes in roles e.g. from carer to being cared for, given there is evidence to suggest these factors can negatively impact mental health and therefore need to be considered in older adult’s formulations (laidlaw et al., 2004, 2016). only one older adult was recruited in the feel­ ing safe trial, and older adults were excluded entirely from the worry intervention trial. this report therefore presents the first known case of applying the worry intervention to an older adult with a persecutory delusion. introduction to the case jack (pseudonym) was referred to our oa cmht from his gp. he was temporarily living with his brother mo, having previously lived with his late mother and been her main carer. jack had struggled with psychotic experiences including voice hearing and delusional thinking for many years, with his symptoms managed through anti-psychotic medication. prior to our input, jack had never been offered psychological therapy. dur­ ing the previous year he began to experience an exacerbation of his symptoms. after an assessment with the cmht, he was referred to psychological therapies while awaiting care-coordinator allocation. brown & crabtree 3 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ assessment in the cmht had raised concerns about a possible alzheimer’s diagnosis due to a low score on the montreal cognitive assessment. however, upon our assess­ ment, no memory difficulties were evident nor did jack report any recent changes in his memory, cognition, or adaptive functioning. further cognitive assessment was therefore not carried out. in our assessment, both jack and mo raised the possibility of jack being neurodivergent and having a learning difficulty, although this had not been identified in his childhood. they reported a long history of jack struggling with social interaction long before he had any psychotic experiences, as well as difficulty with abstracting and generalizing information, both of which can be characteristic of autism (american psychiatric association, 2013). they also noted he had always taken considerable time to process information, often needing things to be phrased more simply and clearly. assessment of a possible autism spectrum condition was unlikely to be possible in the absence of an accurate neurodevelopmental history and was outside the scope of the current intervention and clinical need. moreover, his difficulties were not severe enough to warrant being treated within a specialist intellectual disability service. however, it was considered that these learning difficulties, potentially in addition to his high levels of paranoia and anxiety, may have been what led to the question of a dementia being raised. these hypotheses, including the potential for identifying cognitive change or decline, were held as part of the formulation and the intervention was adapted as required. jack gave informed consent to be seen by a trainee clinical psychologist, and both mo and jack gave consent to record sessions, and for this case to be published and included in an anonymized report written for the clinician’s university. although jack reported often feeling unhappy, he at no point expressed any thoughts of life not being worth living or wanting to hurt himself or others. jack reported no physical health conditions or concerns. his psychiatric medication included sertraline and risperidone 500mcg. assessment the authors gathered assessment information from past clinical notes and through two sessions with jack. at assessment jack described severe anxiety and worry regarding being arrested, which he was certain was due to happen imminently. he spoke about some work he had done for a contractor several years ago and reported worries about being called to trial for tax evasion. he was convinced that although he was innocent of any crime, the police would be able to imprison him. he described hearing a number of nasty voices linked to these worries, including a policewoman who would say she was going to arrest jack, put him in jail, then ensure he would be homeless and bankrupt upon release, and this woman’s husband, also a police officer, who would threaten to beat him up. jack described himself as a ‘natural born worrier’. he felt a lot of responsibility as a child after losing his father at a young age and needing to help care for mo, his younger treating worry in an older adult with delusions 4 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ brother. the exacerbation of his worries and development of psychotic experiences occurred after some challenging life events, including being defrauded by an employee of his bank in 2005, for which jack blamed himself, and experiencing bullying by a previous supervisor at work who was both physically and verbally aggressive to him. mo provided corroboration and further detail on these incidents, which he believed had triggered jack’s current delusion. given evidence that the content of delusions is often based on real past experiences of harm or victimization (freeman, 2016) this seemed a plausible hypothesis. to manage his worries jack typically remained at home, always checking around for police if he did go out. he also avoided talking to anyone apart from mo, for fear of people reporting him to the police. jack struggled to sleep at night due to preoccupation with worry, often napping during the day as a result. day-to-day, jack spent time watching tv and sitting in the garden. despite describing himself as a ‘natural born worrier’, jack’s worries did not appear to generalize to anything other than his concerns about the police. goals jack described wanting to be able to worry less and to feel safer when out and about. although he described finding it very challenging to meet new people, he felt he would like to try a new hobby such as a woodworking course if he were able to escape his worries. we discussed whether attending a local men’s sheds group (a community group where older men come together to share and learn new skills) could be a useful goal to set, and jack agreed this would be suitable to work towards. outcome measures table 1 displays the outcome measures and time points they were completed. design an ab design was followed. a three-week baseline period (a) was established before and during assessment, prior to intervention. the intervention phase (b) comprised weekly cbt sessions with measures completed at the start of each session. this design allowed inferences to be made regarding the impact of therapy on specified outcomes. jack found completing questionnaires each week challenging and the assistance he needed to complete them could take considerable session time. therefore, only service compulsory measures and worry analogue scales were completed weekly, with other measures com­ pleted just once at the start and end of treatment. brown & crabtree 5 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ table 1 outcome measures construct measure when completed worry dunn worry questionnaire (dwq) the dwq (freeman et al., 2020) is a ten item measure of general worry developed as an improvement to the penn state worry questionnaire (meyer et al., 1990). scores range from zero to 40, with higher scores reflecting higher levels of worry. a score of 21 and above indicates clinically significant levels of worry. once at baseline (phase a) and once at end of treatment (phase b) visual analogue scales (vas) two vas were completed: how worried have you been about other people this week on a scale of 0 (not worried at all) to 10 (worried all the time)?’, and ‘how distressed have you been about your worries about other people this week from 0 (not worried at all) to 10 (worried all the time)?’. these scales are recommended for weekly use when using the worry intervention. at the start of each intervention session (i.e. throughout phase b) paranoia revised green et al paranoid thoughts scale (r-gps) the r-gpts-b (freeman, lister, et al., 2019) comprises eight items measuring ideas of persecution and shows excellent psychometric properties. scores range from zero to 40, with scores of above 11 reflecting clinically significant paranoia, and scores of 18-27 the likely presence of a persecutory delusion. although the measure has not been specifically validated for use with older adults, the measure does show invariance between age groups. once at baseline (phase a) and once at end of treatment (phase b) visual analogue scale (vas) an analogue scale ranging from 0 (don’t believe it at all) to 100% (believe it totally) was administered to measure conviction in jack’ persecutory delusion that he would be unjustly arrested for tax evasion. this is a scale within the psychotic symptoms rating scale (psyrats) that is commonly been used as an outcome measure of delusional conviction (e.g. freeman, lister, et al., 2019) once at baseline (phase a) and once at end of treatment (phase b) wellbeing and functioning clinical outcomes in routine evaluationoutcome measure (core-10) the core-10 (barkham et al., 2005) measures wellbeing, functioning, problems/symptoms, and risk. the measure was initially developed for use in adult services, but has been validated for use in older adult populations (barkham et al., 2005). scores range from zero to 40, with higher scores depicting more severe difficulties. presence of clinically significant symptoms (caseness) is defined as a score of 10 or above (barkham et al., 2005). every week throughout baseline (phase a) and intervention (phase b) work and social adjustment scale (wsas) the wsas measures the impact of mental health difficulties on day-to-day functioning (mundt et al., 2002). the scale has five items covering work, home management, social leisure, private leisure, and relationships. scores range from 0 to 40 with higher scores indicating greater impairment. the scale demonstrates good internal consistency, reliability, convergent and criterion validity. caseness is defined as a score of 10 or above (iapt, 2011). this measure is used routinely in older adult services, although no known validation of the scale within older adult populations has been reported. every week throughout baseline (phase a) and intervention (phase b) treating worry in an older adult with delusions 6 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ cognitive behavioural formulation a shared understanding of jack’s difficulties was built using freeman’s cognitive model of paranoia (freeman, 2016). this uses a “vicious flower” formulation to understand why paranoia is maintained. one of the key mechanisms within this model is worry, hence why this model was chosen. two mini cycles that were to be the focus of the inter­ vention were discussed and drawn out together with jack (appendix a, supplementary materials), and the clinician also developed a separate more complete formulation (ap­ pendix b, supplementary materials). the first mini cycle shows how jack’s worried thoughts made him feel anxious in his body, e.g., his heart would race. consequently, he worried more, taking the anxiety to be a sign of something being wrong. the second mini cycle shows how jack’s feelings of unsafety led him to worry, in turn making him feel even more unsafe, because his worries always focused on worst case scenarios. jack also noted his worry meant he slept badly, did limited meaningful activity, and avoided engaging with others meaning his social network was small. these factors were included in the wider formulation. a number of other variables were discussed with jack that were thought to contribute to his feeling unsafe that also form part of the cognitive model of paranoia and were added to the clinician’s formulation. for instance, jack’s experience of hearing nasty voices understandably made him feel unsafe. jack also described some negative beliefs about himself that the clinician considered as important developmental factors in jack’s presentation. he wondered whether he had a ‘weak mind’, possibly due to stigmatising cohort beliefs about psychosis held among some older adults (farrer et al., 2008). jack also reported often feeling different to others – not uncommon among older adults with neurodiversity and who struggle with social interaction (hickey et al., 2018) and possibly exacerbated by his experience of bullying – a common feeling of self-vulnerability that paranoia can build upon (freeman, 2016). moreover, in the past year jack had moved from being a carer for his mother for which he felt much pride, to being cared for by his younger brother. this transition in role investments, a concept within laidlaw’s formulation for older adults (laidlaw et al., 2003), may have contributed to jack viewing himself more negatively. to manage his worries about being unsafe jack used safety behaviours of avoiding places where he felt the police might be more likely to catch him and checking around for police cars. additionally, jack showed evidence of sometimes jumping to conclusions when considering evidence for his beliefs, often struggling to consider alternative ex­ planations. for example, upon hearing a siren he would tend to assume that the police must be coming to arrest him, and not consider alternative explanations. based on this formulation, testable hypotheses were developed. 1. the worry intervention will reduce jack’s levels of worry as measured by the dwq and weekly vas. brown & crabtree 7 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ 2. given worry is a maintenance factor for paranoia (freeman et al., 2015), jack’s paranoia as measured by the r-gpts-b and delusional conviction will also reduce. 3. improving jack’s worry will allow him to engage in more meaningful daily activity and experience better wellbeing, evidenced by improved scores on the core-10 and wsas. intervention treatment comprised ten 60–75-minute sessions face to face over three months. generic cbt for psychosis was considered as an option initially but given jack’s high levels of distressing worry and the demonstrated effectiveness of worry intervention for reducing both worry and paranoia, it was decided a worry intervention would be tried initially. these options and the recommendation were explained to jack in layperson terms, who agreed with and consented to the plan given reducing his worry was something he most wanted help with. the worry module of the feeling safe programme was therefore followed. this intervention is typically six-eight sessions, but content was paced more slowly to account for jack’s learning preferences. frequent feedback was elicited to ensure sessions were clear, helpful, and well-paced, and short session summaries were written as jack found these easier to review than the full intervention module booklets. the intervention began with worry psychoeducation and a diary to identify jack’s time spent worrying. this showed he spent up to 15 hours a day worrying and not engaged in any other form of activity. the diary also identified jack’s triggers and ‘peak times’ of worry. sitting in his living room unoccupied was a clear trigger, and peak times were first thing in the morning and last thing at night. to build motivation to reduce worry, in session two we identified jack’s positive and negative beliefs about worry. jack thought worrying helped him to organise his mind and prepare for bad things happening, but he also felt strongly that worrying made him feel distressed and anxious. overall, therefore, jack was strongly in favour of reducing his worrying. the concepts of worry periods and worry postponement were therefore introduced in session 3. these techniques aim to postpone worry until a designated time and place, allowing an outlet for worry that is time limited and controlled. outside of worry periods the aim is to stay occupied with meaningful activity to help keep worry away. given he spent so many hours each morning lying in bed worrying, jack felt his worry period needed to be early in the day, else he would not be able to keep postponing his worry. he chose the location as a spare room he normally didn’t use. we began a list of enjoyable activities for jack to engage in outside of worry periods. these included a puzzle book, history podcasts, and helping mo prepare meals. given the importance of structure as a tool for reducing boredom and inactivity among older adults (baumann, 2013), to do lists and timetables were co-created with jack to support him to increase his activity. treating worry in an older adult with delusions 8 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ jack initially found the concept of worry periods difficult. given we were aiming to reduce worry, he felt allowing himself to worry at all would make it escalate and impossible to control. we tested this meta-worry in a behavioural experiment, where jack compared his worry on days with and without worry periods. although his beliefs about the worry becoming uncontrollable did not come true, jack also did not find the worry periods helped him to worry less outside of the periods. he felt he did not actually need an outlet for his worries, with activity engagement being the most helpful tool for reducing worry. eliminating worry periods is ultimately the desired outcome by the end of a patient’s recovery from worry and given jack’s worry was already improving considerably, we agreed he would continue without using worry periods. three sessions then focussed on new exercises for letting go of worry. these included getting active, connecting with others, and using positive imagery. jack practised these between sessions, with one task being to visit men in sheds, helping jack to try to meet one of his goals for therapy. finally, we ended with two review sessions where a therapy blueprint was created. jack engaged extremely well in therapy. with jack’s agreement, mo was present for the first six sessions so that he understood the treatment tools and tasks and could support jack with them between sessions when required. jack then attended sessions 7-9 alone so he could practise retaining and implementing the information without assistance, with mo returning for the final review session. throughout, the clinician aimed to instil hope in jack for successful recovery, keeping in mind the stigmatising cohort beliefs that many older adults today can hold about psychosis. validation and empathy were given for how distressing jack’s worries were, and curiosity was shown regarding the evidence for his delusional beliefs whenever jack raised this. these elements helped to form a strong therapeutic relationship. results figure 1 shows jack’s scores on the standardised worry and paranoia measures pre-andpost-treatment. pre-intervention, jack was experiencing clinically significant levels of worry (a score of 28, where above 21 discriminates clinical severity), and paranoia (a score of 19, where above 11 discriminates clinical severity). post-intervention, jack’s worry reduced hugely to a score of just 6, and his paranoia 9, both scores falling below clinical cut-offs. scores on analogue scales of worry (figure 2) also showed this, and an equally large drop was seen in jack’s delusional conviction, which fell from 100% at baseline to 25% at end of intervention. brown & crabtree 9 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ figure 1 pre-and-post-intervention scores for worry and paranoia figure 2 vas scores for worry and associated distress during phase b treating worry in an older adult with delusions 10 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ figure 3 shows jack’s scores on the core-10 and wsas measures across baseline and intervention. jack completed these before each session began, meaning the scores for treatment session 1 were still part of the phase a. at first baseline, jack’s scores on both measures were indicative of ‘moderate’ difficulties. neither baseline remained entirely stable, however, with the scores reducing to the ‘mild range’ for the second and third baseline measures. scores on both measures extended into the ‘moderate-severe’ range early on in treatment, gradually reducing until scores were very low (core-10) or indeed zero (wsas) by end of treatment. figure 3 changes in wellbeing and functioning over phases a and b discussion this report describes the use of a worry intervention in an older adult with a persecutory delusion. all three hypotheses were supported: by the end of treatment, jack’s worry considerably reduced, as did his paranoia and delusional conviction, and his wellbeing and daily functioning improved, all to a clinically significant level. although not formally measured, jack also reported no longer hearing his nasty voices by the end of treatment. although there were large improvements overall, it was discussed in therapy why some of the measures initially increased in score (meaning a worsening of symptoms). brown & crabtree 11 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ at assessment, jack was clear that he was worrying a lot and wanted to reduce this, but it was not until we began a worry diary that he realised just how much time each day he spent worrying and how much of an impact this was having on his daily life and wellbeing. he therefore reflected that his earlier scores had perhaps been an understatement of his difficulties. conversely, there was a striking reduction in jack’s worry on the vas after session 3. this occurred after introducing the concepts of worry periods and worry postponement, and therefore when jack began building more activity into his day. while this did not immediately translate into similar improvements on the wellbeing and daily functioning measures, this was perhaps due to how hard jack found he had to work at postponing and reducing his worry. alternatively, there may simply be a higher margin of error in jack’s core and wsas scores as compared to the vas because jack found these measures difficult to complete. within the wsas jack struggled to separate out the extent to which he had completed daily tasks, with the extent to which worry had impacted his ability to complete daily tasks. it therefore took some time for the clinician to find accurate question phrasing that allowed jack to understand what was being asked and therefore respond accurately. there are a number of threats to validity in this report. the baseline period was brief, and to reduce the burden on jack the non-routine measures were only completed once at baseline. ideally, the r-gpts and dwq would have been measured throughout baseline, but given jack required support to complete them this was not possible within available session time. additionally, the wsas was not stable between the first baseline measure and latter two, with a smaller but still notable lack of stability also evident in the core. as discussed, jack initially found these measures confusing to complete. while the intervention could have been delayed, achieving a longer, more stable baseline, this was considered unethical given there was availability to see jack immediately. these design limitations mean caution is warranted with interpretating the results; it is possible jack could have experienced natural recovery without the intervention. however, the extent of improvement was significant, and tallied closely with different stages of inter­ vention, which does support the conclusion that the intervention was the primary cause of improvement. post-intervention jack reported feeling proud of his achievements and confident for the future. some concern about being arrested remained, but he acknowledged he could not be helped directly with this, and what had been most helpful was reducing his time spent worrying about it. jack was therefore discharged from the psychology team and cmht. due to limited capacity the cmht had not been able to offer care-coordination during therapy, and jack now felt he no longer needed any. overall, this report shows a brief intervention on worry led to large reductions in paranoia in an individual with a persecutory delusion. this supports the cognitive model of paranoia, where worry is a contributory causal factor in paranoia’s maintenance that treating worry in an older adult with delusions 12 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ can be targeted therapeutically (freeman, 2016). moreover, the report is a first step to showing this intervention can successfully be applied with an older adult, including where there is possible neurodiversity. it will be useful to test this further, including with those in their 70s, 80s, and 90s. therapist’s reflections on the case and its clinical implications when discussing this case in a multi-disciplinary meeting, the therapist (pb) was met with surprise by some colleagues who had expected treatment to primarily focus on reality testing jack’s delusion and helping him consider alternative explanations. the successful results of this single case provided further clear and helpful evidence to the team on the importance of intervening on factors around an individual’s delusion, rather than always focussing directly on the delusion itself. having mo as a co-therapist was also extremely helpful in this case, which provided learning for our service in terms of making more use of family members. mo was very well engaged in the sessions, and able to motivate and remind jack of homework tasks during the weeks that he may otherwise have forgotten. as a trainee clinician only working two days a week in the service and thus limited in capacity to do check-in phone calls in between sessions, this was particularly useful. given his longer experience of communicating with jack, mo was also sometimes able to rephrase questions or explanations in a way that was more understandable to jack. however, it was clear that their relationship was very respectful, kind, and stable. mo was careful not to speak or act on behalf of jack, but equally jack was able to look to mo for support when needed. it was reflected in supervision how things might have been different had their relationship been more challenging, and how the therapist might have needed to step in more frequently to manage this, potentially sectioning of parts of session to be conducted with only jack. we are also aware that in some ways this case felt somewhat different to other older adult cases. perhaps most notably, jack was not struggling with any comorbid physical health difficulties, a variable which often needs a lot of attention in older adult work. while it would have been easy to treat jack the same as we might treat an adult of working age, mid-way through therapy it was helpful to step back and apply a laidlaw formulation to his case and consider the potential impact of role investments and cohort beliefs in particular, even though these were not explicitly discussed during therapy. brown & crabtree 13 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ funding: the research received no specific funding from any agency. acknowledgments: the authors offer grateful thanks to dr rebecca dow and dr ceara moore for their advice and comments on this single case, and particularly thankful to jack and mo for their time and consent to write up this report. competing interests: the authors have declared that no competing interests exist. ethics statement: all names and any other identifiable information have been changed in order to preserve confidentiality. the client and their co-therapist gave full, informed, consent for a report to be written regarding their therapy sessions. related versions: the work was completed as part of the first author’s doctorate in clinical psychology at the university of oxford. twitter accounts: @_poppybrown supplementary materials the supplementary materials contain the following items (for access see brown & crabtree, 2023): • appendix a: two mini formulations created with jack. • appendix b: an enhanced formulation created by the clinician to guide intervention but not shared with jack. index of supplementary materials brown, p., & crabtree, a. 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(2020). what constitutes sufficient evidence for case formulation-driven cbt for psychosis? cumulative meta-analysis of the effect on hallucinations and delusions. schizophrenia bulletin, 46(5), 1072–1085. https://doi.org/10.1093/schbul/sbaa045 van der gaag, m., valmaggia, l. r., & smit, f. (2014). the effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: a meta-analysis. schizophrenia research, 156(1), 30–37. https://doi.org/10.1016/j.schres.2014.03.016 vasiliadis, h. m., pitrou, i., lamoureux-lamarche, c., grenier, s., nguyen, p. v. q., & hudon, c. (2022). factors associated with late-life psychosis in primary care older adults without a diagnosis of dementia. social psychiatry and psychiatric epidemiology, 57(3), 505–518. https://doi.org/10.1007/s00127-021-02132-7 treating worry in an older adult with delusions 16 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://doi.org/10.1002/9780470713402 https://doi.org/10.1017/s1352465804001584 https://doi.org/10.1097/jgp.0b013e31818cd3be https://doi.org/10.1016/0005-7967(90)90135-6 https://doi.org/10.1002/gps.2437 https://doi.org/10.1192/bjp.180.5.461 https://www.rcpsych.ac.uk https://doi.org/10.1093/schbul/sbaa045 https://doi.org/10.1016/j.schres.2014.03.016 https://doi.org/10.1007/s00127-021-02132-7 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. brown & crabtree 17 clinical psychology in europe 2023, vol. 5(3), article e11173 https://doi.org/10.32872/cpe.11173 https://www.psychopen.eu/ treating worry in an older adult with delusions overview of the literature introduction to the case assessment goals outcome measures design cognitive behavioural formulation intervention results discussion therapist’s reflections on the case and its clinical implications (additional information) funding acknowledgments competing interests ethics statement related versions twitter accounts supplementary materials references clinical psychology and the covid-19 pandemic: a mixed methods survey among members of the european association of clinical psychology and psychological treatment (eaclipt) research articles clinical psychology and the covid-19 pandemic: a mixed methods survey among members of the european association of clinical psychology and psychological treatment (eaclipt) julia asbrand 1 § , samantha gerdes 2 § , josefien breedvelt 3,4 , jenny guidi 5 , colette hirsch 6,7,8 , andreas maercker 9,10 , céline douilliez 11 , gerhard andersson 12,13 , martin debbané 14,15 , roman cieslak 16 , winfried rief 17 , claudi bockting 4,18 [1] department of psychology, humboldt-universität zu berlin, berlin, germany. [2] nhs veterans’ mental health and wellbeing service, camden and islington nhs trust, london, united kingdom. [3] natcen social research, london, united kingdom. [4] centre for urban mental health, university of amsterdam, amsterdam, the netherlands. [5] department of psychology "renzo canestrari", university of bologna, bologna, italy. [6] institute of psychiatry, psychology and neuroscience, king's college london, denmark hill, camberwell, london, united kingdom. [7] national institute for health research (nihr) biomedical research centre, south london and maudsley hospital, london, united kingdom. [8] south london and maudsley nhs foundation trust, denmark hill, camberwell, london, united kingdom. [9] department of psychology, division of psychopathology and clinical intervention, university of zurich, zurich, switzerland. [10] wissenschaftskolleg berlin–institute of advanced study, berlin, germany. [11] université catholique de louvain, psychological sciences research institute, louvain-la-neuve, belgium. [12] department of behavioral sciences and learning, department of biomedical and clinical sciences, linköping university, linköping, sweden. [13] department of clinical neuroscience, division of psychiatry, karolinska institute, stockholm, sweden. [14] psychoanalysis unit, research department of clinical, educational and health psychology, university college london, london, united kingdom. [15] developmental clinical psychology unit, faculty of psychology and educational sciences, university of geneva, geneva, switzerland. [16] department of psychology, swps university of social sciences and humanities, warsaw, poland. [17] department of clinical psychology and psychotherapy, university of marburg, marburg, germany. [18] department of psychiatry, amsterdam university medical centers (location amc), amsterdam, the netherlands. §these authors contributed equally to this work. clinical psychology in europe, 2023, vol. 5(1), article e8109, https://doi.org/10.32872/cpe.8109 received: 2022-01-10 • accepted: 2022-11-21 • published (vor): 2023-03-31 handling editor: cornelia weise, philipps-university of marburg, marburg, germany this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.8109&domain=pdf&date_stamp=2023-03-31 https://orcid.org/0000-0003-2740-6070 https://orcid.org/0009-0005-5352-2878 https://orcid.org/0000-0003-1864-1861 https://orcid.org/0000-0001-6815-2738 https://orcid.org/0000-0003-3579-2418 https://orcid.org/0000-0001-6925-3266 https://orcid.org/0000-0001-8912-885x https://orcid.org/0000-0003-4753-6745 https://orcid.org/0000-0002-4677-8753 https://orcid.org/0000-0002-2413-5343 https://orcid.org/0000-0002-7019-2250 https://orcid.org/0000-0002-9220-9244 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ corresponding author: josefien breedvelt, josefien breedvelt, natcen social research, london, uk, 35 northampton square, london ec1v 0ax, united kingdom. e-mail: josefienbreedvelt@gmail.com supplementary materials: materials [see index of supplementary materials] abstract background: the covid-19 pandemic has affected people globally both physically and psychologically. the increased demands for mental health interventions provided by clinical psychologists, psychotherapists and mental health care professionals, as well as the rapid change in work setting (e.g., from face-to-face to video therapy) has proven challenging. the current study investigates european clinical psychologists and psychotherapists’ views on the changes and impact on mental health care that occurred due to the covid-19 pandemic. it further aims to explore individual and organizational processes that assist clinical psychologists’ and psychotherapists’ in their new working conditions, and understand their needs and priorities. method: members of the european association of clinical psychology and psychological treatment (eaclipt) were invited (n = 698) to participate in a survey with closed and open questions covering their experiences during the first wave of the pandemic from june to september 2020. participants (n = 92) from 19 european countries, mostly employed in universities or hospitals, completed the online survey. results: results of qualitative and quantitative analyses showed that clinical psychologists and psychotherapists throughout the first wave of the covid-19 pandemic managed to continue to provide treatments for patients who were experiencing emotional distress. the challenges (e.g., maintaining a working relationship through video treatment) and opportunities (e.g., more flexible working hours) of working through this time were identified. conclusions: recommendations for mental health policies and professional organizations are identified, such as clear guidelines regarding data security and workshops on conducting video therapy. keywords psychotherapy, video therapy, online therapy, blended therapy, clinical psychology, covid-19 highlights • rapid change in psychotherapy delivery occurred due to the covid-19 pandemic. • clinical psychologists and psychotherapists report challenges (e.g., reluctance among patients) and opportunities, resulting from changes to the work environment. • data security is crucial as well as access to treatment via video therapy. • national policy and organizational guidance is crucial to support clinical psychologists and psychotherapists in their work. effects of covid-19 on eaclipt members 2 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ health care services globally have faced unprecedented challenges due to the covid-19 pandemic. alongside the physical health consequences of the covid-19 virus, mental health problems are also increasing, with reported increases for anxiety, depression, psychological distress and sleeping problems (bohlken et al., 2020; liu, heinzel, haucke, & heinz, 2021; rajkumar, 2020; salari et al., 2020; vindegaard & benros, 2020; xiong et al., 2020). furthermore, there has been an estimated additional 53.2 million cases of major depressive disorder and an estimated additional 76.2 million cases of anxiety disorders globally (santomauro et al., 2021). as a consequence, mental healthcare needs to be prioritized and clinical psychologists and psychotherapists1 play an important role in the prevention and treatment of these adverse consequences of the covid-19 pandemic. however, as yet little is known about how well clinicians and services have adapted to the increased demand and additional challenges presented by the covid-19 pandemic, and what might be done to improve mental health care for those who have suffered psychologically as a consequence of the covid-19 pandemic. clinical psychologists and psychotherapists had to find rapid alternatives to face-toface treatment such as telephone-based or video therapy (békés & aafjes-van doorn, 2020; humer, stippl, et al., 2020), or in-person sessions whilst adhering to their cov­ id-19 national containment measures from the start of the pandemic. prior studies have shown that the implementation of changes to service delivery can take an average of sixteen years to implement in a health care system (rogers et al., 2017). in contrast, during the pandemic, change in service delivery was rapid and unexpected, and there was little supervision or guidance available for clinicians (e.g., boldrini et al., 2020; probst, stippl, & pieh, 2020). moreover, the pandemic itself led to significantly higher stress levels in clinical psychologists and psychotherapists, especially in younger and less experienced professionals (aafjes-van doorn et al., 2020; probst, humer, stippl, & pieh, 2020). additionally, fear of infection and other issues related to the pandemic itself were also reported by clinical psychologists and psychotherapists (humer, pieh, et al., 2020). in the midst of such rapid and unforeseen changes to practice, several reassuring and thought-provoking phenomena have been observed. for instance, preliminary evidence showed video therapy to be more effective than previously expected (humer, stippl, et al., 2020). interestingly, the ability to adapt to conducting therapy via video is related to the individual clinical psychologists’ and psychotherapists’ attitudes and is influenced by their past experiences with video therapy (békés & aafjes-van doorn, 2020). further, challenges have been reported by mental health professionals regarding the lack of inter­ personal interactions, feelings of isolation and other technical issues whilst conducting therapy online (mcbeath et al., 2020). the aforementioned studies provide an interest­ 1) we use the term “clinical psychologists and psychotherapists” throughout, however in order to accommodate for different definitions between countries, the term includes clinical psychologists as well as psychotherapists, scientist practitioners, and all other mental health professionals who provide psychological therapy. asbrand, gerdes, breedvelt et al. 3 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ ing, yet heterogeneous, picture of the impact of the covid-19 pandemic on mental health professionals. however, most of the studies used closed questions and quantitative methods (e.g., békés & aafjes-van doorn, 2020; boldrini et al., 2020), thus limiting the possibility for participants to provide their own insight into offering psychotherapy during a global pandemic. professional organizations and other commissions have taken the initiative to provide the public and mental health care professionals with information regarding covid-19 (e.g., uk2, germany3, austria4, belgium5). however, it is also important for mental health care professionals who work ‘on the ground’ to share their experiences, in order for organizations to find ways to best support their clinicians. the current survey aimed to gather information ‘from the field’ to gain an understanding of the experiences of clinical psychologists and psychotherapists working during the covid-19 pandemic, across different european countries. members of the european association of clinical psychology and psychological treatment (eaclipt) were consulted; eaclipt is an association that aims to foster research, education and dissemination of scientifically evaluated findings on clinical psychology and psychotherapy. the current study seeks to provide a first european wide insight into the perceived changes to clinical practice and research of clinical psychologists and psychotherapists, as well as the barriers and opportunities, in order to improve support to people as part of the response to the covid-19 pandemic. the study also aims to gather information to highlight helpful ways for clinical psychologists and psychotherapists to approach, prioritize and manage their work in the context of the pandemic. finally, it aims to provide information on how organizations and organizational bodies (such as eaclipt) can best adapt to pandemic related changes. method participants the survey (see appendix a, supplementary materials) was targeted at clinical psychol­ ogists and psychotherapists across europe who are members of eaclipt. potential participants were recruited via the eaclipt members database (n = 698) from 25th may 2020 to 1st september 2020, when covid-19 restrictions were still in place in most countries. however, it should be noted that restrictions at this time were often not as strict as they were during the first wave of the pandemic, and there were also 2) https://www.bps.org.uk/coronavirus-resources/professional 3) https://psychologische-coronahilfe.de/ 4) https://www.boep.or.at/psychologische-behandlung/informationen-zum-coronavirus-covid-19 5) https://www.compsy.be/fr/coronavirus effects of covid-19 on eaclipt members 4 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.bps.org.uk/coronavirus-resources/professional https://psychologische-coronahilfe.de/ https://www.boep.or.at/psychologische-behandlung/informationen-zum-coronavirus-covid-19 https://www.compsy.be/fr/coronavirus https://www.psychopen.eu/ substantial differences between countries. overall, n = 92 participants (13% of eaclipt members) voluntarily agreed to participate in the survey. most of the participants were from the united kingdom (17.6%), germany (16.5%), and austria (13.2%; see figure 1). further, most participants worked in a university or other academic institute (34.4%), hospital (14%), public community clinic (15%) or private clinic (18%). the other 30.7% responses included: academic hospital (6.5%), university clinic (7.5%), retired (1%), courts (1%), prison (1%), and not for profit (1%). finally, most participants self-identified as working in an urban area (79.1%) compared to rural areas (15.4%), suburban areas (3.4%) and national coverage (1.1%). figure 1 country of origin of participants 0 2 4 6 8 10 12 14 16 18 bulgaria czech republic slovenia portugal poland norway malta spain lithuania france ireland switzerland italy belgium the netherlands croatia austria germany united kingdom question: 'in which european country do you live?' note. please note that n = 6 participants chose to not comment on their country of origin. procedure and measures socio-demographic information was collected using nine closed questions (e.g., country of origin, place of work and most commonly presenting patient need during the pandem­ ic). five open questions were used to gain information on perceived changes in the work place, challenges and opportunities during the crisis, the effect of covid-19 safety measures on their practice, and other implications. the survey was open for completion between 25th may 2020 and 1st september 2020. the last response that was included was submitted on 19th august 2020. asbrand, gerdes, breedvelt et al. 5 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ quantitative and qualitative analysis the six phases of thematic analysis (nowell, norris, white, & moules, 2017) were fol­ lowed by the first two authors (j.a. and s.g), including familiarization with the data (phase 1), generating initial codes (phase 2), searching for themes (phase 3), reviewing themes (phase 4), defining and naming themes (phase 5) and producing the report (phase 6). the third author (j.b.) supervised their work and checked the data during phase 4, in order to review the themes that had been generated. this enabled research bias to be evaluated and the interpretation of the data to be confirmed. the first two authors screened the answers independently in phases 1, 2, and 3 and formed their own categories, which were then compared and agreed on and a list of themes per question was finalized. themes were then listed in terms of frequency for each question. the authors were each based in different countries, therefore all meetings took place over remote platforms. regarding the overall process, reflexivity is considered as a key aspect of the thematic analysis process (nowell et al., 2017). therefore, the first two authors kept their own reflexive journal to document the logistics and methodological considerations as well as their own personal reflections. the precise analysis was then conducted in line of the six step technique by braun and clarke (2006). results the results have been analyzed according to the six-phase method by braun and clarke (2006) i.e., familiarization with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. data are organized and summarized in the results section and the interpretation regarding signifi­ cance and implications follows in the discussion. quantitative results changes in patients seeking help based on the question that asked if participants were seeing more or less patients, the number of patient contacts (i.e., number of patients seen by a clinician) seemed to remain relatively stable during the first wave of the covid-19 pandemic, as reported by 42% of the participants who indicated no change in the number of patient contacts. nonetheless, almost 40% reported to see less patients, while 17% reported to see more patients. further, 78.8% reported that patients displayed similar psychological problems as they did prior to the covid-19 pandemic. however, 48.3% also reported that their patients seemed to be more distressed compared to one year before, whereas 28.7% reported no change in their patients’ distress. the most frequently reported patients’ clinical issues effects of covid-19 on eaclipt members 6 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ encompassed anxiety (86%), depression (82%), loss of social contacts and isolation (each 39%) (see figure 2). in terms of clinicians’ working practices, most responders reported that covid-19 had changed their work routines (73.6%), mostly in ways that they perceived to be undesirable. figure 2 main mental health issues reported by patients 0 10 20 30 40 50 60 70 80 anxiety depression loss of social contact isolation lonliness covid-19 economic hardship loss/bereavement substance abuse seperation/divorce psychosis medical interpersonal difficulties adhd other behaviour that challenges others ocd behaviours eating disorders suicidality anger/aggression neuropsychological testing trauma sleep problems life transitions gender transition process personality disorder question: 'please select the main issues patients currently present with ' note. please note that not all patients were seen in standard psychotherapeutic environments which is why alternative topics are listed as the presenting problem. this refers to other medical conditions, neuropsychological testing and other non-identified topics. qualitative results the overarching themes that were identified in the data were: changes to clinical prac­ tice; changes to other work activities and contexts; the challenges and opportunities; the effect of covid-19 measures on clinical practice and further reflections. within these themes, the following categories were found including: changes to working practices such as online working; psychotherapists reflections on the changes and an exploration of what could be improved and, implications for clinical practice and organizations. perceived changes in clinical practice perceived changes in clinical practice were mostly in regards to working online, e.g., conducting video therapy, and working from home. further, several participants reported changes in treatment frequencies (more/less patients, more sessions per patient), hygiene measures (such as wearing face masks, social distancing in assessments), challenges in asbrand, gerdes, breedvelt et al. 7 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ providing treatment while wearing personal protective equipment (such as face masks), redeployment and logistical difficulties if patients were not able to use online platforms. citation regarding hygiene measures: “every patient has to wash first his hands, more disinfection, mouth-nose-protection, plexiglass for breath protection, safety distance, and more time and space are needed between the appointments for disinfection” citation regarding personal protective equipment: “wearing masks, me and patient, which is very disturbing while there is no emotional expression.” some participants also reflected on patients’ concerns regarding treatment, such as more anxiety and individual differences in motivation to access online treatment. further, therapists’ concerns were also mentioned (e.g., if their hygiene procedure is correct). citation regarding therapists’ concerns: “the first thought in every step is 'how correct is my procedure?'” overall, changes in patient contact (i.e., less appointments, fewer face-to-face contact, more support for patients) were named. perceived changes to other work activities and contexts not all participants were necessarily working in clinical practice, and changes in research and teaching were also reported. participants noted that procedures in the work environ­ ment were modified according to covid-19 safety measures, often leading to a lack of contact between colleagues. in an additional question, general aspects of the working environment were covered. here, once again digitalization was mentioned as a central change, as not only video therapy but also remote meetings with colleagues that had been introduced. citation regarding digitalization: “no face to face clinics, therefore replying on phone and video contact. working in isolation more and away from my team to do working from home.” some participants reported that there was an increasing lack of contact between collea­ gues due to the increasing division in teams as a result of remote working. in answers to this question, participants also highlight the adherence to hygiene measures in the work environment such as social distancing, wearing masks and more cleaning. several participants mentioned that they were mainly working from home and some were holding therapy sessions outside. additionally, two participants were engaged in extra activities regarding covid-19 (i.e., at a phone support line). three participants said that there were significant changes to their research, such as delays in recruitment, or needing to stop research entirely. effects of covid-19 on eaclipt members 8 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ challenges and opportunities in the covid-19 pandemic era the challenges and opportunities that participants reported were wide ranging, and there was not always a clear distinction between what constituted a challenge or an opportunity (e.g., only replying “tele-therapy”), and sometimes different participants reported the same issue as a challenge, whereas others saw it as an opportunity. there were several participants who listed an opportunity that arose as a result of the cov­ id-19 pandemic and also at the same time reported it as a challenge of working during the covid-19 pandemic (e.g., no commute vs. constant working from home). change in work logistics — the change to a predominantly technology-based work practice appeared to be either a challenge or an opportunity for participants. while several participants reported problems regarding technical knowledge and support or in­ ternet connection issues, as well as lack of equipment (such as laptops), remote working was also perceived by some as an opportunity to improve their own technology skills. citation regarding technical factors: “videocalls are more tiring, but effective” a similar pattern of both challenges and opportunities emerged for working logistics: additional childcare, the need to develop new work-related rituals and a higher strain of videocalls were mentioned, as well as no time between meetings. however, several positive aspects were also mentioned, such as less need to travel, more flexibility at work, and the opportunity to access patients who may not have had the possibility to receive treatment otherwise. some also felt that video therapy works very well, and some had been able to further develop their self-care strategies. citation regarding working logistics: “the main challenge was man­ aging childcare alongside working while the nurseries were closed.” citation regarding working logistics: “working from home so less mdt [multidisciplinary teams] working, not being able to provide a service for those with sensory impairments primarily hearing loss, increased competing demands on my time, my own response to covid and lockdown and depleted resources over time. new ways of working do include being able to offer video or remote access to appointments not requiring people to travel and being able to support people who are shielding” citation regarding working logistics: “i had to develop new rituals at the end of the work day, digital work exhausts me more than working from the office” asbrand, gerdes, breedvelt et al. 9 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ clinical issues — interestingly, the therapy-related factors also included both challenges and opportunities. interventions for some mental health problems appeared to be more challenging to deliver online (e.g., depression, trauma) compared to the pre-pandemic face-to-face settings (e.g., difficulty in finding new options to increase activity, more insecurity in trauma treatment due to a lack of stabilizing measures). furthermore, par­ ticipants reported that they were at a greater physical distance to patients during faceto-face interactions, whereas online sessions provided less opportunity for non-verbal feedback and therapeutic engagement. participants reported having to spend more time preparing for sessions, and there were concerns about a lack of consent and choice of therapy modality for patients. conversely, less cancellations were noticed. additionally, participants were able to receive contextual information about their patients by seeing their environment. citation regarding therapy-related factors: “less cancellations and non-attendance at sessions. harder developing rapport and doing ther­ apy without the same transference or cues.” citation regarding therapy-related factors: “video sessions allow for less non-verbal feedback/assessment (negative for diagnosis and treat­ ment recommendation); video sessions allow impression of the patient's home environment (important context information and opportunity for the patient to illustrate problems that occur at home = positive)” citation regarding therapy-related factors: “reachability was better for some, but worse for others, especially mothers (closed schools) and women in abusive relationships (often had to talk in their car)” team and organizational factors — several factors were portrayed as rather chal­ lenging, as participants reported difficulties regarding social factors at work, such as a worsening of team cohesion, staff absence, staff conflicts and social isolation. although some found this to be a positive as they could decide who they spent time with. citation regarding social factors: “all disciplines of staff not offered same opportunities to work from home causing conflict/envy; opportu­ nity to avoid toxic colleagues at work.” citation regarding social factors: “prevent social isolation also in my staff without forcing collaborators back to work” furthermore, a number of organizational factors were mentioned. for example, the rapid change of regulations (e.g., weekly changes) and the lack of guidelines and unified standards were reported to make working processes even more difficult. effects of covid-19 on eaclipt members 10 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ citation regarding organizational factors: “trying to keep up with the constant information changes, rapid decision making and trying to look after myself too” alongside organizational factors, data security issues were also mentioned. this often highlighted the problem of patient confidentiality and keeping data safely stored while working from home. finally, participants reported difficulty adapting to new ways of working initially, however this appeared to develop into a new and practiced working routine over time. effects of the covid-19 pandemic measures on clinical practice participants mainly focused on the effects of covid-19 emergency measures on their clinical practice. the general restrictions of contact, i.e., lockdown, social distancing, restricted entrance to buildings and building closures were mentioned by half of all par­ ticipants. these were often brought into close relation to other themes such as increased psychopathology in patients. citation regarding general restrictions: “restrictions concerning cer­ tain hours for meeting the patients.” citation regarding general restrictions: “lockdown and the unlocking of lock down introducing new anxieties and worry” citation regarding general restrictions: “full lock-down, both in ef­ fect on my work directly and how it seeps into clients' existing strug­ gles” another topic mentioned was the effect of wearing masks. citation on wearing masks: “mask....very hard to work without seeing emotional expression. especially hard with kids” citation on wearing masks: “mask wearing conceals the faces of both client and counselor, lack of nonverbal cues” additionally, effects of hygiene measures on treatment were often mentioned, such as wearing protective clothing, opening windows during sessions, no face-to face contacts and short-notice cancellations due to patient concerns about showing covid-19 symp­ toms. citation regarding hygiene measures: “wearing protection clothing it is necessary and important but it makes work harder” both general restrictions issued by the state and individual restrictions in the workplace had a significant effect on participants and their work, such as closure of nurseries, asbrand, gerdes, breedvelt et al. 11 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ quarantine, shielding, and loss of freedom as well as concerns around travelling on public transport. citation regarding individual restrictions: “closure of nurseries hav­ ing to provide childcare between a working couple means a massive reduction in available working time.” participants also reported on the effects on patients, such as changes in psychological symptoms and less motivation to seek help or engage in online sessions. citation regarding effects on patients: “people with mental health conditions hold their breath: that is do not seek help because they are afraid to get covid-19 and because there is a pause in social life” citation regarding effects on patients: “covid-19 measures, at least in italy, did not help in containing the viruses, as people were terrified by the official information, so did not ask for help or did not dare to go to hospitals, and were hampered from going to parks.” further reflections participants shared a variety of interesting insights into prospective changes concerning both mental health professionals and government policies. one major theme was the wish to collect, share and discuss their experiences of using video therapy. this included both concerns (e.g., regarding effectiveness and data security), and desire for specific training in psychotherapy delivered online. participants also shared that they had a new understanding of the importance of being connected to their colleagues. citation regarding sharing with colleagues: “more practice in online therapy, share data concern effectiveness of online therapy versus on said therapy” citation regarding sharing with colleagues: “i think it would be a good idea to set up a section in clinical psychology in europe [journal of the eaclipt] and invite practicing clinical psychologists to describe their experience with new forms of work. i would be motivated by such an opportunity to contribute, and i would also learn from the experience of colleagues.” in terms of policy implications, it was argued that the importance of mental health should be further promoted at national levels, particularly given the collective impact on mental health. a greater flexibility (e.g., introducing video therapy into health insurance plans) and the possibility of choosing the most suitable treatment modality (e.g., face to face or video) were two major points raised by respondents. furthermore, the effects effects of covid-19 on eaclipt members 12 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ of the current pandemic on both research (e.g., regarding long-term effects on mental health), and the healthcare system was mentioned, including implications for research funding. finally, government policy implications regarding the implementation of policy guidelines, such as closure of nurseries and schools, resulted in a dilemma for many parents who are having to work from home while caring for children. citation regarding political implications: “research funding being so fast and associated huge number of reviews; being on funding panels. existing research in nhs stopped due to redeployment.” citation regarding political implications: “acknowledgement of the impact of covid-19 on the mental health of the population should be acknowledged at a national/international level. awareness needs to be raised in governments and there needs to be a way to address the increased level of distress that the population will undoubtedly experience.” citation regarding political implications: “productivity whilst work­ ing from home is understood although not overtly acknowledged to be more limited when children to be cared for at home too which creates unnecessary guilt when torn between roles. some managers (not mine) did not stand up to look after staff by leading and issuing clear guidance.” several participants pointed out that there will be long-term consequences of the cov­ id-19 pandemic on mental health. citation regarding long-term consequences: “to be prepared that covid-19 has a long-lasting effect on young people especially adoles­ cents and students” discussion the current study demonstrates that the covid-19 pandemic brought about unprece­ dented changes in clinical practice for clinical psychologists and psychotherapists across eaclipt members in europe. changes to the clinical practice of psychologists and psychotherapists were sudden, for example the digitalization of therapy, which was at odds with previous attempts to implement digital mental health approaches in healthcare (mohr, riper, & schueller, 2018). some opinions and evidence have suggested that this has been a ‘black swan’ moment, where the covid-19 pandemic has led to a rapid change in how mental health care is provided, including more opportunities for online working (wind, rijkeboer, andersson, & riper, 2020), also in lowand middle-income countries (fu et al., 2020). additionally, the current study showed that clinical psychol­ asbrand, gerdes, breedvelt et al. 13 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ ogists and psychotherapists managed to provide treatment throughout the covid-19 pandemic, despite the additional challenges of working in this context, to patients who were perceived to be experiencing a greater level of distress. although challenges were clearly identified in the current study, participants also identified opportunities from working through the pandemic, such as reduction in commuting time, increased work flexibility and accessibility for patients. despite such a significant change in working context for clinical psychologists and psychotherapists, only one previous study looked at the impact of the pandemic on clinical psychologists and psychotherapists and also used a mixed-methods analysis of qualitative and quantitative data (mcbeath et al., 2020). in that study, clinical psycholo­ gists and psychotherapists who were mostly based in the uk, were recruited via social media and, similar to our results, found that clinical psychologists and psychotherapists were able to cope with the rapidly changing work, and managed immediate problems with imagination and engagement. they also described a significant change of psycho­ therapeutic treatment, especially in relation to video therapy. digitalization even though clinical psychologists and psychotherapists have not yet reached a con­ sensus regarding whether they plan to continue using video therapy in the long run (aafjes-van doorn et al., 2020), the opportunities conferred via video therapy are clearly shown, both in the current study and other research (e.g., humer, stippl, et al., 2020). more than ten years ago, simpson (2009) pointed out the opportunities and challenges of video therapy, naming the lack of research regarding efficacy as one major research goal. simpson (2009) also pointed out that efficacy might be strongly related to patient and therapist’s personality and interpersonal style, as well as therapist skills and experience in the use of technology. a pilot project with university students (simpson, guerrini, & rochford, 2015) and the analysis of the recent, covid-19 induced changes (simpson et al., 2021) clearly points out the potential of video therapy if used correctly. it seems likely that the pandemic has shaped therapists’ attitudes towards technology and led to a more positive view of it now they are more experienced in conducting treatment remotely, even if prior to covid-19 they would not have elected to do so (aafjes-van doorn et al., 2020). as the success is highly dependent on therapists’ overall attitudes and self-con­ fidence regarding technology and remote therapy (e.g., aafjes-van doorn et al., 2020), training courses and supervision in this regard is essential. as simpson (2009) already pointed out, some barriers that prevent access to psychotherapy and counselling might be tackled with video therapy such as geographical distance between major cities and remote and rural communities, and a lack of adequate or affordable transport between them. furthermore, video therapy can be used by patients who are immobile (connolly, miller, lindsay, & bauer, 2020). it might also encourage patients to engage who are indecisive about treatment and worry about stigma. finally, most studies overall tend effects of covid-19 on eaclipt members 14 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ to conclude that video therapy will not be the new standard medium for psychotherapy (e.g., aafjes-van doorn et al., 2020; connolly et al., 2020), but a useful addition under certain circumstances and considering specific adaptations such as providing a rationale for video therapy, maintaining therapeutic boundaries and finding a new way of risk management (for an overview see simpson et al., 2021; for an exemplary analysis of pa­ tients with borderline personality disorder see ventura wurman, lee, bateman, fonagy, & nolte, 2021). conducting therapy with personal protective equipment (ppe) while the changes to working as a result of video therapy clearly brought opportunities, conducting therapy in person while using protective equipment such as face masks pre­ sented significant challenges. clinical psychologists and psychotherapists who conducted face-to-face treatment during the pandemic mostly wore face masks and thus covered more than half of their face. thus, while the disadvantage of video therapy is erased (e.g., no technological difficulties), others might appear: it has been argued both in our study and previous opinion pieces (e.g., hüfner, hofer, & sperner-unterweger, 2020) that emotions are harder to read if someone is wearing a face mask, which can then cause difficulties in the patient-therapist relationship. interestingly, initial evidence from basic research has shown mixed findings. some found that emotions are harder to read when the conversational partner wears a face mask (grundmann, epstude, & scheibe, 2021), while others found in a longitudinal design that participants change which cues they use to detect an emotion, suggesting they adjust to the presence of masks (barrick, thornton, & tamir, 2021). one study of school-aged children who are currently constantly interact­ ing while wearing masks concludes that masks pose a challenge but, in combination with other contextual cues, are unlikely to dramatically impair social interactions (ruba & pollak, 2020). translating these findings to the clinical context, one can assume that psychotherapy with masks is somewhat more challenging than without masks, but could still lead to a good patient-therapist relationship and successful treatment outcomes. however, more research on the effects of masks on psychotherapy is necessary. restriction of contact it is important to acknowledge that clinical psychologists and psychotherapists have not only experienced a significant change in their working logistics, but also in their everyday life outside of work – similar to their patients and all other citizens. as some participants have highlighted, social support at work was less available and the team cohesion diminished, thus personal and work resources were limited. furthermore, additional tasks added to stress (e.g., working from home without a proper place to work; child and other family care etc.). these factors indicate the importance of social support asbrand, gerdes, breedvelt et al. 15 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ among the clinical psychologists’ and psychotherapists’ community in difficult times, and the importance of leadership from professional and governmental organizations. reflections for eaclipt it has been an unprecedented working environment for clinical psychologists and psy­ chotherapists during the covid-19 pandemic. clinical psychologists and psychothera­ pists were required to adapt their approach to work at very short notice during the first wave of the covid-19 pandemic. however, survey respondents reported that they managed to convert working logistics efficiently and have been providing much needed care for patients ever since, even though the examination of the efficacy of treatment still needs more research. this was often done on an individual basis or by smaller groups of colleagues. an important next step is to collect, share and discuss experiences of, and develop guidelines for, video or phone therapy or intervention. this has been done locally (e.g., uk, simpson, richardson, pietrabissa, castelnuovo, & reid, 2021. however, the eaclipt as an organization has provided a position statement and a summary of national statements on what is needed for both patients and clinical psychologists and psychotherapists as well as future research endeavors regarding mental health6 by integrating perspectives from a wide range of clinical psychologists and psychotherapists across multiple countries. reflections for government policy and other institutions although the sample of the current survey was limited to eaclipt members, arguably, this data could be useful to inform the policies of government and other institutions, as the views of clinical psychologists and psychological therapists are represented from across a broad range of occupationals settings, across multiple european countries. the current findings emphasize the importance of including mental health issues in current policy considerations on how to manage the pandemic in the longer term. the long-term effects on mental health as a result of the covid-19 pandemic are still not clear (e.g., de figueiredo et al., 2021). based on previous research on epidemics, further symptom increases in the upcoming one to three years are expected in anxiety, anger, depression, post-traumatic stress symptoms, alcohol abuse, and behavioural changes such as avoid­ ing crowded places and cautious hand washing (e.g., kathirvel, 2020). this needs to be considered both in research (e.g., which factors could lead to mental health problems in the long run, de figueiredo et al., 2021) and in health care (e.g., further flexible inclusion of video therapy into health insurance plans; enlarging mental health treatment provi­ sion; kathirvel, 2020). in addition, the uptake of video therapy by clinical psychologists and psychotherapists during the covid-19 pandemic offers the opportunity to take part 6) https://www.eaclipt.org/?tab=5 effects of covid-19 on eaclipt members 16 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.eaclipt.org/?tab=5 https://www.psychopen.eu/ in treatment long distance (the therapist in one country, the patient in another) which calls for cross-border guidelines. limitations and implications the current study was implemented during the first wave of the covid-19 pandemic, from may to september 2020. the pandemic is still ongoing and, thus, the situation is continually changing. to keep the questionnaire as short as possible to encourage participants to complete the survey, we did not include detailed information on the sociodemographic background and we did not ask for detailed numbers and facts, e.g. re­ garding the number of patient contacts before and during the pandemic. we rather opted to assess the personal estimation of change, which relies on the therapist’s perception of the number of patient contacts and could include inaccuracies. additionally, we are aware that only a small number of members completed the survey (i.e., 13% of eaclipt members) and, thus, the results have to be considered in light of a rather limited and selective sample. however, our results provide a qualitative and quantitative picture of the first abrupt changes to the work of clinical psychologists and psychotherapists as a result of the covid-19 pandemic. furthermore, in the current study, responses to open questions were often quite short, which at times limited the scope of interpretation. however, many answers poin­ ted to similar conclusions as shown above. the current study highlights the tremendous challenges that both patients and clin­ ical psychologists and psychotherapists have experienced during the pandemic. conse­ quently, there are calls for specific training for therapists and clear guidelines regarding the use of technology, data security and solutions to the psychotherapeutic challenges of delivering therapy remotely. however, more research (such as the follow-up to this survey that is underway) is necessary to identify the long-term effects of the covid-19 pandemic on both patients and clinical psychologists and psychotherapists, and to com­ prehensively influence policy and future healthcare considerations. asbrand, gerdes, breedvelt et al. 17 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: winfried rief is one of the editors-in-chief and colette hirsch is a subject editor of clinical psychology in europe. both authors played no editorial role in this particular article or intervened in any form in the peer review process. andreas maercker, céline douilliez, gerhard andersson, martin debbané, roman cieslak, and claudi bockting are editorial board members of clinical psychology in europe but did not intervene in any form in the peer review process. twitter accounts: @julia_asbrand, @samgerdes1, @josefienumh, @jennyguidi, @drcolettehirsch, @cdouilliez, @profgerharda, @martindebb, @rocie, @wrief1, @clbockting supplementary materials the supplementary materials contain the questionnaire which was used in the study (for access see index of supplementary materials below). index of supplementary materials asbrand, j., gerdes, s., breedvelt, j., guidi, j., hirsch, c., maercker, a., douilliez, c., andersson, g., debbané, m., cieslak, r., rief, w., & bockting, c. (2023). supplementary materials to "clinical psychology and the covid-19 pandemic: a mixed methods survey among members of the european association of clinical psychology and psychological treatment (eaclipt)" [questionnaire]. psychopen gold. https://doi.org/10.23668/psycharchives.12563 references aafjes-van doorn, k., békés, v., prout, t. a., & hoffman, l. (2020). psychotherapists’ vicarious traumatization during the covid-19 pandemic. psychological trauma: theory, research, practice, and policy, 12(s1), s148–s150. https://doi.org/10.1037/tra0000868 barrick, e. m., thornton, m. a., & tamir, d. i. (2021). mask exposure during covid-19 changes emotional face processing. plos one, 16, article e0258470. https://doi.org/10.1371/journal.pone.0258470 békés, v., & aafjes-van doorn, k. 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(2020). the covid-19 pandemic: the ‘black swan’ for mental health care and a turning point for e-health. internet interventions, 20, article 100317. https://doi.org/10.1016/j.invent.2020.100317 xiong, j., lipsitz, o., nasri, f., lui, l. m. w., gill, h., & phan, l. (2020). impact of covid-19 pandemic on mental health in the general population: a systematic review. journal of affective disorders, 277, 55–64. https://doi.org/10.1016/j.jad.2020.08.001 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. asbrand, gerdes, breedvelt et al. 21 clinical psychology in europe 2023, vol. 5(1), article e8109 https://doi.org/10.32872/cpe.8109 https://doi.org/10.1002/cpp.2521 https://doi.org/10.1080/09515070.2020.1814694 https://doi.org/10.1016/j.bbi.2020.05.048 https://doi.org/10.1016/j.invent.2020.100317 https://doi.org/10.1016/j.jad.2020.08.001 https://www.psychopen.eu/ effects of covid-19 on eaclipt members (introduction) method participants procedure and measures quantitative and qualitative analysis results quantitative results qualitative results discussion digitalization conducting therapy with personal protective equipment (ppe) restriction of contact reflections for eaclipt reflections for government policy and other institutions limitations and implications (additional information) funding acknowledgments competing interests twitter accounts supplementary materials references research into evidence-based psychological interventions needs a stronger focus on replicability scientific update and overview research into evidence-based psychological interventions needs a stronger focus on replicability helen niemeyer 1 , christine knaevelsrud 1 , robbie c. m. van aert 2 , thomas ehring 3 [1] department of clinical psychological intervention, freie universität berlin, berlin, germany. [2] department of methodology and statistics, tilburg university, tilburg, the netherlands. [3] department of psychology, lmu munich, munich, germany. clinical psychology in europe, 2023, vol. 5(3), article e9997, https://doi.org/10.32872/cpe.9997 received: 2022-07-29 • accepted: 2023-07-17 • published (vor): 2023-09-29 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: helen niemeyer, division of clinical psychological intervention, department of education and psychology, freie universität berlin, schlossstr. 27, 12163 berlin, germany. phone: 0049-30-838-54798. e-mail: helen.niemeyer@fu-berlin.de abstract background: it is a precondition for evidence-based practice that research is replicable in a wide variety of clinical settings. current standards for identifying evidence-based psychological interventions and making recommendations for clinical practice in clinical guidelines include criteria that are relevant for replicability, but a better understanding as well refined definitions of replicability are needed enabling empirical research on this topic. recent advances on this issue were made in the wider field of psychology and in other disciplines, which offers the opportunity to define and potentially increase replicability also in research on psychological interventions. method: this article proposes a research strategy for assessing, understanding, and improving replicability in research on psychological interventions. results/conclusion: first, we establish a replication taxonomy ranging from direct to conceptual replication adapted to the field of research on clinical interventions, propose study characteristics that increase the trustworthiness of results, and define statistical criteria for successful replication with respect to the quantitative outcomes of the original and replication studies. second, we propose how to establish such standards for future research, i.e., in order to design future replication studies for psychological interventions as well as to apply them when investigating which factors are causing the (non-)replicability of findings in the current literature. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9997&domain=pdf&date_stamp=2023-09-29 https://orcid.org/0000-0002-7616-1885 https://orcid.org/0000-0003-1342-7006 https://orcid.org/0000-0001-6187-0665 https://orcid.org/0000-0001-9502-6868 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords replicability, evidence-based interventions, criteria development highlights • refined replicability criteria used to identify empirically supported treatments are proposed. • concrete steps for refining replication in research on psychological interventions are proposed. • a taxonomy of direct to conceptual replication adapted to research on interventions is provided. recent years have seen an increased focus on conceptual approaches to the replicability of research findings, and a growing number of empirical investigations on this issue, in the areas of psychology (klein et al., 2014; klein et al., 2018; open science collaboration [osc], 2015), economics (e.g., camerer et al., 2016), epidemiology (e.g., kaltiala-heino, työläjärvi, & lindberg, 2019; zisook et al., 2007) and medicine (errington, denis, perfito, iorns, & nosek, 2021). replicability refers to “the ability of a researcher to duplicate the results of a prior study if the same procedures are followed but new data are collected” (bollen, cacioppo, kaplan, kronsnick, & olds, 2015; p. 3). research related to psychological interventions has not paid the same level of attention to recent conceptual developments of replicability (tackett et al., 2017) as seen in other fields. yet the strong emphasis on providing evidence-based treatments in clinical psychology and psychiatry (e.g., tolin et al., 2015) demands that clinical practice should be directly informed and guided by the best available empirical evidence on the efficacy of interventions, as typi­ cally collected in randomized controlled trials (rcts). a precondition for evidence-based practice is that the research is replicable in a wide variety of clinical settings in order to demonstrate high external validity. low replicability in a research field may be partly due to so-called “hidden moderators” (van bavel, mende-siedlecki, brady, & reinero, 2016), which prevent the effect from being observed in a replication due to an (unobserved) moderator. examples include characteristics of the clinical population to which the intervention is offered, treatmentrelated moderators, or differences in contextual variables. in other words, a study might be successfully replicated in a research outpatient clinic but not in a regular community clinic. identifying hidden moderators is crucial in order to critically evaluate the general­ izability of treatment effects to different clinical settings. “direct” and “conceptual” are labels for replication studies depending on the similarity to the original study (lebel et al., 2018; zwaan, etz, lucas, & donnellan, 2018). direct replication studies allow to investigate the replicability of a study result, whereas conceptual replications serve to determine the generalizability. the relevance of replication categories has been shown in other fields, such as economics (fiala, neubauer, & peters, 2022; peters, langbein, replicability in mental health research 2 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://www.psychopen.eu/ & roberts, 2018), where different replication rates were found depending on the defini­ tion of the replication studies. in order to define the similarity between original and replication study consensus on the most important characteristics is necessary. the ”con­ straints on generality” criteria (cog; simons, shoda, & lindsay, 2017) help to explicitly determine the targeted population and the study procedures in order to define a direct replication as well as to identify hidden moderators in conceptual studies. a cog state­ ment overcomes the ambiguity of classifying replications as direct or conceptual post hoc because it specifies the target populations for the original claim (simons et al., 2017; simons, shoda, & lindsay, 2018). in addition, non-replicability of effects may also be caused by questionable research practices (qrps; john, loewenstein, & prelec, 2012). qrps comprise a range of activities that are not a research field´s best practices, such as flexibly analyzing data until the results are significant (called p-hacking; whitt et al., 2022) or hypothesizing after the results are known (called harking; john et al., 2012). they cause an overrepresentation of statistically significant results in the literature. performing multiple analyses in combi­ nation with selectively reporting statistically significant results increases the number of false-positive findings in the published literature (forstmeier, wagenmakers, & parker, 2017; simmons, nelson, & simonsohn, 2011) and biases effect size estimation. other fac­ tors that may cause non-replicability are reporting errors or sampling error. importantly, in a given case of non-replicability, more than one factor can be expected to be relevant (nosek et al., 2022). closely related to replicability is reproducibility. reproducibility is obtained when the reanalysis of the original data using the same procedures arrives at the same result (maassen et al., 2020). this is also referred to as computational or analytic reproducibil­ ity (lebel et al., 2018). reproducibility in psychology was investigated by artner and colleagues (2021) who found that 70% of the reported statistical results were reproduci­ ble. when comparing reproducibility rates across disciplines, it is important to note that the definitions of replicability and reproducibility differ across disciplines (artner et al., 2021). to date, reproducibility attempts are highly uncommon in research on psychological interventions (see also, sandve, nekrutenko, taylor, & hovig, 2013). do current research standards pay enough attention to replicability? current standards for investigating psychological interventions, identifying evidencebased interventions, and making recommendations for clinical practice in clinical guide­ lines include criteria that are relevant for the issue of replicability. for example, the criteria for empirically supported treatments (ests; david, lynn, & montgomery, 2018) were laid down by the american psychological association’s (apa) division 12 in the early 1990s (chambless & hollon, 1998; for a recent revision, see tolin et al., 2015). niemeyer, knaevelsrud, van aert, & ehring 3 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://www.psychopen.eu/ according to these criteria, treatment effects must have been demonstrated in several independent studies, and a systematic evaluation of the methodological quality of studies as well as risk of bias needs to have been conducted, e.g., using the cochrane risk-of-bias tool (rob; sterne et al., 2019) or the grading of recommendations, assessment, develop­ ment and evaluations (grade; guyatt et al., 2008), consisting of six domains (e.g., risk of bias, [im-]precision of effect estimates). the need to critically assess study quality and the risk of bias has also led to the development of specific reporting standards for clinical trials, such as the consolidated standards of reporting trials (consort; schulz et al., 2010), and for reporting systematic reviews and meta-analyses, such as the preferred reporting items for systematic reviews and meta-analyses” statement (prisma; moher et al., 2015) or the “meta-analysis reporting standards” (mars; american psychological association, 2020). however, despite these important advances, the criteria used to identify ests and/or recommend clinical interventions for clinical guidelines currently have not yet been updated in line with the recent advances on replicability in the wider field of psycholo­ gy and in other disciplines (errington et al., 2021). although the reporting standards and rating schemes address some of the variables that are relevant to assess (the lack of) replicability in studies on psychological interventions (i.e., pre-specification of the hypotheses and statistical methods, examining publication bias and heterogeneity), they neither include all of the relevant aspects nor do they make an explicit distinction between different types of replication (e.g., direct versus conceptual replications) or specify statistical criteria for a successful replication. a refinement of the criteria for replication in research on psychological interventions and specific suggestions for their application are therefore required. moreover, an assessment of qrps, reporting error and demands for pre-registration are currently not included in the quality assessment of clinical studies. currently there are only few investigations of the replicability of studies on psycho­ logical interventions. one exception is sakaluk et al. (2019) who systematically examined the evidential value of treatments that have been classified as ests by standard criteria. they also applied schimmack’s replicability index (r-index, schimmack, 2016), which focuses on statistical significance, and statistical power, as well as bayesian meta-analy­ sis. results showed that statistical power and replicability estimates were low. moreover, differences in the level of empirical support according to est criteria did not parallel differences in indices of statistical power or replicability. based on their analysis, the au­ thors argued that higher methodological standards are necessary in research on psycho­ logical interventions, including sufficient statistical power and standards for reporting descriptive and inferential statistics. in line with sakaluk and colleagues (2019) as well as with the recommendations developed in other areas of psychology and beyond (ioannidis, 2008; valentine, 2009), we suggest that there is a need to enhance the replicability of research into psychological replicability in mental health research 4 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://www.psychopen.eu/ interventions and therefore propose to refine the definition of and criteria for replicabili­ ty in this field. to this aim, some of the developments and resources from other areas will be adopted and, if necessary, adapted to the specificities of research on psychological interventions, as well as the given criteria and definitions refined. proposing a research strategy for assessing, understanding, and improving replicability in research evaluating psychological interventions to improve the current situation, we propose progress in three interrelated areas (a – c; see figure 1). the concrete steps that need to be taken are described in the following sections. figure 1 a strategy for assessing, understanding, and improving replicability in research on psychological interventions a. replication: definitions & criteria b. evaluating evidence on efficacy of interventions c. planning and conducting replication studies figure 1. a strategy for assessing, understanding, and improving replicability in research on psychological interventions. a. replication: definitions and criteria first, the definition of replication currently used in research on psychological interven­ tions is refined, based on a taxonomy of different study design types of replication, study characteristics that increase the trustworthiness of results, and statistical criteria for (un-)successful replication. at a minimum, we suggest three aspects to be crucial: 1. taxonomy of replication refining replication in research on psychological interventions is a complex endeavor. the definition of replication as aiming to duplicate the results of an original study by applying the same procedures to a new sample (bollen et al., 2015) provides no specific niemeyer, knaevelsrud, van aert, & ehring 5 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://www.psychopen.eu/ criteria as to what constitutes "the same procedure” with respect to the characteristics of an original study. similarly, the est criteria that treatment effects need to be demonstra­ ted in several independent studies do not specify any details of the study designs of the required independent studies (tolin et al., 2015). attempts to refine the concept of replication have been made in other areas of psychology and social sciences. we adopt the approach of lebel et al. (2018) who provide a replication taxonomy ranging from direct to conceptual replication, depending on the degree of similarity between an original and a replication study according to several design facets, such as the operationalization of the independent and dependent variables, or investigator independence. to investigate the replicability of a treatment effect, di­ rect replications are necessary. conceptual replications cannot falsify the hypothesis of replicability, but can, on the other hand, help to evaluate the boundary conditions of treatment effects, the generalizability of intervention effects to different contexts, and/or the mechanisms of change underlying treatment effects. they can help to answer the question of whether (and which) hidden moderators are a cause of low replicability in “combination” with direct replications. in order to define the characteristics that need to be identical for a study to qualify as direct replication, the constraints on generality criteria (cog; simons et al., 2017) are applied. the cog criteria provide a general scheme for which characteristics of study participants (the targeted population), study material and procedures, and the temporal specificity of an effect are necessary to be kept the same for a replication study to be an exact replication. principles for choosing variables for the cog should be known empirical or theoretical boundary conditions, conditions that are tied to the substance of the study, and factors that experts consider to be important. the taxonomy suggested by lebel and colleagues (2018) combined with the cog re­ sults in a continuum from direct to conceptual replication that can be pre-specified. the dimensions underlying the classification of replication types should include procedural details (e.g., diagnostic instruments, blinding of assessors, unconcealed allocation/risk of bias), statistical methods, contextual variables (e.g., cultural context), therapist-related factors (manual adherence), and researcher-related factors (e.g., allegiance, conflicts of interest), all of which are also potential moderator variables. consider, for instance, a case in which a newly developed intervention for depression is first tested against a waitlist condition (wl) and is found to be superior. a subsequent study replicates the initial study, but compares the same intervention to treatment as usual (tau). a direct replication of the newly developed intervention for depression would need to consist of a second comparison to wl, whereas the use of a different control condition (or treatment delivery in a natural setting, or applying the intervention over the internet etc.) constitutes a conceptual replication that already tells us something about the generalizability of the intervention effects and the relative efficacy of the new treatment. as another example, we might consider a case in which a new 12-session replicability in mental health research 6 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://www.psychopen.eu/ treatment for panic disorder is favorably tested against wl. a subsequent study also compares this new treatment to wl but uses a protocol that involves only 10 sessions, is conducted in a different country, and examines a slightly older patient population; and this second study does not find the treatment to be efficacious. is this a failed replication study? due to the lack of clear criteria, we are not currently able to provide a definitive answer to this question. with so many changes at once, we will never know why it did not replicate. therefore, we need the changes to be decided on and documented more specifically; ideally, replication studies should change on one dimension at a time, so that differences in effects can be clearly attributed. incentives for authors for the use of a cog statement integrated into the taxonomy by lebel and colleagues (2018) could be a protection from overly broad claims, a higher likelihood of successful replications, and inspiring follow-up studies that built upon the findings. editors and reviewers could request a cog statement. incentives for editors could be to have an equivalent measure to evaluate all papers, and for reviewers to have a measure for quality control, whereas for readers it helps to learn about the generality of the claims of a study (simons et al., 2017). 2. study characteristics that increase the trustworthiness of results although some important methodological factors are included in current standards of study quality assessment, there is evidence that many intervention studies fall short of characteristics that increase the trustworthiness of results. moreover, qrps and publica­ tion bias distort the literature and limit the replicability of studies. in addition to the existing guidelines we propose to include the following issues: • an assessment of reporting errors should be conducted. for consistency checks of p values, “statcheck” can be applied (epskamp & nuijten, 2016). • pre-registration should be mandatory. the study design and analysis plan need to be pre-specified and saved in a public registry or published prior to data collection. preregistration is a measure to enhance transparency, document timestamped decisions, helping to differentiate between confirmatory and exploratory analyses, and for reducing p-hacking and harking. alternatively, registered reports (rrs) are a sensible publishing format that reduces qrps and publication bias because in rrs the peer review is conducted prior to the data collection. this emphasizes the research question and the quality of methodology instead of the significance of the results (chambers & tzavella, 2022). checklists for pre-registration and recommendations for rrs have been developed in the wider field of psychology to enhance the quality of reports and pre-registrations (nuijten, hartgerink, van assen, epskamp, & wicherts, 2016). developments in adjacent fields are ahead, such as in biomedical research where journals banded together to make registration mandatory (siebert et al., 2020; clinicaltrials.gov). registered reports and replication reports are a promising format also for clinical psychological journals. niemeyer, knaevelsrud, van aert, & ehring 7 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://clinicaltrials.gov https://www.psychopen.eu/ • a systematic assessment of whether the information provided in a pre-registration is sufficient should always be conducted and should be considered in the est criteria or guidelines. • it should be assessed whether the final study report matches the pre-registered plan. we do acknowledge, though, that this places an extra burden on reviewers, who need to spend more time reviewing a manuscript. to reduce this burden journals can invite specialized reviewers to specifically review open science aspects of the manuscript, such as whether the pre-registration matches the final study report or checking any shared materials. • open data and open materials should become standard to enhance transparency. replication studies benefit to a large extent from open data and materials. however, it should be noted that open data and materials is not a prerequisite for replicating studies (buzbas, devezer, & baumgaertner, 2023). if highly sensitive data present challenges to open data principles, restricted access to data, e.g. according to the different access categories of the german psychological association (dgps1), is also a viable alternative. this is in line with the standards of the american psychological association (2020), which invites researchers to share their data. it should be motivated if data cannot be shared due to ethical or legal constraints, e.g. due to participant confidentiality or missing consent. open material and sensitive material with restricted access can both be stored in repositories, such as the open science framework (osf; osf.io). 3. criteria for successful replication as described in the taxonomy of replication, exact versus conceptual replication studies provide different information in case of replication success or failure. for example, when a conceptual replication study shows a failure of replication, this might be the result of hidden moderators. however, criteria are necessary for determining when (both direct and conceptual) replication studies are a success or failure. this conceptual issue has also not been explicitly addressed in mental health research to date, i.e. what defines a successful replication with respect to the statistical outcome of both the original and the replication study. that is, in addition to the definition of the study design as direct or conceptual replication, we propose criteria for the comparison of the quantitative results of an original and a replication study and the assessment of the replication of the study results as successful or failure, which are currently missing in research on psychological interventions. recent large-scale replication studies have proposed and comparatively evaluated different criteria, such as statistical significance, i.e., a study is deemed to be replicated if both the original study and the replication are statistically (non-)significant, or the 1) https://zwpd.transmit.de/images/zwpd/dienstleistungen/ethikkommission/vorlage_opendata_v1.docx replicability in mental health research 8 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://osf.io https://zwpd.transmit.de/images/zwpd/dienstleistungen/ethikkommission/vorlage_opendata_v1.docx https://www.psychopen.eu/ direction of both effect estimates is the same (osc, 2015). however, an application of criteria for (un)successful replication in research on psychological interventions is lacking (see also nosek et al., 2022). given that multiple statistical options to determine replication success exist (osc, 2015; zwaan, etz, lucas, & donnellan, 2018) and that there is no consensus for one particular method, we provide a short overview of the most relevant ones: both original and replication studies are statistically (non-)significant, the direction of both effect estimates is the same, the original effect falls within the confidence interval of the repli­ cation, original and replication result are combined and significance is assessed (osc, 2015), statistical consistency between the original study and replications is evaluated in multisite replication projects (mathur & vanderweele, 2020), the small telescopes approach (simonsohn, 2015), sceptical p-value (held, 2020), and replication bayes fac­ tor (ly, etz, marsman, & wagenmakers, 2019). these criteria represent the currently most prominent options for evaluating replicability. recently, a comparison of seven approaches (significance, small telescopes, classical and bayesian meta-analysis, bayes factor and replication bayes factor, as well as skeptical p-value (held, 2020) has been conducted (muradchanian, hoekstra, kiers, & van ravenzwaaij, 2021). according to the authors, bayesian metrics as well as meta-analytic methods were found to perform slightly better than the other approaches in terms of true and false positives rates. that is, a positive replication result is observed when the underlying true effect is non-zero or when the true effect is practically zero under different levels of publication bias in a simulation study. when evaluating replicability in research on psychological interven­ tions, we suggest applying multiple methods, all of which should be preregistered before conducting the study. researchers should come to conclusions based on the results of all the methods, as they perform quite similarly. moreover, applying more methods also provides more information. all criteria presented in the three categories taxonomy of replication, study charac­ teristics that increase the trustworthiness of results, and criteria for successful replication are provided in an info box (see table 1). we exemplarily propose up to three specific criteria for each cog subdomain. this list is not exhaustive, because study designs and research foci differ considerably. we recommend that researchers adapt the cog specifically to the study designs that are utilized in their research domains. niemeyer, knaevelsrud, van aert, & ehring 9 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://www.psychopen.eu/ table 1 info box for replication studies in clinical psychology overall domains / subdomains 1. taxonomy of replication: constraints on generality (cog) participantsa • diagnoses • symptom severity • comorbidity materials / stimulia • manual used • adherence to manual • therapist training / supervision procedurea • primary and secondary outcomes • type of assessment (e.g., clinician-based vs. self-rated) • type of allocation historical / temporal specificityb • changes in diagnostic criteria (e.g. in dsm) • common use of cellphones or internet access for appand browser-based interventions / blended approaches 2. study characteristics that increase the trustworthiness of results scalesc for quality assessment used (according to study type) are reporting errors absent in the study? preregistration • is a study pre-registered or is it a registered report? • are there sufficient details in the pre-registration/registered report? • do the analyses in the pre-registration match those in the final study report? 3. criteria for successful replication: methods to consider are the data and study materials openly available? are both original and replication study statistically significant? are the effect sizes of both the original and replication study in the same direction? does the effect size of the original study lie in the ci of the replication? is the meta-analytic effect size of combining the original and replication study statistically significant? replicability in mental health research 10 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://www.psychopen.eu/ overall domains / subdomains is the effect size of the original study consistent with the replications in a multisite replication project (mathur & vanderweele, 2020)? small telescopes approach (simonsohn, 2015): is the replication effect size not significantly smaller than an effect size that would have 33% statistical power based on the sample size of the original study? replication bayes factor (verhagen & wagenmakers, 2014; wagenmakers, verhagen, & ly, 2016: is there more evidence that the effect size of the replication is a null effect compared to the effect observed in the original study? note. dsm = diagnostic and statistical manual; ci = confidence interval. athe proposed specific criteria are exemplary and not exhaustive. bthis category takes into account that norms and standards change over time, and studies should be evaluated according to the respective historical period. cthe quality assessment should be conducted according to the specific scale that is used. b. evaluating evidence on efficacy of interventions beyond establishing standards for future research, it is also important to understand which factors are causing the (non-)replicability of findings in the current literature by systematically investigating moderators of treatment effects. specifically, the relative contributions of the different variables outlined in section a to replication success (outcome) are of interest, e.g. study quality, the type of replication design, and contextual variables. pre-registration and a taxonomy of replication should also be systematical­ ly integrated into the classification of ests, clinical guidelines, and meta-analyses to enhance the transparency and methodological comparability. in addition, differences between preregistered/replicated studies and other studies should be studied. moderator analyses can best be addressed with meta-analytic methods. for example, the efficacy of some interventions may be highly dependent on context variables, e.g., successful replication may only be demonstrated in very direct replication designs and may have low generalizability to different contexts. other interventions may be more context-independent, with effects being replicated even in less strict settings regarding patient or therapist characteristics or modes of treatment delivery. that is, the criteria for replication outlined above should be related to the evaluation of studies as ests and considered when summarizing studies in meta-analyses. importantly, findings from this line of research can then be useful to further refine the replication concept and criteria (a). for example, if a particular therapist characteristic is not relevant for determining the replicability, it no longer needs to be taken into account when evaluating whether a study is a direct or conceptual replication. moderators can also include variables that are typically used to address meta-sci­ entific questions, for example whether a study was pre-registered or provides open data. thus, investigating pre-registration as moderator in meta-analyses against the background of replicability can shed light on whether pre-registered studies differ from niemeyer, knaevelsrud, van aert, & ehring 11 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://www.psychopen.eu/ non-pre-registered studies not only in terms of treatment efficacy and study quality, but also in the replicability of their results. c. planning and conducting new replication studies the new definitions and criteria (a) should be used to design future replication studies for psychological interventions in order to test the consistency of treatment effects by means of direct replication studies, as well as the generalizability of findings to varying contexts on the basis of an explicit taxonomy of replication. to guide future replication research, the taxonomy of different types of replication, including the relevant dimen­ sions of similarity vs. dissimilarity of research design features and a cog statement, tail­ ored to research on psychological interventions, should be applied. researchers should start by directly replicating an original treatment effect in order to investigate whether the effect exists. then, to examine the generalizability and detect hidden moderators, they should move on to conceptual replication studies, in which they modify important aspects of the study design (e.g., treatment manual used, characteristics of treatment delivery, definition of outcome, comparison condition, and contextual factors). depend­ ing on how many and which variables in the cog are kept equal, the similarity of replication studies along the continuum from direct to conceptual replications should be varied. thereby it can be determined in a direct replication whether an effect exists, and its boundary conditions and mechanisms can be identified in conceptual replications. thus, the distinction between direct and conceptual replication studies will be helpful for assessing the heterogeneity of findings for a particular intervention. that is, conceptual replications will test whether the proposed constraints on generality are accurate, lead­ ing to a more refined understanding of the robustness of effects. a systematic program of research should evaluate how the size of an effect varies as a function of those constraints (simons et al., 2018). an important first step is to conduct an exact replication study to confirm the result of the original study. second, in order to identify the most important hidden moderators assessed conceptual replications and also meta-analyses should be conducted, once a sufficient number of replication studies has been conducted where as rule-of-thumb can be used that 5 to 10 studies are needed per included moderator in a meta-analysis (van houwelingen, arends, & stijnen, 2002). an agreed set of quality standards and criteria based on the cog concept that must be included in clinical trial reports should be established and constantly refined. the criteria and quality standards will inform future replication studies, and should also be taken into account by experts evaluating the current state of evidence of an intervention, e.g. when developing clinical guidelines or establishing est. in the long term, the adoption of cog statements will lead to a more cumulative understanding of the scope of the effects of psychological interventions. replicability in mental health research 12 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://www.psychopen.eu/ conclusion the current gold standard in evidence-based psychological treatments can be criticized for not paying sufficient attention to replicability. the current discussion surrounding replicability and reproducibility (ioannidis, 2012; munafò et al., 2017) offers the oppor­ tunity to define and potentially increase replicability also in mental health research. the development of an explicit concept and taxonomy of replication will enable the classification of studies investigating clinical interventions with respect to their similari­ ty with original studies and will aid in planning and conducting replication studies in the future. the criteria themselves need to be continuously updated based on advances in replicability research in other areas and informed by emerging evidence regarding (moderators of) replicability in mental health research. however, also a number of limitations have to be noted. even if an effect is true, it is possible to fail to replicate due to seemingly innocuous differences in the implementation of the study (i.e. due to “hidden moderators”). small variations in studies are unavoidable and exact replication is strictly impossible. baribault and colleagues (2018) suggest to randomize variables that may be moderators of an effect in replication studies in order to test the robustness and generalizability of an effect. they propose a random selection of potential moderators, that is characteristics of the design that are not supposed to make a difference. if characteristics do not affect the results, this means that the results are more generalizable and to alter minor things should not matter. this is suggested for experimental research, e.g. different implementations of the same stimulus could be used to study whether the results are robust. however, as a large number of studies is necessary for this approach, it is not applicable to rcts on psychological interven­ tions. compared to research in social psychology, studies in research on psychological interventions are much more costly and time-consuming, which makes it more difficult to study replicability. the question of how much money and effort researchers should spend on studying replicability given that conducting such studies is expensive in clinical psychology is related to the decision when to move on to other research topics, because studying replicability means at the same time that less scientific progress with respect to new findings will be made. this demonstrates that not all recommendations from social psychology are applicable in clinical psychology. based on this we would like to invite the readers to engage in discussions about the concrete criteria and next steps that we proposed. designing replication studies should be based on empirical evidence and on theoretical predictions (simons et al., 2018) and considered to be a collective research enterprise. niemeyer, knaevelsrud, van aert, & ehring 13 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://www.psychopen.eu/ funding: this research received 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(2018). making replication mainstream. behavioral and brain sciences, 41, article e120. https://doi.org/10.1017/s0140525x17001972 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. replicability in mental health research 18 clinical psychology in europe 2023, vol. 5(3), article e9997 https://doi.org/10.32872/cpe.9997 https://doi.org/10.1002/sim.1040 https://doi.org/10.1037/a0036731 https://doi.org/10.3758/s13428-015-0593-0 https://doi.org/10.1111/j.1600-0447.2006.00868.x https://doi.org/10.1017/s0140525x17001972 https://www.psychopen.eu/ replicability in mental health research (introduction) do current research standards pay enough attention to replicability? proposing a research strategy for assessing, understanding, and improving replicability in research evaluating psychological interventions a. replication: definitions and criteria b. evaluating evidence on efficacy of interventions c. planning and conducting new replication studies conclusion (additional information) funding acknowledgments competing interests references psychological processes associated with resilience in uk-based unpaid caregivers during the covid-19 pandemic research articles psychological processes associated with resilience in uk-based unpaid caregivers during the covid-19 pandemic emma wilson 1,2,3 , juliana onwumere 1,4 , colette hirsch 1,4 [1] department of psychology, institute of psychiatry, psychology and neuroscience, king’s college london, london, united kingdom. [2] health service and population research, institute of psychiatry, psychology and neuroscience, king’s college london, london, united kingdom. [3] esrc centre for society and mental health, king’s college london, london, united kingdom. [4] south london and maudsley nhs foundation trust, london, united kingdom. clinical psychology in europe, 2022, vol. 4(4), article e10313, https://doi.org/10.32872/cpe.10313 received: 2022-09-17 • accepted: 2022-11-02 • published (vor): 2022-12-22 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: colette hirsch, department of psychology, institute of psychiatry, psychology and neuroscience, king’s college london, de crespigny park, london se5 8af, uk. phone: +44 207 848 0697. e-mail: colette.hirsch@kcl.ac.uk supplementary materials: materials [see index of supplementary materials] abstract background: unpaid caregivers have faced and dealt with additional challenges during the covid-19 pandemic. understanding the psychological processes associated with their resilience is warranted. the objective of this study was to examine the associations between resilience with mental distress, emotion regulation strategies (i.e., reappraisal and suppression) and interpretation bias in adult caregivers. method: participants were living in the uk, aged 18+, and consisted of 182 unpaid caregivers of an adult aged 18+ living with a long-term health condition, and 120 non-caregivers. data were collected in an online study during the first national uk covid-19 lockdown (may and september 2020). hierarchical multiple regression analyses explored whether emotion regulation strategies and interpretation bias explained unique variance in levels of resilience in caregivers whilst controlling for anxiety and depression. results: compared to non-caregivers, caregivers reported higher levels of anxiety, depression, negative interpretation bias and lower levels of resilience. emotion regulation strategies did not differ between groups. within caregivers, greater resilience was associated with lower mood disturbance, a positive interpretation bias, and greater use of cognitive reappraisal and lower use of this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10313&domain=pdf&date_stamp=2022-12-22 https://orcid.org/0000-0003-4413-8338 https://orcid.org/0000-0001-7119-7451 https://orcid.org/0000-0003-3579-2418 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ suppression strategies to regulate emotions. emotion regulation and interpretation bias together predicted an additional 15% of variance in current levels of resilience. conclusion: our findings indicate that psychological mechanisms such as emotion regulation strategies, particularly reappraisal, and interpretation bias are associated with resilience in caregivers. although preliminary, our findings speak to exciting clinical possibilities that could form the target of interventions to improve resilience and lower mental distress in unpaid caregivers. keywords resilience, interpretation bias, emotion regulation, informal carers, unpaid caregivers, covid-19 highlights • negative interpretation bias, alongside use of emotional regulation strategies (i.e., suppression; reappraisal), and their association with resilience was investigated in unpaid caregivers for the first time. • caregivers report lower levels of resilience and higher levels of anxiety and depression compared to non-caregivers during the covid-19 pandemic. • the tendency to interpret information in more positive ways, and to use reappraisal as a way to regulate emotions, were associated with greater resilience in caregivers. • interpretation bias and reappraisal could form the target of future caregiver tailored interventions to improve resilience. data suggests the united kingdom (uk) is facing an increase in negative mental health outcomes due to the impact of the covid-19 pandemic (li & wang, 2020). unpaid caregivers (also called informal carers, herein ‘caregivers’) have been defined as ‘anyone, including children and adults who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support’ (nhs england, 2014). pre-pandemic, caregivers represented around 7% of the uk population (department for work and pensions, 2020) and carers uk (2020) has suggested that numbers doubled from 6.5 million to 13.6 million during the covid-19 pandemic. compared to the general popula­ tion and pre-pandemic, caregivers were at greater risk of anxiety and depression and poorer health outcomes (smith et al., 2014). this is observable across different illness groups; for example, when caring for someone with dementia (papadopoulos et al., 2019), cancer (leseure & chongkham-ang, 2015), multiple sclerosis (mckeown et al., 2003), and a mental health condition (young et al., 2019). on 23rd march 2020, the uk government introduced a nationwide lockdown with measures aimed to restrict transmission of the virus and mitigate pressure on the nation­ al health service (nhs). measures included staying at home with few exceptions (e.g., essential purposes), working from home unless designated a ‘key worker’ and always resilience and distress in unpaid caregivers during covid-19 2 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ maintaining social distancing rules. people in at-risk groups were asked to ‘shield’ by remaining indoors. caregivers had to navigate the changes to their own routine and con­ sider their own pre-existing health conditions and life situation (onwumere, 2021; vahia et al., 2020). hence, in a group already at a heightened risk of social isolation (hayes et al., 2015) and lower life satisfaction compared to non-caregivers (naef et al., 2017), distress was exacerbated by social distancing rules and inability to access support from friends and family or formal services in their caring role (baker & clark, 2020; whitley et al., 2021). understanding how the psychological wellbeing of caregivers, relative to their non-caregiver peers, was impacted during the pandemic and the key mechanisms driving their presentations is an important step in informing future targeted interventions. however, these types of investigations have been limited. nevertheless, emerging data suggests reduced psychological wellbeing (e.g., heightened anxiety/depressive symptoms, stress/distress related to caregiving, care burden) among family caregivers (gallagher & wetherell, 2020; muldrew et al., 2022), although the psychological mechanisms driving these mood states remain less researched in the literature. one psychological factor associated with better psychological functioning (i.e., posi­ tive adaptation) is resilience (luthar et al., 2015; seery et al., 2010), commonly defined as the ability to bounce back from adversity (rutter, 1985, 1987; southwick et al., 2015). this psychological process can fluctuate over time and across contexts, so one person may be resilient to certain adversities but not others (egeland et al., 1993; pooley & cohen, 2010). windle and bennett’s (2012) theoretical resilience framework for caregivers also highlights how resilience is influenced by interactions in the environment and draws on social resources. restricted access to important resources in health and social care during periods of lockdown, combined with the threat from the virus to the most vulner­ able, may have impacted caregivers in particular, threatening their capacity to remain resilient. identifying factors that may foster lower levels of distress and higher levels of resilience in caregivers during times of extra stress, such as a pandemic, could help us identify those who are likely to need extra support and better tailor future interventions; particularly when resources are limited (rapado-castro & arango, 2021). resilience is associated with higher quality of life, better regulation of emotions, more positive emotions, and less perceived stress, anxiety and depression (balmer et al., 2014; troy & mauss, 2011). in caregivers, reduced mood disturbance (e.g., lower levels of anxiety and depression) is recorded in those reporting higher levels of resilience (simpson et al., 2015). moreover, systematic review data suggests that higher resilience levels are linked to reductions in the risk of stress and care burden and supports greater role adaptation (palacio gonzález et al., 2020). to determine whether caregiver and non-caregiver populations in the uk differed in levels of resilience during early stages (first 3 months) of a global pandemic, data were collected using a widely used, multidi­ mensional self-report measure of resilience with good psychometric properties (connor & davidson, 2003; pangallo et al., 2015). wilson, onwumere, & hirsch 3 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ given the potential importance of resilience to caregiver wellbeing and outcomes, it would seem important to also identify modifiable psychological mechanisms that can foster resilience, such as emotion regulation approaches (palacio gonzález et al., 2020). common approaches include cognitive reappraisal (occurs before an emotion is experienced; seeking alternative perspectives in situations that may change the emotion­ al response) and suppression (purposively attempting to suppress expressive behaviour while emotionally aroused, such as trying not to display anger or annoyance; gross, 1998; gross, 2014; gross & levenson, 1993). reappraisal is seen as an opportunity to grow in times of adversity by reducing maladaptive appraisals (e.g., self-blame), whereas suppression involves the avoidance of expressing one’s feelings and may lead to negative outcomes (gross & john, 2003; john & gross, 2004). the links between emotional regu­ lation and resilience are yet to be explored despite a hypothesised relevance between two concepts that are arguably connected (kay, 2016). the limited work in this area has suggested that high levels of cognitive reappraisal may serve as a protective factor that fosters resilience after adverse situations (polizzi & lynn, 2021; troy & mauss; 2011), while expressive suppression may have a negative effect on resilience (hong et al., 2018; mouatsou & koutra, 2021). another psychological mechanism that might potentially expand our understanding of resilience in caregivers is interpretation bias, which is the tendency to draw negative conclusions from ambiguous information (hirsch et al., 2016). there is already data to suggest that lower levels of interpretation bias are linked to greater resilience in groups such as women living beyond breast cancer (booth et al., 2022; gordon et al., 2022) and in adolescents (booth et al., 2022). such findings support a cognitive model of psychological resilience (booth et al., 2022), whereby interpretation bias influences levels of resilience and is a key mechanism for maintaining internalising disorders such as mood conditions. moreover, interpretation biases may interfere with certain protective emotion regulation strategies (e.g., reappraisal), impacting the regulation of negative affect (joormann & siemer, 2011). it was therefore anticipated that cognitive reappraisal would be associated with interpretation bias, and suppression associated with more negative interpretation biases of ambiguous situations. given the challenges faced by unpaid caregivers, it is important to explore the relevance to their wellbeing of these potentially modifiable psy­ chological mechanisms and by doing so, potentially inform the development of targeted and care focused support interventions. study aims first, we sought to examine caregivers reports of depression, anxiety and resilience, alongside their levels of negative interpretations and compare these to non-caregiver populations. second, we wanted to assess whether more negative interpretations and suppression of emotions, as well as less use of reappraisal, are associated with, and resilience and distress in unpaid caregivers during covid-19 4 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ help predict, resilience levels in uk caregivers between may to september 2020 of the covid-19 pandemic. hypothesis 1 caregivers compared to non-caregivers will have lower levels of resilience, and higher levels of anxiety and depression. exploratory analysis will see if negative interpretation bias, emotion regulation (reappraisal and suppression) varies between caregivers and non-caregivers. hypothesis 2 within the caregiver population, greater resilience will be associated with lower levels of negative interpretation bias and expressive suppression, and greater use of cognitive reappraisal. hypothesis 3 within the caregiver population, emotion regulation and interpretation bias will contrib­ ute extra and unique variance in levels of resilience in a model which controls for factors known to be associated with resilience – anxiety and depression. method participants participants were aged 18+ and living in the uk. we recruited 182 caregivers and 120 non-caregivers. caregivers could participate if they were not in a paid caring role (except for any state benefits/financial support for carers), had been in a caring role for 6 months or more, for someone aged 18+ who has a long-term condition commonly asso­ ciated with caregiving (i.e., dementia, cancer, multiple sclerosis, and any mental health condition). participants were recruited through social media, online message boards, charities (e.g., webpages or newsletters), the join dementia research forum and call for participants. materials and measures demographic questions participants completed several demographic questions regarding age, ethnicity, gender, employment status and relationship status. questions were completed about their experi­ ence of the pandemic, including whether they believed they had had covid-19, were currently self-isolating/quarantining (i.e., not leaving the house or having visitors), and wilson, onwumere, & hirsch 5 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ whether they were a paid keyworker (i.e., paid workers in certain key sectors defined as critical to the covid-19 response; department for education, 2021). caregivers were asked additional questions about the people they provide care for (i.e., number they care for, their relationship to them, their condition). if caregivers selec­ ted more than one medical condition, caregivers were asked to stipulate whether it was the primary condition of the person they care for. for caregivers caring for more than one person, they were asked to respond in relation to the person they currently spent most time caring for. questions covered specific diagnosis, gender, age, employment status of the person cared for, estimated number of hours spent in this caregiving role per week, whether they live together and duration of their caring role. caregivers were also asked if they had people to confide in and if so, how many. see supplementary materials 1 for full list of questions. questionnaire measures connor-davidson resilience scale (cd-risc) — this 25-item questionnaire (connor & davidson, 2003) measures resilience over the past month on a 5-point likert scale (1 = not at all to 5 = true nearly all the time). total scores range from 0 – 100 with higher scores reflecting greater resilience. example item: ‘i tend to bounce back after illness, injury, or other hardships’. the cd-risc has demonstrated high internal consistency in previous studies with caregivers of older adults (α = .94; ong et al., 2018), people with dementia (α = .89; ruisoto et al., 2020), and severe mental illness (α = .93; mulud & mccarthy, 2017). present sample cronbach’s α = .91. generalized anxiety disorder 7 (gad-7) — this 7-item questionnaire (spitzer et al., 2006) measures symptoms of anxiety over the past 2 weeks and asks participants ‘how often have you been bothered by the following problems?’ on a 4-point likert scale (1 = not at all to 4 = never). a sum score is calculated, and scores assigned to the following categories of anxiety: minimal (< 4), mild (5-9), moderate (10-14), severe (15-21). example item: ‘worrying too much about different things’. the gad-7 has been found to have high/good internal reliability in the general population (löwe et al., 2008) and in carers (α = .93; lappalainen et al., 2021). present sample cronbach’s α = .91. patient health questionnaire 9 (phq-9) — this 9-item questionnaire (kroenke & spitzer, 2002) measures symptoms of depression over the past 2 weeks and asks partic­ ipants ‘how often have you been bothered by the following problems?’ on a 4-point likert scale (1 = not at all to 4 = never). the sum of scores indicates the following depression severities: none (<4), mild (5-9), moderate (10-14), moderately severe (15-19), severe (20-27). example item: ‘little interest or pleasure in doing things’. the phq-9 has been found to be a valid and reliable measure of depression (kroenke et al., 2001) and resilience and distress in unpaid caregivers during covid-19 6 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ is widely used in caregiver studies (kishita et al., 2020; ping pang et al., 2020). present sample cronbach’s α = .91. emotion regulation questionnaire (erq) — this 10-item questionnaire (gross & john, 2003) measures how individuals use two emotional regulation strategies in daily life: cognitive reappraisal and expressive suppression. the reappraisal scale contains six items (e.g., ‘when i’m faced with a stressful situation, i make myself think about it in a way that helps me stay calm’) and suppression contains four items (e.g., ‘i control my emotions by not expressing them’), using 7-point likert scales (1 = strongly disagree to 7 = strongly agree). the score for each subscale is the mean of the items (range 1 – 7) and the erq has been used in carer populations (α range from .67 to .84; aerts et al., 2019; lamothe et al., 2018). present sample cronbach’s α = .74. interpretation bias task scrambled sentences test (sst) — adapted from wenzlaff and bates (1998, 2000) and used in hirsch et al. (2020); in 20 trials, participants select 5 words from 6 randomly presented words to form a grammatically correct sentence. potential completions are positive or negative interpretations of self-referent statements. the task is completed over five minutes while holding a six-digit string in mind. the digit string has been used previously to add a cognitive load, allowing latent biases to be observed and limit participants from guessing the purpose of the sentence scrambling task, reducing the risk of answers being subject to demand characteristics such as social desirability (krahé et al., 2022; schoth & liossi, 2017). an interpretation bias score is created by dividing the number of grammatically correct positively unscrambled sentences by the number of correct negatively unscrambled sentences. index scores range from 0 to 1, with higher scores denoting a more positive interpretation bias. procedure the survey was hosted on qualtrics with all data collected between may and september 2020, between the middle of the first covid-19 lockdown and the start of the uk home nations gradually reopening. both caregiver and non-caregiver groups completed the same core survey (questionnaires, sst), and caregivers completed additional demo­ graphic questions about the person(s) they care for. the survey took 35 – 50 minutes to complete and participants could enter a prize draw for amazon vouchers: 1 of 20 £10 prizes, 1 of 2 £50 prizes, or 1 of 2 £100 prizes. the study was approved by the king’s college london research ethics committee (approval number: hr-19/20-14617) and participants provided consent and data electronically. wilson, onwumere, & hirsch 7 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ statistical analysis bivariate descriptive statistics were used to describe sample characteristics and summa­ rise scores of study measures. continuous variables were expressed as means (standard deviation, sd). two-tailed t-tests for continuous variables (e.g., age) and chi-squared tests for categorical variables (e.g., gender) were used to test for group differences in sociodemographic factors and study variables (h1). effect sizes were calculated using cohen’s d for t-tests, and phi and cramer’s v for chi-squared tests. associations between study variables in caregivers were quantified using pearson’s correlation coefficient (h2). in the caregiver sample, a hierarchical regression tested the hypothesis that emotion regulation strategies (i.e., reappraisal and suppression) and interpretation bias would contribute significant variance, beyond anxiety and depression, in predicting levels of resilience (h3). anxiety and depression were entered as independent variables in the model’s first step. emotion regulation and interpretation bias were entered into the second step as independent variables. resilience was the outcome variable. statistical significance was set at p < .05. spss versions 26 and 27 were used to conduct all analyses. results see table 1 for participant demographics and table 2 for characteristics of the individuals that caregivers were caring for and their caregiving role. participants were predominant­ ly women and white british, with a higher proportion in the caregiver group. the higher rates of women as caregivers is similar to levels reported in the literature (tur-sinai et al., 2020). other demographic characteristics were well-matched. caregivers most often cared for someone with dementia (66%) and lived with the person they cared for (61%). mental health conditions included depression (n = 8), anxiety (n = 4), psychosis/schizo­ phrenia, (n = 3), ptsd (n = 2), bipolar disorder (n = 2), personality disorder (n = 2), eating disorder (n = 2), ocd (n = 1), other/multiple conditions including autism and learning difficulties (n = 12), not reported (n = 8). several post hoc power analyses were conducted to test for the power of the analyses conducted for each of our hypotheses (e.g., t-test, correlation, multiple regression). ex­ cept for two t-tests with small effect sizes (i.e., erq-r, erq-s; see table 3), the minimum power achieved for all analyses was .82. resilience and distress in unpaid caregivers during covid-19 8 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ table 1 demographic characteristics baseline characteristic caregiver sample (n = 182) non-caregiver sample (n = 120) statistical test, significance value and effect sizen (%) n (%) age – m (sd)a 56.36 (13.48) 53.76 (17.65) t (207.98) = 1.37, p = .172, d = .166 ethnicity non-white british vs. white british, χ2(1) = 7.64, p = .006, φ = -.159 arab – 1 (0.8) bangladeshi 1 (0.5) – black british 3 (1.6) – chinese 1 (0.5) 1 (0.8) indian 3 (1.6) 1 (0.8) pakistani 1 (0.5) – other 1 (0.5) 22 (18.3) white and asian 1 (0.5) 1 (0.8) white and black caribbean 1 (0.5) 1 (0.8) white british 159 (87.4) 90 (75.0) white gypsy or irish traveller 1 (0.5) – white irish 5 (2.7) 3 (2.5) genderb χ2 (1) = 12.19, p = .001, φ = .201 woman 155 (85.2) 82 (68.3) man 26 (14.3) 37 (30.8) employment status χ2 (3) = 1.68, p = .641, v = .075 full-time employment 25 (13.7) 23 (19.2) part-time employment 34 (18.7) 22 (18.3) retired 62 (34.1) 39 (32.5) other 61 (33.5) 36 (30.0) relationship status χ2 (3) = 11.15, p = .011, v = .192 married/ domestic partnership 108 (59.3) 49 (40.8) cohabiting 23 (12.6) 18 (15.0) single 26 (14.3) 31 (25.8) separated, divorced, widowed 25 (13.7) 22 (18.3) covid-19 questions caregiver has had covid-19c 25 (13.7) 19 (15.8) χ2 (1) = 0.96, p = .327, φ = -.063 self-isolating/ in quarantinede 20 (11.0) 18 (15.1) χ2 (2) = 2.59, p =.274, v = .093 considered a ‘key worker’fg 36 (19.8) 22 (18.3) χ2 (1) = .08, p = .781, φ = .016 adeclined to say: n = 1. bother: n = 2. crespondents asked: n = 245. ddeclined to say: n = 1. eby self-isolating/ in quarantine we mean not leaving the house for any reason and avoiding contact with anyone outside the household. fdeclined to say: n = 1. ga ‘key worker’ was defined as someone who worked in: health and social care, education and childcare, key public services, local and national government, food and other necessary goods, public safety and national security, transport, utilities, communication and financial services. phi (φ) and v (v) are measures of effect size for chi-square tests. wilson, onwumere, & hirsch 9 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ table 2 characteristics of the person/people caregivers cared for and the caregiving role characteristics participants (n = 182) number they care for, mean (sd) 1.25 (0.62) primary condition, n (%)a dementia 120 (65.9) multiple sclerosis 8 (4.4) cancer 10 (5.5) mental health condition 44 (24.2) relationship, n (%) spouse/partner 66 (36.3) son/daughter 62 (34.1) parents 34 (18.7) other relative/friend/neighbour 20 (11.0) hours per week in caregiving role, n (%) 0 – 19 60 (33.0) 20 – 49 49 (26.9) 50 – 90 24 (13.2) over 100 49 (26.9) duration of caregiving role, n (%) under 12 months 18 (9.9) 1 – 5 years 75 (41.2) 5 – 10 years 45 (24.7) over 10 years 44 (24.2) live with person cared for, n (%) yes 111 (61.0) no 71 (39.0) has someone to confide in, n (%) 136 (74.7) number of confidents, mean (sd) 3.32 (2.51) aif more than one condition listed, participant asked to provide primary condition of person they care for. do caregivers exhibit lower levels of resilience and higher levels of distress than non-caregivers and is interpretation bias more negative in caregivers? the mean scores for all questionnaires are presented in table 3. in keeping with hy­ pothesis 1, caregivers demonstrated lower levels of resilience, higher levels of anxiety, depression and interpretation bias with small to medium effect sizes (d = 0.36 to 0.74). exploratory analysis found that emotion regulation techniques did not differ significant­ ly between groups. resilience and distress in unpaid caregivers during covid-19 10 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ table 3 scores for questionnaires and interpretation bias measure, by group measures caregiver group (n = 182) non-caregiver group (n = 120) t-test and significance valuem (sd) m (sd) questionnaire resilience (cd-risc) 62.21 (13.86) 66.98 (12.58) t (300) = -3.04, p = .003, d = 0.36 anxiety (gad-7) 6.91 (5.44) 4.03 (4.63) t (281.09)* = 4.92, p < .001, d = 0.57 depression (phq-9) 8.95 (6.60) 4.63 (5.00) t (294.30)* = 6.47, p < .001, d = 0.74 emotion reappraisal (erq-r) 4.44 (1.18) 4.62 (1.03) t (300) = -1.33, p = .183, d = 0.16 emotion suppression (erq-s) 3.77 (1.35) 3.54 (1.23) t (300) = 1.49, p = .137, d = 0.18 interpretation bias (sst) 0.67 (0.24) 0.76 (0.20) t (285.26)* = -3.60, p < .001, d = 0.42 note. cd-risc = connor-davidson resilience scale; gad-7 = generalised anxiety disorder questionnaire; phq-9 = patient health questionnaire; erq-r = emotion regulation questionnaire – reappraisal; erq-r = emotion regulation questionnaire – suppression; sst = scrambled sentences test. *equal variances not assumed. is there an association between resilience, emotion regulation techniques and interpretation bias in caregivers? to examine how resilience may be associated with emotion regulation techniques and more negative interpretations (h2), we conducted pearson’s correlations; see table 4 (non-caregiver sample on request). as expected, caregivers reporting greater resilience had a more positive interpretation bias, and greater use of cognitive reappraisal and lower use of suppression strategies to regulate emotions. furthermore, greater resilience was associated with lower levels of anxiety and depression symptoms. to determine whether emotion regulation and/or interpretation bias helps account for levels of resilience, we conducted a hierarchical multiple regression (see table 5). in step 1, processes known to be covariates of resilience were entered: anxiety and depression. in step 2 emotion regulation via reappraisal, emotion regulation via suppres­ sion and interpretation bias scores were entered into the model. in step 1, the model accounted for 33% of the variance in resilience, f(2, 179) = 44.69, p < .001 (see table 5). when emotion regulation techniques and interpretation bias were added in step 2, an wilson, onwumere, & hirsch 11 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ additional 15% of variance of resilience was explained (adjusted r 2 = .48), f(5, 176) = 33.96, p < .001. furthermore, both interpretation bias (β = .35, p < .001) and cognitive reappraisal (β = .28, p < .001) significantly predicted independent variance in resilience, but not emotion regulation via suppression (β = -.05, p = .385). results did not change when other covariates associated with caregiving were added into the model (i.e., gender, age, ethnicity, time caring per week, duration of caregiving role; see supplementary analyses 2). table 4 correlations between resilience, anxiety, depression, emotion regulation and an interpretation bias measure (sst) in caregiver participants measure 1 2 3 4 5 1. cd-risc 2. gad-7 -.50*** 3. phq-9 -.57*** .80*** 4. erq-r .49*** -.31*** -.31*** 5. erq-s -.21** .23*** .293** -.03 6. sst .64*** -.65*** -.75*** .41*** -.26*** note. n = 182; cd-risc = connor-davidson resilience scale; gad-7 = generalised anxiety disorder question­ naire-7; phq-9 = patient health questionnaire-9; erq-r = emotion regulation questionnaire – reappraisal; erq-s = emotion regulation questionnaire – suppression; sst = scrambled sentences test. **p < .01. ***p < .001. table 5 hierarchical regression analysis testing the influence of our predictors on resilience predictor variable b se β t step one gad-7 -0.33 0.26 -.13 -1.28 phq-9 -0.98 0.21 -.47 -4.59*** step two gad-7 -0.10 0.23 -.04 -0.42 phq-9 -0.37 0.22 -.18 -1.69 erq-r 3.26 0.69 .28 4.71*** erq-s -0.51 0.58 -.05 -0.87 sst 20.35 4.90 .35 4.15*** note. n = 182. b = unstandardized coefficient; se = standard error; β = standardised coefficient; gad-7 = gener­ alised anxiety disorder questionnaire; phq-9 = patient health questionnaire; erq-r = emotion regulation questionnaire – reappraisal; erq-r = emotion regulation questionnaire – suppression; sst = scrambled sentences test. ***p < .001. resilience and distress in unpaid caregivers during covid-19 12 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ discussion this study aimed to investigate reported levels of resilience and wellbeing in unpaid adult caregivers of a person aged 18+ with a long-term condition (specifically, multiple sclerosis, dementia, any mental health condition, and/or cancer) compared to non-care­ givers during a period of additional stress – the covid-19 pandemic – and what role, if any, potentially modifiable psychological mechanisms (i.e., interpretation bias, emotion regulation via reappraisal and suppression) had on carers’ reported levels of resilience. to the best of our knowledge, this represents the first investigation of its kind. as predicted and in keeping with non-pandemic data, caregivers reported lower lev­ els of resilience and greater levels of depression and anxiety compared to non-caregivers (our control condition). our pattern and direction of findings for these higher levels of caregiver emotional distress and lower resilience support published findings using samples from before (onwumere et al., 2017; smith et al., 2014; windle & bennett, 2012) and during the pandemic (kalb et al., 2021). our study confirmed for the first time that caregivers’ resilience levels were asso­ ciated with greater levels of positive interpretation bias, greater levels of reappraisal emotion regulation techniques and, to a lesser extent, lower levels of suppression. a more positive interpretation bias as well as greater use of cognitive reappraisal accounted for an additional 15% of the variance in resilience scores, with interpretation bias and use of reappraisal to regulate emotions both accounting for independent variance in resilience. to support a more nuanced understanding of these findings, an investigation with a similar sample outside of a global pandemic would be indicated. cognitive reappraisal and expressive suppression are independent constructs within the area of emotion regulation (moore et al., 2008). reappraisal is central to managing one’s emotional reaction to stressful situations, encouraging positive outcomes over time and important for understanding resilience, whereas suppression fails to address the emotion internally (troy & mauss, 2011). although both forms were associated with resilience, the current data found reappraisal, a cognitive construct, more relevant to fos­ tering resilience than suppression, a non-cognitive construct that is focused on changing only the outward expression of emotions (gross, 2014). this supports recent literature, which has found more mixed findings for the relation between expressive suppression and resilience, suggesting that situational factors may influence the longer-term adaptive or maladaptive role of suppression (polizzi & lynn, 2021). as a first step, supporting caregivers with emotional reappraisal techniques may be more beneficial than targeting expressive suppression. our findings on interpretation bias add to a growing body of literature that explores the impact of this cognitive bias in other populations, including adolescents with eat­ ing disorders, individuals with anxiety disorders, pregnant women, parents and their offspring (hirsch et al., 2021; rowlands et al., 2020; subar & rozenman, 2021). all highlight the risk of negative outcomes for negative interpretation biases. importantly, wilson, onwumere, & hirsch 13 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ interpretation bias and reappraisal are known to be modifiable mechanisms that can be targeted in psychological interventions; fostering a more positive interpretation bias or facilitating greater use of reappraisal techniques to regulate emotions could be beneficial in increasing resilience in caregivers. interventions to foster resilience both at an individ­ ual or familial level, and population level, are crucial for managing future pandemics and any longstanding negative impacts from covid-19 (ameis et al., 2020), as well as challenges associated with long-term caregiving in non-pandemic times. it is notable that while resilience is lower in caregivers (62.21) than non-caregivers (66.98), scores are much lower than general populations prior to the covid-19 pandemic (80.4; connor & davidson, 2003). indeed, our caregiver sample have similar levels of resilience to patients commencing a trial for ptsd (62.0; krystal et al., 2014) and psychi­ atric outpatients with a history of recent trauma (64.3; glass et al., 2019), although not as severe as some other ptsd populations (e.g., 49.8 to 55.7; davidson et al., 2006; mcguire et al., 2018). while the mean levels of anxiety and depression reported in caregivers fell within the non-clinical range (i.e., a score of 7 or below for the gad-7 and 9 or below for the phq-9), levels were higher compared to non-caregivers (p < .001, d = 0.57 to 0.84) and 46.2% still reported clinical levels of anxiety and 25.8% reported clinical levels of depression. this remains consistent with current literature (giebel et al., 2021; li et al., 2021) and offers further support of the need to consider the wellbeing of caregivers. the results offer early support for potential therapeutic avenues. cognitive behaviour therapy (cbt), for example, fosters more positive interpretations by reducing maladap­ tive thinking (derubeis et al., 2008) and a greater use of reappraisal to regulate emotion (smits et al., 2012). another approach to increase positive interpretation bias is cognitive bias modification for interpretations (cbm-i); this involves repeated computerised prac­ tice in generating more positive interpretations (menne-lothmann et al., 2014). it is pos­ sible that a caregiver focused cbm-i intervention could be tailored to focus on promot­ ing more positive interpretations of ambiguous and potentially negative situations that caregivers frequently encounter (e.g., uncertainty and ambiguity around implications for changes in symptoms in the person they care for). future qualitative studies could explore the specific caregiver stressors contributing to negative interpretations and its sequalae, compared to those unrelated to caregiving, to see if there is a generalised or situation-specific bias. there are limitations of the current study. firstly, it is cross-sectional, with data collected data within four months near the start of the pandemic. it therefore does not provide information on trajectories of resilience over the longer term during the pandemic, nor provide information on the extent to which interpretation bias predicts later levels of resilience in the caregiver populations. furthermore, we are unable to determine the extent to which general caregiver stress was exacerbated by the pandemic for a given individual in this sample due to lack of pre-pandemic data. while caregiving roles can be held by anyone, irrespective of demography, ethnic minority participants resilience and distress in unpaid caregivers during covid-19 14 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ were largely underrepresented in our sample. this is important given that many of the key conditions in this study disproportionately affect some racial and ethnic minority groups, such as dementia, and caregiver experiences may differ across cultures (liu et al., 2021). consequently, the under-representation limits generalisability of findings to the wider population. additionally, our study did not look at the impact of looking after children during the pandemic. managing home-schooling alongside other responsibilities such as work undoubtedly contributed to additional challenges. these have been considered in great depth elsewhere. finally, participants could only be recruited and participate via the internet and therefore less likely to represent the experiences of informal caregivers with no or limited access to the internet, or those with less time to take part due to increase caregiving demands. in 2020, groups less likely to have internet access in the uk included the over 75s (46%), retired individuals (28.9%) and persons who self-assessed as having a disability (18.6%; office for national statistics, 2021). as convenience samples, our groups were also not matched on all demographic variables. specifically, control participants were more frequently european white, men and single, as compared to caregivers. the under representation of particular groups is part of a broader issue in uk health focused surveys (harrison et al., 2020). nevertheless, future studies should aim to better match the control group to the caregiver sample. in summary, caregivers were reporting less resilience and higher levels of anxiety and depression compared to non-caregivers during the covid-19 pandemic. importantly, the tendency to interpret information in more positive ways and to use reappraisal as a way to regulate emotions was associated with greater resilience and could form the target of future caregiver interventions to improve resilience. funding: ch and jo have salary support from national institute for health research (nihr) biomedical research centre at south london and maudsley nhs foundation trust and king’s college london. the views expressed are those of authors and not necessarily those of the nhs, nihr, king’s college london or the department of health. acknowledgments: we are very grateful to everyone who took part in the study. competing interests: colette hirsch is a subject editor of clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. twitter accounts: @mindfulem supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): wilson, onwumere, & hirsch 15 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://twitter.com/mindfulem https://www.psychopen.eu/ • supplementary materials 1: additional questions asked to unpaid caregivers • supplementary materials 2: hierarchical regression analysis testing the influence of our predictors on resilience while controlling for additional covariates index of supplementary materials wilson, e., onwumere, j., & hirsch, c. 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(2019). exploring the experiences of parent caregivers of adult children with schizophrenia: a systematic review. archives of psychiatric nursing, 33(1), 93–103. https://doi.org/10.1016/j.apnu.2018.08.005 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. wilson, onwumere, & hirsch 23 clinical psychology in europe 2022, vol. 4(4), article e10313 https://doi.org/10.32872/cpe.10313 https://doi.org/10.1007/978-1-4614-0586-3_18 https://doi.org/10.1016/j.apnu.2018.08.005 https://www.psychopen.eu/ resilience and distress in unpaid caregivers during covid-19 (introduction) study aims method participants materials and measures procedure statistical analysis results do caregivers exhibit lower levels of resilience and higher levels of distress than non-caregivers and is interpretation bias more negative in caregivers? is there an association between resilience, emotion regulation techniques and interpretation bias in caregivers? discussion (additional information) funding acknowledgments competing interests twitter accounts supplementary materials references response to the commentary „can a 1-item scale for psychotherapy outcomes be psychometrically robust?” letter to the editor, commentary response to the commentary „can a 1-item scale for psychotherapy outcomes be psychometrically robust?” brian schwartz 1 , miguel m. gonçalves 2 , wolfgang lutz 1 , joão tiago oliveira 2 , suoma e. saarni 3,4,5 , orya tishby 6 , michael barkham 7 , european psychotherapy consortium (epoc) [1] department of psychology, trier university, trier, germany. [2] cipsi – psychology research center, school of psychology, university of minho, braga, portugal. [3] department of psychiatry, faculty of medicine and health technology, tampere university, tampere, finland. [4] department of psychiatry, helsinki university hospital hus and helsinki university, helsinki, finland. [5] department of psychiatry, wellbeing services county of päijät-häme, lahti, finland. [6] department of psychology, hebrew university, jerusalem, israel. [7] clinical and applied psychology unit, school of psychology, university of sheffield, sheffield, united kingdom. clinical psychology in europe, 2025, vol. 7(1), article e16921, https://doi.org/10.32872/cpe.16921 published (vor): 2025-02-28 corresponding author: brian schwartz, clinical psychology and psychotherapy, department of psychology, trier university, d-54286 trier, germany. phone: +49 651 201 4321. e-mail: schwartzb@uni-trier.de we thank the author(s) for their commentary in response to our article on the european psychotherapy consortium (epoc) of the european chapter of the society for psycho­ therapy research (spr) published in clinical psychology in europe (gonçalves et al., 2024) and welcome the opportunity to respond. whilst we appreciate the detailed comments on our article made by the author(s), we would like to take this opportunity to primarily address the specific criticisms of the epo-1 single-item scale. overall, the commentary criticizes our article on a combined theoretical and psycho­ metric basis as a first, but so far, successful, attempt to coordinate the administration of patient outcome data collected during the course of treatment and implemented across europe. such criticism fails to recognize the practical impact of our strategic approach, which aims to significantly advance the paradigm of patient-focused research. our objective has been to advance the field of psychological therapies and pave the way for the first steps towards coordinated data collection, data-based quality assurance, and practice-based evidence into the therapeutic process across national borders. the single-item emotional and psychological outcome-1 measure (epo-1) addresses the real­ ity of identifying a common measurement language across different clinics in different this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.16921&domain=pdf&date_stamp=2025-02-28 https://orcid.org/0000-0003-4695-4953 https://orcid.org/0000-0003-2575-7221 https://orcid.org/0000-0002-5141-3847 https://orcid.org/0000-0001-6624-8816 https://orcid.org/0000-0003-3555-9958 https://orcid.org/0000-0001-6321-8590 https://orcid.org/0000-0003-1687-6376 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ european countries with varying structures of assessment and other healthcare systems, some with already existing measurement systems and some with none. hence, we are attempting what we consider to be a unique program of research implementation that is both feasible in most clinical settings (i.e., minimal demands on patients, therapists, and healthcare systems) and yet has a grand vision in transcending national boundaries that are, so often, limitations to research collaboration. against this background, the commentary fails to fully appreciate the objectives and value of the epo-1 item’s intro­ duction. in addition to presenting our general view of the project, which is broader than that of the commentary’s author(s), we would also like to respond to some specific points of criticism below. the author(s) assumes that the epo-1 item has limited reliability and validity. in response, we direct the author(s) to the high correlations of the instrument with other established outcome instruments, such as the outcome questionnaire-30 (oq-30; r = .601), the questionnaire for the evaluation of psychotherapy (fep-2; r = .626), and the patient health questionnaire-9 (phq-9; r = .630), which can be found in detail in chapter 4 (appendix) of bergin and garfield’s handbook of psychotherapy and behavior change (lutz et al., 2021). the empirical data (n = 521) also show that the pre-post effect sizes, measured with the epo-1, are as strongly related to the above instruments and that the individual effect sizes are comparable to those of the other measures. the epo-1 pre-post-effect sizes refute the assumption that the single-item measure epo-1 is less sensitive to change than multi-item scales (pre-post-effect sizes, e.g., epo-1(likert): d = 1.086; epo-1(analogue): d = 1.469; bsi: d = 0.879; oq-30: d = 1.320; lutz et al., 2021). for future research, the author(s) recommends demonstrating the stability of the item over time without intervention, its change in response to intervention, and its correlations with established measures. the last two points (change sensitivity and convergent validity) have already been empirically demonstrated (see above; lutz et al., 2021), leaving only the first point (reliability in the absence of intervention) to be addressed in future studies. many points of criticism in the commentary refer to the general disadvantages of self-report questionnaires. they are not specifically related to single-item scales (e.g., the varying interpretation of questions by individual patients or the cognitive complexity of evaluating the item). further, the author(s) suggests extending the epo-1 item with an alliance item and using large language models (llms), which are important and topical issues in recent psychotherapy research. however, the epo-1 is intentionally designed as a single-item measure to ensure easy implementation in clinical practice. moreover, this outcome measure assesses psychological well-being, not therapeutic alliance. while llms have become valuable tools in psychotherapy research, the epo-1 item is a low-burden meas­ ure for patients, collected via self-report. therefore, it should not be replaced by video or text analyses, which could capture a different perspective. response to the commentary by scott t. meier 2 clinical psychology in europe 2025, vol. 7(1), article e16921 https://doi.org/10.32872/cpe.16921 https://www.psychopen.eu/ our response addresses the concerns expressed based on theoretical considerations with empirical evidence. furthermore, we would argue that the benefits and potential of these efforts to introduce a standardized outcome measure across europe outweigh the theoretical (and, as demonstrated, not necessarily valid) criticisms. we are aware of the common problems of single-item scales, which is why the epoc does not only focus on the epo-1 item but also on developing and implementing crosswalks to create a standard measure structure between different clinics across europe. in summary, epoc is a project that aims to evolve and create large, heterogeneous data sets from different countries that will facilitate practice-based evidence and datainformed psychological therapy. epo-1 is currently translated into 13 languages, and two more are expected to be added soon. we hope that more institutions will join our initiative in the future and adopt the item in their assessments. ultimately, whether it is taken up in the field is an empirical question. funding: this work was supported by the german research foundation (dfg) under project numbers 493169211, 504507043, and 525286173 granted to wolfgang lutz and partially conducted at the psychology research centre (psi/ 01662), school of psychology, university of minho, and supported by the portuguese foundation for science and technology and the portuguese ministry of science, technology and higher education (uid/psi/01662/2019), through national funds (piddac). acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: michael barkham declares that he is a co-developer of the core-om and core-10. social media accounts: brian schwartz: bluesky: @schwartz-psyres.bsky.social references gonçalves, m. m., lutz, w., schwartz, b., oliveira, j. t., saarni, s. e., tishby, o., rubel, j. a., boehnke, j. r., montesano, a., paiva, d., ceridono, d., zech, e., willemsen, j., saarni, s. i., kompan erzar, k., janeiro, l., gelo, o. c. g., errázuriz, p., holas, p., … barkham, m. (2024). developing a european psychotherapy consortium (epoc): towards adopting a single-item self-report outcome measure across european countries. clinical psychology in europe, 6(3), article 13827. https://doi.org/10.32872/cpe.13827 lutz, w., de jong, k., rubel, j. a., & delgadillo, j. (2021). measuring, predicting and tracking change in psychotherapy. in m. barkham, w. lutz, & l. g. castonguay (eds.), bergin and garfield’s handbook of psychotherapy and behavior change (7th ed., pp. 89–133). wiley. schwartz, gonçalves, lutz et al. 3 clinical psychology in europe 2025, vol. 7(1), article e16921 https://doi.org/10.32872/cpe.16921 https://bsky.app/profile/schwartz-psyres.bsky.social https://doi.org/10.32872/cpe.13827 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. response to the commentary by scott t. meier 4 clinical psychology in europe 2025, vol. 7(1), article e16921 https://doi.org/10.32872/cpe.16921 https://www.psychopen.eu/ has the time come to stop using the “standardised mean difference”? scientific update and overview has the time come to stop using the “standardised mean difference”? pim cuijpers 1 [1] department of clinical, neuro and developmental psychology, amsterdam public health research institute, vrije universiteit amsterdam, amsterdam, the netherlands. clinical psychology in europe, 2021, vol. 3(3), article e6835, https://doi.org/10.32872/cpe.6835 received: 2021-05-31 • accepted: 2021-07-25 • published (vor): 2021-09-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: pim cuijpers, professor of clinical psychology, department of clinical, neuro and developmental psychology, amsterdam public health research institute, vrije universiteit amsterdam, van der boechorststraat 7-9, 1081 bt amsterdam, the netherlands. e-mail: p.cuijpers@vu.nl abstract background: most meta-analyses use the ‘standardised mean difference’ (effect size) to summarise the outcomes of studies. however, the effect size has important limitations that need to be considered. method: after a brief explanation of the standardized mean difference, limitations are discussed and possible solutions in the context of meta-analyses are suggested. results: when using the effect size, three major limitations have to be considered. first, the effect size is still a statistical concept and small effect sizes may have considerable clinical meaning while large effect sizes may not. second, specific assumptions of the effect size may not be correct. third, and most importantly, it is very difficult to explain what the meaning of the effect size is to nonresearchers. as possible solutions, the use of the ‘binomial effect size display’ and the numberneeded-to-treat are discussed. furthermore, i suggest the use of binary outcomes, which are often easier to understand. however, it is not clear what the best binary outcome is for continuous outcomes. conclusion: the effect size is still useful, as long as the limitations are understood and also binary outcomes are given. keywords effect size, standardised mean difference, meta-analysis, outcome studies it was a historical event for the field of clinical psychology. in his presidential address to the american educational research association in 1976 in san francisco, gene glass this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6835&domain=pdf&date_stamp=2021-09-30 https://orcid.org/0000-0001-5497-2743 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ not only coined the term “meta-analysis” but he also introduced the basic ideas of modern meta-analyses (hunt, 1997). this event is broadly considered as the starting point of modern meta-analyses (hunt, 1997). since then this method has conquered the field of clinical psychology and beyond, and meta-analyses have become the standard for integrating the results of multiple studies on the same research question into one estimate of the effects or associations. meta-analyses are now considered to be the gold standard for estimating the effects of interventions and are at the basis of treatment guidelines for mental health and other problems as well as policy recommendations about treatments. glass brought forward two basic ideas that are at the core of modern meta-analyses. the first idea he brought forward was the ‘standardized mean difference’, or what is often called the ‘effect size’. the effect size indicates the difference between two condi­ tions after the intervention in terms of standard deviations instead of actual scores on an outcome instrument. this makes the outcomes ‘standardised’ and therefore they can be compared across studies. the other basic idea of meta-analyses that glass brought forward was that these standardised outcomes can be pooled across studies, while weighting them based on the size of the samples. this pooling of the standardised outcomes results in one overall estimate of the true effect size across multiple studies. it is now 45 years ago that these two basic ideas were introduced. the second idea, the pooling of outcomes according to the size of the study, has hardly been disputed since the introduction by glass. but the idea of the standardised mean difference has been more controversial over the years. in this paper, i will focus on the standardised mean difference. i will discuss whether this is still the best way of indicating the out­ comes of interventions or associations between variables or whether it is better to start using binary outcomes instead. i will call the standardised mean difference the ‘effect size’ which is in fact not correct (higgins & green, 2011), but i will still do that to increase the readability of this paper. the effect size it was a brilliant idea to indicate the difference between two groups in terms of the standard deviation of the outcome measure, instead of the actual difference in scores between the groups. this not only allows to compare these outcomes across different studies regardless of the outcome instrument used, but it also gives an indication of the size of the effect. previous research often only indicated whether the difference between two groups was significant or not. however, that is not very informative and does not say anything about the size of the difference. whether or not a difference is significant depends on the size of the sample, and even a tiny difference becomes significant when the sample size is large enough. the effect size solved this problem, because it goes beyond significance levels and indicates how large the difference is. cohen suggested has the time come to stop using the “standardised mean difference”? 2 clinical psychology in europe 2021, vol. 3(3), article e6835 https://doi.org/10.32872/cpe.6835 https://www.psychopen.eu/ that an effect size of 0.2 should be considered as small, 0.5 as moderate and 0.8 as large (cohen, 1988). however, the use of effect sizes also has several important limitations. one important limitation is that it is still a statistical concept. it may indicate the strength of an outcome, but it still cannot say anything about the clinical relevance of the outcome (cuijpers, turner, koole, van dijke, & smit, 2014). the clinical relevance of an effect size depends on the content. for example, an effect size of 0.1 would be considered a major breakthrough if years to mortality would be the outcome. and effect size of 0.1 with “knowledge of depression” as outcome, however, would be considered trivial by most people. this means that the categories of small, moderate and large effect sizes, as given by cohen (1988) may be misleading because the effect size depends too much on what the outcome actually is. it should be noted that this was fully acknowledged by cohen. one solution to the problem that the effect size is a statistical concept, could be the use of the ‘minimal clinically important difference’ (mcid; mcglothlin & lewis, 2014). the mcid is the smallest difference in score considered clinically worthwhile by the patient and it captures both the magnitude of improvement and the value the patient places on that improvement. for example, it was found in one study that a reduction of 17.5% from baseline to post-test on the bdi-ii can be considered as the minimal clinically important difference (button et al., 2015). currently, it is also possible to convert different measures into one common metric (e.g., wahl et al., 2014), making the use of the effect size no longer needed. the effect size has other problems. for example, it assumes that different outcome scales are linear transformation of each other and the standard deviation units are indeed the same across all studies (cummings, 2011). these assumptions do not necessarily need to be true in all situations. furthermore, the effect size may be influenced by how narrow the inclusion criteria are (cummings, 2011). if a trial only includes participants with a narrow severity range at baseline, it can be expected that the distribution of the severity at post-test is also relatively narrow. if patients with a broader severity range are included, the distribution of severity will be broader as well. this implies that if two trials, one with a narrow severity range and one with a broad severity range, show the same absolute difference (points on a severity scale), the effect size can still vary widely, because the distribution differs across the two studies. what does the effect size mean? the most important problem of the effect size is, however, that it is so difficult to explain what it exactly means to non-scientists. imagine a patient who considers to accept a treatment and asks the clinician what the chances are to get better after treatment. the clinician will have to say something like “if you get the treatment you will score 0.5 standard deviation lower on the outcome measure than not receiving the intervention”. cuijpers 3 clinical psychology in europe 2021, vol. 3(3), article e6835 https://doi.org/10.32872/cpe.6835 https://www.psychopen.eu/ of course a patient has no clue for what this actually means, and many clinicians also find it hard to understand what it means. there are some solutions to this problem. one older solution is to transform the effect size into the ‘binomial effect size display’ (besd) (rosenthal & rubin, 1982). the besd reduces an outcome to a simple dichotomy (for example whether a score is below or above the mean on the outcome instrument) and indicates the difference between the two treatment groups (e.g., therapy and control) in percentages of participants who score below (or above) the mean (randolph & edmondson, 2005). for example, an effect size of 0.2 indicates a difference of 0.10 in the proportion of participants reaching this threshold. one could say that such a value of the besd means that 45% of the control group and 55% of the treatment group had reached the threshold of 'success'. however, this is still a relative outcome and can in no way be interpreted as if 55% of the participants will score below the mean of the outcome measure. another way to make the effect size easier to interpret is to transform it into the number-needed-to-treat (nnt). the nnt indicates the number of patients that have to be treated in order to have one more positive outcome than no treatment (or an alternative treatment) (laupacis, sackett, & roberts, 1988). there are several ways to transform the effect size into the nnt (da costa et al., 2012; furukawa & leucht, 2011), but all are based on the normal distribution of the outcome measure and a cut-off on this normal distribution for a ‘positive outcome’. however, again it is not clear what this ‘positive outcome’ exactly is and the nnt still does not answer the question of the patient what the chances are to get better after treatment. transforming the effect size into the nnt is, however, done by many meta-analyses to make the outcomes easier to interpret from a clinical point of view. moving to binary outcomes? binary outcomes are easier to understand than effect sizes. for example, in a trial the re­ searchers can calculate the proportion of participants that respond (for example defined as a 50% reduction in symptoms from baseline to post-test) in the treatment and control group. they can also calculate the proportion of participants who recover completely (for example by scoring below a cut-off on a symptom measure), who reliably improved, or who reliably deteriorated, or dropped out from treatment. these binary outcomes can answer the question of the imaginary patient that we presented earlier very well. the patient will hear an exact chance of getting better after the treatment compared to no treatment. for example, we recently conducted a meta-analysis of psychotherapies for depres­ sion (cuijpers, karyotaki, de wit, & ebert, 2020) and found that the effect size for psychotherapy versus control conditions was g = 0.72, 95% ci [0.67, -0.78]. that is a considerable effect according to the criteria of cohen. but what does it really mean? has the time come to stop using the “standardised mean difference”? 4 clinical psychology in europe 2021, vol. 3(3), article e6835 https://doi.org/10.32872/cpe.6835 https://www.psychopen.eu/ what is the chance of getting better for a patient receiving therapy compared to the chance in the control conditions? in another recent meta-analysis, we calculated the ex­ act proportions of response (50% reduction of symptoms between baseline and post-test) (cuijpers, karyotaki, ciharova, miguel, noma, & furukawa, 2021) for psychotherapies with at least 10 trials for which the response rate was reported or could be estimated using a validated method (furukawa, cipriani, barbui, brambilla, & watanabe, 2005). we found that the response rate for psychotherapies was 41% (using the most conservative estimate), while the response rate was 17% in the usual care groups. this is definitely more informative for patients and clinicians than the effect size. it shows for example that about 60% of patients do not respond after therapy and that the proportion of patients responding to usual care is really very low. the effect size gives no indication at all for such outcomes. it just says that the effect are “large”, but this “hides” in a way that the majority of patients still don’t respond to treatment. disadvantages of binary outcomes so does this solve the problem? should we all move away from the effect size and instead use binary outcomes? unfortunately, binary outcomes also have problems. maybe the most important problem is that outcomes may be best considered as a continuous phenomenon and not as a binary outcome. one can use binary outcomes that are informative, such as response or remission, but that does not solve the problem that in principle outcomes are still continuous. another problem is that in individual trials binary outcomes have less statistical power to find significant differences between treat­ ment and comparison conditions. furthermore, there is no way to decide what the best binary outcome is. in many trials on psychological treatments the reliable change index (rci) is used (jacobson & truax, 1991), a psychometric criterion used to evaluate whether the change between baseline and post-test is considered statistically significant (the difference between baseline and post-test means divided by the standard error of the difference between the two scores is greater than 1.96, conservatively assuming a cronbach’s alpha of 0.75) (jacobson & truax, 1991). other studies use the response (50% reduction in symptoms from baseline to post-test) or remission (scoring below a cut-off on a rating scale indicating the return to ‘normal’ functioning) as the main outcome. there is no way to decide what the most important binary outcome is and that may therefore vary widely across studies, making meta-analyses of these outcomes more complicated. but it also makes the answer to the question of the patient more complicated. it can be said what the chance of getting better is, but what getting better actually is, is not so clear. another problem with reporting the chance of getting better in the treatment and control conditions is that these chances can be very well reported for individual trials, but pooling them in meta-analyses may be problematic. the problem with exact percen­ cuijpers 5 clinical psychology in europe 2021, vol. 3(3), article e6835 https://doi.org/10.32872/cpe.6835 https://www.psychopen.eu/ tages is that when you pool them, the heterogeneity of the outcome is often very high. heterogeneity indicates the variability in the outcomes of the included studies in a meta­ analysis. if heterogeneity is too high that means that the outcomes are too different from each other to allow pooling. and that is typically the case when proportions are pooled. but on the other hand, these outcomes are so important for patients and clinicians, that one could make the case to pool anyway, but always say that the outcomes can vary considerably. usually, binary outcomes in meta-analyses are not reported in terms of absolute per­ centages, because of the high heterogeneity. in most cases binary outcomes are reported in terms of relative outcomes, such as the relative risk (rr) or the odds ratio (or). the or indicates the odds of getting better in the treatment group compared to the control group. this is also difficult to interpret, because it is not immediately clear what the odds are and it can be argued that the or should be avoided as well because it is not clear what it means (higgins & green, 2011). the rr is easier to interpret. an rr of 1.40 for example indicates that the chance of getting better is 40% higher in the treatment group than in the control group. sometimes the nnt is also used. the nnt is actually the inverse of the risk difference (rd). so if 60% get better in the treatment group and only 40% in the control group, the rd is 20% and the nnt is 5 (1/0.20). but all relative outcomes do not answer the question of the patients what the chances are of getting better after the treatment. in order to answer that, it cannot be avoided to give the actual chances. conclusion so should we stop using the effect size and instead move to reporting the proportions of participants who improve in the treatment and the control group? i don’t think that is needed. many studies already give the effect size and one or more binary outcomes. that is probably the best solution. but we should avoid to obscure outcomes by just saying that a treatment is effective and the effect size is large, moderate or small. 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(2014). standardization of depression measurement: a common metric was developed for 11 self-report depression measures. journal of clinical epidemiology, 67, 73-86. https://doi.org/10.1016/j.jclinepi.2013.04.019 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. has the time come to stop using the “standardised mean difference”? 8 clinical psychology in europe 2021, vol. 3(3), article e6835 https://doi.org/10.32872/cpe.6835 http://www.handbook.cochrane.org https://doi.org/10.1037/0022-006x.59.1.12 https://doi.org/10.1056/nejm198806303182605 https://doi.org/10.1001/jama.2014.13128 https://doi.org/10.7275/zqwr-mx46 https://doi.org/10.1037/0022-0663.74.2.166 https://doi.org/10.1016/j.jclinepi.2013.04.019 https://www.psychopen.eu/ has the time come to stop using the “standardised mean difference”? (introduction) the effect size what does the effect size mean? moving to binary outcomes? disadvantages of binary outcomes conclusion (additional information) funding acknowledgments competing interests twitter accounts references the effect of depression and hopelessness on suicidal risk in young people: the mediating role of impulsivity research articles the effect of depression and hopelessness on suicidal risk in young people: the mediating role of impulsivity anyerson stiths gómez-tabares 1 , olber eduardo arango-tobón 1 , césar núñez 2,3 , gastón adolfo zapata lesmes 4 [1] faculty of social sciences, health and wellness, universidad católica luis amigó, medellín, colombia. [2] psychology program, faculty of social and human sciences, universidad de medellín, medellín, colombia. [3] corporación apicsa, medellín, colombia. [4] faculty of social sciences, health and wellness, universidad católica luis amigó, manizales, colombia. clinical psychology in europe, 2025, vol. 7(2), article e11331, https://doi.org/10.32872/cpe.11331 received: 2023-02-07 • accepted: 2024-11-02 • published (vor): 2025-05-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: anyerson stiths gómez-tabares, faculty of social sciences, health and wellness, psychology program, universidad católica luis amigó, tv. 51a #67b 90, colombia, medellín, antioquia. postal code 050034. phone: +57 (604) 4487666. e-mail: anyerspn.gomezta@amigo.edu.co supplementary materials: materials [see index of supplementary materials] abstract background: previous studies have documented that depression and hopelessness predict higher suicide risk in young people. however, the psychological mechanisms that may mediate these associations are unknown. the aim of this study was to analyze the effects of depression, hopelessness, and impulsivity on suicidal attempts and risk, and to explore the mediating role of impulsivity in these associations. method: a total of 1,645 young people participated with a mean age of 21.604 years (sd = 3.22) (68.8% female and 31.2% male). a sociodemographic form was applied to explore suicide attempts in the last year (sa), the plutchik suicide risk (sr), beck hopelessness (bhs), barratt impulsivity (bis), and beck depression inventory (bdi) scales. direct correlations were found among bhs, bdi, bis, sa, and sr. results: the binary regression model showed that the variables bhs, bdi, and bis explained between 33% and 49% of the variance of suicidal risk and 16% of the variance of suicide attempts. structural equation analysis showed that impulsivity mediated the associations between depression, hopelessness, and suicidal risk, on the one hand, and mediated the associations between depression and suicide attempt, on the other hand, whose total direct and indirect effects were statistically significant. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11331&domain=pdf&date_stamp=2025-05-28 https://orcid.org/0000-0001-7389-3178 https://orcid.org/0000-0002-9831-5734 https://orcid.org/0000-0001-8925-993x https://orcid.org/0000-0002-8869-7644 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: the findings emphasize the importance of impulsivity as the mechanism influencing interactions between mood indicators and suicidal behavior in young populations. keywords suicide, impulsivity, depression, emotions, risk highlights • depression and hopelessness have been identified as significant predictors of suicidal behavior in young people. • the effect of depression and hopelessness on suicidal behavior is mediated by impulsivity. • the effect of depression, hopelessness, and impulsivity on suicidal behavior showed invariance by sex (male/female). according to the global health estimates report (who, 2021), suicide is the fourth lead­ ing cause of death worldwide in young people aged 15-19 years. previous attempts have been reported to be the most important risk factor for suicide in the general population. according to the institute of legal and forensic medicine in colombia 2,952 suicides were registered, and the annual rate corresponds to 6,16 cases per 100,000 inhabitants in 2022 (national institute of legal medicine and forensic sciences, 2023). several current systematic reviews have identified a broad set of risk factors associ­ ated with suicide, including social isolation, mental disorders, alcohol abuse, family-rela­ ted events, information processing styles, and deficits in neuropsychological functions (ati et al., 2021; gonzález sancho & picado cortés, 2020; hernández-bello et al., 2020). nevertheless, the role of personality factors, such as impulsivity, remains under investi­ gation. the current evidence is inconsistent regarding the mediating role of impulsivity among depression, hopelessness, suicide attempts, and suicidal behavior. research on cognitive processing has found that hopelessness plays an important role in suicidal risk and behavior and has a mediating role between depressive symptoms and suicide attempts in adults and youth (choi & shin, 2023; dat et al., 2021). horwitz et al. (2017) found that hopelessness is a longitudinal predictor of depression in youth at high suicidal risk. their study suggests that lack of positive expectations is the most significant predictor of depression and future suicidal behavior, as hopelessness magnifies depressive symptoms, which in turn increases the likelihood of suicide, espe­ cially when combined with loss of social connectedness and loneliness. indeed, negative circumstances related to stressors in various roles, such as family conflicts, lack of support networks, or social pressure, can influence the development of suicidal ideation (dutton et al., 2013; puzia et al., 2014). these factors align with joiner's (2005) theory, which posits that the perception of being a burden to others (e.g., family, the mediating role of impulsivity in suicidal risk 2 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ friends, or society) is associated with both an increased risk of suicide and the acquired capability for suicide. in this context, path analyses proposed by dat et al. (2021) in a sample of 322 young college students demonstrated that hopelessness functions as a mediator of the effect of self-esteem and social anxiety, intensifying depressive symptoms and suicidal ideation. additional studies have indicated that hopelessness is a predictor of depression (choi & shin, 2023), and both psychological factors would strongly predict suicidal risk in young populations (gómez-tabares et al., 2024; núñez et al., 2023). some studies have approached risk factors from a direct effect and mediation ap­ proach to suicidal behavior, noting the importance of recognizing the interaction of these elements in the mechanism that predicts suicide. similarly, wang et al. (2015) found that hopelessness, depression, and impulsivity contribute significantly to the development of suicidal risk and behavior, but such contribution depends on how these factors inter­ act with each other. in their study, they concluded that hopelessness mediated by the severity of depression has an indirect effect on suicidal ideation because hopelessness is not a direct cause of suicidal behavior and only gains strength when mediated by depressive symptomatology. this mechanism of direct and indirect effects is dependent on high or moderate levels of impulsivity in patients with depression since these patients with greater impulsivity are more likely to increase suicide attempts and display suicidal behavior in general. therefore, an important construct in the interaction of suicide risk factors is impul­ sivity. current evidence suggests that impulsivity is a significant component of suicidal behavior and plays an important role in the transition from suicidal ideation to suicide attempt (beach et al., 2022; cole et al., 2019). zhang et al. (2022), in a community sample of 480 college students, examined the effect of impulsivity on suicidal ideation by depression. the results indicated that impulsivity had an indirect but mediating effect on depression and concluded that the higher the students' impulsivity, the stronger the predictive effect of depression on suicidal ideation. other studies indicate that people with higher impulsivity scores report significantly more suicide attempts than patients with lower impulsivity scores (mann et al., 1999). however, in a meta-analysis conducted by anestis et al. (2014), the central role of impul­ sivity in suicide attempts and risk is questioned, noting that impulsivity is a distal risk factor that modulates the effect of more direct factors such as precipitating experiences that increase suicide in individuals. literature has indicated that depression and hopelessness may interact with impulsiv­ ity to generate an increased risk for suicidal attempts and behaviors (arango-tobón et al., 2021; dumais et al., 2005; swann et al., 2008). arango-tobón et al. (2021) points out that impulsivity is a mediator between depression and suicidal behavior and acts as a trigger and determinant of suicide in young people. gómez-tabares, arango-tobón, núñez, & zapata lesmes 3 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ given the above, further evidence on the mediating role of impulsivity between depression and hopelessness may generate better assessment processes for the identifica­ tion of suicidal behaviors and better ways to intervene early in short-term suicide risk indicators during youth. the present study aimed to explore whether impulsivity plays a mediating role between depression and hopelessness concerning suicide attempts and risk. we hypothesized that 1) both depression and hopelessness have significant direct effects on suicide attempts and risk, but 2) impulsivity as a mediator between depression and hopelessness amplifies their direct or indirect effects on suicide attempts and risk in young people. method participants a stratified random probability sampling by academic semesters from three private universities in manizales and medellín (colombia) was used. a total of 2,580 students were invited to participate voluntarily in this study. a total 935 people did not participate in the study for the following reasons: minors (<18 years of age) who did not provide informed parental consent (n = 92), were absent on the day of data collection, or did not want to participate in the study (n = 175), did not complete all the questionnaires admin­ istered or left more than five items in a row unanswered in one or more instruments (n = 668). the main inclusion criterion is that they were young people between the ages of 18 and 30 since the highest suicide rates in colombia occur among young people aged 18 and 19 (10.43 per 100,000 inhabitants), 20 to 24 (9.98 per 100,000 inhabitants) and 25 to 29 (8.16 per 100,000 inhabitants) (instituto nacional de salud, 2023). in addition, the highest incidence of suicide attempts also occurs in the young population and has increased systematically in the last five years in the cities of manizales and medellin, co­ lombia. furthermore, the highest incidence of suicide attempts is observed in the young population, with a notable increase over the past five years in the cities of manizales and medellín, colombia. the final sample consisted of 1,645 young people attending three private universities in two colombian cities, manizales (n = 992, 60.3%), and medellín (n = 653, 39.7%). in terms of sex, 1,131 were women (68.8%) and 514 were men (31.2%). the mean age was 21.604 years (sd = 3.22). regarding the socioeconomic level, 24.4% belonged to the lower level, 65.5% to the middle level, and 10.2% to the upper level. 62.2% reported not having a partner, 30.9% reported having a partner relationship, 3.5% lived with their partner, 2.1% were married and 0.9% reported no information. participants from both cities were from urban areas and did not differ in terms of socioeconomic status (z = -0.894, p = .371). the mediating role of impulsivity in suicidal risk 4 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ there were no indigenous or rural populations. the results section describes the mental health indicators of the youth reported from the instruments. instruments ad hoc sociodemographic form this self-administered form collected data on participants' age, sex, place of residence, socioeconomic status, history of suicide attempts, and number of such attempts. the variable corresponding to suicide attempts was obtained from self-reports of at least one attempt in the past year, assessed using a dichotomous response format (yes/no). responses were coded numerically, assigning a value of 0 to a no response and 1 to a yes response. plutchik suicide risk scale (sr) it is a likert-type instrument designed to assess the risk of suicide attempts (plutchik & van praag, 1989). it includes 15 items, each with dichotomous response options (yes/ no). affirmative responses are scored with one point, resulting in a maximum score of 15. a score above 6 suggests the presence of suicidal risk (rubio et al., 1998). the scale is frequently used in research with young population in colombia (gómez-tabares, 2020; gómez-tabares et al., 2024; núñez et al., 2023; suárez-colorado et al., 2019), dem­ onstrating internal consistency with cronbach's alpha values above 0.75. for this study, internal consistency between 0.77 (cronbach's alpha) and 0.82 (mcdonald's omega) was evidenced. confirmatory factor analysis (cfa) showed that the scale was a good fit for a unidimensional model of suicide risk (gfi = 0.972, agfi = 0.960, rmsea = 0.043). beck hopelessness scale (bhs) it is a screening instrument to detect feelings of hopelessness associated with depression and suicide risk. it was developed by beck et al. (1974) and consists of 20 dichotomous (true/false) items reflecting cognitive and emotional components of hopelessness. scores range from 0 to 20, with higher scores indicating greater severity of hopelessness. the scale allows the severity of hopelessness to be classified as minimal (0 to 3), mild (4 to 8), moderate (9 to 14), and severe (15 to 20). validation studies conducted with the colombian population report a cronbach's alpha between 0.82 and 0.93, test-retest reliability coefficients between 0.60 and 0.69 (rueda-jaimes et al., 2018), and optimal fit for a unidimensional structure (cfi = 0.99, rmsea = 0.03) (pineda-roa et al., 2024). the internal consistency for this study was .84 (cronbach's alpha) and .88 (mcdonald's omega). confirmatory factor analysis was also conducted and indicated that the data were consistent with a unidimensional model (gfi = 0.973, agfi = 0.964, rmsea = 0.033). gómez-tabares, arango-tobón, núñez, & zapata lesmes 5 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ beck depression inventory (bdi) it is a 21-item self-report measure designed to assess the severity of depressive symptoms (beck et al., 1979). it assesses affective, cognitive, physiological, and behavioral aspects of depression. each item is scored on a scale of 0 to 3, with a total score ranging from 0 to 63. higher scores indicate greater severity. the inventory allows the classification of de­ pressive symptoms into minimal (0 to 9), mild (10 to 16), moderate (17 to 29), and severe (30 to 63). studies conducted with university students in colombia have shown internal consistency with cronbach's alpha values between 0.88 and 0.92 (arango-tobón et al., 2021; núñez et al., 2023). in this study, internal consistency was 0.89 (cronbach's alpha) and 0.91 (mcdonald's omega). confirmatory factor analysis supported a unidimensional structure with good fit indices (gfi = 0.967, agfi = 0.959, rmsea = 0.035). barratt impulsivity scale, v. 11 (bis-11) this is a self-report likert-type scale designed to assess impulsivity as a behavioral trait (patton et al., 1995). the linguistic equivalence of the bis-11 has been demonstrated for use in spanish-speaking population (oquendo et al., 2001). the scale consists of 30 items on a 4-point scale (rarely or never, occasionally, often, and always or almost always). studies conducted with colombian adolescent and adult populations have demonstrated acceptable internal consistency for the total scale score, reporting cronbach's alpha values between 0.75 (urrego barbosa et al., 2017) and 0.795 (chachín pinzón et al., 2019). additionally, stanford et al. (2009) highlighted the use of a score of 74 in psychological studies to identify impulsivity. the internal consistency for this study was 0.75 (cron­ bach's alpha) and 0.79 (mcdonald's omega). confirmatory factor analysis supported a unidimensional structure with acceptable goodness-of-fit indices (gfi = 0.943, agfi = 0.931, rmsea = 0.040). procedure and ethical aspects the recruitment of participants did not involve any specific clinical criterion and was carried out through the modality of subjects available in the classrooms, according to the stratification by academic semester of three university institutions in the cities of manizales and medellin, colombia. after the application of the informed consent form and on a voluntary basis, the young people filled out the instruments manually with pencil and paper. the study was approved by the ethics committee of the universidad católica luis amigó and the corporación coetika, manizales, colombia. it was research without risk for the participants (resolution 8430 of 1993) and was ethically oriented in law 1090 of the colombian college of psychologists regarding the exercise of research. law 1266 of 2008; law 1581 of 2012 and decree 1377 of 2013 regarding the handling of personal data were taken into account when considering the criteria for the collection, handling, and special protection of personal data and the use of information for academic research the mediating role of impulsivity in suicidal risk 6 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ purposes. although the sampling did not include specific clinical criteria, young people who showed an indicator of suicidal risk according to the plutchik scale were referred to the university welfare service for counseling and psychological support. data analysis data analysis was performed using spss version 25.0. first, a descriptive analysis of the socio-demographic characteristics of the sample was carried out. the internal consisten­ cy of the instruments was confirmed using cronbach's alpha and mcdonald's omega coefficients. the instruments were also tested for fit to a unidimensional structure from confirmatory factor analysis (cfa) (byrne, 2016). descriptive and frequency statistics were calculated for the suicide risk, suicide attempt, depression, hopelessness and impul­ sivity variables. kolmogorov-smirnov and chi-squared (χ2) tests were used to assess the distribution of the data, which showed that they were not normally distributed. the mann-whitney u test was used to compare scores for suicide risk and attempt, depression, hopelessness and impulsivity by sex on the one hand, and suicide risk factor on the other. the p-value was reported and effect sizes were calculated for these compar­ isons. the eta-squared (η2) was used as a measure of effect size (small (0.01), medium (0.06) and large (0.14) (fritz et al., 2012). spearman's rho was used to assess correlations between the variables of depression, hopelessness and impulsivity and suicide risk and attempt. two path analysis models were then developed to estimate the standardized direct and indirect effects between the variables. these models were analyzed using generalized least squares. bootstrapping with a 95% confidence interval was used to estimate total, direct, and standardized indirect effects (byrne, 2016). model fit was assessed by probability χ2 (p ≥ .05), χ2/df (values < 3), and additional fit indices including comparative fit index (cfi ≥ 0.90), incremental fit index (ifi ≥ 0.90), tucker-lewis index (tli ≥ 0. 90), goodness of fit index (gfi ≥ 0.90), adjusted goodness of fit index (agfi ≥ 0.90), normed fit index (nfi ≥ 0.90), and root mean square error of approximation (rmsea ≤ 0.08) (byrne, 2016; schermelleh-engel et al., 2003). finally, a multigroup analysis was performed to test the invariance of the structural model between sexes (male/female). the δcfi criterion was used to assess model equivalence, with a change equal to or less than 0.01 (δcfi ≤ 0.01) supporting invariance (cheung & rensvold, 2002). path and multigroup analyses were performed in amos v. 24.0 software. results regarding the most relevant mental health indicators reported, a suicide risk factor was found in 26.7% of the young people and a history of a previous suicide attempt in 13.2%. it was also found that 36% of the young people reported some symptoms of depression gómez-tabares, arango-tobón, núñez, & zapata lesmes 7 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ and 27.2% reported indicators of hopelessness (supplementary materials, table 1). we found that women had higher scores than men in suicidal risk and depression. when assessing the effect size of significant sex differences, a small effect size was identified. no differences were found between men and women in suicide attempts, hopelessness, and impulsivity (supplementary materials, table 2). a comparative analysis of psychological variables as a function of suicide risk and attempt was performed (see table 1). the young people who presented a suicide risk factor showed higher scores in depression, hopelessness, and impulsivity compared to the group without risk. additionally, youth who reported any suicide attempt in the last year presented higher scores in suicidal risk, depression, hopelessness, and impulsivity compared to the group with no history of attempts. all differences were statistically significant (p < .001). table 1 differences according to suicide risk and attempt and the variables of depression, hopelessness, and impulsivity variable m sd ar mdn m sd ar mdn z p η2 without risk with risk test statistic suicide attempt 1.02 0.15 734.29 1.00 1.43 0.50 1065.93 1.00 -21.385 < .001 0.278 depression 6.11 5.42 666.59 5.00 17.38 9.59 1251.35 17.00 -22.136 < .001 0.298 hopelessness 2.03 2.11 705.20 2.00 5.49 4.48 1145.60 4.00 -16.872 < .001 0.173 impulsivity 47.48 12.37 715.19 46.00 59.41 13.55 1118.25 60.00 -15.237 < .001 0.141 without suicide attempt with suicide attempt test statistic suicide risk 3.08 2.46 733.72 3.0 7.76 2.23 1410.53 8.0 -19.683 < .001 0.236 depression 8.12 7.64 772.63 6.0 15.70 10.24 1154.44 15.0 -11.050 < .001 0.074 hopelessness 2.68 2.99 789.14 2.0 4.80 4.48 1045.85 3.0 -7.519 < .001 0.034 impulsivity 49.52 13.23 785.47 48.0 58.29 14.65 1069.99 58.0 -8.223 < .001 0.041 note. m = mean; sd = standard deviation; mdn = median; ar = average range; η2 = eta square. table 2 shows the results of the correlational analysis of the various study variables using spearman's rho coefficient. suicide risk and attempt correlated directly and signifi­ cantly (p < .001) with depression, hopelessness, and impulsivity. table 3 presents two binary logistic regression models using the input method, in order to identify the role of depression, hopelessness, and impulsivity variables on the variance of suicide risk and attempt. the first model used the suicide risk factor and the second the history of a suicide attempt as a dependent variable. depression, hopeless­ ness, and impulsivity were the independent variables. both the first model, as assessed by the hosmer-lemeshow test (χ2 = 7.830, df = 8, p = .750), and the second model (χ2 = 12.744, df = 8, p = .521), presented good indicators of goodness of fit. the mediating role of impulsivity in suicidal risk 8 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ table 2 spearman correlation coefficient (rho) between suicide risk and attempt and the variables of depression, hopelessness, and impulsivity variable 1 2 3 4 5 1. suicide risk – 0.485** 0.679** 0.461** 0.474** 2. suicide attempt – 0.273** 0.185** 0.203** 3. depression – 0.516** 0.432** 4. hopelessness – 0.362** 5. impulsivity – **p < .001. table 3 binary logistic regression analysis: suicide risk factor and suicide attempt as dependent variables variable β se χ2 wald df p or 95% ci for or ll ul model 1. suicide risk factor as a dependent variable depression 0.153 0.012 169.694 1 < .001 1.166 1.139 1.193 hopelessness 0.130 0.027 22.395 1 < .001 1.138 1.079 1.201 impulsivity 0.036 0.006 36.967 1 < .001 1.036 1.025 1.048 model 2. suicide attempt history as a dependent variable depression 0.069 0.011 41.677 1 < .001 1.072 1.050 1.095 hopelessness 0.006 0.025 0.065 1 0.799 1.007 0.958 1.058 impulsivity 0.025 0.006 16.511 1 < .001 1.025 1.013 1.038 the first model showed that the independent variables explained between 33% (r2 cox and snell = 0.334) and 49% (r 2 nagelkerke = 0.486) of the suicide risk factor and the second model explained between 8% (r 2 cox and snell = 0.084) and 16% (r 2 nagelkerke = 0.156) of the variation in a suicide attempt. the odds ratios (or) show how much the probability of belonging to the suicide risk and attempt categories increases according to the variance of the independent variables. in model 1, depression, hopelessness, and impulsivity increased the suicide risk factor. for model 2, depression and impulsivity contributed a significant effect that increased the probability of suicide attempts. hopelessness did not contribute a significant effect on a suicide attempt. to establish the total, direct and indirect standardized effects of the independent variables on suicide risk and attempt, two structural equation models were estimated using the generalized least squares method (byrne, 2016). in the first model, the direct ef­ gómez-tabares, arango-tobón, núñez, & zapata lesmes 9 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ fect of the dependent variables depression, hopelessness, and impulsivity on suicide risk and suicide attempt was estimated, but it did not yield good goodness-of-fit indicators at the χ2 probability level and the rmsea indicator, so the model was re-specified to improve goodness-of-fit indicators and establish patterns of association with mediating variables. in model 2, impulsivity was used as a mediating variable between depression, hopelessness, suicidal risk, and suicide attempts. additionally, suicide attempt was placed as a mediator between impulsivity and suicidal risk. this model obtained better good­ ness-of-fit indicators (see table 4). additionally, a sex invariance analysis was performed in order to corroborate whether model 2 is equivalent between males and females (see table 4). table 4 goodness-of-fit statistics of structural models for predicting suicide risk and suicide attempt χ2 df χ2/df ifi cfi nfi tli gfi agfi rmsea model model 1 15.618 2 7.809 0.984 0.984 0.982 0.921 0.996 0.971 0.064 model 2 1.010* 1 1.010 1.000 1.000 0.999 1.000 0.999 0.996 0.002 invariance by sex (male/female) of model 2 without restrictions 1.020* 2 0.510 1.001 1.000 0.999 1.011 0.999 0.996 0.000 structural weights 6.933* 10 0.693 1.004 1.000 0.992 1.007 0.998 0.995 0.000 structural covariance 8.768* 13 0.674 1.005 1.000 0.990 1.008 0.998 0.995 0.000 structural waste 10.070* 16 0.629 1.007 1.000 0.988 1.009 0.998 0.995 0.000 *p ≥ .05. table 4 shows the goodness-of-fit indices of model 2, with different levels of restriction to assess sex invariance (male/female). when comparing the differences in cfi, values of δcfi ≤ 0.010 were observed, demonstrating the sex invariance of the proposed model. figure 1 shows that the variables: depression, hopelessness, impulsivity, and previous suicide attempt explained 66% (r 2 = 0.655, p < .001) of the variation in suicidal risk. depression and impulsivity variables contributed significant effects on suicide attempts (r 2 = 0.101, p < .001), and depression and hopelessness variables explained 21% (r 2 = 0.206, p < .001) of the variation in impulsivity. likewise, it was found that impulsivity mediated the association between depression, hopelessness, and suicidal risk, on the one hand, and mediated the association between depression and suicide attempt, on the other hand, whose total direct and indirect effects were statistically significant (p < .001) (see table 5). the mediating role of impulsivity in suicidal risk 10 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ figure 1 structural equation modeling of suicide risk and attempt and the mediating role of impulsivity impulsivity suicide risk e2 e1 r2 = .66** r2 = .21** β = .12** β = .37** depression hopelessness .63** suicide attempt e3 r2 = .10** β = .35** **p < .001. table 5 standardized total, direct and indirect effects of predictor variables on response variables effect impulsivity (mediator) suicide attempt (mediator) suicide risk value β ci 95% value β ci 95% value β ci 95% ll ul ll ul ll ul hopelessness total 0.122** 0.066 0.179 0.012** 0.005 0.022 0.141** 0.100 0.181 direct 0.122** 0.066 0.179 – – – 0.116** 0.077 0.156 indirect – – – 0.012** 0.005 0.022 0.024** 0.013 0.037 depression total 0.367** 0.311 0.420 0.297** 0.241 0.351 0.621** 0.582 0.659 direct 0.367** 0.311 0.420 0.260** 0.199 0.320 0.458** 0.416 0.499 indirect – – – 0.037** 0.017 0.058 0.163** 0.138 0.189 impulsivity total – – – 0.101** 0.046 0.154 0.199** 0.162 0.236 direct – – – 0.101** 0.046 0.154 0.165** 0.131 0.199 indirect – – – – – – 0.035** 0.016 0.054 suicide attempt total – – – – – – 0.346** 0.311 0.380 direct – – – – – – 0.346** 0.311 0.380 indirect – – – – – – – – – **p < .001. gómez-tabares, arango-tobón, núñez, & zapata lesmes 11 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ table 5 shows the total, direct and indirect standardized effects of the independent, mediating and dependent variables. depression contributed the largest total effect on im­ pulsivity, suicide attempt, and suicidal risk. likewise, impulsivity is a mediator between depression and hopelessness, whose indirect effects were significant (p < .001). since all direct and indirect effects are statistically significant, it can be concluded that the mediation effect of the impulsivity and suicide attempt variables is partial. discussion the aim of the present study was to examine the role of impulsivity relative to depres­ sion and hopelessness in suicidal attempts and risk. we hypothesized that 1) depression, hopelessness, and impulsivity have direct effects on suicide risk and attempts, but the mechanism of influence among these predictors may not be the same as when analyzed together, and, therefore, 2) impulsivity may play a mediating role between depression and hopelessness and this role amplifies their direct or indirect effects on suicidal attempts and risk in youth. according to the results of our study, it is clear that depression, hopelessness, and impulsivity represent significant predictors and have effects on suicidal risk. regarding our first hypothesis, the analyses suggest that people with greater depressive symptoms, feelings of hopelessness, and impulsivity are at greater risk of attempts and, thus, suicidal risk. these findings are consistent with the results of other studies in which lack of premeditation or difficulties in planning before making decisions, depressive symptoms, and hopelessness have been found to be direct predictors of suicide attempts in young people (valderrama & miranda, 2017; yen et al., 2009). however, when analyzing the direct effects of depression, hopelessness, and impul­ sivity on suicidal attempts and risk, the model did not show optimal goodness-of-fit indicators (model 1, table 4). these results may indicate that although the existence of different significant predictors of suicidal behavior is clear as suggested by several meta-analyses (ati et al., 2021; gonzález sancho & picado cortés, 2020; hernández-bello et al., 2020), these results may vary when analyzing the mechanisms by which these factors, along with others related to interpersonal functioning, interact (joiner et al., 2009; o’connor & nock, 2014). specifically, the perception of an inability adequately take responsibility for others, coupled with cognitions associated with dysfunctional affective bonds with other people or the social environment, plays a significant role (van orden et al., 2010). this finding is consistent with wang et al. (2015), who demonstrated that the interac­ tion between depressive symptoms and impulsivity can significantly predict suicide risk. furthermore, they found that impulsivity moderated the relationship between depression and suicide risk. in our study, impulsivity showed the strongest clear relationships with suicidal risk (r = 0.47) and depression (r = 0.43), indicating that people with more severe the mediating role of impulsivity in suicidal risk 12 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ depression tend to be more impulsive and have higher suicidal risk. this is consistent with studies that have analyzed risk factors and mediating effects between impulsivity and suicidal risk (dvorak et al., 2013; gómez-tabares et al., 2020). this mechanism of interaction effects between depressive symptoms, feelings of hopelessness, and impulsivity with respect to suicidal risk and behavior has been ad­ dressed in different research (javdani et al., 2011; koyama et al., 2020; liu et al., 2020; zhang et al., 2022) and indicates that the mediating effect of impulsivity is an important bridge between the relationships of depression and hopelessness. regarding our second hypothesis, our study confirmed that those participants with higher suicide risk were those in whom depressive symptoms and hopelessness were mediated by impulsivity traits, in other words, impulsivity plays a mediating role between depression and hope­ lessness, and such a role increases the effect of both predictors on suicide risk. in addition, it was shown that the proposed model remains invariant when sex differences (male/female) are taken into account, reinforcing the idea that impulsivity is a strong psychological mechanism mediating the interactions between indicators of depression hopelessness, and suicidal behavior in a young population. indeed, the results of suicidal ideation have shown significant indirect effects with risk behavior through impulsivity and low desire to live, but not through hopelessness (smith & wells, 2023), which leaves an interesting axis of research given that ideation and risk behaviors are associated with each other through impulsivity and desire to live. meanwhile, our findings add to the knowledge so far of the mediating effect of impulsivity with respect to depression and hopelessness on suicidal attempts and risk and we can conclude that high levels of trait impulsivity increase the effect of depres­ sion and hopelessness on suicidal behavior, which is consistent with empirical evidence from cross-sectional and longitudinal studies where the mediating role of impulsivity on depression and hopelessness has been studied (arango-tobón et al., 2021; wang et al., 2015). on the other hand, we found that impulsivity is also a mediator in the relationships between depression and suicidal attempts, an aspect that is often related to the association of reiterative death ideation and the presence of suicidal attempts (sohn et al., 2021). now, the correlations we found between impulsivity and suicidal intent are low but significant (r = 0.2) and may indicate that impulsivity has a direct effect on suicidal intent that consequently generates higher suicide risk in young people. findings from studies such as that of zhang et al. (2022) support the conclusion that individuals exhibiting impulsivity traits increase attempts and overall suicidal risk more. having depressive symptoms and impulsivity traits maximizes the individual or joint effect of depression and hopelessness on suicidal behavior. although the data collected allowed us to test the two central hypotheses of our study, it is important to point out some limitations. 1) the cross-sectional design and the unknown predictive validity of the probability of suicide in the sample reduces the gómez-tabares, arango-tobón, núñez, & zapata lesmes 13 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ explanatory capacity of our model on the mediating role of impulsivity in populations of young university students. although there are advances in predictive models related to impulsivity, ideation, and suicidal risk (beach et al., 2022), new studies that increase the explanatory capacity of statistical models that involve impulsivity as a mediator of suicidal risk are worthwhile. in this regard, it is necessary to consider that the study did not consider specific clinical aspects of physical and mental health as inclusion criteria, which may be expanded for analysis in future studies. indeed, as proposed by joiner (2005), ma et al. (2016), baertschi et al. (2017), and chu et al. (2017), it is also necessary to examine other interpersonal variables to deter­ mine whether they moderate or mediate the relationship with suicide risk (chu et al., 2016; o’connor & portzky, 2018). while the study's results show promise in explaining how impulsivity mediates the effect of depression and hopelessness on suicide risk, further exploration of the relationship with interpersonal variables in future studies may enhance the predictive scope for suicidal behavior (joiner et al., 2009; puzia et al., 2014). it is therefore suggested that these findings should be interpreted carefully and that more longitudinal studies are needed to provide predictive evidence of suicide and of the mediating or moderating role of impulsivity. 2) the use of self-report measures to establish depressive symptoms, hopelessness, and impulsivity may represent a bias in the information analyzed since self-reports are based on self-awareness and recall of behavioral patterns related to suicidal attempts and risk. 3) the sample is composed of young university students, and it is not clear that our results can be generalized to other populations, so it is suggested that this study could be replicated in other clinical or non-clinical samples. it would be desirable for future studies to analyze not only trait impulsivity but also impulsivity as a state, in order to analyze the effect that impulsivity as a psychological or neuropsychological characteristic may have on depression and hopelessness. finally, it is suggested, as proposed by anvar et al. (2022), to analyze im­ pulsivity in relation to the severity of emotional fluctuation, uncontrollability, dynamic course, and affective and cognitive precursors of suicidal ideation and suicide attempts. the mediating role of impulsivity in suicidal risk 14 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ funding: this study was funded by the universidad católica luis amigó, medellín, colombia [05020299123]. acknowledgments: the authors would like to extend their gratitude to the study participants for their invaluable collaboration in completing the instruments, which were instrumental in obtaining information on the research variables. competing interests: the authors declare that they have no competing interests. ethics statement: the study was approved by the ethics committee of the universidad católica luis amigó (colombia) in april 2022, through file number 65450. informed consent was obtained from all participants to participate in this study. reporting guidelines: the jars-quant guidelines for non-experimental quantitative research were followed in this study. preregistration: this study is not pre-registered. the study was registered at the universidad católica luis amigó, medellín, colombia [05020299123]. data availability: data supporting the conclusions of this study are available upon reasonable request to the corresponding author. data are not publicly available due to ethical restrictions on informed consent. supplementary materials the supplementary materials contain the following items (for access, see gómez-tabares et al., 2025s): • supplementary table 1: indicators of mental health events (suicide risk and attempt, depression, hopelessness, and impulsivity) • supplementary table 2: sex differences in suicide risk and attempt, depression, hopelessness, and impulsivity index of supplementary materials gómez-tabares, a. s., arango-tobón, o. e., núñez, c., & zapata lesmes, g. a. 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(2022). impulsiveness indirectly affects suicidal ideation through depression and simultaneously moderates the indirect effect: a moderated mediation path model. frontiers in psychiatry, 13, article 913680. https://doi.org/10.3389/fpsyt.2022.913680 the mediating role of impulsivity in suicidal risk 20 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://doi.org/10.1017/s0033291721002117 https://doi.org/10.1016/j.paid.2009.04.008 https://doi.org/10.14349/rlp.2019.v51.n3.1 https://doi.org/10.1016/j.jad.2007.07.011 https://doi.org/10.15332/s1794-9998.2017.0002.01 https://doi.org/10.1016/j.psychres.2017.08.092 https://doi.org/10.1037/a0018697 https://doi.org/10.1016/j.jad.2015.05.001 https://www.who.int/publications/i/item/9789240026643 https://doi.org/10.1111/j.1600-0447.2009.01366.x https://doi.org/10.3389/fpsyt.2022.913680 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. gómez-tabares, arango-tobón, núñez, & zapata lesmes 21 clinical psychology in europe 2025, vol. 7(2), article e11331 https://doi.org/10.32872/cpe.11331 https://www.psychopen.eu/ the mediating role of impulsivity in suicidal risk (introduction) method participants instruments procedure and ethical aspects data analysis results discussion (additional information) funding acknowledgments competing interests ethics statement reporting guidelines preregistration data availability supplementary materials references paul emmelkamp becomes “ambassador of clinical psychology and psychological treatment” letter to the editor, commentary paul emmelkamp becomes “ambassador of clinical psychology and psychological treatment” maaike h. nauta 1 , thomas ehring 2 [1] department of clinical psychology and experimental psychopathology, university of groningen, groningen, the netherlands. [2] department of psychology, clinical psychology and psychological treatment, lmu munich, munich, germany. clinical psychology in europe, 2022, vol. 4(1), article e8303, https://doi.org/10.32872/cpe.8303 published (vor): 2022-03-31 corresponding author: maaike h. nauta, department of clinical psychology and experimental psychopathology, university of groningen, groningen, the netherlands. grote kruisstraat 2/1, 9712 ts groningen, the netherlands. e-mail: m.h.nauta@rug.nl paul emmelkamp is a scientist-practitioner pur sang. from the start of his career on, he has put an emphasis on the importance of integrating science and clinical practice, providing many important contributions to clinical psychology and psychological treat­ ment in europe and beyond. in 1975, paul obtained his phd on ‘the behaviou­ ral treatment of agoraphobia’ from the university of utrecht, where he had previously studied and com­ pleted his postdoctoral training in psychotherapy. he then moved to the university of groningen, starting as an assistant professor and being appointed as a full professor in clinical psychology and psychother­ apy in 1986. since 1996, he has been based as a university of professor of clinical psychology at the university of amsterdam. in 2006, paul received the very prestigious appointment as academy professor of the royal academy of arts and sciences (knaw). from 2013 to 2016, he then served as the rector of the netherlands institute for advanced studies (nias). he is currently a fellow at the institute for advanced studies in paris. paul emmelkamp (2018) (source: paul emmelkamp's own private collection) this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.8303&domain=pdf&date_stamp=2022-03-31 https://orcid.org/0000-0001-7694-1382 https://orcid.org/0000-0001-9502-6868 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ the main focus of paul’s research is to investigate the efficacy and effectiveness of psychological interventions, especially using randomized controlled trial methodology. since the earlier 70s, he has published more 70 randomized controlled trials together with a large number of national and international collaborators. since his early studies on agoraphobia, he has extended his work to cover other anxiety disorders, obsessive compulsive disorder, post-traumatic stress disorder, depression, burn-out, addiction, per­ sonality disorders, perpetrators of sexual violence, and childhood adhd and behavioral problems. his work is not limited to studies on adult populations, but also includes studies on children, adolescents and the elderly. having collaborated closely with him at different time points in his career (mn from 1996-2005; te from 2007 – 2012), we would like to share some impressions of paul emmelkamp as a scientist-practitioner that we think make him an excellent ambassador for eaclipt. readers may wonder what motivates a researcher to focus especially on one of the most challenging and time-consuming type of research in clinical psychology, i.e. mainly conducting clinical trials. in our impression, paul’s motivation has always been to conduct research that matters, that has a real impact on clinical practice. in particular, he is driven to develop and test treatments that can work for many different patients, not just for the highly motivated “yavis” (young, attractive, verbal, intelligent, and successful) patients or students with elevated levels of psychopathology, but in particular for those who typically get referred to mental health institutions, often with a variety of comorbidity and a long duration of mental health problems. when embarking on his career, he perceived psychotherapy as too elitist, and it has always been his mission to have psychotherapy available for all in need, including “the man in the street”. therefore, paul has conducted many rcts with “real-life” patients recruited within routine mental health settings, while at the same time ensuring rigorous methodology and the use of well-described treatment manuals. to study the effectiveness of treatments, paul made important contributions to manu­ alizing treatments. he was the first in the netherlands to break down treatments to manuals that were transparent and transferrable. the first aim was scientific: to define and consolidate the content of the treatments, so that therapists would adhere to the same set of interventions, and that patient would receive a similar treatment in one treatment condition in a trial. the side-effect of this has had a large impact on the field: once treatments were proven effective, they were transparently described, suitable for transfer to new therapists, and available for implementation. paul has contributed to the dissemination of many of such manuals. for paul, the most important quest is to establish scientific evidence of the effective­ ness of treatments, so that individuals with mental health problems can receive those treatments that have been proven effective. even though he has mainly conducted stud­ ies on cognitive behavioral therapy, he is not necessarily identified with this specific treatment orientation. “i am fine with anything, as long as it works” (interview at the ambassador of clinical psychology and psychological treatment: paul emmelkamp 2 clinical psychology in europe 2022, vol. 4(1), article e8303 https://doi.org/10.32872/cpe.8303 https://www.psychopen.eu/ dutch radio series noorderlicht in 2003). he keeps looking for the evidence (and also for the non-evidence, as illustrated by the book “failures in behavior therapy” co-edited with edna foa in 1983). as such, he likes to remain critical of the advances that have been made, to keep questioning things that seem “self-evident” without the data behind them, and to remain looking for further evidence. he is also not shy of – and even enjoys – raising controversial issues, playing the devil’s advocate, or pointing out that the emperor may actually not be clothed. if you are looking for a stimulating and contro­ versial discussion about the state of clinical psychology, invite paul to talk e.g. about the role of experimental psychopathology in clinical innovation, the use of non-clinical or analogue samples in clinical research, the ubiquitous claim of “novelty” in psychological interventions, or the rise of trademarked interventions. you may not necessarily agree with him on all these issues, but will certainly have a good and stimulating time! on the other hand, when a new promising treatment or treatment format is devel­ oped, paul may be among the first to start a trial investigating its efficacy. for example, he was one of the first to investigate e-health interventions and virtual reality therapy. he conducted trials investigating act or emdr when many cbt-oriented researchers in europe were still quite skeptical about these approaches. in addition, he has investigated interventions for mental health conditions that seem hard to implement, like interven­ tions for sexual offenders in the context of a forensic clinic. as a supervisor, paul is and has been an inspiration to many, and has motivated many to continue in his tradition of studying treatment effectiveness. he has supervised 45 phd students as well as numerous master students, bachelor students, and clinicians. he is a co-founder of the research school "experimental psychopathology" (epp), a graduate school and research network uniting epp researchers from various universities in the netherlands and flanders, and was the chair from its foundation in 1995 until 2014. the research school has contributed to the development of a strong and active research network. from the very beginning of his career, he has been building a strong network with colleagues across europe and beyond, starting with a seminal collaboration with edna foa and isaac marks in the 70s. similarly, he has also always been open to collaboration coming from outside of academia. when we were working with paul in groningen (mn) and amsterdam (te), most projects we collaborated on had actually been initiated by practitioners who wanted to answer a research question of relevance for their respective settings. topics ranged from evaluating treatments for ptsd in adults or for oppositional behavior in children in routine clinical settings to studying psychological consequences of a severe earthquake on emergency personnel in pakistan. his current fellowship in paris focuses on mental health interventions for refugees, a very timely and societal relevant topic. the networking and intensive collaboration that is characteristic of his research has certainly been facilitated by the fact that paul is a very approachable, open, and warm person, with a brilliant sense of humor, and an open door. in addition, paul has always nauta & ehring 3 clinical psychology in europe 2022, vol. 4(1), article e8303 https://doi.org/10.32872/cpe.8303 https://www.psychopen.eu/ been the opposite of a remote researcher in the ivory tower. instead, he has continued seeing patients as a therapist throughout his career, has trained and supervised gener­ ations of students and therapists in conducting psychological treatment. he has also provided service to many different institutions, nationally as well as internationally, as a committee member, advisor, or board member, e.g., hosting the eabct conference as president in the netherlands (1987 and 2014), and serving as president of the president of the international federation for psychotherapy from 2014-2018. last but not least, he is the founder of clinical psychology & psychotherapy and has been its editor since 1993. we are confident paul emmelkamp will prove being a wonderful ambassador for eaclipt. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. ambassador of clinical psychology and psychological treatment: paul emmelkamp 4 clinical psychology in europe 2022, vol. 4(1), article e8303 https://doi.org/10.32872/cpe.8303 https://www.psychopen.eu/ assessing diagnostic precision: adaptations of the hopkins symptom checklist (hscl-5/10/25) among tertiary-level students in norway research articles assessing diagnostic precision: adaptations of the hopkins symptom checklist (hscl-5/10/25) among tertiary-level students in norway børge sivertsen 1,2 , jens c. skogen 1,3,4 , anne reneflot 5 , marit knapstad 1 , otto robert frans smith 1,4,6 , leif edvard aarø 1 , benedicte kirkøen 4 , bengt oscar lagerstrøm 7, ann kristin skrindo knudsen 8 [1] department of health promotion, norwegian institute of public health, bergen, norway. [2] department of research & innovation, helse-fonna hf, haugesund, norway. [3] center for alcohol & drug research, stavanger university hospital, stavanger, norway. [4] centre for evaluation of public health measures, norwegian institute of public health, oslo, norway. [5] department of mental health and suicide, norwegian institute of public health, oslo, norway. [6] department of teacher education, nla university college, bergen, norway. [7] department for methodology and data collection, statistics norway, oslo, norway. [8] department of disease burden, norwegian institute of public health, bergen, norway. clinical psychology in europe, 2024, vol. 6(4), article e13275, https://doi.org/10.32872/cpe.13275 received: 2023-11-27 • accepted: 2024-08-01 • published (vor): 2024-12-20 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: børge sivertsen, department of health promotion, norwegian institute of public health, zander kaaes gate 7, 5018 bergen, norway. phone: +47 99 76 92 62. e-mail: borge.sivertsen@fhi.no abstract background: universities worldwide are witnessing a surge in mental health problems among students, particularly in anxiety and depression. the hopkins symptom checklist (hscl) is a popular screening tool, but its reliability in identifying mental disorders remains debated. the aim of this study was to evaluate the criterion validity of the hscl-25, hscl-10, and hscl-5 using 30day prevalence of major depressive episode (mde) and generalized anxiety disorder (gad) from a self-administered electronic version of the composite international diagnostic interview, fifth version (cidi 5.0), as the benchmark. method: data stem from a national survey targeting students in higher education in norway. in a 2023 follow-up study on mental disorders, 5,568 participants completed both the hscl-25 and the cidi. sex-specific optimal thresholds for all hscl versions in relation to mde and gad (from cidi) were determined using the youden index maximization. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.13275&domain=pdf&date_stamp=2024-12-20 https://orcid.org/0000-0003-4654-9296 https://orcid.org/0000-0003-0722-5440 https://orcid.org/0000-0003-0536-5271 https://orcid.org/0000-0003-0958-1596 https://orcid.org/0000-0002-6306-2239 https://orcid.org/0000-0001-5027-3611 https://orcid.org/0000-0003-2641-5477 https://orcid.org/0000-0002-1218-798x https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ results: the optimal cut-off values for detecting mde or gad with the hscl-25 were 1.96 for males and 2.20 for females, displaying a good balance between sensitivity and specificity. similar high and balanced sensitivity and specificity patterns were found for both the hscl-10 and hscl-5. however, all hscl versions overestimated prevalence rates compared to the selfadministered cidi. conclusions: all three hscl versions showed high criterion validity. the data indicate that hscl may be better as a screening tool than for precise estimation of mde and gad prevalence. for improved diagnostic accuracy, future hscl versions should incorporate functional impairment assessment. this update would bring the hscl into closer alignment with clinical diagnostic standards. keywords depression, anxiety, students, young adults, questionnaires, psychometrics highlights • this study assessed hscl's ability to detect anxiety and depression in norwegian college students. • a self-administered version of cidi was used as the gold standard for diagnostic accuracy. • all three hscl versions showed high criterion validity and good diagnostic precision. • hscl may be better as a screening tool than for precise estimation of mental disorders. universities and colleges worldwide are confronting a concerning rise in the incidence of mental health issues among their students, with projections significantly surpassing those observed in the general population (ibrahim et al., 2013; mccloud et al., 2023). recent systematic reviews on anxiety and depression have yielded a cumulative annual prevalence range of 25-30% among tertiary education students (chi et al., 2023; ibrahim et al., 2013; kou et al., 2012; sheldon et al., 2021). although diagnostic interviews maintain their status as the benchmark for mental disorder diagnosis (nordgaard et al., 2013; rettew et al., 2009), their demanding time and resource requirements hinder most researchers from incorporating comprehensive psychiatric interviews into their assessment battery. consequently, a substantial portion of investigations are constrained to incorporating brief survey questionnaires when evaluating mental health issues (auerbach et al., 2016). however, in order to obtain prev­ alence estimates that are as accurate as possible, it is important that the case-detection capabilities of these briefer questionnaires are thoroughly evaluated. also, considering the changing trends and disparities observed across age cohorts and research popula­ tions, it is imperative to re-examine previously established cut-off values to ensure that the case-detection capabilities are effectively validated for each distinct study population. hscl's diagnostic precision in tertiary students 2 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ in this context, a frequently employed survey instrument is the hopkins symptom checklist (hscl), initially devised during the 1950s as a clinical tool for assessing symptoms of several mental disorders. although the original iteration encompassed an extensive array of mental disorders, one of the most commonly used versions today is the hscl-25. this abbreviated version focuses on two symptom dimensions, anxiety and depression. however, the capacity of the hscl-25 to differentiate between these two conditions across different sexes is not fully established (sandanger et al., 1998; skogen et al., 2017). since the 1990s, the efficacy of hscl-25 in identifying cases has been examined a few times through comparisons with structured diagnostic interviews, suggesting that while hscl-25 performs adequately in detecting depression, the results for anxiety are more variable (sandanger et al., 1998; veijola et al., 2003). the hscl-25 uses a scoring range of 1 to 4, and to determine the commonly used mean hscl-25 score, the total score is divided by the item count. a traditional cut-off value of 1.75 is commonly employed to indicate major depressive disorder (glaesmer et al., 2014; sandanger et al., 1998; veijola et al., 2003). however, a recent spanish study has challenged this one-size-fits-all approach, proposing distinct optimal cut-off values for women (1.76) and men (1.84) (rodríguez-barragán et al., 2021). this suggests that sex-specific thresholds might be necessary for more accurate diagnosis, considering the different ways in which men and women experience and report mental health symptoms. further abbreviated iterations of the hscl have been developed, with both hscl-5 and hscl-10 now in widespread use. however, few studies have investigated the casedetection capability of these versions, and none have done so for males and females sepa­ rately. to the best of our knowledge, just one study has directly contrasted hscl-5 and hscl-10 against a structured diagnostic interview. a recent spanish study demonstrated good reliability and validity of both tools for detecting depression (rodríguez-barragán et al., 2023). additionally, a recent norwegian study assessed hscl-5's capacity for iden­ tifying cases in the general population, and its findings indicate that hscl-5 effectively identifies people with generalized anxiety disorder or major depressive disorder within this context (kirkøen et al., manuscript in preparation). based on these considerations, the objective of this current study is to assess the proficiency of hscl-25, hscl-10, and hscl-5 in detecting cases of major depressive episode (mde) and generalized anxiety disorder (gad) in a national sample of college and university students. our focus is on potential sex-specific cut-off values and differ­ ences, using a recently developed self-administered electronic version of the composite international diagnostic interview (cidi) 5.0. this approach aims to enhance the accura­ cy of case-detection and ensure that the nuanced mental health experiences of both sexes are adequately captured. sivertsen, skogen, reneflot et al. 3 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ method setting and participants the primary population for this study is derived from the norwegian shot study (students' health and wellbeing study), a nationwide survey that centres on students pursuing higher education. since 2010, four major surveys have been conducted, with the latest wave conducted in 2022. the shot2022 survey comprehensively explored a multitude of dimensions encompassing health and lifestyle. these dimensions included psychological distress, suicidality, life satisfaction, loneliness, sleep problems, sexual harassment, pain, physical exercise, alcohol and drug use, as well as demographic and educational parameters. comprehensive information concerning the shot study has been previously documented (sivertsen et al., 2019). during the survey period, shot2022 was distributed electronically via a web-based platform and was open for submissions from february 8 to april 19, 2022. invitations for participation were sent to all full-time norwegian students engaged in higher education, both within the country and abroad. extensive efforts were undertaken to increase awareness about the study through channels such as email, sms, and informational campaigns conducted by welfare organizations and educational institutions. a total of 169,572 students met the study's inclusion criteria, which required them to be full-time college or university students and hold norwegian citizenship. of these, 59,544 students completed the online questionnaire after receiving two reminders. this resulted in a re­ sponse rate of 35.1% (which did not differ between geographical regions). for the present study, the inclusion criteria specified that participants be between the ages of 18 and 35 years. consequently, a subset of 53,362 students within this age range was selected for analysis. when consenting to participate in the shot2022, students were given the option to express their interest in participating in a follow-up study on mental disorders. out of the total participants, 26,311 students consented to be a part of this follow-up study. to better reflect the sex distribution of the base study population, more male students were invited to participate in the cidi study. consequently, 16,418 students, officially registered as of january 2023, were invited. however, fewer male students consented to follow-up contact compared to females. this led to females comprising a higher proportion (70.4%) of the invitations for the cidi study. figure 1 illustrates the participation process for the current study. out of 9,552 students who provided valid responses on both the hscl-25 and at least one of the cidi diagnostic sections, half were randomly selected to complete the hscl-25 before the cidi. this resulted in a subset of 5,076 participants who provided valid scores on the hscl-25 and then completed the cidi. the remaining half completed the assessments in the reverse order. this deliberate sequencing was chosen to facilitate future investiga­ tions into the potential influences of the order of questionnaire administration on the reported results from the hscl-25. hscl's diagnostic precision in tertiary students 4 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ figure 1 participant flow in the study study population: all fulltime students in norway aged 18-35 years per january 2022 n = 164,716 shot 2022 sample students aged 18-35 years n = 53,362 invited to cidi n = 16,418 cidi responders n = 9,552 -----------------------------valid response on both hscl-25 and at least one diagnostic section not invited to cidi n = 36,817 -----------------------------women removed after sampling procedure n = 7,070 did not consent to be contacted for fu study n = 29,747 non-response n = 111,354 cidi non-responders n = 5,435 -----------------------------excluded from sample n = 523 no valid diagnostic sections = 522 age outside age range n = 1 included sample n = 5,076 males = 1,493 females = 3,583 randomized to complete cidi after hscl excluded randomized to complete cidi before hscl sivertsen, skogen, reneflot et al. 5 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ for the purposes of the present study, we only used observations where the hscl-25 was administered before the cidi, as screening instruments are normally not preceded by full diagnostic assessments in population-based surveys. the cidi study took place between january 24 and february 6, 2023, approximately 12 months after the shot2022 survey was conducted. more detailed information on the participation process has been published elsewhere (sivertsen et al., 2023). instruments sociodemographic information participants' age and sex information were derived from their 11-digit norwegian nation­ al identity numbers. depression and anxiety disorders: the cidi the data collection utilized a recently developed electronic, self-administered version of the composite international diagnostic interview, fifth version (cidi 5.0), developed for the world health organization (who) world mental health (wmh) surveys (kessler & üstün, 2004). both the original cidi and this self-administered version maintained the same sequence of cidi modules, and the wording of the questions remained nearly identical, though instructions were slightly adapted for self-administration. to reduce participant burden and enhance response rates, the current version excluded certain diagnostic categories, namely bipolar, obsessive-compulsive, ptsd, adhd, and person­ ality disorders. in short, cidi 5.0 is a standardized interview that assesses 30-days, 12 months and lifetime prevalence for several mental and substance use disorders according to diagnostic criteria in the diagnostic and statistical manual of mental disorders 5th edition (dsm-5) (american psychiatric association, 2013). the interview version of cidi 3.0 has shown good concordance with diagnostic instruments such as the structured clinical interview for dsm-iv (scid) (haro et al., 2006) and schedules for clinical assessment in neuropsychiatry (scan) (jordanova et al., 2004). current mental disorder was defined as the presence of mde or gad during the 30 days before study participation. we also estimated prevalence rates for mental disorders spanning a 12-month period and over the lifetime, but these estimations were not incor­ porated into the present study, aligning with its specific emphasis on assessing current mental disorders in comparison with the hscl. the operationalization of these diagno­ ses was based on algorithms developed for cidi 5.0 in the wmh surveys initiative. the hopkins symptom checklist (hscl) mental health problems in the 14 days before the survey were assessed by the widely used hopkins symptom checklist (hscl-25) (derogatis et al., 1974), derived from the 90-item symptom checklist (scl-90). the score for the hscl is determined by taking hscl's diagnostic precision in tertiary students 6 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ the sum of the item scores and dividing it by the total number of items responded to, yielding a potential range of 1 to 4. an investigation of the factor structure based on the shot2014 dataset showed that a unidimensional model had the best psychometric prop­ erties in the student population and not the original subscales of anxiety and depression (skogen et al., 2017). details on the development of mental health problems assessed with the hscl-25 in the shot waves were recently published by knapstad and colleagues (knapstad et al., 2021). the items included in the three different versions of the hscl are listed in table 1. table 1 items included in the different hscl iterationsa item content hscl-25 hscl-10 hscl-5 1. suddenly scared for no reason ◯ ◯ 2. feeling fearful ◯ ◯ ◯ 3. faintness, dizziness, or weakness ◯ ◯ 4. nervousness or shakiness inside ◯ ◯ 5. heart pounding or racing ◯ 6. trembling ◯ 7. feeling tense or keyed up ◯ ◯ 8. headaches ◯ 9. spells of terror or panic ◯ 10. feeling restless, can't sit still ◯ 11. feeling low in energy, slowed down ◯ 12. blaming yourself for things ◯ ◯ 13. crying easily ◯ 14. loss of sexual interest or pleasure ◯ 15. poor appetite ◯ 16. difficulty falling asleep, staying asleep ◯ ◯ 17. feeling hopeless about the future ◯ ◯ ◯ 18. feeling blue ◯ ◯ ◯ 19. feeling lonely ◯ 20. feeling trapped or caught ◯ 21. worrying too much about things ◯ ◯ 22. feeling no interest in things ◯ 23. thoughts of ending your life ◯ 24. feeling everything is an effort ◯ ◯ 25. feelings of worthlessness ◯ ◯ aeach symptom is rated on a four-point frequency scale (1 =  not at all, 2 = a little, 3  =  quite a lot, 4  =   extremely). sivertsen, skogen, reneflot et al. 7 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ statistical analyses in the present study, we first present summary statistics for hscl scores and the prev­ alence of mde and gad, stratified by sex (table 3 and table 4). subsequently, we proceeded to determine sex-specific optimal cut-off points for hscl-25, hscl-10, and hscl-5 in relation to either mde or gad combined, and for mde and gad separately, as identified through cidi. this estimation was grounded in the maximization of the youden index, which is a commonly used metric for binary classification in validation studies aimed at striking a balance between sensitivity and specificity. the formula for the youden index, denoted as ('sensitivity' + 'specificity') 1, yields a scale ranging from 0 to 1. higher values signify better discriminative capacity, where 0 denotes no discrimi­ nation, and 1 reflects perfect discrimination. although rules of thumb always must be considered in conjunction with other aspects, a score below 0.5 on the youden index indicates that the test in question may not be useful as a classification tool, whereas a score surpassing 0.5 can be construed as indicating a valuable test. alongside the youden index, we also present a comprehensive view of overall accuracy, sensitivity, specificity, positive and negative predictive values (ppv and npv), and the area under the curve (auc). all analyses were performed using r 4.2.2. results as detailed in table 2, the sample for the cidi study primarily consisted of female students of norwegian ethnicity, with an average age of 24 years, and about half were single. most participants had parents with high educational levels. compared with the overall shot2022 study, the sociodemographic characteristics were similar, except for a slightly higher proportion of females in the cidi study (70%) compared to the shot2022 study (66%), as shown in table 2. non-respondents to the cidi study, who were invited but did not participate, differed mainly in having parents with lower education levels. the level of mental health problems, measured by the hscl-25 in the shot2022 study, was marginally lower in cidi respondents (m = 1.88, sd = 0.61) compared to non-respondents (m = 1.90, sd = 0.61, cohen’s d = 0.03). however, cidi respondents had a slightly higher hscl-25 score than the overall shot2022 sample (m = 1.86, sd = 0.57, cohen’s d = 0.03). figure 1 details the participation process of the current study. a total of 5,076 partic­ ipants completed both the cidi and hscl-25 in advance. the mental health characteris­ tics of the sample are detailed in table 3. females reported considerably higher average scores on all hscl iterations, and the prevalences of 30-day mde and gad were much higher among females as well, as detailed in table 3. hscl's diagnostic precision in tertiary students 8 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ table 2 demographical characteristics and representativeness of the cidi responders, cidi non-responders and the overall sample based on data from 2022 characteristic cidi responders (n = 9,552) cidi non-responders (n = 6,993) pa shot2022b (n = 53,362) pa age, mean (sd) 24.03 (3.28) 23.97 (3.24) .24 23.98 (1.85) .14 sex, % (n) .35 < .001 women 70.0 (6,686) 71.0 (4,968) 66.4 (35,423) men 30.0 (2,866) 29.0 (2,025) 33.6 (17,939) marital status, % (n) .20 .81 single 51.3 (4,904) 50.4 (3,526) 51.0 (27,197) boy-/girlfriend 22.5 (2,152) 23.7 (1,659) 22.8 (12,152) cohabitant 22.6 (2,156) 22.4 (1,563) 22.6 (12,058) married/registered partner 3.2 (308) 3.0 (207) 3.1 (1,667) missing 0.3 (32) 0.5 (38) 0.5 (288) maternal education, % (n) .01 .27 primary 4.3 (407) 5.3 (369) 4.5 (2,407) secondary 27.2 (2,601) 27.6 (1,931) 27.6 (14,707) college/university 65.9 (6,290) 64.2 (4,488) 64.3 (34,326) missing 2.7 (254) 2.9 (205) 3.6 (1,992) paternal education, % (n) .02 .39 primary 5.7 (544) 6.8 (473) 6.0 (3,182) secondary 34.9 (3,335) 35.0 (2,449) 35.1 (18,735) college/university 54.6 (5,211) 52.7 (3,687) 53.3 (28,446) missing 4.8 (462) 5.5 (384) 5.6 (2,999) hscl-25, mean (sd) 1.88 (0.61) 1.90 (0.61) .03 1.86 (0.59) < .001 missing, % (n) 0.2 (17) 0.3 (24) 0.4 (214) note. shot2022 = students’ health and wellbeing study 2022; cidi = composite international diagnostic interview; hscl-25 = hopkins symptoms checklist – 25 items version. acompared with the cidi responders group (p-values based on chi-squared test [categorical variables] or t-test [continuous variables]). bgrand mean for the shot2022 sample aged 18-35. table 3 mental health characteristics of the study sample characteristic males, n = 1,493 females, n = 3,583 p hscl-25, m (sd) 1.67 (0.53) 1.96 (0.60) < .001 hscl-10, m (sd) 1.70 (0.59) 1.98 (0.67) < .001 hscl-5, m (sd) 1.87 (0.74) 2.23 (0.80) < .001 major depressive episode (mde) 9.8% 16.9% < .001 generalized anxiety disorder (gad) 8.0% 15.7% < .001 mde or gad 13.1% 23.8% < .001 sivertsen, skogen, reneflot et al. 9 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ for the hscl-25, the optimal cut-off values for identifying cases of mde or gad were 1.96 for males and 2.20 for females. there was a good balance between sensitivity (0.92 for males and 0.89 for females) and specificity (0.83 for both males and females), and the youden index was acceptable for both males (0.74) and females (0.72). the ppv and npv for males were 0.45 and 0.99, while the corresponding numbers were 0.62 and 0.96 for females (see table 4 and table 5). for the hscl-10, the best cut-off values to identify cases of mde or gad were 2.10 for males and 2.30 for females. the balance between sensitivity (0.91 for males and 0.88 for females) and specificity (0.81 for both sexes) was good. the youden index was satisfactory for both males (0.72) and females (0.69). the ppv and npv for males registered at 0.42 and 0.98, respectively, and for females, these values were 0.58 and 0.96. for the hscl-5, the optimal cut-off values to identify cases of mde or gad were 2.25 for males and 2.75 for females, and similar to the two longer hscl iterations, the balance between sensitivity and specificity was notably good (see tables 4 and 5 for details). the youden index showed satisfactory results for both males and females at 0.68, and the ppv and npv for males stood at 0.41 and 0.97, respectively, whereas for females, these figures were 0.65 and 0.94. table 4 optimal cut-off values for females for hscl-25, hscl-10, and hscl-5 for major depressive episode (mde) and generalized anxiety disorder (gad) assessed by cidi hscl version and cidi diagnosis cut-off value youden index accuracy sensitivity specificity ppv npv auc hscl-25 mde or gad ≥ 2.20 0.72 0.85 0.89 0.83 0.62 0.96 0.94 mde ≥ 2.28 0.74 0.84 0.92 0.82 0.51 0.98 0.94 gad ≥ 2.08 0.64 0.76 0.91 0.73 0.38 0.98 0.90 hscl-10 mde or gad ≥ 2.30 0.70 0.83 0.88 0.81 0.60 0.96 0.93 mde ≥ 2.44 0.73 0.86 0.88 0.85 0.55 0.97 0.93 gad ≥ 2.30 0.63 0.77 0.88 0.75 0.39 0.97 0.89 hscl-5 mde or gad ≥ 2.75 0.68 0.86 0.81 0.87 0.67 0.94 0.91 mde ≥ 2.75 0.69 0.83 0.86 0.83 0.50 0.97 0.91 gad ≥ 2.80 0.64 0.82 0.83 0.81 0.45 0.96 0.89 note. cidi = composite international diagnostic interview; hscl = hopkins symptom checklist; mde = major depressive episode; gad = generalized anxiety disorder; ppv = positive predictive value; npv = negative predictive value; auc = area under the roc curve. hscl's diagnostic precision in tertiary students 10 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ the corresponding values for only mde and only gad were relatively similar to those of mde or gad. the same optimal cut-off values for all hscl iterations were replicated in bootstrapped analyses with 1,000 runs. as also detailed in table 6, when using the optimal cut-offs, all three hscl iterations were associated with a marked overestimation of the prevalences, according to the self-administered cidi. for example, the 30-day prevalence rates of mde or gad were 13.1% for males and 23.8% for females. however, using the optimal hscl-25 cut-offs, these rates increased to 26.9% for males and 33.8% for females, respectively. discussion the present large-scale study of students in higher education employed a recently adap­ ted self-administered psychiatric diagnostic survey (cidi 5.0) to investigate the efficacy of three iterations of the widely used hscl scale in detecting cases of gad or mde, with an emphasis on potential sex-specific cut-off values. our results show that all three versions of the hscl discern relatively well between students afflicted with and without generalized anxiety disorder (gad) or major depressive episode (mde), and that different cut-offs for males and females should be used to ensure a good balance between sensitivity, specificity and overall accuracy. table 5 optimal cut-off values for males for hscl-25, hscl-10, and hscl-5 for major depressive episode (mde) and generalized anxiety disorder (gad) assessed by cidi hscl version and cidi diagnosis cut-off value youden index accuracy sensitivity specificity ppv npv auc hscl-25 mde or gad ≥ 1.96 0.74 0.84 0.92 0.83 0.45 0.99 0.94 mde ≥ 2.00 0.76 0.84 0.94 0.82 0.37 0.99 0.95 gad ≥ 1.96 0.69 0.80 0.91 0.79 0.27 0.99 0.92 hscl-10 mde or gad ≥ 2.10 0.72 0.82 0.91 0.81 0.42 0.98 0.94 mde ≥ 2.30 0.74 0.87 0.87 0.87 0.41 0.98 0.95 gad ≥ 2.30 0.68 0.85 0.83 0.85 0.32 0.98 0.91 hscl-5 mde or gad ≥ 2.25 0.68 0.83 0.85 0.82 0.42 0.97 0.92 mde ≥ 2.25 0.68 0.81 0.88 0.80 0.32 0.98 0.92 gad ≥ 2.20 0.64 0.74 0.92 0.72 0.22 0.99 0.91 note. cidi = composite international diagnostic interview; hscl = hopkins symptom checklist; mde = major depressive episode; gad = generalized anxiety disorder; ppv = positive predictive value; npv = negative predictive value; auc = area under the roc curve. sivertsen, skogen, reneflot et al. 11 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ a significant finding in this study is the introduction of new, sex-specific cut-off values for all hscl iterations. these values diverge from those in earlier validation studies, which might have lacked the statistical power to evaluate distinct cut-offs for males and females. while the conventional cut-off value of 1.75 for the hscl-25 has been consistently used for both sexes for years, the present study indicates that adopting slightly elevated cut-offs enhances the balance between sensitivity and specificity for both males and females across all hscl iterations. prior research contrasting the full hscl-25 with structured diagnostic interviews have demonstrated a sensitivity ranging from 70-88% and a specificity between 77-85% for mood disorders or depression, and 43-50% sensitivity with 83% specificity for anxiety disorders (rodríguez-barragán et al., 2021; sandanger et al., 1998; veijola et al., 2003). in the current study, both the sensitivity and specificity were generally a little higher both for mde (sensitivity 92-94%, and specificity 82%), and gad (sensitivity 91%, and specificity 73-79%). it is important to note that the different studies employ different anxiety and depression diagnoses. what is noteworthy is that both the shorter hscl-10 and hscl-5 displayed similarly high levels of sensitivity and specificity. although very few studies have investigated the case-detection ability of these shorter hscl iterations, a recent study by rodríguez-bar­ ragán et al. found that the hscl-5 yielded a sensitivity of 78% and a specificity of 73% for depression. based on our dataset using the newly suggested cut-offs, we observed an even higher sensitivity and specificity for both mde and gad, suggesting that both table 6 prevalence of mental disorder according to cidi and the optimal hscl cutoffs hscl version and cidi diagnosis males females cidi hscla cidi hscla hscl-25 mde or gad 13.1% 26.9% 23.8% 33.8% mde 9.8% 25.1% 16.9% 30.2% gad 8.0% 26.9% 15.7% 39.3% hscl-10 mde or gad 13.1% 28.3% 23.8% 35.2% mde 9.8% 20.6% 16.9% 27.2% gad 8.0% 20.6% 15.7% 35.2% hscl-5 mde or gad 13.1% 26.6% 23.8% 28.7% mde 9.8% 26.6% 16.9% 28.7% gad 8.0% 33.3% 15.7% 28.6% note. cidi = composite international diagnostic interview; hscl = hopkins symptom checklist; mde = major depressive episode; gad = generalized anxiety disorder. aestimated prevalences based on the optimal hscl cut-off. hscl's diagnostic precision in tertiary students 12 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ the hscl-10 the hscl-5 may be equally good alternatives to be used in epidemiological research for the purpose of detecting probable cases of depression and anxiety. however, it should be noted that the relative differences between hscl and cidi prevalences were more pronounced in men. this was driven by differences in base prevalence as measured by cidi; specifically, a relatively lower cidi prevalence estimate is, all other things being equal (ceteris paribus), associated with a higher hscl prevalence estimate. another explanation for the disparities between hscl and cidi prevalence is that hscl does not assess how symptoms affect daily functioning, while this is a key requirement for diagnosing a mental disorder in the cidi instrument. this difference might partly explain why specificity was somewhat lower for gad than for mde. anxiety disorders often have a more intricate relationship with functional impairment compared to depression (mcknight et al., 2016). future studies could explore improving the hscl by adding a measure of daily functioning. this addition could address the tool's current limitation of potentially overestimating mental health disorders due to the lack of assessment of the real-world functional impact. a revised hscl with functional impairment questions could offer a more thorough evaluation. alternatively, it could be used initially for screening, followed by more detailed assessments of daily functioning in those with elevated scores, ensuring a balanced approach that combines ease of use with comprehensive symptom analysis. integrating functional impairment assessment would thus significantly enhance hscl's diagnostic accuracy. surprisingly, few recent studies, both generally and specifically on university sam­ ples, have used structured diagnostic interviews, with the latest being over a decade old (kou et al., 2012; verger et al., 2010). the dutch nemesis-3 study (ten have et al., 2023), which monitors mental disorders in the dutch general population, offers valuable insights. using cidi 3.0 (face-to-face interviews), the 12-month prevalence of any mental disorder was found to be 40% among young adults aged 18-24 years and 35% among those aged 25-35 years. lifetime prevalence estimates were 50% and 59%, respectively. a sub-study from the 2020 hunt study also provides relevant data (knudsen et al., 2021). in this study, 2,154 participants from the general population were interviewed using cidi 5.0. the 30-day prevalence of mental disorders among those aged 20-29 years was estimated to be 25.5% just before the covid-19 pandemic. although the prevalence estimates from nemesis-3 and hunt are lower than those in our study of college and university students, they highlight the high prevalence of mental disorders among young adults. some methodological considerations warrant attention. this study's reliance on the standardized and validated cidi psychiatric survey represents a significant strength. however, the shift from traditional face-to-face interviews to a self-administered elec­ tronic format in cidi 5.0 introduces challenges, such as the need for further validation against conventional methods. past research (knudsen et al., 2021) indicates no signif­ icant prevalence differences between face-to-face and telephone interviews, although sivertsen, skogen, reneflot et al. 13 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ recent comparisons between face-to-face and web-based self-reporting of psychological functioning revealed that respondents in face-to-face settings reported slightly fewer symptoms of depression (cohen’s d = 0.25) (kocjan et al., 2023). this raises questions about the accuracy of different administration modes, particularly as previous findings suggest that young, well-educated respondents might underreport mental health issues. assessing the reliability of the self-administered cidi, especially in comparison to faceto-face interviews, is crucial not only for validation but also for understanding how dif­ ferent modes might impact mental health assessments. however, discrepancies between hscl and cidi prevalence estimates, particularly among male respondents, require careful interpretation. these variations underscore the need for contextual adjustments and a deeper understanding of how assessment tools could produce divergent outcomes in mental health research. the proposed cut-offs, tailored for epidemiological research in a student population with unique demographic traits, might not generalize well to other groups due to varying baseline prevalences and cultural perceptions of mental health. therefore, while hscl shows promise as a screening tool in a student population, its broader applicability needs further validation. moreover, the limited differences observed in mental health problems between cidi respondents and non-respondents, along with consistent response rates across norwegian regions, suggest a reasonable level geograph­ ic representativeness. however, our understanding of non-responders, limited to basic demographic details, restricts our ability to fully assess representativeness against the broader norwegian student population. recent findings from denmark (lyngsøe et al., 2023), showing minor participation variations across sociodemographic groups provide some reassurance regarding the generalizability of our results. the best approaches to determining cut-off values based on scales, like the various hscl variants, depend on the intended purpose. if the goal is to identify individuals potentially in need of psychiatric treatment, prioritizing high sensitivity is crucial. how­ ever, when estimating the prevalence of depression or anxiety disorders within a popula­ tion, striking a balance between specificity and sensitivity relative to the true prevalence of the disorder might yield more accurate results. recommending specific cut-off values for future studies lies beyond the scope of this study. such norms can be effectively determined only after conducting several similar studies, ideally across diverse cultures, countries, and population segments. the benefits of using different cut-off points for men and women also warrant more comprehensive evaluation, compared against the challenges posed by adding such complexity. hscl's diagnostic precision in tertiary students 14 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://www.psychopen.eu/ funding: norwegian ministry of education and research. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. ethics statement: the study was approved by the regional committee for medical and health research ethics in western norway (no. 2022/326437). all subjects gave electronic informed consent in accordance with the declaration of helsinki (2013). preregistration: the study was not preregistered. the cidi follow-up survey is registered at clinicaltrials.gov (identifier: nct05731102). reporting guidelines: we adhered to the strobe (strengthening the reporting of observational studies in epidemiology) guidelines in the design, conduct, and reporting of this study. statement of the conclusions: the study revealed high criterion validity for all hscl versions in detecting major depressive episode and generalized anxiety disorder, suggesting their efficacy as screening tools rather than for precise prevalence estimation. data availability: data are available upon reasonable request. all shot data set is administrated by the niph. approval from a norwegian regional committee for 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(2010). psychiatric disorders in students in six french universities: 12-month prevalence, comorbidity, impairment and helpseeking. social psychiatry and psychiatric epidemiology, 45(2), 189–199. https://doi.org/10.1007/s00127-009-0055-z clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. hscl's diagnostic precision in tertiary students 18 clinical psychology in europe 2024, vol. 6(4), article e13275 https://doi.org/10.32872/cpe.13275 https://doi.org/10.1136/bmjopen-2018-025200 https://doi.org/10.1177/1403494817700287 https://doi.org/10.1002/wps.21087 https://doi.org/10.1080/08039480310000941 https://doi.org/10.1007/s00127-009-0055-z https://www.psychopen.eu/ hscl's diagnostic precision in tertiary students (introduction) method setting and participants instruments statistical analyses results discussion (additional information) funding acknowledgments competing interests ethics statement preregistration reporting guidelines statement of the conclusions data availability references uncertainty breeds anxiety and depression: the impact of the russian invasion in ukraine on a swedish clinical population receiving internet-based psychotherapy research articles uncertainty breeds anxiety and depression: the impact of the russian invasion in ukraine on a swedish clinical population receiving internet-based psychotherapy jón ingi hlynsson 1 , oskar gustafsson 2 , per carlbring 1 [1] department of psychology, stockholm university, stockholm, sweden. [2] department of statistics, stockholm university, stockholm, sweden. clinical psychology in europe, 2024, vol. 6(1), article e12083, https://doi.org/10.32872/cpe.12083 received: 2023-05-31 • accepted: 2024-01-15 • published (vor): 2024-03-28 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: jón ingi hlynsson, department of psychology, university of iceland, sæmundargata 12, 102 reykjavík, iceland. phone: +354 774 50 50. e-mail: jih10@hi.is supplementary materials: materials [see index of supplementary materials] abstract background: recent global crises, such as the covid-19 pandemic and the 2022 russian invasion of ukraine, have contributed to a rise in the global prevalence of anxiety and depressive disorders. this study examines the indirect impact of the ukraine war on emotional disorders within a swedish clinical population. method: the sample comprised participants (n = 1,222) actively engaged in an internet-based psychotherapeutic intervention (cognitive-behavioral, psychodynamic, and waitlist) when the war broke out. the patient health questionnaire-9 scale and the generalized anxiety disorder-7 scale were used to measure depression and anxiety. results: anxiety and depressive symptom severity increased following the war's onset, with an average weekly increase of 0.77-points for anxiety (p = .001, cohen's d = 0.08) and 0.09-points for depression (p = .70, cohen's d = 0.01); however, the increase was negligible for depression. furthermore, higher socioeconomic status (ses) predicted declines in depression and anxiety during the study period, with a 0.69-point average weekly decrease in anxiety (p < .001, cohen's d = 0.32) and a 1.09-point decrease in depression (p < .001, cohen's d = 0.48) per one unit increase in ses, suggesting that ses may serve as a protective factor that buffers against psychopathological development during crises. conclusions: these findings have implications for mitigating the development of psychopathology during crises and interpreting treatment efficacy estimates during such events. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12083&domain=pdf&date_stamp=2024-03-28 https://orcid.org/0009-0000-5703-1068 https://orcid.org/0009-0005-0449-4065 https://orcid.org/0000-0002-2172-8813 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ our findings also emphasize the potential of internet-based psychotherapy in addressing emotional disorders during crises. this study presents up-to-date information about the reaction of treatment-seeking individuals to abrupt uncertainty. keywords anxiety, depression, russian–ukrainian war, uncertainty-inducing event, clinical trial, internet-based psychotherapy, emotional disorders highlights • the 2022 russian invasion of ukraine rapidly exacerbated anxiety symptom severity. • socioeconomic status may buffer against psychopathology during heightened uncertainty. • spatially distant uncertainty-inducing events can elevate the risk for psychopathology. • increased anxiety during crises may confound treatment efficacy estimations. in recent years, the world has faced numerous global crises with devastating consequen­ ces for mental health. for instance, depression prevalence rose significantly after the 2008 global financial crisis (guerra & eboreime, 2021), and anxiety and depression rates worldwide increased by roughly 25% during the covid-19 pandemic (ettman et al., 2020; world health organization, 2022). similarly, the russian invasion of ukraine on february 24th, 2022, resulted in increased prevalence rates of anxiety and depression among ukrainians (osokina et al., 2023; xu et al., 2023) and europeans (riad et al., 2022; skwirczyńska et al., 2022). although these crises differ, they share a common characteristic: an increase in symptomatology of emotional disorders in response to an increase in external uncertainty. emotional disorders are characterized by frequent experiences of negative emotions, along with maladaptive reactions to and regulation of these experiences. these maladap­ tive reactions contribute to the persistence of negative emotions and the maintenance of the presenting disorder symptoms (cf. negative feedback loop; bullis et al., 2019). effectively managing uncertainty is already a critical adaptive challenge for humans. however, when environmental uncertainty abruptly increases, as during a global pan­ demic or war outbreak, adaptive information processing becomes even more hindered by internal disorder and uncertainty. these features, known as psychological entropy (hirsh et al., 2012), tend to increase during crises, in turn, raising the likelihood of psychopatho­ logical development. for instance, anxiety and depressive symptoms were significantly higher during the covid-19 pandemic compared to pre-pandemic rates (gao et al., 2020; xiong et al., 2020), with worldwide prevalence rates rising by 25% (ettman et al., 2020; world health organization, 2022) and pandemic-related media exposure increased the odds of presenting with anxiety and combined anxiety and depression (gao et al., 2020). similarly, economic recessions (e.g., the 2008 global financial crisis) are associated with uncertainty breeds anxiety and depression 2 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ an overall increase in depression and anxiety prevalence rates, with low socioeconomic status as a significant risk factor (frasquilho et al., 2016; gili et al., 2013; guerra & eboreime, 2021). focusing on the recent1 war outbreak in ukraine, a study by riad et al. (2022) found that czech university students reported high levels of concern about the ongoing conflict, with increased age correlating with higher levels of concern and media exposure engagement predicting anxiety and depression severity. similarly, skwirczyńska et al. (2022) discovered a positive association between war-related fear and anxiety severity in a polish student sample. intriguingly, access to monetary savings emerged as a protec­ tive factor that reduced the odds of presenting anxiety symptoms. one interpretation of skwirczyńska et al.'s (2022) findings is that socioeconomic status, as indicated by access to monetary savings, buffers against anxiety symptom development (cf. guerra & eboreime, 2021). in summary, the war outbreak in ukraine has noticeably affected the european population. internet-based therapy in recent years, a disparity has emerged between the demand for psychotherapy and its availability. as a result, the utilization of internet-based psychotherapeutic interventions has risen substantially to address this gap (andersson et al., 2019). internet-based psy­ chotherapeutic treatments leverage technological advancements to create a contempo­ rary alternative to traditional therapy. typically, internet-based therapy consists of struc­ tured, manualized psychotherapy delivered online through modules containing self-help texts and the option to communicate with a therapist via encrypted messages (andersson & carlbring, 2022). designed to parallel conventional face-to-face therapy in length and content (andersson et al., 2016), internet-based therapy demonstrates equivalent overall therapeutic efficacy (hedman-lagerlöf et al., 2023). meta-analytic findings support the treatment efficacy of internet-based therapy for emotional disorders, revealing moderate to large effect sizes for anxiety and depressive disorders (andersson et al., 2019; hedmanlagerlöf et al., 2023). aim of the present study this study aims to assess the effects of indirect experiences of the war outbreak in ukraine on the severity of anxiety and depression among individuals seeking treatment through an internet-based intervention, hereafter collectively referred to as "treatmentseeking individuals". although this study was conducted in sweden, which is a neigh­ boring country but not directly bordering ukraine (i.e., approximately 1500 kilometers 1) it should be noted that tensions between russia and ukraine began in 2014, but escalated into a full-blown war in february 2022, following russia's invasion of ukraine (cf. michailova, 2022). hlynsson, gustafsson, & carlbring 3 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ separate sweden and ukraine), previous studies suggest that the war outbreak in ukraine has increased the prevalence rates of anxiety and depression in the general european population (riad et al., 2022; skwirczyńska et al., 2022). indeed, surges in exposures to psychological threats (e.g., media exposure to crisis-related content) can jeopardize individuals' sense of personal security and exacerbate psychopathological development (gao et al., 2020; jayuphan et al., 2020; riad et al., 2022). consequently, we predicted a divergence in weekly therapeutic efficacy trends among treatment-seeking individuals following the war outbreak, as indicated by a spike in anxiety and depression. to our knowledge, this is the first study investigating the effects of the war in ukraine on emotional disorders in a clinical population and thereby aims to provide up-to-date information about the reaction of treatment-seeking individuals to abrupt uncertainty. hypotheses this study has two core hypotheses: scores on the 1) phq-9 and 2) gad-7 will be significantly elevated following the outbreak of war in ukraine when compared to a baseline established by the trend in scores observed over the preceding four weeks, adjusting for treatment group assignment, socioeconomic status, education level, age, and gender. additionally, high socioeconomic status is hypothesized to be a protective factor that buffers against further development of psychopathology following the war outbreak. method participants and recruitment the present study utilizes data from an ongoing clinical trial (clinicaltrials.gov identifi­ er: nct05016843) that is being conducted in sweden. participants were recruited online through a website outlining the study's aims and components (vlaescu et al., 2016). the study was advertised on facebook and also spread through word of mouth. participants did not receive any monetary compensation for their involvement in the study. the only form of compensation provided was the inherent benefits derived from participation in the treatment interventions. see figure s1, supplementary materials, for a flow chart illustration of the study design. sample size all participants (n = 1,222) actively engaged in the study between january 24th, 2022, and march 24th, 2022, were included. this two-month period was chosen to adequately represent treatment efficacy before and after the war outbreak in ukraine on february 24th, 2022. uncertainty breeds anxiety and depression 4 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ eligibility criteria eligibility criteria were assessed during the study's screening phase. participants were required to: a) be at least 18 years of age; b) read and write in swedish; c) have an internet connection via their mobile phone or computer; and d) experience at least mild anxiety symptoms (i.e., gad-7 ≥ 5 points) or mild to moderate depression symptoms (i.e., phq-9 ≥ 10 points), or both. participants were excluded if they: a) were currently seeking other psychological treatment; b) had begun or adjusted psychopharmacological treatment for anxiety, worry, or depression within the nearest month from screening; or c) had severe depression (i.e., phq-9 ≥ 20 points) or suicidality (i.e., phq-9, item nine score > 2 points) indicated during screening. measures demographic variables and anxiety and depression measurements were collected during screening, followed by weekly measurements of anxiety and depression. demographics demographic variables collected during screening included age, gender, socioeconomic status2, marital status, household composition, level of education, employment status, mental health characteristics, and prior psychopharmaceutical medication usage. patient health questionnaire 9-item scale (phq-9) the patient health questionnaire 9-item scale (phq-9) is a self-report questionnaire that quantifies depression severity (kroenke et al., 2001). each item is rated on a scale from 0 to 3, with total scores ranging from 0 to 27. a score of 10 or higher is a diagnostic indicator of depression (kroenke et al., 2001, 2010). the phq-9 consistently demonstrates good accuracy and discrimination ability in clinical settings and the general population (kocalevent et al., 2013; kroenke et al., 2001, 2010) as well as when administered via the internet (martin-key et al., 2022). in this study, the phq-9 exhibited adequate internal reliability during screening, cronbach's alpha = 0.66, 95% ci [0.63, 0.68], indicating ac­ ceptable internal consistency. it should be noted that this internal consistency reliability estimate suffers from a restriction of range and an analysis of the whole sample at screening (both included and excluded participants) yielded cronbach's alpha = 0.81, 95% ci [0.80, 0.62] (hlynsson & carlbring, 2023). 2) socioeconomic status was indirectly measured with a self-rated scale; participants rated their socioeconomic status in relation to others on a scale from 1 to 5 (see table 1 for response options). hlynsson, gustafsson, & carlbring 5 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ generalized anxiety disorder 7-item scale (gad-7) the generalized anxiety disorder 7-item scale (gad-7) is a self-report questionnaire that assesses anxiety and screens for generalized anxiety disorder (spitzer et al., 2006). each item is rated on a scale from 0 to 3, with total scores ranging from 0 to 21. a score of 8 or higher is a diagnostic indicator of anxiety disorders (luo et al., 2019; spitzer et al., 2006). the items align with dsm-5 criteria (american psychiatric association, 2022) and are sensitive to various anxiety disorders (kroenke et al., 2010) in both clinical settings and the general population, as well as when administered online (byrd-bredbenner et al., 2021; johnson et al., 2019; löwe et al., 2008; martin-key et al., 2022). in this study, the gad-7 demonstrated good internal reliability during screening, cronbach's alpha = 0.77, 95% ci [0.75, 0.79], indicating excellent internal consistency. it should be noted that this internal consistency reliability estimate suffers from a restriction of range and an analysis of the whole sample at screening (both included and excluded participants) yielded cronbach's alpha = 0.85, 95% ci [0.83, 0.85] (hlynsson & carlbring, 2023). treatment interventions data was collected as part of an ongoing clinical trial (mechler et al., 2022) comparing cognitive-behavioral therapy (unified protocol [up]; barlow et al., 2017) with psychody­ namic affective phobia (ap) therapy (julien & o’connor, 2017). the trial comprised three factors: a) type of internet-based treatment intervention; b) treatment length; and c) effects of access to a clinician-moderated discussion forum. participants were randomly assigned via a factorial assignment mechanism to one of twelve conditions: up, ap, or a waitlist, each for either 8 or 16 weeks, and each with or without access to a clinician-moderated forum. data analysis the data was analyzed using r studio (r core team, 2021). a panel-data regression analysis was conducted, in which phq-9 and gad-7 scores were separately predicted by the treatment time course in weeks (e.g., data provided between january 24th and january 30th, 2022, was assigned the number 1 corresponding to week one) and a dummy variable containing information about whether data corresponded to the time period before or after the war outbreak (i.e., all data corresponding to dates before february 24th, 2022, was coded as 0 and other data as 1), while adjusting for relevant covariates. in addition, cohen’s d effect sizes were computed to interpret the magnitude of all associations. hemphill's (2003) interpretive framework for effect sizes, derived from an empirical assessment of the magnitude of the average effect sizes produced in psychological studies, was used to interpret effect size magnitudes. the correlational effect size guidelines provided by hemphill (2003) were converted into cohen's d effect sizes (ruscio, 2008). cohen's d effect sizes below 0.4 were considered small in magnitude, uncertainty breeds anxiety and depression 6 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ effect sizes between 0.4 and 0.6 were considered moderate, and effect sizes above 0.6 were considered large. to preserve power and minimize missing data, participants were only compared during the first 8 weeks of treatment/waitlist. this is because data was only collected for half of the participants for 8 weeks (i.e., participants were either assigned to 8 or 16 weeks, and thus observations corresponding to weeks 9-16 would be missing for half of the sample due to the study design). a separate analysis wherein only participants assigned to a 16-week treatment intervention was conducted to corroborate the findings of the present analysis (see table s1, supplementary materials). moreover, since data was stratified by treatment group assignment and the experiment was conducted over several weeks, a heteroscedasticity and autocorrelation consistent (hac) covariance matrix estimation was used to obtain a robust estimation of the linear models' standard errors (cribari-neto & da silva, 2011). additionally, due to a large amount of missing observations in the dataset (i.e., 53% of observations for depression and anxiety), the data was also modeled using a full information maximum likelihood (fiml) estimation (cf. hesser, 2015; hoffart et al., 2022). fiml estimation allows for parameter estimates despite missing data by estimating patterns of missingness (baraldi & enders, 2010). this additional analysis was conducted to assess the convergence between fiml estimation and hac covariance matrix estima­ tion (i.e., compare the results obtained from the two methods). isomorphic parameter estimates from both methods (i.e., in terms of signs and significance) will be taken as indicators of a stable and generalizable parameter estimation. in an effort to approach a model that might suggest potential causal effects of the war outbreak on anxiety and depressive symptom severity, all variables considered relevant were included in the analysis (rohrer, 2018). a directed acyclic graph of the hypothesized causal associations and interdependencies in the assumed data-generating process was constructed using dagitty to guide the choice of variables to adjust and not to adjust for in the present analysis (see figure s2, supplementary materials; textor et al., 2016). results sample characteristics descriptive statistics for the sample demographics are summarized in table 1. during screening, phq-9 scores ranged from 1 to 19 (m = 11.76, sd = 4.16), and gad-7 scores ranged from 0 to 21 (m = 9.74, sd = 4.16). in the four weeks leading up to the war outbreak, phq-9 scores ranged from 0 to 27 (m = 8.84, sd = 5.14), and gad-7 scores ranged from 0 to 21 (m = 7.79, sd = 4.80). in the four weeks following the war outbreak, phq-9 scores ranged from 0 to 27 (m = 8.26, sd = 5.36), and gad-7 scores ranged from 0 to 21 (m = 7.83, sd = 5.14). hlynsson, gustafsson, & carlbring 7 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ table 1 demographical descriptive statistics participant characteristics waitlista, n = 560 psychodynamic affect phobia therapyb, n = 348 cognitive behavior therapyc, n = 314 total, n = 1,222 age 43 (12) 43 (12) 44 (13) 42 (12) education elementary school 14 (2.5%) 13 (3.7%) 7 (2.2%) 34 (2.8%) high school 128 (23%) 89 (26%) 84 (27%) 301 (25%) college-level education (< 3 years) 155 (28%) 96 (28%) 80 (25%) 331 (27%) college-level education (> 3 years) 263 (47%) 150 (43%) 143 (46%) 556 (45%) sex female 483 (86%) 302 (87%) 270 (86%) 1,055 (86%) male 73 (13%) 45 (13%) 43 (14%) 161 (13%) other 4 (0.7%) 1 (0.3%) 1 (0.3%) 6 (0.5%) self-rated socioeconomic status much worse than others 23 (4.1%) 20 (5.7%) 12 (3.8%) 55 (4.5%) worse than others 132 (24%) 88 (25%) 60 (19%) 280 (23%) about the same as others 234 (42%) 149 (43%) 145 (46%) 528 (43%) better than others 152 (27%) 86 (25%) 80 (25%) 318 (26%) much better than others 19 (3.4%) 5 (1.4%) 17 (5.4%) 41 (3.4%) children under 18 in the house no 347 (62%) 195 (56%) 191 (61%) 733 (60%) yes 206 (37%) 144 (41%) 116 (37%) 466 (38%) complicated/sometimes 7 (1.2%) 9 (2.6%) 7 (2.2%) 23 (1.9%) prior medication for anxiety/depression 150 (27%) 85 (24%) 77 (25%) 312 (26%) current occupation working 394 (70%) 226 (65%) 220 (70%) 840 (69%) studying 71 (13%) 48 (14%) 45 (14%) 164 (13%) seeking work 32 (5.7%) 19 (5.5%) 11 (3.5%) 62 (5.1%) retired 26 (4.6%) 20 (5.7%) 15 (4.8%) 61 (5.0%) parental leave 5 (0.9%) 8 (2.3%) 2 (0.6%) 15 (1.2%) sick leave 32 (5.7%) 27 (7.8%) 21 (6.7%) 80 (6.5%) aaggregated from four groups: waitlist for 8 weeks, with discussion forum access (n = 126), waitlist for 8 weeks, no discussion forum access (n = 122), waitlist for 16 weeks, with discussion forum access (n = 154), waitlist for 16 weeks, no discussion forum access (n = 158). baggregated from four groups: affect phobia for 8 weeks, with discussion forum access (n = 59), affect phobia for 8 weeks, no discussion forum access (n = 61), affect phobia for 16 weeks, with discussion forum access (n = 111), affect phobia for 16 weeks, no discussion forum access (n = 117). caggregated from four groups: unified protocol for 8 weeks, with discussion forum access (n = 46), unified protocol for 8 weeks, no discussion forum access (n = 58), unified protocol for 16 weeks, with discussion forum access (n = 100), unified protocol for 8 weeks, no discussion forum access (n = 110). uncertainty breeds anxiety and depression 8 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ missing data for the eight instances when data was provided, a fisher's exact test comparing the propensity for data being differentially missing between the first four and latter four instances revealed non-significant differences for both the phq-9 (p = .168) and gad-7 (p = .204). furthermore, no obvious trends of missingness were discernible as a function of age, gender, or ses. the effects of the war outbreak symptoms of depression in response to the outbreak the outbreak of war did not significantly increase average levels of depression. scores on the phq-9 slightly increased following the war outbreak, t(4566) = 0.39, p = .699, wherein comparing two individuals of the same socioeconomic status, treatment group, education level, age, and gender, while adjusting for the date on which data was provided, revealed a 0.09-point increase in average levels of depression, 95% ci [-0.38, 0.56]; effect size: d = 0.01, following the outbreak of war. the data was most compatible with values ranging from a 0.38-point decrease to a 0.56-point increase in scores on the phq-9. as such, the results do not indicate that the war outbreak significantly affected the severity of depression (see figure 1). figure 1 graphical depiction of unadjusted raw-mean scores and 95% confidence intervals for depression each week, over the course of treatment for all treatment groups hlynsson, gustafsson, & carlbring 9 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ symptoms of anxiety in response to the outbreak the war outbreak significantly increased average anxiety levels. anxiety scores on the gad-7 rose following the outbreak, t(4566) = 3.23, p = .001. comparing two individuals with the same socioeconomic status, treatment group, education level, age, and gender, and adjusting for the data collection date, a 0.77-point increase in anxiety severity, 95% ci [0.30, 1.23]; effect size: d = 0.08, was observed after the war outbreak. the data was most compatible with values ranging from a 0.30-point to a 1.23-point increase in gad-7 scores. a general decline in anxiety symptom severity was detected prior to the war outbreak which then increased abruptly in the wake of the war outbreak before rapidly declining to pre-war outbreak levels (see figure 2). consequently, the results suggest that the war outbreak exacerbated anxiety severity. figure 2 graphical depiction of unadjusted raw-mean scores and 95% confidence intervals for anxiety each week, over the course of treatment for all treatment groups socioeconomic status as a protective factor socioeconomic status was inversely associated with anxiety severity over time, t(4566) = -3.61, p < .001, during this study. when comparing two individuals on the same date, within the same treatment group, of the same age, gender, and education level, while adjusting for the outbreak of war, a 1-point increase in self-rated socioeconomic status was associated with a 0.69-point average decrease in scores on the gad-7, 95% ci [-1.06, -0.31]; effect size: d = 0.32. the data was most compatible with values ranging from uncertainty breeds anxiety and depression 10 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ a 1.06-point decrease to a 0.31-point decrease in scores on the gad-7. thus, anxiety symptom severity is, on average, lower for people with relatively higher socioeconomic status when controlling for the time course of treatment, war outbreak, gender, and treatment group, in turn, suggesting that socioeconomic status may be a potential pro­ tective factor for anxiety symptoms during a war outbreak (cf. entropy increase). adding an interaction term between the war outbreak dummy variable and socioeconomic status did not increase the model fit nor alter the coefficient estimates. socioeconomic status was also inversely associated with depression severity over time, t(4566) = -5.28, p < .001, during this study. when comparing two individuals on the same date, within the same treatment group, of the same age, gender, and education level, while adjusting for the outbreak of war, a 1-point increase in self-rated socioeco­ nomic status was associated with a 1.09-point average decrease in scores on the phq-9, 95% ci [-1.49, -0.68]; effect size: d = 0.48. the data was most compatible with values ranging from a 1.49-point decrease to a 0.68-point decrease in scores on the phq-9. thus, depressive symptom severity is, on average, lower for people with relatively higher socioeconomic status when controlling for the time course of treatment, war outbreak, gender, and treatment group, in turn, suggesting that socioeconomic status may be a potential protective factor for depressive symptoms during a war outbreak (cf. entropy increase). adding an interaction term between the war outbreak dummy variable and socioeconomic status did not increase the model fit nor alter the coefficient estimates. additional analyses full information maximum likelihood (fiml) estimation to further support the previously reported results, linear models for the phq-9 and gad-7 were analyzed using fiml estimations (see table s2, supplementary materials). this analysis produced parameter estimates that were consistent with hac covariance matrix estimation results reported earlier (i.e., equivalent parameter estimates and p-val­ ues). moreover, an additional analysis that adjusted for all background variables at our disposal also produced parameter estimates that were consistent with both the hac covariance matrix estimation and fiml results. taken together, the parameter estimates seem stable in the current analysis, and patterns of missing data do not appear to significantly impact the results. treatment group and treatment efficacy analyses analyses of the differential effects of the war outbreak and overall treatment efficacy were conducted (see supplementary materials). hlynsson, gustafsson, & carlbring 11 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ discussion the present study aimed to elucidate the effects of the outbreak of war in ukraine following the russian invasion on february 24th on measures of anxiety and depressive symptom severity. to our knowledge, this is the first study on the indirect effects of the war in ukraine on emotional disorders in a clinical population, thereby providing up-to-date information about the reaction of treatment-seeking individuals to uncertain­ ty-inducing events. the results indicate that anxiety symptoms significantly increased in response to the war outbreak, as predicted, although this effect was small in magnitude (cf. hemphill, 2003). anxiety symptom severity generally declined before the outbreak of war, spiked following the war outbreak, before rapidly declining to pre-war outbreak levels. however, contrary to our hypothesis, the war outbreak had a negligible effect on depressive symptoms. depressive symptoms gradually declined throughout the duration of the study and did not spike in response to the war outbreak. finally, socioeconomic status had a moderate effect on decreased anxiety symptoms and decreased depressive symptoms over the course of treatment, irrespective of the war outbreak. these findings thus provide support for the notion that socioeconomic status serves as a protective factor against psychopathology in times of heightened uncertainty. the finding that anxiety symptom severity increased in response to the war outbreak, but depressive symptom severity did not, may relate to how anxiety and depression are differentially associated with intolerance of uncertainty. as noted in the introduction, in­ tolerance of uncertainty, which may underpin many psychopathological impairments to daily functioning, has been suggested to be more pronounced in anxiety disorders than depression (jensen et al., 2016). however, meta-analytic findings suggest that intolerance of uncertainty lacks etiological specificity to differentiate anxiety and depression (gentes & ruscio, 2011). nonetheless, the semantic link between anxiety and intolerance of uncertainty is reflected in the american psychiatric association's (2022, p. 215) definition of anxiety as the "anticipation of [a] future threat," which coincides with the definition of intolerance of uncertainty (i.e., responding to uncertainty-inducing events with discom­ fort and anxiety which, in turn, further increases negative affectivity, cf. psychological entropy; hirsh et al., 2012; jensen et al., 2016). furthermore, even though the effect of the war outbreak on anxiety symptoms is small in magnitude by most statistical standards, it is important to consider the clinical implications of uncertainty-inducing events on anxi­ ety symptoms within a treatment-seeking population and place the effect in a broader context. for instance, the magnitude of the effect between increased anxiety symptoms in response to the war outbreak is slightly larger than the association between aspirin consumption and heart attack prevention (rosenthal, 1991, p. 136; see also hemphill, 2003). moreover, this effect size mirrors typical effect sizes that research on the effect of disasters on mental health disorders produces, where pooled effect estimates range from 0.05 and 0.20 (keya et al., 2023). uncertainty breeds anxiety and depression 12 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ the present study has limitations. in line with previous studies (e.g., guerra & eboreime, 2021; skwirczyńska et al., 2022), we found socioeconomic status to buffer against psychopathological development following the abrupt increase in external un­ certainty due to the war outbreak. however, the interpretation of this effect may be limited by using self-reported socioeconomic status, where participants self-rated their socioeconomic status in relation to others. another limitation is our lack of control for media exposure. previous studies indicate frequency of media exposure to covary with anxiety and depression symptom severity (gao et al., 2020; riad et al., 2022). as such, without control for participant exposure to media coverage of the war, effects of the war outbreak on anxiety and depression symptom severity may have been attenuated (or even augmented). furthermore, this study is limited by a lack of qualitative interviews to provide insight into participant's experiences and perceptions of the war outbreak and its effects on their mental health. future studies could ameliorate this limitation by incorporating an ecological momentary assessment protocol (e.g., verhagen et al., 2022), wherein data on exposure to war-related media and self-reported affectedness of the war outbreak is collected with high frequency concomitantly with indices of anxiety and depression. no clinical interviews were conducted to accurately detect whether participants qualified for a diagnosis of an anxiety or depressive disorder. however, only treatment-seeking participants with scores indicative of an emotional disorder were included in the study, and the phq-9 and the gad-7 routinely emerge as good indicators of depressive and anxiety disorders (byrd-bredbenner et al., 2021; johnson et al., 2019; martin-key et al., 2022). additionally, this study is limited by design; temporal precedence was established but true causality cannot be inferred from the present analysis. finally, the large number of missing observations in the measures of anxiety and depression severity somewhat limits the statistical analyses. the possibility that partic­ ipants selectively neglected to provide data when they suffered most severely from depression and/or anxiety cannot be eliminated. however, there were no discernible trends in the missingness of data. moreover, modelling the data with state-of-the-art statistical procedures for handling missing data (i.e., fiml and robust hac versions of the general linear model) did not influence the statistical conclusion of the results as it yielded isomorphic parameter estimations. the present study has numerous strengths. firstly, this study is the first analysis of the impact of the war in ukraine in a clinical sample, and thus provides up-to-date information about the reaction of treatment-seeking individuals to abrupt uncertainty. additionally, although greater average variability in indicators of depression and anxiety is to be expected in clinical samples (hirsh et al., 2012; sauer-zavala & barlow, 2021), a clear upward spike in average levels of depression and anxiety severity in response to the war outbreak was discernible. secondly, measures of anxiety and depression severity were obtained weekly throughout the treatment intervention, allowing for a representa­ hlynsson, gustafsson, & carlbring 13 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ tive estimation of the psychopathological response to the war outbreak. thirdly, given that psychopathological development surges in response to abrupt uncertainty-inducing events (cf. entropy increase; guerra & eboreime, 2021; hirsh et al., 2012; lim et al., 2022; osokina et al., 2023; riad et al., 2022), our study may have buffered psychopathological development among swedish treatment-seeking individuals. other strengths include the exclusive inclusion of treatment-seeking individuals and an adequately large sample size. the present study may have implications for how abrupt uncertainty-inducing events can be mitigated at a population level. briefly, our results suggest that anxiety symptom severity rises in conjunction with increased environmental uncertainty (cf. entropy in­ crease); a particularly interesting finding considering the geographical distance between sweden and ukraine, which exceeds 1500 km. the study underscores the need for heightened vigilance and support for individuals predisposed to psychopathology when confronted with sudden, uncertainty-inducing events, irrespective of their physical prox­ imity. however, it is important to approach these findings with caution. the study did not directly measure participants' perceptions of the war outbreak or ascertain which specific aspects of the conflict were most impactful to them. given this limitation, the direct influence of the war outbreak on the observed increase in anxiety symptoms re­ mains speculative. nevertheless, providing readily accessible health care services, such as government-funded internet-based psychotherapy, in the aftermath of such events could be beneficial. this approach may help alleviate societal impacts and reduce the overall burden of such events, particularly for individuals with below-average socioeconomic status who might encounter additional challenges in the wake of uncertainty-inducing events. finally, this study holds implications for clinicians in practice. it suggests that when psychotherapy is provided during crises, a sudden increase in anxiety symptoms can, in general, be expected in response to heightened environmental uncertainty (cf. entropy increase). however, statistically controlling for this crisis-related increase reveals that overall severity of anxiety symptoms continues to decrease throughout the course of treatment. as such, an increase in anxiety symptoms during crises situations should not automatically be interpreted as an indicator of unsuccessful treatment. instead, it should be recognized as a potential confounding factor in estimating treatment efficacy. furthermore, this effect differed between treatment group assignments (see figures s3 and s4, supplementary materials). conclusion the present study highlights the impact of the ukrainian war outbreak on emotional disorders, particularly anxiety symptoms, in a clinical population. anxiety symptom severity seems to be sensitive to the conflict's influence, experiencing an increase of up to 1.22 points following the war outbreak. moreover, socioeconomic status may serve as a protective factor against the development of psychopathological disorders in uncertainty breeds anxiety and depression 14 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://www.psychopen.eu/ the wake of uncertainty-inducing events. lastly, this study reinforces previous findings demonstrating the effectiveness of internet-based psychotherapeutic interventions in alleviating emotional disorder symptoms. funding: we declare that no financial support was received for the research, authorship, and/or publication of this article. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. ethics statement: the study was approved in 2021 by the swedish ethical review authority (dnr 2021-00034) and again in 2022 following an addendum to the initial proposal outlining our intent to analyze data related to the war (dnr 2022-01362-02). preregistration: this study was not preregistered. twitter accounts: @jonhlynsson data availability: the data that support the findings of this study are available from the corresponding author, jih, upon reasonable request. supplementary materials the supplementary materials include the following items (see hlynsson et al., 2024): • a flow chart illustrating the study design. • an analysis featuring participants exclusively assigned to a 16-week treatment intervention to corroborate the findings reported in this paper. • a directed acyclic graph illustrating the hypothesized causal model and associations between variables. • full information maximum likelihood (fiml) estimates contrasted with the heteroscedasticity and autocorrelation consistent (hac) covariance matrix estimation. • an analysis of the effect of treatment group assignment during the study period. • an assessment of overall treatment efficacy during the study period. index of supplementary materials hlynsson, j. i., gustafsson, o., & carlbring, p. 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(2023). mental health symptoms and coping strategies among ukrainians during the russia-ukraine war in march 2022. the international journal of social psychiatry, 69(4), 957–966. https://doi.org/10.1177/00207640221143919 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. uncertainty breeds anxiety and depression 20 clinical psychology in europe 2024, vol. 6(1), article e12083 https://doi.org/10.32872/cpe.12083 https://doi.org/10.1016/j.jad.2020.08.001 https://doi.org/10.1177/00207640221143919 https://www.psychopen.eu/ uncertainty breeds anxiety and depression (introduction) internet-based therapy aim of the present study hypotheses method participants and recruitment measures treatment interventions data analysis results sample characteristics the effects of the war outbreak additional analyses discussion conclusion (additional information) funding acknowledgments competing interests ethics statement preregistration twitter accounts data availability supplementary materials references from broken models to treatment selection: active inference as a tool to guide clinical research and practice editorial from broken models to treatment selection: active inference as a tool to guide clinical research and practice lukas kirchner 1, anna-lena eckert 2, max berg 1 [1] department of psychology, clinical psychology and psychotherapy, philipps-university of marburg, marburg, germany. [2] department of psychology, theoretical cognitive science, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2022, vol. 4(2), article e9697, https://doi.org/10.32872/cpe.9697 published (vor): 2022-06-30 corresponding author: lukas kirchner, department of psychology, clinical psychology and psychotherapy, philipps-university of marburg, gutenbergstraße 18, 35037 marburg, germany. e-mail: lukas.kirchner@unimarburg.de computational theories have fundamentally changed the scientific understanding of how the mind works for both healthy and pathological experiences and behaviours. in this context, the active inference framework has gained considerable attention within the scientific community (heins et al., 2022; smith et al., 2022). as a process theory, it integrates complex phenomena, such as perception, learning, and action under a unified theory of bayesian inference (da costa et al., 2020; friston et al., 2017). active inference has proven useful in modelling data from heterogeneous fields ranging from cognitive neuroscience to biology and general psychology (e.g., friston et al., 2016, 2017). its com­ putational tractability and biological plausibility have also made it increasingly relevant to clinical psychology in recent years (e.g., smith, badcock, et al., 2021). in active inference and related, bayesian neurocomputational theories, it is assumed that individuals do not have direct access to the circumstances in their surroundings. instead, they have to infer the (probabilistic) properties of their environment through action and perception by integrating prior information about their environment with ambiguous sensory input in a rational (i.e., bayes-optimal) manner (friston et al., 2016; hohwy et al., 2008). the resulting “internal model of the world” (i.e., the agent’s beliefs about how certain sensory information relates to environmental conditions) shapes future perception (friston, 2010) and enables agents to leverage the past to predict the future in an ever-changing environment (badcock et al., 2017). in accordance with this perspective, perception, action, and learning are all subject to inferential process­ this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9697&domain=pdf&date_stamp=2022-06-30 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ es on different timescales (smith et al., 2022). individuals thus take an active role in constructing their experiences, which they can further alter by actively changing their environment. whereas accurate internal models provide good predictions about which action se­ quences lead to preferred sensory observations, distorted internal models can lead to aberrant experiences and behaviours that may hinder the organism from achieving its goals (badcock et al., 2017; schwartenbeck et al., 2015). there is evidence that the internal models of individuals with mental disorders show substantial deviations from each other and from the models of healthy individuals. for example, recent accounts of depression have conceptualised patients' tendency to reappraise or disregard posi­ tive information in terms of highly precise and hence tenacious negative prior beliefs (kube et al., 2020). this computational perspective has inspired novel ideas for the treat­ ment of depression (e.g., chekroud, 2015). similar reconceptualisations with relevance for psychological treatments have been suggested for numerous mental disorders and health conditions, including psychosis (sterzer et al., 2018), persistent somatic symptoms (paulus et al., 2019), and eating disorders (barca & pezzulo, 2020). in this context, the active inference framework offers the opportunity to formalise deviations in a person’s internal models, thus enabling a detailed description and op­ erationalisation of relevant experiential and behavioural distortions (e.g., montague et al., 2012). from our point of view, this could improve clinical research, diagnostics, and the treatment of mental disorders in several ways. clinical research may benefit from a finely grained formalisation of deviant experiences and behaviours within the active inference framework because it opens up a possibility for studying aetiological mechanisms from a computational perspective (stephan, binder, et al., 2016). because of their generative structure, computational theories enable the derivation of well-opera­ tionalised hypotheses about pathological processes in mental disorders and the computer simulation of aberrant experience and behaviour. in comparison with empirical data, researchers could thus rigorously formalise, simulate, and compare different mechanis­ tic models of patients’ experiential and behavioural symptoms. moreover, the active inference perspective could inform the diagnostics of mental disorders (or rather the diagnostics of patients’ implicit belief systems) by providing practitioners with individual estimates of their patients’ internal model parameters in disorder-relevant situations (stephan, bach, et al., 2016). for example, using probabilistic gambling tasks that dis­ tinguish between goal-directed information seeking and random exploration behaviour could provide clinicians with individual parameter diagnostics regarding the relationship between information seeking, reward sensitivity, and psychopathology in substance abusers (smith, schwartenbeck, et al., 2021). such applications could not only strengthen a more transdiagnostic perspective on mental disorders, but also have tangible implica­ tions for treatment development and treatment selection. if we assume that therapeutic interventions may have different effects on patients' model parameters, finely grained active inference – a tool to guide clinical research and practice 2 clinical psychology in europe 2022, vol. 4(2), article e9697 https://doi.org/10.32872/cpe.9697 https://www.psychopen.eu/ operationalisation in the context of active inference could contribute to tailored interven­ tions that target specifically these parameters. from the practitioner's perspective, it would be particularly important to investigate which tasks are likely to diagnose internal models that inform treatment selection and guide psychotherapy. the active inference approach affords an improved mechanistic understanding of pathological processes in mental disorders. as a unifying process theory of brain and mind function, it brings together perception, learning, action, and decision making un­ der the umbrella of a bayesian principle, which predestines it for clinical application. because of its high degree of formalisation and its flexibility, we believe that the active inference approach is well suited to functionally link heterogeneous clinical phenomena to patients’ internal belief systems. this will enable researchers to better differentiate and operationalise underlying mechanisms and tailor the diagnosis, aetiology, and treat­ ment of mental disorders. funding: this work was funded by the hessian ministry of higher education, research, science, and the arts. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: this work was realised within the cluster initiative “the adaptive mind” (tam) which brings together scientists from experimental psychology, clinical psychology, and artificial intelligence to improve the understanding of how the human mind successfully adapts to changing conditions. tam is funded by the hessian ministry of higher education, research, science, and the arts. references badcock, p. b., davey, c. g., whittle, s., allen, n. b., & friston, k. j. 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(2018). the predictive coding account of psychosis. biological psychiatry, 84(9), 634–643. https://doi.org/10.1016/j.biopsych.2018.05.015 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. kirchner, eckert, & berg 5 clinical psychology in europe 2022, vol. 4(2), article e9697 https://doi.org/10.32872/cpe.9697 https://doi.org/10.1016/s2215-0366(15)00360-0 https://doi.org/10.1016/j.biopsych.2018.05.015 https://www.psychopen.eu/ an online mindfulness intervention for international students: a randomized controlled feasibility trial research articles an online mindfulness intervention for international students: a randomized controlled feasibility trial sumeyye balci 1 , ann-marie küchler 1 , david daniel ebert 2 , harald baumeister 1 [1] department of clinical psychology and psychotherapy, institute of psychology and education, ulm university, ulm, germany. [2] department of sport and health sciences, technical university of munich, munich, germany. clinical psychology in europe, 2023, vol. 5(2), article e9341, https://doi.org/10.32872/cpe.9341 received: 2022-04-19 • accepted: 2023-05-03 • published (vor): 2023-06-29 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: sumeyye balci, department of clinical psychology and psychotherapy, institute of psychology and education, ulm university, lise-meitner-straße 16, d-89081 ulm, germany. phone: +49-(0)731/50 32812. e-mail: sumeyye.balci@uni-ulm.de supplementary materials: preregistration [see index of supplementary materials] abstract background: student mobility across borders poses challenges to health systems at the university and country levels. international students suffer from stress more than their local peers, however, do not seek help or underutilize existing help offers. some barriers to help-seeking among international students are insufficient information regarding the health offers, stigma, and language, which might be overcome via culturally adapted internet and mobile-based interventions (imi). method: a randomized controlled feasibility trial with a parallel design assessed the feasibility and potential efficacy of an online mindfulness intervention adapted for international university students. participants were randomized into either an adapted online mindfulness intervention (studicarem-e) (ig, n = 20) or a waitlist control group (wl, n = 20). participants were assessed at baseline (t0) and eight-week post-randomization (t1). the feasibility of studicarem-e was evaluated regarding intervention adherence, client satisfaction, and potential negative effects. the potential efficacy of studicarem-e was measured by means of the level of mindfulness, perceived stress, depression, anxiety, presenteeism, and wellbeing. efficacy outcomes were evaluated with regression models on the intention-to-treat (itt) sample (n = 40), adjusting for the baseline values. results: participants’ formative feedback suggested improvements in the content of the imi. there were no crucial negative effects compared to wl. assessment dropout was 35% (ig: 50%: wl: 20%), this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9341&domain=pdf&date_stamp=2023-06-29 https://orcid.org/0000-0001-8219-6163 https://orcid.org/0000-0003-3305-4892 https://orcid.org/0000-0001-6820-0146 https://orcid.org/0000-0002-2040-661x https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ and intervention dropout was 60%. studicarem-e yielded significant improvements in mindfulness (β = .34), well-being (β = .37), and anxiety (β = -.42) compared to wl. conclusion: studicarem-e might be used among culturally diverse international student populations to improve their well-being. future studies might carefully inspect the extent of the adaptation needs of their target group and design their interventions accordingly. keywords e-health, digital health, student mental health, cultural adaptation, internet intervention, international student highlights • international students suffer from more stress compared to their local peers but rarely seek help. • internet interventions can be adapted to cater to the needs of culturally diverse international students. • the adapted internet intervention for international students offers great potential to improve psychological outcomes. starting university after high school is a challenging time. university students experience stress due to financial issues, love life, and family relationships (karyotaki et al., 2020), and sexual identity (rentería et al., 2021). exposure to these stressors might result in developing a mental health problem or low academic functioning, even dropping out of university (athira et al., 2020; bantjes et al., 2021; bruffaerts et al., 2018). prevalence of mental health problems among university students assessed from eight countries, and 19 universities, resulted in 35% of student participants (n = 13.984) having at least one mental health problem (i.e. anxiety, mood, or substance use), with major depressive disorder (mdd) (21.2% lifetime prevalence, 18.5% 12-month prevalence) being the most common and generalized anxiety disorder (gad) the second most common (18.6% lifetime prevalence, 16.7% 12-month prevalence) (auerbach et al., 2018). the burden from mental health problems comprises 45% of the overall disease burden among 10-24year-olds (gore et al., 2011). moreover, the majority of mental health problems over the lifetime first develop before the age of 24, which makes this time of university crucial to screen for mental health problems and provide prevention and/or treatment opportunities (jones, 2013). students who cross borders to study are increasing in europe, especially in germany, where the number of international students substantially increased from 312.000 in 2018 to 416.437 in 2020 (eurostat, 2018; statistisches bundesamt, 2021). international students encounter similar life challenges as students studying in their home country but are also faced with additional stressors that may trigger homesickness (akhtar & kröner-herwig, 2015), problems in socializing with the local students (byrne et al., 2019), adapting to a new country, lifestyle, and language, and a new academic culture and customs an adapted version of an online mindfulness intervention for international students 2 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ (forbes-mewett & sawyer, 2016; yu & wright, 2016). studying abroad, while mostly associated with positive experiences, can cause some challenges and result in mental burden (orygen, 2020; stokes et al., 2021). even though university students suffer from psychological distress, their help-seek­ ing behavior is very limited (auerbach et al., 2016). this can be attributed to various factors, such as not being familiar with the symptoms of or the help options for mental health problems, social stigma, social and cultural influences (e.g. traditional masculine ideals) (lynch et al., 2018), limited access to professional help via university, and finan­ cial problems (auerbach et al., 2016; gulliver et al., 2010; orygen, 2020). although their psychological stress level is higher compared to students of the host country (lu et al., 2014), international students are less likely to seek help from a counseling service (lu et al., 2014; stokes et al., 2021), have lower mental health literacy, and less positive attitudes towards seeking help (clough et al., 2019). some barriers which are specific to international students might be related to cultural backgrounds where symptom severity is underestimated, hesitation because of their family’s reaction, and language barrier (lu et al., 2014). in general, cultural influences play an important role in attitudes toward mental health and help-seeking (hudak et al., 2018). furthermore, international students who reach out to a counseling service fail to utilize psychological help services, e.g. not attending the necessary number of sessions, and even benefit less from it, compared to local students who utilized these services (stokes et al., 2021), and drop out of the treat­ ment prematurely (nilsson et al., 2004). in summary, there is a persistent discrepancy between mental health needs and actual help-seeking behavior among international stu­ dents. therefore, it is critical to offer appropriate psychological help to this particularly vulnerable sub-group of the student population (teegen & conrad-popova, 2021). barriers to help-seeking could be overcome by an easily accessible offer via deliver­ ing psychological health interventions online. internetand mobile-based interventions (imi) have the advantage of being independent of time and place, ability to reach pop­ ulations otherwise hard to reach, offering interventions to treat and prevent various psychological problems, and are cost-effective (ebert et al., 2018). likewise, imi have proven to be effective in university student populations with small to moderate effects in decreasing psychological symptoms (harrer et al., 2019). provided as guided imi they could work as effectively as face-to-face cognitive behavioral therapy (carlbring et al., 2018). the limited number of studies that targeted international students’ wellbeing via offering an imi resulted in improved mental health (kanekar et al., 2010), reduction of sleep difficulties (spanhel, burdach, et al., 2021), more help-seeking, and reduced stigma (clough et al., 2020). however, issues around the adherence and uptake of imi still persist (batterham et al., 2021; molloy et al., 2021). imi can also aim at treating mental health problems, e.g. depression, but can also be utilized in promoting health skills (galante et al., 2018; sevilla-llewellyn-jones et al., 2018). an example of a helpful skill to promote mental health and well-being is mindfulness. mindfulness refers to balci, küchler, ebert, & baumeister 3 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ experiencing the present and being aware of life with acceptance and self-compassion, without any judgment (slom & kabat-zinn, 2020). mindfulness-based interventions could be delivered successfully online (jayawardene et al., 2017), and have been tested and found effective among students (hall et al., 2018; mak et al., 2015; nguyen-feng et al., 2017) and general and clinical populations (querstret et al., 2018; sevilla-llewellyn-jones et al., 2018). a recent meta-analysis of rcts of online mindfulness interventions resulted in significant small to moderate effects on depression (g = .34), anxiety (g = .26), mindful­ ness (g = .40), stress (g = .44), well-being (g = .22). these effects were maintained in the follow-up for depression (g = .25) and anxiety (g = .23) (sommers-spijkerman et al., 2021). mindfulness interventions can be seen as less threatening due to their associations with well-being and calmness, instead of interventions targeting mental health problems which might impede help-seeking due to stigma (clement et al., 2015). mindfulness interventions could also be adapted to meet the needs of a specific target group. for instance, the delivery method could be changed (e. g. intervention taking place in a cultural community center), the facilitator, researcher/therapist, could be matched with a target group’s cultural background, a culturally congruent recruitment strategy could be adopted, the content could be changed, culturally appropriate analogies could be used (watson-singleton et al., 2019), dispelling myths around mindfulness (castellanos et al., 2020; cotter & jones, 2020; lawlor, 2022), storytelling, and community input can be uti­ lized (le & gobert, 2015). however, the adaptation of online mindfulness interventions is rarely defined in detail in the previous literature, but systematic adaptation frameworks are emerging (loucks et al., 2022; spanhel, balci, et al., 2021). moreover, mindfulness interventions’ transdiagnostic nature and growing popularity in recent years via adver­ tising as a self-care instrument make them more appealing. they could therefore serve as an alternative way to reach out to international students with various psychological problems. objectives in order to explore the feasibility and possible efficacy of the online mindfulness inter­ vention adapted for international students, studicare mindfulness – english version (studicarem-e), the following research questions will be explored.   research questions: 1. are the study methods feasible and transferable to a future, large-scale randomized controlled trial with regard to implementation and the chosen recruitment strategy? 2. what are the levels of intervention satisfaction, adherence, negative effects, and acceptance? 3. does the internet-based intervention studicarem-e have a potential effect on increasing mindfulness levels compared to a waitlist control group? an adapted version of an online mindfulness intervention for international students 4 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ 4. what effects does the studicarem-e have on measures of psychological well-being (depression, stress, anxiety, well-being, and presenteeism) in comparison to the waitlist control group? method this is a two-armed, randomized controlled trial of parallel design (registered in the german clinical trials register drks00017507) comparing guided imi studicarem-e (ig) with a waitlist control group (wl) receiving the unguided version of the same imi eight weeks post-randomization. the study was approved by the ethics committee of ulm university (number 413/18) and followed the consort guidelines for feasibility trials (eldridge et al., 2016). participants the eligibility criteria for participating in the study were: being at least 18 years old, having a low to moderate level of mindfulness (freiburg mindfulness inventory fmi < 37), having internet access, having student status, ability to read and understand english (all self-reported), giving consent to participate in the study. exclusion criteria included being in a mindfulness course, having a higher than moderate mindfulness level, and being in psychotherapy. procedure participants were recruited from july 2019 to march 2020. the recruitment was done through regular emails sent out twice a year from the cooperating universities of the studicare project (harrer et al., 2018; küchler et al., 2019) in germany, switzerland, and austria, complemented by study posters and further on-site recruitment strategies at the ulm university. the email consisted of information regarding various trainings that are offered within the studicare project at a given time along with an invitation to participate in the training. additional emails were sent to universities’ international offices in the above-mentioned countries. potential participants received a direct link to the study website to register and were then invited to the screening via email. after screening and providing informed consent, participants were invited to complete the initial survey. participants were randomized into either intervention (immediate access) or waitlist (access eight weeks post-randomization) control group. afterward, they got access to online training. randomization randomization was carried out by an independent researcher who was not involved in the studicare project. a simple randomization list applying block sizes of two and balci, küchler, ebert, & baumeister 5 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ four by a computer generator was created using sealed envelope1. 20 participants were allocated to each study arm with a 1:1 ratio, making a total of 40 participants. intervention based on acceptance and commitment therapy (hayes et al., 1999) and stress manage­ ment principles (kaluza, 2015), studicarem-e consists of seven weekly modules and two booster sessions; each module takes approximately 50 minutes to complete (küchler et al., 2020; schultchen et al., 2020). studicarem-e has been shown to yield a high effect among german-speaking students compared to a waitlist control group (d = 1.37) (küchler et al., 2022). participants were advised to complete one module per week. participants who com­ pleted seven modules received access to booster sessions one and two, four and 12 weeks, respectively, after completion of the last module. the focus of the intervention is on promoting mindfulness and psychological flexibility. the content is delivered on a content management platform (www.minddistrict.com) via text, images, audio files, and interactive quizzes. participants were able to access the online platform minddistrict at all times. every module aims at improving a different skill, such as identifying stress-inducing thinking patterns and getting in touch with values in life. at the end of each module, homework is assigned to the participant, and at the beginning of the next module, the participants are encouraged to monitor their progress. each module introduces a different kind of meditation exercise, e.g. body scan, interoception. a mind­ fulness journal and a summary of the respective module were available at the end of each module. content and introduced mindfulness exercises of each module are presented in table 1. adaptation of the intervention cultural adaptation of the intervention was based on resnicow’s theory of cultural sensi­ tivity in health behavior intervention development, which has two dimensions: surface and deep structure. according to the theory, interventions could be altered to fit the target groups’ needs and features in these levels where surface-level alterations concern visible characteristics of the target population such as language, music, food choices, and clothing, whereas deep structure changes refer to counting intersecting effects of cultur­ al, social, historical and psychological influences on the target health behavior (resnicow et al., 2000). in this trial, surface structure changes were conducted to make the interven­ tion content more compatible with culturally diverse international students. conducted changes to the original german intervention represented in table 2 based on spanhel et al.’s taxonomy of cultural adaptation of imi for mental health problems (spanhel, balci, 1) https://www.sealedenvelope.com/simple-randomiser/v1/lists an adapted version of an online mindfulness intervention for international students 6 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 http://www.minddistrict.com https://www.sealedenvelope.com/simple-randomiser/v1/lists https://www.psychopen.eu/ et al., 2021). the taxonomy consists of various components that researchers can adapt in order to make imi more appropriate to the new target group: ten components related to the content of the intervention, four methodological, and three procedural components. changes were implemented in content components (e.g. stigmatization of mental health problems), methodological (e.g. guidance in english), and procedural domains (e.g. using a theoretical framework for adaptation). for english-speaking international students, the intervention content of studicare-mindfulness (küchler et al., 2020; schultchen et al., 2020) was translated to english and certain aspects (e.g. language barrier, different education systems) changed in accordance with student life and stress sources. table 1 intervention modules and mindfulness exercises module names content mindfulness meditation exercises awareness an introduction to the concept of mindfulness body scan, mindful walking exercise mindful body perception mindful perception of bodily signals heart meditation, mindful perception of satiety and hunger stress-aggravating thought mindful coping strategies to deal with stress and distancing from stressful thoughts power of thoughts, mindful straightening the posture a beneficial thought developing a beneficial thought to deal with stress inhaling the beneficial thought, short breathing meditation values in life discovering what is important and valuable in life here and now exercise self-care looking at yourself with a loving gaze loving and kindness meditation body&mind enjoying small things in life with mindfulness shavasana and mindful yoga refresh i&ii review of previous modules repeating the previous exercises balci, küchler, ebert, & baumeister 7 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ table 2 culturally adapted elements of studicare mindfulness-e core components / specific components example content components 1. illustrated characters appearances/ names of characters change of names of characters to diverse names (e.g. hua, andrew, farah) content/ stories/ background of characters added characters from various regions of the world who migrated to study in germany 2. illustrated activities daily life walking the dog, tutoring a fellow student, and contact with family members living abroad 3. illustrated environment/ burdens burdens high level of pressure for academic excellence, adapting to a foreign academic culture 4. language translation translating intervention german to english 5. language tailoring simplify text: shortening text passages, simplifying sentences less technical phrasing, modify wording for easier readability use of concrete terms or informal language the colloquial form was used milder descriptions of mental health concepts describing psychological problems in a university context 6. difference in concepts of mental health and its treatment stigmatization of mental health problems framing the goal of the intervention as a mindfulness-based stress management tool instead of mental health intervention in order to reduce the stigma 7. goals of treatment increase understanding of treatment possibilities introducing various ways of coping with university-related stressors. 8. methods of treatment information/ links to other helpful addresses psychological help offers which might be available in english are presented to each participant an adapted version of an online mindfulness intervention for international students 8 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ core components / specific components example methodological components 9. guidance person used as guide guidance by an english-speaking psychologist (sb) format of guidance (tailored feedback) participants can ask for personal contact in addition to semistructured feedback procedural components 10. methods used to obtain information personal interaction (focus groups, interviews, discussions, think-aloud) received feedback in the form of qualitative data for the process evaluation and further implementation of the program surveys/ questionnaires assessed acceptance and effectiveness pilot/ feasibility studies this trial has been conducted to measure the feasibility to inform a future definitive trial. 11. persons involved target group and associated people international students professionals working with the target group international office workers of partner universities distributed recruitment emails 12. theoretical framework guideline for cultural adaptation of face-to-face treatment surface structure changes were based on the cultural sensitivity framework by resnicow (resnicow et al., 2000) guidance at the end of each module, intervention group (ig) participants received feedback from an e-coach, who was a trained psychologist (sb). each feedback consisted of a review of their progress in the intervention and encouragement to continue the intervention such as “dear …., thanks for sending your third module! i am happy that you are working actively on the program.” and continues with a review of completed exercises “the second task was to think about stressful situations in the past and what helped you to cope with stress. you wrote that … was very helpful for you.” and end with an encouragement to continue with the upcoming module “i wish you a relaxed week with many attentive moments and a lot of fun while working on module 4.”. moreover, reminder emails were sent to the participants who did not complete the modules in time. the e-coach was instructed to take no longer than 15 minutes per feedback, which results in a planned e-coaching time of max. 105 minutes per participant for all seven modules. balci, küchler, ebert, & baumeister 9 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ sms coach in imi, receiving sms messages may contribute to adherence and intervention effect (lentferink et al., 2017; webb et al., 2010). consequently, a voluntary text message coach was implemented and offered to each participant. these motivational sms messages were set to be sent every two days, throughout the intervention. they consisted of motivational texts to promote the use of learned skills, be mindful throughout the day, and continue the intervention, such as “‘the true art of life is to see beauty in the daily.’ what beautiful moment did you experience today?”, and “‘every moment is absolute, alive and meaningful.’ – what was your mindful moment today? when was the least mindful moment? how did you feel then?”. control group control group participants received a document summarizing the alternative support offers via email after the randomization. participants of the control group got access to the unguided version of the studicarem-e eight weeks after the randomization. assessment and outcomes assessments were conducted via an online platform, www.unipark.de, at baseline (t0) and eight weeks post-randomization (t1), blinding of outcome assessment was not possi­ ble. all data were self-reported. acceptability was measured via participants’ attitudes towards the imi, their forma­ tive feedback, and satisfaction with the intervention and its potential negative effects. open-ended questions at the end of each module were extracted from the minddistrict platform. these outcomes are reported descriptively. the primary efficacy outcome of this study is mindfulness level. secondary outcomes are anxiety, stress, depression, personality, well-being, presenteeism, client satisfac­ tion, risks and negative effects of psychotherapy, and acceptance and adherence ques­ tions. mindfulness was assessed using the freiburg mindfulness inventory (fmi), which consists of 14 items measuring mindfulness on a 4-point scale ranging from 1= rarely to 4 = almost always, and showed high internal consistency (α = 0.84) (walach et al., 2006). anxiety was measured with a 7-item generalized anxiety disorder questionnaire (gad-7) on a scale from 0 = not at all to 3 = nearly every day and has high internal consistency (α = 0.92) (spitzer et al., 2006). stress outcome was measured with 4-item perceived stress scale (0 = never to 4 = very often), which also showed good reliability (α = 0.77) (warttig et al., 2013). depression was measured with an 8-item patient health questionnaire, where high reliability was observed (α = 0.89) and rated on a scale of 0 = not at all to 3 = early every day (kroenke et al., 2001). an adapted version of an online mindfulness intervention for international students 10 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 http://www.unipark.de https://www.psychopen.eu/ who-5 well-being index was used to assess subjective well-being on a scale of 0 = at no time to 5 = all of the time, which showed high internal consistency, α > 0.80 (lara-cabrera et al., 2022; spanhel, burdach, et al., 2021; topp et al., 2015). presenteeism, i.e. loss of productivity was measured with the presenteeism scale for students. the subscale of work impairment was used to assess the degree of pre­ senteeism, which consist of 10 items; with total scores ranging from 10 to 50, higher scores represent a higher degree of presenteeism and showed high reliability, α = 0.90 (matsushita et al., 2011). eight weeks after randomization, in addition to the above-mentioned tools, assess­ ments of intervention satisfaction were done using the client satisfaction questionnaire (total scores range from 8 to 32) adapted to internet-based interventions (boß et al., 2016). negative effects of psychotherapy were measured using inep (inventory for the assessment of negative effects of psychotherapy) adapted to online interventions with 22 items describing possible negative effects that may occur during the online interven­ tion and whether they are attributed to the intervention (ladwig et al., 2014). the results of this scale are presented descriptively. sample size in order to determine the sample size for this feasibility trial, we followed the recommen­ dation by whitehead et al. (2016), resulting in a sample size of 15 participants per trial arm for pilot testing of a potential confirmatory trial with 90% power and two-sided 5% significance. a meta-analysis resulted in an effect size of 0.40 for mindfulness-based imi, therefore we assumed a higher effect size, i.e. 0.50 because this trial is guided (sommers-spijkerman et al., 2021). with the expectation of a 30% dropout, we aimed at reaching a sample size of 40 in total. statistical analyses ibm spss/version 26 and r studio were used in statistical analyses with a significance level of α = 0.05. descriptive statistics (means, sds for continuous outcomes, and percen­ tages for categorical variables) were used to summarize the demographic and feasibility data for study groups. linear regression models were used to investigate potential group differences, where baseline values were used as covariates in all models (dummy coded predictor: ig = 1). for each outcome, we reported standardized regression coefficients and corresponding 95% ci and adjusted r 2 values. data analyses were based on the intention-to-treat principle (itt). missing data were imputed based on multivariate imputation by chained equations to create 20 completed datasets with 15 iterations. predictive mean matching was applied as an imputation model. balci, küchler, ebert, & baumeister 11 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ results feasibility recruitment and participants recruitment lasted from may 2019 until march 2020. one hundred and twenty-three participants were invited to the screening. n = 46 did not complete the screening. out of 77 screened, 37 were excluded due to the following reasons: not providing informed consent (n = 18), having a high fmi score (> 37) (n = 10), being in psychotherapy (n = 6), being in another mindfulness training (n = 1), not being a student (n = 1), and providing an inaccessible email address (n = 1). n = 40 provided consent and were randomized to either ig or wl groups, see figure 1. the mean age of the participants was m = 26.23 (sd = 4.51), 77.5% were female, 37.5% could speak the host country’s language well (>b2 level), and 97% speak english well (>b2 level). the study level of the participants varied: out of 40, 24 studied in a master's program, nine were in a bachelor's program, six were in a ph.d. program, and one participant was doing an internship semester. the baseline characteristics of the participants are tabulated in table 3. out of 40 randomized participants, 26 (ig: 50%; wl: 80%) completed the t1, resulting in a study dropout of 35%. there was a baseline difference between assessment dropouts and non-dropouts, where non-dropouts had slightly more stress (mean difference = 1.68). intervention adherence out of 20 participants randomized into the ig, eight participants (40%) completed at least five core modules (four of them completed the seven modules), whereas four did not finish the first module. three completed the first module, two participants completed two modules, two participants three modules and one participant completed the fourth module, see figure 2. all the intervention completers also completed the post-randomi­ zation assessment. no reasons were reported regarding no uptake of the intervention. the average intervention duration among the intervention completers was 60 days, five of them completed the intervention within 60 days. eight participants signed up for the sms coach. based on 10 participants’ answers to the open-ended questions on t1, participants practiced mindfulness on average 3.6 days weekly during the intervention. on these days, they spent an average of 18.3 minutes practicing mindfulness. acceptability in order to assess the acceptability of the studicarem-e among the participants, we used various sources: open-ended questions by the end of the post-intervention measurement, treatment satisfaction measured via csq, and potential negative effects measured with inep-on, and formative user feedback extracted via the online platform of minddistrict. an adapted version of an online mindfulness intervention for international students 12 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ according to the data from the open-ended questions at t1 (n = 10), five participants (25%) signed up for the sms coach and found this helpful. six participants stated that mindfulness meditation exercises were the most helpful element of the intervention. body scan and body-related exercises, e.g. mindful yoga, were well-liked by the partici­ pants. two participants stressed that example characters and the quiz on stress sources figure 1 flow diagram screened for eligibility (n = 77) excluded (n = 37) • no informed consent (n = 18) • fmi > 37 (n = 10) • current psychotherapy (n = 6) • not enrolled in college (n = 1) • providing an inaccessible email address (n = 1) assessed for objective 1 (n = 10) assessed for objective 2&3 (n = 20) allocated to intervention (n = 20) • received allocated intervention (n = 8) • did not receive allocated intervention (no reason reported) (n = 12) lost to follow-up (no reason reported) (n = 4) allocated to intervention (n = 20) • received allocated intervention (n = 20) assessed for objective 1 (n = 0) assessed for objective 2&3 (n = 20) lost to follow-up (give reasons) (n = 10) discontinued intervention (no reason reported) (n = 12) allocation assessment follow-up randomized (n = 40) enrollment assessed for eligibility assessment (n = 123) screened balci, küchler, ebert, & baumeister 13 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ were beneficial. the majority of the participants (79%) found the length of the modules just right. on average the participants scored the feasibility of doing the modules with daily tasks 7.3 out of a 10-point scale (0 = not feasible; 10 = very feasible) and scored 3.8 on the same scale regarding the disturbance the processing of modules caused in table 3 baseline characteristics variable all participants (n = 40) ig (n = 20) wl (n = 20) n % n % n % sociodemographic characteristics age (m, sd) 26.23 4.5 25.05 3.5 27.40 5.2 female gender 31 77.5 19 95 12 60 single 23 57.5 12 60 11 55 knowledge of host country language (> b2 level) 15 37.5 5 25.0 10 50.0 country of origin albania (n = 2), belarus (n = 3), belgium (n = 1), cameroon (n = 1), canada (n = 3), colombia (n = 2), costa rica (n = 1), france (n = 2), german (n = 1), ghana (n = 1), india (n = 1), indonesia (n = 2), italy (n = 3), kazakhstan (n = 1), kyrgyz republic (n = 1), mexica (n = 2), nepal (n = 1), pakistan (n = 1), portugal (n = 1), romania (n = 1), russia (n = 1), sweden (n = 1), turkey (n = 4), ukraine (n = 1), usa (n = 2) study characteristics full-time student 34 85 18 90 16 80 semester (m, sd) 10.14 6.8 9.21 5.02 11.06 8.36 study subject business and finance 8 20.0 4 20.0 4 20.0 social sciences 8 20.0 6 30.0 2 10.0 engineering 7 17.5 4 20.0 3 15.0 medicine & health 5 12.5 3 15.0 2 10.0 nature sciences 5 12.5 0 0 5 12.5 computer sciences 4 10.0 1 5.0 3 15.0 design 2 5.0 1 5.0 1 5.0 psychology 1 2.5 1 5.0 0 0 treatment utilization psychotherapy experience 10 25 7 35 3 15 m sd m sd m sd outcome measures mindfulness level 27.28 5.75 27.30 6.27 27.25 5.34 depressive symptoms 16.68 3.39 18.10 2.28 19.25 3.9 anxiety symptoms 17.27 4.42 16.75 4.09 17.80 4.77 presenteeism level 27.85 2.21 27.8 2.40 27.9 2.05 well-being 35.20 17.09 37.60 17.25 32.80 17 stress level 13.38 2.44 13.10 2.31 13.65 2.58 note. m = mean; sd = standard deviation; ig = intervention group; wl = waitlist control group. an adapted version of an online mindfulness intervention for international students 14 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ their everyday life. additionally, they scored 8.9 on their likelihood of participating in a mindfulness-based intervention in the future. in terms of treatment satisfaction, the itt data on csq, the overall satisfaction with the intervention was m = 25.4, sd = 2.2. all of the completers would definitely or probably recommend the intervention to a friend and 90% reported that the intervention met their needs, 70% would like to receive such intervention if they need help in the future, and 80% found the intervention satisfactory. potential negative effects of studicarem-e were evaluated with inep-on in t1. based on the results from inep-on, six ig participants reported seven negative effects caused by the imi in the following domains: anxiety about finding insurance (n = 1), increased financial worries (n = 1), data security (n = 1), feeling forced to do the exercises of the intervention despite not wanting to do it (n = 3), difficulties in making important decisions without asking the therapist (n = 2), found training or the formulations of the e-coach contained hurtful statements (n = 1) and feeling that being made fun of in the intervention material (n = 1). one participant reported negative effects on each of the above-mentioned domains, whereas the rest of the five participants reported negative ef­ fects on a single domain. of the five, two reported feeling forced into finishing modules, and three reported neglecting hobby/social contacts. no suicidal ideation was reported caused by the imi. the magnitude of all negative effects reported was low to moderate. according to the formative feedback extracted from the minddistrict platform, all of the modules were well-liked, scoring ≥ 7 out of a 10-point scale, the most liked being the last module (module 7: body and mind). recommendations included adding more figure 2 intervention completion 4 2 2 1 2 2 3 4 0 1 2 3 4 module 7 module 6 module 5 module 4 module 3 module 2 module 1 no log in intervention completion number of participants balci, küchler, ebert, & baumeister 15 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ video/audio files, diversifying example characters’ experiences, adding more mindfulness meditation exercises, and decreasing the number of text fields. efficacy outcomes descriptive statistics of the study outcomes at the baseline are represented in table 3. there were no baseline differences observed. controlling for baseline mindfulness levels, ig participants showed improvement in mindfulness at the t1 compared to wl (β = 0.34, 95% ci [0.06, 0.63], p < .05; adjusted r 2 = 0.13). moreover, anxiety was improved among ig participants, compared to wl (β = -0.42, 95% ci [-0.72, -0.11], p < .05; adjusted r 2 = 0.14) as well as well-being (β = 0.37, 95% ci [0.07, 0.68], p < .05; adjusted r 2 = 0.13). the effect estimates (β, ci, and p values) of the rest of the secondary outcomes are presented in table 4. table 4 post-randomization between-group differences adjusted for baseline values outcome baseline (t1) m (sd) posttreatment (t2) m (sd) standardized coefficient ß 95% ci p mindfulness (fmi) 27.27 (5.75) 31.79 (4.50) 0.34 [0.06 0.63] .01 depression symptoms (phq-8) 18.68 (3.39) 16.89 (3.88) -0.10 [-0.39 0.21] .52 anxiety symptoms (gad-7) 17.27 (4.42) 15.53 (3.84) -0.42 [-0.72 -0.11] .01 stress level (pss-4) 13.38 (2.44) 11.79 (2.05) -0.14 [-0.46 0.17] .37 wellbeing (who-5) 35.20 (17.09) 44.42 (15.44) 0.37 [0.07 0.68] .02 pss (presenteeism-work impairment score) 13.38 (2.44) 27.66 (1.47) -0.01 [-0.34 0.32] .94 note. m = mean; sd = standard deviation; fmi = freiburg mindfulness inventory; gad-7 = generalized anxiety disorder questionnaire; phq-8 = patient health questionnaire; pss = presenteeism scale for students; pss-4 = short form perceived stress scale; who-5 = world health organization well-being index. discussion this rct evaluated the feasibility, acceptability, and potential efficacy of a cross-cultural version of a mindfulness-based imi among international university students studying in germany, austria, and switzerland. the initial results suggest that the adapted version of studicarem-e was feasible, perceived acceptable, and offered benefits in psychological outcomes compared to wl, and minor negative effects were reported among ig partici­ pants. our preliminary results might guide a powered definitive trial. working examples and recommendations for improvement are presented in the following paragraphs. our recruitment strategy included sending emails via cooperating universities, using social media channels of university groups/student clubs, and hanging hard copy posters around the ulm university campus. we aimed at reaching a total of 40 participants, an adapted version of an online mindfulness intervention for international students 16 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ which took 11 months. the length of the recruitment is longer than a previous digital sleep intervention for international students, where n = 81 was reached in seven months (spanhel, burdach, et al., 2021). one reason for this might be the length and transdiag­ nostic nature of our intervention. moreover, international student offices could be better utilized to aid the recruitment process in a future trial. with the above-mentioned strategy, we reached a population of mostly female (77%) participants, aiming for a post-graduate degree (82.5%), e.g. master's and ph.d., which was higher than daad’s 2019/20 report of international students studying for a postgraduate degree in germany (52%) (daad, 2020). a post-randomization assessment dropout rate of 35% was detected. half of the ig and 20% of the wl failed to do the post-randomization assessment. this rate is in accordance with previous mindfulness imi among students (lahtinen et al., 2023). it is no surprise to have fewer dropouts in a waitlist control condition because the participants of this condition got access to the intervention only after completing the post-randomization assessment. in order to avoid dropouts, we sent out six reminder emails to participants who did not complete this assessment. however, the success of these measures was limited. future trials might include reminder sms or phone calls to decrease the dropout rate. the intervention adherence rate among ig participants was 40%. this rate is in line with a recent meta-analysis of online mindfulness interventions conducted with students and non-student populations, in which adherence rates ranged from 35 to 92% (sommers-spijkerman et al., 2021). although guided imi correlated with higher rates of adherence (treanor et al., 2021; zarski et al., 2016), this was not the case in our trial. according to a review, some factors related to an increase in adherence to imi are the female gender, being in the control group, having time flexibility to do the intervention, computer literacy, guidance, and depth of personalized feedback to increase self-efficacy (beatty & binnion, 2016). although our sample embodied some of these factors, e.g. guidance, others could be improved. program content seems to be a decisive factor in adherence. credibility, positive perceptions of the intervention content, personalization of the intervention team (e.g. providing a photo of the team), and intensity (e.g. too long/short and/or being too generic) of the content play a role in adherence (beatty & binnion, 2016). the inclusion of some persuasive design aspects might aid adherence as well (baumeister et al., 2019). as mentioned by the participants as well, computer-human dialogue support, e.g. audio and visual content, and social support, e.g. competition, categories can be improved in a future definitive trial. one specific component of this trial was that we adapted our intervention to a culturally diverse group of international students. this diversity of the target group might require novel intervention features beyond surface structure changes (resnicow et al., 2000) to increase adherence. adapting an intervention for a group of participants from various cultural, social, and financial backgrounds is particularly challenging, and balci, küchler, ebert, & baumeister 17 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ naturally, offering intervention content as common as possible to be able to appeal to the majority is demanding. therefore, one should carefully inspect all the parameters and make sure that the cultural adaptation of the imi adds a substantial benefit to its target group. in this context, evidence of cultural adaptations’ substantial benefits is still inconclusive. based on a recent meta-analysis, cultural adaptation of health promotion imi might not be worth the considerable amount of effort because such adaptions do not seem to yield better effectiveness compared to active and passive controls (balci et al., 2022). however, a previous review suggested that culturally adapted face-to-face and online interventions resulted in reducing depression and anxiety (harper shehadeh et al., 2016). moreover, cultural adaptions are poorly reported in existing literature, which makes it difficult to compare across studies and draw definitive conclusions (balci et al., 2022). the next step should include comparing an adapted imi to a non-adapted intervention. such dismantling trials could provide insights into whether cultural adapta­ tion processes are actually beneficial. in a recent trial, a non-culturally adapted sleep imi yielded beneficial effects for culturally diverse international student groups (spanhel, burdach, et al., 2021). this might bring out the idea that some intervention contents might not significantly benefit from an elaborate adaptation process, especially for low threshold interventions (böttche et al., 2021; cuijpers et al., 2018; spanhel, burdach, et al., 2021). this trend emerged in our results as well, where we only realized surface-level adaptations (resnicow et al., 2000) and still found potential effectiveness. more impor­ tantly, imi have different mechanisms of change, therefore a detailed cultural adaptation might be beneficial for a certain imi content or delivery, but not for all (domhardt et al., 2021; heim & kohrt, 2019). in a review, most of the culturally adapted interventions did not modify their core contents but included core additions and delivery methods to make the intervention more acceptable to the new target group while ensuring the fidelity of the original intervention (chu & leino, 2017). for mindfulness-based imi, valued living, cognitive fusion, present moment awareness, and acceptance are effective mediators among college students (levin, haeger, pierce, & twohig, 2017; viskovich & pakenham, 2020). some of these mediators are part of the universal human condition, therefore, might not even need any adaptation. lastly, acculturation might play a role in attitudes toward seeking mental health (lu et al., 2014). therefore, acculturation levels of international students might be considered when adapting or developing interventions for this population. only six negative effects were reported and these were low to mild in extent. moreover, the imi caused no suicidal ideation. negative effects of psychotherapy are expected and their reporting is increasing (rozental et al., 2018). this result suggested that studicarem-e is a rather safe intervention, and might be also administered in an unguided form. furthermore, studicarem-e participants showed improvements in mindfulness, anxi­ ety, and well-being levels. stress and depression scores did not reach significance. while an adapted version of an online mindfulness intervention for international students 18 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ a trend suggests possible beneficial effects regarding these outcomes, a powered defini­ tive trial would be necessary to confirm these effects since this trial was only powered for feasibility. the mean effect sizes are higher than in a meta-analysis of online mind­ fulness interventions compared to a waitlist and no-treatment controls (spijkerman et al., 2016). however, trials with waitlist control groups tend to yield higher effect sizes (van agteren et al., 2021), thus in order to validate the studicarem-e’s efficacy, research should initially test this in a powered trial with more follow-up points, and compare it to treatment as usual, a placebo control group or active controls. like any other, this trial is not free from limitations. firstly, our sample mostly consisted of female participants, therefore our results cannot be generalized to male or non-binary populations. however, this is a common trend in psychological interven­ tions. secondly, a major limitation of this trial was grouping international students from various backgrounds and living situations under the label of international students, consequently masking potential differences among them. thirdly, our sample consisted of participants with diverse cultural backgrounds. according to a meta-analysis of 99 studies, it was found that studies with more homogenous participants in terms of cultural background yielded larger effect sizes (soto et al., 2018). even though culturally adapted, this intervention was in english. people prefer to have a unity of language with their mental health care provider (villalobos et al., 2016), and providing interventions in the chosen language of the client is a significant predictor of better outcomes (soto et al., 2018). despite this fact, participants assessed the language of the intervention as being easy to understand. however, still providing the intervention content in the participant’s chosen language might increase the efficacy of the intervention further. therefore, a future definitive trial might consider offering the same intervention in different languag­ es to choose from and might adapt the intervention based on parsimonious social and cultural features. fourth, this feasibility trial used a wl control group. as expected, trials of culturally adapted face-to-face mental health interventions with a wl group resulted in higher effect sizes, compared to an active control condition (d = 0.53 vs d = 0.47) (soto et al., 2018). this is also true for imi (sommers-spijkerman et al., 2021). fifth, due to high dropout and low adherence, we were able to collect less qualitative and quantitative data to inform acceptability and potential efficacy. assessment dropout was 35% in total, which is in accordance with the previous research (nilsson et al., 2004). possible reasons for this may include a lack of monetary incentives, procrastination, and the typical work­ load of student life. in order to tackle potential bias arising from differential dropout, we multiply imputed our data with the assumption of missing at random (bell et al., 2013), and added baseline values as covariates in all regression models. however, there was a baseline difference between assessment dropout and non-dropouts where, participants who completed the post-randomization assessment had a slightly higher stress level in the beginning of the study, therefore might be more motivated, needed a medium to deal with the stress, and had more place to grow. lastly, this feasibility trial reached a limited balci, küchler, ebert, & baumeister 19 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://www.psychopen.eu/ sample size; therefore, the initial efficacy results should be interpreted with caution. an inspection of sustainability of intervention effect beyond post-treatment is warranted. conclusion online interventions to decrease stress and improve the well-being of international university students seem to have great potential, whereas face-to-face offers are not often utilized and benefited in limitation. despite being presented to vastly culturally diverse student groups, studicarem-e yielded beneficial results with good acceptability and non-crucial negative effects. a future definitive rct might offer a more robust efficacy and potential moderator and mediator effects. funding: s.b. receives a scholarship granted by the ministry of national education in turkey. open access funding was provided by the university of ulm. the funders had no role in the study design, data collection, analysis, decision to publish, or preparation of the manuscript. acknowledgments: we would like to acknowledge the valuable support from our interns ms. ayse yürekli and ms. kevser aksoy in study management, content creation, and our research assistants tim dretzler, jana moos, and francesca mildenberger in assessment procedure and study administration, and mathias harrer for his support in offering the english webpages of studicare, and yannik terhorst for his consultation on data analyses. we would like to especially thank all the cooperating universities around germany, austria, and switzerland for their support of recruitment. competing interests: the authors have declared that no competing interests exist. ethics statement: the study was approved by the ethics committee of ulm university (number 413/18). reporting guidelines: this article follows the guidelines of consort statement. twitter accounts: @psksumeyyeb data availability: the dataset may be obtained (from s.b.) on request depending on to-be-specified data security and data exchange regulation agreements. to ensure confidentiality, shared data will exclude any identifying participant information. supplementary materials the supplementary materials contain the pre-registration information for the study (for access see index of supplementary materials below). an adapted version of an online mindfulness intervention for international students 20 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://twitter.com/psksumeyyeb https://www.psychopen.eu/ index of supplementary materials balci, s., küchler, a., ebert, d. d., & baumeister, h. 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(2016). adherence to internet-based mobile-supported stress management: a pooled analysis of individual participant data from three randomized controlled trials. journal of medical internet research, 18(6), article e146. https://doi.org/10.2196/jmir.4493 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. balci, küchler, ebert, & baumeister 29 clinical psychology in europe 2023, vol. 5(2), article e9341 https://doi.org/10.32872/cpe.9341 https://doi.org/10.2196/jmir.1376 https://doi.org/10.1177/0962280215588241 https://doi.org/10.1080/13583883.2015.1127405 https://doi.org/10.2196/jmir.4493 https://www.psychopen.eu/ an adapted version of an online mindfulness intervention for international students (introduction) objectives method participants procedure randomization intervention adaptation of the intervention guidance sms coach control group assessment and outcomes sample size statistical analyses results feasibility efficacy outcomes discussion conclusion (additional information) funding acknowledgments competing interests ethics statement reporting guidelines twitter accounts data availability supplementary materials references allegiance and treatment quality as moderators of the comparative effectiveness of psychotherapy? a systematic review and meta-analysis of studies comparing humanistic psychotherapy to other psychotherapy approaches systematic reviews and meta-analyses allegiance and treatment quality as moderators of the comparative effectiveness of psychotherapy? a systematic review and meta-analysis of studies comparing humanistic psychotherapy to other psychotherapy approaches olivia schünemann 1 , alessa jansen 2 , ulrike willutzki 3 , nina heinrichs 4 [1] institute of psychology, tu braunschweig, braunschweig, germany. [2] bundespsychotherapeutenkammer, berlin, germany. [3] department for psychology and psychotherapy, witten/herdecke university, witten/herdecke, germany. [4] department of psychology, bielefeld university, bielefeld, germany. clinical psychology in europe, 2025, vol. 7(1), article e9709, https://doi.org/10.32872/cpe.9709 received: 2022-06-20 • accepted: 2024-10-15 • published (vor): 2025-02-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: olivia schünemann, institute of psychology, tu braunschweig, humboldtstr. 33, 38106 braunschweig, germany. phone: +49 531 391 2852. e-mail: o.schuenemann@tu-bs.de supplementary materials: materials, preregistration [see index of supplementary materials] abstract background: achieving positive outcomes in comparative rcts examining psychotherapy interventions may be moderated by other factors than treatments alone, namely allegiance and treatment quality (bona fide, adherence). using the study sample of a recent comprehensive review on humanistic interventions by the german scientific board of psychotherapy, we assumed that higher allegiance towards non-humanistic approaches and lower treatment quality in the humanistic intervention arm would result in worse outcomes for the humanistic groups. method: we included studies in which a humanistic psychotherapy (sub-)approach was compared to another type of psychotherapy. data was extracted independently by the authors. a priori defined meta-regression analyses were performed with allegiance and treatment quality as main moderators and study quality (risk of bias), type of active control, humanistic psychotherapy and target population (children/adolescents; adults) as exploratory. results: the majority of studies showed non-allegiance towards humanistic intervention arms; only about half of the humanistic interventions were bona fide treatments demonstrating high percentages of potential biases in these comparative intervention studies. however, allegiance and this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9709&domain=pdf&date_stamp=2025-02-28 https://orcid.org/0000-0001-9545-2074 https://orcid.org/0000-0003-1013-3918 https://orcid.org/0000-0002-0149-4554 https://orcid.org/0000-0002-8301-5798 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ bona fide were significant moderators only for two (allegiance) resp. one (bona fide) of five outcome comparison. type of active control (cognitive behavioural therapy) and disorder group (anxiety disorders) emerged as further moderators. conclusion: we found no clear evidence for allegiance or treatment quality impacting upon treatment outcome in this re-examination. allegiance and treatment quality were not as relevant for outcomes in this meta-analysis of rcts as expected. keywords rct, allegiance, bona fide, study quality, adherence, humanistic psychotherapy highlights • analysed studies displayed substantial heterogeneity concerning allegiance and treatment quality. • only 10% of the studies showed allegiance in favour of hpt. • allegiance and bona fide were significant moderators in 2 (alleg.)/1 (bona fide) of 5 comparisons. • allegiance and treatment quality were not as relevant for outcomes as expected in our examination. humanistic psychotherapy (hpt) has been characterized as a psychotherapeutic ap­ proach focusing on “the conditions or stances by which people can come to intimately know themselves and, to the extent possible, to fulfill their aspirations” (schneider & leitner, 2002, p. 949). international literature lists hpt as one of the major psychotherapy approaches next to cognitive-behavioural, psychodynamic and systemic psychotherapy (e.g., lambert, 2013). like other psychotherapy approaches hpt is a broad and diverse psychotherapeutic approach embracing various subapproaches, for example client / per­ son-centered psychotherapy (rogers, 1961), constructivist psychotherapy (neimeyer, 1995), emotion-focused psychotherapy (greenberg et al., 1998), existential meaning mak­ ing psychotherapy (schneider & krug, 2010), focusing-oriented psychotherapy (gendlin, 1981), gestalt psychotherapy (perls et al., 1994) and transpersonal psychotherapy (wilber et al., 1986; selection suggested by angus et al., 2015). schneider and längle (2012, p. 428) summarized the common assumptions of hpt as follows: “humanism is concerned with such existential themes as meaning, mortality, freedom, limitation, values, creativity, and spirituality as these arise in personal, interpersonal, social, and cultural contexts. in psychotherapy, humanism places special emphasis on the personal, interpersonal, and contextual dimensions of therapy and on clients’ reflections on their relationship with self, others, and the larger psychosocial world”. accordingly, all hpt subapproaches share the following principles: endorsement of the centrality of an empathic and prizing therapeutic relationship and a focus on the promotion of client experiencing in the therapy process (elliott et al., 2013). nevertheless, significant differences between these allegiance and treatment quality: systematic review 2 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ subapproaches exist, e.g., in their preferred methods for building a therapeutic alliance, treatment indications, case conceptualizations or concepts for individual treatment plan­ ning (e.g., elliott et al., 2021; gsbp, 2018). a significant attempt to aggregate empirical results in the context of hpt is reflected in the meta-analysis by elliott et al. (2013) who analysed 191 hpt-studies (through 2008) involving person-centered, supportive or nondirective, and other hpt subapproaches. regarding pre-post effects of hpt (n = 191 studies with n = 14,235 clients), elliott et al. (2013, p. 10) reported a weighted pre-post effect size of d = 0.93 with stable pre-follow up effects up to d = 1.11 when pooling effects of all subapproaches of hpt. their comparison of hpt to other therapy approaches indicated no differences in pre-post results (weighted effect size d = 0.01; 95% ci [-0.05, 0.07]. however, the comparison group “other therapies” in this meta-analysis is not well described. comparing hpt to cognitive-behavioural therapy (cbt) only, hpt was described as slightly inferior to cbt (d = -0.13, 95% ci [-0.21, -0.06]; elliott et al., 2013, p. 10). there are currently a number of psychotherapy approaches available for practitioners to deliver clinical services around europe. in germany, however, hpt is not part of the list accredited psychotherapists can choose from and be reimbursed for their services. to become part of this list, psychotherapy approaches have to undergo two independent evaluations in germany: (1) a scientific evaluation conducted by the german scientific board of psychotherapy (gsbp [wissenschaftlicher beirat psychotherapie]); and – if they are evaluated positively by the gsbp – (2) subsequent assessment concerning cost-utility aspects (conducted by another, independent board). a recent evaluation of hpt by the gsbp on request of the work group humanistic psychotherapy (arbeitsgemeinschaft humanistische psychotherapie, 2012) resulted in the conclusion that the approach is not evidence-based according to the board’s criteria. potential reasons for these discrepant results: allegiance and treatment quality the discrepancy between the review result of the gsbp and other international reviews on hpt (e.g, by elliott et al., 2013; elliott et al., 2021) can be explained through the different methodological approaches, e.g. using meta-analyses and pooling effects for a certain disorder (elliott et al., 2013; elliott et al., 2021) vs. defining a required minimum of evidence (at least three rcts with sufficient internal and external validity) for a certain number of diagnostic groups (currently: 4 out of 12) in the gsbp approach. moreover, the discrepant definition of what constitutes hpt as defined by the german work group humanistic psychotherapy from the international definition, e.g. as defined in the reviews by elliot is likely to be relevant here. the assignment of subapproaches to hpt is different across author groups and also within type of publications. elliott et al. (2021) use the term hpt to embrace 10 subapproaches (person-centered therapy, emotion-focused therapy, motivational interviewing, gestalt, existential, psychodrama, schünemann, jansen, willutzki, & heinrichs 3 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ focusing-oriented, expressive and body-oriented as well as “supportive / nondirective”), while in elliott et al. (2013) the respective analyses included 9 subapproaches, omitting motivational interviewing. on the basis of current discussions in psychotherapy research (e.g., wampold, 2015), we hypothesized in addition that two key reasons may have an impact on the effectiveness on hpt subapproaches (schünemann et al., 2019): 1) researchers’ allegiance that may be associated with a decrease of the (possible) ef­ fects of the non-preferred treatment condition (munder et al., 2011), in case of the review of the gsbp a decrease of the effects of subapproaches of hpt. leykin and derubeis (2009, p. 55) define “allegiance, in the context of treatment outcome research, …[as] a belief in the superiority of a treatment. it usually also entails a belief in the superior validity of the theory of change that is associated with the treatment”. often, this belief is associated with therapy outcomes and may reflect a risk of bias. a meta-analysis on the allegiance bias hypothesis demonstrated a moderate association between allegiance and treatment outcome moderated by methodological quality (munder et al., 2011), indicating that allegiance as well as methodological quality may need to be taken into account for treatment comparisons (munder et al., 2011). in the context of the hpt evaluation of the gsbp, researchers’ allegiance may have had an effect because many studies in the pool used a study design in which a humanistic subapproach was designed as control group in comparison to other psychotherapeutic approaches (e.g., cbt). 2) we further assumed that treatment quality of hpt studies in the gsbp evaluation may have an impact on outcomes. in this context, the two aspects of bona fide psycho­ therapy and adherence can be differentiated. whereas bona fide represents conceptual quality of a treatment, adherence is rather concerned with process quality. for the present study, bona fide psychotherapy will be defined as follows: mentioning or describing an established psychological approach, psychological treatment principles, a treatment manual or active treatment ingredients (benish et al., 2008) as well as the requirement that the intervention is implemented by a trained therapist (wampold et al., 1997). further, we use a definition of adherence in accordance with munder et al.’s (2013) definition of treatment integrity: “[…] conceptualized broadly including adherence to specific treatment procedures (e.g., the importance of exposure in psychotherapy for post-traumatic stress disorder), common factors (e.g., therapeutic alliance), and therapist effects (i.e., differences in the effects due to individual therapists)” (munder et al., 2013, p. 8). concerning treatment quality, wampold (2015) summarizes that trainers’ competence has only a small (d = 0.14) and adherence to protocol an almost negligible effect (d = 0.04) on treatment outcome. the (non-) effect of adherence to protocol may be explained with associated decreased patient-therapist alliance, increased likelihood of resistance to treatment and a lack of flexibility by the therapist. we hypothesized that the gsbp-evaluation included studies implementing hpt subapproaches (often as control group) in potentially fuzzy and poor quality so that significant hpt mechanisms allegiance and treatment quality: systematic review 4 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ could not work properly resulting in potentially decreased effects of the respective hpt subapproach. objectives the aim of this meta-analysis is the re-examination of studies included in the gsbp evaluation of hpt (gsbp, 2018) (based on the application of the work group humanistic psychotherapy and the additional searches conducted by the gsbp) to examine poten­ tial moderating effects of allegiance and treatment quality (bona fide psychotherapy and adherence) on the comparative effectiveness of hpt (including both efficacy and effectiveness studies). we examine whether in the hpt subapproaches vs. others psycho­ therapeutic interventions included in the gsbp evaluation 1) allegiance to a particular psychotherapeutic intervention and 2) treatment quality (bona fide/adherence) signifi­ cantly moderate effect sizes. we expected higher allegiance towards other psychotherapy approaches and lower treatment quality to be significant predictors of lower effect sizes in the hpt condition. method design, study search and procedure this study was registered in the prospero international prospective register of system­ atic reviews (crd42019128983). the present full report relates to the second objective in this protocol (comparison of humanistic subapproaches versus other psychotherapeutic interventions). the study pool which builds the basis of the present analysis is taken over from the gsbp (2018). for their final sample, the gsbp screened abstracts of n = 481 studies from which n = 114 went into the final pool of evaluated studies. the abstract screening procedure was based on 1) a list of studies submitted by the work group humanistic psychotherapy (n = 313), and 2) results from an independent literature search conduc­ ted by an independent institution. according to pre-specified picos criteria, all study abstracts were screened; the ones included went into full-text screening review by two independent reviewers (members of the gsbp) to decide about their further inclusion. the present systematic review used the identical study pool of the gsbp (n = 114) in order to compare the results of this systematic review directly with the conclusions of the gsbp and by this to be able to provide recommendations for future analyses on psychotherapeutic approaches or methods by the gsbp. it was necessary to conduct a secondary study screening for eligibility because the present systematic review needs specific study data beyond the data relevant for the pur­ pose of the gsbp. as result, we used n = 50 studies which compared hpt subapproaches schünemann, jansen, willutzki, & heinrichs 5 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ to alternative evidence-based psychotherapeutic interventions (see flowchart figure 1). the remaining studies were either excluded or relate to inactive control conditions. figure 1 prisma flow diagram showing the process for search and selection of studies records identified from: studies included in application hpt and application gestalt therapy (12.10.12 & 26.04.15) and subsequently submitted studies by hpt societies after application: n = 639 systematic study search (04.12.13): n = 6265 update: systematic study search (07.07.16): n = 1654 subsequently submitted studies by hpt societies after application: n = 326 records removed before screening: duplicate records removed or publication not available (n = 66) records screened (n = 8558) records excluded (n = 7976) reports assessed for eligibility (n = 516) reports excluded: studies with double or shared publication (after screening; n =35) studies not fulfilling methodological requirements (n = 367) total studies included in review (n = 114) identification of studies via databases and registers and other methods id en ti fi ca ti on (b y g sb p) sc re en in g (b y g sb p) in cl ud ed g sb p studies screened for the metaanalysis (n = 73) in cl ud ed m et aa na ly si s studies excluded: due to study design (n = 6) due to missing outcome values (n = 12) publication not available (n = 1) by other reasons excluded from gsbp’s evaluation (n = 22) studies excluded: due to inactive comparison group or comparison group without psychotherapy (n = 23) studies included in the metaanalysis (n = 50) allegiance and treatment quality: systematic review 6 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ study characteristics for the present meta-analyses were extracted by one author (either os or aj). study results, study quality, allegiance and treatment quality were rated by two of the authors independently (os & nh or aj & uw or nh & uw). inter-rater reliability (cohen`s kappa) for adherence (only available for one of the two rater teams: nh, os) across all intervention groups (ig and cg) was moderate (altman, 1999): κ = .507 (p < .001); agreement = 76.7%. inter-rater reliability (intra-class correlation, icc) for allegiance (mars index) was .91 (95% ci [.82, .95]; two-way mixed-effects icc, absolute agreement, average for two coders, same rater team). discrepancies were first discussed within dyads and if discrepancies could not be clarified, were discussed among all four authors until a final decision was reached. inclusion and exclusion criteria inclusion criteria were based on those of the gsbp and complemented by the availability of data we needed for the meta-analysis. inclusion criteria were: 1) rcts or non-random­ ized controlled trials with active control group and 2) report of preand post-assessments regardless of follow-up assessments. these criteria were complemented with the follow­ ing exclusion criteria: 1) an active control group was missing (only two or more hpt subapproach-groups with no additional active control group precluding the examination of allegiance); 2) a metric outcome measure or post mean were lacking or 3) an indication of data manipulation could be found. for more details see schünemann et al. (2019) or supplementary materials (additional inclusion and exclusion criteria). data collection we extracted information on participant characteristics, study characteristics, interven­ tion characteristics, primary and secondary outcomes, risk of bias, allegiance, treatment quality (bona fide and adherence). guidelines of the cochrane collaboration were used to estimate and substitute missing data for outcomes, e.g., calculating standard errors from exactly reported t-values. the primary effectiveness outcome was symptom severi­ ty at the end of treatment measured on a metric symptom specific scale. outcomes on self-rating scales (e.g., bdi) were given priority over observer-rated scales (e.g., hdrs). as symptom reduction is not necessarily the primary target of change across different psychotherapy approaches, we extracted data for different outcome domains to analyse moderator effects specific to different outcome domains. secondary outcomes were inter­ personal outcomes (e.g., das), general assessment of functioning (e.g., gaf) and quality of life (e.g., who qol). the primary outcome was extracted for short-term (end of intervention) and follow-up if available (6 months after end of intervention or the one closest to 6 months). as primary negative outcome drop-out until end of intervention was extracted. schünemann, jansen, willutzki, & heinrichs 7 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ assessment of main and exploratory moderators: study quality, allegiance and treatment quality allegiance was assessed according to the multilevel allegiance rating-scale (mars) pro­ vided by steinert et al. (2017). this instrument combines information about 1) research­ ers’ allegiance either respective treatment development or contribution to an etiological understanding of the treated disorder; 2) therapists’ allegiance; 3) trainers’ allegiance and 4) supervisors’ allegiance to a total score (0-4; steinert et al., 2017). treatment quality with bona fide psychotherapy and adherence were rated using the definition by wampold et al. (1997) and benish et al. (2008) according to the following items: using/citing an established psychotherapy manual; used intervention is based on psychological principles; author mentions hpt (subapproach)/cg on own his/her website; author has other relevant hpt (subapproach)/cg publications; intervention was carried out by trained therapists. to meet the criterion of bona fide two of the items needed to be fulfilled. in the moderator analyses “bona fide” was compared to “non or unclear bona fide”. to fulfill the criterion of treatment adherence, treatment conditions and therapeutic procedure needed to be described in detail and adherence must have been proved by external raters. in the moderator analyses “non-adherence” was compared to “adherence”. study quality of the included studies was rated according to the second version of cochrane’s risk of bias tool (rob 2.0; higgins et al., 2018) considering the adaptions by munder and barth (2018) for its use in psychotherapy outcome research. thus, the methodological quality was assessed via: 1) bias arising from the randomization process; 2) bias due to missing outcome data; 3) bias in outcome measurement; and 4) bias in selection of the reported result (cochrane’s risk of bias tool) as well as 5) effect of adhering to intervention (see higgins et al., 2018; munder & barth, 2018). for non-randomized controlled trials, the robin-i tool (sterne, hernán, et al., 2016) was used to rate risk of bias. for moderator analyses a “low risk of bias” in each category was compared to an “unclear or high risk of bias”. statistical analyses standardized mean difference for metric measures and odds ratios for rare outcomes between the intervention groups at end of intervention and follow-up were calculated using the intention-to-treat sample, if available. for all analyses, a random effects model with inverse variance weights was applied (dersimonian & laird, 2015). cochran’s q-test was used and quantified using the i2-statistic (higgins et al., 2003) to test statistical heterogeneity between study results for significance. visual examination of funnel plots and egger’s test (sterne, egger, & smith, 2016) were applied to examine possible publica­ tion bias. a priori defined subgroup (in case of categorical predictors) or meta-regression (in case of metric predictors) analyses (univariate) were conducted concerning study allegiance and treatment quality: systematic review 8 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ quality, allegiance, treatment quality, type of non-active control (waitlist vs. all others including tau), type of hpt subapproach (client centered vs. all others) and population (children/adolescents vs. adults). differences between subgroups were tested formally (bucher et al., 1997; deeks et al., 2001; song et al., 2003). a posteriori (explorative) metaregression analyses (univariate) were performed in case of considerable heterogeneity between studies for number of sessions, length of intervention, percentage of women, affective disorder, anxiety disorder, post-traumatic stress disorder (ptsd), f 54, study design (no rct) and comparator (cbt). all analyses were conducted using the metafor package in r (viechtbauer, 2010). results descriptive and additional results because of space limitations additional information and results are documented in the supplementary materials. individual characteristics of all studies are shown in the supplementary materials (supplementary table 1). all ratings for cochrane’s risk of bias and robin-i tool (study quality) as well as for allegiance and treatment quality for each study can be found in the supplementary materials (supplementary table 2). further, the overall main effect sizes are presented in supplementary table 3. in order to avoid misunderstandings when interpreting the results of the overall effects a more detailed explanation of the main effects can also be found in appendix c – supplementary information (see preliminary results: overall main effect sizes of hpt). the forest plot for the primary outcome is displayed in figure 2. main results: univariate moderator effects – the role of allegiance and treatment quality we will first report on moderation effects (pre-specified moderators followed by explora­ tory moderators) for post-intervention outcomes and then move to reporting the results for the same moderators at follow up. the results for the moderator analyses for the symptom severity (primary outcome) are presented in table 1a. no significant moderating effects on the primary comparative effectiveness outcome symptom severity at end of intervention could be shown for the pre-specified moderators study quality, allegiance or treatment quality. exploratory subgroup analyses indicated that the difference between hpt and other psychotherapies regarding symptom severity increased significantly favouring other psy­ chotherapies when cbt was used as comparator and in studies examining anxiety disor­ ders. sensitivity analysis for this comparison showed that results were not influenced by the study design. schünemann, jansen, willutzki, & heinrichs 9 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ figure 2 exemplary forest plot of the comparison hpt approaches vs. other psychotherapy only for the primary outcome symptom severity at end of intervention allegiance and treatment quality: systematic review 10 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ ta bl e 1a m od er at or s a na ly si s fo r pr im ar y o ut co m e: s ym pt om s ev er ity a t e nd o f i nt er ve nt io n an d at f ol lo w -u p m od er at or sa sy m pt om s ev er it y en d of in te rv en ti on (n = 47 b ) sy m pt om s ev er it y at fo llo w -u p (n = 30 c ) in te rc ep t β se p r2 in % in te rc ep t β se p r2 in % no o r un cl ea r al le gi an ce a ga in st h pt 0. 31 5 -.1 83 0. 12 5 .1 44 6. 84 0. 36 5 -.2 08 0. 10 3 0. 04 4 70 .6 2 no n or u nc le ar b on a fi de h pt 0. 18 5 .1 16 0. 12 7 .3 61 < 0. 01 0. 19 1 .1 59 0. 11 8 .1 78 17 .4 1 no n or u nc le ar b on a fi de c g 0. 24 3 -.0 42 0. 23 0 .8 54 < 0. 01 0. 30 0 -.2 41 0. 23 5 .3 05 0. 91 no n ad he re nc e h pt 0. 26 0 -.0 54 0. 13 2 .6 79 < 0. 01 0. 29 4 -.0 18 0. 12 5 .8 87 < 0. 01 no n ad he re nc e c g 0. 22 6 .0 70 0. 16 0 .6 73 < 0. 01 0. 24 0 .1 90 0. 14 0 .1 75 8. 27 lo w r ob r p 0. 17 5 .1 11 0. 12 8 .3 85 < 0. 01 0. 28 4 .0 01 0. 12 6 .9 96 < 0. 01 lo w r ob a i 0. 21 0 .0 67 0. 12 9 .6 02 < 0. 01 0. 36 9 -.2 08 0. 12 4 .0 94 < 0. 01 lo w r ob m i 0. 19 4 .0 80 0. 12 9 .5 37 < 0. 01 0. 22 8 .1 01 0. 12 2 .4 07 < 0. 01 lo w r ob m o 0. 19 3 .0 65 0. 14 0 .6 42 < 0. 01 0. 32 4 -.0 62 0. 13 0 .6 37 < 0. 01 lo w r ob s r 0. 29 2 -.2 17 0. 14 8 .1 42 < 0. 01 0. 28 6 -.0 08 0. 16 5 .9 60 < 0. 01 cl ie nt c en te re d ps yc ho th er ap y 0. 28 7 -.0 60 0. 15 6 .6 98 < 0. 01 0. 30 2 -.0 22 0. 15 6 .8 87 < 0. 01 po pu la tio n: c hi ld re n 0. 21 3 .1 28 0. 15 8 .4 19 < 0. 01 0. 22 3 .2 80 0. 14 3 .0 50 21 .7 9 ag e* d 0. 23 9 < .0 01 0. 00 3 .9 32 < 0. 01 0. 49 3 -.0 06 0. 00 4 .1 27 19 .6 0 % o f w om en *d 0. 25 7 < .0 01 0. 00 3 .8 67 < 0. 01 0. 55 8 -.0 04 0. 00 2 .0 74 44 .1 6 af fe ct iv e di so rd er * 0. 25 6 -.0 88 0. 16 0 .5 84 < 0. 01 0. 28 6 -.0 06 0. 15 0 .9 69 < 0. 01 an xi et y di so rd er * 0. 16 1 .4 00 0. 14 7 .0 06 25 .8 4 0. 28 3 .0 06 0. 19 8 .9 75 < 0. 01 pt sd * 0. 24 0 -.0 05 0. 16 3 .9 77 < 0. 01 0. 23 8 .2 73 0. 15 9 .0 87 16 .1 2 f 54 * 0. 28 3 -.1 81 0. 14 2 .2 02 0. 40 0. 34 6 -.1 97 0. 12 4 .1 14 16 .3 4 de si gn : n o rc t * 0. 24 9 -1 .0 30 0. 64 2 .1 08 2. 80 0. 28 5 -.1 28 0. 57 2 .8 23 < 0. 01 le ng th o f i nt er ve nt io n h pt *d 0. 29 1 < .0 01 0. 00 6 .9 66 < 0. 01 0. 26 1 .0 02 0. 00 7 .8 08 < 0. 01 nu m be r of s es si on s h pt *d 0. 19 7 .0 03 0. 00 5 .6 04 < 0. 01 0. 30 0 -.0 01 0. 00 5 .8 54 < 0. 01 c om pa ra to r: c bt * -0 .3 57 .6 38 0. 23 6 .0 07 21 .0 3 -0 .0 29 .3 21 0. 37 0 .3 86 < 0. 01 nu m be r of s es si on s c g *d 0. 15 4 .0 06 0. 00 6 .3 48 < 0. 01 0. 20 1 .0 06 0. 00 7 .4 36 < 0. 01 n ot e. g re y sh ad ow s fo r m ai n (i. e. p re -s pe ci fi ed ) m od er at or s. s ig ni fi ca nt r es ul ts o f m od er at or a na ly se s (p < .0 5) a re s ho w n in b ol d. r ob = r is k of b ia s; c g = c on tr ol gr ou p; c bt = c og ni tiv e be ha vi ou ra l t he ra py ; n a = m od er at or a na ly si s co ul d no t b e co nd uc te d du e to in su ff ic ie nt v ar ia nc e in m od er at or . e xa m pl e fo r in te rp re ta tio n of a c at eg or ic al p re di ct or : i n st ud ie s w ith n o or u nc le ar a lle gi an ce a ga in st h pt th e di ff er en ce b et w ee n h pt a pp ro ac he s an d ot he r fo rm s of p sy ch ot he ra py in le ve ls of s ym pt om s ev er ity a t f ol lo w -u p is s ig ni fi ca nt ly r ed uc ed (β = -0 .2 08 , p = .0 44 ). ex am pl e fo r in te rp re ta tio n of a m et ri c pr ed ic to r: in s tu di es w ith o ne p er ce nt ag e m or e w om en th e di ff er en ce b et w ee n h pt a pp ro ac he s an d ot he r fo rm s of p sy ch ot he ra py in le ve ls o f s ym pt om s ev er ity a t e nd o f i nt er ve nt io n is n ot s ig ni fi ca nt ly in cr ea se d (β = < .0 01 , p = .8 67 ). a n v ar ie s fo r in di vi du al m od er at or a na ly si s as s tu di es w ith m is si ng d at a in m od er at or s w er e re m ov ed fr om m et ar eg re ss io n an al ys es . b o ne s tu dy (d ie tz e t a l., 2 01 5) w as id en tif ie d as a n ou tli er a nd r em ov ed fr om a ll fu rt he r m et aan al ys is . c o ne s tu dy (h er sc hb ac h et a l., 2 01 0) w as id en tif ie d as a n ou tli er a nd re m ov ed fr om a ll fu rt he r m et aan al ys is . d m et ri c pr ed ic to r (a ll ot he r pr ed ic to rs a re d ic ho to m ou s) . * a p os te ri or i a na ly se s. schünemann, jansen, willutzki, & heinrichs 11 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ for the outcome symptom severity at follow-up subgroup analyses indicated that the dif­ ference between hpt in comparison to other psychotherapies was reduced significantly in studies with no or unclear allegiance against hpt (β = -0.208, p = .044; for examples for interpretation, please see table note). results for secondary outcome domains are shown in table 1b. for the outcome interpersonal problems subgroup analyses indicated that the difference between hpt in comparison to other psychotherapies was reduced significantly in studies with no or unclear allegiance against hpt. also, the difference between hpt in comparison to other psychotherapies was reduced when bona fide hpt was used, in studies with a low risk of bias due to missing data and in studies not examining anxiety disorders. yet, somewhat contradictory, the difference increased in favour of other psychotherapies when the control group was not adherent to intervention. no significant moderator effects were detected for the outcomes general functioning and quality of life. the results for some of the outcome measures should be interpreted with caution because of the small number of studies (n = 9 for interpersonal problems, n = 12 for general functioning, n = 8 for quality of life) in comparison to the large number of moderator analyses. to test whether primary moderators were sufficiently independent, we examined their associations post-hoc via fisher’s exact test (fet). results showed a significant association between allegiance and bona fide hpt (p = .01, fet). moreover, bona fide hpt was significantly associated with adherence hpt (p = .007, fet) as well as with adherence to the control condition (p = .02, fet). there were no other significant associations between primary moderators. discussion the purpose of this study was to investigate the effects of allegiance and treatment quality (bona fide psychotherapy, adherence) for assessing the comparative effectiveness of psychotherapy. we used data comparing the effects of hpt subapproaches (from a study pool used in a recent evaluation of the gsbp) to other evidence-based treatments. allegiance and treatment quality: systematic review 12 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ ta bl e 1b m od er at or s a na ly si s fo r se co nd ar y o ut co m e d om ai ns m od er at or sa in te rp er so na l p ro bl em s (n = 9 b ) g en er al fu nc ti on in g (n = 1 2) q ua lit y of li fe (n = 8 )c in te rc ep t β se p r2 in % in te rc ep t β se p r2 in % in te rc ep t β se p r2 in % n o or u nc le ar a lle gi an ce a ga in st h pt 0. 50 2 -.5 19 0. 16 9 .0 02 > 0. 99 -0 .2 75 .3 31 0. 22 4 .1 40 7. 22 -0 .3 78 .2 80 0. 17 1 .1 02 87 .4 9 n on o r un cl ea r bo na fi de h pt 0. 02 7 .5 68 0. 19 7 .0 04 > 0. 99 0. 08 4 -.3 35 0. 23 5 .1 54 2. 40 -0 .0 98 -.2 80 0. 17 1 .1 02 87 .4 9 n on o r un cl ea r bo na fi de c g n a n a n a n a n a n a n a n a n a n a n a n a n a n a n a n on a dh er en ce h pt 0. 01 3 .3 53 0. 23 1 .1 27 18 .7 7 -0 .1 65 .0 69 0. 23 9 .7 72 < 0. 01 -0 .0 99 -.2 34 0. 16 3 .1 51 > 0. 99 n on a dh er en ce c g 0. 07 1 .8 30 0. 29 0 .0 04 > 0. 99 -0 .1 00 -.1 70 0. 32 0 .5 96 < 0. 01 -0 .0 90 -.2 90 0. 17 0 .0 79 > 0. 99 lo w r ob r p 0. 02 8 .3 62 0. 16 9 .0 32 > 0. 99 0. 03 6 -.2 75 0. 22 7 .2 26 8. 16 -0 .1 37 -.1 04 0. 22 1 .6 39 < 0. 01 lo w r ob a i 0. 07 5 .2 88 0. 27 0 .2 85 < 0. 01 -0 .0 26 -.2 14 0. 23 1 .3 53 < 0. 01 -0 .3 63 .2 13 0. 20 4 .2 96 22 .3 8 lo w r ob m i 0. 40 4 -.4 08 0. 16 3 .0 12 > 0. 99 -0 .0 37 -.1 66 0. 24 0 .4 89 < 0. 01 -0 .2 14 -.0 03 0. 21 1 .9 87 < 0. 01 lo w r ob m o 0. 25 4 -.1 20 0. 27 2 .6 59 < 0. 01 -0 .0 47 -.1 40 0. 24 0 .5 59 < 0. 01 -0 .2 80 .0 81 0. 25 6 .7 52 < 0. 01 lo w r ob s r 0. 15 7 .0 63 0. 27 8 .8 19 < 0. 01 -0 .1 05 -.0 86 0. 27 3 .7 53 < 0. 01 -0 .2 49 .1 08 0. 20 5 .5 97 < 0. 01 c lie nt c en te re d ps yc ho th er ap y -0 .1 02 .3 91 0. 22 9 .0 88 41 .7 4 0. 01 6 -.1 76 0. 31 4 .5 76 < 0. 01 -0 .1 65 -.0 84 0. 21 1 .6 91 < 0. 01 po pu la tio n: c hi ld re n 0. 14 3 .1 96 0. 33 3 .5 55 < 0. 01 -0 .1 20 -.0 48 0. 32 2 .8 82 < 0. 01 n a n a n a n a n a a ge *d 0. 29 8 -.0 04 0. 01 2 .7 48 < 0. 01 -0 .1 02 -.0 01 0. 01 2 .9 47 < 0. 01 -0 .3 84 .0 04 0. 01 1 .7 29 < 0. 01 % o f w om en *d 0. 72 1 -.0 08 0. 00 7 .2 38 14 .7 4 0. 00 3 -.0 02 0. 00 5 .6 46 < 0. 01 -0 .5 58 .0 05 0. 00 5 .3 21 < 0. 01 a ff ec tiv e di so rd er * 0. 27 3 -.2 90 0. 26 3 .2 70 < 0. 01 -0 .1 85 .2 91 0. 29 3 .3 22 < 0. 01 n a n a n a n a n a a nx ie ty d is or de r* 0. 07 1 .8 29 0. 29 1 .0 04 > 0. 99 -0 .0 81 -.3 17 0. 31 8 .3 18 0. 05 -0 .1 80 -.2 90 0. 30 8 .3 46 8. 89 pt sd * 0. 22 9 -.1 91 0. 29 2 .5 14 < 0. 01 -0 .0 20 -.3 95 0. 23 3 .0 91 24 .7 6 -0 .2 15 -.0 05 0. 22 2 .9 81 < 0. 01 f 54 * n a n a n a n a n a -0 .1 33 .0 63 0. 44 6 .8 88 < 0. 01 -0 .2 64 .0 93 0. 20 2 .6 45 < 0. 01 d es ig n: n o rc t * n a n a n a n a n a n a n a n a n a n a n a n a n a n a n a le ng th o f i nt er ve nt io n h pt *d 0. 23 7 .0 03 0. 01 6 .8 55 < 0. 01 -0 .0 63 -.0 02 0. 01 0 .8 01 < 0. 01 -0 .4 34 .0 05 0. 00 8 .5 52 < 0. 01 n um be r of s es si on s h pt *d 0. 34 1 -.0 08 0. 00 7 .2 74 < 0. 01 -0 .4 17 .0 13 0. 00 7 .0 57 26 .0 8 -0 .2 78 .0 05 0. 01 1 .6 65 < 0. 01 c om pa ra to r: c bt * n a n a n a n a n a n a n a n a n a n a n a n a n a n a n a n um be r of s es si on s c g *d 0. 24 3 -.0 01 0. 01 6 .9 38 < 0. 01 -0 .3 35 .0 08 0. 01 3 .5 36 < 0. 01 -0 .2 61 .0 04 0. 00 9 .6 91 < 0. 01 n ot e. g re y sh ad ow s fo r m ai n (i. e. p re -s pe ci fi ed ) m od er at or s. s ig ni fi ca nt r es ul ts o f m od er at or a na ly se s (p < .0 5) a re s ho w n in b ol d. r ob = r is k of b ia s; c g = c on tr ol gr ou p; c bt = c og ni tiv e be ha vi ou ra l t he ra py ; n a = m od er at or a na ly si s co ul d no t b e co nd uc te d du e to in su ff ic ie nt v ar ia nc e in m od er at or . e xa m pl e fo r in te rp re ta tio n: in s tu di es w ith n o or u nc le ar a lle gi an ce a ga in st h pt th e di ff er en ce b et w ee n h pt a pp ro ac he s an d ot he r fo rm s of p sy ch ot he ra py in le ve ls o f s ym pt om s ev er ity a t fo llo w -u p is s ig ni fi ca nt ly r ed uc ed (β = -0 .2 08 , p = .0 44 ). a n v ar ie s fo r in di vi du al m od er at or a na ly si s as s tu di es w ith m is si ng d at a in m od er at or s w er e re m ov ed fr om m et ar eg re ss io n an al ys es . b o ne s tu dy (d ie tz e t a l., 2 01 5) w as id en tif ie d as a n ou tli er a nd r em ov ed fr om a ll fu rt he r m et aan al ys is . c q ua lit y of l ife : h ig he r sc or e fo r be tt er q ol . d m et ri c pr ed ic to r (a ll ot he r pr ed ic to rs a re d ic ho to m ou s) . * a p os te ri or i a na ly se s. schünemann, jansen, willutzki, & heinrichs 13 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ moderator analyses did not indicate consistent effects of allegiance, treatment quality or study quality on the comparison between hpt and other forms of psychotherapy across all outcomes and assessment points. at the end of intervention, we found a moderating effect in one (interpersonal problems) out of four outcomes (symptom severity, general lev­ el of functioning, quality of life) for allegiance (no or unclear against hpt subapproach) and treatment quality (non bona fide hpt subapproach, non-adherence to control condi­ tion) and – to a somewhat lesser extent – also for study quality. at follow-up (with only one outcome domain still available: symptom severity), allegiance significantly moderated comparative treatment effects: in studies with no allegiance against hpt the difference between hpt and other forms of psychotherapy was significantly reduced for symptom severity at follow-up. the beta coefficient for symptom severity at end of intervention is pointing in the same direction (ß = -0.183) as at follow-up (ß = -0.208) but is not as pronounced in size. exploratory subgroup analyses showed that the difference between subapproaches of hpt in comparison to other psychotherapies was reduced in studies not examining anxiety disorders and in studies not using cbt as a comparator. allegiance the high proportion of allegiance against hpt as well as the high number of non-bona fide treatments in the hpt-treatment arm in the present meta-analysis has also been reported in other studies (cuijpers et al., 2012; elliott et al., 2013; elliott et al., 2021). cuijpers et al. (2012) concluded that non-directive supportive therapy (as a subapproach of hpt) for depression is equally effective as other psychological treatments after re­ searcher allegiance was controlled. similarly, elliott et al. (2013) report a drop in (weigh­ ted) effects when comparing supportive therapies to other psychotherapy approaches. in addition, researcher allegiance has been demonstrated to have an impact on outcomes in psychotherapy studies not focusing on hpt alone (munder et al., 2013). when focusing on the impact of allegiance, it is important to keep in mind that it is not useful to interpret it as a purposeful attempt to skew results but rather take it into account as a human tendency to believe in one’s own ideas and practices in a way that objectivity is compromised (lomangino, 2016; yoder et al., 2019). this perspective is supported by research that shows that awareness and acceptance of its potential impact may reduce its effects (munder et al., 2013). another option to avoid a bias through alle­ giance are allegiance-controlled trials where the interventions in the different conditions are planned and supervised by proponents of the respective approaches (barkham et al., 2021; leichsenring et al., 2009). similarly, more recently, bona fide is also explicitly considered in trial designs: in their recent rct comparing person-centered experiential therapy (pcet as a hpt subapproach) and cbt, barkham et al. (2021) carefully imple­ mented bona fide treatment arms with a similar level of professional training with the help of trainers qualified in the respective interventions. allegiance and treatment quality: systematic review 14 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ adherence we did not find moderation effects of adherence on comparative effectiveness. a recent systematic review and meta-analysis of the role of adherence for outcome in child and adolescent psychotherapy found a small (statistically significant) (interventional, non-comparative) effect size for adherence of d = 0.096 (95% ci [.058, .124]. considering the very small effect size, the authors conclude despite the statistical significance that other factors than adherence are much more relevant to consider for outcome. they included primary studies if “external or independent observer rated measures of adher­ ence or competence, measures across multiple time points (…)., and interrater agreement established in the study or use of coders trained to this level (…) (icc) > -0,60 or kappa > -0,61 or percent agreement > 90% or the score is based on agreement by multiple rates” (collyer et al., 2020, p. 419). our criteria to evaluate adherence were less demanding than in collyer et al. (2020). when adherence as a construct is significantly linked to outcome, quite likely its actual impact upon explaining differences in outcomes remains very small with the presented mean effect size estimation of r < 0.10 (i.e. accounting for less than 1% of the variance in therapy outcome). study quality with respect to study quality (risk of bias, assessed via rob), we found no clear evidence for moderation effects. these results are in line with the recent studies by cuijpers, quero, et al. (2021) as well as hoppen and morina (2020). in this context it has to be kept in mind that study quality is quite likely not fully independent from allegiance: munder et al. (2011) found that allegiance is more strongly related to outcome in studies with lower methodological quality. the inclusion criteria of the gsbp define relatively high methodological standards. these standards may have prevented that allegiance effects unfold as strongly in our study as maybe in other meta-analyses where inclusion criteria are less methodologically strict. strengths and limitations the present study compasses a considerable number of trials, examined important pre­ defined moderators and demonstrates the challenges in evaluating the significance of allegiance and treatment quality (bona fide and adherence). however, in conducting this meta-analysis, we also were faced with a number of problems: limitations: allegiance allegiance was defined via an aggregate score taking into account researchers’ alle­ giance, therapists’ allegiance, trainers’ allegiance and supervisors’ allegiance was used (steinert et al., 2017). this aggregation forecloses to identify which type of allegiance may be more (or less) relevant for treatment outcome. schünemann, jansen, willutzki, & heinrichs 15 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ limitations: treatment quality following benish et al. (2008) and wampold et al. (1997) we used a sophisticated bona fide rating scheme with five criteria: use of a manual; application of an intervention based on psychological principles; author(s) indicate(s) affiliation with the examined intervention (sub)approach on own website; author has other publications concerning the examined intervention (sub)approach; therapists received a training (benish et al., 2008; wampold et al., 1997). we decided to use a liberal categorization with only two of the above aspects necessary in order to categorize the intervention as an overall bona fide treatment. despite these seemingly clear criteria, the assessment of bona fide turned out to be challenging because of often insufficient information. further difficulties arose concerning the manual criterion. many studies reported the use of a manual, also in the hpt condition. however, referenced manuals differed considerably in terms of accessibility, comprehensiveness as well as in terms of content (common manuals vs. review or overview articles). this constitutes a general problem in psychotherapy research and practice, affecting not only hpt (willutzki & andermann, 2019). therefore, extensive discussions about the manual criterion were necessary, and decisions on the categorization are sometimes not clear cut. for rating adherence, all following criteria had to be fulfilled: treatment conditions needed to be described pre­ cisely; the exact (sub)approach must be presented in detail; adherence had to be rated by external observers. related to the latter, studies sometimes indicated that adherence was rated by external observers but the actual result was missing. in these cases, we decided to rate the criterion of adherence liberally, even if authors did not report their adherence results. further limitations the most common diagnostic groups of the systematic review were psychological and behavioural factors associated with disorders or diseases classified elsewhere (f54). the gsbp used this category for a wide scope of applications. thus, there were also studies included examining subjects with (only) a diagnosis of a somatic illness (e.g., patients with age-related macular degeneration, rovner et al., 2014). while we based our analysis on the 114 studies taken into account by the gsbp it is important to note that our study pool for the moderator analysis is not identical to the study pool underlying the differentiated gsbp-evaluation of hpt (gsbp, 2018). discrepancies are due to differences between the method paper (gsbp, 2010) and our study protocol. as an example, the gsbp excluded some of the 114 studies from further analysis due to insufficient methodological quality. however, studies with low methodo­ logical quality were included in the present meta-analysis as study quality was one of the moderators by using cochrane’s risk of bias or robin-i tool. on the other hand, we had to exclude 19 studies for which either the study design was not appropriate for the present research question (e.g., hpt subapproach vs. other hpt subapproach or hpt allegiance and treatment quality: systematic review 16 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ subapproach mixed with other psychotherapy approach), or no mean values were given needed to conduct statistical analyses going beyond the evaluation of the gsbp. as in many meta-analyses trying to explore heterogeneity among studies via sub­ group analyses we face power problems, particularly because studies are not evenly distributed between subgroups. it is still useful and necessary to run the respective sub­ group analyses. on the other hand, one could also argue that experiment wise error rates may assist in arguing that the significant results may have occurred by chance alone in the absence of any true effects. further, it has to be kept in mind that no evidence of the moderators’ impact does not mean that this is evidence of no difference (cuijpers, griffin, & furukawa, 2021). finally, most of the humanistic studies were studies based on rogerian psychotherapy and thus results are particularly relevant for this kind of interventions. conclusion the present results could not demonstrate effects of the examined moderators on treat­ ment outcome. however, we mainly examined studies with high study quality. this is crucial to consider for generalizing our results and it is necessary to prove whether results can be replicated for studies with low study quality. funding: there are no funders to report for this submission. acknowledgments: the authors would like to thank all members of the german scientific board of psychotherapy in the period from 2014 to 2018 for their openness to have uw and nh follow up on these research objectives which is based on the joint work done in the gsbp. competing interests: aj is an employee of the federal chamber of psychotherapists. nh and uw are members of the german scientific board of psychotherapy. all authors are trained in cognitive behavioral therapy; uw is also trained in systemic therapy. reporting guidelines: the study followed the preferred reporting items for systematic reviews and meta-analyses (prisma; page et al., 2021). data availability: the set of extracted data is available upon request. schünemann, jansen, willutzki, & heinrichs 17 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://www.psychopen.eu/ supplementary materials the supplementary materials contain the following items: • study protocol: schünemann et al. (2019) • online appendices: schünemann et al. (2025s): ◦ appendix a – supplementary tables – supplementary table 1. study characteristics (n = 50) – supplementary table 2. study quality (cochrane’s risk of bias tool for rct or robin-i for non-rct); allegiance, bona fide and adherence rating (n = 50) – supplementary table 3. different outcome domains for the comparison humanistic psychotherapy approaches vs. other psychotherapies ◦ appendix b – supplementary figure – supplementary figure 1. exemplary funnel plot of the comparison hpt approaches vs. other psychotherapy only for the primary outcome symptom severity at end of intervention ◦ appendix c – supplementary information – the evaluation procedure of the gsbp – additional inclusion and exclusion criteria – preliminary results: overall main effect sizes of hpt index of supplementary materials schünemann, o., jansen, a., willutzki, u., & heinrichs, n. 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(2019). researcher allegiance in research on psychosocial interventions: meta-research study protocol and pilot study. bmj open, 9(2), article e024622. https://doi.org/10.1136/bmjopen-2018-024622 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. allegiance and treatment quality: systematic review 22 clinical psychology in europe 2025, vol. 7(1), article e9709 https://doi.org/10.32872/cpe.9709 https://doi.org/10.1136/bmj.i4919 https://doi.org/10.18637/jss.v036.i03 https://doi.org/10.1002/wps.20238 https://doi.org/10.1037/0033-2909.122.3.203 https://doi.org/10.1055/a-0771-7771 https://doi.org/10.3238/arztebl.2018.gut_hpt01 https://doi.org/10.1136/bmjopen-2018-024622 https://www.psychopen.eu/ allegiance and treatment quality: systematic review (introduction) potential reasons for these discrepant results: allegiance and treatment quality objectives method design, study search and procedure inclusion and exclusion criteria data collection assessment of main and exploratory moderators: study quality, allegiance and treatment quality statistical analyses results descriptive and additional results main results: univariate moderator effects – the role of allegiance and treatment quality discussion allegiance adherence study quality strengths and limitations conclusion (additional information) funding acknowledgments competing interests reporting guidelines data availability supplementary materials references exploring characteristics of preoccupation and failure to adapt among patients suffering from adjustment disorder: a qualitative study research articles exploring characteristics of preoccupation and failure to adapt among patients suffering from adjustment disorder: a qualitative study alexis vancappel 1,2 , rania chkili 2, david j. eberle 3 , andreas maercker 3 , wissam el-hage 1,4 , rahel bachem 3 [1] chru de tours, pôle de psychiatrie-addictologie, centre régional de psychotraumatologie cvl, tours, france. [2] département de psychologie, qualipsy, qualité de vie et santé psychologique, université de tours, tours, france. [3] department of psychology, universität zürich, zurich, switzerland. [4] umr 1253, ibrain, université de tours, inserm, tours, france. clinical psychology in europe, 2024, vol. 6(2), article e11565, https://doi.org/10.32872/cpe.11565 received: 2023-03-15 • accepted: 2024-01-15 • published (vor): 2024-06-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: alexis vancappel, clinique psychiatrique universitaire, chru de tours, 12-26 rue du coq, 37540 saint cyr sur loire, france. phone: +33 02 47 47 37 28. e-mail: a.vancappel@chu-tours.fr abstract background: adjustment disorder (ajd) is a frequent diagnosis in psychological and psychiatric consultations. recently, the icd-11 has introduced preoccupation and failure to adapt as core symptoms of ajd. however, empirical research that explores the various possible manifestations of preoccupation and failure to adapt in ajd patients is sparse. therefore, the study aimed to explore patients’ experiences of the core symptoms of ajd in a qualitative study. method: we recruited 16 patients suffering from icd-11 ajd who filled in self-report questionnaires to assess sociodemographic information, adjustment disorder symptoms, anxiety and depression. then, they participated in a semi-structured interview with a trained psychologist to explore the determinants and characteristics of their preoccupation and failure to adapt symptoms. thematic analysis was applied to analyze the responses. results: six themes were identified in our analysis 1) preoccupation triggers, 2) preoccupations and negative emotions, 3) strategies to stop preoccupation, 4) consequences of preoccupation, 5) manifestation of difficulties/failure to adapt and 6) strategies to address difficulties/failure to adapt. conclusion: we found partial congruence between our data and previous conceptualizations of ajd. preoccupations seem to be time-consuming, center around stressors and their consequences, and be associated with negative emotions. some preoccupations reported by the patients could also this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11565&domain=pdf&date_stamp=2024-06-28 https://orcid.org/0000-0002-3206-2009 https://orcid.org/0000-0002-9578-667x https://orcid.org/0000-0001-6925-3266 https://orcid.org/0000-0003-3877-0855 https://orcid.org/0000-0002-9586-6020 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ be labeled as ruminations or worries. the failure to adapt symptoms seemed to be broader than the exemplary symptoms highlighted in current measures of ajd. keywords adjustment disorder, preoccupations, failure to adapt, icd-11, coping strategies highlights • qualitative data set out preoccupations and failure to adapt among patients suffering from ajd. • the preocupations seem to overlap ruminations and worries. • preocupations are associated with negative emotions. adjustment disorder (ajd) is a maladaptive reaction to an identifiable psychosocial stressor or multiple critical life events (e.g. divorce, illness or disability, socio-economic problems, conflicts at home or work) that usually emerges within a month of the stressor. the icd-11 has recently introduced a new conceptualization of ajd, focusing on the two core symptom clusters of preoccupation with the stressor or its consequences and failure to adapt symptoms (world health organization, 2019). these core symptoms must result in significant impairment of personal, social, educational, professional or other important areas of functioning. the definition of specific core symptoms was a response to longstanding criticism of ajd being difficult to distinguish from normal stress reactions as well as from clinical and subclinical presentations of other mental disorders (e.g., depression) (bachem & casey, 2018; baumeister & kufner, 2009; casey et al., 2001). even though ajd is the 7th most used diagnosis in the mental health field (reed et al., 2011), there are comparatively few empirical studies on ajd. epidemiologic studies have found a high prevalence of ajd among people exposed to stressful experiences. for instance, perkonigg et al. (2018) found a prevalence of 27.3% of ajd among people who lost their job. moreover, a recent large-scale study among cancer patients also found a prevalence of 12.4% of ajd (hund et al., 2016). an up to 12-fold increased risk of suicide emphasizes the high clinical relevance of ajd (casey et al., 2015; gradus et al., 2010). to advance the understanding of icd-11 ajd, further research on its psychopathological nature and symptomatic characteristics is required (bachem & casey, 2018; eberle & maercker, 2022). as core features of ajd, the newly introduced preoccupation and failure to adapt symptoms are particularly relevant for future research. the icd-11 notes that preoccupation with the stressor or its consequences includes different cognitive phenomena, such as excessive worry, recurrent and distressing thoughts about the stressor, or constant rumination about its implications. similarly, in past studies, preoccupation has often been defined using other cognitive symptoms, such as rumination or worry (e.g., lehtonen et al., 2009). however, it is unclear how these different forms of repetitive thinking symptoms are differentiated and if preoc­ qualitative exploration of adjustment disorder 2 clinical psychology in europe 2024, vol. 6(2), article e11565 https://doi.org/10.32872/cpe.11565 https://www.psychopen.eu/ cupation may not possess its own and independent symptom structure. in a recent review of the literature, a new characterization of preoccupation was proposed, in which preoccupation was defined as stressor-related factual thinking, which is time-consuming and often associated with negative emotions (eberle & maercker, 2022). this definition differentiates preoccupation from rumination, defined as negative and dysfunctional thinking, and worry, defined as anxiety-based and exclusively future-oriented thinking (eberle & maercker, 2022). such a specific definition and distinction of major cognitive symptoms, including preoccupation, rumination, and worry, is highly needed in light of the numerous overlapping and conflicting constructs in the area of cognitive symptoms (for an overview, see smith & alloy, 2009). however, the validity of the proposed preoc­ cupation characterization is unclear. considering the current lack of research in this field, preoccupation needs to be further investigated in empirical studies, which could have fundamental implications for the understanding of cognitive symptoms in clinical psychology. similar to preoccupation, the current characterization of failure to adapt in icd-11 ajd is rather rudimentary: the icd-11 defines failure to adapt without providing details on possible psychopathological manifestations of this symptom cluster. measurement instruments, such as the adjustment disorder new module (adnm; einsle et al., 2010) or the international adjustment disorder questionnaire (iadq; shevlin et al., 2020) describe failure to adapt symptoms as concentration problems, sleep disturbances or difficulties to achieve a state of inner peace. previous research has drawn attention to the fact that failure to adapt seems to be a much more heterogeneous symptom cluster than propccupations (bachem & maercker, 2016; levin et al., 2021). however, to our knowledge, no study has systematically explored other psychological problems of ajd patients that potentially fall under the category of failure to adapt symptoms. for example, individuals experiencing failure to adapt might also report problems such as memory issues or excessive fatigue. identifying and incorporating such psychological problems into diagnostic processes could contribute to improving the clinical practices of ajd treatment. moreover, there is a possibility that failure to adapt is closely related to preoccupation processes, an assumption supported by studies showing a close association between concentration problems and repetitive thinking (e.g., watkins & roberts, 2020). there is also a chance that sleep disturbances are a consequence of increased repetitive thoughts about the distressing life event(s) (takano et al., 2012), which could mean that failure to adapt and preoccupation are strongly interrelated processes. insights in this area have the potential to discover major dynamics in ajd psychopathology and recovery. empirical research that further explores the manifestations of failure to adapt in ajd patients is therefore essential. despite the icd-11’s efforts to specify the clinical picture of ajd, the core symptom groups of preoccupation and failure to adapt should be further defined and differentiated. vancappel, chkili, eberle et al. 3 clinical psychology in europe 2024, vol. 6(2), article e11565 https://doi.org/10.32872/cpe.11565 https://www.psychopen.eu/ shedding light on the psychopathological characteristics of these symptoms would likely improve the validity of ajd in research and clinical practice as previous problems related to ajd are essentially caused by the vague conceptual characteristics of this disorder. a qualitative bottom-up approach investigating different clinical presentations of ajd might provide useful results that could enrich past findings from quantitative analyses. the present study recognizes this potential and aimed to explore the characteristics and determinants of preoccupation and failure to adapt in qualitative interviews. for this purpose, a sample of individuals from an inpatient setting who suffered from ajd was investigated. method participants and procedure participants were recruited within the university hospital of tours. they were first assed by regular psychiatrists who performed the diagnostic evaluation based on the icd-11 criteria. patients suffering from ajd received information about the current study and were invited to pariticipate. the diagnosticians knew that the study aimed to develop the understanding of icd-11 ajd through a qualitative analysis, but this did not influence the section of the patient since all ajd patients were offered to participate. the interviews were conducted by the first author, who is a psychologist. participants signed a consent form after receiving written and verbal information about the study. next, they answered demographic questions about their age, sex, years of study after high school, and use of medication. finally, they completed questionnaires assessing symptoms of ajd, anxiety and depression. semi-structured interviews were then conducted to identify the determinants and characteristics of preoccupations and failure to adapt. these inter­ views were recorded with the participants’ consent, to enable qualitative analysis. they were then transcribed by the first two authors. all participants completed the study. the study was approved by the ethics committee of the university of tours. sixteen participants (eight women) (mean age = 41.75 ± 18.28) were recruited during psychiatric consultations in a public hospital between may and october 2022. one inter­ view had a duration of only 5 minutes because the patient presented an intellectual limitation. otherwise, the duration of the interviews was between 12 and 55 minutes. participants were at least 18 years old and had been diagnosed with ajd in a clinical interview by their regular psychiatrist, using the icd-11 criteria. one patient also met the criteria for schizophrenia and another one for bipolar disorder. however, they had been well stabilized with medication and the emotional response they presented was clearly related to the event they experienced (a break-up) rather than their chronic men­ tal disorder. moreover, these two patients had received the diagnosis of schizophrenia or bipolar disorder during prior visits, but they did not present with psychotic, depressive qualitative exploration of adjustment disorder 4 clinical psychology in europe 2024, vol. 6(2), article e11565 https://doi.org/10.32872/cpe.11565 https://www.psychopen.eu/ or manic symptoms during the current visit. such symptoms were absent for a long time due to well-balanced medication. four participants had not completed high school, five participants completed high school and seven participants completed a college degree. six patients received psychiatric medication at the time of the interview. three patients received an antidepressant treatment, one a hypnotic treatment, three an antipsychotic treatment and one a benzodiazepine treatment. the mean scores and standard deviation of the different scales were 59.12 ± 11.06 (adnm), 9.81 ± 4.82 (had-anxiety) and 10.59 ± 3.50 (had-depression). the stressful events they experienced are displayed in table 1. table 1 exposure to critical life events dimension events mentioned (n) main event (n) break-up/divorce 5 3 familial conflict 3 1 conflict at work 2 0 disease of a loved one 6 2 death of a loved one 4 3 jobless 3 0 too much/too little work 2 0 time pressure 4 0 new home 2 0 financial problems 2 0 own disease 6 5 accident 2 0 end of a leisure activity 5 0 quarantine due to an outbreak 2 0 other event 5 2 measures the adjustment disorder new module (adnm) the adnm-20 (einsle et al., 2010) consists of two parts. in the first part, participants indicate stressful events that occurred during the past two years and have burdened them during the last six months. then, participants indicate the most burdensome event(s), henceforth referred to as main events. finally, they provide a symptom rating of icd-11 core symptoms and accessory symptoms related to these events on a four-point likert scale from 1 (never) to 4 (often). previous results have found excellent psychometric properties within a french population (α = .92) (vancappel et al., 2021). we also found good reliability in the present sample (α = .84). a score above 47 indicates the probable presence of ajd (lorenz et al., 2016). vancappel, chkili, eberle et al. 5 clinical psychology in europe 2024, vol. 6(2), article e11565 https://doi.org/10.32872/cpe.11565 https://www.psychopen.eu/ the hospital anxiety depression scale (had) the had is a self-report questionnaire that assesses depression and anxiety (zigmond & snaith, 1983). seven questions are related to anxiety and seven are related to depression. participants answer multiple choice questions, withfour response options. the french version showed good psychometric properties (cronbach alpha from .67 to .90) (razavi et al., 1989). a score above seven indicates a borderline abnormal case and a score above 10 indicates the probable presence of depression or anxiety disorder. semi-structured interview a semi-structured interview schedule was conducted. the interview was developed based on the icd-11 criteria for ad and the available questionnaires that assess ajd. it also left enough flexibility for the participants to mention content that was not already identified in classifications or questionnaires. the questions are presented below. preoccupations • what do you think about the event? • what is the content of your preoccupations? • what do you feel when you are preoccupied with the event? • what triggers preoccupations? • how do the preoccupations stop? • what do you do to stop your preoccupations? • what are the consequences of your preoccupations? • what do you feel about the event? failure to adapt • how do you adapt to the event? • how does the event impact your ability to relax? • how does the event impact your ability to achieve inner peace? • how did your expectations of the future change after you experienced the stressful event? • how did your ability to work or carry out the necessary tasks in everyday life change after the event? • what is the impact of the event on your daily life (in work, social relationship and leisure activities)? the clinician explored the patient’s response to each question and asked if they had anything to add before moving on to the next question. thematic analysis we used thematic analysis to process the data (braun & clarke, 2006). the interviews were transcribed and were first read for overall familiarization and then read again and qualitative exploration of adjustment disorder 6 clinical psychology in europe 2024, vol. 6(2), article e11565 https://doi.org/10.32872/cpe.11565 https://www.psychopen.eu/ coded using a double-coding procedure. the data were coded first by the first author and then by the second author; minor disagreements were resolved, and the codes were categorized into themes and sub-themes. results thematic analysis six themes were identified. the number and percentage of participants who mentioned each theme and sub-theme are presented in table 2. theme 1: preoccupation triggers the participants described what triggers their preoccupation. they mostly mentioned that their preoccupation “never stops” and that they have the event “always in mind”. they also mentioned that preoccupation is more frequent when their mind is free and not distracted by another task and when there is a reminder of the event (e.g., a message from the ex-partner, seeing the scar of a surgery, or a picture of a lost loved one). one patient who had experienced a break-up explained that he wakes up, looks for his partner in the bed and starts thinking about the event for the rest of the day. theme 2: preoccupations and negative emotions all participants mentioned the presence of preoccupation and negative emotions. from the patients’ perspective, preoccupation and negative emotions were strongly interre­ lated. they described anger, explaining that “what happened is unfair”. one patient suffering from a somatic disease explained that she did not do anything to deserve her disease and that there is no justice. the patients mentioned anxiety and wondered a lot about what the event may cause in the future. for example, a patient who was engaged in an unfair lawsuit wondered what people will think about him after this event. they also referred to sadness, mostly explaining that life will not be the same for them. many patients described inappropriate guilt, perceiving that the event was her/his fault. they also described powerlessness and fear. one patient who lost custody of her children said again and again “whatever i will do the judge will not give me my children back.” theme 3: strategies to stop preoccupation almost all participants mentioned different strategies aimed at stopping preoccupations. they frequently used substances (e.g., “i sometimes drink a bit of alcohol, but it makes my mood worse”), distraction strategies (e.g., “i keep my mind busy, do some shopping or read a bit”) and suppression strategies. for instance, a patient who lost a friend explained that he tried to bury his emotions about the event. several patients also mentioned that vancappel, chkili, eberle et al. 7 clinical psychology in europe 2024, vol. 6(2), article e11565 https://doi.org/10.32872/cpe.11565 https://www.psychopen.eu/ table 2 number and percentage of participants who mentioned each theme and sub-theme theme / sub-theme n % preoccupations triggers 16 100.0 constance-uncontrollability 10 62.5 reminders 10 62.5 preoccupations and negative emotions 16 100.0 anger-injustice 10 62.5 anxiety-stress-worries 11 68.8 frustration 1 6.3 sadness 13 81.3 guilt 10 62.5 remorse-regrets 3 18.8 powerlessness 8 50.0 fear 10 62.5 other 12 75.0 strategies to stop preoccupations 16 100.0 substances 3 18.8 keeping the mind busy 13 81.3 inability to set strategies 8 50.0 suppression strategies 3 18.8 consequences of preoccupations 10 62.5 inner peace 6 37.5 inability to relax 4 25.0 envy 5 31.3 sleep 3 18.8 food intake 2 12.5 manifestation of failure/difficulties to adapt 16 100.0 ability to relax 13 81.3 inner peace 6 37.5 projections into the future 14 87.5 dependence 1 6.3 sense of utility 2 12.5 efficacy 12 75.0 others’ look 4 25.0 sleep 1 6.3 thoughts 16 100.0 self-confidence 1 6.3 motivation 11 68.8 life 11 68.8 social relationships 4 25.0 injunction of adaptation 4 25.0 difficulties of acceptance 3 18.8 ruminations-impact of event 10 62.5 strategies to address difficulties/failure to adapt 12 75.0 adjustment strategies 8 50.0 adjustment abilities 8 50.0 resilience 1 6.3 qualitative exploration of adjustment disorder 8 clinical psychology in europe 2024, vol. 6(2), article e11565 https://doi.org/10.32872/cpe.11565 https://www.psychopen.eu/ they were not able to stop their preoccupation despite such efforts. when the patients were asked how the preoccupation stops, some of them responded “it never stops.” theme 4: consequences of preoccupation interestingly, when asked to describe the negative consequences of preoccupation, par­ ticipants mentioned several symptoms corresponding to the icd-11 core symptom clus­ ter of failure to adapt. they confirmed experiencing an impaired inner peace or ability to relax (“e.g., my thoughts are like in a circle and i cannot find inner peace”). they also described that preoccupations alter the quality of their sleep, their motivation for proper alimentation and their general level of energy. one patient explained that after his break-up he has “eaten nothing but surimi for weeks”. theme 5: manifestation of failure/difficulties to adapt similarly, when patients described the negative consequences of the event more general­ ly, further difficulties or failed attempts to adapt were mentioned. mostly, the patients tended to describe failure to adapt as the direct consequences of the event and did not perceive how their attitude could be involved in their difficulties. they sometimes mentioned “it is not possible to adapt” to the event. among the consequences, the patients described a disrupted inner peace or ability to relax (e.g., “i do not have inner peace”). they mentioned a negative impact of the event on their prospects for the future (e.g., “i do not picture myself in the future anymore”). they talked about a dependence on other people. for instance, one patient who suffered from a neurologic disorder that restrained her mobility said “i have gone from hyperactive to being a vegetable”. the patients also mentioned a lack of utility or efficacy and the related feeling that people may judge them (e.g., “people do not like someone who is complaining all the time”), a decrease of self-confidence and motivation (e.g., “i do not have energy anymore”). they mentioned a negative impact on social life or life more globally and an inability to accept what happened that disrupts daily life. theme 6: strategies to address difficulties/failure to adapt finally, the patients mentioned individual adaptation strategies. one patient who suf­ fered from a break-up explained that he was telling himself that other people have also suffered from a break and tried to tell himself that things are going to be better. patients developed abilities to cope with the situation. one patient who lost his wife explained that he changed his habits and that he kept doing things (e.g., going for walks, seeing friends) without his wife. finally, some patients described experiences of growth. for instance, a patient who lost a close friend explained that this event made him stronger and that he enjoys more deeply the time spent with close people because of this event. vancappel, chkili, eberle et al. 9 clinical psychology in europe 2024, vol. 6(2), article e11565 https://doi.org/10.32872/cpe.11565 https://www.psychopen.eu/ discussion this study aimed to identify the characteristics and the determinants of preoccupations and failure to adapt among patients suffering from icd-11 ajd. overall, ample examples of icd-11 core symptoms of preoccupations and failure to adapt were identified in patient reports, which confirms the validity of the icd-11 ajd concept. more specifically, we found six themes in our analysis to describe the nature and context of the core symptoms: 1) preoccupation triggers, 2) preoccupations and negative emotions, 3) strat­ egies to stop the preoccupations, 4) consequences of preoccupations, 5) manifestation of failure/difficulties to adapt and 6) strategies to address difficulties/failure to adapt. eberle and maercker (2022) suggested a narrower definition of preoccupations than the one currently presented in the icd-11, describing them as stressor-related factual thinking, which is time-consuming and associated with negative emotions. in line with this suggestion, the present study found that preoccupations were stressor-related and associated with negative emotions. they were also found to be time-consuming as patients reported thinking about the event all the time. however, our data show limited support for the suggestion that repetitive negative cognitions in ajd solely refer to factual thinking. the patients reported neutral, negative, factual and nonfactual thoughts related to the index stressors. the content of the preoccupations was broad and related to multiple topics: thoughts about responsibility, questions about the future or regrets about the past. in this way, some thoughts could be labeled as ruminations, worries, preoccupations or negative automatic thoughts, according to the different theoretical backgrounds of cognitive symptoms. future research should undertake a more detailed examination of the different cognitive phenomena to determine if preoccupation in the narrower sense as suggested by eberle and maercker (2022) is the core characteristic of ajd or whether different kinds of cognitive phenomena are relevant to represent patients’ suffering. a combination of different cognitive symptoms, as it was found in the present study, also appears in other disorders, such as depression or generalized anxiety disorder (muris et al., 2005; smith & alloy, 2009). however, some types of repetitive thoughts may be particularly prevalent in ajd. for example, it was shown that altough generalized anxiety disorder is characterized by both worry and rumination, worry has a more significant impact on its clincal presentation (yang et al., 2014). likewise, it is possible that while repetitive thoughts about a stressful life event in ajd might manifest as preoccupation, rumination, and worry, one of these symptoms could be particularly relevant in the psychopathological presentation. clarifying the significance of such symptoms could enhance the clinical psychological classification of ajd. manifestations of failure to adapt symptoms included the difficulties mentioned in current ajd questionnaires (e.g. sleep problems, inability to find inner peace, decreased motivation) (einsle et al., 2010; shevlin et al., 2020), but also included additional experi­ ences, such as disturbances in appetite, lowered sense of utility, and impaired social relationships. this finding raises the question of whether failure to adapt symptoms qualitative exploration of adjustment disorder 10 clinical psychology in europe 2024, vol. 6(2), article e11565 https://doi.org/10.32872/cpe.11565 https://www.psychopen.eu/ are adequately covered in existing ajd questionnaires. additional research is needed to explore the diverse manifestations of failure to adapt and to determine which manifesta­ tions of failure to adapt may be most central for ajd patients. here, a starting point could be to explore the concept of lack of recuperative ability (maercker, 2017) as the core of this symptom group (e.g., sleep disorders, concentration disorders, inability to find inner peace, lowered sense of utility). concerning the pathogenesis of ajd, patient reports suggest that preoccupation may be the starting point of their difficulties and eventually result in failure to adapt. specifi­ cally, manifestations of failure to adapt, such as difficulties finding inner peace or falling asleep, were described as a consequence of prolongued constant preoccupation with the stressor. this is in line with recent findings based on network analyses, which found that after a critical life event, preoccupation symptoms were most central in non-clinical samples whereas among participants with a suspected diagnosis of ajd, failue to adapt and functional impairment were most central (levin et al., 2021, 2022). the present study strengthens the assumption that preoccupation plays an important role in the pathogenesis of ajd. this study has several limitations. due to the qualitative design, the number of participants was limited, making it difficult to generalize the conclusions. the research was also conducted in a single hospital, limiting the representativeness of the general population. the sample was also diverse with regard to the stressors experienced, age, medication. however, such diversity is representative of the patient group suffering from ajd. moreover, a few patients had comorbid mental disorders. even though their psycho­ pathological state was clearly dominated by the current ajd symptoms, the additional disorders may have influced their cognitions and emotions, which were investigated in the present study. finally, the use of thematic analysis is per se subjective. this means that the interpretation of the data may have been biased by the previous knowledge of the researchers. nevertheless, the present study highlighted the significance of stressor-related and emotionally aversive cognitions in ajd, which has clinical implications. preoccupations should be a prime target in interventions as they seem to be crucial in the stress response and as they are related to maladaptive coping strategies such as alcohol consumption. a reduction in preoccupation symptoms during the earlier stages of the stress-response may be related to a decrease in failure to adapt symptoms. this assumption is consistent with interventions focused on other cognitive symptoms. for instance, it was found that worry causes mental impairment beyond the cognitive level (e.g., problem solving) and that in turn, a reduction of worry might reduce a broad range of psychological problems (llera & newman, 2020). psychoeducation about the nature and maladaptive effects of preoccupation and cognitive restructuring or cognitive defusion (assaz et al., 2023) could be used to address distressing repetitive thoughts. vancappel, chkili, eberle et al. 11 clinical psychology in europe 2024, vol. 6(2), article e11565 https://doi.org/10.32872/cpe.11565 https://www.psychopen.eu/ funding: this work did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors. acknowledgments: we would like to thank all the participants and the colleagues who helped us to gather the data. competing interests: the authors have declared that no competing interests exist. author contributions: all authors took part in developing the methodology. the first author performed the semistructured interviews. the first and second author performed the qualitative analysis. the first, third and last author wrote the first version of the manuscript. all authors added modifications and approved the final version. 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(introduction) method participants and procedure measures semi-structured interview thematic analysis results thematic analysis theme 1: preoccupation triggers theme 2: preoccupations and negative emotions theme 3: strategies to stop preoccupation theme 4: consequences of preoccupation theme 5: manifestation of failure/difficulties to adapt theme 6: strategies to address difficulties/failure to adapt discussion (additional information) funding acknowledgments competing interests author contributions ethics statement data availability references behind the doors: 24 insights into scientific publishing editorial behind the doors: 24 insights into scientific publishing cornelia weise 1 [1] department of psychology, clinical psychology and behavioral health technology, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany. clinical psychology in europe, 2025, vol. 7(4), article e20861, https://doi.org/10.32872/cpe.20861 published (vor): 2025-11-28 corresponding author: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, department of psychology, clinical psychology and behavioral health technology, nägelsbachstr. 49b, 91052 erlangen, germany. email: cornelia.weise@fau.de how do you write a farewell editorial after having founded, built, and led a journal as editor-in-chief for seven years? and how do you do that at the end of the year, when many of us feel a little exhausted after another fully packed twelve months? this is the season when most of us are less eager to dive into the latest scientific breakthroughs and are more ready to simply count the days until things finally quiet down. the ever-buzzing inbox falls silent, pressing deadlines fade away, and even universities close for the holidays to save a little energy. but perhaps that’s exactly the right mindset for this piece: counting days. so why not draw on that good old german tradition of the advent calendar – opening one little door after another? let’s open the doors and see what surprises (and lessons) they hold from my seven years as editor-in-chief.   #1 new beginnings. it all began in 2018, when we got in touch with armin günther, who was then the managing editor at the leibniz institute for psychology (zpid). we discussed the pros and cons of launching a new journal and quickly became convinced that this project would be a great and innovative way to increase the visibility of clinical psychology in europe. #2 open access. at the heart of cpe’s mission is the diamond open access model, i.e., no fees for authors or readers. this model reflects our belief that scientific knowl­ edge should circulate freely, independent of financial barriers or institutional privileges. my sincere thanks go to the leibniz-institute for psychology for making this true open access possible. #3 psychologists as brand designers. of all the tasks that came with launching the journal, designing our logo was one of the unexpected creative challenges. it turned this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.20861&domain=pdf&date_stamp=2025-11-28 https://orcid.org/0000-0001-5216-1031 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ out to be a lot of fun, and i’m still very happy with the result. can you guess all the ideas hidden within it? #4 team spirit. cpe has been a true team effort. working with my co-editors and our editorial board made the journal what it is today. sharing ideas, debating choices, and solving problems together was, and is, what kept it moving forward. #5 innovation. for a journal, innovation means staying curious and open to new ways of advancing scientific communication. at cpe, we welcome ideas that enhance both the journal’s visibility and the impact of clinical psychology. our new early career researcher board is one step in that direction, helping shape cpe’s future and bring fresh ideas to life. #6 editor’s st. nicholas. in an editor’s world, st. nicholas wouldn’t fill shoes with sweets and oranges, but with submissions that follow the author guidelines, carefully revised manuscripts, or messages from reviewers who agree to review. #7 cornerstones. cpe rests on the steady support of its academic home, eaclipt. over the years, eaclipt has provided stability and exchange, while giving us the freedom to shape the journal’s identity. we couldn’t have wished for a better foundation. #8 copyediting pro tip. when you submit your paper and receive detailed instruc­ tions on how to prepare your figures and tables, please make sure to follow them. other­ wise, the copyediting team might ask again (and again… and again) to fix the layout. we can’t help it. we’re a bit nerdy when it comes to the look of a final manuscript. #9 responsibility. an academic journal must actively protect and promote scien­ tific freedom – especially when censorship or financial restrictions threaten research, and thus the progress needed to safeguard mental health. i’m deeply grateful that our association, eaclipt, published a statement on the importance of academic freedom (martin-soelch et al., 2025). at cpe, we stand firmly by this commitment. #10 student assistants do the trick. behind every successful project is a great team. over the years, several student assistants have supported cpe from submission to publication behind the scenes. thank you, juliane haas, ania hoffmann salán, hannah sandner, and annkatrin simon, for being such an essential part of the team. #11 transparency. for cpe, open science is not just a policy, it’s a commitment to trust. from the very beginning, we’ve taken transparent and reproducible research seriously. by implementing the transparency and openness promotion (top) guidelines (center for open science, 2025), cpe actively contributes to making empirical research more transparent, credible, and verifiable. #12 recommend reviewers. the better your reviewer suggestions, the sooner you’re likely to hear from us. and just to clarify: we won’t contact the colleague with whom you’ve co-authored 200 papers, the person in the next office, or anyone we can’t find in a five-minute web search. behind the doors: 24 insights into scientific publishing 2 clinical psychology in europe 2025, vol. 7(4), article e20861 https://doi.org/10.32872/cpe.20861 https://www.eaclipt.org https://www.psychopen.eu/ #13 recommend further reviewers. yes, three potential reviewers are great, but an even longer list makes us truly happy. keep in mind that it can take up to 15 invitations to secure just two reviewers who agree. #14 backbone. peer review is the backbone of scientific self-regulation. imperfect as it is, it ensures that ideas are challenged, refined, and strengthened through the scrutiny of one’s peers. i greatly appreciate all reviewers who shared their time and expertise. #15 supplementary material. once upon a time, in the 1990s, “available upon request” was acceptable. today, in 2025, transparency demands more. upload your sup­ plementary materials, and we’ll gladly assist via psycharchives. #16 core of clinical psychology. cpe strives to highlight new developments that shape clinical psychology and its practice. our special issue on mental health innovations in the icd-11 illustrates this mission (maercker, 2022). as a european journal, we aim to connect global advances with the realities of clinical work and training across europe. #17 curiosities. work can wait – curiosity can’t! for a quick mental break, take a look at last year’s season’s editorial on visualizations of sex and gender on toilet doors (rosmalen et al., 2024). who knows – perhaps it might inspire you to explore some unanswered questions of your own. #18 impact. one of the first topics we discussed with our publisher was how to achieve an impact factor as quickly as possible. even though it took some time, we are grateful and proud that cpe is now listed in the web of science and has received its first – and already impressive – impact factor in 2025. cpe will continue to strive for excellence and to further strengthen this achievement. #19 revise and resubmit. a second or third round of revision is rarely pleasant for authors. as editors, we share those sighs. it is challenging for us, too, to ask for more changes. although the process can be time-consuming and frustrating, the outcome almost always speaks for itself: the papers become stronger. so, keep going; it's worth it. #20 the invisible architecture. no journal thrives without the steady, precise, and patient work of its publisher. people who quietly build up the system, organize workflows, answer support questions, and step in at the last minute to keep everything running. for cpe, the leibniz institute for psychology (zpid) has been this foundation. without it, many of our ideas would never have left the drawing board. #21 christmas reading. for those celebrating christmas, i’d like to highlight our 2022 editorial on how singing under the christmas tree can positively impact mental health (kanske & rief, 2022). it’s well worth revisiting at this time of year. #22 special issues. we’ve published three special issues so far, each capturing a snapshot of a particular research area. my personal favourite is the one on cultural adap­ tation of psychological interventions. it brings together various approaches to culturally sensitive psychotherapy and provides clear guidelines for reporting cultural adaptations in clinical trials, making it a key resource for transcultural research worldwide (heim & weise, 2021). weise 3 clinical psychology in europe 2025, vol. 7(4), article e20861 https://doi.org/10.32872/cpe.20861 https://www.psycharchives.org https://leibniz-psychology.org https://www.psychopen.eu/ #23 the joy of discovery. amid the long list of editorial to-dos, there is one moment that stands out: when you read a submission and suddenly pause. a novel idea, an unexpected dataset, or a brilliant line of reasoning emerges. and for a moment, you remember why you entered academia in the first place: the quiet thrill of discovering something new. #24 farewell. over these years, i have learned a great deal, not only about academic publishing, impact, indexing, and copyediting, but also about responsibility, tackling challenges, and working under a very different kind of time pressure. along the way, i’ve met many fascinating people and am very grateful for the projects, collaborations, and initiatives that grew out of these encounters. i am especially thankful for the support of my wonderful co-editors, winfried rief and nadine-messerli-bürgy, and our colleagues at zpid, particularly judith tinnes, gerrit fröhlich, and armin günther. building this journal together was more often joy than work, and even when things didn’t go as planned, our collaboration always stayed constructive. my gratitude also goes to my colleagues and friends who suggested topics, authors, or reviewers (and occasionally stepped in themselves). and to my own research team – thank you for your patience whenever a new journal issue took precedence over our own papers. cpe will always remain close to my heart. i’m truly grateful to have served as edi­ tor-in-chief for so many years, and i wish the continuing and new editors a confident, inspired hand and every success in using cpe to strengthen the visibility of clinical psychology in all its relevance, excellence, and diversity. funding: the author has no funding to report. acknowledgments: the author wishes to thank jette angenendt and monica mihailescu for their helpful comments and proofreading assistance. competing interests: cornelia weise is editor-in-chief of clinical psychology in europe. references center for open science. (2025). transparency and openness promotion (top) guidelines. https://www.cos.io/initiatives/top-guidelines heim, e., & weise, c. (2021). cultural adaption of psychological interventions. clinical psychology in europe, 3(special issue), article e7627. https://doi.org/10.32872/cpe.7627 kanske, p., & rief, w. (2022). is singing under the christmas tree psychologically recommended? a scientific evaluation. clinical psychology in europe, 4(4), article e10841. https://doi.org/10.32872/cpe.10841 behind the doors: 24 insights into scientific publishing 4 clinical psychology in europe 2025, vol. 7(4), article e20861 https://doi.org/10.32872/cpe.20861 https://www.cos.io/initiatives/top-guidelines https://doi.org/10.32872/cpe.7627 https://doi.org/10.32872/cpe.10841 https://www.psychopen.eu/ maercker, a. (2022). the icd-11 diagnoses in the mental health field – an innovative mixture. clinical psychology in europe, 4(special issue), article e10647. https://doi.org/10.32872/cpe.10647 martin-soelch, c., bockting, c., breedvelt, j., frostholm, l., heinrichs, n., hirsch, c., popiel, a., & rief, w. (2025). eaclipt statement on the importance of science and evidence-based treatment for mental health. clinical psychology in europe, 7(2), article e18031. https://doi.org/10.32872/cpe.18031 rosmalen, j., plug, i., & ballering, a. (2024). all i want for christmas is a loo: visualizations of sex and gender on toilet doors. clinical psychology in europe, 6(4), article e16159. https://doi.org/10.32872/cpe.16159 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service provided by the leibniz institute for psychology (zpid), germany. weise 5 clinical psychology in europe 2025, vol. 7(4), article e20861 https://doi.org/10.32872/cpe.20861 https://doi.org/10.32872/cpe.10647 https://doi.org/10.32872/cpe.18031 https://doi.org/10.32872/cpe.16159 https://www.psychopen.eu/ feasibility and acceptability of a mobile app for prolonged grief disorder symptoms research articles feasibility and acceptability of a mobile app for prolonged grief disorder symptoms anaïs aeschlimann 1 , nicolas gordillo 2 , taro ueno 3 , andreas maercker 1 , clare killikelly 1,4 [1] department of psychology, university of zurich, zurich, switzerland. [2] department of informatics, university of zurich, zurich, switzerland. [3] susmed inc., tokyo, japan. [4] department of psychiatry, university of british columbia, vancouver, canada. clinical psychology in europe, 2024, vol. 6(1), article e10881, https://doi.org/10.32872/cpe.10881 received: 2022-12-19 • accepted: 2024-01-15 • published (vor): 2024-03-28 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: clare killikelly, department of psychology, university of zurich, binzmuehlestrasse 14/17, ch-8050 zurich, switzerland. e-mail: c.killikelly@psychologie.uzh.ch supplementary materials: materials [see index of supplementary materials] abstract background: mobile apps provide a unique platform for mental health assessment and monitoring. they can provide real time, accessible data on symptoms of mental disorders that may yield rich data for detailed clinical assessment and help individuals gain insight into their current mental state. we developed one of the first apps for tracking symptoms of prolonged grief disorder. method: in this pilot feasibility study, we assess the feasibility and acceptability of a new mobile app mgage for use once a day for 3 weeks. 27 participants completed mental health assessments at t1 and t2. results: adherence to the app protocol was very high with 100% for the first two weeks of use. a surprising finding was the improvement of grief symptoms at t2. debriefing interviews revealed general qualitative categories including positive feedback, negative feedback and specific recommendations. overall, the app was found to be feasible for use for the first two weeks and acceptable for bereaved individuals. conclusions: this app could provide valuable data for in depth clinical assessment, may support individuals to gain greater insight into their symptoms and may have a therapeutic effect in terms of improved grief symptoms. implications for future studies including use in larger intervention studies are discussed. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10881&domain=pdf&date_stamp=2024-03-28 https://orcid.org/0000-0001-7049-5131 https://orcid.org/0000-0002-1537-6719 https://orcid.org/0000-0003-3697-4301 https://orcid.org/0000-0001-6925-3266 https://orcid.org/0000-0003-2661-4521 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords prolonged grief disorder, e-mental health, mobile app, self-monitoring intervention highlights • prolonged grief disorder is a new mental health disorder in the icd-11: this is one of the first mobile apps developed to assess the new icd-11 pgd. • the app is found to be easy to use and acceptable by bereaved individuals. this may improve clinical assessment as it provides real time data on the intensity and stability of grief over a 2-week period. • the act of self-monitoring may have an intervention effect; after two weeks of reporting grief symptoms there was a significant improvement in grief symptoms. the death of a loved one represents one of the most severe life stressors (breslau et al., 1998). in a majority of those affected (80-90%), acute grief symptoms dissipate after a certain time, however, approximately 10% experience a prolonged and severe grief reac­ tion (lundorff et al., 2017). with the introduction of the diagnostic category prolonged grief disorder (pgd) in 2018, the world health organization’s international classifica­ tion of diseases (icd-11) allows the diagnosis of disordered grief reactions for the first time. pgd is characterized by two core symptoms relating to longing or yearning for the deceased and persistent preoccupation with the deceased, accessory symptoms of emotional distress and a time and functional impairment criterion. the criteria also take into account varying cultural norms and practices, stating that symptoms must exceed the typical duration and intensity in an individual’s culture and context (maercker et al., 2013). however, the applicability of the diagnostic criteria, including the time criterion, have not yet been established beyond the western-european contexts (stelzer et al., 2020). if left untreated, individuals affected by pgd are at risk of experiencing a range of further serious health and psychosocial problems including increased rates of cardio­ vascular problems, high blood pressure, harmful health behaviors, substance abuse, or suicidality (fujisawa et al., 2010; kersting et al., 2011; maercker et al., 2008; prigerson et al., 2009). being a relatively recent diagnostic category however, pgd may be difficult for clinicians to differentiate from normal grief (keeley et al., 2016). furthermore, pgd does not respond well to interventions that are intended and effective for other bereave­ ment-related mental health problems, e.g., depression, but rather calls for interventions specifically tailored to the precursor to pgd, complicated grief (m. k. shear et al., 2016). hence, a correct diagnosis is highly relevant for identifying individuals in need of treatment and providing suitable interventions. although recent evidence has shown the effectiveness of interventions specifically tailored to pgd, research still remains limited and further investigation is necessary (boelen et al., 2006; bryant et al., 2014; killikelly & maercker, 2017; shear et al., 2005). mgage mobile assessment for grief 2 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ another domain of research, which is still lacking, concerns providing the individual with the right support at the right time (wagner, 2013; wakefield, 2012). currently, the long-term trajectories of pgd are poorly understood and further research on the heter­ ogeneity in the fluctuations of symptoms over time is needed (bonanno & malgaroli, 2020; sveen et al., 2018). some individuals may need immediate psychotherapy support while others may benefit from self-help and monitoring (johannsen et al., 2019). in addition, recall bias can be problematic for individuals who provide a one-off self-report questionnaire on symptoms. from depression to psychosis there can be variability in the presentation and reporting of symptoms day by day. digital technology provides the opportunity to more reliably monitor symptoms daily over a longer period of time to ensure a robust assessment and valid measurement (lenferink et al., 2022). alongside more accurate diagnosis, symptom tracking and self-monitoring has two uses for inter­ ventions. firstly, daily monitoring alongside psychological and behavioral interventions would allow participants to see the effect of interventions as they unfold day to day. secondly, the mere act of tracking and monitoring symptoms could provide more insight into symptoms and their severity. in recent years, digitalization has gained importance in the domain of mental health, bearing the potential to overcome access barriers, as well as expanding the availability and quality of mental health treatment (chandrashekar, 2018; torous et al., 2019). inno­ vative solutions to self-management of mental health problems are especially relevant, given the large treatment gap, meaning that only a small proportion of individuals in need of treatment receive professional help (kohn et al., 2004). e-mental health interven­ tions delivered via smartphones bring many advantages including immediate support, constant availability, anonymity, low cost, greater access and equity of mental health resources (olff, 2015). there has been an increase in the number of available smartphone apps for monitor­ ing and management of mental health symptoms (wang et al., 2018). this method of ambulant monitoring possesses a number of advantages, which have been demonstrated for various mental health problems (myin-germeys et al., 2011; wichers et al., 2011). this type of data may deliver insights on symptom triggers, relapse signatures, real-time effects of treatment and can provide early detection of change in symptoms (birchwood et al., 2000; gleeson et al., 2005; palmier-claus, 2011). this has the potential of facilitating earlier interventions, preventing relapse and avoiding hospital admissions, thus also reducing costs (whelan et al., 2015). recently ‘my grief app’ was developed by a swedish collaborator for bereaved parents after the death of a child (eklund et al., 2021, 2022). it includes modules focused on psychoeducation and intervention with some brief symptom tracking (one item, grief severity). in a pilot study 13 parents used the app for 4 weeks and it was found to be an acceptable and useful intervention. a follow-up randomized control trial is currently underway to assess the effectiveness in reducing pgd symptoms. in terms of grief monitoring, a recent study confirmed the feasibility aeschlimann, gordillo, ueno et al. 3 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ and acceptability of grief symptom monitoring using a mobile app and experience sampling methodology (lenferink et al., 2022). bereaved individuals responded to pgd symptom questions five times a day for two weeks. adherence was variable with a high drop out rate of 35-40%. our current study adds to this new wave of symptom tracking research by developing a mobile app to directly assess icd-11 pgd symptoms using a validated questionnaire, the international prolonged grief disorder scale (ipgds) and using a less intensive monitoring frequency. a mobile self-report tool to assess pgd: mgage taking into consideration the current knowledge on the benefits of symptom monitoring and harnessing the potential of digitalization, we designed and developed the mobile grief assessment guide and e-resource (mgage). mgage was designed employing the user-centered design process and two focus groups of bereaved individuals. the first step in our development process was to design an app for use by bereaved individuals in general, not only those with clinically severe pgd. focus group partici­ pants were recruited from a convenience sample and using the snowball technique and the inclusion criteria included adults who had experienced the death of a loved one at least 6 months ago. the first focus group (n = 4) openly explored the need for and qualities of an app for grief, including advantages and disadvantages of such an app. the second focus group (n = 4) elaborated on a preliminary design for the app and gathered feedback on the design and specific planned features of the app. examples of the focus group questions include: what type of information about grief would you like to know? how many questions would you answer? what kind of feedback would be helpful for you? one important consideration in the further development of this app is the purpose of the app. we have sought to ensure that the user centered design (schnall et al., 2016) is applied to all stages of the app development. user centered design is defined as an itera­ tive developmental process that incorporates user feedback across different stages of app development. this can be achieved through interviews and focus groups. related to this, the findings from the current study confirm that it is important to provide participants with the choice of how and when to use the app. several participants identified the need for personalization of the app. in the next iterative round of development, we will add options to ensure that participants can choose when they complete the app, for how long they would like to use it and how frequently. moreover, self-monitoring tools, such as mgage, have the potential to promote a more empowered and active role of patients in treatment (huber et al., 2011). future research should explore these possibilities in the form of a randomized controlled trial with an active control group and importantly, with a clinical sample of those diagnosed with pgd. mgage mobile assessment for grief 4 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ in the current version of the mgage app it can be delivered via an ios and android app, which can be used online on mobile devices. users create a personalized login id and are then led to two introduction pages containing information on pgd and the mgage app respectively. the app sends users a daily reminder to fill out the integrated questionnaire on pgd symptoms. the completion of the questionnaire takes around 5 minutes. at the end of the questionnaire, users have the option to utilize the diary function, which additionally allows them to record their mood, thoughts, behaviors or actions (see figure 1). after completion, users receive a feedback concerning the severity of their symptoms, as well as help-seeking recommendations. if the user scores above the cut-off score, indicating that they may suffer from pgd, a direct link to different local services and resources including psychological support appears at the bottom of the page. furthermore, mgage includes a graph function (see figure 1), which allows users to visualize their assessment history, helping them track the course of their symptoms. additionally, mgage provides users with a support resource page, which lists different professional support resources for bereaved individuals. figure 1 screenshot of the mgage app welcome page and symptom tracking screens symptom course diary track your mood, thoughts, behavior, and activities here regularly. studies show that this promotes awareness for our emotions and that this can lead to a reduction of psychological problems and promote coping strategies. figure 1: screen shot of the mgage app welcome page and symptom tracking screens. the aim of the present study is to (1) evaluate the feasibility of the app in terms of adherence and use of the app as well as (2) the acceptability of the mgage app in terms of feedback and evaluation of the app by bereaved individuals. we also explore the variability of ipgds scores across the 2 weeks and provide insights that may guide the app use to evaluate the effectiveness of pgd interventions. aeschlimann, gordillo, ueno et al. 5 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ method study design we conducted an observational feasibility study with the aim of developing and assess­ ing the feasibility and acceptability of a new mobile grief symptom tracking tool to assist bereaved individuals in self-tracking and monitoring their grief symptoms. the study protocol was approved by the ethics review board of the university of zurich. participants and recruitment participants were bereaved individuals, who had experienced the loss of a close person. inclusion criteria specified: 1) fluency in german; 2) age of 18 or older; 3) ability to provide written informed consent; 4) loss of a loved one (family or friend) at least 6 months prior; 5) use of a smartphone. exclusion criteria were a severe mental health disorder (e.g., major depression, suicidality, current schizophrenia) or currently being an in-patient. participants were remunerated for their time to complete the pre-assessment with 30 swiss francs (chf) and the post-assessment with 50 chf. furthermore, participants who were psychology students had the option of being compensated with course credit (4 hours) as an alternative. additionally, participants had the option of being reimbursed up to 20 chf for travel expenses related to study participation. recruitment took place between august 24th and november 4th, 2020. methods of recruitment included the posting of advertisements and recruitment links on different facebook groups and mailing lists of the university of zurich, as well as through whatsapp groups. four people who had agreed to participate dropped out before t1. reasons for drop out included personal reasons and lack of readiness to discuss the death (10 people were interested in the study but did not meet criteria). measures participants were assessed twice in-person at the department of psychology of the uni­ versity of zurich: for the pre-assessment (t1) and the post-assessment (t2). assessments were conducted by the project manager and a bachelor’s student in psychology under the supervision of a clinical psychologist. the bachelor’s student was previously trained by the project manager on the study procedures, including the administration of the questionnaires. additionally, participants were encouraged to provide daily online data regarding their grief symptoms for 3 weeks between t1 and t2. one participant continued to use the app for longer than the required 21 days (up to 27 days). however, this was only 1 participant and beyond the scope of our protocol. the duration of assessment of up to 3 weeks was determined as a limit based on previous experience sampling methods mgage mobile assessment for grief 6 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ with bereaved individuals who found that adherence to self-monitoring significantly declined after 2 weeks (lenferink et al., 2022; mintz et al., 2023). socio-demographic data data on socio-demographic information (age, gender, nationality, marital status, educa­ tion, psychotherapy experience) was collected at t1. mental health outcomes at t1 and t2, we assessed several mental health outcomes using the measures and descriptions listed here. grief was assessed using the international icd-11 prolonged grief disorder scale, including both the standard subscale and the cultural supplement, ipgds killikelly et al., 2020). the standard subscale consists of 13 items based on the icd-11 definition of pgd, while the cultural supplement consists of an additional 19 possible items that can be used for treatment planning and cultural acceptability. symptoms are rated on a 5-point scale: 1 = almost never (less than once a month), 2 = rarely (monthly), 3 = sometimes (weekly), 4 = often (daily), and 5 = always (several times a day). an impairment item as well as screening items for the length of time since bereavement and the violation of socio-cultural norms was also included. pgd strict criteria requires the fulfillment of the following criteria: one of items 1 or 2, 1 or more of items 3-12 and the impairment criteria (item 13) all rated 4 or above (lenferink et al., 2021). pgd moderate criteria is the same as the strict criteria except all items are rated 3 or above. finally, the maciejewski et al. (2016) criteria includes one of items 1 or 2, 3-5 of items 3-12 and no impairment criteria, all rated 4 or higher (breen & o’connor, 2007; maciejewski et al., 2016). depression: the patient health questionnaire (phq) is a self-administered version of the prime – md diagnostic instrument for common mental disorders (kroenke et al., 2001). the phq-9 is the depression module, which scores each of the 9 dsm – iv criteria as “0” (not at all) to “3” (nearly every day). a cutoff score of ≥ 10 has been recommended to indicate moderate to severe depression (kroenke, spitzer, & williams, 2001). anxiety: the 7-item generalized anxiety disorder scale (gad-7) is a practical selfreport anxiety questionnaire that proved valid in primary care according to dsm-iv (spitzer et al., 2006). scores for all 7 items range from 0 (not at all) and 3 (nearly every day). a cutoff score of 8 or above is recommended to identify possible anxiety disorder. post traumatic stress disorder: international trauma questionnaire (itq) is the icd-11 based post-traumatic stress disorder (ptsd) measure (cloitre et al., 2018). the first 9 items of the scale relate to core symptoms of ptsd including re-experiencing, avoidance and sense of current threat and functional impairment. for the purposes of this current study we used only the first 9 items to assess ptsd. for the diagnostic algo­ rithm see cloitre et al. (2018) furthermore, we assessed subjective wellbeing (who-five wellbeing index, who-5, bech et al., 2003) the total raw score, ranging from 0 to 25, is aeschlimann, gordillo, ueno et al. 7 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ multiplied by 4: 0 indicates worst well-being and 100 indicates the best well-being. daily mobile app data regarding grief symptoms was collected using the standard subscale from the ipgds (13 items) which was recently psychometrically validated in terms of reliability and validity (killikelly et al., 2020). previous research using similar daily sampling or experience sampling methodology has purported the importance of allowing participants the option to personalize the assessment method and tailor questions based on their current needs or experiences. here we pilot the use of personalized assessment by including three idiosyncratic, personally relevant items chosen from the cultural supplement alongside the standard scale of 13 items (van os et al., 2017). feasibility, clinical utility and acceptability outcomes to examine the feasibility of the intervention, we analyzed usage data, specifically (i) percent of participant completing all entries (ii) average entries completed per week. ac­ ceptability was assessed during an unstructured exit interview, where participants were asked about their experience using mgage and their suggestions for improvement in a potential updated version. additionally, we employed a questionnaire on acceptability to assess the quality of health-related mobile apps at t2 (mobile app rating scale, mars, stoyanov et al., 2015). the mars evaluates the quality of mobile apps (engagement, functionality, visual aesthetics, information quality and subjective quality subscales) on a scale from 1 (inadequate) to 5 (excellent). procedure preceding t1, participants were sent an e-mail confirming their appointment for t1, including the study information sheet, the informed consent form, directions to the de­ partment of psychology and an information sheet about the mgage app. additionally, participants received a reminder e-mail one day before t1. assessments were conducted in our offices by the project manager or a psychology student, who received training on administering the assessment. participants provided written informed consent. participants then completed a questionnaire battery about their current mental health status and grief symptoms. subsequently the participants had the option to select up to three items from the cultural supplement of the ipgds to be included in their online questionnaire on the mgage app. a brief introduction to the app was given where a team member helped participants download the app and create a personal user id, as well as elaborating all app functionalities and answering any questions participants had (see supplementary materials on mobile app information). participants were instructed to complete the ipgds within the mgage app once a day for three weeks. the ipgds in this case meant the standard subscale of the ipgds and the potential maximum of 3 additional individual items selected from the cultural supplement of the ipgds by the participants. additionally, an information sheet, summa­ mgage mobile assessment for grief 8 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ rizing all app functionalities was provided. furthermore, all participants received a list of resources and links for bereaved individuals. three weeks after t1, participants were invited to return for the post-assessment t2 and received a reminder e-mail one day before t2. at t2, participants were asked to com­ plete the same questionnaires as for t1 and an additional questionnaire concerning their experience with the mgage app. upon completion, a brief unstructured exit interview was conducted assessing the acceptability of the app. after this, participants received a short debriefing to discuss their experience of participating in the study. analyses all statistical analyses were conducted in spss version 24. inspection of histograms and the kolmogorov–smirnov test statistic (i.e., significance indicates that the distribution of the data significantly differs from a normal distribution) was used to determine whether parametric or non-parametric testing was appropriate. the main outcome measures for grief (ipgds t1 and t2) were normally distributed while all other measures were normal­ ly distributed at one time point. to ensure consistency, the results of the parametric tests (paired samples t-tests) were confirmed with non-parametric tests (mann-whitneywilcoxon test). feasibility and acceptability variables included percentage of participants completing the daily entry and averaged over the week. the debriefing interview was analyzed using qualitative thematic analysis. firstly, the interview data was in vivo transcribed into short relevant sentences and translated into english. secondly the text was coded and grouped into large categories following iterative categorization (neale, 2016). finally, the codes and themes were reviewed by ck and aa and final consensus codes were determined. results table 1 presents the demographic characteristics of the participants. participants were mostly university educated (40.7%) young (average age 25.7) women (88.9%). time since loss ranged from 6 months to more than 10 years. almost 30% of participants had pre­ vious experience with psychotherapy. mean scores on the mental health outcome meas­ ures are presented in table 2. paired sample t-tests revealed no significant differences between t1 and t2 on all mental health measures, except for the ipgds standard scale (13 items) (t1 mean 21.3 vs. t2 mean 18.5, p = .002). table 3 presents the diagnostic algorithm findings. none of the participants met criteria for a strict diagnosis of pgd, while one met criteria for moderate pgd at t1 and two participants at t2. three participants met criteria for ptsd at t2. aeschlimann, gordillo, ueno et al. 9 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ table 1 sociodemographic, loss-related and symptom characteristics variable total sample (n = 27) n % gender male 3 11.1 female 24 88.9 education maturaa 16 59.3 college/university 11 40.7 relationship status singleb 26 96.3 married 1 3.7 time since loss 6 to 12 months ago 8 29.6 1 to 5 years ago 13 48.1 10 to 20 years ago 2 7.4 other previous psychotherapy for griefc 8 29.7 current psychotherapyc 2 7.4 note. n = 27. participants were on average 25.70 years old (sd = standard deviation). aequivalent to high school education or above in switzerland. bis defined here as non-married individuals. creflects the number and percentage of participants answering “yes” to this question. in order to assess the feasibility of mgage use, variables related to adherence to the app were examined. only one participant completed all entries over the total possible 21 days. up to day 15 all participants completed the required daily entry. from day 16 to 21, there was a drop in adherence. as revealed in figure 3, the average number of entries drops in week 3 (67.7%) compared to week 1 and 2 (100%). the average ipgds score was calculated for days 1 to 15 (with all data points complete for all participants) to examine the variability in the average score. (see figures 2 and 3). paired samples t-test compared the highest scored day (day 2, 20.0) vs. lowest average scored day (day 11, 18.52) and confirmed a statistically significant difference (p = .049). mgage mobile assessment for grief 10 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ table 2 questionnaire data at pre (t1) assessment and post (t2) assessment variable t1 pre t2 post difference test m sd m sd paired samples t-test pgd sum score (13 standard items) 21.3 6.4 18.5 6.3 .002* pgd cultural supplement 26.5 5.9 26.2 8.7 .779 phq9 4.2 2.7 4.4 3.9 .790 gad7 4.2 3.2 3.8 3.1 .374 itq re 1.3 1.7 1.6 1.9 .387 itq av 1.6 2.2 1.3 2.0 .235 itq th .6 1.0 .7 1.3 .574 who wellbeing scale 15.1 5.2 15.4 4.8 .704 pg13 17.6 5.7 16.8 6.4 .204 note. m = mean; sd = standard deviation; pgd = prolonged grief disorder; phq9 = patient health questionnaire 9; gad7 = generalized anxiety disorder 7; itq re = international trauma questionnaire – reexperiencing subscale; itq av = international trauma questionnaire – avoidance subscale; itq th = international trauma questionnaire – threat subscale; who = world health organization wellbeing scale; pg13 = prolonged grief 13. *p < .05. **p < .01. ***p < .001. table 3 diagnostic algorithm comparison diagnostic test t1 pre t2 post % n % n pgd strict 0.0 0.0 pgd moderate 3.7 1 7.4 2 maciejewski 2016 criteria 3.7 1 0.0 ptsd 0.0 11.1 3 note. pgd = prolonged grief disorder; ptsd = posttraumatic stress disorder. acceptability of mgage overall mean scores on the mars questionnaire ranged from 3 to 5 indicating average to very good acceptability for the app (across all questions mean score of 4). the lowest scored question was ‘would you pay for this app’ (average 2). the highest scored ques­ tions were ease of use, navigation and gestural designs (all scored average of 5). for the question ‘overall star rating’ (question 11) participants’ mean score was 4/5. aeschlimann, gordillo, ueno et al. 11 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ figure 2 daily average ipgds score for all participants 17,50 18,00 18,50 19,00 19,50 20,00 20,50 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 a ve ra ge day average ipgds score * * figure 2 daily average ipgds score for all participants note. ipgds= international prolonged grief disorder scale, * statistically significant differencenote. ipgds = international prolonged grief disorder scale. *statistically significant difference between average daily ipgds on day 2 and day 11; p < .05. figure 3 adherence per weekfigure 3 adherence per week 0 20 40 60 80 100 120 week 1 week 2 week 3pe rc en t o f pa rt ic ip an ts c om pl et ed week average entries per week note. percent of participants completing the daily questionnairenote. percent of participants completing the daily questionnaire. mgage mobile assessment for grief 12 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ thematic analysis was conducted on the debriefing interviews. overall, three broad cate­ gories of responses were identified, each with related themes (see table 4 for exemplar quotes). table 4 summary of qualitative feedback and example quotes themes example quotes positive feedback useful links especially the links to get help were helpful, self-monitoring and reflection but she liked the app, it helped her to reflect and process her grieving thoughts. ease of use easy to use, also good for older people, fulfilled its purpose, good design the design was very simple but good; negative feedback effect on symptoms he said even though he thought, that he had already processed his grief symptoms, the app made him a bit sad in the beginning notifications and technical issues the reminders didn't work on a daily basis. some days the app reminded her, some days not repetitive after two weeks he thought, that the questions were getting boring and annoying, cause they were always the same design issues but the design wasn't that appealing specific recommendations personalization and timing the participant would have liked the app to react to the questions and ask more specific questions variation she would have preferred the questions to be in a different order each time, cause it was a bit repetitive other functions tips like breathing exercises for when score is red (instead of just contact numbers) ipgds changes the ipgds should have more gradations or possibly a slider bar for more sensitivity chart improvement it would be nice to have a summary of the scores if the app should be used for a longer period of time (e.g. a smaller graph) other even though she liked the app, she wouldn't pay for it. her grief symptoms aren't as strong anymore as they used to be, that's why she didn't find the questions disturbing. note. ipgds = international prolonged grief disorder scale. aeschlimann, gordillo, ueno et al. 13 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ the first category was ‘positive feedback’ with related themes including useful links, selfmonitoring and reflection, ease of use, and good design. the second category was ‘negative feedback’ with related themes including effect on symptoms, notifications and technical issues, repetitive, and design issues. the third category ‘specific recommendations’ inclu­ ded related themes such as personalization and timing, variation, other functions, ipgds changes, chart improvement. discussion main findings this pilot study provides preliminary support for the feasibility and acceptability of the mgage app for use by bereaved individuals. feasibility, assessed through adherence to the app, was extremely high for the first two weeks of use (100%). acceptability, assessed by high ratings on the mobile app rating scale (mars) questionnaire (mean score of 4/5), was also confirmed. qualitative feedback from debriefing interviews revealed sev­ eral themes supporting the acceptability of the app (useful links, self-monitoring and reflection, ease of use, and good design). however, participants also identified possible negative effects on mood as well as specific recommendations for improving the app. the final aim of this study was to explore variability in grief symptoms over two weeks. here we confirmed high variability (a statistically significant difference between highest and lowest mean scores) over the two weeks. this has important implications for better understanding variation and intensity of grief scores in real time as outlined below. additionally, the process of self-monitoring may have a therapeutic effect. at t2 participants had significantly lower scores on the international prolonged grief dis­ order scale (ipgds). this significant reduction in symptoms may indicate that online self-monitoring is a beneficial intervention and could be used to supplement face to face therapy, which is in accordance with results from previous studies (e.g. bakker & rickard, 2018; kauer et al., 2012). however, this result should be interpreted with caution as no control group was included in this study. the finding that one participant met moderate diagnostic criteria for pgd and two participants met criteria for ptsd at t2 although not at t1 attests to the need for a control group to unpick the effect of pgd symptom monitoring compared to other possible confounding or moderating effects on t2 outcomes. previous research has confirmed that adherence to e-mental health apps wavers. response rates of around 60-80% have been found in previous e-mental health studies of depression (70%; putnam & mcsweeney, 2008), substance misuse (88.8%; phillips et al., 2014), and trauma (67.5%; dewey et al., 2015). evidently the current study found excep­ tionally high adherence; 100% of responses completed by all participants. however, after two weeks adherence declines substantially (week 3 average response 67.7%). this is also mgage mobile assessment for grief 14 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ found in other areas of e-mental health. after an initial burst of interest participants typically decrease their use of health apps after two weeks (dorsey et al., 2017). reasons for decline in use include poor user centered design, lack of incentive and decreased internal motivation (torous et al., 2019). importantly, it should be noted that many participants mentioned technical problems as a reason for decline in use. the current study developed the mgage app following a user centered iterative design and we plan to build on the current findings to redesign elements of the app to improve acceptability. mohr et al. (2011) developed a model of ‘supportive accountability’ which seeks to improve adherence to e-mental health interventions by adding person-to-person contact throughout the intervention. they argue that participants are more likely to continue the intervention if they experience contact with a ‘coach’ who is supportive, trustworthy and kind. to improve adherence to the current app we would consider adding contact with a weekly coach to check-in and provide support and encouragement. however, based on the current findings we may consider limiting the required use of the app to two weeks. after two weeks participants have provided daily real-time data on their grief symptoms. this may be enough data to capture a comprehensive clinical picture for further assessment and treatment by a clinician. additionally, this may provide the individual with more insight into their current symptoms. one interesting finding of the current study was the possible therapeutic effect of self-monitoring. previous literature has revealed that the repeated act of completing an outcome measure may be an intervention in itself (amble et al., 2015). this study found that participants had decreased grief scores at t2. previous studies have also found that daily self-monitoring may improve mental health symptoms. for example, after 30 days of mood monitoring with a new mobile app, moodprism, participants experienced a significant decrease in symptoms of depression and anxiety, and this was directly related to app use (bakker & rickard, 2018). the act of daily self-reflection and improved insight into symptoms is the goal of several cognitive-behavioral therapy interventions for grief and other disorders (boelen et al., 2011; kavanagh, 1990; spuij et al., 2015). these are found to be predictors of positive affect, cognitive reappraisal as well as emotional self-awareness (kauer et al., 2012; o’toole et al., 2014). emotional self-awareness is thought to be a key factor that may improve self-regulation and wellbeing (barrett & gross, 2001). overall participants rated the app as highly acceptable. however, they identified some important areas for improvement. several participants identified that daily selfmonitoring may not have a positive effect on mood, but instead remind bereaved individuals of their sadness and grief. one participant identified that she thought she experienced more negative symptoms after using the app daily. another worried that it could be difficult for people to be reminded of their loss everyday (see table 4). this is an important consideration and will be an important topic for the next phase of research, particularly when conducting research with a clinical sample (wykes & brown, 2016). aeschlimann, gordillo, ueno et al. 15 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ as mentioned above, we would consider adding the model of supportive accountability, not only to improve intrinsic motivation to complete the app but to offer participants support, as well as for risk assessment. clinical implications and future research overall, the findings of this pilot study confirm that the mgage app may have an important use in future randomized controlled trials and grief interventions. firstly, it can deliver real time daily data on symptom variability and intensity, which provides researchers with a tool to accurately investigate the heterogeneity in the fluctuations of pgd symptoms over time in future research (bonanno & malgaroli, 2020; sveen et al., 2018). this may also be used to inform clinical assessments and treatment options by providing more depth and richer information than a singular self-report assessment. secondly, daily monitoring can be used to track the effectiveness of grief interventions. as change in symptom severity may vary and effects may waver, mgage could be used as an addition to standard, face-to-face therapy and help to track progress and effective­ ness, as suggested by torous and roux (2017). it could also be used in conjunction with existing online grief interventions (wagner et al., 2006). additionally, mgage has the potential to aid clinicians in identifying individuals with pgd. by facilitating early iden­ tification of cases and accelerating access to appropriate treatment, it could also prevent hospitalization or relapses (whelan et al., 2015). thirdly, the act of self-monitoring may be a useful intervention by increasing emotional self-awareness. developing insight into the severity and variability of symptoms may be an effective therapeutic tool (bakker & rickard, 2018). limitations this study was limited in the following ways. the sample size was small and homoge­ neous. it was a largely female sample of the same age group and education level. we did not include individuals from a clinical sample. this is the next required step to ensure acceptability for pgd diagnosis. there were also several technical issues with the app (such as server unavailable, only worked with internet connection) that may have prevented optimal data collection. in terms of the qualitative debriefing interviews, there may have been a social desirability effect as the participants were not blinded to the interviewer. the finding that two participants met criteria for ptsd or moderate pgd at t2 needs further investigation. currently no participants at t1 or t2 met ‘strict’ criteria for pgd is reassuring as our intention was not to investigate a clinical sample in this pilot study. the diagnostic algorithm for pgd is currently under debate with no clear consensus on whether the ‘strict’ ‘moderate’ or another algorithm for icd-11 pgd may yield the most reliable and valid diagnosis (boelen & lenferink, 2020). in the present study if a participant met criteria for moderate pgd, currently this does not necessarily mgage mobile assessment for grief 16 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://www.psychopen.eu/ indicate disorder. however, it may mean elevated symptoms. this should be monitored and follow up with a case control analysis or an rct including a control group. another significant limitation in the sample that requires follow up is the heterogeneity in the time criteria. time since death is a significant predictor of grief symptom severity and although all included participants experienced a death more than 6 months ago, there was still large variability in the duration since loss. the impact of time since loss on daily sampling and grief symptom variability should be assessed in future studies. funding: ck and tu have established a research partnership to develop a mobile app. this is funded by the innovation partnership grant, ipg 05-122017 from the university of zurich. this study is part of a larger study in collaboration with susmed inc. acknowledgments: we would like to acknowledge the participation of bereaved participants during the covid-19 pandemic and the hard work of interns at the universtiy of zurich. competing interests: aa, ck, ng and am report no conflict of interest. taro ueno is member of japanese based startup company, susmed inc. author contributions: ck and aa wrote the manuscript and conducted the study. ng developed the app. am and tu advised on the study and the project management. ethics statement: ethical approval was obtained from the university of zurich. supplementary materials the supplementary materials contain the following item (for access, see aeschlimann et al., 2024): • information pamphlet in german and english describing the functions and features of the mgage app for prolonged grief disorder. index of supplementary materials aeschlimann, a., gordillo, n., ueno, t., maercker, a., & killikelly, c. 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(2011). momentary assessment technology as a tool to help patients with depression help themselves. acta psychiatrica scandinavica, 124(4), 262–272. https://doi.org/10.1111/j.1600-0447.2011.01749.x wykes, t., & brown, m. (2016). over promised, over-sold and underperforming? – e-health in mental health. journal of mental health, 25(1), 1–4. https://doi.org/10.3109/09638237.2015.1124406 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. aeschlimann, gordillo, ueno et al. 23 clinical psychology in europe 2024, vol. 6(1), article e10881 https://doi.org/10.32872/cpe.10881 https://doi.org/10.1111/j.1600-0447.2011.01749.x https://doi.org/10.3109/09638237.2015.1124406 https://www.psychopen.eu/ mgage mobile assessment for grief (introduction) a mobile self-report tool to assess pgd: mgage method study design participants and recruitment measures procedure analyses results acceptability of mgage discussion main findings clinical implications and future research limitations (additional information) funding acknowledgments competing interests author contributions ethics statement supplementary materials references the role of expectancy violation in extinction learning: a two-day online fear conditioning study research articles the role of expectancy violation in extinction learning: a two-day online fear conditioning study daniel gromer 1 , lea k. hildebrandt 1 , yannik stegmann 1 [1] department of psychology, university of würzburg, würzburg, germany. clinical psychology in europe, 2023, vol. 5(2), article e9627, https://doi.org/10.32872/cpe.9627 received: 2022-06-03 • accepted: 2023-04-03 • published (vor): 2023-06-29 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: daniel gromer, department of psychology, marcusstraße 9-11, 97070 würzburg, germany. phone: +49 931 31-80030. fax: +49 931 31-80030-0. e-mail: daniel.gromer@uni-wuerzburg.de supplementary materials: data, materials, preregistration [see index of supplementary materials] abstract background: exposure therapy is at the core of the treatment of pathological anxiety. while the inhibitory learning model proposes a framework for the mechanisms underlying exposure therapy, in particular expectancy violation, causal evidence for its assumptions remains elusive. therefore, the aim of the current study was to provide evidence for the influence of expectancy violation on extinction retention by manipulating the magnitude of expectancy violation during extinction learning. method: in total, 101 individuals completed a web-based fear conditioning protocol, consisting of a fear acquisition and extinction phase, as well as a spontaneous recovery and fear reinstatement test 24h later. to experimentally manipulate expectancy violation, participants were presented only with states of the conditioned stimulus that either weakly or strongly predicted the aversive outcome. consequently, the absence of any aversive outcomes in the extinction phase resulted in low or high expectancy violation, respectively. results: we found successful fear acquisition and manipulation of expectancy violation, which was associated with reduced threat ratings for the high compared to the low expectancy violation group directly after extinction learning. on day 2, inhibitory cs-nous associations could be retrieved for expectancy ratings, whereas there were no substantial group differences for threat ratings. conclusion: these findings indicate that the magnitude of expectancy violation is related to the retrieval of conscious threat expectancies, but it is unclear how these changes translate to affective components (i.e., threat ratings) of the fear response and to symptoms of pathological anxiety. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9627&domain=pdf&date_stamp=2023-06-29 https://orcid.org/0000-0002-8619-7478 https://orcid.org/0000-0002-5513-3893 https://orcid.org/0000-0002-0933-8492 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords fear, anxiety, exposure therapy, inhibitory learning, expectancy violation, fear conditioning highlights • causal evidence for expectancy violation as a key mechanism of exposure therapy is sparse. • the current study experimentally manipulates the magnitude of expectancy violation. • high expectancy violation promotes extinction retention for threat expectancy ratings. • affective components of the fear response were not affected by expectancy violation. exposure therapy is considered the gold standard for the treatment of a variety of mental disorders, particularly anxiety disorders (hofmann & smits, 2008; norton & price, 2007). exposure-based interventions focus on repeated confrontations with the fearful object or situation, which typically results in fear extinction characterized as the reduction in fear responses (e.g., behavioral avoidance, physiological arousal, subjective feelings of fear) over time. there is unanimous evidence for the effectiveness of exposure therapy for the treatment of anxiety disorders (butler et al., 2006; carpenter et al., 2018; hofmann & smits, 2008; norton & price, 2007). yet, there is a considerable amount of patients, who do not profit from treatment, which is reflected in high rates of nonresponding and relapse (ali et al., 2017; arch & craske, 2009, 2011; taylor et al., 2012). the main obstacle to increasing the effectiveness of exposure-based interventions is that the underlying mechanisms are not yet fully understood (cooper et al., 2017; craske et al., 2008; craske et al., 2014). the inhibitory learning model suggests extinction learning as a key mechanism underlying exposure-based interventions resulting from a discrepancy between the con­ scious expectancy of an aversive event and its omission (craske et al., 2014; craske et al., 2022; rescorla & wagner, 1972). instead of erasing the original stimulus-harm associ­ ation, the omission of the expected aversive outcome (expectancy violation) is assumed to generate a new associative memory trace between the stimulus and the absence of harm, which is thought to exert an inhibitory influence on the original stimulus-harm association (bouton, 1993; bouton & king, 1983; quirk & mueller, 2008). see figure 1 for a graphical summary of the processes underlying the inhibitory learning model. to take advantage of inhibitory learning and expectancy violation during therapy, patients should become aware of their expectations for the upcoming exposure session and focus on the discrepancy between the expected and the actual outcome during exposure. in summary, the inhibitory learning model predicts that the strength of expectancy violation is positively related to symptom reduction and thus to the outcome of exposure therapy (craske et al., 2014; craske et al., 2022). the role of expectancy violation in extinction 2 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ figure 1 overview of the inhibitory learning model note. the exposure to a conditioned stimulus (cs, e.g., a dog), associated with an unconditioned stimulus (csus association, e.g., getting bitten), triggers the expectation of an aversive outcome (us-expectancy, e.g., getting bitten again). during therapy, patients are exposed to the cs, while the expected aversive outcome is omitted (expectancy violation, e.g., the patient was not attacked by the dog), giving rise to a new cs-nous memory trace, which is able to inhibit the original cs-us association. until now, although the inhibitory learning model provides a plausible mechanistic explanation for extinction, studies demonstrating unanimous evidence in support of the role of expectancy violation for positive treatment outcomes are sparse (craske et al., 2022). while recent models provide a comprehensive framework for studying the mech­ anisms underlying expectancy violation (panitz et al., 2021), more research is needed that specifically tests the key mechanisms of the inhibitory learning model. to address this issue, pavlovian fear conditioning protocols are well suited to examine changes in threat expectancy and thus allow to experimentally test the prediction of the inhibitory learning model that expectancy violation leads to enhanced fear extinction. in fear condi­ tioning paradigms, one conditioned stimulus (cs+) is repeatedly paired with an aversive event (us), resulting in a cs-us association (pavlov, 1927). during the following extinc­ tion phase, us delivery is usually omitted to generate a second cs-nous association. at a later timepoint, the spontaneous recovery of the cs-us and cs-nous associations can be tested by re-presenting the cs, while reinstatement of conditioned fear is usually tested by repeating the cs after an us presentation. using fear conditioning paradigms, extinc­ tion learning has been associated with the activation of inhibitory circuits including the ventromedial prefrontal cortex (vmpfc), potentially reflecting the neural correlate of the inhibitory influence of the cs-nous association on the original cs-us association (milad & quirk, 2012). however, how the extent of expectancy violation relates to the inhibitory influence of the cs-nous association is less well understood. for example, brown et al. (2017) investigated the relationship between expectancy violation and extinction retention, i.e., the persistent extinction at a follow-up reinstatement test. the authors demonstrated that the variation in us-expectancy during extinction learning, rather than gromer, hildebrandt, & stegmann 3 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ the decline in subjective or psychophysiological fear responding, predicted extinction retention at a follow-up test. these results provide correlational evidence for the role of expectancy violation in extinction learning. importantly, variation in us-expectancy during extinction as an index for expectancy violation only predicted us-expectancy ratings but not subjective fear or facial emg at the reinstatement test. in another fear conditioning study by scheveneels, boddez, vervliet, et al. (2019) a hierarchical extinction (i.e., presenting stimuli that increasingly signal the us with an incrementally increasing probability) was compared to a random extinction. although random extinction led to more expectancy violation during extinction, this did not result in improved cs-discrimi­ nation at a follow-up test. however, across groups, the amount of expectancy violation and the variability in us-expectancy during extinction were both positively associated with cs-discrimination at the follow-up test. in addition, findings of clinical (analogue) studies testing the relevance of expectancy violation are also mixed. while some studies support the role of expectancy violation during exposure therapy (guzick et al., 2020; salkovskis et al., 2007) others report no association between expectancy violation and therapy outcome (blakey et al., 2019; de kleine et al., 2017; raes et al., 2011; scheveneels, boddez, van daele, et al., 2019). most of these studies, however, used correlational designs: expectancy violation was measured by asking participants for their subjective ratings. while these correlational designs can be useful for detecting relationships, correlation does not imply causation – which is a prerequisite to interpret these relationships mechanistically. to demonstrate its impact on extinction learning, it is thus necessary to manipulate expectancy violation systematically. therefore, the goal of the current study is to experimentally test the influence of expectancy violation on extinction retention. specifically, we expected that increased expectancy violation during fear extinction leads to a) lower threat ratings towards the conditioned stimulus directly after extinction, and lower threat ratings and lower us-expectancy b) at a spontaneous recovery test as well as c) at a reinstatement test on the day following fear extinction. we used a web-based fear conditioning protocol in which participants are divided into two groups. during extinction, the high expectancy violation (he) group sees only the states of the cs that are strongly associated with an us. thus, a strong expectancy violation is possible. in contrast, the low expectancy violation (le) group is presented only with the cs states that are weakly related to the us. therefore, the magnitude of expectancy violation is minimized. furthermore, in the current study, we exploit the benefits of conducting a fear conditioning paradigm remotely. recent evidence suggests that fear conditioning data can be economically collected outside of the laboratory context (mcgregor et al., 2021; purves et al., 2019; stegmann et al., 2021; wise & dolan, 2020), providing a unique opportunity to draw on a larger and more diverse participant pool. the role of expectancy violation in extinction 4 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ method all hypotheses and methods of this study were preregistered at https://osf.io/7bgtv subjects in total, 127 individuals completed the web-based paradigm. participants had to be at least 18 years and were excluded if they were classified as non-learners (i.e., if they reported higher us-expectancy ratings for the least reinforced conditioned size compared to the most reinforced conditioned size; n = 22) or if they admitted to having muted their computer audio during the main task (n = 1) or rated the volume of the us with zero (i.e., total silence, n = 3). after exclusion, complete datasets of 101 participants (77 females) with a mean age of 21.8  ±  4.3 years remained for analyses. all experimental procedures were approved by the ethics committee of the department of psychology at the university of würzburg. procedures were in agreement with the declaration of helsinki. all participants provided informed consent online. they received either course credits or could join a lottery for one of five 50€ coupons as compensation. stimuli and materials the cs consisted of a light grey sphere, which was centrally presented on a dark grey background. to manipulate threat imminence, the size of the cs varied between the baseline size of either 1.25% or 26.25% and eight potential final sizes (5%, 7.5%, 10%, 12.5%, 15%, 17.5%, 20%, and 22.5%) relative to the participant’s screen size. the stimulus size inor decreased from the baseline to the final size, resulting in a visual 3d effect of an approaching/receding sphere. to enhance this effect, two circular lines with a radius of 15% and 22.5% were displayed. the us was a female scream with a duration of 2.5 s (maderadeleste films, 2011). at the beginning of the experiment, participants had to adjust the volume of their computer using a pleasant example melody (frei, 2020) so that it was perceived as 5 on a scale from 0 (absolute silence) to 10 (unbearable volume). the setting was to be maintained during the experiment. after the main experiment, participants were asked to rate the loudness of the scream using the same scale. there was no difference in perceived loudness among groups, f(3, 97) = 1.26, p = .292 (see figure 2). design and procedure day 1: after giving informed consent, participants completed german versions of a demographic questionnaire and the anxiety sensitivity index-3 (asi-3; kemper et al., 2009; taylor et al., 2007), using an online survey platform (www.formr.org, arslan et al., 2020). they were then redirected to www.pavlovia.org, where the main experiment took place (peirce, 2007). the conditioning protocol on day 1 consisted of a habituation, gromer, hildebrandt, & stegmann 5 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://osf.io/7bgtv http://www.formr.org http://www.pavlovia.org https://www.psychopen.eu/ acquisition, and extinction phase (see figure 3). during habituation, each cs level was presented once. each trial started with the presentation of the baseline-sized cs (either 1.25% or 26.25% relative to the participant’s screen). after 0.8 – 1.3 s, the cs started to become larger/smaller (with a median rate of 6.8% per s) until it reached one of the 8 final sizes (5%, 7.5%, 10%, 12.5%, 15%, 17.5%, 20%, and 22.5%). once reaching its final size, the cs returned to its baseline size with the same velocity. since we expected that larger, approaching stimuli are perceived as inherently more threatening (coker-appiah et al., 2013), the cs for one half of the participants started at its smallest size and became larger (baseline size: 1.25%; cs level 1: 5% – cs level 8: 22.5%; approaching cs group), whereas the cs for the other half started at its largest size and became smaller (baseline size: 26.25%; cs level 1: 22.5% – cs level 8: 5%; receding cs group). during acquisition, each cs level was presented five times (40 total trials) in a randomized order with the following conditions: no cs level should be presented three times in a row and the us should not be presented three times in a row. in each trial, when the stimulus had reached its final size, participants were asked to rate how much they expected the us on a visual analog scale from 0 ("very unlikely") to 100 ("very likely"). subsequently, the us were presented according to the following pattern: no us were presented at cs level 1 (0% reinforcement rate; rr), one us was presented at cs levels 2 and 3 (20% rr), two us were presented at cs levels 4 and 5 (40% rr), three us figure 2 rain cloud plot of the perceived volume of the us asked at the end of day 2 note. code based on allen et al. (2021). it should be noted that one participant in the he group gave a loudness rating of 2. in order to avoid arbitrary post-hoc cut-offs, we decided not to exclude this outlier from the analyses. however, in exploratory re-analyses, excluding this participant did not change our results. the role of expectancy violation in extinction 6 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ were presented at cs levels 6 and 7 (60% rr), and four us were presented at cs level 8 (80% rr). the trial ended with the cs returning to its baseline size. figure 3 (a) summary of the experimental procedure and (b) description of the trial structure note. (a) on day 1, participants were divided into the receding (rec) and approaching (app) cs groups, before undergoing a habituation (hab) and fear acquisition phase (acq). in the subsequent extinction phase (ext), participants were again divided into two groups. to experimentally manipulate the extent of expectancy violation, one group (low expectancy violation; le group) was presented only with the cs levels associated with low us likelihoods (cs levels 1 – 4), whereas the other group (high expectancy violation; he group) saw only the cs levels associated with high us likelihoods (cs levels 5 – 8). on day 2, all participants completed a spontaneous recovery (spont rec) and reinstatement (reinst) test. threat ratings were collected for each cs level after each phase on day 1. on day 2, threat ratings for each cs level in each phase were collected directly after the expectancy rating for the respective cs level. (b) each trial started with the presentation of the baseline-sized cs (smallest size for the approaching groups or largest size for the receding groups). after 0.8 – 1.3 s, the cs started to become larger/smaller until it reached one of the 8 final sizes. once reaching its final size, participants were asked to rate the likelihood of being presented with an us (us expectancy rating). during acquisition, us were then presented according to the specific reinforcement rate related to the cs level before the cs returned to its baseline size. note, that no us expectancy ratings were collected during habituation. in the habituation, spontaneous recovery, and reinstatement phases, the cs reached each final size once, while in acquisition it reached each final size five times. in extinction, each of the group's four final sizes were reached ten times. gromer, hildebrandt, & stegmann 7 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ in the subsequent extinction phase, participants were again divided into two groups. to experimentally manipulate the extent of expectancy violation, one group (low expect­ ancy violation; le group) was presented only with the cs levels associated with low us likelihoods (cs levels 1 – 4), whereas the other group (high expectancy violation; he group) saw only the cs levels associated with high us likelihoods (cs levels 5 – 8). each respective cs level was presented 10 times (40 trials in total). importantly, no us was administered during the extinction phase and participants received no instruction about the cs-us contingencies. day 2: in the morning of the following day, participants received an email containing the hyperlink for the second part of the main experiment, consisting of spontaneous recovery and reinstatement test. at the beginning, participants were asked to re-adjust the volume of their computer. to test for spontaneous recovery, each cs level was presented once while online us-expectancy ratings were collected as described above. for the subsequent reinstatement test, a single us was delivered before each cs level was presented again. in addition to the online us-expectancy ratings, participants were asked to rate the perceived threat (“how threatening do you perceive this stimulus?”) for each cs level on a visual analogue scale from 0 (“very harmless”) to 100 (“very threatening”) after each phase (i.e., habituation, acquisition, extinction) and for spontaneous recovery and reinstatement. statistical analysis all statistical analyses were conducted with r 4.1.2 (r development core team, 2021). the afex package (singmann et al., 2020) was used for anova with type 3 sum of squares, the effectsize package (ben-shachar et al., 2020) was used to calculate omega squared (ω2), and the emmeans package (lenth, 2023) was used for simple contrasts. for acquisition, spontaneous recovery, and reinstatement, mean differences in threat and us-expectancy ratings were analyzed separately using 2 (expectancy violation: he vs le; between-subject factor) x 2 (cs direction: approaching vs receding; between-subject factor) x 8 (cs level: cs levels 1 – 8; within-subject factor) mixed anovas. threat ratings after habituation were analyzed using the identical procedure. significant main and interaction effects were followed-up with simple contrasts. to quantify the extent of expectancy violation, us-expectancy ratings obtained during the extinction phase were summarized analogous to scheveneels, boddez, vervliet, et al. (2019) and compared be­ tween groups using a 2 (expectancy violation: he vs le) x 2 (cs direction: approaching vs receding) anova. since the true probability of an us-occurrence during extinction was always zero, expectancy violation can be calculated as the trial-wise us-expectan­ cy ratings minus zero. thus, the sum of the us-expectancy ratings across individual trials yields the total value of expectancy violation. a significance level of .05 was used for all analyses and greenhouse–geisser correction was applied where appropriate the role of expectancy violation in extinction 8 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ (greenhouse & geisser, 1959). throughout this manuscript, we report corrected degrees of freedom, corrected p values and the omega squared (ω2). data and code for the reported analyses are available at https://osf.io/tg2fb/. results online expectancy ratings all results for us-expectancy ratings are illustrated in figure 4. the analysis of the last presentation of each stimulus in the acquisition phase demonstrated successful fear con­ ditioning as indexed by a significant main effect of cs level, f(5.73, 555.56) = 112.90, p < .001, ω2 = .44, indicating that participants expected the us more strongly with increasing threat imminence (larger physical sizes in the approaching cs groups, smaller physical sizes in the receding cs groups). in addition, there was a main effect of cs direction, f(1, 97) = 8.10, p = .005, ω2 = .07, which was further qualified by a significant interaction between cs level and cs direction, f(5.73, 555.56) = 2.57, p = .020, ω2 = .01. together, these results indicate higher us-expectancy ratings in the approaching compared to the receding cs groups, particularly, for the 6th, t(97) = 2.72, p = .008, and 7th level, t(97) = 3.84, p < .001, of cs level (all other levels, p’s > .050), suggesting that physical size interfered with acquisition learning, i.e., that larger physical sizes of an approaching cs are more readily associated with the occurrence of the us than smaller physical cs levels in the receding group. importantly, there were no differences between he and le groups, p’s > .259. during extinction training, the he group showed higher summarized us-expectancy ratings and thus stronger expectancy violation than the le group, f(1, 97) = 25.08, p < .001, ω2 = .19, implying a successful experimental manipulation of expectancy violation. on day 2 at the spontaneous recovery test, there was a main effect of cs level, f(2.97, 287.72) = 96.82, p < .001, ω2 = .35, demonstrating higher expectancy ratings with increasing threat imminence in all groups, while a significant cs level x expectancy vio­ lation interaction, f(2.97, 287.72) = 6.73, p < .001, ω2 = .03, indicates higher us-expectancy ratings and thus a stronger recovery of conditioned fear for le compared to he groups at the 7th: t(97) = 3.03, p = .003, and 8th: t(97) = 2.66, p = .009, cs levels (all other levels, p’s > .078). no effect of direction reached significance, p’s > .366. the us presentation at reinstatement did not substantially change these results. the main effect of cs level, f(3.08, 298.44) = 76.64, p < .001, ω2 = .29, and the cs level x expectancy violation interaction, f(3.08, 298.44) = 4.05, p = .007, ω2 = .02, remained significant. again, le compared to he groups reported higher expectancy ratings at the 6th: t(97) = 2.17, p = .032, 7th: t(97) = 2.47, p = .015, and 8th: t(97) = 2.05, p = .044, cs levels (all other levels, p’s > .167). no effect of direction reached significance, p’s > .161. gromer, hildebrandt, & stegmann 9 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://osf.io/tg2fb/ https://www.psychopen.eu/ threat ratings after habituation, the 2x2x8 anova for subjective threat ratings revealed a significant main effect of cs level, f(2.08, 201.70) = 10.10, p < .001, ω2 = .03. crucially, there was figure 4 us-expectancy ratings note. (a) summary of the us-expectancy ratings on single trial level for low (le) and high (he) expectancy violation groups, and each experimental phase (error bars indicate the standard error of the mean). (b) shows the same results separately for the approaching (app) and receding (rec) cs groups. conditioned stimulus level (cs level) corresponds to threat imminence, i.e., larger physical sizes for approaching cs groups and smaller physical sizes for receding cs groups. the role of expectancy violation in extinction 10 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ also a significant interaction between cs level and cs direction, f(2.08, 201.70) = 46.15, p < .001, ω2 = .12, indicating higher threat ratings for increasing cs levels (i.e., increasing sizes) in the approaching cs groups and higher threat ratings for decreasing cs levels (i.e., increasing sizes) in the receding cs groups (see figure 5). figure 5 threat ratings note. (a) summary of the threat ratings for low (le) and high (he) expectancy violation groups, and each experimental phase (error bars indicate the standard error of the mean). (b) shows the same results separately for the approaching (app) and receding (rec) cs groups. conditioned stimulus level (cs level) corresponds to threat imminence, i.e., larger physical sizes for approaching cs groups and smaller physical sizes for receding cs groups. gromer, hildebrandt, & stegmann 11 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ this result is in line with the notion that visual stimuli appear inherently more threaten­ ing with increasing physical size, i.e., lower cs levels in receding cs groups and higher cs levels in approaching cs groups. at the end of the acquisition phase, successful conditioning was indexed by a signif­ icant main effect of cs level, f(2.91, 282.23) = 92.07, p < .001, ω2 = .27. in addition, there was a cs direction x cs level interaction, f(2.91, 282.23) = 5.58, p = .001, ω2 = .02. taken together, these results demonstrate that participants perceived more threat with increasing threat imminence. yet, physical size of the cs still influenced threat ratings as indexed by slightly higher threat ratings in the approaching cs compared to the receding cs groups at the 4th: t(97) = 1.95, p = .055, 5th: t(97) = 1.98, p = .050, 6th: t(97) = 2.56, p = .012, 7th: t(97) = 2.45, p = .016, and 8th: t(97) = 1.81, p = .074, cs level. please note, that the 8th cs level was the largest physical size in the approaching cs group but the smallest physical size in the receding cs group. importantly, no differences between le and he groups were found, p’s > .610. directly after extinction, the effect of the expectancy violation manipulation was evi­ dent in a significant cs level x expectancy violation interaction, f(2.53, 245.24) = 12.42, p < .001, ω2 = .04, which could be retrieved in addition to main effects of expectancy violation, f(1, 97) = 6.18, p = .015,, ω2 = .05, and cs level, f(2.53, 245.24) = 58.70, p < .001, ω2 = .19. as illustrated in figure 5, the he groups reported lower threat ratings compared to the le groups at the 5th: t(97) = 2.45, p = .016, 6th: t(97) = 2.98, p = .004, 7th: t(97) = 3.78, p < .001, and 8th: t(97) = 3.95, p < .001, cs level, while there were no differences for smaller cs levels, p’s > .579. furthermore, we found no effect of cs direction, p’s > .521. to further analyze the effect of expectancy violation on threat ratings, we tested the differences between groups from acquisition to extinction. indeed, for the he group, we found a decrease in threat ratings for all cs levels, p’s < .003, except for the lowest level, t(48) = 1.62, p = .112, while threat ratings in the le groups decreased only for the four lowest (cs levels 1 – 4), p’s < .015, but not for the four highest levels (cs levels 5 – 8), p’s > .184, suggesting that participants in the le groups still perceived higher cs levels as threatening. for threat ratings at spontaneous recovery on day 2, the main effect of cs level, f(2.36, 229.23) = 54.61, p < .001, ω2 = .18, and the interaction between cs level and expectancy violation, f(2.36, 229.23) = 4.38, p = .009, ω2 = .01, remained significant. yet, simple contrasts revealed no significant differences between le and he groups at the individual cs levels, all p’s > .063. in addition, there was a cs level x cs direction interaction, f(2.36, 229.23) = 8.10, p < .001, ω2 = .03, indicating spontaneous recovery of the effect of physical size on threat ratings similar to the results of the habituation phase. together, these results suggest that the differential effect of expectancy violation on threat ratings did not persist until the second day of the study. to substantiate this finding, we also analyzed change scores between the end of acquisition and spontaneous recovery at the individual cs levels separately for the he and le groups. student’s the role of expectancy violation in extinction 12 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ t-tests revealed decreased threat ratings for cs levels 3 to 8 in the he groups, p’s < .029, and decreased threat ratings for cs levels 2 to 5 in the le groups, p’s < .018. a similar pattern of results could be obtained for threat ratings at the reinstatement test. main effects of cs direction, f(1, 97) = 5.31, p = .023, ω2 = .04, and cs level, f(2.08, 201.73) = 54.39, p < .001, ω2 = .18, were qualified by significant interactions between cs direction and cs level, f(2.08, 201.73) = 9.54, p < .001, ω2 = .03, as well as between cs level and expectancy violation, f(2.08, 201.73) = 3.68, p = .025, ω2 = .01. higher cs levels were generally associated with higher threat ratings, while physical size interfered with actual threat imminence similarly to the description above. again, simple contrasts revealed no significant differences between le and he groups at the individual cs levels, p’s > .079. discussion the main goal of our study was to provide causal evidence for the influence of expect­ ancy violation on extinction retention. to this end, we employed a web-based fear conditioning protocol, in which we manipulated the magnitude of expectancy violation during the extinction learning phase. subjective threat and us-expectancy ratings were obtained throughout the acquisition and extinction phase on day 1, as well as during a spontaneous recovery and reinstatement test on day 2. in line with previous fear conditioning studies, our results showed successful fear acquisition and extinction for us-expectancy and threat ratings, indicating that partici­ pants learned the cs-us and cs-nous associations. consistent with our manipulation of expectancy violation, however, the he groups reported higher expectancy ratings than the le groups. because no us was presented during extinction, higher us-expectancy ratings also imply stronger expectancy violation, and according to the inhibitory learn­ ing model, stronger expectancy violation should have led to a stronger formation of the cs-nous association (craske et al., 2014; craske et al., 2022; scheveneels, boddez, vervliet, et al., 2019). as predicted by the inhibitory learning model, the he groups indeed reported lower subjective threat compared to the le groups at the end of the extinction phase on day 1, providing causal evidence for the notion that the strength of expectancy violation is related to the decline of subjective threat during fear extinction. on the second day, results for us-expectancy and threat ratings during the spontane­ ous recovery and reinstatement test were less conclusive. whereas reduced expectancy ratings, and thus, a stronger retrieval of the cs-nous association could be retrieved for the he compared to le groups, we found no substantial group differences for threat ratings. these findings indicate that the strength of expectancy violation did influence the extent of extinction retention, however, the effect was not as large as would have been expected according to the inhibitory learning model. this small effect might be due to extinction learning took place directly after fear acquisition and, therefore, might be gromer, hildebrandt, & stegmann 13 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ influenced by the immediate extinction deficit. the immediate extinction deficit refers to the phenomenon that extinction retrieval is impaired for shorter intervals compared to longer intervals (e.g., 24 hours) between initial fear acquisition and subsequent extinction training and has been previously demonstrated in rodent and human studies (chang et al., 2010; huff et al., 2009; maren, 2014; merz et al., 2016). however, it is important to mention that on day 2 we could retrieve the expected results for us-expectancy ratings, i.e., reduced us-expectancy ratings and thus a stronger retrieval of the cs-nous association for the high compared to low expectancy violation groups, as predicted by the inhibitory learning model. yet, the cs-nous association did not appear to inhibit the perceived threat. recently, it has been suggested that us-expectancy ratings are more likely to represent the conscious, cognitive component (boddez et al., 2013), whereas threat ratings are more likely to capture the affective component of the fear response (constantinou et al., 2021; lonsdorf et al., 2017). taken together, our results suggest that expectancy violation plays an important role in fear extinction, but it is unclear how it translates to changes in the affective component of the fear response. crucially, this finding is consistent with experience from clinical psychology and previous empirical findings. patients with anxiety disorders usually know that their fears are irrational and are aware that the probability of their feared event occurring is low (zimmerman et al., 2010). yet, they report intense affective reactions. in a similar line of thought, buchholz et al. (2022) compared treatment outcomes after exposure therapy following cognitive restructuring and vice versa. according to the inhibitory learning theory cognitive restructuring prior to exposure exercises should reduce threat expectancies and thus hinder expectancy violation. indeed, patients who received cogni­ tive restructuring before exposure showed a trend toward reduced expectancy ratings. however, contrary to the predictions of the inhibitory learning theory, the cognitive intervention did not attenuate the magnitude of change of expectancies due to exposure. in addition, the treatment outcomes of both groups were similar after treatment and at follow-up. in an analogous fear conditioning paradigm, scheveneels, boddez, de ceulaer, et al. (2019) instructed half of the participants before extinction that the probability of the us will be small, whereas the control group did not receive this information. according to the inhibitory learning theory, this safety information should attenuate inhibitory learning and thus lead to an increased return of fear. although participants in the informed group had a less pronounced decrease in us expectancies during extinction (which is consistent with the assumptions of the inhibitory learning model), it did not promote return of fear. on the contrary, the safety information reduced the return of fear compared to the control group. combined with the results of our current study, these findings underscore that the violation of conscious expectancies does not directly translate to the outcome of exposure therapy. in line with this, a recent therapy study (pittig et al., 2023) showed that not expectancy violation per se but rather how patients changed their threat expectancies after exposure exercises, calculated as pre-minus-postthe role of expectancy violation in extinction 14 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ exposure expectancy, i.e., “imagine repeating the same exposure practice. how likely is it that the aversive outcome will occur this time?” (craske et al., 2022), predicted treatment outcome. there are also some limitations that need to be discussed in the context of the current study. first, we found strong effects of cs direction. as expected, threat ratings after habituation revealed that cs physical size was associated with higher threat ratings, such that closer cs appeared generally more threatening. in line with preparedness theories of fear learning (coker-appiah et al., 2013; mineka & öhman, 2002; öhman & mineka, 2001), we also found that the cs direction interfered with fear conditioning, i.e., larger physical cs sizes were more readily associated with the occurrence of the us than smaller sizes during fear acquisition. importantly, the effect of cs direction on us-expectancy and threat ratings diminished during extinction learning. however, we found a strong return of this inherent fear in threat ratings during the spontaneous re­ covery and reinstatement test, suggesting that despite participants in the receding groups had learned that larger physical sizes indicated relative safety, they almost reverted to pre-acquisition threat levels, paralleling the difficulties in treating pathological forms of fear, as most anxiety disorders are rooted in evolutionarily prepared fears (e.g., fear of heights, spiders, snakes). it is also important to mention that this study was conducted remotely only, and therefore, we were not able to record physiological measures of the fear response. even though ratings are a valid and important measure of subjective threat perception (boddez et al., 2013), future studies should seek complementary evidence from physiological indices of defense system activation, such as cardiovascular or electrodermal activity (ojala & bach, 2020). in contrast to laboratory studies, we were not able to standardize us-intensities and had to rely on participants’ self-reported perceived loudness, which was collected at the end of day 2. based on these ratings and in combination with the us-expectancy ratings, we excluded participants who turned off their volume. neverthe­ less, the average us-intensity could be lower than in laboratory studies, and replications with offline samples are needed to ensure that effects remain consistent across different methods of stimulus delivery. importantly, when using a human scream as us, successful fear conditioning was already reported at us-intensities below 80 db (beaurenaut et al., 2020). in summary, the present web-based fear conditioning study demonstrated that exper­ imentally increasing the magnitude of expectancy violation increased extinction reten­ tion for us-expectancy ratings, but this did not affect subjective threat ratings on day 2. future studies need to further test the predictions of the inhibitory learning model, particularly how violation of conscious expectancies may translate to subjective feelings and symptoms of anxiety. this study provided a paradigm to experimentally target these processes. gromer, hildebrandt, & stegmann 15 clinical psychology in europe 2023, vol. 5(2), article e9627 https://doi.org/10.32872/cpe.9627 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. ethics statement: all experimental procedures were approved by the ethics committee of the department of psychology at the university of würzburg. procedures were in agreement with the declaration of helsinki. twitter accounts: @leahilde, @yannikstegmann data availability: data and code for the analyses reported in this article are freely available (gromer, hildebrandt, & stegmann, 2023) supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • pre-registration protocol for all hypotheses and methods of the study • data and code for the analyses reported in this article index of supplementary materials gromer, d., hildebrandt, l. k., & stegmann, y. 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[2] cis-iul – centro de investigação e intervenção social, iscte – instituto universitário de lisboa, lisbon, portugal. [3] cies-iul – centro de investigação e estudos de sociologia, iscte – instituto universitário de lisboa, lisbon, portugal. clinical psychology in europe, 2024, vol. 6(2), article e11477, https://doi.org/10.32872/cpe.11477 received: 2023-02-28 • accepted: 2023-11-03 • published (vor): 2024-06-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: ana catarina nunes da silva, faculdade de psicologia, universidade de lisboa, alameda da universidade, 1649-013, lisboa, portugal. phone: +351939442906. e-mail: acsilva@psicologia.ulisboa.pt supplementary materials: materials [see index of supplementary materials] abstract background: the transtheoretical conceptualization of the working alliance and the resultant evaluation tools often overestimate the collaboration between therapist and client, while neglecting the negotiation process. the degree to which therapists and clients can negotiate disagreements regarding goals and tasks is an important indicator in establishing and maintaining the alliance. even though the negotiation concept is not new, there is still a lack of reliable and parsimonious self-report measures of the construct. the purpose of this study was to translate, execute the cultural adaptation and, also, to perform a preliminary psychometric analysis of the portuguese form of the therapist version of the alliance negotiation scale (ans-t_pt). method: data were collected online from 100 portuguese psychologists. two random sub-samples were used to conduct both exploratory factorial analysis and confirmatory factorial analysis. convergent validity was assessed through comparison with the portuguese version of the working alliance inventory. results: the ans-t_pt showed a one-factorial structure, consistent with previous versions, and demonstrated adequate internal consistency. evidence supporting criterion-related validity was found based on the correlations between ans-t_pt and wai-t scores. the results showed moderate to large associations between the instruments. these results support the usefulness of the scale, construct’s relevance and its transtheoretical nature. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11477&domain=pdf&date_stamp=2024-06-28 https://orcid.org/0000-0001-7125-716x https://orcid.org/0000-0002-6673-2082 https://orcid.org/0000-0001-5885-3039 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: these results are a step forward for portuguese therapists’ and researchers’ ability to evaluate the bond between client and therapist and to compare results from different countries. keywords negotiation, alliance negotiation scale, portuguese version, therapist version, psychometric properties, scale validation highlights • the portuguese form of the ans – therapist version showed good psychometric characteristics. • negotiation in challenging relationships was positively associated with the therapist experience. • the measure can be useful not only for research but also for clinical practice and supervision. the quality of the therapeutic alliance between psychotherapists and clients has been showed, for decades, to be an essential ingredient in promoting therapeutic change, espe­ cially as perceived by the client (flückiger et al., 2012; horvath et al., 2011). the most used concept of alliance in psychotherapy is based on the working alliance definition by bordin (1979) who defined it as a collaborative stance between the client and the therapist. the concept of working alliance is composed of three aspects: (a) agreement on the therapeutic goals to be reached; (b) agreement on the tasks to be developed; and (c) the quality of the relational bond, which encompasses the affective quality of the relationship between the client and the therapist. bordin (1979) also hypothesized that different theoretical frameworks would emphasize different aspects of the working alliance, since different theoretical orientation emphasize different tasks and goals. indeed, the working alliance has systematically proved to be a solid predictor of the therapeutic results, regardless of the therapists’ theoretical orientation (safran & muran, 2000; zuroff & blatt, 2006). however, clinicians commonly observe that, especially with clients facing severe psychological conditions like personality disorders, an initially poor working alliance can be repaired and transformed into a positive one (e.g., safran et al., 2011). this underscores that a robust alliance alone does not guarantee therapy effec­ tiveness; rather, it can result from effective interventions. working together in therapy eventually allows a good alliance between both parties to develop, especially when able to work on rupture and repair (råbu et al., 2011; safran et al., 2011). for some clients, the goal of therapy might even be to develop the ability to be in a close and secure relationship (e.g., norcross & wampold, 2018). safran and muran (2006) sustained that the quality of the therapeutic relationship is related to the processes involved in the resolution of conflicts in case they arise, and not determined by the absence of conflicts or lack of collaboration. therefore, it is important portuguese form of alliance negotiation scale – therapist version 2 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ to re-conceptualize the working alliance as a process of a continuous negotiation of the needs of two independent subjects involved in the relationship. the concept should include how far disagreements and tension are processed by and within the therapeutic relationship (muran et al., 2009; safran & muran, 2000). from this perspective, the negotiation process allows for change to occur and it is a central component of the process of change (doran et al., 2012). furthermore, considering the association between the process of rupture-repair and the therapeutic results, it is important to understand the underlying and facilitating mechanisms in this process, which leads us to the concept of the alliance negotiation. alliance negotiation consists of the client and therapist’s ability to solve relational problems and disagreements, in their therapeutic goals and tasks, during therapy (doran et al., 2016; safran & muran, 2006). as a dyadic concept, it holds significant clinical implications across various theoretical frameworks. it is important to emphasize that the dimensions of collaboration and negotiation are not mutually exclusive and offer complementary points of view of the working alliance (doran et al., 2016). an important body of literature have suggested that alliance negotiation is one of the most important elements of therapy and a common factor for different theoretical approaches (baier et al., 2020; e.g., wampold & imel, 2015; zilcha-mano & ben david-sela, 2022). currently, the measurement of alliance negotiation between clients and therapists is limited to a single self-report instrument, encompassing one scale from the clients' perspective (doran et al., 2012, 2016) and another from the therapists’ perspective (doran et al., 2018; gómez-penedo et al., 2019). the alliance negotiation scale (ans) was modelled in structure and form after the working alliance inventory (wai, horvath & greenberg, 1989) which is one of the most used measures of the working alliance. the ans was developed to introduce a specific focus on negative aspects of the therapeutic process, particularly addressing the presence and resolution of ruptures in therapy (doran et al., 2016). indeed, dealing with different types of difficulties related to the working alliance is essential to the course of therapy (for a review see doran et al., 2016). the alliance negotiation scale – therapist version (ans‐t) was jointly devel­ oped in its north american and argentinian versions. considering the transtheoretical and cross‐culturally importance of the concept, a collaborative cross‐cultural effort to create a therapist version was made. the ans‐t is not an identical translation of the client version. the client version contains 12 items and two factors, while the ans‐t is unidimensional and contains only nine items. the authors argue that although it would have seemed preferable to have a version of the ans‐t that more closely mirrored the client ans (12 items and/or two factors), it was deemed more important to create the most psychometrically sound scale possible (for a detailed description of the scale development see doran et al., 2018). results from both samples support the composition of the ans‐t and provide initial support for the reliability and validity of the measure (doran et al., 2018; gómez-penedo nunes da silva, matos, & carvalho 3 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ et al., 2019). through a principal components analysis procedure, it presented nine unidimensional items and was moderately correlated with therapist‐reported working alliance (r = .468, r = .51), north american and argentinian results respectively (doran et al., 2018; gómez-penedo et al., 2019). given the dyadic nature of alliance negotiation, having both a client version and a therapist version is essential. in the european-portuguese context, there already exists a client version of the ans (galvão et al., 2019). therefore, the primary goal of the present study is to introduce and make available the therapist version of the scale. considering the importance of the alliance negotiation and its implications for the outcomes of the therapeutic process, the present study seeks to address the absence of a portuguese form of the therapist version of the ans. accordingly, this study aims to translate, perform the cultural adaptation and a preliminary psychometric analysis of the portuguese form of the therapist version of the alliance negotiation scale (ans-t_pt) in a portuguese sample of therapists. furthermore, by previously adapting the clients' form of the ans (galvão et al., 2019), we enable research into dyadic perceptions of alliance negotiation. this approach facilitates a comprehensive examination of alliance negotiation from both therapist and client perspectives. method participants one hundred therapists participated in this study. participants were mostly females (n = 85, 85.0%). mean age was 38.58 (sd = 9.82) and ranged between 23 and 63. sixty six percent of participants had a master’s degree, 24.0% graduated from university, and 10.0% had a phd. the average of years of clinical experience of the participants of the sample were 12.06 years old (sd = 8.68 years old). the therapist with the least experience had one year of clinical practice, while the most experienced referred 35 years of clinical practice. seventy six percent worked in private practice, 11.0% in a social solidarity private institution, 8.0% in hospitals and 6.0% in primary care facilities (non-excluded response categories). thirty three percent reported a cbt-based integrative approach, 14.0% a cbt approach, 5.0% psychodynamic approach, 1.0% systemic and 47.0% did not specify their theoretical approach. each participant provided with data on two cases – (1) perceived as a good therapeu­ tic relationship (gtr) and (2) perceived as a more challenging therapeutic relationship (ctr). for the clients assigned to gtr, therapists reported that more than half of their clients were female (62.0%). with a mean age of 34.93 (sd = 13.00 years old) ranging from 18 to 77 years old. with a medium number of 29 sessions ranging from 2 to 107. client diagnoses included relational problems (55.0%), depressive disorders (39.0%), anxiety disorders (49.0%), or other clinical syndrome such as an eating disorder or adjustment portuguese form of alliance negotiation scale – therapist version 4 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ disorders (10.0%). a subset of the sample was diagnosed with a personality disorder (10.0%), mostly defined as dependent, avoidant or borderline personality disorder. for the clients assigned to ctr, therapists reported that more than half of their clients were female (58.0%). with a mean age of 37.91 (sd = 13.02 years old) and range from 18 to 80. with a medium number of 25 sessions ranging from 1 to 160. client diagnoses were very similar to the ones reported in the gtr group, with mainly anxiety disorders (58.0%), relational problems (56.0%), depressive disorders (41.0%), or other clini­ cal syndrome such as an eating disorder, or adjustment disorders (9.0%). a subset of the sample was diagnosed with a personality disorder (25.0%), mostly defined as borderline, narcissistic, avoidant, histrionic, or dependent personality disorder. instruments sociodemographic data for the purposes of this research a short questionnaire was created to list the demo­ graphic data of the participants. clinicians indicated their gender, age, nationality, level of education, and also provided information about their theoretical orientation, number of sessions, and their client's age, gender, presenting problems and diagnoses. alliance negotiation scale – therapist version the purpose of the alliance negotiation scale – therapist version (ans-t; doran et al., 2018; gómez-penedo et al., 2019) is to assess the degree of negotiation in the therapeutic alliance, from the therapist’s perspective. it includes nine items. items are rated on a 7-point likert-type scale ranging from 1 (never) to 7 (always). therapists are asked to indicate the number that best applies to the way they feel about their relationship with their client. the total average result reflects the therapists’ perception of the degree of negotiation in the therapeutic alliance. the scale computation was done by summing the nine items, with high results indicating a higher level of negotiation. in the present sam­ ple, for the purpose of testing reliability and validity two different alliance negotiation variables were computed, according to the two types of cases, both showing excellent and very good internal consistency (αgtr = .89; αctr = .80) (kline, 2011). working alliance inventory – short form concerning the therapeutic alliance, the working alliance inventory – short form (wai-s, horvath & greenberg, 1989; tracey & kokotovic, 1989), portuguese version (machado & horvath, 1999), was used. the wai-s is an inventory that assesses the working alliance and is composed by three dimensions regarding the conceptualization of bordin (1979): bond, agreement between therapist and client on goals and agreement between therapist and client on tasks. participants reported the frequency of feeling and thoughts in relation to the other element of the therapeutic dyad, on a likert scale (from nunes da silva, matos, & carvalho 5 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ 1 “never” to 7 “always”). the short version has 12 items, four for each dimension (tracey & kokotovic, 1989). the scale computation was done by summing the items for each sub-scale and for the global scale. higher results indicate a higher level of strength and quality of the working alliance, from the therapist’s perspective. the internal consistency of this instrument, in this study, for both cases – good therapeutic relationship (gtr) and challenging therapeutic relationship (ctr) – for each sub-scale and the total scale ranged from fair to excellent: global scale (αgtr = .89; αctr = .88) which is consistent with the original portuguese version (α = .89; machado & horvath, 1999), goals (αgtr = .74; αctr = .77), tasks (αgtr = .58; αctr = .60) and bond (αgtr = .89; αctr = .81). procedures firstly, regarding the translation and cultural adaptation several steps were taken to, following beaton et al. (2000) guidelines to cross-cultural adaptation of self-report meas­ ures. permission was sought and obtained from jennifer doran for the portuguese adaptation of the measure. the ans-t (doran et al., 2018) was, then, translated into portuguese, by three therapists fluent in portuguese and english which resulted in three versions. the different versions were compared, and a discussion was held to reach an agreement between the experts. subsequently, a portuguese form was back translated into english (retroversion) by an experienced portuguese psychotherapist highly profi­ cient in english language. the original items were compared with the new items in english, the result of the backward translation (hambleton et al., 2005), and there were no substantial differences between both versions. finally, jennifer doran approved the back translation. to ensure the clarity of the translated items, a pre-test was conducted with 10 therapists. this process confirmed the clarity of the items (final version can be accessed in the supplementary materials). secondly, concerning the psychometric study, participants were recruited following two inclusion criteria: a) being a psychologist registered in the border of portuguese psy­ chologists and b) having portuguese nationality. data was collected on-line using google forms, and participants were asked for written consent and assured of confidentiality on the first page of the online form and after were presented with the instruments. data collection was done only once per participant, but there was an indication that they should report data on two clients: a client with a “good” relationship and with a “chal­ lenging” relationship, which resulted into each participant filling the instruments twice – one for each case (adapted from doran et al., 2018). the average time for completing all instruments was 15 minutes. as all questions were mandatory, there were no missing values. this methodology ensured comprehensive data collection and adherence to the study's objectives. portuguese form of alliance negotiation scale – therapist version 6 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ data collection the sampling method employed was a non-probabilistic snowball technique, utilizing social networks (e.g., facebook, linkedin), email, and the researchers' personal contacts for participant recruitment. an invitation post was presented with a link that led to the questionnaire. some portuguese psychotherapy associations were also contacted by e-mail to disseminate the study through their associates. to participate, individuals were required to click on the provided link, leading them to the online google form containing the informed consent. upon providing consent, participants proceeded to complete the previously described instruments. all participants met the established criteria for inclusion in the sample of 100 psychologists, and no individuals were excluded from the study. statistical analyses first, to explore and to confirm the factorial structure of the ans-t_pt, the data from each participant was randomly split into two different sub-samples constituted by 50% of participants data reported to a gtr and the other 50% to ctr. both random sub-samples have the same therapists; in the first half therapists responded reporting a good relation­ ship and the second half a challenging relationship and vice-versa. the exploratory factor analysis was conducted with the first sub-sample (n = 100) and to decide the number of factors a parallel analysis was used. the confirmatory factor analysis was performed in the second random sub-sample (n = 100) using maximum likelihood (ml) estimation. multiple fit indexes were used to analyze model fit (hooper et al., 2008; hu & bentler, 1999): the chi-square (χ2) and the normed chi-square (χ2/df) less than 3, the comparative fit index (cfi > .95), the tucker–lewis index (tli > .95), the root mean square error of approximation and the standardized root mean square residual (rmsea and srmr ≤ .08). a composite reliability score was assessed to evaluate internal consistency. efa and cfa were conducted using r software (r core team, 2019). afterwards, criterion-related validity was investigated through pearson bivariate cor­ relation analysis to assess the relationship between the ans-t_pt and the wai-t, with therapists’ variables and variables from the therapeutic relationship. results construct validity factor structure and internal consistency firstly, the matrix factorability was supported with a kmo of .80 and the items were significantly correlated, χ2(36) = 507.00, p < .001. a principal components analysis was conducted and based on parallel analysis, a one-factor solution was obtained, as the orig­ nunes da silva, matos, & carvalho 7 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ inal measure (doran et al., 2018). that factor explained approximately 53% of the total variance. the loadings ranged between .63 and .83. afterwards, a confirmatory factor analysis was performed in the second random sub-sample (n = 100). to the exception of the rmsea (.09, 95% ci [.05, .14]), all the others goodness of fit indices showed that unifactorial structure had a good fit to the data: χ2(24, n = 100) = 46.00, p = .004, χ2/df = 1.92; cfi = .94; tli = .92; srmr = .07. the standardized factor loadings ranged from .39 to .86 (figure 1) and all were significant (p < .001). figure 1 alliance negotiation scale, confirmatory factor model alliance negotiation scale ans1 ans2 ans3 ans4 ans5 ans6 e1 e2 e3 e4 e5 ans7 ans8 ans9 .50 .37 .81 .84 .73 the internal consistency reliability of the ans-t_pt was assessed through the composite reliability, and the obtained result demonstrated an adequate reliability (cr = .83, hair et al., 2019). criterion-related validity a bivariate pearson correlation between the portuguese version of wai-t and ans-t_pt showed that the ans-t_pt was positively correlated with all the wai-t, for the subscales and the sample (table 1). however, the relationship between the ans-t_pt and the wai-t were stronger in the challenging relationship (table 2). portuguese form of alliance negotiation scale – therapist version 8 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ table 1 correlations between ans and wai for good therapeutic relationship variable 1 2 3 4 1. ans − − − − 2. wai goals .47* − − − 3. wai tasks .39* .72* − − 4. wai bond .48* .73* .66* − wai total .50* .91* .87* .90* note. n = 100. ans = alliance negotiation scale; wai = working alliance inventory. *p < .001. table 2 correlations between ans and wai for challenging therapeutic relationship variable 1 2 3 4 1. ans − − − − 2. wai goals .56* − − − 3. wai tasks .56* .79* − − 4. wai bond .47* .61* .58* − wai total .60* .91* .89* .84* note. n = 100. ans = alliance negotiation scale; wai – working alliance inventory. *p < .001. furthermore, through bivariate pearson correlation we have explored the relationship between the alliance negotiation and therapist features, and the analysis indicate that alliance negotiation in the challenging relationship was positively associated with the therapist years of experience (r = .24, p = .019) and the mean number of patients per week (r = .22, p = .026). and the alliance negotiation in the good relationship was associated with the mean number of patients per week (r = .24, p = .019). for the challenging relationship, higher alliance negotiation was positively associated to how close the therapist felt to his/her client (r = .47, p < .001) and how please the therapist felt with the therapeutic work done so far (r = .43, p < .001). as for the good relationship cases, higher alliance negotiation was also positively associated to how close the therapist felt to his/her client (r = .21, p = .039) and how please the therapist felt with the therapeutic work done so far (r = .26, p = .008). however, these correlations were lower than the other ones. nunes da silva, matos, & carvalho 9 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ discussion in this study, we aimed to translate, perform the cultural adaptation and a preliminary psychometric analysis of the portuguese form of the therapist version of the alliance ne­ gotiation scale (ans-t_pt). this contribution enhances our understanding of alliance ne­ gotiation within portuguese-speaking psychotherapeutic processes. moreover, this study provides preliminary evidence for the unifactorial structure of the ans-t_pt, its internal consistency, and its criterion-related validity with the working alliance construct. in terms of construct validity, the portuguese version exhibited a structure akin to the original version, featuring a single factor with nine items. the cronbach's alpha coefficient for the portuguese form of the ans-t was adequate for both case types and comparable to values reported in prior version (α = .84 english version; α = .82 spanish version; doran et al., 2018; gómez-penedo et al., 2019). furthermore, evidence was found to establish the criterion-related validity of the instrument, based on the correlations between the ans-t_pt and wai-t scores. the results showed moderate to large associations between the instruments (cohen, 2016), suggesting that both measures are correlated despite measuring different constructs (as previous showed in the english and spanish versions). other similar aspect is that the correlations between the ans-t_pt and the wai-t (r = .50 and r = .60 respectively, p < .001), were lower than those observed in the client’s versions (r = .72, p < .001). as discussed in the spanish version (gómez-penedo et al., 2019), this suggests that in the therapist's version there may be a higher degree of differentiation between the alliance studied as collaboration and the alliance as negotiation. the distinct structure, both in terms of the number of factors and items, may also contribute to these findings. the measure, in contrast to the client version, comprises a singular factor. the authors (doran et al., 2018; gómez-penedo et al., 2019) suggested that this difference may stem from the perspective shift—while the client's viewpoint considers two facets (degree of client comfort to present negative feelings and flexibility of the therapist), the therapist's perspective presents alliance negotiation as a more encompassing phenomen­ on. while this proposition holds merit, we advocate for further research to validate this assumption. other interesting aspect is that, in our study we tried to overcome previous referred limitations trying to gather information about the client. on the group of cases perceived by the therapist has having a challenging relationship, there was a higher degree of asso­ ciation between wai-t total scores and its subscales and ans-t_pt. alliance negotiation was associated with the working alliance specially when in presence of a challenging relationship. noteworthy, is the higher correlation between tasks and goals in the chal­ lenging relationships when compared with the good relationships, where this association is lower. in our study, we have also explored the relationship between the alliance negotiation and therapist’s features. the analysis indicates that the alliance negotiation in the chal­ portuguese form of alliance negotiation scale – therapist version 10 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ lenging relationship was positively associated with the therapist years of experience and the mean number of clients per week. considering the nature of the negotiation process, in dealing with alliance ruptures (in more challenging relationships) this result might be explained by the fact that a more experienced therapist may be more capable to deal with these challenges. also, for the challenging relationship, higher alliance negotiation was positively associated to how close the therapist felt to his/her client and how pleased the therapist felt with the therapeutic work done so far. this result may also be linked to the association observed between the bond and tasks subscales of the wai-t, where there was a higher association in the challenging relationship cases. also noteworthy, is the mean number of sessions of this group, 25, which means that even though it was perceived as a challenging relationship it was an enduring one. as for the cases perceived as having a good relationship, higher alliance negotiation was also positively associated to how close the therapist felt to his/her client and how pleased the therapist felt with the therapeutic work done so far. however, these correla­ tions were lower when compared to the challenging relationship cases, meaning that this may be less associated with the negotiation aspect of the alliance. this may also mean that with challenging relationships therapists may invest more, which may contribute to the closeness of the client and feeling more satisfied with the work. it is not possible to determine whether it is the working alliance that allows for the negotiation or the negotiation that allows for the working alliance. nevertheless, this result is important because it may capture the nature of the alliance negotiation as a different aspect from the working alliance, even though these are related constructs. the development and negotiation of an alliance is both a critical and pivotal point in the therapeutic process. a key to a successful therapeutic alliance may be the ability of the intervenient to develop a relationship supported by mutual trust and commitment. limitations and future research despite the usefulness of the present scale, these results may need further investigation. in data collection we asked for good and challenging relationships, not specifically for bad relationships which could lead to different results. a challenging relationship may indeed allow for a more negotiated process but still be a good (enough) one, which can be different from a bad relationship where this negotiation may not even be possible and could even lead to earlier dropouts. also, and related, is that this was a cross sectional study and data was collected online, with an heterogenous sample regarding the timing of the therapeutic process, and with different number of sessions (ranging from 1 to 160), meaning that the therapeutic alliance was at different stages. with some clients the therapeutic alliance was only beginning, while with others it was a long one. it is possible that the results might have been different with other conditions, such as limited to a particular point in time of the therapeutic process, with a high variability between participants or a representative sample, and data collected in person or immediately nunes da silva, matos, & carvalho 11 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ following therapy sessions or even considering different case characteristics such as, for example, drop out cases. in addition, the cross-sectional nature of our study limits the exploration of the stability of the construct and its evolution over time. a longitudinal study utilizing a repeated measures design would enable the examination of fluctuations in therapist perceptions and the evolution of negotiation (ans) and quality (wai) of the therapeutic alliance. this approach would provide clarity on whether it is the quality of the working alliance that facilitates negotiation or the degree of negotiation that fosters the quality of the working alliance. the negotiation as a concept appears to re-conceptualize the therapeutic alliance as a continuous negotiation of the needs of two independent subjects involved in the relationship and reflect on how far disagreements and tension are pro­ cessed by and within the therapeutic process. therefore, in future studies the self-report measure could be revised to capture this process or be better though to be used in a continuum assessment. recent studies indicate that the alliance is codeveloped with clients, which reinforces this perspective of the alliance being developed and negotiated rather than a static construct (escudero et al., 2022). we suggest that more studies are needed regarding its structure and replication with different samples. given that the client version has two factors, a revision of the measure may be considered to create better symmetry between measures. we would argue that a good measure for assessing the quality of the working alliance would integrate items that capture several aspects such as: quality of the bond, ability to express disagreements, agreement of goals and tasks, negotiation of goals and tasks. in future studies, it could also be of interest to further study the impact of the therapist characteristics such as age, gender or therapeutic model, and its matching with the client and its impact on the alliance negotiation. while our sample predominantly comprised females (85%), aligning with the gender distribution of psychologists in portu­ gal (84.2% according to the 2014 census of the border of portuguese psychologists), this gender composition may pose some limitations that warrant further investigation. implications and contributions to the best of our knowledge, the ans is the first measure to assess the negotiation concept using a brief self‐report format. existing research on the presence of ruptures and their repair traditionally rely on observer‐based coding methods rather than client and therapist self‐report (e.g., eubanks-carter et al., 2015). reinforcing doran and col­ laborators (doran et al., 2018) arguments, although interesting and informative, such methods are costly and time consuming in nature. being brief and easy to use, may not only contribute to the study of alliance negotiation, but may also be a significant measure for clinical practice and supervision, allowing to use the response to the items has a reflection on the negotiation work with the client. portuguese form of alliance negotiation scale – therapist version 12 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ our results seem promising, in line with the previous studied versions of the scale and will allow to increase the alliance negotiation studies in portuguese speaking coun­ tries. meanwhile, to have both versions, for clients and therapist, of ans will also allow the dyadic study of negotiation. even if we have come a long way on research regarding the relationship between process and outcome, there remains unexplained variance and critical gaps in our understanding about what processes produce therapeutic change (e.g., doran et al., 2018; zilcha-mano & ben david-sela, 2022). it seems useful and necessary to understand the relationship and the impact alliance negotiation has more fully on treatment and treatment outcome. conclusion this was a preliminary validation of the ans therapist version to portuguese, showing that this instrument is reliable, valid and a parsimonious measure of the alliance negotia­ tion which allows for the evaluation of the efficacy of the therapeutic processes that can be used in clinical settings and to research purposes. funding: the authors have no funding to report. acknowledgments: we would like to thank inês galvão and antónio branco vasco for helping as experts in the initial translation of the measure; inês galvão for the help in the data collection and magda roberto for consultation on the initial analysis. competing interests: the authors have declared that no competing interests exist. ethics statement: the study was approved by the ethics committee of the faculdade de psicologia da universidade de lisboa (2019/12). data availability: the data that support the findings of this study are available from the corresponding author upon reasonable request. supplementary materials the supplementary materials contain the following item (for access see nunes da silva et al., 2024): • escala de negociação da aliança terapêutica (versão do terapeuta) [portuguese form of the alliance negotiation scale – therapist version] index of supplementary materials nunes da silva, a. c., matos, m., & carvalho, h. (2024). supplementary materials to "the alliance negotiation scale – therapist version: psychometric properties in a sample of portuguese nunes da silva, matos, & carvalho 13 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://www.psychopen.eu/ psychologists" [portuguese form of the alliance negotiation scale – therapist version (anst_pt)]. psychopen gold. https://doi.org/10.23668/psycharchives.14181 references baier, a. l., kline, a. c., & feeny, n. c. (2020). therapeutic alliance as a mediator of change: a systematic review and evaluation of research. clinical psychology review, 82(12), article 101921. https://doi.org/10.1016/j.cpr.2020.101921 beaton, d. e., bombardier, c., guillemin, f., & ferraz, m. b. (2000). guidelines for the process of cross-cultural adaptation of self-report measures. spine, 25(24), 3186–3191. https://doi.org/10.1097/00007632-200012150-00014 bordin, e. s. 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(2015). the great psychotherapy debate: the evidence for what makes psychotherapy work (2nd ed.). routledge/taylor & francis group. zilcha-mano, s., & ben david-sela, t. (2022). is alliance therapeutic in itself? it depends. journal of counseling psychology, 69(6), 786–793. https://doi.org/10.1037/cou0000627 zuroff, d. c., & blatt, s. j. (2006). the therapeutic relationship in the brief treatment of depression: contributions to clinical improvement and enhanced adaptive capacities. journal of consulting and clinical psychology, 74(1), 130–140. https://doi.org/10.1037/0022-006x.74.1.130 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. portuguese form of alliance negotiation scale – therapist version 16 clinical psychology in europe 2024, vol. 6(2), article e11477 https://doi.org/10.32872/cpe.11477 https://doi.org/10.1037/cou0000627 https://doi.org/10.1037/0022-006x.74.1.130 https://www.psychopen.eu/ portuguese form of alliance negotiation scale – therapist version (introduction) method participants instruments procedures data collection statistical analyses results construct validity criterion-related validity discussion limitations and future research implications and contributions conclusion (additional information) funding acknowledgments competing interests ethics statement data availability supplementary materials references alcohol and substance use disorders diagnostic criteria changes and innovations in icd-11: an overview scientific update and overview alcohol and substance use disorders diagnostic criteria changes and innovations in icd-11: an overview alice matone 1 , claudia gandin 1 , silvia ghirini 1 , emanuele scafato 1 [1] osservatorio nazionale alcol, centro nazionale dipendenze e doping, istituto superiore di sanità, rome, italy. clinical psychology in europe, 2022, vol. 4(special issue), article e9539, https://doi.org/10.32872/cpe.9539 received: 2022-05-24 • accepted: 2022-10-04 • published (vor): 2022-12-15 handling editor: andreas maercker, university of zurich, zurich, switzerland corresponding author: emanuele scafato, istituto superiore di sanità, viale regina elena, 299 – 00161, roma, italy. tel.: 06 49904028. e-mail: emanuele.scafato@iss.it related: this article is part of the cpe special issue “innovations in icd-11”, guest editor: andreas maercker, clinical psychology in europe, 4(special issue), https://doi.org/10.32872/10.32872/cpe.v4.si abstract background: the new revision of the icd came into effect on january 1st, 2022, and significant changes have been introduced in the section related to substance use disorders. method: in the present work we describe the new icd-11 section “disorders due to substance use and addictive behaviors” and outline the innovations in classification and diagnosis introduced, with a view to addressing the most important issues in terms of new opportunities for identifying and caring for people in need of treatment. results: the main innovations introduced in the icd-11 chapter of interest are the expanded classes of psychoactive substances, the introduction of single episodes of substance use, the introduction of harmful patterns of substance use and severity qualifiers for substance intoxication. furthermore, the new category “disorders due to addictive behaviors” has been added, including “gambling disorder” and the new diagnostic category “gaming disorder”. conclusions: icd-11 calls for renewed public health response and policies fostering the multiprofessional and multidisciplinary management of alcohol and substance abuse treatment, giving to these forms of addiction new chances also towards the reaching of the un 2030 agenda sustainable development goals. keywords disease international classification, icd-11, substance use disorders, addictive behaviors, public health, psychoactive substances this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.9539&domain=pdf&date_stamp=2022-12-15 https://orcid.org/0000-0003-4530-908x https://orcid.org/0000-0002-2039-1171 https://orcid.org/0000-0001-8552-7474 https://orcid.org/0000-0001-5663-6751 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • icd-11 represents a new opportunity for those who are in need for treatment to be timely identified. • icd-11 allows to fill the existing therapeutic gap and increase the coverage of substance use disorders. • icd-11 pushes for necessary changes in the post-covid era: an integrated approach aimed at using standard tools and training for adequate intervention. • the new definitions adopted by icd-11 are in line with the un 2030 agenda, aimed at ensuring healthy lives and promote well-being for all ages. on january 1st, 2022, the 11th revision of the international classification of disease (icd) system, icd-11, came into effect. the icd is a collection of human disorders and related health conditions which is used from approximately 180 countries around the globe and is periodically revised from the world health organization (who). disease classification and coding is crucial not only for accurate clinical diagnosis and effective communica­ tion between medical professionals, but also for epidemiological data gathering in order to monitor trends in disease prevalence and incidence, and for providing a basis for precision in research (sanusi et al., 2022; saunders, 2017). within the wide spectrum of recognized disorders that have an impact on human health and society, of non-trivial importance are disorders related to psychoactive sub­ stance use. psychoactive substances, when taken in or administered into a person’s system, affect mental processes such as consciousness, cognition, perception, mood and emotions. especially if untreated, substance use disorders increase morbidity and mortal­ ity risks, and can lead to major suffering and impairment in important areas of function­ ing, such as family, occupational and social life. substance use disorders are associated with significant costs to society due to lost productivity, premature mortality, increased health care expenditure, and costs related to criminal justice, social welfare, and other social consequences (world health orgnization, 2022). therefore, careful consideration of these spectrum of diseases within the international coding systems is necessary and unavoidable. the section of the icd-11 dedicated to mental health is called “mental, behavioral or neurodevelopmental disorders” (mbnd), and is the result of a wide international, multidisciplinary and participative process that involved many experts and stakeholders around the world, such as mental health professionals and users of mental health serv­ ices (gaebel et al., 2020; reed et al., 2019). the who department of mental health and substance abuse (dmhsa) assigned a dedicated advisory group for the revision of icd-10 chapter on mental health, and working groups were established worldwide in order to collaborate to the development of the new mbnd chapter in icd-11. based on the available evidence, the working groups proposed improvements to the classification system related to mental health, resulting in a beta draft that was made available online innovations in icd-11 and substance use disorders 2 clinical psychology in europe 2022, vol. 4(special issue), article e9539 https://doi.org/10.32872/cpe.9539 https://www.psychopen.eu/ from 2015, in order to receive additional comments and inputs (gaebel et al., 2020). the 11th version of the icd was approved in may 2019 by the world health assembly, after which the who dmhsa published the clinical description and diagnostic guidelines (cddg) for the icd-11 mbnd, as the result of a multidisciplinary and international collaboration process that lasted for over a decade (reed et al., 2019). the main criteria adopted for the development of the icd-11 mbnd process have been the consideration of clinical utility, adherence to scientific soundness, and global applicability. further­ more, since the development of the diagnostic and statistical manual of mental disor­ ders (dsm)-5 was partially contemporary to the one of the icd-11 clinical descriptions and diagnostic guidelines, the coherence between the two tool was considered of crucial importance, particularly in terms of minimizing arbitrary differences between the two (reed et al., 2019). the dsm is one of the most widely used diagnostic tools for mental disorders, it is published from the american psychiatric association (apa), and the 5th revision was completed in 2013. the dsm covers all categories of mental health disorders and has a widespread importance and influence on how disorders are diagnosed, treated, and investigated. although great efforts have been made to harmonize the icd-11 with the dsm-5, the two systems do have some differences, also considering that they have, to some extent, different aims. while the dsm-5 aims at providing a common research and clinical language for mental health problems, the icd-11 pays particular attention to issues of clinical utility in a broad range of settings, aiming at global applicability, and especially the area of ‘addictions’ has been handled by the latest revisions of the two systems with somewhat divergent approaches, that will be discussed later in this article (grant & chamberlain, 2016). the icd-11 mbnd chapter includes disorders related to substance use in the section “disorders due to substance use and addictive behaviors” (saunders et al., 2019; world health organization, 2019). several important changes have been made in this section with this last revision, that reflect adjustment to modern times, in terms of new sub­ stances, behaviors and psychological dynamics (poznyak et al., 2018). in this work we describe the changes in substance use disorders and addictive behaviors classification between icd-10 and icd-11 and their implications, specifically: 1. expanded classes of psychoactive substances; 2. introduction of single episodes of substance use; 3. introduction of harmful patterns of substance use; 4. severity qualifiers for substance intoxication; 5. introduction of the category “disorders due to addictive behaviors” that includes “gambling disorder” (previously under “habit and impulse disorders”) and the new diagnostic category “gaming disorder”. matone, gandin, ghirini, & scafato 3 clinical psychology in europe 2022, vol. 4(special issue), article e9539 https://doi.org/10.32872/cpe.9539 https://www.psychopen.eu/ globally, the need for treatment for substance use disorders did not yet reach a satisfying level and the changes introduced in the icd-11 have important implications for public health in terms of opportunities for improved monitoring, prevention and treatment and for restructuring of health services in such a way that patient-centered care is prioritized. interventions must be supported from informed strategies and one of the main priorities in this respect is to provide health professionals with an effective tool for identifying people in need (poznyak et al., 2018). therefore, with the present manuscript we aim at providing professionals with valuable insights by outlining the main changes in the 11th revision of the icd that will have important implications in terms of public health approaches. icd-11 “disorders due to substance use and addictive behaviors” chapter 6 of the icd-11, “mental, behavioral and neurodevelopmental disorders”, in­ cludes a new grouping of conditions in the 12th section called “disorders due to sub­ stance use and addictive behaviors” (see figure 1) which is described as follows: “disorders due to substance use and addictive behaviors are mental and behavioral disorders that develop as a result of the use of pre­ dominantly psychoactive substances, including medications, or spe­ cific repetitive rewarding and reinforcing behaviors” (world health organization, 2019). the who strategic approach to minimize harm from substance use is reflected in this new version of the icd-11, where the public health approach to substance use and addic­ tive behaviors is emphasized from diagnoses (reed et al., 2019). the section is divided itself in two parts, “disorders due to substance use” and “disorders due to addictive behaviors”. disorders due to substance use expanded classes of psychoactive substances in icd-11 disorders due to substance use include disorders that result from a single occasion or repeated use of substances that have psychoactive properties, including certain medica­ tions, and are classified according to the substance. the list of substances has been broadened from 9 (icd-10) to 14, to comprehend contemporary patterns of use: alcohol, cannabis, synthetic cannabinoids, opioids, sedative hypnotics and anxiolytics, cocaine, stimulants including amphetamine methamphetamine or methcathinone, synthetic cath­ inones, caffeine, hallucinogens, nicotine, volatile inhalants, mdma and related drugs, dissociative drugs including ketamine and phencyclidine (poznyak et al., 2018). other innovations in icd-11 and substance use disorders 4 clinical psychology in europe 2022, vol. 4(special issue), article e9539 https://doi.org/10.32872/cpe.9539 https://www.psychopen.eu/ classes have been added to include for those substances that are not mentioned and are known of not known: “disorders due to use of…” other specified psychoactive substan­ ces, including medications; multiple specified psychoactive substances, including medica­ tions; unknown or unspecified psychoactive substances; non-psychoactive substances. figure 2 illustrates the differences between the list of substances in icd-10 and icd-11. the structure of the classification implies that diagnosis should start from the substance rather than the clinical syndrome. the grouping revision is meant to allow capturing health information to be used in different contexts, support accurate monitoring and inform prevention and treatment. following the list of substance classes is the list of specific diagnostic categories that apply to the classes of psychoactive substances (reed et al., 2019; world health organization, 2019). figure 1 schematic representation of chapter 6 of the icd-11, “disorders due to substance use and addictive behaviors” matone, gandin, ghirini, & scafato 5 clinical psychology in europe 2022, vol. 4(special issue), article e9539 https://doi.org/10.32872/cpe.9539 https://www.psychopen.eu/ figure 2 list of substances in icd-10 and icd-11 icd-10 icd-11 chapter v: “mental and behavioural disorders” chapter 6: “mental, behavioural or neurodevelopmental disorders" f10-f19 mental and behavioural disorders due to psychoactive substance use disorders due to substance use or addictive behaviours mental and behavioural disorders due to use of… f10 alcohol f11 opioids f12 cannabinoids f13 sedatives or hypnotics f14 cocaine f15 other stimulants, including caffeine f16 hallucinogens f17 tobacco f18 volatile solvents f19 multiple drug use and use of other psychoactive substances disorders due to use of… 6c40 alcohol 6c41 cannabis 6c42 cannabinoids 6c43 opioids 6c44 sedatives, hypnotics or anxiolytics 6c45 cocaine 6c46 stimulants including amphetamines, methamphetamine or methcathinone 6c47 synthetic cathinones 6c48 caffeine 6c49 hallucinogens 6c4a nicotine 6c4b volatile inhalants 6c4c mdma or related drugs, including mda 6c4d dissociative drugs including ketamine and phencyclidine [pcp] 6c4e other specified psychoactive substances, including medications 6c4f multiple specified psychoactive substances, including medications 6c4g unknown or unspecified psychoactive substances 6c4h non-psychoactive substances 6a41 catatonia induced by substances or medications 6c4y other specified disorders due to substance use 6c4z disorders due to substance use, unspecified note. entries in bold show the new or differently classified/named substances in icd-11 compared to icd-10. substance use related diagnoses: innovations in icd-11 introduction of single episodes of substance use and of harmful patterns of substance use are among the main features introduced in this version of the icd for classification of primary diagnoses of substance use disorders (sud): while with the icd-10 these were only “substance dependence” and “harmful substance use” classifications, with the icd-11 the primary diagnoses classes are “substance dependence”, “harmful pattern of psychoactive substance use” and “episode of harmful psychoactive substance use”. one of these three diagnoses, or “disorder due to substance use, unspecified” – when the use pattern in unknown at the time of evaluation – must be given when making a diagnosis of a disorder due to substance use (world health organization, 2019). these categories are hierarchical and mutually exclusive, in such a way that only one of these can diagnosed for one substance group, therefore removing overlapping and ambiguity. early identification and response of sud can be eased from having different catego­ ries for harmful substance use and substance dependence as these can be addressed with different intervention schemes, for instance there are substance use patterns that may innovations in icd-11 and substance use disorders 6 clinical psychology in europe 2022, vol. 4(special issue), article e9539 https://doi.org/10.32872/cpe.9539 https://www.psychopen.eu/ benefit from brief psychological interventions (for instance motivational interviewing), while other require more extensive treatment (such as detoxification or agonist mainte­ nance). in addition, the who considers harmful consumption categories to be very important for understanding the impact of substance use on public health in morbidity and mortality statistics (first et al., 2021). furthermore, there are a number of diagnoses that can be added to the primary ones, which include “substance intoxication”, “substance withdrawal” and different “substance induced mental disorders”. the manual includes also categories related to “hazardous substance use”, which are classified in chapter 24, ‘factors influencing health status or contact with health services’, and not considered to be mental disorders and can be referred to in cases where no evident harm has occurred but the pattern of use increases the risk of harmful health consequences to the user, or to others, in a way that advice from health professionals is needed (reed et al., 2019; world health organization, 2019). episode of harmful psychoactive substance use inclusion of the single episode of harmful substance use in the icd-11 is noteworthy, as it allows for early intervention and prevention of increased use and worsening of the condition and harm. the diagnosis should follow an episode where damage has been caused to someone’s physical or mental health, not only referred to the user but also to others: this is an important added value of the icd-11, where harm to the health of others is explicitly included (reed et al., 2019). the episode of harmful use usually refers to acute effects and may include substance-induced psychological disorders and should not include harm due to a known harmful pattern of use (world health organization, 2019). harmful pattern of psychoactive substance use the harmful pattern of use definition, instead, indicates a case where interventions must be intensified, and refers to a situation where clinically significant harm to a person’s physical or mental health is evident, and can be due not only to the direct intoxicating effects of the substance, but also to secondary effects or harmful route of administration. the pattern can be further specified as episodic or continuous and should be detected for a period of at least one year for episodic use and at least one month for continuous use. furthermore, harm to health should not be better accounted for by another medical condition or another mental disorder, including another disorder due to substance use, such as substance withdrawal or substance dependence. harm caused by substance dependence can be similar to that observed in harmful pattern of psychoactive substance use, however, alcohol dependence also includes additional features of the diagnosis and requires at least two of three central features to be present at the same time: impaired control after substance use, substance use becomes an increasing priority in life, phys­ matone, gandin, ghirini, & scafato 7 clinical psychology in europe 2022, vol. 4(special issue), article e9539 https://doi.org/10.32872/cpe.9539 https://www.psychopen.eu/ iological features that indicate neuroadaptation to the substance, such a tolerance and withdrawal symptoms (world health organization, 2019). severity qualifiers for substance intoxication diagnosis of substance intoxication requires some essential characteristics, that include transient and clinically significant alteration – such as in behavior, consciousness or coordination – that appear during or shortly after substance use, the pharmacological effects of which must be compatible with the symptoms. intoxication can last from only a few minutes or even several days after the episode of use. the effects of intoxication are limited in time and fade away as the substance is cleared from the body and symp­ toms are not better attributable to other medical conditions or mental disorders. the icd-11 allows for specification of severity of intoxication, that can be classified as mild, moderate or severe, and depends on a variety of factors, such as the amount of substance used, its half-life and the route of administration, and of course individual susceptibility which can be influenced from body weight, tolerance or concurrent conditions such as kidney of liver impairment. substance intoxication is considered mild if disturbances in psychophysiological functions and responses (for instance attention, judgement or motor coordination) are clinically recognizable but there is no – or little – disturbance in the level of consciousness. in moderate intoxication, instead, the above-mentioned disturban­ ces are evident and the tasks that require psychophysiological functioning and response are substantially impaired. there is also some disturbance in the level of consciousness. severe substance intoxication is a state in which motor coordination, attention and judgement are obviously impaired, as well as the level of consciousness. the person may not be capable of self-care or self-protection and may not be capable to communicate or cooperate with assessment and intervention. the intensity of intoxication decreases after reaching a peak of absorption of the substance, and the effects eventually disappear in there is no further use of the substance (world health organization, 2019). disorders due to addictive behaviors the new section introduced in the 6th icd-11 chapter, called “disorders due to addictive behaviors”, includes “gambling disorder”, which was previously listed in the category “habit and impulse control disorders (icd-10)”, and the new diagnostic category “gam­ ing disorder” (saunders, 2017). diagnosis of gambling and gaming disorders need the manifestation of clinical signs and functional impairment that are observed for a period of at least 12 months, unless severe symptoms arise. both gambling and gaming disorders are classified as “predominantly online” or “predominantly offline” and are characterized by a pattern of persistent or recurrent behavior. the disorders are defined by impaired control over gambling or gaming, increasing priority given to it, and continuation or escalation despite the occurrence of negative consequences. the pattern of the behavior may be continuous or episodic and recurrent, and results in marked distress or signifi­ innovations in icd-11 and substance use disorders 8 clinical psychology in europe 2022, vol. 4(special issue), article e9539 https://doi.org/10.32872/cpe.9539 https://www.psychopen.eu/ cant impairment in important areas of functioning, such as occupational, family and social life. gambling disorder in icd-10 gambling was classified under the “disorders of adult personality and behav­ ior” section “habit and impulse disorders” and was named “pathological gambling”. since recent evidence shows important phenomenological analogies between substance use disorders and disorders due to addictive behaviors, gambling has been associated, togeth­ er with gaming, in the “disorders due to substance use and addictive behaviors” section. this change is important also because a high co-occurrence has been detected within the phenomena, as well as the fact that they are both initially pleasurable and then followed by progression to loss of hedonic value and need for increased use. there is also some scientific evidence that disorders due to substance use and disorders due to addictive behaviors share similar neurobiology, especially activation and neuroadaptation within the reward and motivation neural circuits (fauth-bühler et al., 2017; reed et al., 2019). gaming disorder gaming disorder, either ‘digital gaming’ or ‘video-gaming’, is described as pattern of persistent or recurrent gaming behavior, which may be online or offline, characterized by impaired control over gaming in terms onset, frequency, intensity, duration, termina­ tion, and context. furthermore, increasing priority is given to gaming in such a way that it takes precedence over other life interests and daily activities and, despite the occurrence of negative consequences, the disorder shows continuation or escalation of gaming (world health organization, 2019). solid evidence and intensive discussions among experts over the past years recognized excessive gaming patterns as a clinically significant syndrome, leading to the inclusion of gaming disorder in the 11th revision of the icd, making a diagnosis for this disfunction a real possibility for patients and clinicians, where the issue is of such a nature and intensity that it results in marked distress or significant impairment in personal, family, social, educational or occupational functioning (borges et al., 2021; world health organization, 2018). in fact, implications of gaming disfunction are not limited to gaming itself, but come along with other health issues, such as aggressive behaviors, depression, insufficient physical activity, unhealthy diet, eyesight and hearing issues and sleep deprivation (higuchi et al., 2021; world health organization, 2018). unlike gambling disorder, gaming disorder does not involve the betting of money or other valuables with the hope of obtaining something of greater value. if gaming behavior is focused on wagers (for instance internet poker), gambling disorder is generally the more appropriate diagnosis (world health organization, 2019). matone, gandin, ghirini, & scafato 9 clinical psychology in europe 2022, vol. 4(special issue), article e9539 https://doi.org/10.32872/cpe.9539 https://www.psychopen.eu/ icd-11 and dsm-5 the icd and the dsm both have a substantial impact of psychiatric practice and research worldwide, and much effort has been made over the years to harmonize the two clas­ sifications and both the who and the american psychiatric association believe that the differences between the two systems should be minimized and maintained only if conceptually justified (first et al., 2021; reed et al., 2019). nevertheless, there are some significant differences in the classification of sud between the icd-11 and the dsm-5. the icd-11 paragraph “disorders due to substance use and addictive behaviors” has a corresponding one in the dsm-5: “substance-related and addictive disorders”. in order to facilitate data collection on their public health impact, some psychoactive substances have been added in the icd-11 due to their increasing global importance (european monitoring centre for drugs and drug addiction and eurojust, 2016): synthetic canna­ binoids (in the dsm‐5 are included in the cannabis class), cocaine (in the dsm‐5 are included in the stimulant class), synthetic cathinones (in the dsm‐5 included in the “other or unknown” class), and methylenedioxyphenethylamine (mdma) (in the dsm‐5 are included in the hallucinogen class) (first et al., 2021). distinct categories for pattern of use included in the icd-11 are discussed above, the dsm-5, instead, considers only one “substance use disorder” category, and identifies three levels of severity depending on the number of recognized symptoms among a list of 11: two or three symptoms identify mild sud, four or five symptoms identify moderate sud, and six or more symptoms identify severe sud. furthermore, dsm-5 does not consider classification of sud based on harm caused to the person’s physical or mental health or health of others. although there is a noticeable similarity between the dsm-5 11 classifications for sud and the three icd-11 categories, a number of cases detected with dsm-5 would not find correspondence in the icd-11: diagnosis of sud in icd-11 requires two out of three items, while in dsm-5 two out of 11. “craving” and “recurrent use in situations which are physically hazardous” are two items of dsm-5 that are not included nor have a correspondence in icd-11. furthermore, all the items related to a substance taking over in daily life activities described in the dsm-5: time spent using or obtaining substances, failure to fulfill role obligations, continued use despite social or interpersonal problems, important activities given up, and continued use despite physical or psychological prob­ lems, in icd-11 are represented in only one category: “increasing precedence of sub­ stance use over other aspects of life” (first et al., 2021). all the above might imply that, since there is not a complete homogeneity between the two tools in identifying all the sud categories, different diagnoses can be made for some groups of sud (degenhardt et al., 2019). as for gaming disorder, some studies suggest that there might be noticeable differen­ ces between the two classification systems in gaming disorder cases detection, where prevalence of cases detected with the dsm-5 are much higher compared to icd-11 innovations in icd-11 and substance use disorders 10 clinical psychology in europe 2022, vol. 4(special issue), article e9539 https://doi.org/10.32872/cpe.9539 https://www.psychopen.eu/ (borges et al., 2021). however, clinical validity studies are needed in order to assess these differences. conclusions overall, icd-11 can represent a new opportunity for several harmful behaviors and for those who are in need for treatment to be timely identified, filling the existing therapeu­ tic gap and increasing the coverage of alcohol and substance use disorders. icd-11 also pushes for some needed changes, particularly in the post-covid era (lópez-pelayo et al., 2020), to support a much more integrated approach aimed at using standard tools to identify the level of risk as well as training on how to ensure an adequate form of intervention valuing renewed treatment systems for substance use disorders. finally, the new definitions adopted by icd-11 call for renewed public health response and policies fostering the multi-professional and multidisciplinary management of alcohol and substance abuse treatment, giving to these forms of addiction new chances also towards the reaching of the un 2030 agenda sustainable development goals (sdgs) (united nations, 2015), aimed at ensuring healthy lives and promote well-being for all ages by mean "strengthen the prevention and treatment of substance abuse including narcotic drug abuse and harmful use of alcohol". funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. twitter accounts: @scafato references borges, g., orozco, r., benjet, c., martínez, k. i. m., contreras, e. v., pérez, a. l. j., cedrés, a. j. p., uribe, p. c. h., couder, m. a. c. d., gutierrez-garcia, r., chávez, g. e. q., albor, y., mendez, e., medina-mora, m. e., mortier, p., & ayuso-mateos, j. l. 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(2017). substance use and addictive disorders in dsm-5 and icd 10 and the draft icd 11. current opinion in psychiatry, 30(4), 227–237. https://doi.org/10.1097/yco.0000000000000332 saunders, j. b., degenhardt, l., reed, g. m., & poznyak, v. (2019). alcohol use disorders in icd-11: past, present, and future. alcoholism, clinical and experimental research, 43(8), 1617–1631. https://doi.org/10.1111/acer.14128 united nations. (2015). transforming our world: the 2030 agenda for sustainable development. https://sustainabledevelopment.un.org/post2015/transformingourworld/publication world health organization. (2019). international statistical classification of diseases and related health problems (11th ed.). world health organization. (2018). inclusion of “gaming disorder” in icd-11. https://www.who.int/news/item/14-09-2018-inclusion-of-gaming-disorder-in-icd-11 world health orgnization. (2022). mental health and substance use. https://www.who.int/teams/mental-health-and-substance-use/overview clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. matone, gandin, ghirini, & scafato 13 clinical psychology in europe 2022, vol. 4(special issue), article e9539 https://doi.org/10.32872/cpe.9539 https://doi.org/10.1186/s12889-022-13118-8 https://doi.org/10.1097/yco.0000000000000332 https://doi.org/10.1111/acer.14128 https://sustainabledevelopment.un.org/post2015/transformingourworld/publication https://www.who.int/news/item/14-09-2018-inclusion-of-gaming-disorder-in-icd-11 https://www.who.int/teams/mental-health-and-substance-use/overview https://www.psychopen.eu/ innovations in icd-11 and substance use disorders (introduction) icd-11 “disorders due to substance use and addictive behaviors” disorders due to substance use disorders due to addictive behaviors icd-11 and dsm-5 conclusions (additional information) funding acknowledgments competing interests twitter accounts references responding to key process markers as a focus of psychotherapy training and practice scientific update and overview responding to key process markers as a focus of psychotherapy training and practice james f. boswell 1 , michael j. constantino 2 , averi n. gaines 2 , ashleigh e. smith 1 [1] department of psychology, university at albany, state university of new york, albany, ny, usa. [2] department of psychological and brain sciences, university of massachusetts, amherst, ma, usa. clinical psychology in europe, 2024, vol. 6(special issue), article e11967, https://doi.org/10.32872/cpe.11967 received: 2023-05-15 • accepted: 2023-07-28 • published (vor): 2024-04-26 handling editor: wolfgang lutz, department of psychology, university of trier, trier, germany corresponding author: james f. boswell, university at albany, state university of new york, 1400 washington avenue, albany, ny 12222, usa. phone: 518-442-3402. e-mail: jboswell@albany.edu related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract historically, evidence-based psychotherapy training has favored the standardized application of discrete treatment packages, with key outcomes being the therapist’s adherence to and competent delivery of theory-prescribed ingredients. however, this model often fails to align with the priorities and values of clinicians, and research casts doubt on the notion that a therapist’s faithful application of treatment protocols is a valid index of clinical expertise. considering this, training and practice models that emphasize evidence-based clinician flexibility and patient-centered tailoring of interventions are receiving increased attention. in this article, we outline one such model informed by the context-responsive psychotherapy integration (crpi) framework. consistent with crpi principles, we describe several “if this/then try that” marker-response sequences that could become a centerpiece of a more nuanced, clinically representative, and evidence-based psychotherapy training paradigm. finally, we offer several recommendations for future work on crpi. keywords psychotherapy training, therapist development, responsiveness, context-responsive psychotherapy integration, evidence-based practice this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11967&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0001-6214-0787 https://orcid.org/0000-0003-3126-2575 https://orcid.org/0000-0001-5856-7059 https://orcid.org/0000-0003-3411-5837 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • psychotherapy training has traditionally valued therapist fidelity to narrow intervention packages over other facilitative therapy processes. • growing research supports that psychotherapy training and practice can be more effective if it is personalized to both the patient and provider with contextual and intentional responsivity. psychotherapy training, particularly in clinical psychology, has traditionally focused on the theory and application of discrete treatment models. for example, students in a given training program may be expected to complete coursework and supervised practica cen­ tered on empirically supported treatments (ests), such as cognitive behavioral therapy (cbt) or psychodynamic psychotherapy. within the cbt tradition, in particular, clinical training has privileged the use of diagnosis-specific treatment protocols or manuals that outline a specific and structured sequence of interventions that, ostensibly, help standardize across patients the clinician actions presumed to be therapeutic. yet, beyond the training context, the chasm between applied clinical science (which often touts using ests like cbt) and everyday clinical practice remains wide. when clinical researchers lament this science-practice gap, discussions often focus on the perceived low rate at which therapists adopt est manuals, or even when adopted, therapist variability in adhering to and competently delivering the theory-specific ingre­ dients to their patients. at a basic level, the ability to skillfully apply what one is trained to do strikes us as an appropriate goal for clinical training and practice. however, when considering the psychotherapy research base, it is hard to ignore that greater therapist protocol adherence tends not to correlate with better patient outcomes (southam-gerow et al., 2021; webb et al., 2010). although there is more evidence to support a small competence-outcome correlation, this finding is far from consistent (power et al., 2022). perhaps the null or mixed results for the adherenceand competence-outcome associ­ ations, respectively, are unsurprising when considering the methodological and clinical complexities. for example, despite each construct’s inherent focus on theory-specific treatment actions, competence assessments often include more general therapist behav­ iors, such as rapport building, which are not necessarily tied to the unique treatment model being delivered. in addition, training therapists to become sustainably adherent and competent in the delivery of a multi-component treatment protocol has proven quite difficult (frank et al., 2020). even in controlled trials that involve intensive training and ongoing supervision, treatment adherence and competence can vary significantly among therapists (e.g., imel et al., 2011). thus, outside of controlled efficacy studies, adherence and competence levels among routine practicing therapists are predictably even more suspect. finally, on a broader scale, psychotherapy training practices and trainee outcomes are not consistently linked with patient outcomes (knox & hill, 2021). process markers in therapy training and practice 2 clinical psychology in europe 2024, vol. 6(special issue), article e11967 https://doi.org/10.32872/cpe.11967 https://www.psychopen.eu/ although we are painting a sobering picture of prevailing training and clinical practi­ ces, alternative (or complementary) approaches exist and are receiving more attention (e.g., boswell et al., 2020). in this article, we (a) introduce and briefly summarize one such approach that veers away from the goals of unwavering adherence to a theory-specific treatment package; (b) suggest potential training structures and activities to support the implementation of this more flexible and context-responsive approach; and (c) provide recommendations for future work in this area. responsive clinical practice and training it is important to acknowledge that even within the protocol-adherence approach to training and practice, the importance of flexibility and adaptability is arguably still recognized (kendall & frank, 2018; wiltsey stirman et al., 2017). many theorists, re­ searchers, and clinicians appreciate that a one-size-fits-all approach to psychotherapy is limited, and even treatments with the most research support have the potential to result in negative outcomes for certain patients or under certain circumstances (castonguay et al., 2010). notably, results from a meta-analysis of studies that directly compared manualized versus non-manualized treatments failed to find significant outcome differ­ ences (truijens et al., 2019), which generally supports there being benefit to therapist plasticity and clinical improvisation. moreover, studies have demonstrated the potentially detrimental effects of rigidly adhering to a treatment protocol (e.g., castonguay et al., 1996), as well as the potential benefits of within-adherence flexibility (i.e., the natural integration of techniques from other approaches; owen & hilsenroth, 2014). another sign of the growing recognition of the importance of flexibility and adapt­ ability can be found in transdiagnostic (e.g., barlow et al., 2017) and modular (e.g., weisz & chorpita, 2012) treatments, which explicitly instruct therapists to select from a menu of potential strategies and sequence them in different ways, and for different du­ rations, from patient to patient. in addition, approaches to integrating model-exogenous strategies into cbt have been proposed and tested (e.g., constantino et al., 2008). such approaches are consistent with the emerging evidence base and are likely to be more consistent with how therapists operate in routine practice (weisz & chorpita, 2012). however, the field has been slow to adopt coinciding training methods. an underlying feature of evidence-informed flexibility and adaptation is the metacompetency of responsiveness (castonguay et al., 2023). such action involves responding appropriately to the clinical context, both at the start of treatment (e.g., selecting the most suitable initial intervention) and during sessions in key moments (e.g., when a patient feels micro-aggressed against; constantino et al., 2023). for clinical training and practice, both preand within-treatment responsiveness imply an if-then decision-mak­ ing scheme (e.g., if a patient presents with these characteristics, then begin treatment with this cbt module; if a patient views a cbt intervention as low in credibility, then boswell, constantino, gaines, & smith 3 clinical psychology in europe 2024, vol. 6(special issue), article e11967 https://doi.org/10.32872/cpe.11967 https://www.psychopen.eu/ shift to a different cbt strategy or to a different therapy that has a more personally credible rationale). one training framework that privileges such if-then decision-making is context-responsive psychotherapy integration (crpi; constantino et al., 2013, 2023). context-responsive psychotherapy integration to guide clinical training and practice, crpi supports the use of timely evidence-based strategies that can be employed in response to the identification of specific and com­ monly occurring treatment markers (constantino et al., 2020, 2023). these markers can include patient characteristics and within-session processes, which sometimes call for “staying the course” (e.g., when a current strategy is mutually agreed upon and achieving the expected or intended impact) or doing something deliberate and possibly different when particular contexts that have established relevance for patient outcomes present themselves. such contextual markers have been, and can continue to be, identified through research and systemic clinical observations. for example, some clinical scholars have identified the following notable candidate “if” markers that may indicate a need to “then” engage in a clinical departure (either temporarily or more permanently): alliance ruptures, low patient motivation or change ambivalence, diminished patient outcome expectation, missed cultural opportunities or missteps, and not-on-track signals from routine outcomes monitoring (rom) (constantino et al., 2013, 2020; constantino, goodwin, et al., 2021; constantino et al., 2023). example candidate markers and responses alliance rupture-repair the quality of the therapeutic alliance is a well-recognized contributor to treatment outcome across different psychotherapies for various mental health concerns (flückiger et al., 2018). alliance ruptures reflect negative shifts in the patient-therapist bond or collaboration and are associated with maladaptive treatment processes and outcomes (eubanks et al., 2018). rupture markers are thought to typically fall into one or both of two categories: withdrawal or confrontation (both of which can be overt or covert). thus, to be engaging in evidence-based practice beyond the aforementioned delivery of ests, therapists must be equipped to recognize potential rupture markers (if) and re­ spond to them skillfully (then)—which may often require at least a temporary departure from the existing treatment plan (especially one that is not centered on interpersonal processes within the patient-therapist relationship). theory and research point to some core resolution strategies, such as inviting patients to discuss potential problems in the relationship, exploring and validating patients’ experience of the rupture, and taking at least partial responsibility for the rupture (constantino et al., 2008; eubanks et al., 2018). these strategies are core components of alliance-focused training (eubanks-carter et al., process markers in therapy training and practice 4 clinical psychology in europe 2024, vol. 6(special issue), article e11967 https://doi.org/10.32872/cpe.11967 https://www.psychopen.eu/ 2015). contrary to an earlier meta-analysis, eubanks et al. (2018) did not find a statistical­ ly significant effect of rupture-resolution training on patient outcome. however, they examined theoretical model as a potential moderator of the training-outcome association and found that rupture-resolution training was associated with better patient outcomes in cbt-oriented treatments when compared to psychodynamic treatments. missed cultural opportunities or missteps psychotherapy quality disparities exist for patients with underrepresented and historical­ ly marginalized sociocultural identities (e.g., race/ethnicity, sexual orientation, gender, economic, etc., mcguire & miranda, 2008). awareness of and responsiveness to such identities and associated contextual factors is part of evidence-based practice, yet re­ search findings illuminate that patients often experience their therapist as missing the cultural or identity mark (owen et al., 2016, 2018). moreover, patients often view their therapist as engaging in potentially harmful behaviors and microaggressions (hook et al., 2016). consistent with the broader alliance rupture-repair literature, engaging in potentially harmful behavior (of omission or commission) in the absence of acknowledg­ ment and steps to address it is worse for patient outcome than engaging in potentially harmful behavior and making an explicit attempt to address and correct it (yeo & torresharding, 2021). to help guide training and practice in making attempts to redress cultur­ al missteps, the multicultural orientation framework outlines three transtheoretical and transdiagnostic therapist factors/actions: cultural comfort, cultural humility, and cultural opportunities (davis et al., 2018). the latter stresses the ever-present importance of iden­ tifying (if) and responding to (then) culturaland identity-relevant patient characteristics and communications in session. such markers can be present when patients express a belief or value, discuss a role, or mention other personally relevant characteristics (e.g., family customs). owen et al. (2016) found that patients who perceived a higher degree of missed cultural opportunities from their therapist also reported poorer treatment outcomes, yet this negative effect was attenuated when patients perceived the same therapist as possessing above average cultural humility. though in need of further test­ ing, personally tailoring treatment and responding to a patient’s salient (and especially marginalized) sociocultural identities holds promise for better addressing long-standing quality disparities in mental health care. routine outcomes monitoring as another framework for guiding evidence-informed training and practice, rom in­ volves routinely assessing patient progress using standardized tools, and then integrating the feedback from these assessments into treatment decision-making. there is convinc­ ing evidence that the integration of rom feedback into routine psychotherapy enhan­ ces patient improvement relative to routine care without rom feedback (de jong et al., 2021). procedurally, many of the controlled rom feedback-outcome studies have boswell, constantino, gaines, & smith 5 clinical psychology in europe 2024, vol. 6(special issue), article e11967 https://doi.org/10.32872/cpe.11967 https://www.psychopen.eu/ involved systems that alert a therapist when their patient is “not on track” (not) for an expected positive outcome based on predictive modeling. notably, the magnitude of the rom-feedback effect is further enhanced for these not cases. thus, this negative outcome risk signal (if) can prompt the therapist to consider specific actions (then) to address the problem (e.g., learning that a patient has a recently diminished social support network) and get the psychotherapy back on track. evidence indicates that a therapist’s subsequent attention to potentially relevant factors for not cases, such as alliance quality, social determinants, and treatment intensity, further reduces the risk of a negative outcome (barkham et al., 2023). in fact, the relevance of routine monitoring to aid clinical responsiveness extends beyond outcome scales, with some systems moni­ toring and providing valued feedback on process variables, such as the working alliance and motivation (e.g., demir et al., 2022). a focus on such relevant if-then scenarios may require unique and complementary training methods. next, we identify and briefly discuss potential training structures and activities to support crpi implementation. training activities although a comprehensive review of the crpi framework and its implementation is beyond the scope of this article, we comment briefly on potential training structures and foci. process research findings are the foundation of crpi, including what is known about clinically relevant markers and the responsive clinical strategies that typically optimize outcomes. taking alliance rupture-repair as an example, one must learn how to identify rupture markers and then repair them. we conceive of this if-then scenario as a potential training module. psychotherapy courses and practica could be designed to cover a series of such modules (e.g., rupture identification and resolution training), which could be delivered in efficient doses that heighten their appeal to trainees. in addition, these training modules can be packaged in training videos for use by licensed professionals as part of continuing education. we now provide a few select examples of potential training activities. training on first-step responsiveness addressing this first form of responsiveness, one key task is for trainees to become at least conversational on key principles and strategies from as many theoretical models as possible (constantino et al., 2023). this breadth of theoretical and practical knowledge will allow therapists to maximize their ability to flexibly offer personalized therapy directions that a given patient finds credible and inspiring (e.g., one patient may find be­ havioral notions of exposure personally compelling, whereas another may find credible the idea of exploring relationship patterns about which they may be currently unaware). as another key task, trainees should become humbly knowledgeable about their own process markers in therapy training and practice 6 clinical psychology in europe 2024, vol. 6(special issue), article e11967 https://doi.org/10.32872/cpe.11967 https://www.psychopen.eu/ strengths and weaknesses (as grounded in patient outcomes data) in treating specific types of problem domains or using certain types of therapeutic interventions or process­ es. doing so will both allow current personalization to the patient (by matching patients to therapists’ current strengths; constantino, boswell, et al., 2021) and personalization to the therapist (by directing training efforts to fortify strengths and improve weaknesses; coyne et al., 2022). training on timely departures in response to in-session markers addressing this second form of responsiveness, one key task is for trainees to gain proficiency in marker identification. in addition to reading and hearing about markers, training therapists in process coding schemes is a complementary and potentially fruitful training activity that is receiving increased attention (westra & di bartolomeo, in press). an example observational coding system is the rupture resolution rating system (3rs; eubanks et al., 2019), which identifies the presence of within-session alliance ruptures and therapist engagement in resolution strategies. the 3rs can help trainee-therapists learn how to identify rupture markers and their surrounding nuance, and demonstrate therapist resolution attempts, whether good, bad, or ugly. viewing and discussing these behaviors is likely to be a useful training activity, yet it will ultimately need to be augmented to support its translation to trainees’ own clinical practice. to facilitate this translation, deliberate practice methods provide an opportunity for trainees to engage in repeated practice and to receive more direct feedback regarding marker identification and responsive behavior (rousmaniere, 2017). the responsive behavior component re­ flects the second key task in training on timely clinical departures. for example, trainees can both learn and practice pointed theory-driven strategies that have an empirically demonstrated greater likelihood of effectively addressing contextual markers (such as using motivational interviewing to address diminished motivation for change), rather than simply adhering to the original treatment course (e.g., westra et al., 2016, 2021). recommendations and future directions as the field reckons with growing evidence for therapist flexibility over strict model adherence, it stands to reason that research should place more weight on the therapist themselves and the benefit of their timely, in-the-moment interventions. it is notable that psychotherapy process research has uncovered more about potentially facilitative or hindering patient characteristics and behaviors than it has about therapist responses to these contexts (although see ladmanová et al., 2022, for a qualitative meta-analysis of patient identified helpful events). for example, although therapist rupture repair, broadly conceived and measured, is associated with better outcome, we lack more pre­ cise empirical evidence supporting the effectiveness of specific resolution strategies for boswell, constantino, gaines, & smith 7 clinical psychology in europe 2024, vol. 6(special issue), article e11967 https://doi.org/10.32872/cpe.11967 https://www.psychopen.eu/ specific types of alliance rupture. a similar absence of fine-grained if-then empirical evidence exists to guide responsiveness to rom markers, although innovations such as the trier treatment navigator (ttn; lutz et al., 2019) have shown promise to advance both marker detection and intervention selection. furthermore, any shifts in our training models will also need to account for therapist differences in using interventions to beneficial effect, including with “then” responses to identifiable “if” markers; that is, even if everyone learned to notice a key marker, we need to contend with the fact that no one responsiveness strategy is likely to be effective in the hands of all clinicians. this complexity necessitates another thread of future research to match clinician to responsiveness options in order to optimally address negative process. similar challenges can be found on the patient side. for example, in its fullest form, context-responsiveness is concerned with responding to both patient characteristics (e.g., initial treatment selection) and within-treatment markers (e.g., alliance ruptures). it would reinforce uniformity myths in psychotherapy to assume that a particular therapist response will be optimal for all patients with a particular pre-treatment characteristic or all instances of a particular within-session process marker. accordingly, optimizing our training paradigm to align with the realities of real-world practice will require that psychotherapy process research continue to explicitly uncover a range of key contextual markers (for a precedent of such work, see greenberg & watson, 2006) and test the best ways therapists can respond to them. in addition, there is both direct and indirect evidence that even clinically and empiri­ cally well-grounded training interventions can be associated with negative consequences in specific contexts (castonguay et al., 2010). furthermore, the universal trainability of process-acuity related skills, in particular, remains an open question. individual differ­ ences among therapists present a key challenge to training implementation. training methods, such as deliberate practice, emphasize the importance of tailoring the focus and difficulty of training to the individual (rousmaniere, 2017), yet more research on deliberate practice implementation process and outcome is required. the need for more research on training implementation process and outcome is not unique to deliberate practice and remains broadly relevant to preand post-grad­ uate training in psychotherapy (knox & hill, 2021). although the benefit of contextresponsiveness integration has been demonstrated in multiple research studies (e.g., constantino et al., 2008; westra et al., 2016), the feasibility of implementing the crpi framework in routine practice and training contexts remains an open question. as described at the beginning of this article, the prevailing training structures and philoso­ phy represent potential barriers. however, frameworks such as the crpi embrace the inherent complexity and nuance of psychotherapy. although rather speculative, this acknowledgement of complexity may ring truer for therapists, and thus, predict greater openness to adoption. moreover, crpi may have inherent adoption appeal in that the use of focused, timely, and often temporary “then” responses, which can be integrated process markers in therapy training and practice 8 clinical psychology in europe 2024, vol. 6(special issue), article e11967 https://doi.org/10.32872/cpe.11967 https://www.psychopen.eu/ into any foundational treatment being administered, does not require a clinician to dramatically change their professional identity—other than to include that they are an empirically responsive [insert treatment modality] clinician! funding: this work was not based on external funding. there are no funding or financial arrangements to disclose. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have no competing interests to disclose. twitter accounts: @jfboswellphd references barkham, m., de jong, k., delgadillo, j., & lutz, w. 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(2021). rupture resolution strategies and the impact of rupture on the working alliance after racial microaggressions in therapy. psychotherapy, 58(4), 460–471. https://doi.org/10.1037/pst0000372 process markers in therapy training and practice 12 clinical psychology in europe 2024, vol. 6(special issue), article e11967 https://doi.org/10.32872/cpe.11967 https://doi.org/10.1037/ccp0000736 https://doi.org/10.1037/ccp0000538 https://doi.org/10.1002/jclp.22712 https://doi.org/10.1037/a0018912 https://doi.org/10.1037/ccp0000098 https://doi.org/10.1037/pst0000311 https://doi.org/10.1111/cpsp.12218 https://doi.org/10.1037/pst0000372 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. boswell, constantino, gaines, & smith 13 clinical psychology in europe 2024, vol. 6(special issue), article e11967 https://doi.org/10.32872/cpe.11967 https://www.psychopen.eu/ process markers in therapy training and practice (introduction) responsive clinical practice and training context-responsive psychotherapy integration example candidate markers and responses training activities training on first-step responsiveness training on timely departures in response to in-session markers recommendations and future directions (additional information) funding acknowledgments competing interests twitter accounts references loneliness across the covid-19 pandemic: risk factors in norwegian young people research articles loneliness across the covid-19 pandemic: risk factors in norwegian young people mari hysing 1 , keith j. petrie 2 , allison g. harvey 3 , kari-jussie lønning 4,5, børge sivertsen 6,7 [1] department of psychosocial science, faculty of psychology, university of bergen, bergen, norway. [2] department of psychological medicine, university of auckland, auckland, new zealand. [3] department of psychology, university of california, berkeley, ca, usa. [4] modum bad psychiatric hospital, vikersund, norway. [5] the student welfare organization in oslo and akershus (sio), oslo, norway. [6] department of health promotion, norwegian institute of public health, bergen, norway. [7] department of research & innovation, helse-fonna hf, haugesund, norway. clinical psychology in europe, 2023, vol. 5(3), article e10483, https://doi.org/10.32872/cpe.10483 received: 2022-10-17 • accepted: 2023-07-17 • published (vor): 2023-09-29 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: mari hysing, department of psychosocial science, faculty of psychology, university of bergen, post box 7807, 5020 bergen, norway. +47 55 58 86 98. e-mail: mari.hysing@uib.no abstract background: there is evidence of increasing levels of loneliness in norwegian young people before the covid-19 pandemic. it is not clear how the covid-19 pandemic, and the associated necessary restrictions, impacted on these trends. aims: to examine how loneliness in young people changed across the pandemic, how loneliness relates to demographic characteristics and how different pandemic restrictions impacted loneliness. method: we analyzed data from three waves of a norwegian national higher education student survey (the shot-study). data was examined from 2018 from a total of 49,836 students, 2021 from 62,212 students, and from 2022 from 53,362 (response rates 31-35%). loneliness was measured by “the three-item loneliness scale” (t-ils). results: there was a sharp increase in loneliness from 2018 to 2021, and a reduction in levels of loneliness in 2022, although at increased levels compared to prior to the pandemic. females consistently report higher levels of loneliness than males, with a larger difference during the peak of the pandemic. there were higher rates of loneliness in geographical regions with higher covid rates and greater pandemic-related restrictions during 2021. loneliness was lower among students reporting more days on campus in 2021 and for those with lectures on campus in 2022, both with dose-response associations. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10483&domain=pdf&date_stamp=2023-09-29 https://orcid.org/0000-0001-5303-8879 https://orcid.org/0000-0002-6337-2480 https://orcid.org/0000-0002-8609-0005 https://orcid.org/0000-0003-4654-9296 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusions: loneliness is a major public health problem among young adults in higher education. loneliness increased during the pandemic and has decreased but is still not back to prepandemic levels. the results suggest the importance of open campuses and in-person lectures, for increased social connectedness among young people. keywords loneliness, social isolation, mental health, young adult, covid-19 highlights • loneliness increased among university students from 2018 to 2021 and decreased from 2021 to 2022, but was still higher in 2022 than pre-pandemic levels. • loneliness was higher in areas with higher restriction levels in 2021. • spending time on campus was associated with lower levels of loneliness. • online learning was related to higher levels of loneliness. loneliness is often described as a perceived deficiency in social relationships and is asso­ ciated with a number of negative psychological and physical health outcomes (hawkley & cacioppo, 2010). there is growing recognition of loneliness as a significant public health issue with negative effects comparable to risk factors such as physical inactivity, obesity and smoking (holt-lunstad et al., 2017; holt-lunstad et al., 2010) a recent review of the prevalence of loneliness prior to the covid-19 pandemic indicated heterogenous but at substantial levels of loneliness in many countries (surkalim et al., 2022). there is also evidence that loneliness is increasing in young adults. a recent metaanalysis and systematic review of 345 studies of adults aged 18-29 who completed the ucla loneliness scale between 1976 and 2019 found loneliness levels increased linearly each year (buecker et al., 2021). consistent with this pattern, hysing and colleagues (2020) highlighted an increase in loneliness among norwegian fulltime students from 2014 to 2018 with an overall increase in students feeling lonely from 16% to 23%. the study also found males reported the greatest increase in loneliness over time. however, it is not known if this trend continued. based on pre-pandemic studies, the gender differen­ ces in loneliness have been inconsistent. on the one hand, two meta-analyses concluded that males had higher levels of loneliness (maes et al., 2019; mahon et al., 2006). on the other hand, a higher level of loneliness has been observed among women, relative to men, among young adults (wickens et al., 2021). we have previously found that the youngest and oldest students reported the highest levels of loneliness pre-pandemic (hysing et al., 2020), and the youngest may be at an extra risk of loneliness during the pandemic since they may not have established social networks. the covid-19 pandemic in 2020 gave rise to strict social restrictions and government mandated lockdowns in most countries to combat the spread of the virus. in norway there were both national restrictions, and regional restrictions during the pandemic loneliness across the pandemic 2 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ based on covid rates (han et al., 2020). for university students, a range of covid-19 preventive measures impacted their everyday life from social distancing restrictions in the population at large to closed campuses and restrictions on time on campus and reliance on online teaching (han et al., 2020). there were both regional differences in restriction level, but also differences in the transition from online to campus-based teaching when the restrictions were lifted. for university students, these restrictions on social activities and reliance on online education may have set the scene for an even further increase in the rate of loneliness. this is confirmed by unprecedented high levels of loneliness reported among young adults during periods of pandemic restrictions (horigian et al., 2021; padmanabhanunni & pretorius, 2021; sigfridsson & brandt, 2021). the uk covid-19 social study found young adults were at greater risk of loneliness during the pandemic, compared to pre-pandemic. also, being a student was an increased risk for loneliness (bu et al., 2020). similarly, we have previously found that mental health problems were more prevalent among students in areas with a higher level of restrictions for going onto campus and greater online learning (sivertsen et al., 2022). the aim of the present study is to assess changes from prior to the pandemic (2018) to a period of restrictions for students during the pandemic (2021) and after most of the restrictions were lifted (2022). further, we will assess if loneliness levels differ across key sociodemographic groups. given the contradictory findings, we do not have a specific hypothesis regarding gender differences in loneliness. however, we hypothesize that younger students will report higher loneliness levels over time. further, loneliness is expected to be higher in areas with high restriction levels during the pandemic and with more online and off-campus learning. method procedure the shot study (students' health and wellbeing study) is a large norwegian survey of students in higher education, conducted by three large student welfare organizations. five surveys have been completed since 2010. this report is based on the three latest waves, conducted in 2018, 2021 and 2022. the shot 2018 and the shot 2022 were both conducted between february and april. shot 2021 was a briefer version focusing specif­ ically on the covid19 pandemic. shot 2021 was conducted between march and april. all full-time norwegian students pursuing higher education were invited to participate. for shot 2018, shot 2021 and shot 2022, 162,512, 181,828, and 169,572 students fulfil­ led the inclusion criteria, of whom 50,054 (response rate: 30.8%), 62,498 (response rate 34.4%) and 59,554 (response rate: 35.1%) students completed the online questionnaires, respectively. in 2018, only students aged 18 to 35 years were included, while the 2021 and 2022-studies also included students older than 35. to enable comparisons across the hysing, petrie, harvey et al. 3 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ three time points, the current study included students aged 18 to 35 years, yielding final sample sizes of 49,836 (2018), and 62,212 (2021), and 53,362 (2022). detailed information of the shot study has been described elsewhere (sivertsen et al., 2019). data collection and pandemic restrictions in norway, the national and regional restrictions triggered by the covid-19 pandem­ ic changed over time. during the 2021 data collection, there were both national and regional restrictions, and there was mainly online teaching for the students and closed campuses, with some exceptions. for the 2022 data collection, there was still an ongoing pandemic, but the national and regional restrictions had lifted in norway just before the data collection started. still, some restrictions were in place and a hybrid of live and online teaching was offered. statistical analyses ibm spss statistics 28 for windows (spss inc., chicago, il) was used for all statistical analyses. pearson’s chi-squared tests were used to examine changes in the prevalence of loneliness (the three t-ils items) for male and female students separately. the magnitude of gender differences was examined using cohen’s h, which is measure of distance between two proportions (and interpreted similarly to cohen’s d). chi-squared tests were also used to examine the association between loneliness and age group, and levels of campus closure (shot 2021) and online lectures (shot 2022). geographical differences in loneliness (t-ils) in the shot 2021 were examined by computing estimated marginal means, means adjusting for sociodemographic factors (age, sex, relationship status and ethnicity), and covid-19 factors (# of tests, positive test, having been in quarantine). there was generally very little missing data on the included variables across all three waves, and the missing values were handled using listwise deletion. ethics all procedures involving human subjects/patients were approved by the regional com­ mittee for medical and health research ethics in western norway (shot 2018: no. 2017/1176, shot 2021: no. 176205, and shot 2022: no. 326437, respectively). electronic informed consent was obtained after complete description of the study to the partici­ pants. following completion of the surveys, the participants had received detailed infor­ mation about the findings. patient and public involvement the planning and design of all three shot studies were initiated and governed by the three largest student welfare organizations, which included deciding inclusion and exclusion criteria, and selecting potential research questions and instruments. students loneliness across the pandemic 4 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ were not involved in the actual collection of data, although recruitment was conducted in close collaboration with all the student welfare organizations in norway. instruments demographic and covid-19-related information in all three shot studies, the students provided data on their age, gender, relationship status (single versus married/partner/boyfriend/girlfriend) and the education attained by their parents. indication of gender had three response options: “woman,” “man” and “other”. ethnicity was coded as norwegian if the student or his/her parents were born in norway, and “other” for all other countries. based on the geographical location of each educational institution, students were categorized according to norway’s recent county reform, which now includes 10 counties. in the shot 2021 study, all students were also asked how many days they had physically spent on campus during the last 14 days, due to covid-19 restrictions. in 2022, respondents were asked how much of the teaching had been online since fall, 2021. they also reported if they had been tested for covid-19, number of tests, positive test (confirmed by an established test), and whether they had been in quarantine (which typically entails 10 days of staying at home/avoiding social contact). loneliness in all three shot studies, loneliness was assessed using an abbreviated version of the widely used ucla loneliness scale, the “three-item loneliness scale (t-ils)” (hughes et al., 2004). the t-ils items (lack of companionship, feeling left out, and isolation) were each rated along a 5-point scale (“never”, “seldom”, “sometimes”, “often”, and “very often”). the t-ils has displayed satisfactory reliability and both concurrent and discrimi­ nant validity (hughes et al., 2004). more information about loneliness in the shot study has been published elsewhere (hysing et al., 2020). in addition, the shot 2022 study also included a single item assessing to what extent the student felt s/he had enough friends at their campus, with the response options “i have many friends”, “i have some friends”, “i have few friends”, and “i have no friends”. the cronbach’s alphas of the t-ils were 0.87 (2022), 0.84 (2021), and 0.88 (2018). results sample characteristics as detailed in table 1, female students comprised approximately 2/3 of the participants in all surveys. this differs a little from the gender distribution in higher education in norway (around 60% women). the age range is similar across studies (18-35) and the mean age was 23.1 in 2018, 24,1 in 2021 and 24,0 in 2022. about half of the participants hysing, petrie, harvey et al. 5 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ in all three samples reported being single. ethnicity across the three shot samples was also relatively stable, with 8-10% percent being immigrants, defined as either the student or their parents being born outside norway. table 1 sociodemographic and clinical characteristics of the three shot studies characteristics men women total shot 2018 age, mean (sd) 23.4 (3.0) 23.0 (3.0) 23.1 (3.0) gender, % (n) 30.9% (15,399) 69.1% (34,437) single, % (n) 56.2% (8617) 47.5% (16,238) 49.9% (24,855) ethnicity, % (n) norwegian 91.8% (14,137) 92.1% (31,711) 92.0% (45,848) non-norwegian 8.2% (1262) 7.9% (2726) 8.0% (3988) t-ils score, m (sd) 7.13 (3.06) 7.66 (3.05) 7.50 (3.06) shot 2021 age, m (sd) 24.3 (5.0) 24.1 (5.2) 24.1 (5.2) gender, % (n) 34.2% (21,405) 65.6% (40,807) single, % (n) 55.1% (11,777) 48.5% (19,756) 50,8% (31,533) ethnicity, % (n) norwegian 91,3% (19,542) 91.4% (37,305) 91.4% (56,847) non-norwegian 8.7% (1,863) 8.6% (3,502) 8.6% (5,365) covid-19 positive 3.1% (622) 2.8% (1091) 2.9% (1703) t-ils score, m (sd) 8.64 2.98) 9.41 (2.87) 9.15 (2.93) shot 2022 age, m (sd) 24.3 (3.3) 23.8 (3.2) 24.0 (3.2) gender, % (n) 33.6% (17,939) 66.4% (35,423) single, % (n) 44.7% (8023) 51.2% (18,142) 49.0% (26,165) ethnicity, % (n) norwegian 89.6% (16,080) 89.6% (31,741) 89.6% (47,821) non-norwegian 10.4% (1859) 10.4% (3682) 10.4% (5541) covid-19 positive 48.6% (9636) 47.9% (18905) 48.1% (28,541) t-ils score, m (sd) 7.60 3.05 8.23 2.95 8.02 3.00 at the time of the shot 2021 data collection, 2.4% of the sample had tested positive for covid-19, while 48.1% reported having tested positive by the time of shot 2022. loneliness across the pandemic 6 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ changes in loneliness from 2018 to 2022 there was a sharp increase in loneliness across all three t-ils items from 2018 to 2021 (see figure 1 for details). and while the prevalence of loneliness decreased from 2021 to 2022, the levels of loneliness were still higher in 2022 than before the pandemic in 2018. for example, 47.1% of female students reported “often” or “very often” lacking companionship during the pandemic in 2021, while the corresponding estimates before the pandemic (2018) and after pandemic restrictions were lifted (2022) was 24.1% and 29.6%, respectively. this trend was similar for male students too, but as detailed in figure 1 (red diamonds indicating cohen’s h), the gender differences showed that females reported more loneliness in 2021, compared to both 2018 and 2022. figure 1 trend in loneliness from 2018 to 2022 among female and male students in the shot study note. red diamonds represent gender differences expressed as cohen’s h. age differences in loneliness figure 2 shows the prevalence of the three loneliness items across the different age groups in the shot 2021 and shot 2022 studies. as indicated by the dotted trend lines, there was a significant curvilinear relationship (all ps < .001) on feeling left out and isola­ ted; both the youngest and oldest age-groups reported higher levels of feeling left out and feeling isolated (see figure 2 for details). for the item on lacking companionship, the trend was more linear; the younger the student – the more they lacked companionship. the magnitude of differences between 2021 and 2022 was largest for feeling isolated and lacking companionship, with cohen’s h effect sizes of around 0.4 and 0.3, respectively. hysing, petrie, harvey et al. 7 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ figure 2 loneliness and age group (in men and women combined) in the shot 2021 and shot 2022 studies note. red diamonds represent differences between 2021 and 2022 expressed as cohen’s h (with 95% confidence intervals). geographical differences in 2021 there were large geographical differences in covid-19 cases, as displayed in figure 3; panel a. in march 2021, the south-eastern region surrounding the capital of oslo and parts of northern norway had substantially more covid-19 cases compared with other areas in norway. as displayed in figure 3; panel b, there were also large geographical variations in terms of imposed covid-19-related restrictions in march 2021. as expec­ ted, the strictest measures (marked in red) followed the same geographical distribution as the covid-19 cases. although the shot waves in 2018 and 2022 found no geograph­ ical differences in loneliness (data not shown), the 2021 survey revealed significant geographical differences in adjusted levels of loneliness during the data collection in march 2021. as displayed in figure 3; panel c, students studying at an institution in the south-eastern region (marked in red) and parts of northern norway (marked in orange), reported significantly more loneliness compared with other geographical regions, after adjusting for sociodemographic-related and covid-19-related factors. loneliness and campus closure in 2021 figure 4 displays the association between loneliness and campus closure in the shot 2021 study. there was a significant negative dose–response association between all three t-ils items and days spent on campus. students spending 7+ days on campus during the last 2 weeks, reported significantly less loneliness during this period, compared with students who were not permitted on campus, after adjusting for sociodemographic and covid-19-related factors. the trend was similar for both male and female students. loneliness across the pandemic 8 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ figure 3 geographical differences in number of positive covid-19 cases (panel a), covid-related restrictions (panel b) and loneliness prevalence (with 95% confidence intervals) in the shot 2021 study (t-ils; panel c) note. data for all three figures are based on the situation in march (only) 2021. sources: a–b: the norwegian institute of public health. $ estimated loneliness prevalence (any of the three t-ils items “often” or “very often”), adjusting for sociodemographic and covid-19 factors (# of tests, positive test, quarantine). figure 4 loneliness by campus closure due to covid-19 in the shot 2021 study note. red diamonds represent gender differences expressed as cohen’s h. hysing, petrie, harvey et al. 9 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ loneliness and remote learning in 2022 as displayed in figure 5, there was also a significant dose–response association between all loneliness items and the use of online lectures in 2022. students who had their physical classes replaced by online lectures in 80-100% of the time since august 2021, reported significantly more loneliness compared to students who had more in person teaching. this graded association was present for all t-ils items, but was especially strong for the item assessing to what extent students lacked friends at their place of study. for example, among female students who had predominantly remote learning, 49.8% reported having “no” or “few” friends, compared to 35.1% among those who had less than 20% of online lectures. the trend was similar for male students. figure 5 loneliness and lack of friends by degree of digital lectures in the shot 2022 study note. red diamonds represent gender differences expressed as cohen’s h. discussion the study showed a significant increase in loneliness during 2021 compared to the 2018 pre-pandemic shot survey. the level of loneliness was highest in regions with high covid-19 associated restrictions in 2021 and among those students who did more remote learning, as well as among the youngest students. the 2022 shot study showed loneliness reduced significantly from 2021 but was still higher relative to pre-pandemic levels. females consistently showed higher levels of loneliness, relative to men, with these gender differences increasing during the pandemic. prior research has suggested loneliness across the pandemic 10 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ that higher levels of loneliness in females may be due to a greater sensitivity of females to interpersonal relationships starting at adolescence (maes et al., 2019). further, the increased rate of mental health problems for women during the pandemic was partly explained by loneliness, underscoring the adverse consequences of loneliness (dotsikas et al., 2023) together, these results confirm the higher levels of loneliness during the covid-19 pandemic experienced by young adults that have reported in previous studies (horigian et al., 2021; padmanabhanunni & pretorius, 2021; sigfridsson & brandt, 2021). similar levels have also been found in the general population during the pandemic (ernst et al., 2022). the increase in loneliness, with a twofold increase in some items that comprise the loneliness measure, confirms young adults are at high-risk group for loneliness. the rise in off campus online lectures seems to have been particularly difficult for female students, who reported feeling more socially isolated and lonely than students who were less affected by campus restrictions. the results confirm a trend of loneliness as an increasing public health concern (lim et al., 2020), given that the level of loneliness has shown a gradual increase from 2010 until 2022, in addition to the time limited peak during the pandemic (hysing et al., 2020). still, a meta-analysis has shown lower rates of loneliness among northern european countries compared to other geographical regions, and thus this may indicate that loneliness rates are even higher in other countries (surkalim et al., 2022). the high rate of loneliness is especially worrisome given it is an established risk factor for both mental and physical health problems in this age group (christiansen et al., 2021). consistent with this finding, the increase in depression symptoms observed in a study of young adults may be due to this the rise in loneliness (horigian et al., 2021). although beyond the scope of the present study, future studies should investigate how loneliness is associated with later mental and physical health in young adults. the unprecedented high levels of loneliness among young adults in higher education seem to be driven largely by the restriction levels which impacted on the formation of normal friendship patterns. this is in line with previous studies which have found higher levels of loneliness among students during lockdown periods in comparison to times with less restrictions (macalli et al., 2022) the regional differences in loneliness related to the impact may be accounted for by a range of restrictions, both restrictions directly related to being a student, such as campus lock downs and online teaching, but also on more general restrictions on social contact. still, the dose-response associations between days on campus in 2021, and similarly to online teaching in 2022, raises the potential importance of live face-to-face instruction on student’s loneliness. this may be especially important to establish social relationships in the class and student group, which is indicated by the strong association between the proportion of online teaching and having friends at the study site. hysing, petrie, harvey et al. 11 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ the strength of the present study is that the surveys are similar in inclusion and recruitment across the three data collections and have identical measures of loneliness. the results should be interpreted in light of some limitations. the attrition rate is high across the health surveys with no information about non-participants other than age and gender. we cannot exclude the possibility of selective attrition among those with health problems. also, it is possible that students who a particularly lonely may not participate. if so, the results might have underestimated the true level of loneliness in the population. the loneliness measure is a well-validated and commonly used assessment of loneliness, but it is an indirect measure and does not ask the participants directly if they fell lonely as has been done in some previous studies (wickens et al., 2021) further, the data collection has been done at set time points, and more frequent assessments could have given more detailed information about stability and changes in loneliness across the pandemic and restriction levels. regarding the reported rates of covid-19, these are uncertain and could be an underestimation due to the lack of testing and confirmation of covid-19. the current results confirm the adverse public health consequences of the covid-19 pandemic and related pandemic restrictions. in norway, higher education was one of the domains with high levels of restrictions (helsingen et al., 2020). when governments and health officials are making decisions regarding restrictions, the results underscore the need to consider the adverse psychological consequences of restrictions in addition to direct health impact. the study helps to identify high risk groups and predictors of loneliness that could inform policy and interventions to reduce harm in these groups. further, the results of the present study confirm loneliness as a major public health concern among young adults in higher education and interventions in these settings may be needed. the youngest students were at higher risk, and this indicates the importance of supporting young adults in establishing a social network during the transition to universityand college life. there are available and effective interventions to reduce loneliness, however, they have mainly been tested in high risk groups and with individ­ ual or group based approaches (eccles & qualter, 2021). there are still relatively few interventions to reduce loneliness among young adults (hawkley et al., 2022). identifying predictors of loneliness among young adults may also give insights into how we can reduce loneliness by systemic changes. for instance, finding the right balance between online teaching and physical presence for students may be areas that need to be consid­ ered both in response to future pandemic restrictions and when planning for teaching in higher education post pandemic. at present, higher learning institutions are redesigning their teaching to find the balance between in-person and digital presence, and preventing loneliness and establishing social relationships is an important aspect to consider. loneliness across the pandemic 12 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://www.psychopen.eu/ funding: shot 2022 was supported by the norwegian ministry of education and research (grant number: n/a) and the norwegian ministry of health and care services (grant number: n/a). acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: none of the authors have any competing interest. references bu, f., steptoe, a., & fancourt, d. 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(2021). the unbearable loneliness of covid-19: covid-19-related correlates of loneliness in south africa in young adults. psychiatry research, 296, article 113658. https://doi.org/10.1016/j.psychres.2020.113658 sigfridsson, a., & brandt, h. (2021). loneliness among a sample of swedish university students during the covid-19 pandemic [master’s thesis, umeå university, umeå, sweden). https://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-183318 sivertsen, b., knapstad, m., petrie, k. j., o’connor, r., lønning, k. j., & hysing, m. 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(2019). cohort profile: the shot-study, a national health and well-being survey of norwegian university students. bmj open, 9(1), article e025200. https://doi.org/10.1136/bmjopen-2018-025200 surkalim, d. l., luo, m., eres, r., gebel, k., van buskirk, j., bauman, a., & ding, d. (2022). the prevalence of loneliness across 113 countries: systematic review and meta-analysis. bmj, 376, article e067068. https://doi.org/10.1136/bmj-2021-067068 wickens, c. m., mcdonald, a. j., elton-marshall, t., wells, s., nigatu, y. t., jankowicz, d., & hamilton, h. a. (2021). loneliness in the covid-19 pandemic: associations with age, gender and their interaction. journal of psychiatric research, 136, 103–108. https://doi.org/10.1016/j.jpsychires.2021.01.047 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. hysing, petrie, harvey et al. 15 clinical psychology in europe 2023, vol. 5(3), article e10483 https://doi.org/10.32872/cpe.10483 https://doi.org/10.1136/bmjopen-2021-057492 https://doi.org/10.1136/bmjopen-2018-025200 https://doi.org/10.1136/bmj-2021-067068 https://doi.org/10.1016/j.jpsychires.2021.01.047 https://www.psychopen.eu/ loneliness across the pandemic (introduction) method procedure instruments results sample characteristics changes in loneliness from 2018 to 2022 age differences in loneliness geographical differences in 2021 loneliness and campus closure in 2021 loneliness and remote learning in 2022 discussion (additional information) funding acknowledgments competing interests references four versions of transtheoretical stances, and the bernese view scientific update and overview four versions of transtheoretical stances, and the bernese view franz caspar 1 , thomas berger 1 [1] department of clinical psychology and psychotherapy, university of bern, bern, switzerland. clinical psychology in europe, 2024, vol. 6(special issue), article e12453, https://doi.org/10.32872/cpe.12453 received: 2023-07-23 • accepted: 2023-08-31 • published (vor): 2024-04-26 handling editor: wolfgang lutz, department of psychology, university of trier, trier, germany corresponding author: franz caspar, department of clinical psychology and psychotherapy, university of bern, fabrikstr. 8, ch 3012 bern, switzerland. phone: 0041 31 631 47 31. e-mail: franz.caspar@unibe.ch related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract a brief characterization of transtheoretical stances to which existing approaches can be allocated is followed by a description of the "bernese view", that is, what klaus grawe and his colleagues, including the authors of this article have developed: the origins, a model of the multiple constraint satisfaction construction of therapist action, a discussion of psychotherapy integration, the crucial role of supervisors in an integrative multiple constraint satisfaction approach, and a discussion of when and how trainees should be introduced to a transtheoretical stance. keywords transtheoretical, psychotherapy integration, multiple constraint satisfaction, individualization, supervision this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12453&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0003-2595-2975 https://orcid.org/0000-0002-2432-7791 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • various understandings of transtheoretical exist. • two differences are particularly important: the degree to which theories are integrated, as opposed to conveyed/used as separate approaches, and the striving for "the" right approach vs. emphasizing that we should rather expect and further a neverending process. • a concept of satisfying multiple constraints in the moment to moment construction of therapist action is more realistic than adapting standardized procedures. • using multiple theoretical concepts is advantageous in the endeavour of offering an optimally fitting psychotherapy. your personal preference let's assume you have (or a person you really care about has) a major psychological problem. your problem may fit into a diagnostic category (such as major depression, or one or the other kind of anxiety disorder) or not, in any case, in the individualized as­ sessment of problems and treatment goals (goal attainment scaling; kiresuk et al., 2014), the reduction of depression (or anxiety) would appear as secondary or third treatment goal only. more concerned you are about the fact that you have severe conflicts with your adolescent children, or being treated badly at work. the work-related problems you see as a consequence of mobbing. let's also assume that as a psychotherapy-interested person, you are informed about the approximative contribution to outcome of a specific approach, the therapist, and the relationship. still, you are also aware that these are averages, while for the individual patient, a detail may make all the difference. let's assume that you are also familiar with research showing that professional top performers in general, are contextually oriented. that is, they consider a wealth of circumstances before and while they act (caspar, 2017), and this is in line with your own professional experience in a different field. what kind of treatment and what kind of therapist would you look for? let's leave this question open at the moment. four transtheoretical stances while many variations are possible, we see four major ways in which a therapist or training program can be transtheoretical: 1. learn several approaches to psychotherapy (e.g., psychodynamic and behavioral) in parallel or sequentially and practice somehow based on a limited number of pure approaches. transtheoretical stances, and the bernese view 2 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://www.psychopen.eu/ 2. strive towards the one coherent approach that integrates several existing approaches to psychotherapy. 3. use elements of various origin in an integrative way while maintaining the view that various approaches should maintain differences, as this is a precondition for an ongoing dialectical process in which many therapists and researchers actively participate. 4. start with a particular, ideally already integrative, approach, then strive for continuous development, integrating further conceptual and practical elements not only from existing approaches to psychotherapy, but also basic science. not only integrating what appears useful but also dealing with contradictory concepts and evidence. the first version, while open beyond one single approach, sticks to a view of the world of psychotherapy as divided into approaches. the stance is practiced in institutions seeing themselves as transtheoretical as not one single approach is taught, but if the exchange between these approaches is limited, one might say, it's "transtheoretical light". to the defense of this version, one might say that such a version is based on history, and, after all, somehow complexity needs to be reduced. critically one might say that in this version, the goal of integrating the approaches is not dominating, and the individual therapist is, by and large, left alone with the task of combining conceptual and interven­ tive elements in practice. the second version is attractive for institutes or individuals intending to provide and "sell" the integrative approach in general, or use integration in favor of an approach with more limited claims of validity (such as cbasp for chronic depression; mccullough, 2000). the risk of this variation is that unlike versions three and four, there is a consider­ able chance of petrification and a development to just another approach defending its superiority. the third version is well represented in the society for the exploration of psycho­ therapy integration (sepi). as a sepi steering committee member, one of us (fc) has participated in many discussions about whether sepi should switch to tempting version two and certify therapists as sepi-proved integrative therapists aiming at the gaining of attractiveness. but always those have won who defended the dialectical version three, which is also signaled by the unwieldy name component "exploration of …". as wolfe (2000) states: “… only a minority of sepi members believes it is even possible to develop an integrative psychotherapy theory. even if it were possible, such a theory would not be a great idea, some argue, because it would have a chilling effect on therapeutic crea­ tivity” (p. 234). most colleagues would, while acknowledging the importance of guidance coming from theoretical concepts, agree that none of the existing theories satisfies all needs and preferences (walder, 1993), and that maintaining a variety of approaches may be the best and maybe only antidote against the loss of diversity which may prove useful when it comes to new challenges – analogously to biological diversity and gene pools. caspar & berger 3 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://www.psychopen.eu/ while to some extent compatible with this third version, the fourth version, corre­ sponding to the bernese view, based on grawe's general psychotherapy, seems to incor­ porate most advantages, and will therefore get more space here. the origins of the bernese view in the mid 1970s, grawe and colleagues, working at the hamburg eppendorf university psychiatry hospital, were confronted with patients with mixed diagnoses who were treated in behavioral group therapies. from a technical point of view, therapists did everything right, but some patients did not really engage in therapy and brought various difficulties into the therapeutic relationship. while it was not common at that time to use personality disorder diagnoses, nowadays, many of them would be characterized by such diagnoses. grawe developed a form of case formulation that focused more on the motivational background of problem behavior and its instrumental function. this over­ riding of some of the limits of behaviorism allowed the development of individualized "complementary" strategies in the therapeutic relationship. of influence on his thinking was also the fact that at that time, research on client centered therapy (in which he also had a partial training) showed equally good results as behavior therapy, even with anxiety disorders, which many considered to be a domain of behavior therapy (grawe, 1976). in the early 1980s, caspar developed grawe's "vertical behavior analysis" further with particular respect to the role of emotions and the analysis of the patients' problems. these additions led to a replacement of the name "vertical behavior analysis" with "plan analysis" (caspar, 2018b, 2022). in plan analysis an instrumental perspective is taken: for conscious and non-conscious, interpersonal and intrapsychic behaviors it is asked what purpose or motives they serve. plans are the basic unit of analysis: they consist of a motivational component and means serving this motive. the two-dimensional plan structure represents the whole of inferred strategies of a person, ordered in a hypotheti­ cal instrumental hierarchy with concrete behaviors on the bottom and general needs on top. plan analysis case formulations serve two major purposes: to understand the func­ tioning of patients in the therapy relationship, and the development and maintenance of psychological problems. these can be a consequence of instrumental strategies (e.g., a depression developing when a person avoids leaving home for two years to avoid agoraphobic anxieties), or they can be means serving the solution of problems (e.g. a depression serving the hypothetical purpose of avoiding the conflict in a difficult pro/con decision related to a potential coming out by a homosexual person in a homophobic environment). plan analysis is neutral as far as schools of therapy are concerned, and various approaches to therapy can guide the hypothesis generation: instrumental conditioning: behavior therapy; testing the therapist with challenging behavior in the relationship: psychodynamic control-mastery approach; avoidance of threating emotions transtheoretical stances, and the bernese view 4 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://www.psychopen.eu/ by transformation into emotions that are less threatening on a short by maladaptive on a long range: emotion focused therapy; etc.). in a major rct, a plan analysis based form of broad spectrum behavior therapy has been compared to a form of broad spectrum behavior therapy based on traditional behavior therapy case formulations (lazarus, 1971), and classical client centered ther­ apy without any explicit form of case formulation (grawe, caspar, & ambühl, 1990). plan analysis based therapies fared better in some outcome criteria, but not pervasively, while the process was stunningly more favorable from patient, therapist and observer perspectives. an important feature of this study was that the three rct conditions were not defined in a narrow algorithmic but in a rather heuristic way by prescribing three differ­ ent approaches in terms of case conceptualization while leaving the concrete procedure open as long as it was based on the respective individual case conceptualization. of course, it was considered necessary to know how therapists proceeded concretely, but this was described retrospectively based on video analyses. these showed by far the most technical and conceptual richness in the plan analysis condition, including the reference to psychodynamic and gestalt therapeutic elements. the justification for and advantages of such a heuristic, integration-friendly form of rcts is described in more detail in caspar (2018a), for a recent study related to the assimilative integration of emotion focused elements see caspar et al. (2023). grawe (1998, 2004) termed the classical therapy orientations first-generation ap­ proaches. typical for them is that usually, charismatic founders formulate a coherent approach incorporating theoretical and practical concepts. typically, they reinforce and defend their approach against competing approaches by (over-) emphasizing its advan­ tages and, more often than not, ignoring or suppressing information incompatible with their assumptions, and fostering group thinking: "we, the good and smart ones, own the best concepts and our patients are blessed that they can profit from this. the others are ignorant, ineffective, not thorough enough, even unethical, etc." second-generation approaches, in contrast, are open to dealing with concepts and findings challenging their existing views, and continually strive to deal with evidence, integrating useful parts not only of alternative existing approaches to psychotherapy, but also of insights from basic and applied science. the ideal of reaching a point of saturation is asymptotic, that is, it is never reached, because approaches of psychotherapy ever evolve further, and so does science. this stance has been denominated general psychotherapy. it is not yet another approach with content and techniques, let alone a transdiagnostic model striving to correspond to the second type (see above), but a model for a continuous process with which a holding on to a particular state in the development would be incompatible. the explicit reference to other concepts and approaches, new and old ones, in a continuous process of change, is a bastion for scientific honesty and appreciation for concepts of others, which is a value considered crucial for further development. caspar & berger 5 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://www.psychopen.eu/ grawe has compared first generation approaches to "konfessionen" (german for religious denominations) and entitled a book "von der konfession zur profession" (from religion to profession; grawe, donati, & bernauer, 1998), that is, characterizing the behavior of founders and followers of first generation approaches as unprofessional. the direction of development should, of course, be from confession to profession. it is hard to avoid seeing many developments within the "third wave of behavior therapy" going the other way: "from profession to confession" by uncritically following (more or less charismatic) leaders and believers, who don't justify their actions based on a comprehensive individual case formulation but rather do what their approach suggests: "i'm doing this, because i'm an xy-therapist." for the bernese approach, a clear emphasis was all along on individual case concep­ tualizations as a basis for custom-tailoring the therapy to the patient and the concrete situation on the level of relationship as well as working on the problems. plan analysis captures the recurrent patterns while being open to systematic variations across situa­ tions. the therapist adapts to stable patient characteristics as well as to characteristics and particularities in the moment. grawe (1988) has entitled one article, arguing for a rather heuristic than algorithmic, process-oriented understanding of therapy with "der weg entsteht beim gehen" (the path develops as one walks it). such a view of therapy has been grounded for him and fc in training in humanistic therapies. this corresponds to the idea of "contextual" acting, which is typical for top perform­ ers in various professions (caspar, 2017; see below) and is also seen as a precondition for "responsiveness" in psychotherapy (stiles, 2021). responsiveness (overlapping with the terms personalization and precision psychotherapy) is across orientations one of the most topical issues in the current psychotherapy discussion when asking how we can further improve psychotherapy (see, e.g., programs of international psychotherapy conferences). a model of creative multiple constraint satisfaction a therapist should be contextual, that is, able to include as many relevant properties of the patient and the situation as possible. a model for this we call “multiple constraint satisfaction model of constructing therapeutic action anew” or “creative construction model” (figure 1) the model may appear pretty complex, yet it is assumed to represent what good, experienced therapists include in their construction process. three assumptions are important: transtheoretical stances, and the bernese view 6 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://www.psychopen.eu/ 1. not all aspects are equally relevant in each case and situation: a patient with a straightforward agoraphobia without instrumental function, easy in the therapeutic relationship, requires less multiple constraint satisfaction than average. 2. such a multiple constraint satisfaction process is, once a therapist has practiced it several times in a conscious, step-by-step manner, relatively intuitive. the processes become fast and thus workable. 3. novices can't be expected to master the complexity of all potentially relevant aspects from the outset. it is temporally the supervisor's task to make sure that no crucial aspect gets neglected (see below). figure 1 creative construction model therapist action therapy relationship: possibilities and limitations concrete therapeutic procedures (may come from manuals as prototypes) everyday knowledge disorder specific etiological concepts systemic aspects general knowledge about change patient’s main problem second problem third problem general etiological concepts monitoring: state patient alliance rupture concept monitoring: state therapist therapist personal strengths and weaknesses patient resourcesinstitutional context contextual model of responsiveness basic scientific knowledge balance model supervisor input figure 1 note. model of parallel multiple constraint satisfaction in the construction of therapist action. the brackets at the problems indicate that they are typically interconnected. the list of aspects to be considered is not exclusive (adapted from caspar, 2000, 2022). the development of expertise therapist information processing (hypothesis generation, decision making, etc.) and the development of expertise in such processing has been a main working area of both authors of this article, and cognitive science is seen as providing models and language suitable for neutral transtheoretical reflection and discussion. the question of when caspar & berger 7 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://www.psychopen.eu/ and how in their development psychotherapists can deal with how much complexity is crucial when advocating the described creative construction model vis a vis psycho­ therapy trainees. for an answer, it is obvious to look into the literature on the devel­ opment of professional expertise. there are several phase models for the professional development of therapists. a non-clinical model of high relevance stems from dreyfus and dreyfus (1986). according to them in an initial phase, professionals stick to clear, simple when-then rules, and to relatively simple models. this simplicity is appropriate for their beginning level of development, but the results are at the same time considered to be suboptimal. the experience of limitations with individual tasks/cases is seen as the driving force behind a process of enlarging perspectives as well as concrete procedures. according to the dreyfus and dreyfus model, the subjective confidence first decreases instead of increasing as the therapist gains experience. this is due to the awareness that multiple perspectives are possible, and that the responsibility of the therapist is not only to use rules properly, but also to decide on the right perspective or combination of concepts. in the later stages of professional experience psychotherapists develop an ease and efficiency in the form of a good combination of rationally and intuitively knowing what is right, a process which is expected to take about 10 years (caspar, 2017; ericsson, krampe, & tesch-römer, 1993), and leads to the ability to and practice of including a big number of aspects, or contextuality. psychotherapy integration the advantage of psychotherapy integration is obvious from the perspective of a model of continuously constructing therapist action anew: widening the perspective and the tool-box, and breaking free from the limitations of one single approach is supposed to increase the a priori chance of finding the optimal view and procedure in the sense of maximal desired main and positive side effects, accompa­ nied by minimal negative side effects. all possible procedures have negative side effects, sometimes relatively harmless, but often more severe. the more flexibility, the higher the chance to succeed with an optimal main/side effects balance – unless the therapist fails in mastering the complexity. (caspar, 2010, pp. 18-19) this chance for optimizing psychotherapy is fertile ground for psychotherapy integra­ tion—acknowledging the limitations of each narrow approach when it comes to explain­ ing and treating complex individuals—and for theoretical pluralism (caspar, 2008, p. 77; caspar & grawe, 1989). in germany, beginning some 35 years ago, when training was still less formalized, there has been a trend among employers to prefer therapists who have had at least partial training in more than one orientation (e.g., behavior therapy transtheoretical stances, and the bernese view 8 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://www.psychopen.eu/ plus gestalt, or plus some psychodynamic elements). since training has been regulated by law, there seems to be more identification with and concentration on one approach, but trainings usually include some elements from other approaches. formally, however, integration is forbidden in the strongly approach-oriented regulation of psychotherapy practice in germany (caspar, 2008). in reality, the process of integration begins early: in a poll of 78 trainees undertaken for caspar (2010) in a convenience sample of participants in postgraduate cbt training in switzerland and germany, a majority reported that their supervisors also proposed non-cbt-concepts, and even more frequently that they proposed non-cbt interventions. "when the supervisees brought in such concepts/interventions they felt strongly sup­ ported by their supervisors. the trainees reported furthermore that the inclusion of non-cbt elements was useful for the individual therapies, and they reported with over­ whelming clarity that this inclusion increased their therapeutic expertise" (caspar, 2010, p. 18). the crucial role of supervisors in such an opening up, supervisors are of crucial importance, and their tasks are mani­ fold: to help the trainees recognize their development, to encourage and guide the search for appropriate concepts and procedures, to give support in tolerating ambiguity and complexity, to give feedback and guidance with case formulations, to help with procedures the therapist had not originally learned, including role playing with the therapist to teach a technique, to stabilize the therapist when s/he becomes temporarily desperate, but also to challenge when a supervisee avoids relevant interventions due to personal anxieties. halgin (1985) has formulated that “supervisors play a critical role in escorting beginners through their experiences of artificial security, subsequent confusion, and onward to a process of integration. the supervisor who pushes a beginner into an inappropriate affiliation with a singular model is really col­ luding with the beginner’s simplistic notion that there might indeed be only one correct way of doing therapy. such a supervisor is not likely to be sensitive to the struggles of the beginner who is trying to make sense of an overwhelming number of theories and techniques. this beginning period in an individual’s professional development provides an excellent opportunity for communicating the importance of developing integrated methodologies, for it is during this period that the individual is most malleable” (p. 560; caspar, 2010, pp. 19-20). caspar & berger 9 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://www.psychopen.eu/ if one assumes "that every patient requires a unique combination of concepts and interventions to best fit and treat the case, things become more complex (fc: than in a narrowly manualized procedure)—and pos­ sibly more integrative. this has implications for the supervisor’s tasks: s/he also needs to supervise the selection and use of these concepts and interventions. castonguay (2000) recommends that a deliberate decision be made as to whether a supervisee wishes to stay within a single therapeutic approach, or to take an integrative perspective. if supervisee and supervisor decide on an integrative stance, concepts and interventions may be chosen from a wide menu." (caspar, 2010, p. 19). if the decision is in favor of "a wide menu", the supervisor's task varies: it "depends on the therapist: it may be to convey concepts a less knowledgeable therapist is unfamiliar with, or it may be to help a therapist overwhelmed by the range of possibilities to sort out, decide, and manage complexity in order to maintain the capacity to act." (caspar, 2010, p. 19). a good supervisor helps a therapist take the issue of fit between therapist and procedure seriously, and then to deliberate. this is not a trivial task, as it may be difficult to decide whether the view and procedure a therapist decides on is completely appropriate and in the interest of a patient, or whether the therapist imposes his or her own preferences on a patient at the disadvantage of the latter." the individualization of the psychotherapy training process has long been proposed (caspar, 1997), but has for a variety of reasons made little progress overall. the extent to which therapists should become integrative as opposed to limiting themselves in the scope of concepts consid­ ered is certainly an aspect which can and should be considered explicitly independent of other aspects of individualization: "in any case, the supervisor should also reflect with the therapist on the extent to which the use of an integrative stance is actually advantageous in comparison with a pure approach. in spite of a general preference for flexibility expressed here, it is important that before an integrative approach is chosen, it must be better for each patient and situation." (caspar, 2010, p. 19). when and how the attitude related to when and how trainees should be confronted with a transtheoreti­ cal stance is clear: one should not spare them from the view that as experience grows, they are expected to gain in transtheoretical knowledge and skills in handling and using this knowledge. yet the point of departure remains an integrative, but coherent approach (psychological therapy, grawe, 2004), it is communicated that they are not expected to transtheoretical stances, and the bernese view 10 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://www.psychopen.eu/ master unlimited complexity, that it is okay to initially be guided by simple rules which give them security and comfort – absolutely essential when they do their first steps as therapists! excellent pre-post effect sizes for novice therapists with patients with a broad range of diagnoses, comorbidity and severity at our outpatient clinic at the university of bern (grosse holtforth et al., 2011) illustrate that such a practice is feasible and does not lead to overburdening, although novices certainly struggle with complexity. now back to the question "what kind of treatment and what kind of therapist would you look for?" whatever further details are considered: we truly hope that you would go for a therapist open to a transtheoretical stance and educated in several approaches, or in useful conceptual and technical elements of such approaches. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references caspar, f. (1997). what goes on in a psychotherapist’s mind? psychotherapy research, 7(2), 105–125. https://doi.org/10.1080/10503309712331331913 caspar, f. (2000). therapeutisches handeln als individueller konstruktionsprozess. in j. margraf (ed.), lehrbuch der verhaltenstherapie (2nd ed., vol. 1, pp. 155-166). hogrefe. caspar, f. (2008). the current status of psychotherapy integration in germany and switzerland. journal of psychotherapy integration, 18(1), 74–78. https://doi.org/10.1037/1053-0479.18.1.74 caspar, f. (2010). supervision from a psychotherapy integration perspective. psychotherapy bulletin, 45(1), 14–18. caspar, f. (2017). professional expertise in psychotherapy. in l. g. castonguay & c. e. hill (eds.), how and why are some therapists better than others? understanding therapist effects (pp. 193-214). american psychological association. caspar, f. (2018a). studying effects and process in psychotherapy for personality disorders. psychopathology, 51(2), 141–148. https://doi.org/10.1159/000487895 caspar, f. (2018b). beziehungen und probleme verstehen. eine einführung in die psychotherapeutische plananalyse (4th ed.). hogrefe. caspar, f. (2022). optimizing psychotherapy with plan analysis. in t. d. eells (ed.), handbook of psychotherapy case formulation (3rd ed., pp. 209-251). guilford. caspar, f., berger, t., grosse holtforth, m., babl, a., heer, s., lin, m., stähli, a., gomez penedo, j. m., holstein, d., egenolf, y., frischknecht, e., krieger, t., ramseyer, f., regli, d., schmied, e., flückiger, c., brodbeck, j., greenberg, l., carver, c. s., castonguay, l. g., kramer, u., auszra, caspar & berger 11 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://doi.org/10.1080/10503309712331331913 https://doi.org/10.1037/1053-0479.18.1.74 https://doi.org/10.1159/000487895 https://www.psychopen.eu/ l., herrmann, i., & belz, m. (2023). the impact of integrating emotion focused components into psychological therapy: a randomized controlled trial. journal of clinical psychology, 79(2), 296– 315. https://doi.org/10.1002/jclp.23421 caspar, f., & grawe, k. 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(1990). die berner therapievergleichsstudie: wirkungsvergleich und differentielle indikation. zeitschrift für klinische psychologie, 19(4), 338–361. grawe, k., donati, r., & bernauer, f. (1998). therapy in transition from faith to facts. hogrefe. grosse holtforth, m., wilm, k., beyermann, s., rhode, a., trost, s., & steyer, r. (2011). differential change in integrative psychotherapy: a re-analysis of a change-factor based rct in a naturalistic setting. psychotherapy research, 21(6), 631–643. https://doi.org/10.1080/10503307.2011.602749 halgin, r. p. (1985). teaching integration of psychotherapy models to beginning therapists. psychotherapy: theory, research, practice, training, 22(3), 555–563. https://doi.org/10.1037/h0085540 kiresuk, t. j., smith, a., & cardillo, j. e. (2014). goal attainment scaling: applications, theory, and measurement. psychology press. lazarus, a. (1971). behavior therapy and beyond. mcgraw-hill. mccullough, j. p. (2000): treatment for chronic depression: cognitive behavioral analysis system of psychotherapy (cbasp). guilford. stiles, w. b. (2021). responsiveness in psychotherapy research: problems and ways forward. in j. c. watson & h. wiseman (eds.), the responsive psychotherapist: attuning to clients in the moment (pp. 15-35). https://doi.org/10.1037/0000240-002 walder, e. (1993). supervision and instruction in postgraduate psychotherapy integration. in g. stricker & j. r. gold (eds.), comprehensive handbook of psychotherapy integration (pp. 499–512). plenum press. transtheoretical stances, and the bernese view 12 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://doi.org/10.1002/jclp.23421 https://doi.org/10.1037/0033-295x.100.3.363 https://doi.org/10.1080/10503307.2011.602749 https://doi.org/10.1037/h0085540 https://doi.org/10.1037/0000240-002 https://www.psychopen.eu/ wolfe, b. e. (2000). toward an integrative theoretical basis for training psychotherapists. journal of psychotherapy integration, 10(3), 233–246. https://doi.org/10.1023/a:1009492728103 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. caspar & berger 13 clinical psychology in europe 2024, vol. 6(special issue), article e12453 https://doi.org/10.32872/cpe.12453 https://doi.org/10.1023/a:1009492728103 https://www.psychopen.eu/ transtheoretical stances, and the bernese view your personal preference four transtheoretical stances the origins of the bernese view a model of creative multiple constraint satisfaction the development of expertise psychotherapy integration the crucial role of supervisors when and how (additional information) funding acknowledgments competing interests references missed opportunities in clinical psychology: what about running factorial design internet trials and using other outcomes than self-report? editorial missed opportunities in clinical psychology: what about running factorial design internet trials and using other outcomes than self-report? gerhard andersson 1,2 [1] department of behavioural sciences and learning and department of biomedical and clinical sciences, linköping university, linköping, sweden. [2] department of clinical neuroscience, karolinska institutet, stockholm, sweden. clinical psychology in europe, 2023, vol. 5(2), article e12063, https://doi.org/10.32872/cpe.12063 published (vor): 2023-06-29 corresponding author: gerhard andersson, department of behavioural sciences and learning, linköping university, se-581 83 linköping, sweden. e-mail: gerhard.andersson@liu.se clinical psychology and in particular research on and implementation of psychological treatments can be regarded as a success story (hofmann et al., 2012). many treatment guidelines and recommendations now acknowledge that psychological treatments can serve as adjuncts to pharmacological treatments, and they are also described as standalone and first-line recommended treatments for mild to moderate psychological prob­ lems and diagnoses like major depression and the anxiety disorders. the reason for this is not based on opinion and consensus (which used to be the case in medicine and psychiatry 100 years ago), but increasingly well conducted research studies inform health care and the practice of clinical psychology. not only controlled intervention studies change practice but also research on mechanisms and processes including self-report measures, brain-imaging and tests of information processing, to give a few examples. in particular, when it comes to cognitive-behavioural treatments (cbt), it can rightfully be argued that there is less need for new studies repeating the same finding that getting cbt is often better than not getting it (there might still be a need to study different psy­ chotherapy orientations like psychodynamic psychotherapy). one way to bring interven­ tion research forward is to use factorial designs in order to discern effective components (watkins & newbold, 2020). as i will return to it has not been possible to obtain large enough sample sizes in regular clinical research to run factorial design trials but the use of the internet and modern information technology has changed this (andersson et al., 2019). this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12063&domain=pdf&date_stamp=2023-06-29 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ are there any problems? but there are problems. being an intervention researcher having done many controlled trials i am aware of the fact that almost all outcome studies in clinical psychology only rely on self-report measures. these are relevant, valid, and sensitive to change and should not be removed from research. a treatment study on say major depression should definitely include a validated measure of symptoms of depression (like for example the beck depression inventory). trials also benefit from adding measures of other constructs like quality of life, health care consumption and sometimes also repeated administration of self-report measures to capture change processes and study mediation. however, what happened to actual behaviour? in my phd i had a trial on older adults with hearing loss including a behavioural test of communication skills (andersson et al., 1995). later when we began doing trials on the internet we included a behavioural approach test in studies on specific phobia (e.g., andersson et al., 2013). more recently i was part of a trial on virtual reality exposure for spider phobia using the standard behavioural approach task (miloff et al., 2019). but with those and a few other exceptions most of the trials i have been involved with have not included any direct observation of behaviour. it is important to note the ecological momentary assessment (ema) very often is just another format for self-report of behaviour. there are exceptions, for example sleep and activity monitoring, but overall modern information technology and smartphones have not been used often as ways to collect behavioural outcomes, in spite of calls for such research (mohr et al., 2017). modern information technology as a way to speed up the process clinical psychology and psychotherapy research overall has benefitted much from tech­ nological innovations and in particular computerized assessments and treatment delivery over the internet. now internet intervention trials can be larger, less costly, reach more people and also suffer less from data loss compared to traditional studies (schuster et al., 2021). as i mentioned it is now also possible to run factorial design trials with better power than used to be the case in traditional face-to-face studies. i will use an example of a factorial design trial in which we both measured and manipulated one crucial aspect of most psychological treatments namely knowledge and the role of learning support. we began studying knowledge acquisition more than 10 years back (andersson et al., 2012), but returned to the topic and were also inspired by harvey and co-workers (2014). in berg et al. (2020) we included 120 adolescents who suffered from mixed anxiety/depres­ sion. they were randomised to one of four treatment groups, in a 2×2 design with two factors: with or without learning support and/or chat-sessions. we did not have a waitlist control group. interestingly and in addition to large improvements overall we found missed opportunities in clinical psychology 2 clinical psychology in europe 2023, vol. 5(2), article e12063 https://doi.org/10.32872/cpe.12063 https://www.psychopen.eu/ that adding learning support (different ways to boost learning of treatment material) lead to larger effects on the beck anxiety inventory (d = 0.38), and also increased knowledge gain (d = 0.42), when compared against the group who did not receive this boost of learning. to our surprise chat-sessions did not have any additional effects. the point here is that knowledge has not been the focus of much research in spite of the fact that in particular cbt focus on psychoeducation and that clients both understand and remember the rationale behind the treatment techniques. my second point is that internet intervention research can speed up our understanding of what works for whom and more rapidly test new ideas by for example adding behavioural outcomes. future hopes for psychologists i hope future research can inform us more about actual behavioural change including cognitive aspects of everyday function. there is so much more to do. to take one exam­ ple, prospective cognition is something we use on a daily basis. examples of prospective cognition can be for example to remember to take medication, call a friend or pick up milk at the grocery store when passing the dairy section in the store. prospective cogni­ tion is most likely crucial for a client who has been in therapy when confronted with an unexpected trigger for anxiety (with avoidance being a likely reaction). the former client then needs to recall and practice what was learned and rehearsed in therapy (which can be years back). surprisingly, this has not been studied much and we basically do not know how important it is for long term outcome following therapy. in conclusion, i hope we can move our field forward by having larger samples, using factorial design and focus more on outcomes that have either been forgotten (behavioural change) or not even studied much (prospective cognition and knowledge). funding: the author is supported by linköping university, sweden. acknowledgments: the author thanks his coworkers and fellow researchers. competing interests: the author has declared that no competing interests exist. references andersson, g., carlbring, p., furmark, t., & sofie research group. (2012). therapist experience and knowledge acquisition in internet-delivered cbt for social anxiety disorder: a randomized controlled trial. plos one, 7(5), article e37411. https://doi.org/10.1371/journal.pone.0037411 andersson 3 clinical psychology in europe 2023, vol. 5(2), article e12063 https://doi.org/10.32872/cpe.12063 https://doi.org/10.1371/journal.pone.0037411 https://www.psychopen.eu/ andersson, g., melin, l., scott, b., & lindberg, p. (1995). an evaluation of a behavioural treatment approach to hearing impairment. behaviour research and therapy, 33(3), 283–292. https://doi.org/10.1016/0005-7967(94)00040-q andersson, g., titov, n., dear, b. f., rozental, a., & carlbring, p. (2019). internet-delivered psychological treatments: from innovation to implementation. world psychiatry, 18(1), 20–28. https://doi.org/10.1002/wps.20610 andersson, g., waara, j., jonsson, u., malmaeus, f., carlbring, p., & öst, l.-g. (2013). internetbased vs. one-session exposure treatment of snake phobia: a randomized controlled trial. cognitive behaviour therapy, 42(4), 284–291. https://doi.org/10.1080/16506073.2013.844202 berg, m., rozental, a., de brun mangs, j., näsman, m., strömberg, k., viberg, l., wallner, e., öhman, h., silfvernagel, k., zetterqvist, m., topooco, n., capusan, a., & andersson, g. (2020). the role of learning support and chat-sessions in guided internet-based cognitive behavioural therapy for adolescents with anxiety: a factorial design study. frontiers in psychiatry, 11, article 503. https://doi.org/10.3389/fpsyt.2020.00503 harvey, a. g., lee, j., williams, j., hollon, s. d., walker, m. p., thompson, m. a., & smith, r. (2014). improving outcome of psychosocial treatments by enhancing memory and learning. perspectives on psychological science, 9(2), 161–179. https://doi.org/10.1177/1745691614521781 hofmann, s. g., asnaani, a., vonk, i. j. j., sawyer, a. t., & fang, a. (2012). the efficacy of cognitive behavioral therapy: a review of meta-analyses. cognitive therapy and research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1 miloff, a., lindner, p., dafgård, p., deak, s., garke, m., hamilton, w., heinsoo, j., kristoffersson, g., rafi, j., sindermark, k., sjölund, j., zenger, m., reuterskiöld, l., andersson, g., & carlbring, p. (2019). automated virtual reality exposure therapy for spider phobia vs. in-vivo one-session treatment: a randomized non-inferiority trial. behaviour research and therapy, 118, 130–140. https://doi.org/10.1016/j.brat.2019.04.004 mohr, d. c., zhang, m., & schueller, s. m. (2017). personal sensing: understanding mental health using ubiquitous sensors and machine learning. annual review of clinical psychology, 13, 23– 47. https://doi.org/10.1146/annurev-clinpsy-032816-044949 schuster, r., kaiser, t., terhorst, y., messner, e. m., strohmeier, l.-m., & laireiter, a.-r. (2021). sample size, sample size planning, and the impact of study context: systematic review and recommendations by the example of psychological depression treatment. psychological medicine, 51(6), 902–908. https://doi.org/10.1017/s003329172100129x watkins, e. r., & newbold, a. (2020). factorial designs help to understand how psychological therapy works. frontiers in psychiatry, 11, article 429. https://doi.org/10.3389/fpsyt.2020.00429 missed opportunities in clinical psychology 4 clinical psychology in europe 2023, vol. 5(2), article e12063 https://doi.org/10.32872/cpe.12063 https://doi.org/10.1016/0005-7967(94)00040-q https://doi.org/10.1002/wps.20610 https://doi.org/10.1080/16506073.2013.844202 https://doi.org/10.3389/fpsyt.2020.00503 https://doi.org/10.1177/1745691614521781 https://doi.org/10.1007/s10608-012-9476-1 https://doi.org/10.1016/j.brat.2019.04.004 https://doi.org/10.1146/annurev-clinpsy-032816-044949 https://doi.org/10.1017/s003329172100129x https://doi.org/10.3389/fpsyt.2020.00429 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. andersson 5 clinical psychology in europe 2023, vol. 5(2), article e12063 https://doi.org/10.32872/cpe.12063 https://www.psychopen.eu/ missed opportunities in clinical psychology (introduction) are there any problems? modern information technology as a way to speed up the process future hopes for psychologists (additional information) funding acknowledgments competing interests references longitudinal associations of experiential and reflective dimensions of meaning in life with psychopathological symptoms research articles longitudinal associations of experiential and reflective dimensions of meaning in life with psychopathological symptoms albert anoschin 1 , michael k. zürn 2 , carina remmers 1 [1] department of psychology, institute for mental health and behavioral medicine, hmu health and medical university potsdam, potsdam, germany. [2] nuremberg institute for market decisions (nim), nuremberg, germany. clinical psychology in europe, 2024, vol. 6(3), article e11381, https://doi.org/10.32872/cpe.11381 received: 2023-02-14 • accepted: 2024-05-06 • published (vor): 2024-09-30 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: albert anoschin, hmu health and medical university potsdam, schiffbauergasse 14, 14467 potsdam, germany. e-mail: albert.anoschin@hmu-potsdam.de supplementary materials: data, materials, preregistration [see index of supplementary materials] abstract background: rather than being rooted in deliberate reflection, the experience of meaning has been shown to evolve from intuitive processes (heintzelman & king, 2013b, https://doi.org/ 10.1007/978-94-007-6527-6_7). accordingly, experiential and reflective dimensions of meaning in life can be distinguished (hill et al., 2019, https://doi.org/10.1080/09515070.2018.1434483). in this preregistered study, we explored how these dimensions are longitudinally associated with psychopathological symptoms. we expected that experiencing more meaning would predict fewer depressive symptoms and fewer personality functioning impairments six months later, whereas reflecting about meaning would predict more psychopathological symptoms. method: a german-speaking sample of n = 388 completed self-report measures assessing meaning in life, depression, and personality functioning at baseline and six months later. results: controlling for depression at baseline, elevated levels of experiencing meaning in life predicted a decrease in depressive symptoms. experiencing meaning did not predict personality functioning impairments six months later. however, exploratory analyses with a larger sample tentatively showed that experiencing meaning in life predicted less impairments in personality functioning. evidence supporting the hypothesized association between reflection and future depression as well as future personality functioning impairments was discerned through exploratory analyses. generalizability of results to clinical care settings is limited due to the this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11381&domain=pdf&date_stamp=2024-09-30 https://orcid.org/0000-0002-9315-1224 https://orcid.org/0000-0002-8614-4464 https://orcid.org/0000-0003-1359-5747 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ studied non-clinical sample. no causal conclusions can be drawn from the data because the study employed an observational design with two assessment points. conclusion: experiencing meaning in life emerged as a potential protective factor against future psychopathological symptoms, whereas exploratory analyses pointed to an opposite relationship for reflection about meaning in life. results are discussed with regard to clinical implications and directions for future research. keywords meaning in life, reflection, depression, personality functioning, longitudinal study highlights • increased experience of meaning in life may contribute to a reduction in depressive symptoms and personality functioning impairments. • preliminary evidence suggests that reflection about meaning is associated with future personality functioning impairments and depressive symptoms. • further investigation of bi-directional relationships between meaning in life and psychopathology is suggested. experiencing one’s life as meaningful is associated with adaptive coping (miao et al., 2017; ward et al., 2023), physical health (czekierda et al., 2017; hooker et al., 2018) and various indicators of psychosocial well-being. these include self-esteem, goal attainment, satisfaction with life and satisfaction with interpersonal relationships (j.-b. li et al., 2021; morgan & robinson, 2013; schultheiss, 2021; soucase et al., 2023). conversely, existential meaninglessness goes along with adverse mental health outcomes, such as depression, suicidal ideation and addictive behaviors (hu et al., 2022; w. li et al., 2020; schnell et al., 2018). are existential crises merely by-products of depression, or is meaning in life a relevant marker that predicts the extent to which a person will suffer from depression in the future? despite its clinical relevance, only few studies have investigated this question longitudinally (dulaney et al., 2018; krause, 2007; mascaro & rosen, 2008; park et al., 2020). for instance, mascaro and rosen (2008) performed a cross-lagged panel analysis with n = 395 students and found that higher levels of meaning were significantly associated with less depressive symptoms two months later. although the authors used multiple instruments to assess meaning in life, they combined these measurements into one ‘global sense of meaning’ factor. a recent account by hill et al. (2019), however, suggests that a core distinction between the reflective and experiential dimension of meaning in life should be made. cross-sectional findings indicate that these dimensions are differentially related to psychopathology (remmers et al., 2023). with the current study, we aimed to investigate the presumably differential contributions of experiencing meaning and reflecting about meaning to future psychological impairment. meaning in life and psychopathology 2 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ experiencing and reflecting on meaning and the association with psychopathology research on meaning in life has so far mostly dealt with the question how people construct meaning (for an overview see park, 2010). this line of research emphasizes that meaning in life is something people must establish actively. however, the subjective sense of life being meaningful may be experienced in the absence of deliberate meaning making (heintzelman & king, 2013b). hill et al. (2019) proposed a framework with two distinct meaning in life dimensions termed experience and reflection, fitting with the idea that experiencing meaning can be dissociated from cognitive occupation with meaning. this conceptualization is in line with dual-process theories of cognition (thompson et al., 2011) that differentiate experiential and affective processing modes from abstract, reflective processing modes. clinical accounts point to a differential adaptivity of these processing modes when faced with stressful experiences (watkins et al., 2008). prior re­ search has shown that the experience of meaning arises from an intuitive process which enables persons to recognize coherent patterns in their experiences and environments (heintzelman & king, 2013a). this intuitive process operates unconsciously, fast and associatively. as a result, intuitions of coherence and meaning are phenomenologically experienced as “knowing something without knowing how one knows” (bowers et al., 1990; topolinski & strack, 2009). given the fast and easy nature of the underlying proc­ ess, detecting coherence automatically feels right (thompson et al., 2011) and positive (topolinski & strack, 2008). when no meaning is found intuitively, a deliberate reflective process may follow (thompson et al., 2011). ironically, trying to find rational explan­ ations why life has meaning may neither be conducive to psychological functioning nor to perceiving meaning on an experiential level (j.-b. li et al., 2021; topolinski & strack, 2008). several studies show that people who report searching for meaning also experience being more depressed, less happy and less satisfied with life (soucase et al., 2023; steger et al., 2006, 2009). in a similar fashion, reflective thought about meaning may be maladaptive in some individuals (watkins & roberts, 2020), because it overrides intuitive meaning cues and disrupts the subjective experience of meaning (remmers et al., 2023; topolinski & strack, 2008). the current study we aimed to determine whether experience of meaning in life and reflection on meaning in life prospectively predict depressive symptoms over a time-period of six months. in a recent cross-sectional study, experiencing meaning was negatively associated with de­ pression, whereas reflecting on meaning showed a positive association with depression (remmers et al., 2023). the aim of the current study was to elucidate such differential relationships longitudinally. if experiencing meaning turns out to be prognostically fa­ vorable for mental health, this would tentatively suggest that practitioners should focus anoschin, zürn, & remmers 3 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ on the experiential level when designing interventions. if, at the same time, a positive longitudinal association between reflection and depression were found, this would sup­ port the view that increased cognitive preoccupation with topics of meaning in life may be detrimental to mental health. we expected that the hypothesized associations would not be specific to depression but generalize to personality functioning impairments as a global indicator of psycho­ pathology. personality functioning refers to a person’s ability to regulate the self and interpersonal relationships. impairments in self-other regulation are to be expected in persons with various psychopathological symptoms (friborg et al., 2014). the construct of personality functioning impairments accommodates recent dimensional conceptuali­ zations of psychopathology (caspi & moffitt, 2018; forbes et al., 2021) and lies at the core of the diagnostic approach to personality pathology in the icd-11 and the alternative dsm-5 model for personality disorders (bach et al., 2020; bach & simonsen, 2021). some authors propose that personality functioning represents the p-factor explaining a general vulnerability for psychopathology (bender, 2019). hypotheses in our preregistered hypotheses, we expected more experience of meaning in life at baseline (t1) to predict less depression and less impairments in personality functioning six months later (t2). conversely, we expected that participants’ propensity to reflect about meaning in life at t1 would be predictive of more depressive symptoms and greater personality functioning impairments at t2. importantly, in all our analyses we controlled for baseline levels of psychopathological symptoms, as we were interested in the unique predictive value of experiential and reflective dimensions of meaning in life. the study design was preregistered prior to follow-up data collection1 (remmers et al., 2022s). method sample participants were recruited via prolific (www.prolific.co), an online participant pool for academic research. all measures were administered online. participants provided informed consent and were compensated for participation. the follow-up study was displayed on the prolific website only to persons who participated in the baseline assess­ ment (n = 1,189; see remmers et al., 2023). these participants could choose to participate 1) note that additional hypotheses regarding the predictive role of intuitive coherence detection for meaning in life and psychopathology were preregistered. as these associations were not of interest for the current thrust, we opted not to report them in the present article. meaning in life and psychopathology 4 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 http://www.prolific.co https://www.psychopen.eu/ at follow-up voluntarily, but were not actively contacted or requested to participate. from the baseline sample, n = 538 participants completed the follow-up assessment (response rate: 45%). in our preregistration we stated that analyses should only include participants who took part within the first two weeks of the baseline assessment. we hereby aimed to keep the time interval constant between baseline and follow-up. confirmatory hypothe­ sis tests reported below pertain to this preregistered sample, which consisted of n = 388 participants. within this analyzed sample (age: m = 27, sd = 9), 69% identified as female, 29% identified as male and 2% identified as non-binary. 33% of the participants had a university degree, 6% had an advanced technical certificate, 52% had a high-school degree, 7% had a secondary school degree and 1% had a lower secondary school degree. since the procedure to only include participants from the first two weeks of the baseline assessment resulted in a loss of statistical power, we decided to relax our preregistered restriction in a second step and conducted further analyses with the total follow-up sample (n = 538). within the total sample, the median interval between base­ line and follow-up assessment was 202 days (range: 164 to 238 days), which corresponds to approximately 6.66 months. the higher-powered analyses with the full sample are reported in the exploratory analyses section. procedure the study was part of a larger research project which was approved by the ethics committee of the freie universität berlin (proposal number 005/2019). baseline (t1) at baseline, participants filled out questionnaires in randomized order, assessing mean­ ing in life, depression and personality functioning impairments. additional self-report instruments and a behavioral task were employed, which were not relevant for the current study and are detailed in remmers et al. (2023). participants were reimbursed immediately after completing the baseline assessment. follow-up (t2) the follow-up assessment was made available six months later for participants who completed the baseline assessment. the same self-report instruments that assessed the meaning in life dimensions and psychopathology were re-applied. measures meaning in life experience of meaning in life and reflection on meaning in life were assessed with the german translation (anoschin et al., 2022) of the meaning in life measure (hill et al., anoschin, zürn, & remmers 5 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ 2019). participants rated their agreement to eight items on a 9-point likert scale (exem­ plary experience item: “i experience my life as meaningful”; exemplary reflection item: “i think about what gives me meaning”). verbal markers were placed at the scale points 1 (“strongly disagree”), 5 (“neutral”) and 9 (“strongly agree”). we computed mcdonald’s ω as reliability estimate, yielding ω = .75 for the experience scale and ω = .85 for the reflection scale. depressive symptoms the german version of the 8-item patient health questionnaire was used to assess presence of depressive symptoms at baseline and follow-up (phq-8; kroenke et al., 2009). participants rated items on a 4-point likert scale that queried depressive symptoms in the past two weeks (e.g., “feeling tired or having little energy”). when used as a screen­ ing instrument, a cutoff point ≥ 10 can be applied to detect current major depression with high diagnostic accuracy (wu et al., 2020). reliability of the phq-8 in the present study was ω = 86. personality functioning impairments we used the level of personality functioning scale brief form (lpfs-bf; spitzer et al., 2021) to assess impairments in personality functioning. participants rated 12 items on a 4-point likert scale (e.g., “i often think very badly of myself”). the measure showed a reliability of ω = .88. systematic dropout to explore systematic dropout, we investigated whether and with respect to which varia­ bles participants (from the first two weeks of the baseline assessment) who participated in the follow-up assessment differed from participants (from the two first weeks of baseline assessment) not participating in the follow-up assessment. we found that partic­ ipants who participated at t2 were significantly older, t(767.39) = 3.85, p < .001; mδ = 2 years, reported less depressive symptoms, t(797.73) = -2.27, p = .024; mδ = -0.9, and less impairments in personality functioning, t(788.46) = -2.48, p = .013, mδ = -1.16. age and psychopathological symptoms were significantly correlated, with older participants reporting a lower burden (r = -.22, p < .001 for phq-8; r = -.24, p < .001 for lpfs-bf). due to this data pattern, and conforming to our preregistration, we conducted regression analyses with a full information maximum likelihood approach (fiml), including age as an auxiliary variable (enders, 2008; graham, 2003). meaning in life and psychopathology 6 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ results descriptive statistics and zero-order correlations for the self-report measures across both time-points are summarized in table 1 and table 2, respectively. descriptive statistics for the full sample are listed in anoschin et al., 2024s, table s1. experience of meaning in life scores (mt1 = 6.05, mt2 = 6.03) were descriptively above the scale midpoint of 5, but lower than scores observed by hill et al. (2019) in two us samples (mstudy1 = 7.45, mstudy2 = 7.13). reflection scores (mt1 = 6.50, mt2 = 6.19) were within a similar range to those observed by hill et al. (mstudy1 = 6.52, mstudy2 = 6.74). we noted a substantial preva­ lence of depressive symptoms in our studied sample. when applying the recommended phq-8 cutoff ≥ 10 (kroenke et al., 2009), 48% of participants screened positive for major depression at baseline, and 43% at follow-up. scores of the lpfs-bf corresponded to norm values of t = 64 at baseline and t = 63 at follow-up, indicating above-average impairments in personality functioning within our sample (spitzer et al., 2021). table 1 descriptive statistics of meaning in life and psychopathology measures (n = 388) measures baseline follow-up m (sd) m (sd) meaning in life experience 6.05 (1.45) 6.03 (1.39) reflection 6.50 (1.57) 6.19* (1.69) depression 9.78 (5.51) 9.02* (4.79) personality functioning 27.15 (6.77) 25.60* (6.90) note. asterisks indicate significant differences in scores between baseline and follow-up assessments (based on paired t-tests, p < .001). meaning in life: scale means of milm (possible range: 1 – 9); depression: scale sums of phq-8 (possible range: 0 – 24); personality functioning: scale sums of lpfs-bf (possible range: 12 – 48, higher scores reflect greater impairment). confirmatory hypotheses testing we preregistered ols regression analyses with two-sided significance tests2 (remmers et al., 2022s). in each model, the dependent variable at t2 was regressed on the independent variable at t1, controlling for effects of the dependent variable at t1. as hypothesized, lower levels of experienced meaning in life at t1 significantly predicted more depres­ sive symptoms at t2 (six months later), controlling for depressive symptoms at t1. in 2) we did not conduct an a priori power analysis because the achievable sample size was limited by the number of persons who participated in the baseline assessment. a post-hoc sensitivity analysis showed that, given our sample size and an alpha error probability of α = .05, an effect size of f 2 = .02 would be required to be detectable with a power of .80. anoschin, zürn, & remmers 7 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ contrast, experienced meaning in life at t1 did not significantly predict impairments in personality functioning at t2. we further hypothesized that higher levels of reflection on meaning in life would be associated with more psychopathological symptoms six months later. however, reflection did not significantly predict future depression nor future per­ sonality functioning impairments when statistically controlling for psychopathology at t1. the results of the regression analyses are summarized in table 3 and table 4. table 3 regression analyses predicting depressive symptoms at t2 from experienced meaning in life and reflection on meaning in life assessed six months prior, at t1 measures t2 depression model 1 model 2 β 95% ci p f2 β 95% ci p f2 t1 depression .641 [.574, .708] < .001 0.601 .680 [.627, .732] < .001 0.846 t1 mil experience -.093 [-.177, -.009] .031 0.014 t1 mil reflection .033 [-.043, .109] .389 0.002 r 2 .477 .471 note. regression analyses are based on observed variables and were computed with the full-information maximum likelihood method using a sample of n = 800 at t1 and n = 388 at t2. age was entered as an auxiliary variable. p statistics are based on two-tailed tests as preregistered. mil: meaning in life (milm; hill et al., 2019); depression: phq-8 (kroenke et al., 2009). table 2 bivariate correlations among study variables for both assessment time points (n = 388) measures 1 2 3 4 5 6 7 8 1. t1 mil experience – 0.19*** -0.48*** -0.58*** 0.69*** 0.12* -0.40*** -0.49*** 2. t1 mil reflection – 0.18*** 0.13* 0.10 0.63*** 0.15** 0.15** 3. t1 depression – 0.69*** -0.44*** 0.12* 0.68*** 0.61*** 4. t1 personality functioning – -0.50*** 0.12* 0.58*** 0.79*** 5. t2 mil experience – 0.17*** -0.47*** -0.52*** 6. t2 mil reflection – 0.10* 0.14** 7. t2 depression – 0.66*** 8. t2 personality functioning – note. mil: meaning in life (milm; hill et al., 2019); depression: phq-8 (kroenke et al., 2009); personality functioning: lpfs-bf (spitzer et al., 2021). *p < .05. **p < .01. ***p < .001. meaning in life and psychopathology 8 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ non-preregistered exploratory analyses for exploratory purposes, we reconducted our analyses including experienced meaning in life and reflection on meaning in life simultaneously as predictors into one regression model. as we aimed to increase power, regression models were computed with the total follow up-sample of nt2 = 538. given this sample size, it would be possible to detect an effect of f 2 = .014 with a power of .80. this procedure resulted in two linear regression models, one with depression at t2 and one with personality functioning t2 as dependent variables. again, t1 levels of psychopathology were entered as control variable and age was entered as auxiliary variable using the fiml approach. exploratory analyses confirmed the negative and significant association of experiencing meaning in life at t1 with depressive symptoms at t2 (β = -.133, 95% ci [-0.205, -0.061], p < .001, f 2 = 0.023), when controlling for reflection and depressive symptoms at t1. in contrast to our preregistered analyses but in line with our hypothesis, experiencing meaning in life at t1 significantly predicted less personality functioning impairments at t2 (β = -.085, 95% ci [-0.156, -0.014], p = .019, f 2 = 0.010), controlled for reflection and personality functioning at t1. furthermore, deviating from the results of the preregistered analysis but in line with our hypothesis, reflection about meaning in life at t1 was now significantly and positively associated with depression at t2 (β = .085, 95% ci [0.021, 0.149], p = .009, f 2 = 0.010), and with personality functioning impairments at t2 (β = .072, 95% ci [0.014, 0.131], p = .016, f 2 = 0.010). regression tables for these analyses are presented in anoschin et al., 2024s (table s2 and table s3). table 4 regression analyses predicting personality functioning impairments at t2 from experienced meaning in life and reflection on meaning in life assessed six months prior, at t1 measures t2 personality functioning model 1 model 2 β 95% ci p f2 β 95% ci p f2 t1 pers. func. .761 [.704, .818] < .001 0.960 .778 [.742, .814] < .001 1.551 t1 mil experience -.042 [-.119, .036] .295 0.003 t1 mil reflection .053 [-.011, .116] .105 0.007 r 2 .616 .617 note. regression analyses are based on observed variables and were computed with the full-information maximum likelihood method using a sample of n = 800 at t1 and n = 388 at t2. age was entered as an auxiliary variable. p statistics are based on two-tailed tests as preregistered. mil: meaning in life (milm; hill et al., 2019); pers. func.: personality functioning impairments (lpfs-bf; spitzer et al., 2021). anoschin, zürn, & remmers 9 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ in a further step, we explored bidirectional effects between experienced meaning in life, reflection on meaning in life and psychopathology. for this purpose, we fitted two separate cross-lagged structural equation models (sem) that included meaning in life experience and reflection at t2 as dependent variables. effects of meaning in life at t1 on psychopathology at t2 were significant and consistent with the exploratory analyses reported above. additionally, the cross-lagged models indicated significant neg­ ative associations between depression at t1 and experience of meaning in life at t2 (β = -.151, 95% ci [-0.223, -0.078], p < .001). depression at t1 was not significantly associated with reflection about meaning in life at t2 (p = .523). similarly, personality functioning impairments at t1 predicted lower experienced meaning in life at t2 (β = -.178, 95% ci [-0.252, -0.103], p < .001), but were not significantly associated with reflection about meaning in life at t2 (p = .085). sems are illustrated in anoschin et al., 2024s (figure s1 and figure s2). discussion in this preregistered longitudinal study, we examined whether experiential and reflective dimensions of meaning in life would uniquely predict psychopathology six months later in a general population sample. participants in our online sample presented with varying levels of depression severity and impairments in personality functioning. as hypothesized, we found that participants who experienced more meaning in life reported fewer depressive symptoms six months later, even after controlling for baseline levels of depression. this observation underscores the potential clinical relevance of meaning in life. it is consistent with research suggesting that a diminished experience of life being meaningful may act as a risk factor for the onset or worsening of depressive symptoms (glaw et al., 2017; steger, 2022). conversely, our data suggests that fostering the experience of meaning in life, even in the presence of depressive symptoms, may aid in symptom reduction over time. assuming that the benefit of experiencing meaning in life extends beyond depres­ sive symptomatology, we hypothesized that a heightened experience of meaning would predict fewer subsequent impairments in personality functioning. our preregistered analyses did not support this hypothesis. however, when relaxing our preregistered constraints and conducting our analyses in a larger sample, we discovered a significant negative association between experienced meaning in life and future personality func­ tioning impairments, aligning with our hypothesis. should this finding be reproducible and robust, it would emphasize that undergoing an existential crisis could not only pose a risk for developing depressive symptoms but may ultimately result in disturbances of self and interpersonal functioning. it must be noted that in regression analyses, symptom severity at baseline explained a large proportion of variance in symptom severity at follow-up. in comparison, the unique meaning in life and psychopathology 10 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ predictive effects of meaning in life on future psychopathology were very small. we suppose that this pattern of results is attributable to conceptual and statistical overlaps between the studied constructs. for example, it is conceivable that core symptoms of depression, such as feeling hopeless, are strongly negatively associated with aspects of meaning in life, such as having a goal in life. hence, the true contribution of meaning in life to the progression of psychopathological symptoms may be underestimated when both variables are entered simultaneously into a regression model. we advise to take into account the substantial zero-order correlations when assessing the clinical relevance of meaning in life for predicting future mental health outcomes (see table 2). in the current study, we focused on potential benefits and drawbacks of meaning in life within the context of prospective psychological impairments. contrasting with cross-lagged findings reported by mascaro and rosen (2008), we also found preliminary evidence for bidirectional effects. personality functioning impairments and depression at baseline were associated with less experienced meaning at follow-up. although this does not confirm a causal relationship, it is conceivable that greater interpersonal and self-regulatory ability may strengthen the experience of meaning in life. potential me­ diators of this effect may be greater positive mood and better satisfaction of basic psychological needs, such as the need for social relatedness (autin et al., 2022; demirbaşçelik & keklik, 2019; martela et al., 2018). the absence of such experiences that occurs in psychopathology is likely to unfold negative prospective effects on the experience of meaning in life. conversely, the experience of meaning in life seems to promote positive mood and adequate self-regulation, thereby protecting against psychopathology (dulaney et al., 2018; miao et al., 2017). future studies should explore in more detail the directional dynamics between selfand interpersonal functioning, need satisfaction, and the experience of meaning. daily diary and experience sampling designs are promising approaches for such endeavor (kaurin et al., 2023). is reflection about meaning harmful? both at baseline and follow-up, more psychopathological symptoms were associated with heightened reflection about meaning in life. this cross-sectional finding suggests that a “low experience, high reflection” pattern might evolve as a trans-diagnostic marker for psychopathology such as depression and impaired personality functioning (see also remmers et al., 2023). this raises the question about prospective effects of reflection. the literature suggests that persons suffering from depression lack experiential sources of meaning, such as fulfilling social contacts, daily routines or elaborated life goals (king & hicks, 2021). this condition may lead them to be more preoccupied with the topic of meaning in life (cohen & cairns, 2012). however, it is unclear whether reflection about meaning contributes to depressive symptoms. although reflection did not emerge as sig­ nificant predictor in our preregistered analyses, exploratory analyses in a larger sample anoschin, zürn, & remmers 11 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ provide preliminary evidence for a positive link between reflection about meaning in life and future psychopathology. ultimately, how one reflects about meaning in life may be more important than how much one reflects about it. for example, it is conceivable that abstract ruminative think­ ing about meaning in life exacerbates depressive symptoms (watkins & roberts, 2020), and such maladaptive cognitive schemas are more likely to be found in persons who already suffer from depression. future studies should therefore explore how reflection about meaning interacts with self-regulatory success when symptom severity, cognitive schemas and maladaptive personality traits are taken into account (kerber et al., 2022). in contrast, reflecting upon practical sources of meaning in daily life may be beneficial for attending to these sources in the future (takano & tanno, 2009; watkins et al., 2008). when reflection is therapeutically guided, it might predate better metacognitive insight into one’s troubles and turn out as an indicator for recovery and reinstatement of meaning (lysaker & klion, 2017). clinical implications whereas experiencing meaning in life was predictive of a lower symptom burden, re­ flection about meaning in life was associated with more psychopathological symptoms cross-sectionally and, to a limited extent, longitudinally. moreover, reflection about meaning in life was not significantly associated with future experiencing of meaning (see table 2 and anoschin et al., 2024s). we tentatively conclude that therapeutic approaches seem promising which encourage individuals to explore new contexts where meaning can be intuitively experienced (hirsh, 2013; shin & steger, 2014). this suggestion is in line with research highlighting the importance of experiential appreciation for meaning in life (kim et al., 2022). one mechanism under discussion through which meaning in life exerts beneficial effects (e.g., dulaney et al., 2018) is the stress buffer hypothesis (he et al., 2023). for instance, eisenbeck et al. (2022) found that meaning-centered coping strategies were the best predictors of lower psychological distress and greater well-being during the covid-19 pandemic. importantly, the authors went beyond mere cognitive aspects when defining meaning-centered coping. they explicitly included behavioral and emotional manifestations of meaning in life, such as life appreciation, pro-sociality and engagement in meaningful activities. therefore, interventions that promote meaningful action may prove effective in the treatment of depression and personality pathology (eakman, 2014; van tongeren et al., 2016). despite being recognized as an important factor for under­ standing the dynamics of psychopathology (steger, 2022), little attention has been paid to the systematic investigation of meaning in life in psychotherapeutic settings. future research should establish how meaning is co-created within a therapeutic relationship (summers, 2001) and how patients may benefit from meaning-centered interventions (e.g., böhmer et al., 2022; breitbart et al., 2015). meaning in life and psychopathology 12 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ regarding reflection about meaning, it must be highlighted that reflection is not syn­ onymous with comprehension. hence, reflection could be misguided in certain contexts, for instance, when it is ruminative (watkins & roberts, 2020). an affective component is strongly implied in the subjective experience of meaning (hicks et al., 2010). therefore, to experience meaning, it might not suffice to abstractly reflect about it. limitations the generalizability of our results to the clinical context is limited because we drew our sample from the general population. notably, an unusually large proportion of our sample reported clinically relevant levels of psychopathology, which could be attributa­ ble to greater psychological distress observed during the covid-19 pandemic (daly & robinson, 2022) or to peculiarities of the online participant pool (ophir et al., 2020). in addition, participants were not actively reminded to take part in the follow-up assessment, and this procedure may have introduced self-selection bias. furthermore, only two assessment time-points were employed, limiting conclusions about temporal dynamics between the investigated constructs. future research should explore in more temporal detail the covariation of experienced meaning, reflection on meaning and psychopathology. for example, ecological momentary assessments (kaurin et al., 2023; steger & kashdan, 2013) may provide much needed empirical insights about within-per­ son mechanisms on a timescale of days or even hours. our conclusions may be further limited by the moderate reliability of the utilized “experience of meaning in life” subscale. future studies could consider longer scales that tend to reach higher internal consistency. additionally, experimental designs should be employed to test causal hypotheses formu­ lated on the basis of the present results. for example, one could induce reflection on meaning in life and compare the effects on measures of affect and well-being between healthy participants and those undergoing treatment. conclusion the present findings imply that the experience of meaning in life could aid in the reduc­ tion of depressive symptoms, and possibly personality functioning impairments over time. conversely, psychopathological symptoms may reduce the experience of meaning in the future, as indicated by exploratory cross-lagged analyses. cross-sectionally, a greater depressive burden is accompanied by increased reflection about meaning in life. our data tentatively suggests that reflection is also longitudinally associated with depressive symptoms and personality functioning impairments. however, further studies are needed to conclude whether reflection may be causally linked to an exacerbation of psychopathological symptoms. scholars and practitioners may be well advised to anoschin, zürn, & remmers 13 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://www.psychopen.eu/ consider the role of both reflective and experiential components of meaning in life for symptom change. funding: this research received funding from the internal grant program (project iff 2022-17) of the faculty of health at witten/herdecke university, germany. acknowledgments: we would like to thank sebastian unger for his help with data collection and conduction of the study. we thank charlotte vetten for assistance with proofreading. competing interests: the authors have declared that no competing interests exist. author contributions: mz and cr conceptualized the study and coordinated the assessment. mz and aa conducted the data analyses. aa and cr drafted the manuscript. all authors critically revised the manuscript and approved the final version to be published. ethics statement: the study was approved as part of a research project by the ethics committee of the freie universität berlin (proposal number 005/2019). reporting guidelines: in writing the manuscript, we followed the jars-quant reporting standards for studies using no experimental manipulation. data availability: the raw data supporting the conclusions of this article is available in an online repository on the open science framework (osf) (see remmers et al., 2024s). supplementary materials the supplementary materials contain the following items: • the preregistration for the study (remmers et al., 2022s) • the raw data supporting the conclusions of the article (remmers et al., 2024s) • additional information: the supplementary file includes descriptive statistics and regression tables for the full sample of n = 538 participants. additionally, it includes exploratory sems testing longitudinal bi-directional associations between meaning in life and psychopathology measures (anoschin et al., 2024s). index of supplementary materials anoschin, a., zürn, m. k., & remmers, c. (2024s). supplementary materials to "longitudinal associations of experiential and reflective dimensions of meaning in life with psychopathological symptoms" [additional information]. psychopen gold. https://doi.org/10.23668/psycharchives.15036 remmers, c., zimmermann, j., topolinski, s., & zürn, m. k. (2022s). intuition and meaning in life in persons with varying level of depressive symptoms and impairments in personality functioning: a follow-up study [preregistration]. osf registries. https://osf.io/3zprc meaning in life and psychopathology 14 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://doi.org/10.23668/psycharchives.15036 https://osf.io/3zprc https://www.psychopen.eu/ remmers, c., zürn, m. k., topolinski, s., zimmermann, j., & anoschin, a. 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(2020). equivalency of the diagnostic accuracy of the phq-8 and phq-9: a systematic review and individual participant data metaanalysis. psychological medicine, 50(8), 1368–1380. https://doi.org/10.1017/s0033291719001314 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. meaning in life and psychopathology 20 clinical psychology in europe 2024, vol. 6(3), article e11381 https://doi.org/10.32872/cpe.11381 https://doi.org/10.1037/a0014678 https://doi.org/10.1080/17439760.2015.1048814 https://doi.org/10.1177/01461672211068910 https://doi.org/10.1037/1528-3542.8.3.364 https://doi.org/10.1016/j.brat.2020.103573 https://doi.org/10.1017/s0033291719001314 https://www.psychopen.eu/ meaning in life and psychopathology (introduction) experiencing and reflecting on meaning and the association with psychopathology the current study hypotheses method sample procedure measures systematic dropout results confirmatory hypotheses testing non-preregistered exploratory analyses discussion is reflection about meaning harmful? clinical implications limitations conclusion (additional information) funding acknowledgments competing interests author contributions ethics statement reporting guidelines data availability supplementary materials references learning a practical psychotherapeutic skill in higher education in sweden: a conceptual paper concerning the importance of constructive alignment when teaching therapeutic alliance politics and education learning a practical psychotherapeutic skill in higher education in sweden: a conceptual paper concerning the importance of constructive alignment when teaching therapeutic alliance ann-sophie lindqvist bagge 1 , rolf holmqvist 2 , therése skoog 1 , malin hildebrand karlén 1 [1] department of psychology, university of gothenburg, gothenburg, sweden. [2] department of behavioral sciences and learning, linköping university, linköping, sweden. clinical psychology in europe, 2024, vol. 6(3), article e12037, https://doi.org/10.32872/cpe.12037 received: 2023-05-25 • accepted: 2024-04-12 • published (vor): 2024-09-30 handling editor: anton-rupert laireiter, university of vienna, vienna, austria corresponding author: ann-sophie lindqvist bagge, department of psychology, university of gothenburg, box 500, s-gothenburg, sweden. e-mail: alb@gu.se abstract background: in addition to theoretical education, clinical psychology programs should include practical skills training. this skill training may be tied to specific assessment and treatment methods; other skills, such as the ability to create a collaborative alliance with patients, are more generic. previous research has shown that the ability to build a therapeutic alliance (ta) is often not systematically taught in clinical psychology programs and it is uncertain how this competence is examined. a lack of competence in establishing ta on the part of the psychologist might diminish the effects of psychotherapy. to meet the bologna declaration, european universities need to demonstrate constructive alignment, i.e. a relationship between elements of the course content and intended learning outcomes in course documents, and show how the acquired knowledge, abilities, and approaches are assessed. method: this conceptual paper reviewed the syllabuses for universities in sweden offering the five-year clinical psychology program to illustrate how higher education in sweden adheres to the bologna recommendation on constructive alignment when teaching ta to future clinical psychologists. results: only two universities out of all eleven universities in sweden offering a psychology program described satisfactory constructive alignment concerning ta. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12037&domain=pdf&date_stamp=2024-09-30 https://orcid.org/0000-0001-7932-8233 https://orcid.org/0000-0003-2093-2510 https://orcid.org/0000-0001-7456-2397 https://orcid.org/0000-0002-2170-3317 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: this conceptual paper raises awareness of the importance of pedagogic structure when teaching ta in higher education by pointing to the prevailing lack of constructive alignment in teaching ta. the increased awareness will hopefully lead to improved structuring in the teaching of ta. keywords constructive alignment, clinical psychology training, psychology education, therapeutic alliance highlights • shortcomings in ta training may reflect broader challenges in psychotherapy education across european universities. • ta training should be a core element of future clinical psychology program curricula. • european institutions are encouraged to integrate ta training consistently into curricula and ilos. background research and theoretical reflection about the significance of general relational factors in contrast to more specific techniques and methods in psychological treatment have been in focus for decades (norcross & wampold, 2019). recent theoretical and empirical work indicates a complex interaction between specific and general relational factors for patient outcomes (heinonen & nissen-lie, 2020; lorenzo-luaces & derubeis, 2018; uhl et al., 2022; webb et al., 2010). considering the importance of relational factors, it is interesting that professional training and clinical experience do not seem to improve the competencies needed to increase patient outcomes (christensen & jacobson, 1994). hayes and colleagues (2022) recently commented on “the paradox that experience in psycholog­ ical intervention reliably leads to increases in confidence but not in competence” (p. 19). in parallel with this discussion, the issue of the significance of therapists’ adhering to treatment integrity has also evoked research interest. although the findings on this issue are heterogeneous, it seems apparent that general relational factors contribute substantially to patient change (heinonen & nissen-lie, 2020; uhl et al., 2022; webb et al., 2010) the question of how to combine technique with relational competence is complex (seewald & rief, 2023). studies on facilitative interpersonal skills (fis; anderson et al., 2016) have shown that factors like a therapist’s capacity for establishing warmth, persuasiveness, hopeful­ ness, and ability to create an alliance and repair problems are associated with more positive treatment outcomes. bennett-levy summarized recent studies about the role of the therapist by stating that effective therapists are characterized by “the relational qualities and skills associated with alliance building and maintenance, and cognitive and emotional personal qualities such as resilience, mindfulness, tolerance of ambigui­ teaching of therapeutic alliance 2 clinical psychology in europe 2024, vol. 6(3), article e12037 https://doi.org/10.32872/cpe.12037 https://www.psychopen.eu/ ty, self-confidence, healthy self-doubt, capacity for self-reflection and self-awareness” (bennett-levy, 2019, p. 141). therapeutic alliance (ta) the most studied relational factor is the therapeutic alliance (ta) (bordin, 1979; wampold, 2015). the usual definition implies that ta consists of three components: (1) goal – the therapeutic purpose, (2) task – the therapeutic process, and (3) bond – the therapeutic relationship (bordin, 1979). the creation of the alliance can be seen as a joint effort by the patient and therapist. the alliance contributes significantly to the effects of psychotherapy (flückiger et al., 2018). the explicit aspect of ta concerns agreement and negotiations about goals and tasks, whereas the bond aspect of ta comprises the patient's emotional ties to the therapist and the therapist's empathetic ability and involvement in the patient's situation (summers & barber, 2003). a meta-analysis (del re et al., 2021) concludes that average differences between therapists in the alliance with their patients have a stronger influence on outcomes than differences between patients within therapists. this finding underscores the importance of stimulating therapists to improve their ability to create constructive cooperation with the patient. studies have shown that the quality of the ta contributes to treatment outcomes (flückiger et al., 2018; summers & barber, 2003). a two-stage individual meta-analysis showed reciprocal within-patient correlations between higher ratings of alliance and lower symptom load in the first seven sessions of psychotherapeutic contact, indicating that better ta contributes to symptom reduction (flückiger et al., 2020). the authors concluded that at least in the early phase of psychotherapeutic contact, symptoms, and alliance were reciprocally related to one other, generating a positive spiral, increasing the sense of alliance, and lowering symptom load in the subsequent sessions (flückiger et al., 2020). the causal relationship between alliance and session outcome is complex. most studies do, however, find that the primary causal link is from better alliance to better outcomes (crits-christoph & gibbons, 2021). the alliance-outcome relationship is a key factor across different psychotherapeutic treatment approaches (flückiger et al., 2018). this is also valid for patients with personality disorders and severe mental conditions (caspar, 2019). can ta be taught? summers and barber (2003) concluded that: (1) the ability to develop ta can improve during training, (2) trainees become more focused on ta with accumulated training and complex case formulations, (3) the goal and task aspects of ta may be more learnable and teachable than the bond aspect, and (4) there are preexisting therapeutic factors that affect the ability to develop ta (summers & barber, 2003). summers and barber (2003) further argue that of the three factors likely to influence the development of lindqvist bagge, holmqvist, skoog, & hildebrand karlén 3 clinical psychology in europe 2024, vol. 6(3), article e12037 https://doi.org/10.32872/cpe.12037 https://www.psychopen.eu/ ta, namely patient characteristics, therapist characteristics, and the therapist's technical activity during treatment, it is probably the therapist's technical activity that is most susceptible to training. zilcha-mano (2021) points to the importance of distinguishing between trait-like and state-like aspects of the therapist’s contribution. therapists need to be able to distinguish between their trait characteristics and their reactions which are more situational (zilcha-mano et al., 2019). ever since delaney and heiman (1966) and later grace et al. (1995) showed that train­ ees could be taught increased sensitivity to non-verbal communication, several studies have shown positive outcomes of various forms of alliance training. crits-christoph and colleagues (2006) found in a small study with five therapists that ta training improved the quality of therapistand patient-rated ta, but not patient outcomes. another study found that guidance from a supervisor that focused on ta ability or the alliance process was associated with a reduction in psychiatric symptoms and retention of positive outcomes in patients in therapy – these patients evaluated the therapy more positively at the end of treatment (bambling et al., 2006). in still another alliance training study, smith-hansen et al. (2011) found improved alliance but no patient outcome effects. recently, interest has been focused on the restoration of alliance ruptures. studies have found that therapies where alliance ruptures are repaired attain better outcomes (eubanks-carter et al., 2015; larsson et al., 2018; safran et al., 2002). for example, the alliance-focused training program (aft) (eubanks-carter et al., 2015; safran & muran, 2000; safran et al., 2011) is based on studies of alliance ruptures and their reparation. this program focuses on training self-awareness, affect regulation, and interpersonal sensitivity to increase therapists’ awareness of strains in the alliance and competence in repairing conflicts and ruptures. recently, the facilitative interpersonal skills (fis) model has been combined with the aft to create another training model, the aft/fis training (perlman et al., 2023). the personal practice model created by bennett-levy also contains elements that focus on alliance-building (bennett-levy & finlay-jones, 2018). studies of the results of skills training of relational variables show varying results. in a research overview, knox and hill (2021) conclude that although some persons may have more talent than others for psychotherapy, skills training does improve performance. regardless of the specific programs used in training to increase prospective thera­ pists' ta competence, summers and barber (2003) recommended the following pedagog­ ical approaches to improve ta: (1) early didactic and tutoring focus on ta concept and its techniques, (2) sustained attention on ta throughout the students' practical clinical tlas (case formulations, conceptualizations, providing clinical tutor guidance in expected alliance ruptures within the discussed cases, etc.), (3) didactic and tutorial focus on establishing appropriate, realistic, and discussed goals and on identifying the patient’s and therapist's tasks in the therapy context, and (4) the concept ‘to develop ta’ should be integrated with clinical data regarding ta in case formulations and conceptualizations when teaching ta (summers & barber, 2003). in addition to the authors' belief that ta teaching of therapeutic alliance 4 clinical psychology in europe 2024, vol. 6(3), article e12037 https://doi.org/10.32872/cpe.12037 https://www.psychopen.eu/ should be a central learning aspect of clinical psychology programs given its significant role as ta in psychological treatment, it is important to include clinical practitioners as lecturers when teaching practical skills in higher education courses to obtain a construc­ tive balance between theory and practice (williams & joyce, 2009). the pedagogic necessity of constructive alignment (ca) as the therapist’s ability to establish and consolidate ta is a significant factor in treat­ ment outcome, it is important to ascertain if and how this skill is taught in clinical psychology courses. it could be expected that training in ta would be a central learning target in clinical psychology programs. as early as 1990, it was suggested that train­ ing therapists should attend to the interpersonal processes in treatment relationships (alberts & edelstein, 1990). studies have found, however, that ta is often not taught sys­ tematically in higher education (constantino et al., 2017; constantino et al., 2013). since ta is usually not taught systematically there is an obvious need for a pedagogic focus on how ta is taught. if this pedagogic need is not met, graduate clinical psychologists could leave higher education without sufficient ta skills, despite research showing the importance of improving ta during the education of prospective psychologists (grace et al., 1995). constructive alignment (ca) to meet the european aim of establishing general standards of teaching in higher educa­ tion, i.e., the bologna declaration of 19 june 1999. joint declaration of the european ministers of education (european higher education area [ehea] and bologna process, 1999), universities need to demonstrate a logical relationship between elements of the course content and intended learning outcomes (ilos) in course documents and how the acquired knowledge, abilities, and approaches are assessed (ehea, 2015; gonzález & wagenaar, 2003). the pedagogic idea that a constructive link, or alignment, should exist between ilos, teaching and learning activities (tlas) and assessments was developed by biggs (1999). according to biggs, constructive alignment makes explicit the standards needed if the ilos are to be achieved and maintained. the underlying principle of constructive alignment is that the assessment tasks should comprise an authentic representation of the ilos (biggs & tang, 2011). constructive alignment could be used as a theoretical tool for planning tlas and assessment tasks that aim to directly address the ilos (biggs & tang, 2011), where the tlas include what the teacher does (teaching activities) and what the student does (learning activities). ilos did not feature in the original bologna declaration of 1999 but were included in the 2003 berlin communiqué and have since lindqvist bagge, holmqvist, skoog, & hildebrand karlén 5 clinical psychology in europe 2024, vol. 6(3), article e12037 https://doi.org/10.32872/cpe.12037 https://www.psychopen.eu/ become the core component for evidencing qualifications at the european level, ca has been explicitly referenced from 2015 onwards (hailikari et al., 2022; loughlin et al., 2021). ca is today the foundation for the current standards and policies for program specification, and declarations of ilos, in europe (fransson & friberg, 2015; ruge et al., 2019; schmidt, 2019) since the establishment of the european higher education area in 2010 (ehea, 2021) and the standards and guidelines for quality assurance in the european higher education area (esg) in 2015 (enqa et al., 2015). the ects (the european credit transfer and accumulation system) users’ guide is a tool of ehea that specifies the responsibility of university teachers to ensure that the constructive alignment of ilos, tlas, and assessment is “an essential requirement for educational programmes” (european commission, directorate-general for education, youth, sport and culture, 2015). an illustrative example from swedish higher education despite the recommendations of the bologna process, there is much heterogeneity be­ tween european countries regarding clinical psychology training (laireiter & weise, 2019). sweden has been a full member of the bologna process/european higher educa­ tion area since 1999. the bologna declaration and constructive alignment are highly rel­ evant to the swedish clinical psychology program. to practice as a clinical psychologist in sweden, the student must complete five years of master’s level university studies in the national psychology program (master of science in psychology, 300 european credit transfer and accumulation system [ects]) and then complete one year of practical service under continuous supervision (swe. praktisk tjänstgöring för psykologer [ptp]). after approved ptp, the student is granted a license as a clinical psychologist by the swedish national board of health and welfare (https://www.government.se/ government-agencies/national-board-of-health-and-welfare--socialstyrelsen/) and the psychologist can then practice clinical psychological treatment without supervision in private settings or within the swedish public healthcare system. during the 5-year psy­ chology program, the clinical psychotherapy courses are often taught during the latter part of the program. the psychotherapy courses are taught separately or as integrated into other courses in the psychology programs. during the psychotherapy courses, the psychology student is taught theoretical psychotherapeutic knowledge and is allowed to practice this knowledge during supervised psychotherapeutic treatment with patients with milder forms of psychological problems. to become a licensed psychotherapist in sweden, as opposed to a licensed clinical psychologist, students who have taken the clinical psychology program must also complete another 3-year program (a graduate diploma course in psychotherapy). this conceptual paper aimed to illustrate how higher education in sweden adheres to the bologna recommendation on constructive alignment when teaching ta to future clinical psychologists. to assess the extent of training in ta, we observed how ta was teaching of therapeutic alliance 6 clinical psychology in europe 2024, vol. 6(3), article e12037 https://doi.org/10.32872/cpe.12037 https://www.government.se/government-agencies/national-board-of-health-and-welfare--socialstyrelsen/ https://www.government.se/government-agencies/national-board-of-health-and-welfare--socialstyrelsen/ https://www.government.se/government-agencies/national-board-of-health-and-welfare--socialstyrelsen/ https://www.psychopen.eu/ taught regarding ca. a country-wide overview of the course syllabuses and ilos of ta-relevant psychotherapy courses in the clinical psychology program was performed in 2019, by two of the authors, for all eleven universities in sweden offering the five-year clinical psychology program. the two authors analyzed independently of each other the presence of explicit mention of the term ta (or its synonyms cf. working alliance, treatment alliance, etc.) based on the definition of bordin (1979) in the ta-relevant clinical psychotherapy courses’ syllabuses and ilos. the reviewed document analysis showed that out of the eleven universities in swe­ den offering a clinical psychology program, only two universities specifically stated, ‘therapeutic alliance’ (or its synonyms) in the ilos in their course syllabuses. at nine universities, different aspects of the concept of ta were in some (vague) way described in the ilos. when ta (or its synonyms) is not mentioned in the courses’ ilos and when imprecise ta definitions do not fully correspond to the established definition of ta, a constructive link between ilos, tlas, and assessment/examination when teaching ta cannot be said to exist. the obvious lack of ca was due to an absence of a clear and explicit description of ta (or its synonyms) in the ilos of the clinical courses for nine out of the eleven universities in sweden offering a clinical psychology program. definitions of ta should be operationalized in the ilo for programs to be able to teach and examine the students’ ta abilities/knowledge when applying the pedagogic concept of ca. the present illustrative example shows that teaching – and training – of ta is not done systematically in swedish universities when training clinical psychology students’ ability to create a viable and constructive cooperative alliance with patients. as the data collection was conducted in sweden only, the results cannot be generalized to universities in other european countries. the results can, however, hopefully serve as an illustration of a pedagogical problem that has been described in scientific journals (constantino et al., 2017; constantino et al., 2013) as well as has been informally dis­ cussed among colleagues internationally. conclusion teaching ta is difficult as it concerns a relational and, to a large extent, implicit skill. nevertheless, this skill – alliance building and alliance maintenance – is a precondition for effectively using specific methods in psychotherapy. at the same time, psychother­ apy is a craft as well as a science, and training programs need to ascertain that the student has acquired sufficient ta competence both theoretically and practically. the craft aspect of ta may be challenging to conceptualize in traditional university teaching contexts. we fear that the illustrative example of the current paper – showing vague descriptions of ta and a lack of constructive alignment between course objectives, ilos, and examination methods – reflects a situation where ta is not systematically taught in clinical psychology programs in sweden. considering the significance for psycholo­ lindqvist bagge, holmqvist, skoog, & hildebrand karlén 7 clinical psychology in europe 2024, vol. 6(3), article e12037 https://doi.org/10.32872/cpe.12037 https://www.psychopen.eu/ gists and their future patients of developing competence in alliance-building, preferably through constructive alignment, and the findings in this study, it is doubtful whether the current structure for teaching ta at swedish universities offers prospective clinical psychologists an opportunity to develop sufficient ta knowledge and skills. a lack of ba­ sic ta competence in this might diminish the efficacy of psychotherapy given by future clinical psychologists. this conceptual paper hopefully directs the focus on the structure around the teaching of practical psychotherapeutic skills in higher education, illustrated by the lack of constructive alignment when teaching ta to clinical psychology students in higher education. it is also hoped that this conceptual paper will stimulate improved structuring of the teaching of ta. based on the backdrop of the current conceptual paper – and given the important role of ta in enhancing the effectiveness of treatment and fostering positive outcomes for patients – our strong recommendation is to make alliance-building training a core element of future clinical psychology program curricula in sweden. a good way to start is with ta being specifically mentioned in the ilos. the importance of ta in clinical psychology education resonates with the esg's emphasis on fostering student-centered learning outcomes and ensuring education effectiveness (enqa et al., 2015). the identified shortcomings in ta training may reflect broader challenges in psychotherapy education across european universities, not just in sweden. we encourage european institutions to adhere to the esg principles by integrating ta training consistently into curricula and aligning it 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(2019). not just nonspecific factors: the roles of alliance and expectancy in treatment, and their neurobiological underpinnings. frontiers in behavioral neuroscience, 12, article 293. https://doi.org/10.3389/fnbeh.2018.00293 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. teaching of therapeutic alliance 12 clinical psychology in europe 2024, vol. 6(3), article e12037 https://doi.org/10.32872/cpe.12037 https://doi.org/10.1177/21677026221094331 https://doi.org/10.1037/a0022184 https://doi.org/10.1176/appi.ap.27.3.160 https://doi.org/10.1037/ccp0000738 https://doi.org/10.1002/wps.20238 https://doi.org/10.1037/a0018912 https://doi.org/10.1037/amp0000629 https://doi.org/10.3389/fnbeh.2018.00293 https://www.psychopen.eu/ teaching of therapeutic alliance background therapeutic alliance (ta) can ta be taught? the pedagogic necessity of constructive alignment (ca) constructive alignment (ca) an illustrative example from swedish higher education conclusion (additional information) funding acknowledgments competing interests data availability references developing a european psychotherapy consortium (epoc): towards adopting a single-item self-report outcome measure across european countries latest developments developing a european psychotherapy consortium (epoc): towards adopting a single-item self-report outcome measure across european countries miguel m. gonçalves 1 § , wolfgang lutz 2 § , brian schwartz 2 , joão tiago oliveira 1 , suoma e. saarni 3 , orya tishby 4, julian a. rubel 5 , jan r. boehnke 6 , adrian montesano 7 , dario paiva 1, davide ceridono 8 , emmanuelle zech 9 , jochem willemsen 9 , samuli i. saarni 3 , katarina kompan erzar 10 , luís janeiro 11 , omar c. g. gelo 12, paula errázuriz 13 , pawel holas 14 , rafał styła 14 , tatjana rožič 15 , tom rosenström 3 , vera békés 16 , zsolt unoka 17 , michael barkham 18 [1] cipsi – psychology research center, school of psychology, university of minho, braga, portugal. [2] department of psychology, university of trier, trier, germany. [3] helsinki university hospital, university of helsinki, helsinki, finland. [4] department of psychology, hebrew university, jerusalem, israel. [5] department of psychology, osnabrück university, osnabrück, germany. [6] school of health sciences, university of dundee, dundee, united kingdom. [7] faculty of psychology and educational sciences, universitat oberta de catalunya, barcelona, spain. [8] institute for research on intrapsychic and relational processes, irpir, rome, italy. [9] université catholique de louvain, ottignieslouvain-la-neuve, belgium. [10] university of ljubljana, ljubljana, slovenia. [11] university of algarve, faro, portugal. [12] university of salento, salento, italy. [13] pontificia universidad católica de chile / psiconecta mental health ngo, santiago, chile. [14] university of warsaw, warsaw, poland. [15] sigmund freud university vienna – ljubljana branch, ljubljana, slovenia. [16] yeshiva university, new york, usa. [17] semelweis unversity, hungarian cognitive behavior therapy association, budapest, hungary. [18] clinical and applied psychology unit, school of psychology, university of sheffield, sheffield, united kingdom. §these authors contributed equally to this work. clinical psychology in europe, 2024, vol. 6(3), article e13827, https://doi.org/10.32872/cpe.13827 received: 2024-01-27 • accepted: 2024-05-14 • published (vor): 2024-09-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: joão tiago oliveira, cipsi – psychology research center, school of psychology, university of minho, 4710-057, braga, portugal. e-mail: jtoliveira@psi.uminho.pt supplementary materials: materials [see index of supplementary materials] this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.13827&domain=pdf&date_stamp=2024-09-30 https://orcid.org/0000-0003-2575-7221 https://orcid.org/0000-0002-5141-3847 https://orcid.org/0000-0003-4695-4953 https://orcid.org/0000-0001-6624-8816 https://orcid.org/0000-0003-3555-9958 https://orcid.org/0000-0002-9625-6611 https://orcid.org/0000-0003-0249-1870 https://orcid.org/0000-0001-9201-8694 https://orcid.org/0009-0008-2630-8202 https://orcid.org/0000-0002-7607-7042 https://orcid.org/0000-0003-4843-5209 https://orcid.org/0000-0002-9348-5435 https://orcid.org/0000-0002-1613-528x https://orcid.org/0000-0003-3699-5401 https://orcid.org/0000-0003-4890-7050 https://orcid.org/0000-0002-4210-3396 https://orcid.org/0000-0002-3792-8473 https://orcid.org/0000-0003-2011-8893 https://orcid.org/0000-0001-8277-3776 https://orcid.org/0000-0003-3043-5155 https://orcid.org/0000-0003-0103-5064 https://orcid.org/0000-0003-1687-6376 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ abstract background: complementing the development of evidence-based psychological therapies, practice-based evidence has developed from patient samples collected in routine care, addressing questions relevant to patients and practitioners, and thereby expanding our knowledge of psychological therapies and their impact. implementation of assessments in routine care allows for timely clinical decision support and the collection of multiple practice-based data sets by addressing the needs of patients and clinicians (e.g., routine outcome monitoring) and the needs of researchers (e.g., identifying the impact of therapist variables on outcomes). method: in this article we describe an initiative developed in europe, through the european chapter of the society for psychotherapy research, aimed at creating a consortium that has the potential for collecting data on tens of thousands of patients per year. results: a survey identified one of the main problems in the development of a common data set to be the heterogeneity of measures used by members (e.g., 87 different pre-post outcomes). we report on the results of the survey and the initial stage of identifying a single-item – the emotional and psychological outcome (epo-1) – measure and the process of its translation into multiple european languages. conclusions: we conclude this first stage of the overall project by discussing the future potential of the consortium in relation to the development of procedures that allow crosswalks of outcome measures and the creation of a task force that may be consulted when new data sets are collected, aiming for new common measures to be implemented and shared. keywords psychological therapies, european psychotherapy consortium, epoc, practice-based evidence, routine outcome monitoring highlights • many clinics in europe collect patient data and assess outcomes using different measures. • developing common metrics across different countries would facilitate data sharing and analyses. • an existing single item, measuring patient emotional and psychological outcomes (epo-1), was adopted. • the epo-1 has been translated into 11 languages, to date, and is being used in many countries. over the past two decades, a complementary paradigm to evidence-based practice has developed in the form of practice-based evidence as a means of enhancing the overarch­ ing evidence-base of psychological therapies (barkham & lambert, 2021; castonguay et al., 2021; lutz et al., 2021). while the former concentrates on treatments and techniques using the methodologies of randomized controlled trials (rcts) and meta-analyses, the latter aims to systematically collect patient data in routine clinical settings in connection european psychotherapy consortium (epoc) 2 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://www.psychopen.eu/ with specific treatment goals or desired outcomes. however, data administration, man­ agement, and processing of outcome measures in routine practice are time consuming and a burden to under-funded services. in response to aspirations to collect data but also reduce administrative demands, there has been a move towards the development and adoption of relatively brief outcome measures, often comprising 10 items or less: for example, the patient health questionnaire-9 (phq-9; kroenke et al., 2001), the generalized anxiety disorder-7 (gad-7; spitzer et al., 2006), the clinical outcomes in routine evaluation-10 (core-10; barkham et al., 2013), recovering quality of life-10 (reqol-10; keetharuth et al., 2018), or the short warwick-edinburgh mental wellbeing scale (swemwbs; stewart-brown et al., 2009). a separate line of activity within psychological therapy research has been the attempt to agree a core outcome battery in which researchers, in addition to selecting specific outcome measures appropriate for their particular study, adopt a single common out­ come measure in order to make direct cross-study comparisons (e.g., waskow & parloff, 1975). such an aspiration can then also be extended to cross-country and cross-cultural comparisons. but agreeing on a common measure carries many challenges and also places an additional burden on patients and on individual research studies, as well as re­ quiring agreements between researchers from multiple countries and treatment concepts. establishing the european psychotherapy consortium (epoc) partly in response to these two lines of activity, the overarching framework under­ pinning the current project was establishing the european psychotherapy consortium (epoc) with the initial aim of coordinating a level of standardized data collection across multiple european countries. in doing so, the aspiration was to generate data sets of considerable size, accessible to researchers that could add a new dimension to research findings and thereby extend our current knowledge base regarding the psychological therapies. in particular, such a development could provide researchers who have difficul­ ty in securing funding, with access to a valuable data source to pursue their particular research projects. the idea of creating epoc was launched at the rome meeting of the european chapter of the society for psychotherapy research (eu-spr) in september 2022 with the aim of promoting the collection and sharing of data that is common in other sciences (e.g., physics, medicine, genetics) with the aspiration of improving research data in clinical psychology and psychological therapies in four specific ways. first, it would be relevant to psychological therapy research to have data from different countries, representing different cultural, political, and socio-economic realities. second, it would facilitate cooperation between european countries, with enough data that could be used to better understand psychotherapy in naturalistic clinical settings. third, in the long term, if the consortium were to be successful in collecting sufficient data, it may have some influence on decision-making processes at the individual patient level as well as on gonçalves, lutz, schwartz et al. 3 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://www.psychopen.eu/ the implementation of psychological therapy at the mental health service level. fourth, the consortium could facilitate the construction of large datasets, with considerable diversity (e.g., clients, diagnoses, cultural backgrounds, therapists), which would enable better possibilities for research on topics relevant to both practitioners and researchers as well as for cross-validation and replication of research findings. aim the immediate task within epoc was to identify the measures used in different services within and across member countries. our hypothesis was that there would be great heterogeneity in the measures used within and across countries, making it difficult to initiate international research collaborations. if this were indeed the case, our second task would be to find a pragmatic first-step solution to establish a common research ground for our international collaboration. as a consequence, it needed to be a measure that made the least demands on services, but which had sufficient face validity and psychometric credibility to be acceptable to members. in addition, services in multiple countries would have to be willing to voluntarily adopt it and administer it multiple times during treatment in order to build an international common research database. a decision was taken to focus on the adoption of a single-item measure as the least burdensome method for clinics and services. to support this agenda would require a level of cross-country co-ordination and co-operation via the establishment of a virtual organization (i.e., epoc). accordingly, the current article sets out the organizational deliberations and actions to progress collaborations between psychological therapy re­ searchers and practitioners across europe with the initial aim of adopting a common single-item patient outcome measure. method the initial task at the beginning of the project was to establish the range of outcome measures used and to capture some of the key features of the way practice has been im­ plemented in different contexts. a survey of eu-spr members was the selected method of data gathering combined with an invitation to join epoc. part 1: survey on practice-based evidence survey design in addition to obtaining identification of a service, the survey was designed to capture basic information on four main areas relating to the functioning of a clinical service: (1) the setting and service provision, (2) the clinical populations served, (3) size/vol­ ume/throughput, and (4) the range of outcome/process measures used. table 1 lists the 10 questions addressing these four areas. european psychotherapy consortium (epoc) 4 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://www.psychopen.eu/ table 1 question topics in the epoc survey question topic 1. identification data (e.g., country, type of service) 2. treatment options (e.g., outpatient, inpatient) 3. therapy models used (e.g., psychodynamic, cognitive-behavioural) 4. treatment modality (e.g., individual, couples) 5. patients under treatment (e.g., diagnoses) 6. estimates of number of patients per year and average number of sessions per patient 7. pre-post treatment measures used 8. outcome and process measures used at each session 9. other process and outcome measures that are used at regular intervals 10. whether there was routine outcome monitoring in the clinic procedure the survey opened 1st february 2023 and was advertised on the spr mailing list, at scientific meetings, and on the eu-spr website. the initial stock take of responses was carried out 31st january 2024, thereby yielding data for a period of 12 months. part 2: selection of a single-item outcome measure status of single item measures as making significant changes to the instruments used in each clinic would be at best, challenging and at worst, impractical, a decision was made to propose introducing a single common item to be adopted by all participating clinics, translated in the language of each participating country. this was judged to be the minimal demand to achieve the maximum extent of possible participation by individual clinics. historically, single-item measures have not been viewed in the most positive light. however, recent research has re-evaluated the evidence, which appears much more favorable (e.g., ahmad et al., 2014). in addition, a recent editorial set out a ‘call to action’ regarding the adoption and testing of single item measures in psychological science (allen et al., 2022). hence, our strategy is consistent with such an agenda. similarly, vitry et al. (2024) have endorsed the ration­ ale for single-item measures, and suggest they are particularly suited to psychotherapy patients and repeated measurements due to their low level of burden. in terms of our method for the selection of a measure, we set two criteria. first, that the measure comprised a patient-completed item that captured the general psychological state or health of a patient. this criterion therefore excluded the global assessment of functioning (aas, 2010) and the clinical global impression (cgi; guy, 1976) scale. second, that the selected measure utilized a likert scale as we considered this to be easier to adopt, initially, in clinics as it did not require a subsequent stage of transferring gonçalves, lutz, schwartz et al. 5 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://www.psychopen.eu/ the visual analogue scale into a numerical value. this criterion excluded consideration of the ors, which actually comprises 4 items derived from the oq-45 and, while there is considerable psychometric data reported on the ors, a recent review offered some caution regarding its use (harris et al., 2019). results the results are presented in two parts. first, we summarize the data relating to the clinical activity and use of outcome measures. second, we present the selection of a single-item outcome measure for adoption across all participating clinics. part 1: survey of clinical activity and outcome measures responses were received from 31 clinics in 16 different countries, most of them europe­ an: austria, belgium, finland, germany, hungary, israel, italy, poland, portugal, slovenia, spain, switzerland, turkey, united kingdom, as well as argentina and chile. the estima­ ted total number of clients per year was 25,000, with a median of 100 and a range from 12 in receipt of couple therapy to 15,000 per clinic. in terms of treatment settings, 31 were outpatient of which 10 were private, 3 were day clinical treatment, 3 were inpatient, and 1 was home-based treatment. of the 20 differing modalities of psychological therapy offered, the two most common were cognitive-behavioral therapy (n = 15) and psychodynamic (n = 14), followed by social-cognitive transactional analyses (n = 5), and then systemic, family therapy, and person-centered with each receiving 2 endorsement, and the remaining 11 endorsements captured single entries for the following therapeutic modalities: mindfulness-based therapy, solution / focused, dynamic-interpersonal therapy, brief relational, eye move­ ment desensitization and reprocessing, dialectical-behavioral therapy, mentalizing model, schema therapy, schema group therapy, cognitive behavioral analysis system of psychotherapy, and interpersonal psychotherapy. in terms of outcome data, 25 reported they were currently collecting data utilizing a total of 87 different pre-post measures, 22 measures used at each session, and 13 process measures. the most common pre-post outcome measure was the clinical outcomes in routine evaluation−outcome measure (core-om; evans et al., 2002), which was used in 13 clinics, the phq-9 (kroenke et al., 2001) and gad-7 (spitzer et al., 2006) in 8 clinics, anint-a36 (scilligo, 2000) and espero (scilligo et al., 1999) in 5 clinics, oq-45 (lambert et al., 1996) in 4 clinics, a further five measures were used in 3 clinics, 12 measures were used in 2 clinics, and the remaining 63 outcome measures used in only a single clinic. in terms of outcome monitoring measures, the most common measure was the out­ come rating scale (ors; duncan & reese, 2015), used in three clinics, with the oq-10 (lambert et al., 2005) used in 2 clinics. a further 19 measures were used in single clinics. european psychotherapy consortium (epoc) 6 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://www.psychopen.eu/ when considering process measures, the most common was the working alliance inven­ tory–short revised (wai-sr; hatcher & gillaspy, 2006), used in three clinics, with the bern-post report (flückiger et al., 2010) and the srs (duncan & reese, 2015) used in 2 clinics. five further measures were used in single clinics. part 2: selection of a single-item outcome measure: emotional and psychological outcome (epo-1) in response to the survey, we focused solely on available single-item measures meeting our two election criteria. our scoping of available single items identified one taken from the work of ken howard, for which a first version can be found in orlinsky and howard (1986), and has been adapted and employed successfully in several large-scale studies (e.g., howard et al., 1996). the item was adapted and asks clients to evaluate their current emotional and psychological impairment using the question: “at this moment, how well do you feel you are getting along emotionally and psychologically?”. based on the original item, the item is scored on a 5-point scale from 0 ("very poorly; i can barely manage to deal with things") to 4 ("very well; i have no important complaints"). the item can also be used dimensionally with a visual analog scale (0 to 100), which was introduced at the outpatient clinic of the university of trier (lutz et al., 2019). hence, it provided the possibility of using a visual analog scale at a future date. robust correlations with various outcome measures have been demonstrated on a clinical sample (n = 521) with the correlations for the single item in both likert and analog forms with the phq-9, the bsi depression and anxiety scales, oq, and gad-7 at baseline, for pre-post change, and overall effect size, exceeding those of the ors 4 item total score (supplemental materials in lutz et al., 2021). these data indicate that the single item has the potential to establish a common standard across diverse societies. in order to make the single item identifiable in the literature, we took the focus on the emotional and psychological components (ep) together with outcome (o) and signified the single item by the digit (1); hence the name epo-1. program of european translations epoc members developed a narrative description of the content of the item (“lay descrip­ tion”) and a translation process for the item based on current best-practice recommenda­ tions (table 2; e.g., hernández et al., 2020) that required the following: active participa­ tion of members of the target population represented in the local setting (both clinicians and clients), and which offered good resource use for the purpose of translating one item. in addition to the english version, there are versions of the item translated into finnish, french, german, hungarian, italian, polish, portuguese as well as slovenian, and epoc members are now involved in translating and adapting the item into hebrew, and spanish. this process results in a total of 11 language versions. gonçalves, lutz, schwartz et al. 7 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://www.psychopen.eu/ table 2 steps of the epoc translation process for the item 1. translation of the lay description of the item content provided by the consortium (to be used as supporting resource in the following process). 2. forward translation of the item and the response anchors by a team. 3. backward translation to english from the previous step, by a different team. 4. evaluation of the translation by practitioners (if the translation resulted in multiple possible versions, these would all be evaluated). 5. evaluation of the translation by clients (if the translation resulted in multiple possible versions, these would all be evaluated). 6. development of a final version based on results from steps 3-5 by the local team (potentially including epoc members in the discussions). 7. approval of final version by epoc, licensing, and documentation on consortium’s web page. implementation and dissemination we have placed no restrictions on the use of the item, as some clinics may use it in every session, and others at regular intervals. hence, the item will be adopted such that it is consistent with the current practice of each clinic. the item translations will be freely available and under a creative commons license after a free registration on the website of the european chapter of the society for psychotherapy research (item available at https://www.psychotherapyresearch.org/page/spr-eu-consortium). discussion we have set out the rationale and aims of a european-wide collaboration aimed at providing a common thread by which to yield a fuller understanding of the similarities and differences between the practices and outcomes of psychological therapies across multiple countries. importantly, these are initial steps, achieved with no external grant funding by virtue of a shared vision to build a more robust and representative evidencebase for routine practice. in addition, this practical approach, focusing on a single item in a first step, allows routine clinics with diverse treatments and clinical populations to easily adopt ongoing monitoring in addition to established pre-post assessments. future collaboration will involve developing standardized reporting strategies (snyder et al., 2019) and crosswalks between different measures (schalet et al., 2021). the practical advantage of generating crosswalks is that it will enable a level of comparison between clinics and countries where different outcome measures are used. this could be at the level of individual scores or banding of scores signifying, for example, differing severity levels. from an organizational perspective, the availability of crosswalks means that clinics are able to select, within reason, their preferred outcome measure (i.e., european psychotherapy consortium (epoc) 8 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://www.psychotherapyresearch.org/page/spr-eu-consortium https://www.psychopen.eu/ protecting the principle of choice) but still be able to make direct comparisons (i.e., benchmark) with other clinics using different outcome measures, providing there is an existing crosswalk. one way to do this is to focus on standardizing at least the underlying metrics of the instruments, to ease interpretation, for example by using t scores as a method of delivering uniformity to the reporting of outcomes from the diversity of measures (e.g., see de beurs et al., 2022 for an illustration). another solution is based on item response theory: to develop an algorithm based on existing data with which values from different instruments that record similar constructs can be converted into each other. in this way, a common metric for existing data is generated a posteriori (e.g., böhnke et al., 2014; cardace et al., 2022; schalet et al., 2021; wahl et al., 2014). other methods have also been used to deliver crosswalk tables (de beurs et al., 2022), for example, between the bdi and core-om (leach et al., 2006). so, the next step would be to create analytical routines among epoc members that would allow comparison of similar constructs (e.g., depression, anxiety) despite using different instruments to measure them. a final future course of collaboration involves the creation of new datasets that could be articulated from the onset. epoc has colleagues with considerable experience of collecting data in routine care, and this offers the opportunity to create a task force that could be employed when new clinics want to start collecting data and have no external constraints on the instruments they need to use. this could be the starting point for the collection of more common measures. in fact, the survey also revealed that 23 additional clinics would like to start collecting new datasets, which would make it possible to introduce more common instru­ ments that would allow a more direct comparison of measures. currently, the reality for the vision focuses on multiple clinics across differing coun­ tries harmonizing their data and is an initial step. however, it is likely that the greater challenge will arise with aspirations for data sharing. hence, initial outputs from epoc are likely to be locality specific with sharing occurring at the level of outputs or latent variables representing a common metric from crosswalk calculations and not primary data, thereby remaining within the existing agreements regarding patient consent and ethical approvals. it is now a priority to determine the scope, and likely hurdles, for data sharing in the future. conclusion efforts to improve the effectiveness of psychotherapy require an understanding of the complex interplay between therapeutic interventions and the needs of individual clients in real-world settings. the launch of this project hopefully will mark a pivotal moment in collaborative psychotherapy research and practice in europe. bringing together com­ mitted researchers and practitioners from across europe (and, in time, other countries), epoc aims to harness the potential of assessments in routine care to provide a more gonçalves, lutz, schwartz et al. 9 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://www.psychopen.eu/ nuanced understanding of psychotherapy in the setting in which it naturally occurs. with the potential to include a range of service settings, epoc also offers an opportunity to improve our understanding of the implementation of systems for routine outcome monitoring, both on the organizational as well as on the concrete technical level (böhnke & rutherford, 2021). its ambition extends beyond the present to a future in which collaborative efforts produce large, accessible datasets that can inform service delivery both at a local, na­ tional, and international level. the participation of colleagues from latin america in epoc will enhance collaboration with the latin american chapter and is a first step toward data collection collaboration between different continents. the aim is to address specific issues of practice-based evidence in different regions, for example, regarding im­ plementation but focusing on the same long-term goals. this scientific endeavor invites therapists to join forces in a collective quest to advance research on psychological thera­ pies, contribute to a growing body of knowledge, and thrive in a community that shares insights and is committed to unraveling the intricacies of effective clinical practice. european psychotherapy consortium (epoc) 10 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://www.psychopen.eu/ funding: this work was supported by the german research foundation (dfg) under project numbers 493169211, 504507043, and 525286173 granted to wolfgang lutz and partially conducted at the psychology research centre (psi/ 01662), school of psychology, university of minho, and supported by the portuguese foundation for science and technology and the portuguese ministry of science, technology and higher education (uid/psi/01662/2019 and uidb/psi/04345/2020), through national funds (piddac). acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: michael barkham declares that he is a co-developer of the core-om and core-10. author contributions: wolfgang lutz and michael barkham conceptualized this paper as a first output of the epoc. miguel m. gonçalves and wolfgang lutz wrote the first draft of this paper. brian schwartz, joão tiago oliveira, suoma saarni, orya tishby, jan r. boehnke and michael barkham revised the paper and suggested modification in content and style. jan r. boehnke drafted the methodological procedures for translation and adaptation of the different language’s versions of the single item. julian rubel, brian schwartz, and wolfgang lutz were involved in the translation and adaptation of the single item from english to german. adrian montesano and paula errazuriz were involved in the translation and adaptation of the single item from english to spanish dario paiva, miguel m. gonçalves, joão tiago oliveira, and luis janeiro were involved in the translation and adaptation of the single item from english to portuguese. omar c.g. gelo and davide ceridono were involved in the translation and adaptation of the single item from english to italian. orya tisby was involved in the translation and adaptation of the single item from english to israeli. jochem willemsen and emmanuelle zech were involved in the translation and adaptation of the single item from english to french. suoma saarni, samuli i. saarni, and tom rosenström were involved in the translation and adaptation of the single item from english to finnish. katarina kompan and tatjana rožič were involved in the translation and adaptation of the single item from english to slovak. pawel holas and rafał styła were involved in the translation and adaptation of the single item from english to polish. vera békés and zsolt unoka were involved in the translation and adaptation of the single item from english to hungarian. all authors reviewed the manuscript critically for important intellectual content and all authors have given their final approval of the version to be published. ethics statement: as the survey was an information management gathering exercise and did not involve any patients or patient data, it was not deemed necessary to obtain ethical approval. the translations were generated from publicly available data (i.e., the original howard & orlinsky single item questionnaire) and approval for the translations was sought from, and provided by, dr. orlinsky. translations were carried out by appropriately qualified adults in each individual language with no patient involvement. social media accounts: @jtcruzoliveira reporting guidelines: we followed principles of good and open reporting in the absence of any specific guideline. data availability: the data that support the findings of this study are available on request from the corresponding author, joão tiago oliveira. the data are not publicly available due to containing information that could compromise the privacy of research participants. gonçalves, lutz, schwartz et al. 11 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://x.com/jtcruzoliveira https://www.psychopen.eu/ supplementary materials epoc – european consortium of psychotherapy – is a group closely associated with the society for psychotherapy research (spr). the list of members that make up this group is available in a supplementary file (see gonçalves et al., 2024s). index of supplementary materials gonçalves, m. m., lutz, w., schwartz, b., oliveira, j. t., saarni, s. e., tishby, o., rubel, j. a., boehnke, j. r., montesano, a., paiva, d., ceridono, d., zech, e., willemsen, j., saarni, s. i., kompan erzar, k., janeiro, l., gelo, o. c. g., errázuriz, p., holas, p., . . . barkham, m. 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(1975). psychotherapy, change, measures: report of the clinical research branch outcome measures project (vol. 74). national institute of mental health. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. gonçalves, lutz, schwartz et al. 15 clinical psychology in europe 2024, vol. 6(3), article e13827 https://doi.org/10.32872/cpe.13827 https://doi.org/10.1186/1477-7525-7-15 https://doi.org/10.1111/jmft.12690 https://doi.org/10.1016/j.jclinepi.2013.04.019 https://www.psychopen.eu/ european psychotherapy consortium (epoc) (introduction) establishing the european psychotherapy consortium (epoc) aim method part 1: survey on practice-based evidence part 2: selection of a single-item outcome measure results part 1: survey of clinical activity and outcome measures part 2: selection of a single-item outcome measure: emotional and psychological outcome (epo-1) discussion conclusion (additional information) funding acknowledgments competing interests author contributions ethics statement social media accounts reporting guidelines data availability supplementary materials references what is the common ground for modern psychotherapy? a discussion paper based on eaclipt’s 1st webinar editorial what is the common ground for modern psychotherapy? a discussion paper based on eaclipt’s 1st webinar stefan g. hofmann 1 , jacques p. barber 2 , paul salkovskis 3 , bruce e. wampold 4 , winfried rief 1 , anne-catherine i. ewen 1 , leonora nina schäfer 1 [1] department of clinical psychology and psychotherapy, philipps-university of marburg, marburg, germany. [2] gordon f. derner school of psychology, adelphi university in garden city, new york, ny, usa. [3] department of experimental psychology, university of oxford, oxford, united kingdom. [4] counseling psychology, university of wisconsin – madison, madison, wi, usa. clinical psychology in europe, 2022, vol. 4(1), article e8403, https://doi.org/10.32872/cpe.8403 published (vor): 2022-03-31 corresponding author: anne-catherine i. ewen, philipps-university of marburg, department of clinical psychology and psychotherapy, gutenbergstraße 18, 35032 marburg, germany. e-mail: ewen@uni-marburg.de abstract psychotherapy as it is implemented today, can be seen as the composition of unconnected groups of practitioners and scientists pursuing different theories. the idea of finding a common “umbrella” for all evidence-based treatments in the field of psychotherapy is gaining more interest. based on this background, experts in clinical psychology from various backgrounds led a fundamental discussion about modern psychotherapy and its basic mechanisms. process-based therapy (pbt) was presented by stefan hofmann as a possible novel approach to clinical research and practice. in this article we present the different perspectives of the four panelists on pbt and in how far the model builds a common ground for different treatment approaches. learning mechanisms and the therapeutic alliance were almost unanimously considered as indispensable factors in a global model of psychotherapy. in conclusion, the panelists emphasized a much-needed focus on characteristics and competencies of therapists themselves e.g., in communication, listening and empathy. these core competencies should be trained and promoted independently of the therapeutic approach. keywords psychotherapy, common ground, process-based therapy, panel discussion, eaclipt webinar this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.8403&domain=pdf&date_stamp=2022-03-31 https://orcid.org/0000-0002-3548-9681 https://orcid.org/0000-0002-8762-2595 https://orcid.org/0000-0002-2951-2283 https://orcid.org/0000-0003-1507-980x https://orcid.org/0000-0002-7019-2250 https://orcid.org/0000-0002-9738-5300 https://orcid.org/0000-0002-4911-1073 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • the formulation of a common ground of modern psychotherapy is needed that integrates all evidence-based psychological therapies. • process-based therapy was proposed as a new overarching concept that complements former general psychotherapy approaches. • basic mechanisms of psychotherapy were discussed that considered different psychotherapeutic approaches. • implications for education and training in psychological therapies should focus on a competence-based approach. the european association of clinical psychology and psychological treatment eaclipt has the goal to promote and develop research in clinical psychology, its application and in psychological treatments and fostering the communication throughout the world. in this framework, a webinar has been organized by eaclipt leading a theoretical discussion about “what is the common ground for modern psychotherapy?” with stefan hofmann, jacques barber, bruce wampold, and paul salkovskis as panelists, and chaired by winfried rief. the webinar was streamed live on the 16th of november 2021, whereas already over 1.800 people watched the video (still online available on youtube under the following link: https://www.youtube.com/watch?v=wffzx2lolts). the background of organizing this expert panel was based on the idea of finding a common “umbrella” (eaclipt, 2019; rief, 2021), i.e. a common language, for all evidence-based treatments in the field of psychotherapy. the webinar was introduced with the following comments: psychotherapy was developed from different roots, and many clinicians and scientists still consider psychotherapy as a collection of unconnected groups of theories and associated interventions. however, as long as psychotherapy is not considered as one academic and clinical field, progress and reciprocal stimulation of developments is seriously hampered. goldfried labeled this stage as “prescientific”, and calls for search for a common ground, language and theory of psychotherapy, to develop one science and intervention model that could be used as overarching framework, before specifying into single approaches (goldfried, 2020). hofmann and hayes believe that the evaluation of complete treatment packages (e.g., exposure for phobias) has reached its limit and needs more flexible, process-based, and problem-focused treatment planning, grounded in scientifically proven mechanisms of change (hayes & hofmann, 2018). consequently, training of young clinical psychologists and psychotherapists may require a switch from a single traditional “school” of psychotherapy to a competence-based edu­ cation that can integrate different, scientifically proven methods, derived from different backgrounds (rief, 2021). this article summarizes the main discussion points. a short introduction about the presented theoretical background of process-based therapy (pbt) developed by hayes finding common ground for modern psychotherapy 2 clinical psychology in europe 2022, vol. 4(1), article e8403 https://doi.org/10.32872/cpe.8403 https://www.youtube.com/watch?v=wffzx2lolts https://www.psychopen.eu/ and hofmann (2018) is given, followed by the main statements about common ground theories of psychotherapy between the panelists. an introduction to process-based psychotherapy by hofmann nowadays, clinical psychology based on the nomothetic approach focuses strongly on disorder categories and general treatment approaches instead of on the individual as well as on treatment change processes. classification systems such as the icd or dsm laid grounds to study various mental problems and provided effective alternatives to drug treatments. however, they are based on the latent disease model which cannot measure, quantify, or test these syndromes properly. instead, syndrome clusters or disorders are an expression of symptoms based on a subjective report. hofmann argued that clinical scientist should be more interested in the interrelationships of complaints and psycho­ logical variables, regardless of a possibly underlying latent disease model. within this context hofmann referred to the complex network approach on clinical research of psychotherapy (hofmann et al., 2016). this network perspective considers therapy as a highly complex process that involves a multitude of variables that typically form dynamic processes. to target these processes hayes and hofmann propose a tran­ sition from the nomothetic approach to an idiographic approach of theory-based and process-based therapy. hofmann pointed out that pbt focuses on the biopsychosocial processes that should be targeted specifically for the given client and therapy goals to not only reduce symptoms but to enhance the client’s prosperity. next, he referred to one of his own reviews which examined the most frequently validated mediators of psychosocial interventions. as a result, features such as self-efficacy, acceptance, expect­ ations, psychological flexibility, coping skills etc. presented themselves as functionally important pathways of change, irrespective of being systemized into particular schools of psychotherapy. based on the idea to get away from a syndromic perspective, hayes and hofmann developed the so-called “extended evolutionary meta-model” (eemm). as a meta model of adaptive change, the facilitation of clients’ competencies for adaption is targeted as a primary goal in pbt. this model is based on evolutionary theories assuming (mal-)adap­ tive change based on context-dependent variation, selection, and retention. to achieve a specific situational outcome, it is important to firstly be aware of various options (variation), secondly to select the most fitting one (selection) and thirdly to retain it (retention) for the given context, respectively. these change processes are expressed in interrelated dimensions of affect, cognition, attention, self, motivation, overt behavior, physiology and social background/ culture. by developing a whole problem network with the client called ‘grid’, it is possible to identify maladaptation of the individual in the dimensions, respectively, and to help change it to an adaptive self-sustaining hofmann, barber, salkovskis et al. 3 clinical psychology in europe 2022, vol. 4(1), article e8403 https://doi.org/10.32872/cpe.8403 https://www.psychopen.eu/ network. this concept opens the possibility to quantify and therefore predict (critical) psychological events (through e.g., critical slowing) such as psychotic breaks, suicide attempts or state of recovery. in summary, the strategy of pbt is to depart from the latent disease model and embrace an idiographic and functional analytic approach. according to hofmann, pbt emphasizes on flexibility and the widening of treatment goals from merely reducing negative affect towards positive affect to social connectedness, purpose, and quality of life. discussion points the main discussion points are summarized in the following: moving away from a syndrome-based approach: is there an additional benefit of process-based therapy as new concept? all panelists agreed on the current issues in clinical research and practice presented by hofmann in his talk: clinical psychology is too focused on the syndrome level, whereby the individual moves more and more in the background, especially in research. psycho­ therapy is a more complex mechanism than just “reducing symptoms” or following treatment protocols. salkovskis and wampold pointed out, that these tedious issues are still leading to a constant formation of “new” therapy approaches which basically are still based on old concepts. these therapy approaches are not supposed to be disorder-specif­ ic but should rather focus on formulation and the client’s adaptation of that formulation as a mechanism of change. this covers helping the client to be less rigid and to formulate alternative interpretations of situations. by working in that collaboration therapy can help the person to learn how to operate in the world. further, the novelty of the pbt approach was questioned as several process or contextual models of therapy were gener­ ated in clinical research over time. other well-established concepts and therapy models were referenced which address similar therapeutic aspects as pbt such as epistemic trust, common factors model, the idea of flexibility or behavioral activation. wampold and salkovskis agreed with hofmann that different approaches and interventions in ther­ apy should be evaluated to improve the understanding of underlying processes. hofmann added that the pbt approach is meant to provide broad guidelines from a wide length of therapeutic strategies to make therapy more individualized. from the pbt perspective therapy is a dynamic process of change. through the complex network concept, it can be visualized and explained to the client as well as systematically adapted as goals change over time within the therapeutic context. finding common ground for modern psychotherapy 4 clinical psychology in europe 2022, vol. 4(1), article e8403 https://doi.org/10.32872/cpe.8403 https://www.psychopen.eu/ concept of learning vs. evolutionary theory the eemm model of pbt is based on an evolutionary perspective on adaptation. build­ ing psychotherapy concepts on evolutionary processes was highly discussed between the panelists. this perspective was compared with learning principles as basic mechanism of therapy, whereas learning itself can be seen as an adaption process. it was pointed out that evolutionary theories are rather associated with long-term development processes on a group level whereas learning principles are possibly more applicable and compre­ hensible for patients on the individual level in a short-term context and therapeutic setting, respectively. where to find the therapeutic relationship in pbt? the therapeutic relationship in the pbt-model can be found and considered in the social dimension. salkovskis, wampold, and barber expressed the idea, to include it in a more salient way into the pbt-model, especially if pbt should present a ground for different psychotherapy traditions. as the need of an evidence-based grounding is crucial in psy­ chotherapy, the therapeutic alliance should be included in experimental psychopathology research. it was proposed to go even further and to include the different aspects of a therapeutic relationship (e.g. communication; expectations about the therapeutic alliance; therapeutic alliance as corrective emotional experience). for psychodynamics this would be essential, as the therapist takes a much more active role in shaping and interpreting the therapist-patient relationship. further on, computerized psychotherapy with no real therapeutic relationship was consulted. even in this context, the therapeutic alliance could be seen as the expertise and authority presumed by the patient of the person they imagine behind the book or the program, whereas trust in the medium is discussed as crucial. in agreement, wampold pointed out that the therapeutic alliance in computer-assis­ ted therapies is just as predictive as in face-to-face therapy. inclusion of different therapy training approaches? pbt aspires to be a therapy schoolindependent approach that integrates different therapy training approaches. in accordance with all panelists, the idea of finding a com­ mon language for different schools of therapy was welcomed. however, it was argued that although the combination in pbt of neurobiological aspects with psychology is admirable, important aspects of psychotherapy in general e.g., the ability to listen to somebody well are not instantly recognizable in this model. it was questioned if pbt rather creates a common language for cognitive-behavioral therapy (cbt) and not for all therapies. in response hofmann pointed out that over the years ‘cbt’ has become a very broad term for a therapy school including constantly evolving therapy approaches hofmann, barber, salkovskis et al. 5 clinical psychology in europe 2022, vol. 4(1), article e8403 https://doi.org/10.32872/cpe.8403 https://www.psychopen.eu/ and clinical strategies which do not necessarily represent the traditional image of cbt. it should therefore just be called “therapy”. implications in psychotherapy training according to hofmann, one core issue is that therapists are mainly trained based on guidelines that are based on disorders, although therapy is a much more complex process than just reducing symptoms. the therapy school approach is too rigid. related to this, the selection of therapist in training itself should be considered. characteristics of a decent human being with the ability to empathize and collaborate with people should be looked out for. the importance of empirical grounding in training and the need of a permanently self-correcting system on the level of own therapy outcomes as well as on the service level was discussed. in this context the example of the iapt improving access for psychological treatment by david clark was proposed (clark, 2018). using feedback systems and informing about deviances from expected improvements, different measures can be taken such as proposing additional supervision or shifting the training. furthermore, to evolve psychotherapy training, the question about what characterizes an effective therapist in delivering different treatments should be addressed. as a main criterion, therapists should be trained, regardless of what model they adopt, to do it effectively. finding common ground for modern psychotherapy 6 clinical psychology in europe 2022, vol. 4(1), article e8403 https://doi.org/10.32872/cpe.8403 https://www.psychopen.eu/ conclusion the present paper summarizes the main discussion points between the panelists jacques barber, stefan hofmann, paul salkovskis, and bruce wampold on finding a common ground in psychotherapy within the context of the pbt model presented by s. hofmann. the common agreement about getting away of a school-dependent system towards a more global approach considering school-independent factors became clear. pbt as a proposed modern therapy approach brought up different points of criticism and addition. the focus on more general evidence-based change processes is welcomed, but a better consideration of common factors was proposed, and the therapeutic alliance was specifi­ cally highlighted to be integrated. moreover, the basic process of psychotherapy based on evolutionary theory in pbt was balanced against using the basic principles of learning. to conclude, the way to a common ground in psychotherapy is a highly important and well discussed topic, and when further perspectives are integrated, this can result in a dynamic and developing meta-model for psychotherapy. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: winfried rief is editor-in-chief of clinical psychology in europe but played no editorial role for this particular article. references clark, d. m. (2018). realizing the mass public benefit of evidence-based psychological therapies: the iapt program. in t. widiger & t. d. cannon (eds.), annual review of clinical psychology (vol. 14, pp. 159-183). https://doi.org/10.1146/annurev-clinpsy-050817-084833 eaclipt task force on “competences of clinical psychologists”. (2019). competences of clinical psychologists. clinical psychology in europe, 1(2), article e35551. https://doi.org/10.32872/cpe.v1i2.35551 goldfried, m. r. (2020). the field of psychotherapy: over 100 years old and still an infant science. clinical psychology in europe, 2(1), article e2753. https://doi.org/10.32872/cpe.v2i1.2753 hayes, s. c., & hofmann, s. g. (2018). process-based cbt: the science and core clinical competencies of cognitive behavioral therapy. new harbinger publications. hofmann, s. g., curtiss, j., & mcnally, r. j. (2016). a complex network perspective on clinical science. perspectives on psychological science, 11(5), 597–605. https://doi.org/10.1177/1745691616639283 rief, w. (2021). moving from tradition-based to competence-based psychotherapy. evidence-based mental health, 24, 115–120. https://doi.org/10.1136/ebmental-2020-300219 hofmann, barber, salkovskis et al. 7 clinical psychology in europe 2022, vol. 4(1), article e8403 https://doi.org/10.32872/cpe.8403 https://doi.org/10.1146/annurev-clinpsy-050817-084833 https://doi.org/10.32872/cpe.v1i2.35551 https://doi.org/10.32872/cpe.v2i1.2753 https://doi.org/10.1177/1745691616639283 https://doi.org/10.1136/ebmental-2020-300219 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. finding common ground for modern psychotherapy 8 clinical psychology in europe 2022, vol. 4(1), article e8403 https://doi.org/10.32872/cpe.8403 https://www.psychopen.eu/ finding common ground for modern psychotherapy (introduction) an introduction to process-based psychotherapy by hofmann discussion points moving away from a syndrome-based approach: is there an additional benefit of process-based therapy as new concept? concept of learning vs. evolutionary theory where to find the therapeutic relationship in pbt? inclusion of different therapy training approaches? implications in psychotherapy training conclusion (additional information) funding acknowledgments competing interests references case conceptualization in clinical practice and training scientific update and overview case conceptualization in clinical practice and training eva gilboa-schechtman 1 [1] department of psychology and the gonda brain research center, bar-ilan university, ramat-gan, israel. clinical psychology in europe, 2024, vol. 6(special issue), article e12103, https://doi.org/10.32872/cpe.12103 received: 2023-06-03 • accepted: 2023-08-22 • published (vor): 2024-04-26 handling editor: wolfgang lutz, department of psychology, university of trier, trier, germany corresponding author: eva gilboa-schechtman, department of psychology and the gonda brain science center, bar-ilan university, ramat-gan, 52900, israel. tel: 972-3-531-8744. e-mail: evagilboa@gmail.com related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract case conceptualization is central to the success of the therapeutic process. however, integrative case conceptualization research has lagged behind research on integrating therapeutic intervention techniques. a successful case conceptualization provides (a) a dynamic, context-sensitive, yet parsimonious model of the client’s functioning; (b) relevant treatment targets and associated assessment procedures; and (c) a treatment plan including intervention phases and potential obstacles. success in case conceptualization is a core clinical competency goal for trainees in clinical psychology and a career-long learning goal even for expert clinicians. emerging technological trends and the formation of adversarial collaborative teams may assist research on the utility of well-constructed case conceptualizations. keywords case conceptualization, case formulation, integration, personalized treatment, supervision highlights • case conceptualization is central to the success of the therapeutic process. • a successful case conceptualization promotes effective and personalized interventions. • research on integrative case conceptualization is lagging behind treatment by a factor of 1:100. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12103&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0002-2831-5835 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ case conceptualization: there is nothing more practical than a good theory the global burdens associated with many common mental health conditions appear unaffected by diagnosis, prevention, and treatment advances, impacting individuals’, families’, and societies’ quality of life (bruffaerts et al., 2018). given this discouraging situation, calls are made to create trans-theoretical and empirically based ways of ap­ proaching mental health difficulties, combining elements from diverse treatment orienta­ tions to personalize treatments (lutz & schwartz, 2021; schiepek & pincus, 2023). in the following, i argue that the first step to such an integration is enhanced attention to a clinically central stage of the therapeutic process: case conceptualization. our lives are dynamic, and our goals, concerns, behaviors, and aspirations are modi­ fied in response to various challenges and opportunities. our difficulties and strengths are similarly sensitive to various biological, psychological, and sociocultural processes and factors. thus, there is wide agreement that psychiatric diagnoses are insufficient for clinical practice because they provide only a subset of the information clinicians need to help their patients. case conceptualization, also known as case formulation, is created to weave a complete understanding of a person, of which diagnosis is only one aspect (mcwilliams, 2021). case conceptualization is a comprehensive and individualized understanding of a client’s presenting concerns, psychological symptoms, and interper­ sonal patterns. it thus integrates information from various sources, such as client inter­ views, assessment tools, and clinical observations. this information is used to formulate hypotheses regarding the factors responsible for developing (etiology) and maintaining the client’s pattern of difficulties. case conceptualization aims to create a coherent and succinct narrative that provides a plausible framework for understanding the client’s difficulties and informs treatment planning (british psychological society, division of clinical psychology, 2011; eells, 2015, 2022a; johnstone & dallos, 2014; persons, 2022; sperry & sperry, 2020). case conceptualization may serve as a linchpin between initial clinical assessment, personalized treatment development, and the intervention’s efficacy evaluation. a com­ prehensive, well-informed, theoretically rich (and thus, integrative), and source-diverse conceptualization will likely advance the construction of an effective and flexible treat­ ment plan. in contrast, an insufficiently detailed or biased assessment is likely to result in a misguided conceptualization that leads, in turn, to an ill-formed treatment plan. importantly, case conceptualization is an evolving process: throughout the therapeutic process, case conceptualization is continually refined and updated to reflect new informa­ tion, insights, and responsivity to specific triggers and interventions. integrative case conceptualization – case conceptualization informed by multiple in­ terwoven theoretical perspectives – is crucial if a treatment plan is also to be informed by such an integrative perspective. yet, despite the centrality of case conceptualization for treatment planning, only a few dozen articles have been published in the last decade case conceptualization in clinical practice and training 2 clinical psychology in europe 2024, vol. 6(special issue), article e12103 https://doi.org/10.32872/cpe.12103 https://www.psychopen.eu/ concerning case conceptualization (or formulation) and integration1. this paucity is strik­ ing compared to a few thousand papers concerning treatment integration. this factor of 1:100 favoring the focus on intervention is maintained when we examine the direct com­ parison of two central research approaches – psychodynamic and cognitive-behavioral.2 case conceptualization: an attempt at theoretical integration a case conceptualization needs to integrate diverse and complex information. first, it needs to include both nomothetic and idiographic information. the nomothetic informa­ tion is derived from empirically supported models of individual differences, while the idiographic information contains specific data regarding the individual’s idiosyncratic history, concerns, motivations, and aspirations. one of the main goals of case concep­ tualization is to connect the specific patterns of distress that bring the individual to treatment (idiographic concerns) with this rich database of nomothetic information. for example, it is important to assess which symptoms of distress are specifically significant for this client. indeed, recent research suggests the need to broaden and refine our defi­ nitions of distress even in the most well-known conditions, such as depression, post-trau­ matic stress disorder, and social anxiety (gilboa-schechtman, 2020; gilboa-schechtman et al., 2020; keshet & gilboa-schechtman, 2017). moreover, standard clinical measures of depression have been criticized for measuring domains of limited relevance to patients and leaving out significant areas of concern, such as sick leave, work difficulties, or impaired relationships (fried & nesse, 2015). second, a case conceptualization needs to integrate information from several time frames. a macro timescale (decades, years) may include information concerning the client’s personal history from early childhood to the present and their aspirations and concerns about the future. the ability of the client to achieve developmental milestones (such as moving to independent living) and handle common stressors (loss of a relationship or a job) is important for the eventual under­ standing of the person’s vulnerabilities and areas of resilience. a meso timescale (weeks, days) may include data concerning their affect, behavior, cognition, and physiological reactions in the period preceding their turn to treatment. finally, micro timescale (hours, minutes) information may include multi-modal data concerning their response to in-ses­ sion interactions. this information may be used to examine the way clients experience 1) psychnet for 2013-2023 identified 33 peer-reviewed articles published with “integrat*” and “case conceptualiza­ tion” or “case formulation” as the keywords. this is compared to 3434 articles with “therap*” or “treatment*,” or “intervention*,” and “integrat*” in keywords. 2) psychnet for 2013-2023 identified 65 articles published with the keywords “case conceptualization” or “case formulation” crossed with “cognitive-behavioral” or cbt or “psychodynamic”. this is compared to 9193 peer-reviewed articles with “therapy,” “treatment”, or intervention,” were crossed with cognitive-behavioral,” or“psychodynamic.” gilboa-schechtman 3 clinical psychology in europe 2024, vol. 6(special issue), article e12103 https://doi.org/10.32872/cpe.12103 https://www.psychopen.eu/ their therapists and therapists’ responses to their clients. third, case conceptualization needs to consider how culture (communal, individualistic) and societal context (such as social class or sexual orientation) impact our lives. importantly, culture affects not only our values (e.g., honoring the dead, obedience), beliefs (say, “direct communication is important,” “time progresses linearly”), and coping strategies (such as help-seeking from family and friends, prayers, and spiritual practices), but also the emotions that we value and cherish (for example, the value of individualistic pride appears to be higher in western than non-western cultures, kitayama et al., 2006). social class impacts thoughts, feelings, and behavior (manstead, 2018; stephens et al., 2014). understanding how our identities, shaped by culture and context, intersect offers a greater depth of the client’s history and challenges. fourth, the construction of a comprehensive case conceptualization may involve, when possible, information from several perspectives, including the individual’s own experiences, as well as input from family members, other healthcare providers, and the therapist’s own evaluation of the client’s behavior during the assessment and the treatment processes. clinically, the development of a case conceptualization involves several steps. first, identifying the client’s presenting problems, such as the specific symptoms, issues, or difficulties the client is experiencing. these can be emotional, cognitive, behavioral, or interpersonal in nature. second, understanding the client’s background and context by exploring their personal history, family dynamics, social environment, and cultur­ al background may contribute to developing or maintaining their difficulties. indeed, the first two stages offer the opportunity to utilize diverse theoretical orientations, as different orientations emphasize diverse sources of information as significant (e.g., early family dynamics, genetic factors, learning history). third, assessing the client’s strengths and resources: social and intellectual skills, coping mechanisms, and social support. fourth, formulating hypotheses about the underlying mechanisms or patterns that contributing to the client’s difficulties. crucially, these hypotheses can be informed by various psychological theories or models, such as cognitive-behavioral (cbt), psycho­ dynamic, humanistic, or trans-theoretical perspectives (e.g., eubanks & goldfried, 2019). cbt makes an important distinction between etiological and maintenance factors for disorders. including diverse factors in the conceptualization (wong & rapee, 2016 in the case of social anxiety disorder) may clarify the immediate and long-term treatment targets. fifth, establishing treatment goals. in collaboration with the client, the clinician can set specific, measurable, and achievable goals for therapy, which will address the identified problems and promote overall well-being. again, such goals may be enriched by inputs from trans-theoretical models of psychotherapy (bailey & ogles, 2023) and include, besides, reduction of distress, increase in insight, and in self-efficacy. finally, developing an individually tailored intervention plan that outlines the therapeutic ap­ proaches, techniques, and strategies that will be employed to help the client achieve their goals. thus, case conceptualization serves as a roadmap for both the therapist and the case conceptualization in clinical practice and training 4 clinical psychology in europe 2024, vol. 6(special issue), article e12103 https://doi.org/10.32872/cpe.12103 https://www.psychopen.eu/ client, guiding the direction and focus of therapy and helping to monitor progress and outcomes. training implications case conceptualization is a widely agreed upon core clinical competency (eells, 2022a; page et al., 2008; rief, 2021; sperry & sperry, 2020). this competency is based on theories of personality and psychopathology, coursework on assessment and diagnostics, and the treatment outcome literature learned in lectures and dialogues conducted during clinical supervision. thus, clinical supervision aims to assist supervisees in shifting from abstract knowledge about case conceptualization to the case-specific clinical implementation of this knowledge (page et al., 2008). case conceptualization can be thought of as a model of the client’s intraand inter­ personal dynamics. given that models are inherently “wrong” in that they are incomplete approximations of reality, the utility of a model for clinical inference is determined by its ability to provide actionable insights for psychotherapy (fried, 2020). clinical supervision needs to help trainees find a compromise between simple models and elabo­ rated models by emphasizing that the model is as good as the insights into treatment planning it allows. whereas most beginner clinicians can identify some presenting prob­ lems, strengths, and precipitating factors, elements of the conceptualization concerning etiological and maintaining mechanisms are typically more difficult to articulate. formu­ lating and testing nuanced hypotheses inherent in each conceptualization is an elusive yet important part of the conceptualization (ridley et al., 2017). this elusiveness is illustrated in the study by eells and colleagues, who found that experienced clinicians with decades of professional experience were almost as likely to include a psychological mechanism in their case conceptualization as novices (eells et al., 2005). another study with experienced clinicians providing a psychodynamic conceptualization found that many clinicians used a relatively low inference level and an experience-near terminology, again suggesting that many therapists introduce few maintenance mechanisms in their case conceptualizations (sørbye et al., 2019). providing a specific structure for the case conceptualization and encouraging trainees to refer to all components of the conceptuali­ zation may improve the completeness and quality of their models. one of the most important tasks of the supervisor is the gentle yet consistent encour­ agement to construct a “good enough” conceptualization at the onset of treatment. there is extensive agreement that an early attempt to construct a case conceptualization is an important and necessary foundation for competent practice in several approaches (cbt; kuyken et al., 2009; persons, 2008), dynamic therapy (mcwilliams, 2011; shedler, 2022), and interpersonal therapy (hopwood et al., 2019). moreover, there is an emergent agreement regarding the clinical importance of the involvement of clients in case con­ ceptualization, goal setting, and treatment planning (beck et al., 1979; hopwood et al., gilboa-schechtman 5 clinical psychology in europe 2024, vol. 6(special issue), article e12103 https://doi.org/10.32872/cpe.12103 https://www.psychopen.eu/ 2019; kuyken et al., 2009; mcfarquhar et al., 2023; tee & kazantzis, 2011). such client involvement is crucial for enhancing the transparency of clinical practice and facilitating the client’s understanding of – and, therefore, engagement in – therapy itself. a competently developed, high-quality conceptualization goes beyond a summary of information about the client (eells et al., 2005). it is important to enhance the trainees’ ability to check their conceptualization for completeness (eells, 2013). specifically, the case conceptualization should be (a) comprehensive in addressing multiple aspects of a client’s functioning; (b) understandable to the client and thus use language that is precise and non-technical; (c) parsimonious yet not simplistic; (d) coherent, providing an internal­ ly consistent model of the individual’s problems, explaining the presenting complaints by reference to predisposing vulnerabilities and strengths, precipitating events, etiological and maintaining factors; (e) science-informed, offering explanatory hypotheses linked to knowledge about personality and psychopathology; (f) generative, highlighting the ways in which the treatment plan logically flows from the explanatory hypotheses and predicts measurable outcomes; and finally, (g) cohesive, offering a treatment plan that links the hypotheses with a therapeutic course of action. ultimately, it is important to stress to trainees that the skill of conceptualizing in­ volves career-long learning. case conceptualization is a complex process that requires clinicians to draw on a wide range of theoretical and practical knowledge to understand each client’s unique needs and challenges. by promoting career-long learning, we can continually expand our knowledge base and develop new skills that can enhance our ability to formulate effective treatment plans for our clients. additionally, ongoing men­ toring and supervision can provide clinicians with feedback and guidance that can help us refine our case formulation skills and approaches. supervisors who view clinical science as a process of continuous development and who model intellectual humility and healthy skepticism as parts of their professional improvement process are likely to foster up-to-date psychological methods among their supervisees. this, in turn, can lead to more effective treatment outcomes for clients and enhance the overall quality of clinical practice. research on case conceptualization research on case conceptualization traditionally examined questions of validity and reliability (easden & kazantzis, 2018; eells, 2022b). most studies evaluate the reliability of various case conceptualization methods to assess whether different clinicians, using the same case conceptualization approach, arrive at similar or consistent conceptualizations for a given client or case. this line of research typically involves comparing the concep­ tualizations of multiple clinicians who independently review the same case information (easden & kazantzis, 2018; persons & hong, 2015). case conceptualization in clinical practice and training 6 clinical psychology in europe 2024, vol. 6(special issue), article e12103 https://doi.org/10.32872/cpe.12103 https://www.psychopen.eu/ the validity of case conceptualization examines the extent to which different concep­ tualization methods accurately capture and explain the client’s presenting problems, underlying mechanisms, and treatment progress (easden & kazantzis, 2018; horowitz et al., 1995). validity is typically established when predictions made by a case concep­ tualization match actual treatment outcome or when different approaches arrive at similar conclusions (bucci, french, & berry, 2016; mumma, 2011; mumma et al., 2018). indeed, examining the clinical advantage of case conceptualization involves assessing whether more accurate, thorough, or complete case conceptualizations are associated with better treatment outcomes, such as reduced distress, increased client satisfaction, or enhanced therapeutic alliance, yet only scant research has examined this question (bucci et al., 2016). to further examine the effectiveness of different case conceptualiza­ tion approaches, researchers may conduct well-powered randomized controlled trials or comparative studies investigating whether certain case conceptualization approaches lead to better treatment outcomes than others or whether specific approaches are more suitable for particular client populations, problem areas, or therapeutic modalities (see eells, 2022b for a review of initial attempts in this direction). additional important questions involve the role of therapist factors (e.g., training, experience, theoretical orientation) in the comprehensiveness and effectiveness of case conceptualization. finally, the importance of the timing of case conceptualization may be explored, and the timing of the construction and sharing of case conceptualization with clients may be examined. for example, research may compare sharing a case conceptualization with the client early in treatment (in the first third of the treatment sequence) versus late treatment (in the middle or the final third of the treatment se­ quence). such research can use case conceptualization methodologies to translate the idiographic nature of psychotherapy into quantitative research designs (haynes et al., 2009; kramer, 2020). for example, when idiosyncratic mechanisms are defined (e.g., over-utilization of cues of social status as opposed to cues of affiliation in social anxiety, gilboa-schechtman, 2020), the outcomes of these specific mechanisms can be assessed in a quantitative design. a way forward an ongoing challenge for reliable, valid, and therapeutically useful clinical case concep­ tualization is the time constraints for completing this complex task. however, we are witnessing exciting advances promising to assist us in the timely completion of this task. on the methodological side, with the advancement of ecological momentary assess­ ment (ema, mostly relying on self-report), ambulatory monitoring (which may include physiological data), and routine outcome assessment (e.g., schaffrath et al., 2022) we can look forward to collecting a wealth of data about a single individual from a variety of intra-personal (including physiology, behavior, passive sensing of a digital footprint, and gilboa-schechtman 7 clinical psychology in europe 2024, vol. 6(special issue), article e12103 https://doi.org/10.32872/cpe.12103 https://www.psychopen.eu/ expressive signals such as voice, as well as subjective self-report) as well as interpersonal (e.g., family, close friends) sources. with advancing technology, techniques enabling the automated analysis of such intensive data will become increasingly available. such innovations require a willingness to critically evaluate and adapt one’s own clinical practice based on emerging clinical tools, empirical findings, and client feedback. on the theoretical side, a unified effort to foster adversarial collaborations between representatives of diverse schools of clinical thought in creating a comprehensive scheme for case conceptualization appears to be needed. these collaborations may enhance trans-diagnostic approaches and pluralism by increasing awareness of confirmation biases inherent in any one approach (doherty et al., 2019). adversarial collaborations may also help representatives from various schools of thought clarify and refine the assumptions underlying the components needed for a successful case conceptualization. such collaborations may strengthen the link between research in psychopathology and psychotherapy and foster integration between treatment orientations. funding: financial support from the israeli science foundation (isf grant 796/22) is gratefully acknowledged. acknowledgments: i thank eshkol rafaeli and alexandra klein for their helpful comments and an anonymous referee for his/her insightful and helpful suggestions. competing interests: the author has declared that no competing interests exist. references bailey, r. j., & ogles, b. m. 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(2016). the aetiology and maintenance of social anxiety disorder: a synthesis of complementary theoretical models and formulation of a new integrated model. journal of affective disorders, 203, 84–100. https://doi.org/10.1016/j.jad.2016.05.069 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. gilboa-schechtman 11 clinical psychology in europe 2024, vol. 6(special issue), article e12103 https://doi.org/10.32872/cpe.12103 https://doi.org/10.1002/jclp.23362 https://doi.org/10.1002/capr.12641 https://doi.org/10.1186/s40359-019-0337-5 https://doi.org/10.1146/annurev-psych-010213-115143 https://doi.org/10.1111/j.1468-2850.2010.01234.x https://doi.org/10.1016/j.jad.2016.05.069 https://www.psychopen.eu/ case conceptualization in clinical practice and training case conceptualization: there is nothing more practical than a good theory case conceptualization: an attempt at theoretical integration training implications research on case conceptualization a way forward (additional information) funding acknowledgments competing interests references why we need a stronger focus on women’s health in clinical psychology and psychological treatment editorial why we need a stronger focus on women’s health in clinical psychology and psychological treatment cornelia weise 1 § , carola hajek gross 2 § [1] clinical psychology and behavioral health technology, department of psychology, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany. [2] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. §these authors contributed equally to this work. clinical psychology in europe, 2024, vol. 6(3), article e15683, https://doi.org/10.32872/cpe.15683 published (vor): 2024-09-30 corresponding author: cornelia weise, clinical psychology and behavioral health technology, department of psychology, friedrich-alexander-universität erlangen-nürnberg, nägelsbachstraße 49b, 91052 erlangen, germany. email: cornelia.weise@fau.de despite advances in healthcare, women’s health issues—both physical and mental—re­ main underrepresented, underserved, and often misunderstood. the field of “gender medicine” highlights that many diseases manifest differently across various genders1 (mauvais-jarvis et al., 2020). yet these differences are frequently neglected, leading to suboptimal care and increased health risks for women. a striking example is cardio­ vascular disease: women are significantly more likely to die from heart attacks than men, partly because their symptoms, such as nausea, fatigue, and back pain, are easily overlooked compared to the classic chest pain seen in men (mousavi et al., 2023; van oosterhout et al., 2020). moreover, women are often underrepresented in medical clinical trials, and even when included, the unique impacts of therapies on women are often overlooked (kalathoor et al., 2024; vitale et al., 2017). this bias reflects a broader issue: medicine often treats men as the default, neglecting the specific needs of women. while clinical psychology exhibits a more balanced gender representation, the bias in medicine carries over, when psychological perspectives are applied to women's medical issues. 1) for the purposes of this paper, 'women' refers to individuals with a uterus. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.15683&domain=pdf&date_stamp=2024-09-30 https://orcid.org/0000-0001-5216-1031 https://orcid.org/0000-0001-5734-1293 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ women face unique health challenges that significantly impact their mental health several women-specific factors increase the risk of mental health disorders, with repro­ ductive events, gender-based violence, socioeconomic factors, and hormonal fluctuations being prominent examples. reproductive events such as miscarriage, infertility, or fear of childbirth often cause intense emotional distress, contributing to anxiety and depressive symptoms (e.g., cuenca, 2023). likewise, perinatal post-traumatic stress disorder is often overlooked or inadequately managed despite evidence that trauma-informed maternity care can drastically improve outcomes for affected women (horsch et al., 2024). genderbased violence, including sexual assault and domestic abuse, have a profound impact on mental health and often lead to trauma-related disorders (e.g., sediri et al., 2020). socioe­ conomic challenges, such as the significantly higher poverty risk among single mothers (hübgen, 2020; lu et al., 2020) contribute to chronic stress and burnout, further elevat­ ing the risk of anxiety and depression (soares et al., 2007). fluctuations in hormonal balance, such as those occurring during the menstrual cycle, pregnancy, or menopause, can exacerbate or trigger psychological complaints (albert & newhouse, 2019; behrman & crockett, 2023; nolan & hughes, 2022). premenstrual dysphoric disorder (pmdd) is one example where hormonal changes during the menstrual cycle can lead to severe depressive and anxiety symptoms. hormonal fluctuations also affect stress-response sys­ tems, including cortisol and alpha-amylase levels (hantsoo et al., 2023; helpman, 2023) and are closely linked to other conditions such as endometriosis or polycystic ovary syndrome (pcos). those affected experience both debilitating physical symptoms (e.g. chronic pain), and significant emotional distress (chen et al., 2021; dutkiewicz et al., 2024; silva et al., 2024). this dual burden often restricts participation in social, family and working life, exacerbating psychological distress and potentially resulting in financial strain, particularly for women juggling caregiving responsibilities (della corte et al., 2020). the covid-19 pandemic further intensified these burdens, as many women faced disrupted routines, increased caregiving responsibilities, and limited access to healthcare services (di blasi et al., 2021). despite their prevalence and substantial economic burden, these conditions often remain underdiagnosed or untreated (azziz et al., 2005; ruszała et al., 2022). a critical need for gender-specific treatment approaches women’s mental and physical health are deeply interconnected, necessitating treatment strategies based on a biopsychosocial understanding of their unique needs (engert et al., 2020). recent research indicates that psychotherapeutic interventions can alter bio­ logical markers, underscoring the potential for gender-sensitive approaches to enhance women’s health in clinical psychology 2 clinical psychology in europe 2024, vol. 6(3), article e15683 https://doi.org/10.32872/cpe.15683 https://www.psychopen.eu/ outcomes for female patients (laufer et al., 2018). by integrating both psychological and physiological factors into treatment, we can more effectively address the full scope of women’s health conditions. for instance, our recent intervention for endometriosis, rooted in cognitive-behavioral therapy (cbt) and a biopsychosocial framework, has been well-received by patients, who appreciate the focus on psychological distress associated with the chronic condition (schubert et al., 2022). barriers to effective psychotherapeutic support despite the clear need for gender-sensitive mental health care, several barriers prevent women from receiving adequate support. this is often due to a lack of awareness of the psychological impacts of their physical symptoms, or the fear that their distress will be dismissed (salk et al., 2017). compounding this issue, many healthcare providers are not adequately trained to identify and address gender-specific health concerns, creating significant gaps in care. endometriosis provides a striking example of this problem: symptoms are frequently trivialized with menstrual pain often dismissed as "normal". this misconception contributes to an alarming delay in diagnosis – an average of 10 years in german-speaking countries (hudelist et al., 2012). such delays are particularly concerning because prolonged unmanaged pain can lead to central sensitization, where the nervous system becomes hypersensitive to pain stimuli, making treatment more complex and less effective (hudelist et al., 2012; mechsner, 2022). failure to address the psychological aspects of chronic conditions like endometriosis represents a missed op­ portunity to alleviate suffering and modulate the pain experience. while some promising multidisciplinary programs have been developed (e.g.; cunningham et al., 2024; weise et al., 2019), they remain underutilized. towards a gender-sensitive approach in clinical psychology to improve women's health outcomes, clinical psychology must broaden its scope and address the unique mental health needs of women, particularly in relation to physical health conditions. this calls for stronger interdisciplinary cooperation between psycho­ therapists and medical practitioners, such as gynecologists and endocrinologists (nagel et al., 2013). medical professionals need training in gender-specific health to identify early signs of mental distress and facilitate referrals. psychotherapists should develop expertise in conditions like endometriosis and pmdd, as well as in understanding the impact of hormonal changes across life stages on mental health. research suggests that synchronizing psychological interventions with menstrual cycle phases could enhance their effectiveness, given the influence of estradiol and weise & hajek gross 3 clinical psychology in europe 2024, vol. 6(3), article e15683 https://doi.org/10.32872/cpe.15683 https://www.psychopen.eu/ progesterone (nillni et al., 2021). however, the limited number of studies highlight the need for further research. additionally, incorporating psychophysiological assessments (e.g., cortisol and oxytocin levels) could help refine psychotherapeutic approaches to better align with women’s stress-responses (fischer & zilcha-mano, 2022). evidence-based treatments such as cognitive-behavioral therapy (cbt) have proven effective in reducing the psychological burden of chronic physical illnesses (e.g., chalder et al., 2023; weise et al., 2016). however, these interventions are still scarce in the field of women’s health and not widely accessible, particularly within resource-constrained public health systems (hansen et al., 2023). expanding such integrated interventions will improve care by ensuring more holistic and personalized treatment. despite the potential of integrated care models, particularly in the field of behavioral medicine, many women face significant barriers to timely mental health care. time constraints, caregiving duties, and the stigma surrounding mental health issues often prevent women from seeking support. addressing these barriers requires more flexibility in clinical psychology, such as offering flexible schedules, remote psychotherapy, individ­ ualized interventions based on the biopsychosocial model, or improved access to online interventions. policymakers must also foster research in gender-specific health care to ensure treatments that address the needs of diverse genders. with growing awareness and emerging innovative approaches (e.g.; cunningham et al., 2024; weise et al., 2019), there is significant potential to improve women’s mental health. funding: the authors have no funding to report. acknowledgments: the authors wish to thank nadine then for her valuable support during the literature review. competing interests: cornelia weise is editor-in-chief of clinical psychology in europe. references albert, k. m., & newhouse, p. a. 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(2016). internet-delivered cognitive-behavior therapy for tinnitus: a randomized controlled trial. psychosomatic medicine, 78(4), 501–510. https://doi.org/10.1097/psy.0000000000000310 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. women’s health in clinical psychology 8 clinical psychology in europe 2024, vol. 6(3), article e15683 https://doi.org/10.32872/cpe.15683 https://doi.org/10.1097/psy.0000000000000310 https://www.psychopen.eu/ women’s health in clinical psychology (introduction) women face unique health challenges that significantly impact their mental health a critical need for gender-specific treatment approaches barriers to effective psychotherapeutic support towards a gender-sensitive approach in clinical psychology (additional information) funding acknowledgments competing interests references why did our trial not work out? a qualitative analysis research articles why did our trial not work out? a qualitative analysis eva heim 1 , bleta ademi 1, ardiana dacaj 1, nadine hosny 1 , sebastian burchert 2 , arlinda cerga pashoja 3,4 , anna hoxha 5, mirëlinda shala 6 [1] institute of psychology, university of lausanne, lausanne, switzerland. [2] department of education and psychology, division of clinical psychological intervention, freie universität berlin, berlin, germany. [3] faculty of population health, london school of hygiene and tropical medicine, london, united kingdom. [4] st marys university, twickenham, london, united kingdom. [5] department of psychology, university of zurich, zurich, switzerland. [6] department of economics, lucerne university of applied sciences and arts, lucerne, switzerland. clinical psychology in europe, 2024, vol. 6(2), article e12887, https://doi.org/10.32872/cpe.12887 received: 2023-09-27 • accepted: 2024-05-06 • published (vor): 2024-06-28 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: eva heim, institut de psychologie, université de lausanne, géopolis, bureau 4114, 1015 lausanne, switzerland. tel: +41 21 692 31 75. e-mail: eva.heim@unil.ch supplementary materials: materials [see index of supplementary materials] abstract background: an online self-help programme for the treatment of depression called hap-pas-hapi was tested among albanian-speaking immigrants in switzerland and germany, and two different levels of cultural adaptation were compared. despite a massive recruitment effort, an insufficient number of participants could be recruited, and the drop-out rate was over 90%. aims: we conducted a qualitative study to better understand the reasons for the non-use of happas-hapi. method: eleven interviews were conducted with 17 albanian-speaking participants aged 19-59. participants were recruited for the purpose of this study and were not participants from the trial. they went through the recruitment material and the hap-pas-hapi introduction module, commented on the graphic design, usability, content, and shared their views about mental health and self-help. results: participants criticised the lack of a “design system” (i.e., a clearly identifiable and consistent graphic design) on social media for hap-pas-hapi, and the recruitment messages were unclear. the programme itself was perceived to be important and helpful for the community at large, but most participants said that they would not use it for themselves. the younger generation would have preferred an application in german or french, while the older generation did not see a benefit in using an online self-help programme to manage their psychological distress. negative this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12887&domain=pdf&date_stamp=2024-06-28 https://orcid.org/0000-0001-7434-7451 https://orcid.org/0000-0002-6666-7524 https://orcid.org/0000-0003-3126-5485 https://orcid.org/0000-0002-7029-947x https://orcid.org/0000-0001-6997-467x https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ beliefs about mental disorders and psychological interventions were perceived to be common in this target group. discussion: a professional recruitment strategy, a more careful selection of the target population (e.g., age groups) and different kinds of adaptations might have resulted in a better acceptance of the intervention. at the same time, anti-stigma campaigns and psychoeducation are needed to enhance treatment motivation. keywords cultural adaptation, online self-help, albanians, ethnic minorities, access to care, recruitment highlights • our randomised controlled trial among albanian-speaking immigrants encountered major challenges. • considering different age groups within the target population might have made a difference. • a professional recruitment strategy and a consistent graphic design on social media was suggested. • negative beliefs about mental health services need to be addressed in the target population. background we recently published the results of a randomised controlled trial (rct) that was con­ ducted among the albanian-speaking population in switzerland and germany (heim et al., 2024, this issue). in this rct, we aimed to compare two levels of cultural adaptation of an online self-help intervention called hap-pas-hapi (albanian for step-by-step) for the treatment of depression (carswell et al., 2018; shala et al., 2020a). a massive recruit­ ment effort through different channels resulted to be ineffective: instead of the targeted n = 320 participants, we were able to recruit n = 97 (completed baseline assessments). more than half (56%) of the consented participants did not complete the baseline assess­ ments. furthermore, drop-out rates (completed post-assessment) were over 90% in both treatment conditions (i.e., surface vs. deep structure level adaptation), with no observed differences between groups. there are several potential explanations for these difficulties. first, it is possible that the recruitment strategy did not reach the community. second, it could be that the recruitment strategy reached the community, but it was not clear what hap-pas-hapi was, or how it could be beneficial. and third, we must also consider the possibility that the recruitment strategy was seen and was properly understood by the community, but hap-pas-hapi may not fulfil the needs of this particular target population. there are compelling reasons to reject the first hypothesis. we achieved up to 23,000 reaches through our facebook ads. the events (online and face-to-face) that were organ­ learning from a trial that did not work out 2 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://www.psychopen.eu/ ised among albanian associations (see heim et al., 2024, this issue) were well attended, and we received very positive feedback about the project and hap-pas-hapi. albanianspeaking health professionals in switzerland and germany promoted the intervention among their patients and within their networks, and a group of “cultural brokers” (wenger, 1998) tried to reach participants outside the health sector. thus, given the resources and efforts put into promoting the study, it seems unlikely that the albanian community would have missed information on the project or the opportunity to sign up. as a second option, hap-pas-hapi, the study, or some related aspects might have been misconceived or misinterpreted by the community. in other words, our recruitment strategy and the introduction module of the intervention might have missed the central messages, might have contained messages that were not relevant, or might even have caused resistance or mistrust. for this option, it is important to consider that the alba­ nian community in switzerland and germany is highly diverse, including people from different countries of origin who immigrated for a variety of reasons, including labour migration, family reunion and armed conflicts (shala et al., 2020b). second-generation immigrants differ from first-generation immigrants regarding their relationship with albanian culture, their integration in switzerland, their expression of psychological distress, and their attitudes towards mental health services (pnishi et al., 2024). all these aspects must be considered when reflecting about messages and contents of recruitment materials and the platform. the third explanation, i.e., that hap-pas-hapi is not relevant for the community or does not correspond to a real need, must be considered, as well. there are some indica­ tions suggesting that this is not the case. in a representative study, the swiss health observatory (obsan) found that the risk for mental distress was twice as high (relative risk = 2.0) among first-generation immigrants aged 50-64 than among natives of the same age group. our own ethnopsychological studies also showed pronounced psychological distress among albanian-speaking individuals in switzerland (pnishi et al., 2024; shala et al., 2020b). in addition, the online self-help intervention has shown to be acceptable and efficacious in two large-scale rcts in lebanon among syrian displaced people and the lebanese population (cuijpers et al., 2022a; cuijpers et al., 2022b). in these trials, more than 1200 participants were recruited within six months, during the covid pandemic and amidst major economic, social, and political turmoil. drop-out rates (completed post-assessment) were much lower, i.e., 65% in the lebanese population (cuijpers et al., 2022a) and 46% among syrian refugees (cuijpers et al., 2022b). in summary, there seems to be a need in terms of psychological distress in the target population, and the intervention itself was tested successfully under challenging conditions in a different setting. hence, to better understand the reasons and factors that contributed to the low uptake and high attrition in our trial, we conducted a qualitative study with albanianspeaking participants in switzerland who participated in semi-structured interviews. in heim, ademi, dacaj et al. 3 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://www.psychopen.eu/ our ethnopsychological studies that were conducted prior to adapting hap-pas-hapi, we had identified clear differences between the older first-generation immigrants, and the younger second-generation group, regarding their cultural concepts of distress and treatment expectations (pnishi et al., 2024; shala et al., 2020b). therefore, we aimed to include both groups in this post-hoc qualitative study, to better understand their views. method participants and procedures seventeen (eight female and nine male) participants were interviewed in this study. inclusion criteria were: albanian origin (i.e., albania, macedonia, and kosovo); under­ standing of albanian language; age 18-65. the participants’ age range was 19-59 years old where nine individuals were 19-27 years old, and eight were between 45-59 years old. participants were recruited by two albanian-speaking master students at the university of lausanne through their respective social networks including facebook, instagram, emails, and face to face communications. some of the participants were personal acquain­ tances of the two master students who conducted the interviews. most interviews were conducted in french and two in albanian language. participants were informed about their voluntary participation, their right to withdraw from the study without giving any reasons, data protection, and the use of the results. they signed an informed consent form before starting the interview. participants received a voucher of chf 50 for their time and travel due to participation in the study. the study was revised and approved by the ethical review commission of the university of lausanne (e-ssp-072o22-oo). ba and ad conducted 11 interviews: four were conducted with pairs, i.e., participants of two different age groups; one with three participants and six were individual inter­ views. we anticipated that discussions among two participants of different age groups could reveal potentially diverging views. by contrast, the method of larger focus groups was not deemed efficient for logistical reasons, as participants had to go through a lot of material (recruitment and parts of the platform), which would be difficult to realise in a timely manner with larger groups. interview guide the interview guide contained three parts: first, participants commented on the recruit­ ment material, i.e., facebook and instagram ads, flyers, and a promotional video. all materials except the flyers were shown on a tablet, and participants were free to browse through the materials for as long as they needed. the flyers were printed so that partici­ pants reviewed them in paper format. participants were asked to express their opinion about the materials (e.g., “what do you think about these posts?”, see heim et al., 2024s). learning from a trial that did not work out 4 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://www.psychopen.eu/ second, they reviewed the introduction session of the hap-pas-hapi programme online, and were invited to provide feedback on its content, graphic design, and usability. we decided to focus on the introduction session, since in the rct (heim et al., 2024), less than 50% had completed it. although dropout rates had been equal between the two levels of cultural adaptation in the rct, we showed participants the deep structure adap­ tation in this post-hoc, qualitative study. this adaptation is described elsewhere (shala et al., 2020a). the adapted introduction session contains a narrative and an exercise part. in the narrative part, a main character (male or female) gives an illustrated account of their history of depression, how they sought help and started therapy with a doctor. the doctor (who wears a white coat, see abi ramia et al., 2018) provides psychoeducation and recommends psychological exercises. all parts are presented online either as text or as audio recordings. in the exercise part, participants are asked to complete lists with their own symptoms and perceived causes for distress. they can choose albanian idioms of distress (e.g. mërzi, vuajtie) and potential causes (e.g., family problems, fatalistic beliefs about symptoms) from drop-down lists or write down their own idioms of distress (shala et al., 2020a). participants in our study went through this introduction section, and their behaviour was observed while navigating through the platform and were invited to “think aloud” (willis, 2004). interview questions addressed the content of the narrative part and the exercises (see heim et al., 2024s) in the third part of the interview, participants were asked about their cultural beliefs related to mental health in general. interviews lasted between 50 and 120 minutes each. an interview question was, e.g., “how would you describe mental health issues and attitudes towards mental health services in the albanian-speaking community?” (see heim et al., 2024s). data analysis we conducted thematic analysis (braun & clarke, 2006), which includes six phases. ba and ad transcribed the data and read all the transcripts several times to familiarise themselves with the data. they created a first set of inductive codes using maxqda 2020 (verbi software, 2017). codes were then grouped into themes by the same authors. this initial coding frame was revised in the larger research group (ba, ad, eh, and nh), before all interviews were coded by ba and ad. results results are presented along the interview guide structure. first, we present results related to recruitment materials, followed by results concerning the hap-pas-hapi intro­ ductory session. lastly, we summarise participants’ cultural beliefs concerning mental health. heim, ademi, dacaj et al. 5 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://www.psychopen.eu/ recruitment materials after looking through the social media ads, participants agreed that hap-pas-hapi’s “design system” on social media was inconsistent, and not sufficiently convincing. one participant perceived the communication strategy as being “under construction”, and another as “work in progress”. they suggested using a design system with consistent colours, as it has been done for the platform itself. as to the other materials, the flyer was perceived to be overloaded with information. the content of the ads was also criticised. participants said that the information pro­ vided through different ads was too diverse, and that important information was missing (e.g., content and aims of the app). for example, a simulated exchange on whatsapp, in which one person recommends hap-pas-hapi to another, apparently gave the impression that hap-pas-hapi was based on an actual exchange between people, not a self-help platform. others mistook it for a platform for exchanging messages with a psychologist. participants also expressed their doubts about the potential benefits of using happas-hapi (“i really don’t understand how it will help me”). they asked questions about the target population (“who is this for?”), and the younger participants expressed doubts that the generation of their parents (i.e., first-generation) would apprehend the face­ book ads or download a self-help app on their mobile phones. they would rather use whatsapp and viber to communicate with their family who are often dispersed across different countries. this lack of “digital literacy” was mentioned frequently as one major barrier to a wider distribution and use of hap-pas-hapi. mistrust was another barrier observed recurrently by participants. some of them expressed that they would never download an app just because they had seen a facebook ad, and they asked questions about data use and protection. they suggested that ads should focus much more on privacy and data protection, to make sure people would trust before they downloaded the app. one participant said that the idea of receiving 30 chf for participating in the study provoked a feeling of being instrumentalized for research purposes, especially if the social media campaign was perceived to be “work in progress”. this gave him the impression that he was used for something that was not fully developed. participants of both generations also wanted to know more about the creators of hap-pas-hapi, and the concept behind it. they thought that people would need more information about its use and benefits before embarking on it. a picture showing researchers “behind the scenes” was unanimously perceived to be a good strategy for reaching people’s attention, as it illustrated the (albanian speaking) researchers’ academ­ ic career, and therefore increased trust in the study. participants also suggested posting statements by real people who have used hap-pas-hapi and recommend it, or using ambassadors, influencers, celebrities, who can promote the platform more efficiently and increase trust. learning from a trial that did not work out 6 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://www.psychopen.eu/ the hap-pas-hapi programme hap-pas-hapi was perceived to be relevant, well developed, and professional, which stands in contrast to the perception of the recruitment strategy. however, most partici­ pants felt that the application’s interface was not clear enough. in nine out of eleven interviews, participants mentioned difficulties in understanding the instructions and navigating through the platform. these difficulties were even more pronounced in the older age group. by consequence, many participants expressed annoyance, impatience, or frustration when they did not understand how to continue, or when a lot of apparently irrelevant information was presented. even the personal stories provided in the interven­ tion were perceived to be cumbersome by some of them. participants suggested to jump right to the exercises, and not to make people read or listen to the story of the main character. they also preferred the easier exercises (e.g., a grounding exercise) to the more complex ones (e.g., planning an activity with several steps). one important result concerned the narratives of the main characters in the applica­ tion. in the older age group, several participants expressed difficulties in relating to this story. they felt that the narratives caused a certain feeling of “being exchangeable” and a lack of taking their own history and emotions seriously. one participant said: “…to say that in fact a quarter of the world’s population is affected by this, that can be good because it puts the problem into perspec­ tive, we tell ourselves that we are not the only ones. but at the same time, it also takes away the personal side, of saying, well, once again, i am one of the two billion, and they are not going to look after me, because they are not going to look after the two billion.” the graphic design was positively commented. some participants liked the illustrations, others disliked them, which is to be expected as it corresponds to personal taste. partici­ pants’ opinions regarding the doctors’ white coat were also diverse. three participants from the younger generation thought that the white coat was unnecessary, whereas one participant from the older generation considered it to be important. the others did not comment on the doctors’ white coat. as to the audios, they were appreciated by the younger generation, but the older generation preferred reading. language was another frequently mentioned topic. first, the younger generation would have preferred the option to choose between albanian and a swiss language (i.e., french or german). second, since it had not been possible to accommodate the two albanian dialects (gheg and tosk), the standard albanian language was used in hap-pas-hapi (see shala et al., 2020a), which caused controversial discussions. while some of them thought that the language was well chosen, others disagreed. this is illustrated in the citation below: “…it can be a problem for some people, but it's always a problem because you can't adapt to both populations, those who speak well heim, ademi, dacaj et al. 7 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://www.psychopen.eu/ and those who don't understand. intrinsically, from the outset the project starts with a limit.” cultural beliefs related to mental health the last part of the interview guide revealed important insights about perceptions and attitudes related to mental health. participants mentioned a high stigmatisation of mental disorders in the community, and a lack of mental health literacy, which prevented people from seeking help. many said that hap-pas-hapi was a great platform and much needed by the community (they would even recommend it to other people), but at the same time, they all said that they would not use it personally, as they were not faced with mental health problems. one participant also said that people would not use the platform because they would not want to be associated with “crazy” people. explicitly expressing distress was perceived as being difficult, as people would often not have words for their feelings. by consequence, participants perceived a lack of intro­ spection in their own community. one participant said that this caused difficulties in using hap-pas-hapi, as people would not know which option(s) to choose (e.g., regarding symptoms), and some might even have difficulties in understanding the word “symptom” in the first place. discussion this qualitative study revealed important insights on reasons for our difficulties with recruitment and adherence in the hap-pas-hapi randomised controlled trial in switzer­ land and germany (heim et al., 2024, this issue). first, participants strongly criticised the recruitment material. the flyer was perceived to be overloaded with written information, which can be explained by restrictions concerning recruitment materials as imposed by ethical standards. participants also criticised the messages and pictures promoted on social media such as facebook and instagram, and particularly the lack of a clear “design system” in the sense of a consistent graphic design. this is in contrast with the recruitment strategy that was used in lebanon, where a professional agency was hired to implement the social media campaign (heim et al., 2021). a difficulty also comes from the fact that, for ethical reasons, we promoted participation in a study, and not the app itself. in summary, these results suggest that it is worth collaborating with a professional promotional agency, and investing financially, not just towards the online platform, but also (quite substantially) towards recruitment. it is important to create clear and consis­ tent messages to inform the audience about the app, potential benefits of participating in the study and of using the app, as well as about data use and protection. in addition, our results suggest that personalised recruitment works best, as the picture showing learning from a trial that did not work out 8 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://www.psychopen.eu/ researchers “behind the scenes” was well received. in lebanon, personalised recruitment, e.g., through whatsapp broadcasts sent by united nations high commissioner for refugees (unhcr), seemed to be efficient (heim et al., 2021). we can learn from these experiences and use it for future trials. on the other hand, would it really have made a difference if we had invested in a professional recruitment strategy? maybe we would have reached a wider population. however, there is strong indication that this would not have been sufficient. we have anecdotal and empirical evidence from the present study that albanian-speaking indi­ viduals in switzerland perceived the app to be very relevant and useful – for others; that is, for those who suffer from psychological distress, but not for themselves. this strong division into “them” and “me” reflects the stigma related to mental disorders in the albanian community (thornicroft et al., 2022). is this stigmatisation stronger than in other communities? we have no evidence, but our results suggest that there is a strong resistance against using mental health care, even if it comes in the form of an anonymous self-help app that can be used in private. it is possible that anti-stigma campaign before launching hap-pas-hapi, or in parallel, could have been effective. strong beliefs in suffering being part of one’s life and destiny which has to be endured with patience, may prevent people from seeking professional help (shala et al., 2020b). we aimed to address these beliefs with a deep structural adaptation of the hap-pas-hapi introduction session, by using culturally relevant terms, expressions, sayings, and beliefs, and using exercises to challenge these beliefs (shala et al., 2020a). we used an adapted version of an intervention that has shown to reduce fatalistic beliefs and enhance treatment motivation among turkish participants in ger­ many (reich et al., 2021). it seems that in our sample, this intervention was not robust enough, as it did not result in less drop-outs than in the group who received the standard hap-pas-hapi without the culturally adapted introduction (heim et al., 2024, this issue). cultural concepts related to emotions and emotion expression in the community – i.e., the fact that one’s own emotions and inner life are not supposed to be expressed explicitly – might be one major barrier to using the application. as to the feedback on the platform itself, most of it corresponds to what has been found in other qualitative studies about step-by-step (abi ramia et al., 2018). despite this feedback, the app was used more frequently among different populations in lebanon, while the albanian version remained unused. we have some indication that we missed the target population because we did not pay sufficient attention to the different genera­ tions within the albanian community. the younger generation who in general is more open towards mental health treatments and online self-help applications consistently said that they would have preferred an application in german or french, or the option to choose the language. in the albanian version, the use of a specific dialect of one sub-group may cause resistance in another sub-group within the target population. heim, ademi, dacaj et al. 9 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://www.psychopen.eu/ as a further difficulty, the older generation, for whom the intervention was mainly adapted (e.g., by including albanian concepts of distress) was not sufficiently “tech-sav­ vy” to use an application for their mental health. in our planning, we thought that an app would help overcome stigma and the barriers of seeking help. but it seems that with a technology-based intervention, we even added another barrier, because the digital skills and interest is limited in the group of first-generation immigrants to whom we adapted the content. promoting digital health literacy in this population could increase motivation for treatment and thus improve the accessibility and effectiveness of such interventions in the future. even though it is suggested that clinical research in high-income countries is not sufficiently “inclusive” when it comes to ethnic minorities (hussain-gambles et al., 2004; wendler et al., 2006), it rather seems that in our target population, there was some kind of “auto-exclusion” from research, due to mistrust and the feeling of being instrumen­ talised, which leads to a lack of interest or motivation to contribute to research. we observed a strong mistrust in the platform itself, data use and protection, the purpose of this research, and the benefit for oneself in using hap-pas-hapi. from our research in this community (pnishi et al., 2024; shala et al., 2020b), it seems that people are enough burdened with their own daily lives and struggles, and hap-pas-hapi was not perceived as something that could help with this, but rather as a tool without considerable poten­ tial benefit. the fact that 56% of participants dropped-out during baseline assessments (heim et al., 2024), and the negative comments about the intervention in the present study, strongly suggest that this was the case. what lessons can be learnt from this difficult endeavour? it seems that despite a massive effort of conducting an ethnopsychological study among the target group, a meticulous cultural adaptation, and a carefully developed recruitment strategy, engaging our hard-to-reach target group has proven to be more difficult than expected. the lan­ guage skills and cultural knowledge of our extensive research team, composed primarily of albanian-speaking members, were surely and asset, but this was still insufficient to motivate the larger community to engage in our project. some limitations to this study are related to sampling, as participants were recruited in the social networks of two authors (ba, ad), and some were their acquaintances. this might have influenced the responses during the interviews. however, this is not necessarily a limitation, since the pre-existing rapport between the authors and some participants could have led to more uninhibited and in-depth accounts and might have given researchers the ability to delve deeper into topics and prompt participants more effectively, thereby eliciting richer and more relevant insights. furthermore, participants in the present qualitative study had not participated in the randomized controlled trial themselves. it would have been interesting to interview those who dropped out, but it was very difficult to reach them once we lost contact with them. on the other hand, having a “fresh view” on the recruitment materials and the introductory module may learning from a trial that did not work out 10 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://www.psychopen.eu/ have delivered more valid data. we also did not assess participants’ level of depression, which might have been relevant for interpreting our data. the two interviewers, who also conducted the analyses, both speak albanian and french, which can be viewed as a strength of our study. as we reflect on our approach, we identify potential avenues for optimising future efforts. most likely, we should have targeted the younger generation with an application in the local language (german or french) and address their needs more specifically, rather than carefully adapting the programme to the cultural concepts of distress of first-generation immigrants who would not use such a programme in the first place. for those, a different kind of approach would be needed, most likely based on direct human contact. furthermore, an anti-stigma campaign before promoting an app could help address the major barriers in this community. such campaigns, if well planned and implemented, are effective, as evidence shows (thornicroft et al., 2022). we hope that in the future, other researchers can benefit from our experience, and more inclusive interventions can be developed for minority groups who are in need of mental health care. funding: this study was funded by the swiss national science foundation (snsf, grant number: 10001c_169780.2) and the swiss foundation for the promotion of psychiatry and psychotherapy. we also received funding by the freie universität berlin and university of zurich to build a strategic partnership. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. ethics statement: the study was revised and approved by the ethical review commission of the university of lausanne (e-ssp-072o22-oo). reporting guidelines: the study followed the consolidated criteria for reporting qualitative research (coreq, tong et al., 2007). data availability: the dataset is available upon request. supplementary materials the supplementary materials contain the following items (for access, see heim et al., 2024s): a. interview guide: questions related to the recruitment material and the hap-pas-hapi selfhelp programme. b. coding framework: themes and sub-themes used in the data analysis process. heim, ademi, dacaj et al. 11 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://www.psychopen.eu/ index of supplementary materials heim, e., ademi, b., dacaj, a., hosny, n., burchert, s., cerga pashoja, a., hoxha, a., & shala, m. (2024s). supplementary materials to "why did our trial not work out? a qualitative analysis" [interview guide and coding framework]. psychopen gold. https://doi.org/10.23668/psycharchives.14648 references abi ramia, j., harper shehadeh, m., kheir, w., zoghbi, e., watts, s., heim, e., & el chammay, r. (2018). community cognitive interviewing to inform local adaptations of an e-mental health intervention in lebanon. global mental health, 5, article e39. https://doi.org/10.1017/gmh.2018.29 braun, v., & clarke, v. (2006). using thematic analysis in psychology. qualitative research in psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa carswell, k., harper-shehadeh, m., watts, s., van’t hof, e., abi ramia, j., heim, e., wenger, a., & van ommeren, m. 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(2020b). a point in the heart: concepts of emotional distress among albanian-speaking immigrants in switzerland. culture, medicine and psychiatry, 44(1), 1–34. https://doi.org/10.1007/s11013-019-09638-5 thornicroft, g., sunkel, c., alikhon aliev, a., baker, s., brohan, e., el chammay, r., davies, k., demissie, m., duncan, j., fekadu, w., gronholm, p. c., guerrero, z., gurung, d., habtamu, k., hanlon, c., heim, e., henderson, c., hijazi, z., hoffman, c., . . . winkler, p. (2022). the lancet commission on ending stigma and discrimination in mental health. lancet, 400(10361), 1438– 1480. https://doi.org/10.1016/s0140-6736(22)01470-2 tong, a., craig, j., & sainsbury, p. (2007). consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups. international journal for quality in health care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042 verbi software. (2017). maxqda 2018 [computer software]. verbi software. available from https://www.maxqda.com wendler, d., kington, r., madans, j., wye, g. v., christ-schmidt, h., pratt, l. a., brawley, o. w., gross, c. p., & emanuel, e. (2006). are racial and ethnic minorities less willing to participate in health research? plos medicine, 3(2), article e19. https://doi.org/10.1371/journal.pmed.0030019 wenger, e. (1998). communities of practice: learning, meaning, and identity. cambridge university press. https://doi.org/10.1017/cbo9780511803932 willis, g. b. (2004). cognitive interviewing: a tool for improving questionnaire design. sage. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. heim, ademi, dacaj et al. 13 clinical psychology in europe 2024, vol. 6(2), article e12887 https://doi.org/10.32872/cpe.12887 https://doi.org/10.3389/fpsyg.2024.1321452 https://doi.org/10.32872/cpe.5583 https://doi.org/10.1016/j.invent.2020.100339 https://doi.org/10.1007/s11013-019-09638-5 https://doi.org/10.1016/s0140-6736(22)01470-2 https://doi.org/10.1093/intqhc/mzm042 https://www.maxqda.com https://doi.org/10.1371/journal.pmed.0030019 https://doi.org/10.1017/cbo9780511803932 https://www.psychopen.eu/ learning from a trial that did not work out (introduction) background method participants and procedures interview guide data analysis results recruitment materials the hap-pas-hapi programme cultural beliefs related to mental health discussion (additional information) funding acknowledgments competing interests ethics statement reporting guidelines data availability supplementary materials references a 21st century principle-based training approach to psychotherapy: a contribution to the momentum of transtheoretical work scientific update and overview a 21st century principle-based training approach to psychotherapy: a contribution to the momentum of transtheoretical work anna babl 1 , catherine f. eubanks 1 , marvin r. goldfried 2 [1] department of clinical psychology, leiden university, leiden, the netherlands. [2] department of psychology, stony brook university, new york, ny, usa. clinical psychology in europe, 2024, vol. 6(special issue), article e11925, https://doi.org/10.32872/cpe.11925 received: 2023-05-10 • accepted: 2023-07-28 • published (vor): 2024-04-26 handling editor: wolfgang lutz, department of psychology, university of trier, trier, germany corresponding author: anna babl, adelphi university, gordon f. derner school of psychology, hy weinberg center, 158 cambridge ave, garden city, new york 11530, united states of america. e-mail: ababl@adelphi.edu related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract background: despite the finding that the majority of psychotherapists adopt a rather processoriented and integrative stance, it is uncommon that psychotherapy trainings are transtheoretical and transdiagnostic. considering principles of change that cut across different schools of therapy holds promise for developing truly research-informed psychotherapy trainings. common principles of change may answer the question what should be trained. another important question is how to train. in current psychotherapy training programs, transfer of theory into practice relies mainly on role-playing exercises and supervised practice, both of which have their limitations. aims: a fantasy for the future would be the development, implementation, and evaluation of a complementary 21st century online principle-based and marker-led psychotherapy training: incorporating the concepts of deliberate practice as well as expert training, the huge potential of technologies, and considering the importance of (context) responsiveness. conclusion: to illustrate this idea, we present a training that we are currently developing, an online alliance-focused training. keywords principles of change, psychotherapy training, alliance-focused training, deliberate practice, markers this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11925&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0002-9187-1025 https://orcid.org/0000-0002-0561-1607 https://orcid.org/0000-0003-4659-8127 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • considering principles of change that cut across different schools of therapy holds promise for developing truly research-informed psychotherapy trainings. • a fantasy for the future would be the development, implementation, and evaluation of a complementary 21st century online principle-based and marker-led psychotherapy training. • we are currently developing, an online alliance-focused training. for a long period of time it was common for psychotherapists to work exclusively within their own theoretical framework – referred to by norcross (2005) as an “ideological cold war.” those first-generation approaches to psychotherapy, as developed by their founders, neglected or even suppressed and fought concepts and findings that were not in line with their original stance (grawe & caspar, 2011). despite substantial theoretical and practical differences, and some evidence suggesting some advantages for certain approaches when treating certain conditions (e.g., marcus et al., 2014), most comparison studies have found that bona fide therapies are equally effective (e.g., wampold & imel, 2015). as saul rosenzweig (1936) presciently observed when he quoted the dodo bird from lewis carroll’s alice’s adventures in wonderland, "everybody has won, and all must have prizes." given the lack of sizable differential treatment effects across psychotherapy orien­ tations, increasingly more attention is being paid to the impact of the therapist on treatment outcome. stiles and horvath (2017) proposed that therapists’ responsiveness may be a key component of effective therapy: therapists are responsive by flexibly tailoring their relational connection and interventions to support individual patients’ needs in that moment (stiles, 2009) in the context of their transdiagnostic characteristics (hayes & hofmann, 2020). based on a qualitative meta-analytic review on therapist responsiveness, wu and levitt (2020) concluded that in order to be responsive, therapists need to develop awareness of and attunement to the process of therapy and to markers of shifts in patients’ experience. despite the finding that the majority of psychotherapists adopt a rather process-ori­ ented and integrative stance (norcross & rogan, 2013), it is uncommon that psychothera­ py trainings are transtheoretical and transdiagnostic; rather, the field remains entrenched in a training approach in which different theoretical orientations are siloed and implicitly pitted against one another. given how much training is based on theoretically specific methods, it is surprising how little evidence there is for its effectiveness, especially comparing different theory-specific approaches (knox & hill, 2021). 21st century principle-based psychotherapy training 2 clinical psychology in europe 2024, vol. 6(special issue), article e11925 https://doi.org/10.32872/cpe.11925 https://www.psychopen.eu/ what to train one promising way to advance previous approaches to training is to consider principles of change that cut across different schools of therapy as complementary training mod­ ules when aiming for truly research-informed psychotherapy trainings. transtheoretical and transdiagnostic change principles can help us identify and focus on areas of unity rather than develop new training approaches. in the following, a few key efforts to identify such principles of change are outlined. an important landmark was goldfried’s (1980) attempt to identify a set of change principles. he argued that change principles are located at an intermediate level of abstraction between the more abstract level of theoretical framework and the more con­ crete level of specific techniques. at this intermediate level of abstraction, it is possible to grant therapists some freedom with regard to the specific interventions they choose to apply with a specific patient in a specific situation but at the same time ensure that important change processes are facilitated. drawing on the research literature, goldfried (1980; eubanks & goldfried, 2019) proposed the following 5 principles of change shared across the major theoretical orientations: • fostering the patient’s hope, positive expectations, and motivation • facilitating the therapeutic alliance • increasing the patient’s awareness and insight (e.g., awareness of connections between thoughts, feelings, needs, actions) • encouraging corrective experiences (i.e., encouraging patients to take risks and engage in new behaviors that lead to a shift in cognitions and emotions) • emphasizing ongoing reality testing (i.e., helping patients to process corrective experiences and consolidate positive changes by recalibrating their expectations and self-views to be in line with their new reality) klaus grawe and colleagues were also interested in change processes in psychotherapy, with the aim of developing a research-informed psychotherapy that would flexibly use all empirically supported mechanisms of change in psychotherapy (caspar & grosse holtforth, 2010). based on a meta-analysis of approximately 900 comparative outcome studies on the effectiveness of psychotherapy (grawe et al., 1994), they identified five general change factors: • problem mastery/coping (i.e., the patient learns to cope with difficult or anxietyprovoking situations) • clarification of meaning (i.e., the patient gains greater understanding of the source of their difficulties) • problem actuation (i.e., the patient’s emotional experience of the problem is activated during psychotherapy, to provide the optimal opportunity to foster change) babl, eubanks, & goldfried 3 clinical psychology in europe 2024, vol. 6(special issue), article e11925 https://doi.org/10.32872/cpe.11925 https://www.psychopen.eu/ • resource activation (i.e., the patient’s own resources—motivation, skills, strengths—are activated in the service of change) • therapeutic relationship another effort to identify principles of change with empirical support is the work by castonguay and beutler (2006). the five categories of principles they identified are framed in terms of guiding therapists as they predict how therapy will go and determine how best to intervene: • patient prognostic principles (i.e., patient characteristics that predict good treatment outcome such as baseline impairment, personality disorder, attachment, expectations, stage of change) • treatment/provider moderating principles (i.e., patient characteristics, often present at baseline, that therapists should be responsive to such as patient resistance, ambivalence, coping style) • patient process principles (i.e., patient during-treatment behaviors that facilitate or interfere with improvement such as active participation or resistance, respectively) • therapy relationship principles (i.e., elements of the patient-therapist exchange that facilitate or interfere with improvement such as alliance quality, alliance rupture repair, therapist empathy, therapist positive regard) • therapist intervention principles (i.e., therapist during-treatment behaviors that either facilitate or interfere with improvement such as receiving feedback based on routine outcome monitoring, being flexible, fostering more emotional experiencing and behavior change) the different attempts to identify transtheoretical principles of change all have agreed on the therapeutic relationship or alliance as a key component of effective therapy. many original studies and meta-analyses positioned the therapeutic alliance as a robust predic­ tor of psychotherapy outcome across a wide range of patient diagnoses and different treatment types (e.g., flückiger et al., 2018, 2020). this is true for both between-patient alliance effects (flückiger et al., 2018) and within-patient early alliance effects on post­ treatment outcome (flückiger et al., 2020). further, a survey of a diverse pool of 1,998 psychotherapy clinicians on the perceived presence of the five principles of change iden­ tified by goldfried indicated strongest consensus for the therapeutic alliance and when participants estimated whether the principles were common to all schools of therapy, strong consensus was only indicated for the therapeutic alliance (twomey, o’reilly, & goldfried, 2023). how to train common principles of change may answer the question about what should be trained, but another important question is how change principles can be implemented in psycho­ 21st century principle-based psychotherapy training 4 clinical psychology in europe 2024, vol. 6(special issue), article e11925 https://doi.org/10.32872/cpe.11925 https://www.psychopen.eu/ therapy training. research has found mixed evidence as to whether standard methods of therapist training are effective (perlman et al., 2020). in current psychotherapy training programs, transfer of theory into practice with actual patients relies mainly on roleplaying exercises and supervised practice. however, both forms of learning have their limitations: role-playing exercises might not be realistic and may thus fail to provide the trainee with useful preparation (beutler & harwood, 2004), while supervision usually only follows the trainee’s contact with the patient with some time-delay. immediate feedback, for example in the context of live supervision, can only be realized at high cost and applied to a sub-sample of patients and relevant clinical situations. no satisfactory training procedure is currently in place by which novice psychotherapists can obtain in-vivo hands-on experience in dealing with the range of problems presented by a variety of patients, and in which they get immediate, accurate and consistent feedback (beutler & harwood, 2004). for a long time, the field of psychotherapy research has lacked a successful model for therapist skill advancement (rousmaniere et al., 2017). the study of expertise in other fields provides a potential model for understanding the key mediating factors involved in the development of top-level performers in psy­ chotherapy. across a variety of domains, researchers have found that engagement in extended, deliberate practice facilitates incremental development, resulting in superior performance (chow et al., 2015). according to ericsson (2006), deliberate practice is defined as individualized training activity especially designed to improve specific aspects of an individual’s performance through repetition and successive refinement. empirical research suggests that deliberate practice can significantly improve the effectiveness and efficiency of psychotherapy education and training (e.g., rousmaniere et al., 2017). bailey and ogles (2023) go as far as making deliberate practice suggestions for rupture and repair interventions, such as video-assisted observation of your work, getting con­ sultant feedback, setting small incremental goals, solo deliberate practice, and feedbackinformed treatment. an important next step would be its online application, with the advantages of easy and flexible availability of the training and its time-independent use (berger, 2015). a meta-analysis of 201 studies has shown that in the health professions, internet-based learning was associated with large positive effects compared with no in­ tervention and with equal effects compared to non-internet instructional methods (cook et al., 2008). a systematic review synthesized the mental-health training literature pub­ lished since 2010 to evaluate how different training models affect therapists’ knowledge, beliefs, and behaviors (frank, becker-haimes, & kendall, 2020). with regard to online training (20 studies), there was clear evidence that it can improve therapist knowledge, skills, and use of the intervention after online training (frank et al., 2020). one promising framework for guiding therapist responsiveness that has been pro­ posed by constantino and colleagues (2013) is context-responsive psychotherapy integra­ tion (crpi), a transdiagnostic if-then approach. based on empirical associations with therapy outcomes, constantino and colleagues identified several patient characteristics babl, eubanks, & goldfried 5 clinical psychology in europe 2024, vol. 6(special issue), article e11925 https://doi.org/10.32872/cpe.11925 https://www.psychopen.eu/ and treatment processes that therapists will encounter and to which they need to react and be responsive, including low outcome expectations, ambivalence/resistance, patient self-strivings, alliance ruptures, and alarm signals from outcome monitoring (constantino et al., 2013). trainees can be taught to recognize markers of these common characteristics and processes and to select from several principle-driven, evidence-based methods to address the markers (if this occurs, then try one of these responses). crpi is a promising model that requires more empirical support and further investigation of com­ monly occurring markers (constantino et al., 2017). focusing on markers as indicators of problems as well as patients’ readiness to work on those problems is a defining feature of alliance-focused training (aft; muran & eubanks, 2020). aft works with markers of ruptures in the alliance during the psychotherapeutic process as indicators that it is time to pay close attention to the therapeutic relationship and be curious about what is taking place. a new vision for psychotherapy training combining the questions “what to train” and “how to train”, the first and second au­ thor of this article are developing an online aft as a concrete example and starting point for our 21st century online principle-based and marker-led psychotherapy training. the online aft will be modeled after the aft approach to training and supervision developed by muran, safran, and eubanks, which aims at helping therapists recognize and negotiate ruptures in the therapeutic alliance both through observation of patient and therapist behaviors, as well as attending to the therapists’ own internal emotional experience (muran & eubanks, 2020). the effects of aft have been shown to foster rupture repair and patient outcome in six studies (eubanks et al., 2019), including a randomized controlled trial (muran et al., 2018). in psychotherapy research, the alliance is typically conceptualized as consisting of the patient-therapist affective bond, and a purposeful collaboration on the tasks and goals of therapy (bordin, 1979). it has been shown that during treatment, the alliance is characterized by rupture-repair episodes (e.g., eubanks, muran, et al., 2018). ruptures are defined as moments of weakness or deterioration in the alliance (eubanks et al., 2015) and they can be organized into two general categories: confrontation ruptures, in which patients or therapists move against the other person or the work of therapy, typically showing their concern directly; and withdrawal ruptures, in which patients or therapists move away from the other person or the work of therapy, usually having difficulties either recognizing their feelings or directly expressing them. the following three markers are indicators of confrontation ruptures: complaining/criticizing, pushing back, and controlling/pressuring (eubanks & muran, 2022); these three markers suggest the occurrence of withdrawal ruptures: shutting down, avoiding, and masking one’s own experience (eubanks & muran, 2022). ruptures are common events (muran & safran, 21st century principle-based psychotherapy training 6 clinical psychology in europe 2024, vol. 6(special issue), article e11925 https://doi.org/10.32872/cpe.11925 https://www.psychopen.eu/ 2016), which is why it is important that there is a chance to repair them by means of resolution strategies (eubanks, muran, et al., 2018). resolution strategies can include immediate strategies, in which the alliance rupture is immediately addressed and then the dyad returns to the therapy task they were previously engaged in. examples of immediate strategies include changing the task or goal, illustrating the task or providing a rationale, and redirecting or refocusing on a therapy task (eubanks & muran, 2022). ruptures can also be addressed using expressive repair strategies, which involve explor­ ing the rupture in depth and can include inviting the other to explore the rupture, validating their experience of the rupture, and disclosing one’s own experience of the rupture. in addition, therapists and patients can address ruptures by acknowledging their own contribution to the rupture and by linking the rupture to larger interpersonal patterns in the patient’s life. online aft will begin with short, introductory theoretical videos (based on the research evidence on rupture and repair) as well as videos of prototypical case examples of confrontation markers and withdrawal markers, which indicate potential ruptures in the alliance, as well as corresponding immediate and expressive resolution strategies. in a second part of the training, therapists will be provided with various patient-thera­ pist video scenarios and will be encouraged to recognize markers of alliance ruptures when they occur as well as corresponding rupture resolution strategies. exercises will increase in difficulty as therapists move from recognition (e.g., selecting options from a predefined list) to recall. they will receive immediate computer-generated feedback and the possibility to reflect on and refine their responses. therapists will then practice their skills in recognizing and negotiating alliance ruptures by responding to short video scenarios of withdrawn, confrontational or otherwise interpersonally complex patients. their responses as therapists will be video recorded and played back to them accompa­ nied by questions designed to foster their curiosity about the therapeutic process as well as access to their own internal experience. thereby, the online aft implements deliberate practice for rupture and repair interventions as previously suggested (bailey & ogles, 2023). an essential aspect of developing online aft will be collecting data on its efficacy and based on that data, refining and adapting the training as needed to ensure that it meets the aim of improving therapist skills and treatment outcomes. a fantasy for the future would be the development, implementation, and testing of additional modules of a 21st century online principle-based and marker-led psychotherapy training: incorporating the concepts of deliberate practice as well as expert training, the huge potential of technologies, and considering the importance of (context) respon­ siveness. such a training could include an online library of a range of clinical markers (e.g., a patient showing vulnerability may best be met with empathy on the side of the therapist. a bodily felt sense or abstract, intellectualized talk about emotions may be encountered with focusing interventions to enable emotional deepening. self-critical processes may be played out using two-chair dialogue and uncompleted processes with babl, eubanks, & goldfried 7 clinical psychology in europe 2024, vol. 6(special issue), article e11925 https://doi.org/10.32872/cpe.11925 https://www.psychopen.eu/ significant others may be attended to by means of empty-chair dialogue to increase self-compassion and acceptance of emotions and needs) with example patient-therapist videos of how to respond to them (thereby already building a bridge to practice) together with a brief description of relevant basic and applied research. markers are nested within and can be classified under change principles so that relevant ones can be searched for when needed. in a second step, therapists could be provided with videos of clinical scenarios and corresponding exercises of increasing degree of difficulty (e.g., answers to choose from are given, answers must be generated and written down to meet certain keywords, therapists receive immediate and automated feedback on their choices with the possibility to repeatedly refine their responses, therapists immediately respond to patient scenarios and their responses are video-recorded, the recordings are played back to the therapists together with questions facilitating self-observation and self-reflection, they are then invited to respond again and differently to the same patient scenario). the idea is that therapists can practice their skills in a safe and supportive environment before applying them to their work with actual patients. such a training could be distrib­ uted easily and inexpensively, offers time-independent use, and provides a cost-effective model for therapist skill advancement and ultimately psychotherapy success at the indi­ vidual patient level. it could complement traditional psychotherapy trainings of different approaches: it could be used by professors in classes, as well as by supervisors who could access resources from the online library while meeting with a trainee in individual or group supervision. such a training could also facilitate lifelong learning: it could be incorporated into continuing education programs as well as being accessed by practicing therapists when they want to review or learn new skills. we would like to conclude with some broader ideas for the future of what we are suggesting as a principle-based and marker-led psychotherapy training. to really advance our understanding of how best to practice therapy and train therapists, we need to delineate a full range of principles of change, and we should regard “what works” as an empirical question. one important future direction for principles of change would be to see other principles and common factors enjoy the “success” that the therapeutic alliance has achieved in attracting the interest of researchers, practitioners, and trainers (eubanks & babl, in press). as more principles of change are in a position to receive that kind of attention, it will pave the way for more research looking at interactions between them (norcross & lambert, 2019). given that principles of change cut across different approaches to therapy, many practicing clinicians have experience with them and can make valuable contributions by sharing how they understand and employ them. researchers and clinicians can actively partner with each other in an effort to build an online 21st century principle-based and marker-led psychotherapy training. 21st century principle-based psychotherapy training 8 clinical psychology in europe 2024, vol. 6(special issue), article e11925 https://doi.org/10.32872/cpe.11925 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: we have no known conflict of interest to disclose. references bailey, r. j., & ogles, b. m. 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(2020). a qualitative meta-analytic review of the therapist responsiveness literature: guidelines for practice and training. journal of contemporary psychotherapy, 50(3), 161–175. https://doi.org/10.1007/s10879-020-09450-y clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. 21st century principle-based psychotherapy training 12 clinical psychology in europe 2024, vol. 6(special issue), article e11925 https://doi.org/10.32872/cpe.11925 https://doi.org/10.1007/s10879-020-09450-y https://www.psychopen.eu/ 21st century principle-based psychotherapy training (introduction) what to train how to train a new vision for psychotherapy training (additional information) funding acknowledgments competing interests references the (neuro)-science behind resilience: a focus on stress and reward editorial the (neuro)-science behind resilience: a focus on stress and reward chantal martin-soelch 1 [1] ireach lab, unit of clinical and health psychology, department of psychology, university fribourg, fribourg, switzerland. clinical psychology in europe, 2023, vol. 5(1), article e11567, https://doi.org/10.32872/cpe.11567 published (vor): 2023-03-31 corresponding author: chantal martin-soelch, university of fribourg, department of psychology, rue p-a faucigny 2, ch-1700 fribourg. tel: +41 26 300 76 87. e-mail: chantal.martinsoelch@unifr.ch mental disorders represent one of the major causes of disability worldwide, with depres­ sive disorders being the leading causes of burden among mental disorders in all age categories above 14 years old, followed by anxiety disorders (gbd 2019 mental disorders collaborators, 2022). although knowledge concerning their etiology has improved, it is still unclear why one person will develop a mental disorder while another will not when facing adversities. in this context, the identification of resilience mechanisms is crucial. adopting an approach based on mechanisms allows us to have a transdiagnostic and transtheoretical approach and to target specific processes for the development of psychological interventions. indeed, better knowledge of resilience mechanisms allows the development of tar­ geted interventions in at-risk populations. some risk factors for the development of mental disorders have been well identified, such as childhood abuse or in general early adverse childhood experiences (els) (kessler et al., 2010; mandelli et al., 2015). els have received increased attention from research, which led recently to the development of a consortium in the framework of the global traumatic stress collaboration dedicated to the investigation of socio-emotional consequences of els (pfaltz et al., 2022). a further well-investigated risk factor is being the offspring of one or more parents suffering a mental health condition, particularly depression, bipolar disorder or schizophrenia (rasic et al., 2014). resilience can be defined as the capacity of an individual to adapt successfully to highly adverse events and keep a healthy functioning by harnessing resources (southwick et al., 2014). it is most often measured by questionnaires, although these may be limited by issues of internal validity in particular because little is known about the this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11567&domain=pdf&date_stamp=2023-03-31 https://orcid.org/0000-0003-3859-9023 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ different elements that make up resilience. these questionnaires therefore often focus on one or a set of measures related to well-known protective factors or resources, such as feelings of self-efficacy, self-esteem, sense of mastery, optimism, positive affect, good emotion regulation skills or sense of coherence (southwick et al., 2014). neuroscience has provided new insights in this area and indicates that neurocognitive and neuroaffective factors, such as cognitive flexibility or reactivity to stress or reward may play a role in resilience. these two processesreward and stressare linked to well-defined brain systems that are considered to be crucial for human motivation and adaptation (godoy et al., 2018; schultz, 2000). blunted neural responses to reward have been consistently observed in depressive disorders, and have been hypothesized to underly the symptoms of anhedonia, apathy and loss of interest observed in these conditions (pizzagalli et al., 2009). and a large body of empirical evidence shows the importance of stress in the development of several psychopathological conditions, among others depression (liu & alloy, 2010). recently, it has been postulated that not only the responses to reward or the effect of stress, but rather an interaction between both is involved in the etiology of men­ tal disorders. thus, a high reactivity of the brain to stress and a reduced brain reactivity to reward, also conceptualized as an imbalance between the neural responses to stress and to reward, has been hypothesized to be a vulnerability factor for the development of mental disorders, in particular depressive disorders (admon et al., 2013). this model has been completed with research works showing that not only the neural responses during the presentation of stressful stimuli or rewarding information is important, but also the neural recovery after these events, in particular longer recovery after stress and shorter recovery after reward, might play a role. this has been conceptualized as emotional inertia and brought in relationship with difficulties in emotion regulation (koval et al., 2015). our laboratory, the ireach lab at the department of psychology of the university of fribourg (switzerland), has been particularly interested in the stress-reward interac­ tions and their role in understanding the development of disorders in a transdiagnostic approach based on clinical neuroscience research results. preliminary studies from our group suggest that in children of parents suffering from depression, reactions to rewards are impacted differently than in a control group under acute stress conditions (gaillard et al., 2020; martin-soelch et al., 2020). these results are interesting because our partici­ pants had no clinical symptoms, but they showed different neural activation to reward stimuli and to the effect of stress on their processing. this may suggest a form of latent vulnerability that is not observable at the behavioral level. these results are in line with differences observed in response to rewarding information (without stress) in offspring of depressed parents (mccabe et al., 2012). understanding and integrating the interactions between the reward and stress sys­ tems in a model (see figure 1) can serve as basis for developing and testing psychological prevention and/or treatment interventions that target these mechanisms. on this basis, the (neuro)-science behind resilience: a focus on stress and reward 2 clinical psychology in europe 2023, vol. 5(1), article e11567 https://doi.org/10.32872/cpe.11567 https://www.psychopen.eu/ we developed for instance a multi-modal stress management program that has shown effects in activating resources in general and increasing the feeling of reward in daily life in particular (recabarren et al., 2019). other therapeutic programs have also shown significant effects on reward processing. for instance, a study by dichter et al. (dichter et al., 2009) suggests that behavioral activation restores the brain's reactivity to reward in association with improvement of depressive symptoms in individuals diagnosed with major depressive disorder. furthermore, a recently developed and validated intervention, the mindfulness-oriented recovery enhancement (more) program, which was original­ ly developed for the management of substance use and addiction problems, in particular opioid use in connection with chronic pain management (garland et al., 2022), also seems to show beneficial effects on the brain's responses to reward and to increase positive affect and emotion regulation (garland et al., 2017). this group intervention program combines cognitive-behavioral techniques, mindfulness and meditation methods with savoring training. this 8-weeks training has shown significant beneficial effects on opioid use and improvement in chronic pain symptoms in large clinical trials in the usa (garland et al., 2022). a current study of our group is interested in investigating whether this program can improve pain symptoms as well as affective symptoms of women suffering from fibromyalgia at a clinical level and to investigate as well the neural responses to reward changes and in the functioning of dopamine, a neurotransmitter that has been linked to reward, before and after the intervention (ledermann et al., 2021). figure 1 simplified schematic model of the stress-reward interaction as mediator of the relationship between stress exposure and the development of psychopathological symptoms psychopathological symptomsexposure to stress stress reactivity reward reactivity note. a higher neural reactivity to stress and a lower reactivity to reward are hypothesized to be a vulnerability factor for psychopathology. interventions targeting one or both mechanisms can be used in a preventive manner or as treatment. martin-soelch 3 clinical psychology in europe 2023, vol. 5(1), article e11567 https://doi.org/10.32872/cpe.11567 https://www.psychopen.eu/ what does this mean for psychologists? integrating results and approaches from other disciplines such as neuroscience to understand and identify neural mechanisms that are important for the development of disorders and that are directly associated with psychological mechanisms allows the development of targeted psychological interventions that can be used preventively in groups of individuals at risk of developing psychological disorders, for example in offspring of depressed parents. these interventions can also be used in addition to or in complement to usual psychotherapeutic treatment for individuals currently diagnosed with a mental disorder in order to offer targeted treatment. these mechanism-based interventions enrich the clinical psychologist's range of interventions and allows for a transdiagnostic approach. finally, as their neural correlates are known, it is possible to perform neuroimaging measures of these mechanisms before and after the intervention in randomized controlled trials to show the effect of the psychological interventions not only at a clinical level, but also at a neural level. this approach is therefore a promising avenue for the development of new clinical psychological interventions either for the prevention or the treatment of mental disorders. funding: the author has no funding to report. acknowledgments: the author has no additional (i.e., non-financial) support to report. competing interests: the author has declared that no competing interests exist. twitter accounts: @psychologiecli1 references admon, r., lubin, g., rosenblatt, j. d., stern, o., kahn, i., assaf, m., & hendler, t. 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(2014). resilience definitions, theory, and challenges: interdisciplinary perspectives. european journal of psychotraumatology, 5(1), article 25338. https://doi.org/10.3402/ejpt.v5.25338 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. the (neuro)-science behind resilience: a focus on stress and reward 6 clinical psychology in europe 2023, vol. 5(1), article e11567 https://doi.org/10.32872/cpe.11567 https://doi.org/10.3389/fpsyt.2020.563475 https://doi.org/10.1016/j.biopsych.2012.04.034 https://doi.org/10.1159/000523667 https://doi.org/10.1176/appi.ajp.2008.08081201 https://doi.org/10.1093/schbul/sbt114 https://doi.org/10.3389/fpsyt.2019.00088 https://doi.org/10.1038/35044563 https://doi.org/10.3402/ejpt.v5.25338 https://www.psychopen.eu/ icd-11 prolonged grief disorder, physical health, and somatic problems: a systematic review systematic reviews and meta-analyses icd-11 prolonged grief disorder, physical health, and somatic problems: a systematic review james cunningham 1 , mark shevlin 1 , catalina cerda 1 , eoin mcelroy 1 [1] school of psychology, ulster university, coleraine, united kingdom. clinical psychology in europe, 2025, vol. 7(1), article e14351, https://doi.org/10.32872/cpe.14351 received: 2024-04-09 • accepted: 2024-08-26 • published (vor): 2025-02-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: mark shevlin, ulster university (psychology), room h256, cromore road, coleraine, northern ireland, bt52 1sa. phone: +442870123141. e-mail: m.shevlin@ulster.ac.uk supplementary materials: materials, preregistration [see index of supplementary materials] abstract background: since prolonged grief disorder’s (pgd) inclusion as a mental health disorder in the icd-11 in 2018, much of the peer-reviewed research has focused on its prevalence, assessment, and co-occurrence with other mental health disorders. there is also emerging research literature on the association between pgd and physical and somatic health outcomes. in light of this, the objective of this review was to identify and summarise the extant research on the association between pgd, and outcomes related to physical health and somatic complaints among bereaved individuals. method: a systematic review utilized electronic databases (web of science, medline, cochrane library, psycinfo) up to october 10, 2023. included were cohort and cross-sectional studies since 2018 exploring links between icd-11 pgd and physical/somatic health outcomes. two researchers independently identified eligible studies meeting inclusion/exclusion criteria, employing quality assessment instruments to evaluate methodological rigor. results: from the 418 articles that were initially screened, 18 met the inclusion criteria. the studies reported significant associations between pgd and physical health, somatic symptom distress, insomnia severity, blood pressure, bodily distress syndrome, chronic physical diseases, and poorcaregiver health profiles. conclusion: out of the 18 studies eligible for analysis, 13 (72%) established a significantly strong or moderate association between pgd and physical or somatic illness, highlighting the intricate nature of this connection. further research is required to assess the breadth of physical and somatic health problems associated with pgd and to understand the psychological and biological mechanisms that underpin these observed relationships. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.14351&domain=pdf&date_stamp=2025-02-28 https://orcid.org/0009-0003-2630-5670 https://orcid.org/0000-0001-6262-5223 https://orcid.org/0009-0008-7738-0159 https://orcid.org/0000-0001-5466-8522 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords prolonged-grief, bereavement, pgd, physical, somatic, somatization, illness highlights • most studies found a strong to moderate link between pgd and physical/somatic illness. • pgd impacts caregiver health, somatic distress, insomnia, and comorbid chronic diseases. • findings align with ptsd, with clinically relevant psychological and medical effects. physical health is defined by the centers for disease control and prevention as the condition of one’s body, with the ability to carry out daily activities without experiencing pain, discomfort, or limitation (elgaddal et al., 2022). somatic problems, on the other hand, are physical symptoms that are not caused by an identifiable medical condition (kolappa et al., 2013). the association between mental health disorders and physical health or somatic symptoms has been consistently reported in the research literature. for example, depression has been identified as a risk factor for long-term physical conditions such as diabetes (cosgrove et al., 2008; gonzalez et al., 2008), cancer (massetti et al., 2017; massie, 2004), and cardiac disease (berg et al., 2018; chaddha et al., 2016; dhar & barton, 2016). studies conducted by haug et al. (2004) and carlehed et al. (2017) have also explored how depression relates to physical symptoms in large community samples, revealing a strong and significant relationship between depression and experiencing functional so­ matic symptoms. moreover, gili et al. (2010) reported a higher prevalence of depression among primary care patients with chronic somatic diseases compared to their physically healthy counterparts. one disorder that has consistently been found to be associated with physical and somatic problems is post-traumatic stress disorder (ptsd). the icd-11 outlines ptsd as a mental health condition that can emerge after experiencing a threatening or horrifying event or a sequence of such events (barbano et al., 2019) and the associated allostatic load has been argued to cause physical morbidity (mcfarlane, 2010). there has been a plethora of studies examining the association between ptsd, trauma exposure, physical illness, and somatization, and various systematic reviews have analyzed and described the extant research evidence. an early systematic review by qureshi et al. (2009) found evidence for a consistent association between ptsd and arthritis, however, mixed results were observed for conditions such as diabetes, coronary heart disease, and stroke. in a more comprehensive systematic review of 62 studies, pacella et al. (2013) reported a significant association between ptsd and overall poorer physical health outcomes. this encompassed general health symptoms, medical conditions, and health-related quality of life. gupta’s (2013) review further emphasized the link between ptsd and diverse prolonged grief, physical and somatic health: review 2 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ medical conditions by highlighting the severity of ptsd symptoms to be significantly associated with an increased risk of physical conditions such as hypertension and coro­ nary heart disease. sleep disturbances, such as sleep paralysis, were also prevalent in ptsd patients, suggesting a multifaceted impact on physical health. afari et al.’s (2014) systematic review of 71 studies indicated that individuals with reported exposure to trau­ ma were more likely to have functional somatic syndromes, with ptsd also identified as a contributor to cardiovascular and immune-mediated disorders. lastly, ryder et al.’s (2018) meta-analysis underscored a robust association between ptsd and increased risks of cardiovascular, metabolic, and musculoskeletal disorders. collectively, these studies emphasize the intricate connection between ptsd and various physical health outcomes. poorer physical and somatic health status also appear to be associated with stressful life experiences such as bereavement. parkes (1964) was among the first to show a signif­ icant correlation between bereavement and physical health in older adults by reporting a 65% increase in medical consultation rates among a sample of widows following bereavement. large-sample cross-sectional research from thimm et al. (2020) also dem­ onstrated that severe grief reactions in elderly individuals were significantly associated with self-reported physical health problems as well as an increased use of health services. additionally, sillis et al. (2022) and toblin et al. (2012) have shown that this association was also present in samples of younger people by reporting significant associations between grief and somatic complaints among bereaved university students and infantry soldiers. moreover, a systematic review by ennis and majid (2021) found a significant, positive relationship between bereavement and adverse physical and physiological health outcomes, including inflammation, cardiovascular risk, chronic pain, and mortality. a significant issue in the field of bereavement has been the lack of acknowledgment of enduring, distressing grief reactions as specific conditions related to grief. there has been a warranted reluctance to pathologize any form of grief, leading to inconsistencies in its definitions and measurement. as a result, depression was often diagnosed instead. however, the inclusion of prolonged grief disorder (pgd) in the 11th revision of the international classification of diseases (icd-11: who, 2019) and the diagnostic and statistical manual of mental disorders, fifth edition, text revision (dsm-5-tr) (american psychiatric association, 2022) has facilitated a more standardized approach to the study of grief. on the other hand, the published peer-reviewed literature exploring pgd and physi­ cal health problems has also not been systematically examined since pgd was officially classified as a mental health disorder. to address this, we conducted a systematic review of the scientific literature to investigate the association between icd-11 pgd, and out­ comes related to physical health and somatic complaints among bereaved individuals. by synthesizing existing research, this review aims to provide a clearer understanding of the impact of pgd on physical and somatic health, which could inform clinical practices, guide future research, and ultimately contribute to improved care for bereaved cunningham, shevlin, cerda, & mcelroy 3 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ individuals. this review represents the first comprehensive assessment of the evidence for associations between icd-11 pgd, and physical and somatic health outcomes since pgd’s inclusion in the icd-11. method the protocol for this systematic review was preregistered at the prospero repository (crd42023471080) on 10/10/2023 (for access, see cunningham et al., 2023s). to ensure transparency and completeness in the processing and reporting of the results, the pris­ ma 2020 guidelines (page et al., 2021) were adhered to. inclusion and exclusion criteria this systematic review incorporated any form of quantitative studies that met the fol­ lowing inclusion criteria: 1. the study reported original, empirical research published in peer-reviewed journals, that utilized quantitative and validated measures of prolonged grief disorder (pgd) and physical or somatic illness. 2. investigated the association between pgd symptoms from standardized assessment tools and physical and somatic health symptoms. 3. included a report of quantitative measures of association or group difference such as correlations, odds ratio, t-test, etc. the exclusion criteria were: 1. non-peer reviewed published research studies. 2. research that did not employ a quantitative methodology. 3. single-item quantitative scale measurement of pgd or physical or somatic illness. 4. non-english language. 5. studies prior to 2018. search strategy four electronic databases web of science, medline, cochrane library, and psycinfo up to the 10th of october 2023 were searched using full-text terms to identify studies reporting an association between pgd, and physical and somatic health symptoms. the search was limited to research studies published in the english language since 2018 that underwent peer review. searches were conducted using boolean operators of the following search terms: “prolonged grief disorder” or “prolonged grief” or “traumatic grief” and “somatic symptoms” or “physical illness”. prolonged grief, physical and somatic health: review 4 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ in addition, reference lists of selected studies were screened for any other relevant study. reporting guidelines this article was prepared in accordance with the prisma (preferred reporting items for systematic reviews and meta-analyses) guidelines (page et al., 2021). adherence to prisma standards ensures that the research was reported with transparency and rigor, providing a clear, comprehensive, and reproducible account of the systematic review process. following these guidelines enhanced the quality and integrity of our research findings. data collection, extraction and quality assessment after identifying studies that met the inclusion/exclusion criteria, the researchers re­ trieved the full-text articles. two independent reviewers (j.c and c.c) assessed the articles for eligibility, and any disagreements were resolved by consensus. the reviewers were not blinded to the journals or authors of the studies. the researchers created a standardized data extraction sheet to gather information on publication details, study location, methodological features (such as sample size and study design), exposure and outcome measures, pgd type, and the scales used for physical and somatic health out­ comes (supplementary table 3). the evaluation then focused on the appropriateness of quality assessment tools to measure the level of bias in each study. the resultant tool was a modification of the two most relevant instruments. the joanna briggs institute critical appraisal checklist for analytical cross-sectional studies (jbi) (joanna briggs institute, 2017a) (supplementary table 1) was applied to cross-sectional studies, while the jbi criti­ cal appraisal checklist for cohort studies (joanna briggs institute, 2017b) (supplementary table 2) was employed for longitudinal studies. the description of effect sizes were based on cohen (1988) descriptions of mean difference (small d = 0.20, medium d = 0.50, and large d ≥ 0.80) and correlations (small r = .10, medium r = 0.30, and large r ≥ .50). results details of the search and selection of studies is presented in figure 1. out of the initial screening based on title and abstract, 418 articles were identified, 112 of which were du­ plicates, and once removed, 306 articles remained. there was a high degree of agreement between the two reviewers (24 and 25 articles) in selecting articles that met the inclusion criteria (kappa = .62, t = 10.90, p < .001). after full-text screening and discussion, a final set of 18 articles were selected to take forward to full review. cunningham, shevlin, cerda, & mcelroy 5 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ figure 1 prisma flow diagram showing the process for search and selection of studies results of the reviewed studies are summarized in table 1, covering information on asso­ ciations between pgd, and physical and somatic health outcomes, mode of bereavement, sample characteristics, study design, measures, main findings, and risk of bias. prolonged grief, physical and somatic health: review 6 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ ta bl e 1 su m m ar y of a ss oc ia tio ns b et w ee n pg d a nd p hy si ca l, so m at ic h ea lth o ut co m es st ud y m od e of be re av em en t (n at ur al , s ud de n/ un ex pe ct ed / sp ec if ic il ln es s) ti m e si nc e be re av em en t sa m pl e si ze a nd c ha ra ct er is ti cs st ud y d es ig n (c ro ss -s ec ti on al /lo ng it ud in al ) si ng le g ro up o r ca se -c on tr ol / co m pa ri so n m ea su re s of p g d a nd p hy si ca l a nd so m at ic h ea lt h m ai n fi nd in gs r is k of b ia s lu nd or ff e t a l. (2 02 0) d en m ar k lo ss o f a s po us e (n at ur al ) 2, 6 , a nd 1 1 m on th s po st -l os s n = 8 57 fe m al e: 6 9. 8% m al e: 3 0. 2% m ea n ag e: 7 0. 30 pr os pe ct iv e lo ng itu di na l si ng le g ro up 11 -m on th s po st lo ss t he 1 3ite m p ro lo ng ed g ri ef -s ca le (p g -1 3; p ri ge rs on e t a l., 2 00 9) ; r ev is ed ic g -r (p ri ge rs on & ja co bs , 2 00 1) ; t he s ho rt -f or m h ea lth s ur ve y (w ar e et al ., 19 96 ) ph ys ic al h ea lth s ig ni fi ca nt ly p re di ct ed th e m od er at est ab le c la ss , e st = -0 .0 41 , s e = 0. 01 6, p = .0 08 w hi ch a ls o in cl ud ed s ub st an tia l pr op or tio ns o f p ro ba bl e pg d c as es , a nd ap pr oa ch ed s ig ni fi ca nt ly a s a pr ed ic to r of th e pr ol on ge d gr ie f c la ss e st = -0 .0 41 , s e = 0. 01 6 p = .0 52   lo w k ill ik el ly e t a l. (2 02 0) c ro ss -n at io na l st ud y c hi na , s w itz er la nd an d th e u ni te d st at es lo ss o f a lo ve d on e (n at ur al ) 6 to 3 6 m on th s n = 5 39 c hi ne se s pe ak in g: 32 5 g er m an s pe ak in g: 21 4 fe m al e: 7 2. 4% m al e: 2 7. 6% m ea n ag e to ta l: 35 .3 9 c hi ne se s am pl e: 33 .1 4 g er m an s am pl e: 38 .7 1   c ro ss -s ec tio na l c om pa ri so n gr ou p in te rn at io na l i c d -1 1 pr ol on ge d g ri ef d is or de r sc al e (k ill ik el ly & m ae rc ke r, 20 17 ) t he s om at ic s ym pt om s ca le (g ie rk e t a l., 20 14 ) c or re la tio n co ef fi ci en ts b et w ee n pg d (i pg d s) an d so m at ic s ym pt om s (s ss -8 ) s ho w ed m od er at ele ve l r el at io ns hi ps fo r ea ch o f t he th re e ip g d s sc al es fo r bo th s am pl es . c hi ne se sp ea ki ng s am pl e: ip g d s 32 it em s & s ss -8 = .5 38 , i pg d s 13 it em s & s ss -8 = .4 80 , a nd ip g d s st an da rd w ith c ul tu ra l s up pl em en t & ss s8 = .5 40 . g er m an s pe ak in g sa m pl e: ip g d s 32 it em s & s ss -8 = .5 08 , i pg d s 13 it em s & ss s8 = .4 58 a nd ip g d s st an da rd w ith c ul tu ra l su pp le m en t & s ss -8 = .5 14 lo w vo ge l e t a l. (2 02 1) g er m an y lo ss o f a lo ve d on e n at ur al a t l ea st 6 m on th s pr ev io us ly n = 2 0 fe m al e: 8 0% m al e: 2 0% m ea n ag e: 5 6 pr os pe ct iv e lo ng itu di na l si ng le g ro up 3 m on th pg -1 3 (p ri ge rs on e t a l., 2 00 9) t he s cr ee ni ng fo r so m at of or m d is or de rs (s o m s7d ; r ie f & h ill er , 2 00 3) t he re w er e no s ig ni fi ca nt d iff er en ce s be tw ee n th e pg d g ro up b ef or e an d af te r th e pe rs on ce nt er ed th er ap y in te rv en tio n in r eg ar d to so m at of or m s ym pt om s (s o m s7d ) t 0t1 d = 0. 07 , t 0t2 d = 0 .2 9 p = .6 65   m od er at e m ill er e t a l. (2 02 0) u ni te d st at es lo ss o f a lo ve d on e ill ne ss : c an ce r 6 to 1 5 m on th s po st -l os s n = 1 98 fe m al e: 6 1% m al e: 3 9% m ea n ag e: 6 4. 40 pr os pe ct iv e lo ng itu di na l si ng le g ro up s tu dy : h ow ev er la te nt c la ss m ix tu re m od el in g is u se d to c ha ra ct er iz e ca re gi ve r he al th b y id en tif yi ng d is tin ct pr of ile s 15 m on th s po st lo ss pg -1 3 (p ri ge rs on e t a l., 2 00 9) o ve ra ll he al th w as a ss es se d w ith 3 se pa ra te m ea su re s: a s in gl e se lfre po rt ite m , t he h ea lth s ub sc al e of c ar eg iv er re ac tio n a ss es sm en t ( g iv en e t a l., 1 99 2) , an d t he m ee tin g ph ys ic al d em an ds su bs ca le o f t he p er ce iv ed s el fc ar e an d d ai ly l iv in g c om pe te nc ie s sc al e (c as er ta et a l., 2 00 4; u tz e t a l., 2 01 2) . tw o di st in ct h ea lth p ro fi le s w er e id en tif ie d in th e to ta l s am pl e. p oo re r h ea lth p ro fi le g ro up (n = 4 9; 2 5% ) h ad s ig ni fi ca nt ly g re at er h ea lth im pa ct fr om c ar eg iv in g d = 0. 85 (p < .0 00 1) , m or e se lfre po rt ed h ea lth p ro bl em s d = 0. 53 (p = .0 02 ), an d gr ea te r di ff ic ul ty m ee tin g th e ph ys ic al d em an ds o f d ai ly li fe d = 1 .1 6 (p < .0 00 1) th an th e di st in ct p ro fi le (n = 1 49 ). re gr es si on m od el s sh ow ed th at h av in g a po or er c ar eg iv er h ea lth p ro fi le w as a si gn if ic an t p re di ct or o f h ig he r le ve ls o f g ri ef sy m pt om s d = 4. 62 (p < .0 01 ) i n th e su bs am pl e of p ar tic ip an ts w ho w er e el ig ib le fo r th e be re av em en t a na ly se s (n = 8 1) .   m od er at e cunningham, shevlin, cerda, & mcelroy 7 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ st ud y m od e of be re av em en t (n at ur al , s ud de n/ un ex pe ct ed / sp ec if ic il ln es s) ti m e si nc e be re av em en t sa m pl e si ze a nd c ha ra ct er is ti cs st ud y d es ig n (c ro ss -s ec ti on al /lo ng it ud in al ) si ng le g ro up o r ca se -c on tr ol / co m pa ri so n m ea su re s of p g d a nd p hy si ca l a nd so m at ic h ea lt h m ai n fi nd in gs r is k of b ia s m ar cu ss en e t a l. (2 02 1) c ro ss -n at io na l st ud y d en m ar k, a us tr al ia a nd n or w ay lo ss o f a p ar en t c an ce r, su dd en un ex pe ct ed , s ui ci de an d ch ro ni c di se as e do es n ot p ro vi de da ta o n th e tim e si nc e be re av em en t n = 19 0 fe m al e: 9 1% m al e: 9 % m ea n ag e: 1 7. 90 c ro ss -s ec tio na l c om pa ri so n gr ou p t he p g -1 3 (p ri ge rs on e t a l., 2 00 9) t he c m d q 3 6 (l u et a l., 2 00 8; t eb ek a et al ., 20 16 ). (b od ily d is tr es s sy nd ro m e su bs ca le ) pr ol on ge d gr ie f a nd b od ily d is tr es s sy nd ro m e sh ow ed a w ea k co rr el at io n at .2 4. t he re w as a si gn if ic an t d iff er en ce b et w ee n th e di vo rc ed pa re nt al d ea th g ro up n = 5 2 co m pa re d to th e no ndi vo rc ed p ar en ta l d ea th g ro up n = 1 30 o n bo di ly d is tr es s sy nd ro m e d = 0. 37 5 p = .0 4. t he r is k of b od ily d is tr es s sy nd ro m e w as fo un d to b e si gn if ic an tly a ss oc ia te d w ith pa re nt al d iv or ce b ef or e pa re nt al d ea th b = 3. 53 , p = .0 09 .   m od er at e le ng er e t a l. (2 02 0) d en m ar k lo ss o f a p at ie nt ca re gi ve rs w ho ex pe ri en ce d th e de at h of p at ie nt s 6 m on th s af te r be re av em en t n = 2 ,1 25 fe m al e: 7 0% m al e: 3 0% m ea n ag e: 6 2. 00 pr os pe ct iv e lo ng itu di na l si ng le -g ro up h ow ev er , s am pl e sp lit in to w ith p g d a nd w ith ou t p g d 6 m on th s po st -l os s t he p g -1 3 (p ri ge rs on e t a l., 2 00 9) sh or t f or m h ea lth s ur ve y36 (s f36 ) (w ar e, 1 99 9) su bs ca le s: p hy si ca l f un ct io ni ng , r ol eph ys ic al b od ily p ai n, a nd g en er al h ea lth po or p hy si ca l h ea lth s ta tu s du ri ng c ar eg iv in g pr ed ic te d pr ol on ge d gr ie f d is or de r: o dd s ra tio 1. 05 (9 5% c i [ 1. 04 , 1 .0 7] ). t he p hy si ca l su bs ca le s of p hy si ca l f un ct io ni ng o dd s ra tio 1. 02 , ( 95 % c i [ 1. 02 , 1 .0 3] ). ro le p hy si ca l o dd s ra tio , 1 .0 2, (9 5% c i [ 1. 01 , 1 .0 2] ). bo di ly p ai n od ds r at io 1 .0 3, (9 5% c i [ 1. 02 , 1 .0 3] ). an d ge ne ra l h ea lth o dd s ra tio 1 .0 4, (9 5% c i [ 1. 03 , 1. 04 ]) . a ll pr ed ic te d pr ol on ge d gr ie f d is or de r.   m od er at e z ho u et a l. (2 02 0) c hi na lo ss o f a n on ly ch ild v io le nt a nd n on vi ol en t 6 m on th s af te r be re av em en t n = 1 ,0 30 fe m al e: 6 2% m al e: 3 8% m ea n ag e: 5 9. 91 c ro ss -s ec tio na l si ng le -g ro up t he p g -1 3 (p ri ge rs on e t a l., 2 00 9) t he p re se nc e of c hr on ic p hy si ca l d is ea se s w as a ss es se d th ro ug h a se ri es o f b in ar y qu es tio ns . ( yi n et a l., 2 01 8) . c um ul at iv e ill ne ss r at in g sc al e (l in n et al ., 19 68 ) t he n um be r of c hr on ic p hy si ca l d is ea se s w as c al cu la te d an d co de d in to a s co re ra ng in g fr om z er o to s ix .   m or e co m or bi d ch ro ni c ph ys ic al d is ea se s w er e si gn if ic an tly r el at ed to th e in cr ea se d ri sk o f pr ol on ge d gr ie f d is or de r t = 1 0. 25 , β = .3 3 (9 5% c i [ 1. 03 , 1 .5 1] ) lo w z ha ng e t a l. (2 02 0) c hi na lo ss o f a n on ly ch ild d is ea se a nd ac ci de nt m ea nt im e po st -l os s 7. 6 ye ar s n = 1 49 fe m al e: 6 0% m al e: 4 0% m ea n ag e: 6 2. 25 c ro ss -s ec tio na l c om pa ri so n st ud y t he p g -1 3 (p ri ge rs on e t a l., 2 00 9) in fo rm at io n ab ou t w he th er th e pa rt ic ip an ts h ad u nd er ly in g ch ro ni c di se as es w as r ec or de d. n um be r of o ut pa tie nt v is its fo r ph ys ic al he al th o r ot he r re as on s in th e pa st y ea r. it w as r an ke d in 4 le ve ls .   t he o ve ra ll m or bi di ty o f o st eo ar th ro si s in th e pg d -p os iti ve g ro up w as s ig ni fi ca nt ly h ig he r th an th at in th e pg d -n eg at iv e gr ou p (χ 2 = 7. 18 , p < .0 07 ). t he re w as n o si gn if ic an t di ff er en ce in th e nu m be r of h os pi ta l v is its be tw ee n th e tw o gr ou ps . lo w po hl ka m p et a l. (2 01 9) sw ed en lo ss o f a c hi ld c an ce r 1 to 5 y ea rs a ft er lo ss n = 2 25 fe m al e: 5 9% m al e: 4 1% m ea n ag e: 4 6. 00 c ro ss -s ec tio na l si ng le -g ro up s tu dy t he p g -1 3 (p ri ge rs on e t a l., 2 00 9) t he in so m ni a se ve ri ty in de x (m or in , 19 93 ) in s ym pt om s of in so m ni a, th er e w as n o si gn if ic an t e ff ec t o f y ea rs s in ce lo ss , f 4 = 1 .1 2, .3 5 an d no d iff er en ce b et w ee n ge nd er s, f 1 = 1. 92 , . 17 . t he re w as n o si gn if ic an t i nt er ac tio n be tw ee n ye ar s si nc e lo ss a nd g en de r on in so m ni a f 4 = 1. 16 , . 33 .   m od er at e prolonged grief, physical and somatic health: review 8 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ st ud y m od e of be re av em en t (n at ur al , s ud de n/ un ex pe ct ed / sp ec if ic il ln es s) ti m e si nc e be re av em en t sa m pl e si ze a nd c ha ra ct er is ti cs st ud y d es ig n (c ro ss -s ec ti on al /lo ng it ud in al ) si ng le g ro up o r ca se -c on tr ol / co m pa ri so n m ea su re s of p g d a nd p hy si ca l a nd so m at ic h ea lt h m ai n fi nd in gs r is k of b ia s sv ee n et a l. (2 02 0) sw ed en lo ss o f a s ig ni fi ca nt ot he r tr au m at ic ev en t, in th e pa st 5 y ea rs n = 1 23 fe m al e: 8 1% m al e: 1 9% m ea n ag e: 3 7. 85 pr os pe ct iv e lo ng itu di na l su bs am pl es : c om pa ri so n gr ou p o ng oi ng lo ng itu di na l s tu dy (t ra c es st ud y) t he p g -1 3 (p ri ge rs on e t a l., 2 00 9) t he s ym pt om c he ck lis t 2 7 (s c l27 ) (h ar dt e t a l., 2 00 4) pg -1 3 co rr el at io ns w ith th e so m at iz at io n su bs ca le w er e st ro ng er in th e be re av em en t gr ou p 0. 57 (p < .0 01 ) c om pa re d to th e co m pa ri so n gr ou p 0. 29 : z v al ue = 1 .7 7. t he re w er e no s ig ni fi ca nt d iff er en ce s be tw ee n th e be re av em en t g ro up n = 7 2 an d th e co m pa ri so n gr ou p n = 51 o n so m at iz at io n, d = -0 .1 45 .   m od er at e de l an g et a l. (2 02 3) n et he rl an ds lo ss o f a lo ve d on e, n at ur al a cc id en t an d su ic id e 1 m on th to m or e th an 5 ye ar s n = 3 43 fe m al e: 8 8% m al e: 1 2% m ea n ag e: 5 4. 00 pr os pe ct iv e lo ng itu di na l si ng le -g ro up 1 ye ar p os tlo ss tr au m at ic g ri ef in ve nt or y se lfre po rt pl us (t g isr ; l en fe ri nk e t a l., 2 02 2) . ba se d on th e tg isr (b oe le n & s m id , 20 17 ) t he in so m ni a se ve ri ty in de x (m or in , 19 93 ) c or re la tio ns b et w ee n pr ol on ge d gr ie f a nd in so m ni a sy m pt om s al l s ho w ed a m od er at e re la tio ns hi p be tw ee n th e tw o va ri ab le s ac ro ss th e th re e tim e po in ts a t 6 m on th in te rv al s. pg s at ti m e 1 di sp la ye d a w ea ke r co rr el at io n ov er ti m e ag ai ns t i ns om ni a sy m pt om s ov er tim e (t 1 .3 9) , ( t 2 .3 7) (t 3 .3 5) p g s at ti m e 2 eb be d an d flo w ed a s a co rr el at io n ov er ti m e ag ai ns t i ns om ni a sy m pt om s ov er tim e (t 1 .3 5) , (t 2 .4 7) (t 3 .4 2) p g s at ti m e 3 di sp la ye d a st ro ng er c or re la tio n ov er ti m e ag ai ns t in so m ni a sy m pt om s ov er ti m e (t 1 .3 6) , ( t 2 .4 4) (t 3 .4 9) . a ll co rr el at io ns a re s ig ni fi ca nt , p < .0 01 pa rt ic ip an ts w ith h ig he r tr ai ts o f p ro lo ng ed gr ie f s ym pt om s al so r ep or te d hi gh er tr ai ts o f in so m ni a sy m pt om s b = .0 22 (p < .0 01 ). fo r in so m ni a sy m pt om s, th er e w as a s ig ni fi ca nt au to re gr es si ve p at h (p = .0 11 ) a nd a c ro ss la gg ed e ff ec t f ro m in so m ni a to p ro lo ng ed g ri ef sy m pt om s b = .0 23 (p = .0 28 ).   m od er at e h en ne m an n et a l. (2 02 3) c ro ss -n at io na l st ud y g er m an y, sw itz er la nd a nd ir el an d lo ss o f a c lo se lo ve d on e na tu ra l, ac ci de nt , su ic id e, s ub st an ce ab us e, h om ic id e, an d na tu ra l d is as te r. n o sp ec if ic d ur at io n si nc e th e lo ss n = 1 ,3 37 fe m al e: 7 6% m al e: 2 4% m ea n ag e: 2 3. 74 c ro ss -s ec tio na l si ng le -g ro up in te rn at io na l i c d -1 1 pr ol on ge d g ri ef d is or de r sc al e (k ill ik el ly & m ae rc ke r, 20 17 ) so m at ic s ym pt om s ca le (g ie rk e t a l., 20 14 ) t he d ir ec t e ff ec t o f p g d o n so m at ic s ym pt om di st re ss r em ai ne d si gn if ic an t w he n in cl ud in g m ed ia to rs (c = 0 .0 3, p = .0 03 ), in di ca tin g a pa rt ia l m ed ia tio n of s om at ic s ym pt om di st re ss . 2 3% o f t he v ar ia nc e in e xp la in in g so m at ic s ym pt om d is tr es s w as e xp la in ed b y pr ol on ge d gr ie f d is or de r b = 0. 48 p = < .0 01 . tw oth ir ds o f i nd iv id ua ls w ith p os si bl e pg d re po rt ed h ig h or v er y hi gh le ve ls o f s om at ic sy m pt om d is tr es s in th e ss s8, w hi ch is re m ar ka bl y hi gh er th an p re va le nc es in th e ge ne ra l p op ul at io n n on -p g d m = 6 .8 8 pg d m  = 1 2. 91 p < .0 01 , d = 0 .9 0.   lo w c ar ls so n et a l. (2 02 3) sw ed en lo ss o f f am ily m em be r ca rd ia c ar re st si x m on th s af te r lo ss n = 1 08 fe m al e: 6 9% m al e: 3 1% m ea n ag e: 6 1. 50 c ro ss -s ec tio na l si ng le -g ro up : h ow ev er , s ub sa m pl es o f sp ou se s an d no nsp ou se s w er e co nd uc te d 11 it em s of th e 13 -i te m p g -1 3 (p ri ge rs on et a l., 2 00 9) t he r a n d -3 6 m ea su re d he al th -r el at ed qu al ity o f l ife (h ay s & m or al es , 2 00 1) sp ou se s re po rt ed m or e pr ob le m s w ith sy m pt om s of p ro lo ng ed g ri ef a nd s el fre po rt ed he al th th an n on -s po us es (p < .0 01 ). n o si gn if ic an t d iff er en ce s w er e fo un d be tw ee n sp ou se s an d no nsp ou se s in te rm s of sy m pt om s of p ro lo ng ed g ri ef a nd s el fre po rt ed h ig h cunningham, shevlin, cerda, & mcelroy 9 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ st ud y m od e of be re av em en t (n at ur al , s ud de n/ un ex pe ct ed / sp ec if ic il ln es s) ti m e si nc e be re av em en t sa m pl e si ze a nd c ha ra ct er is ti cs st ud y d es ig n (c ro ss -s ec ti on al /lo ng it ud in al ) si ng le g ro up o r ca se -c on tr ol / co m pa ri so n m ea su re s of p g d a nd p hy si ca l a nd so m at ic h ea lt h m ai n fi nd in gs r is k of b ia s he al th . 2 5% o f f am ily m em be rs in th e pr es en t st ud y re po rt ed th ei r ge ne ra l h ea lth a s fa ir o r po or a nd th ei r he al th to b e w or se c om pa re d to a ye ar a go   pa lit sk y et a l. (2 02 3) u ni te d st at es lo ss o f c lo se re la tiv e n at ur al w ith in th e pa st y ea r n = 5 9 fe m al e: 6 9% m al e: 3 1% m ea n ag e: 6 6 c ro ss -s ec tio na l si ng le -g ro up t he p g -1 3 (p ri ge rs on e t a l., 2 00 9) g e d in am ap p ro 1 00 b p m on ito rs : pr ov id ed m ea su re s of s bp s ys to lic b lo od pr es su re a nd d ia st ol ic b lo od p re ss ur e d bp in cr ea se s w er e ob se rv ed in s bp fr om b as el in e (m ea n [s ta nd ar d er ro r] , o r m [ se ] = 12 4. 32 [1 5. 01 ] m m h g) to im m ed ia te ly p os tg r (m ea n [s ta nd ar d de vi at io n] , m [ sd ] = 14 5. 43 [2 5. 17 ], p < .0 01 , 9 5% c i [ 16 .6 8, 2 5. 52 ]) . d bp al so in cr ea se d fr om b as el in e (m [ sd ] = 69 .0 5 [8 .4 7] ) t o im m ed ia te ly p os tg r (m [ sd ] = 77 .1 5 [1 0. 67 ], p < .0 01 , 9 5% c i [ 5. 87 , 1 0. 34 ]) . pr ol on ge d gr ie f d is or de r al so s ig ni fi ca nt ly pr ed ic te d sb p (b = 0 .4 47 , s e = 0. 21 5, p = .0 42 , 95 % c i [ 0. 02 4, 0 .8 71 ]) .   lo w k ai se r et a l. (2 02 2) g er m an y lo ss o f a lo ve d on e he m at ol og ic al ca nc er tim e si nc e lo ss n ot ou tli ne d n = 8 7 fe m al e: 8 3% m al e: 1 7% m ea n ag e: 4 7. 32 in te rv en tio n g = 47 .8 0 w c g = 4 6. 84   pr os pe ct iv e lo ng itu di na l a r an do m iz ed c on tr ol le d tr ia l w ith a w ai tli st c on tr ol g ro up 1 ye ar p os tlo ss t he g er m an v er si on o f t he ic g (p ri ge rs on e t a l., 1 99 5) 12 -i te m s ho rt -f or m h ea lth s ur ve y (b ul lin ge r, 19 95 ) n o si gn if ic an t g ro up in te ra ct io n w as fo un d fo r pr ol on ge d gr ie f a nd p hy si ca l h ea lth , s le ep qu al ity , o r so m at iz at io n. a s ig ni fi ca nt w ith in -g ro up e ff ec t o f t im e w as fo un d in th e ig a nd th e w c g fo r pr ol on ge d gr ie f a nd s om at iz at io n at p = .0 3 (w c g ) a nd p < .0 01 (i g ) d = -0 .0 1   lo w c om te ss e et a l. (2 02 0) g er m an y lo ss o f a c hi ld , pa rt ne r, pa re nt a nd ot he r. na tu ra l a nd u nna tu ra l 6 m on th s po st -l os s n = 1 13 fe m al e: 8 1% m al e: 1 9% m ea n ag e: 5 1. 68 pr os pe ct iv e lo ng itu di na l c om pa ri so n gr ou p t he p g -1 3 (p ri ge rs on e t a l., 2 00 9) t he s cr ee ni ng fo r so m at of or m d is or de rs (s o m s7 d ; r ie f & h ill er , 2 00 3) t he re w as n o si gn if ic an t d iff er en ce b et w ee n th e pg d /p g d e m p gr ou ps a nd n on -p g d / pg d e m p gr ou ps in s om at iz at io n t = 2 .1 6 d = 0. 64 3 an d t = 1 .6 2 d = 0 .3 9. t he p er si st en t co m pl ex b er ea ve m en t d is or de r gr ou p sh ow ed an a pp ro ac hi ng s ig ni fi ca nc e di ff er en ce r es ul t p = .0 55 c om pa re d to th e no npc bd g ro up d  = 0 .1 36   h ig h m ac ca llu m a nd br ya nt (2 02 0) a us tr al ia lo ss o f a p ar tn er , ch ild , p ar en t si bl in g or o th er m ed ic al , a cc id en t, su ic id e an d h om ic id e, 6 m on th s af te r lo ss   n = 2 15 fe m al e: 8 2% m al e: 1 8% m ea n ag e: 4 9. 24 c ro ss -s ec tio na l si ng le -g ro up t he p g -1 3 (p ri ge rs on e t a l., 2 00 9) t he w h o q o lbr ie f (p ow er e t a l., 1 99 9) re gu la ri ze d pa rt ia l c or re la tio n ne tw or k an al ys is s ho w ed a s ig ni fi ca nt n eg at iv e as so ci at io n be tw ee n pr ol on ge d gr ie f d is or de r an d ph ys ic al h ea lth e l = -0 .0 2 m od er at e yı ld ır ım (2 02 3) tu rk ey lo ss o f f ir st -d eg re e re la tiv e c o v id -1 9, na tu ra l a nd un na tu ra l d ea th s 12 -2 4 m on th s af te r lo ss n = 6 8 fe m al e: 8 5% m al e: 1 5% m ea n ag e: 4 5. 35 pg d g ro up = 4 1. 90 n on p g d g ro up = 48 .8 0 c ro ss -s ec tio na l si ng le -g ro up : h ow ev er , s ub gr ou ps o f p g d an d n o p g d w er e us ed t he p g -1 3 (p ri ge rs on e t a l., 2 00 9) in so m ni a se ve ri ty in de x (m or in , 1 99 3) po si tiv e co rr el at io ns b et w ee n pg d s ev er ity an d in so m ni a (r = 0 .5 01 ; p < 0 .0 1) t he re w as a s ig ni fi ca nt d iff er en ce b et w ee n th e pg d g ro up n = 3 0 an d th e n on p g d g ro up n = 3 8 in s ev er ity o f i ns om ni a t = 2 .6 3 p = .0 11 lo w prolonged grief, physical and somatic health: review 10 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ across the 18 studies eligible for examination, 13 (72%) demonstrated a significantly strong or moderate association between pgd and physical or somatic illness. this was displayed across divergent research designs, types of loss and different somatic and phys­ ical health problems. cross-sectional and longitudinal designs were used in all studies. using a cross-sectional design killikelly et al. (2020) reported a moderate correlation between pgd (three ipgds sub-scales) and somatic symptoms, and this is consistent with hennemann et al. (2023) who reported that a significant proportion of variance (r 2 = 23%) in somatic related distress was attributed to pgd. in contrast, maccallum and bryant (2020) identified a negative association between prolonged grief and physical health. in prospective longitudinal studies, comtesse et al. (2020) found no significant differences in somatization between individuals with pgd and those without it. in contrast, sveen et al. (2020) highlighted stronger correlations between prolonged grief and somatization in bereavement. vogel et al. (2021) showed no significant differences in somatoform symptoms pre and post-person-centered therapy, while kaiser et al. (2022) found no significant group interaction but observed within-group effects over time. however, both intervention studies featured small sample sizes and a 4:1 ratio of females to males, impacting statistical power and generalizability. the types of loss reported in the studies included in this review were mostly losing a child, spouse/partner, or parent as well as the losses of patients and family members. zhou et al. (2020) and zhang et al. (2020) examined chinese parents who had lost an only child and they reported associations between an increased risk of pgd and chronic physical diseases. studies on spousal loss by lundorff et al. (2020) and carlsson et al. (2023) identified spousal grief symptoms as a predictor of physical health problems. marcussen et al. (2021) found a strong correlation between prolonged grief and bodily distress syndrome in a sample who had experienced parental loss. similarly, lenger et al. (2020) and miller et al. (2020) showed a significant association between prolonged grief symptoms and poorer physical health in a sample of bereaved caregivers. these findings suggest that the type of relationship with the deceased may influence the nature and severity of health outcomes associated with prolonged grief, with different relationships potentially leading to specific patterns of physical and somatic symptoms. there were specific health outcomes that were found to be associated with grief. yıldırım (2023) and de lang et al. (2023) both reported a significant association between grief severity and insomnia, although this was not replicated in the pohlkamp et al. (2019) study. the diversity of outcome types that have been investigated is reflected in the study by palitsky et al. (2023) who found a significant association between pgd and systolic and diastolic pressure. supplementary tables 1 and 2 show the comprehensive evaluation of bias risk for each study, conducted through the joanna briggs institute critical appraisal checklist for analytical cross-sectional and cohort studies. this showed that 40% of cross-sectional studies exhibited moderate to high levels of bias, in contrast to the higher rate of 75% for cunningham, shevlin, cerda, & mcelroy 11 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ the longitudinal studies. significant heterogeneity was also noted. the primary bias in cross-sectional studies stemmed from the lack of control over confounding variables. few studies controlled for participant’s previous physical health status, which is significant since individuals experiencing loss tend to be older, and older individuals tend to have more physical health complaints (james et al., 2018; wu et al., 2022). in contrast, incom­ plete follow-up in cohort studies contributed to the most common element of potential bias. discussion this is the first systematic review of peer-reviewed published studies assessing the association between icd-11 prolonged grief disorder (pgd) and outcomes related to physical and somatic health among bereaved individuals since pgd was included in the icd-11. among the 18 eligible studies, 13 (72%) reported moderate (carlsson et al., 2023; de lang et al., 2023; killikelly et al., 2020; lenger et al., 2020; lundorff et al., 2020; sveen et al., 2020) to strong associations (hennemann et al., 2023; marcussen et al., 2021; miller et al., 2020; palitsky et al., 2023; yıldırım, 2023; zhang et al., 2020; zhou et al., 2020) between pgd and physical or somatic illness. there were a number of studies that reported non-significant associations, or failed to report p-values and were unclear in describing effect sizes (comtesse et al., 2020; kaiser et al., 2022; maccallum & bryant, 2020; pohlkamp et al., 2019; vogel et al., 2021). it appears that there is reliable scientific evidence, with a relatively low risk of bias, that the experience of prolonged grief is associated with poorer physical health and a higher risk of somatization. this prompts inquiry into the underlying mechanisms connecting these phenomena. several theoretical frameworks, including attachment theory, the stress response syndrome, and the dual-process model, offer potential explanations for these observed associations. first, attachment theory (bowlby, 1958, 2018) provides a conceptual basis for under­ standing the substantial and moderate associations observed between pgd and intimate types of loss. the loss of a child, especially for mothers, has been shown to produce higher rates of pgd compared to other close loved ones (buur et al., 2024; goldstein et al., 2019). attachment theory helps explain these findings due to the intense emotional bonds between parents and children, making such losses especially devastating. more­ over, the significant associations in our review studies by (zhang et al., 2020; zhou et al., 2020), indicate an increased risk of pgd and chronic physical diseases among chinese parents who had lost an only child. attachment anxiety has also been shown to predict membership into pgd groups over depression and low-symptom groups, dem­ onstrating incremental predictive ability for both prolonged grief and somatic symptoms (field et al., 2005; king & werner, 2012; maccallum & bryant, 2018). in light of this, future research could employ quantitative measurement scales and tools for assessing attachment styles based on attachment theory. this could explore associations between prolonged grief, physical and somatic health: review 12 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ attachment types and physical and somatic health outcomes for individuals meeting icd-11 pgd criteria. if an association between attachment styles and physical/somatic health outcomes were found to be consistent, such findings may help shape practices and policies, such as identifying profiles of attachment types that pose a high risk of physical/somatic health outcomes. second, horowitz’s (1986) stress response syndrome (srs) offers a robust framework for understanding the significant associations between pgd, insomnia, and excessive blood pressure. the srs delineates between psychological and physiological responses that individuals may undergo following traumatic or highly stressful events. this persis­ tent state of hypervigilance has the potential to magnify the grieving process and con­ tribute to mental health challenges, adversely impacting somatic and physical well-being (joiner et al., 1999; riemann et al., 2010). regarding insomnia, the srs would explain heightened emotional distress during nighttime, exacerbating the challenges of coping with complicated grief in solitude (baker et al., 2016; germain et al., 2005, 2006; lancel et al., 2020). furthermore, elevated blood pressure in prolonged grief sufferers may stem from persistent emotional distress and difficulties in adapting to loss, triggering complex stress responses (mason & duffy, 2019). in consideration of this evidence, future research could utilize biological markers and neuroimaging techniques to study hyperarousal in pgd, insomnia, and elevated blood pressure. objective sleep monitoring (polysomnogra­ phy or actigraphy) could quantify disruptions in sleep architecture. results may show correlations between hyperarousal markers and specific sleep parameters, supporting interventions such as cognitive-behavioral therapy for insomnia (cbt-i). advocating for cbt-i inclusion in treatment plans and workplace policies accommodating insomnia due to prolonged grief could be significant. identifying factors moderating prolonged grief and elevated blood pressure may also inform tailored interventions and prevention strategies. a broader perspective on the association between pgd and physical health may also be gained by examining how chronic stress and inflammation, which elucidate similar relationships in other mental disorders such as post-traumatic stress disorder (ptsd) and major depressive disorder (mde), apply to pgd. both ptsd and mde are linked to prolonged activation of the stress response, leading to increased inflammation (ehlert et al., 2001; slavich & irwin, 2014; wichmann et al., 2017). this inflammatory process con­ tributes to various physical health issues, including cardiovascular disease and metabolic disorders (black & garbutt, 2002; liu et al., 2017). given that pgd involves sustained emotional distress, analogous stress-induced inflammatory pathways may also underlie the physical health problems observed in pgd. moreover, ptsd and mde are associated with somatic complaints such as chronic pain and gastrointestinal issues (gupta, 2013; thom et al., 2019), which may similarly manifest in pgd as physical symptoms due to intense grief and emotional turmoil. by exploring these parallels, researchers may cunningham, shevlin, cerda, & mcelroy 13 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ gain a deeper understanding of the mechanisms through which pgd impacts physical well-being, thus guiding future research and clinical practice. lastly, the dual process model of coping with bereavement (stroebe & schut, 1999) offers a bidirectional insight into the significant associations between pgd and physi­ cal/somatic illness following unnatural loss through loss-oriented and restoration-orien­ ted stressors (tur et al., 2022). unnatural or traumatic loss poses unique challenges to the grieving process, triggering intense emotions such as shock, disbelief, and intrusive thoughts (layne et al., 2018; lobb et al., 2010; walsh, 2007). these emotions fall under loss-oriented stressors, as they prompt individuals to face the reality of their abnormal loss. simultaneously, coping with the aftermath of unnatural loss involves practical challenges, such as legal processes, funeral arrangements, and dealing with the societal aftermath. it is highly plausible that individuals experiencing unnatural loss may oscil­ late between addressing their emotional pain and engaging in such constructive tasks. for instance, someone grieving the sudden abnormal loss of a loved one in an accident may alternate between processing the emotional trauma and dealing with the adminis­ trative aspects, such as legal procedures or insurance matters. this consistent fluctuation may create cognitive dissonance (festinger, 1957) in those experiencing unnatural loss which may elucidate the substantially significant associations observed between pgd and physical and somatic illness through abnormal loss circumstances. for example, dickerson and kemeny (2004) have shown how stressors that involve social-evaluative threats a key component of cognitive dissonance lead to significant increases in cortisol levels, which has been shown to suppress the immune system, making individuals more vulnerable to illness. in the context of pgd, the ongoing internal conflict and chronic stress may result in a sustained physiological response, thereby weakening immunity and increasing susceptibility to physical ailments. additionally, cognitive dissonance has also been linked to an increased risk of cardiovascular disease. linden et al. (2007) found that stress arising from conflicting emotions or behaviours which are key elements of cognitive dissonance significantly heightens the risk of hypertension and other cardio­ vascular problems. for individuals with pgd, the persistent cognitive dissonance they experience may intensify their stress, thereby increasing the likelihood of developing cardiovascular issues. keeping this in consideration, future research could refine and adapt existing prolonged grief and coping scales to better align with the nuances of the dual process model. a dual-process model questionnaire could focus on addressing spe­ cific components of prolonged grief that contribute to cognitive dissonance and potential physical and somatic health complications. policymakers could integrate such screening tools into routine health assessments, while employers and community organizations could offer more targeted support programs. the studies under review exhibited both strengths and limitations. they notably demonstrated consistency in measuring pgd, alongside showcasing geographical and cultural diversity, which enriched external and ecological validity. however, this cultural prolonged grief, physical and somatic health: review 14 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ diversity may explain the assorted findings found across the reviewed studies regarding the strength of the association between pgd and physical and somatic health outcomes. future research could investigate this by examining how cultural factors influence this relationship, potentially through incorporating culturally sensitive measures in assess­ ments. the majority of studies also presented substantial sample sizes, often supported by reported power analyses. on the other hand, the bias risk evaluation revealed dif­ ferences in bias levels. cross-sectional studies tended to have lower bias than longitudi­ nal studies. moderate bias was noted in cross-sectional studies, while higher bias was observed in cohort studies. both designs exhibited relatively low levels of high bias. future studies, especially in cohort designs, can benefit from proactive strategies and experimental designs to mitigate bias and enhance generalizability. however, given the intrinsic difficulty in manipulating grief as an emotional state in experimental settings, researchers must approach this challenge with caution and creativity. methodologically, it’s noteworthy that the majority of studies relied on self-reported measures that lacked control for confounding variables, while only 44% utilized longitudinal methodology, potentially impacting internal validity and result interpretability. substantial heterogene­ ity was observed among the studies analyzed, with four distinct scales employed to evaluate physical health and five to measure somatic health outcomes. moreover, three studies adopted alternative quantification methods, including the use of monitors, chron­ ic disease assessments, and outpatient visits. this disparity in measurement complicates direct result comparisons, as it’s unclear if differences stem from variable characteristics or scale usage. developing universal physical and somatic health scales could address this, offering standardized measures across cultures. this would aid cross-cultural com­ parisons and deepen our understanding of physical and somatic health outcomes. the included studies also exhibited a fairly high mean age of 50 which may not capture the unique prolonged grief experiences of younger individuals who may have different coping mechanisms, support structures, and life contexts compared to older adults. in conclusion, this pioneering review on pgd’s association with physical and somat­ ic illness exhibited numerous strengths such as the consistent measurement of pgd, substantial sample sizes, and a high level of regional diversity. however, limitations included disparities in bias levels between transverse and cohort studies, heterogeneity in attaining the measurement of physical and somatic illness and the use of self-reported measures that lacked control for confounding variables. the reviewed results revealed a hierarchy of associations. most studies demonstrated a significantly strong or moderate association between pgd and physical or somatic illness. notable findings include pgd’s impact on caregiver health decline, somatic symptom distress, insomnia severity, and comorbid chronic diseases such as osteoarthrosis and elevated blood pressure. these results are consistent with ptsd findings and highlight the clinically relevant effect sizes both psychologically and medically. these findings may assist in the differential diagnosis of pgd by emphasizing the unique combination of psychological and physio­ cunningham, shevlin, cerda, & mcelroy 15 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ logical symptoms, which can help distinguish pgd from other disorders such as ptsd. given the significant impact of pgd on physical health, it is important to consider these physiological symptoms more prominently in the diagnostic process to ensure comprehensive assessment and appropriate treatment. an important additional consideration is the impact of behavioural changes associ­ ated with pgd on overall health. pgd has been shown to cause behavioural changes that contribute to poor physical and mental health. for instance, individuals with complicated grief may engage in behaviours such as binge drinking, smoking, and a lack of physical activity (stroebe et al., 2007). these behaviours can exacerbate chronic illness, which in turn impacts an individual's mental health and affects their ability to participate effectively in therapy (lando, 2006). understanding these interactions is crucial, as social withdrawal known as a common response in pgd (szuhany et al., 2021) can lead to fur­ ther physical and mental health problems. a comprehensive approach to pgd treatment must consider these behavioural changes and their impact on overall health to enhance therapeutic outcomes and support holistic recovery. future research avenues include integrating quantitative tools based on attachment theory for intimate losses in routine pgd screenings or employing biological markers and neuroimaging techniques to study hyperarousal in pgd, insomnia, and elevated blood pressure. additionally, the dual process model of coping with bereavement could be utilized through a standardized questionnaire tailored to measure the framework, potentially predicting physical or somatic health issues among prolonged grief sufferers. however, future studies must prioritize methodological rigor, diverse participant sam­ ples, and ethical standards to ensure valid and applicable findings in clinical practice. prolonged grief, physical and somatic health: review 16 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. ethics statement: this article includes studies that involved human participants, all of which received appropriate ethical approval from their respective ethics committees. ethical approval was not required for this review, as it involved the analysis of publicly available data. social media accounts: @mark_shevlin_ preregistration: the protocol for this systematic review was preregistered at the prospero repository (crd42023471080), and is available at https://www.crd.york.ac.uk/prospero/display_record.php?recordid=471080 reporting guidelines: this article was prepared following the prisma guidelines (preferred reporting items for systematic reviews and meta-analyses) (page et al., 2021). data availability: all materials are freely available from the corresponding author on request. supplementary materials the supplementary materials contain the following items: • preregistered prospero protocol (cunningham et al., 2023s) • online appendices (cunningham et al., 2025s): ◦ appendix a: jbi critical appraisal checklist for analytical cross-sectional studies. ◦ appendix b: jbi critical appraisal checklist for cohort studies. ◦ appendix c: standardized data extraction sheet. ◦ appendix d: descriptions of the included studies. ◦ appendix e: references from systematic review. index of supplementary materials cunningham, j., shevlin, m., cerda, c., & mcelroy, e. (2023s). icd-11 prolonged grief disorder, physical health and somatic problems: a systematic review [preregistration]. prospero. https://www.crd.york.ac.uk/prospero/display_record.php?recordid=471080 cunningham, j., shevlin, m., cerda, c., & mcelroy, e. (2025s). supplementary materials to "icd-11 prolonged grief disorder, physical health, and somatic problems: a systematic review" [online appendices]. psychopen gold. https://doi.org/10.23668/psycharchives.16037 cunningham, shevlin, cerda, & mcelroy 17 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://x.com/mark_shevlin_ https://www.crd.york.ac.uk/prospero/display_record.php?recordid=471080 https://www.crd.york.ac.uk/prospero/display_record.php?recordid=471080 https://doi.org/10.23668/psycharchives.16037 https://www.psychopen.eu/ references note. references marked with an asterisk (*) are the articles included in the systematic review. afari, n., ahumada, s. m., wright, l. s., mostoufi, s., golnari, g., reis, v., & cuneo, j. g. (2014). psychological trauma and functional somatic syndromes. psychosomatic medicine, 76(1), 2–11. https://doi.org/10.1097/psy.0000000000000010 american psychiatric association. 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(2020). prolonged grief disorder in chinese shidu parents who have lost their only child. european cunningham, shevlin, cerda, & mcelroy 25 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.1097/psy.0000000000000678 https://doi.org/10.1016/j.jad.2011.10.048 https://doi.org/10.1016/j.invent.2022.100558 https://doi.org/10.1093/geront/gnr110 https://doi.org/10.3389/fpsyt.2021.534664 https://doi.org/10.1111/j.1545-5300.2007.00205.x https://doi.org/10.1097/00005650-199603000-00003 https://doi.org/10.1016/j.psyneuen.2017.06.005 https://icd.who.int/browse11/l-m/en https://doi.org/10.1186/s12888-022-03907-1 https://doi.org/10.1177/00302228231187296 https://doi.org/10.1186/s12888-018-1621-2 https://www.psychopen.eu/ journal of psychotraumatology, 11(1), article 1726071. https://doi.org/10.1080/20008198.2020.1726071 *zhou, n., wen, j., stelzer, e.-m., killikelly, c., yu, w., xu, x., shi, g., luo, h., wang, j., & maercker, a. (2020). prevalence and associated factors of prolonged grief disorder in chinese parents bereaved by losing their only child. psychiatry research, 284, article 112766. https://doi.org/10.1016/j.psychres.2020.112766 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. prolonged grief, physical and somatic health: review 26 clinical psychology in europe 2025, vol. 7(1), article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.1080/20008198.2020.1726071 https://doi.org/10.1016/j.psychres.2020.112766 https://www.psychopen.eu/ prolonged grief, physical and somatic health: review (introduction) method inclusion and exclusion criteria search strategy reporting guidelines data collection, extraction and quality assessment results discussion (additional information) funding acknowledgments competing interests ethics statement social media accounts preregistration reporting guidelines data availability supplementary materials references does practice make perfect? the effects of an eight-week manualized deliberate practice course with peer feedback on patient-rated working alliance in adults: a pilot randomized controlled trial research articles does practice make perfect? the effects of an eightweek manualized deliberate practice course with peer feedback on patient-rated working alliance in adults: a pilot randomized controlled trial håkan lagerberg 1 , james f. boswell 2 , michael j. constantino 3 , gerhard andersson 4,5,6 , per carlbring 1 [1] department of psychology, stockholm university, stockholm, sweden. [2] department of psychology, university at albany, state university of new york, albany, ny, usa. [3] department of psychological and brain sciences, university of massachusetts, amherst, ma, usa. [4] department of behavioural sciences and learning, linköping university, linköping, sweden. [5] department of biomedical and clinical sciences, linköping university, linköping, sweden. [6] department of clinical neuroscience, karolinska institute, stockholm, sweden. clinical psychology in europe, 2024, vol. 6(3), article e12353, https://doi.org/10.32872/cpe.12353 received: 2023-07-06 • accepted: 2024-04-24 • published (vor): 2024-09-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: per carlbring, department of psychology, stockholm university, 106 91 stockholm, sweden. phone: +46 8 16 39 20. e-mail: per.carlbring@psychology.su.se abstract background: deliberate practice (dp), which underscores the importance of expert mentorship, personalized learning objectives, feedback, and repetition, has been suggested as a method to enhance the effectiveness of therapists. method: the study tested the efficacy of an eight-week, structured, group-based online course, enriched with peer feedback, for 37 cognitive behavioral therapists. the goal was to assess whether this intervention could boost the quality of therapist-patient alliances, as compared to a control group. to measure this, therapists had their patients anonymously fill out the session alliance inventory both before and after the course. the trial encompassed 120 patient alliance ratings at baseline and 64 at the post-course measurement. the dp course was comprised of a 75minute remote video workshop each week for eight weeks, supplemented by related study materials. each workshop focused on a specific skill, such as responding to client resistance, and included 55 minutes of concentrated role-play activities, providing ample opportunities for repetition and feedback. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12353&domain=pdf&date_stamp=2024-09-30 https://orcid.org/0000-0003-0720-8130 https://orcid.org/0000-0001-6214-0787 https://orcid.org/0000-0003-3126-2575 https://orcid.org/0000-0003-4753-6745 https://orcid.org/0000-0002-2172-8813 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ results: using a linear mixed model we did not find an effect on patient alliance ratings. however, we observed a trend (p = .054) indicating that the dp group decreased their alliance ratings (cohen’s d = -0.40), while the control group demonstrated an increase in their scores (d = 0.49). conclusion: this pilot study did not find support for dp leading to better patient-rated alliance compared to a waitlist control. however, the study had several methodological limitations. further and more rigorous investigation of the effects of dp on patient outcomes is recommended. keywords deliberate practice, working alliance, cognitive behavioural therapy, professional development, psychotherapy outcomes, therapist effects highlights • an eight-week deliberate practice course did not significantly improve patient-rated therapeutic alliance. • an unexpected trend showed that deliberate practice training decreased alliance ratings, while the control group showed improvement. • peer feedback without expert mentorship may limit the effectiveness of deliberate practice courses. • further research on deliberate practice's effects is needed, focusing on individualized learning objectives and expert mentorship. background contrary to what might be expected, emerging evidence indicates that therapists do not necessarily improve their psychotherapeutic outcomes with increased experience, defined as accumulation of time in routine clinical practice. for example, in a large-scale longitudinal therapist professional development study using data from more than 150 therapists and 6,500 patients, goldberg et al. (2016) found that therapists overall became slightly less effective over time. consequently, establishing new tools for developing expertise over time appears to be in the interest of the field of psychotherapy. to this end, deliberate practice (dp) is emerging as a tool for psychotherapists to continually improve their therapy outcomes (boswell et al., 2020; miller et al., 2020; rousmaniere et al., 2017; wampold et al., 2019). the effectiveness of dp in the acquisition and refinement of skill has been demonstrated in athletics and music (ericsson & pool, 2016), and is now being applied to therapist development. miller et al. (2017) summarized four central elements of dp for psychotherapists: 1) a focused and systematic effort to improve performance pursued over an extended period; 2) involvement and guidance from a coach/teacher/mentor; 3) immediate and ongoing feedback; and 4) successive refinement and repetition via solo practice outside of performance. deliberate practice and patient alliance: a pilot rct 2 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ one proposed method of applying dp with therapists is to practice therapy skills using vignette-based role-play (vaz & rousmaniere, 2022). to this end, a series of prac­ tice manuals for different psychotherapy orientations have been published, including emotion-focused therapy (goldman et al., 2021), cognitive behavioral therapy (cbt; boswell & constantino, 2021), motivational interviewing (manuel et al., 2022), systemic family therapy (blow et al., 2023), and child and adolescent psychotherapy (bate et al., 2022). the manuals include method-specific skills (e.g., working with cognitions in the case of cbt) and several method-non-specific skills (e.g., responding to client resistance). each skill is described, and skill criteria are provided, with the manuals’ emphasis placed on client vignettes for therapists to role-play and actively work with feedback from expert supervisors or other trained peers. to our knowledge, the effects of these manuals on therapy outcomes have not yet been empirically investigated. although the research on the role of dp in psychotherapy is still in its infancy, some progress has been made. chow et al. (2015) found that the time spent engaged in dp activities predicted therapist-level treatment outcomes across 1,632 patients and 17 therapists. however, the variance explained by dp was extremely small (0.3%) and the retrospective dp self-rating instrument used has been criticized because it relies on therapists’ retrospective recall and the ability of therapists to accurately differentiate dp from other forms of practice (clements-hickman & reese, 2020). the study did not report participants theoretical orientation. also, janse et al. (2023) were not able to repli­ cate the findings in the previously mentioned study. in an experimental study, westra et al. (2021) found that participants randomized to a dp workshop were significantly more likely to respond effectively to client resistance when compared to participants in a tradi­ tional workshop, both at post-workshop and at a three-month follow up. however, the study involved simulated patients and did not include any real patient data. participants reported several primary theoretical orientations. hill et al. (2020) reported a single-case study on seven psychodynamically oriented doctoral students who participated in an eight-hour workshop and four individual dp training sessions with in-between session homework. they found that the dp training improved the students’ self-ratings of their knowledge of the practiced skills, emotional self-regulation, countertransference, and working alliance. however, there was no sig­ nificant effect on the client-rated working alliance. perlman et al. (2020) completed a randomized controlled trial where therapists who participated in a dp workshop scored higher on facilitative interpersonal skills than therapists who underwent a traditional workshop (anderson et al., 2009). the therapists reported several primary theoretical orientations. interpersonal skills were measured using an instrument that has been found to predict therapy outcome (anderson et al., 2016). in line with previous research, the study involved simulated patients and did not include real patient data which could be viewed as a limitation. goldberg et al. (2016) completed a study at a canadian health agency that applied dp and routine outcome monitoring (lambert & harmon, 2018) lagerberg, boswell, constantino et al. 3 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ over seven years, including over 5,000 patients and 135 therapists. the intervention achieved an increased effectiveness, as per the routine outcome tool, of d = 0.035 per year, reflecting a compounded increase of d = 0.25 over seven years. however, the study had no control condition and combined routine outcome monitoring with dp, preventing us from isolating the effects of dp. in conclusion, although dp has been demonstrated to have a positive effect on some factors related to patient outcomes (including simulated patients), there is, to date, paucity of evidence that dp directly influences patient-rated outcomes. this was also the conclusion of the systematic review of the research on dp, conducted by nurse et al. (2024). in their review, they emphasize the lack of studies investigating the impact of dp on client outcomes as a main limitation in the literature and encourage studies exploring the impact of dp on client outcomes in actual practice settings. for example, the study by hill et al. (2020) found that after dp, therapists increased their self-rated efficacy and therapist rated alliance but found no increase in patient-rated alliance. the current study attempted to bridge this gap in the literature, using working alliance as a patient-rated outcome. there is robust evidence for a moderate correlation between alliance and therapy outcome (r = .28, flückiger et al., 2018). for many years, whether alliance leads to symptom reduction or vice versa has been up to debate. however, a recent meta-analysis found empirical evidence that alliance and symptom reduction have a reciprocal relationship, predicting each other, at least in the early stages of treatment (flückiger et al., 2020). also, working alliance has been suggested as one of the mechanisms through which dp could improve therapy outcome (miller et al., 2020). in the current study design, using working alliance ratings enabled the researchers to collect within-therapist data at the preand post-measure, while collecting cross-sec­ tional data on the patient-level. in order to use symptom outcomes, longitudinal withinpatient data would have been necessary, which was not in the scope of the current study. the current design made it possible to recruit therapists from a multitude of psychotherapy settings, increasing the ecological validity. the authors recognize that in this study, working alliance acts as a proxy for patient therapy outcomes, and see this as a major limitation. however, we believe that this study is a step forward for the research literature on dp in moving towards patient-level data. given the recently published dp manuals which allow for the use of standardized and approved working materials and methods, the present pilot study examined whether patients of therapists who participa­ ted in an eight-week dp course improved their patient alliance ratings compared to patients of therapists in a waitlist control group. based on the results of perlman et al. (2020) and westra et al. (2021), along with the literature on skill development and dp for therapists, we expected that the dp group would improve their patient-rated alliance measures compared to the waitlist control group. deliberate practice and patient alliance: a pilot rct 4 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ method study design the pilot study used a randomized parallel-arm controlled trial design, allocating the therapists to either receive the dp course or a waitlist control group. the study was conducted in sweden, and therapists and patients were recruited nationally during january 2022. the study was approved by the swedish ethical review authority (id: 2021-05913-01). outcome measurements and data collection therapeutic alliance was the primary outcome measure assessed using the session alli­ ance inventory (sai; falkenström et al., 2015). the sai is a brief patient-rated instrument consisting of six items that measure the client’s experience of the alliance during the past session on a scale from 0 (“not at all”) to 5 (“completely”). the sai is a shortened version of the working alliance inventory (wai; horvath & greenberg, 1989), which is a common instrument for measuring therapeutic alliance. the sai correlates highly with the wai (r = .91; falkenström et al., 2015) but takes much less time to complete, potentially resulting in fewer missing data. in the current study, we observed an internal consistency of α = .87 at the baseline measurement and α = .85 for the post-measure. procedure and participants swedish cbt-therapists interested in receiving dp training were recruited through pro­ fessional online forums and the listserv for members of the swedish association for cbt and the swedish association for behaviour therapy. the inclusion criteria were having received a swedish undergraduate diploma in cbt (involving approximately a minimum of four years of full-time studies and 2 years of clinical practice), currently providing individual cbt for adult patients, being able to commit to 75 minutes of dp weekly for the duration of the program, and being able to recruit patients for the study. a total of 60 therapists initially applied (see figure 1), of which 37 were included and subsequently randomized. of the 23 excluded participants, 15 did not complete the initial submission form or did not confirm their participation, and eight did not meet the inclusion criteria, including not having the required credentials, not having enough time or enough clients. see table 1 for the therapists’ sociodemographic information and professional backgrounds. since the therapists worked in different organizations, therapy was delivered in a number of settings, both privately and community financed. the therapists were asked to report previous experience with dp. in the dp-group, one therapist reported previous experience with feedback-informed treatment and having attended a conference on dp. one other therapist had attended a single lecture on dp. in the waitlist, one reported having attended a workshop in dp, one reported no training lagerberg, boswell, constantino et al. 5 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ but significant interest in dp and one reported having a supervisor who was influenced by dp. figure 1 study procedure patient recruitment took place during a two-week period before and after the dp course. all therapists were instructed to recruit all of their patients who fulfilled the inclusion criteria: at least 18 years of age and receiving individual cbt. the therapists were told to briefly describe and supply the patients with written information about the study and to obtain informed consent. the therapists were told to clarify that participation was completely anonymous and voluntary, that the decision to participate or not would not have any consequences for the patient, and that the therapist would not be able to access their patients’ ratings or even see if the patient joined the study. video and telephone sessions were included but text-based or internet-only delivered treatments were excluded. patients who agreed to participate in the study used a web link or qr code to access the research platform iterapi (vlaescu et al., 2016), where they read about the study and provide informed consent for anonymous participation. they then completed the sai and submitted their therapist’s name. for privacy and ethical reasons, no information about the patients was recorded. deliberate practice and patient alliance: a pilot rct 6 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ therapists were instructed to collect data from every patient they had a therapy session with, irrespective of diagnosis, how long the patient had been in therapy, or if they had or had not previously participated in the study. this means that some patients may have participated multiple times during the same measurement period, and that some participated only during baseline, some only during post-measure and some at both measurement points. because the patients participated anonymously, we were not able to follow the patients over time—only the therapists. the patient recruitment procedure resulted in the researchers having no information about the diagnosis status, severity, previous therapy experience or demographic data from the patients. this was partially for privacy and ethical reasons, but also a careful decision to prioritize making participation extremely brief, allowing for as many partici­ pations as possible. exploration of the effects of these variables was not in the scope of the current study. table 1 sociodemographic background for the therapists at baseline sample characteristics deliberate practice (n = 18) waiting list (n = 19) total (n = 37) gender, n (%) female 13 (68.4) 15 (78.9) 28 (75.7) male 5 (26.3) 4 (21.1) 9 (24.3) age m (sd) 40 (12.5) 44.7 (9.0) 42.4 (10.9) min-max 26 – 64 26 – 58 26 – 64 years clinical experience m (sd) 10.3 (9.2) 11.8 (6.2) 11.1 (7.8) min-max 1 – 26 1 – 22 1 – 26 treatment sessions/week at baseline m (sd) 17.2 (12.3) 18.2 (7.9) 17.7 (10.1) min-max 1 – 45 5 – 30 1 – 45 therapy setting, n (%)a n = 19 n = 20 n = 39 primary care 4 (21.1) 5 (25.0) 9 (23.1) psychiatry 6 (31.6) 4 (20.0) 10 (25.6) private practice 5 (26.3) 6 (30.0) 11 (28.2) privately owned clinic 4 (21.1) 4 (20.0) 8 (20.5) other 0 (0) 1 (5.0) 1 (2.6) aparticipants working in multiple organizations have been counted multiple times. the percentages are calcula­ ted based on the number of work contexts, not the number of individuals. lagerberg, boswell, constantino et al. 7 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ after the first week of recruiting patients, the therapists were randomized to a dp course (n = 18) or waiting list (n = 19). for the allocation of participants, a fellow msc student who was not involved in the study used random.org, a web-based automated randomization service. once the recruitment period was terminated, the dp group en­ tered the dp course. when all the data had been collected, we observed that a significant number of sai ratings had been reported during the week after both measurement periods. we interpre­ ted this as patients remembering to participate the week after they were formally invited, and thus extended both data collection periods by one week to include the delayed patient ratings. because of this delay, it is possible that some of these patient-ratings were completed after the therapist had participated in up to two dp-sessions. deliberate practice course the dp course was inspired by deliberate practice in cognitive behavior therapy (boswell & constantino, 2021) and was facilitated by the first author of this paper, a master’s student in stockholm university’s clinical psychologist program. throughout the dp course, the facilitator consulted a certified dp coach who was a licensed psychologist and psychotherapist. the dp coach cofacilitated one of the dp sessions. the participants had online access to translated working materials for each session, consisting of a brief introduction to the skill being practiced, skill criteria, and client vignettes. the work material was produced by boswell and constantino (2021). in line with westra et al. (2021) and perlman et al. (2020), we designed the dp course to be group-based for two reasons. first, we wanted to recruit enough therapists to perform statistical analyses. second, a group-based format improves the affordability of and access to expert mentors. accordingly, the dp course was offered online in its entirety using digital meeting software and an online platform. each of the eight weekly sessions was 75 minutes long and consisted of a short introduction to the skill to be practiced, followed by 55 minutes of role-plays and concluded with a few minutes to reflect. during the role-plays, the participants were divided into groups of two or three in separate breakout rooms. they took turns playing the roles of client, therapist, and observer. the client role-played the vignettes, and the therapists attempted to give an authentic response in line with the skill criteria being practiced. see table 2 for the vignettes and example responses from the working manual. the participants did not have access to example responses during the practice sessions, as we assumed that this would have hampered the authenticity of their responses. after this, the observer and the client gave feedback to the therapist based on the skill criteria and their own observations. after receiving the feedback, the process was repeated, maximizing repetition and feedback exposure for the therapist. deliberate practice and patient alliance: a pilot rct 8 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ table 2 examples of client vignettes and example therapist responses (boswell & constantino, 2021) skill client vignette example therapist response working with behaviours [frustrated] i don’t know why i keep blowing up at people. i just do. let’s try to understand this together. understanding your response in context can help us achieve some clarity. let’s start with a recent example and try to identify what was happening just before the “blow up”. responding to client resistance [pessimistic] i know i agreed to this approach, and i understand what we’re trying to do here, but i’m starting to doubt it’s a good fit. i’m so glad you told me this, as your outlook on therapy is central to it working. let’s shift gears for a moment, put aside our agenda, and just discuss what has or has not felt like a fit for you. how does that sound? each role-play was very brief and was terminated after the therapist had given their response to the vignette. this approach of using very short sessions is a hallmark of dp role-play (vaz & rousmaniere, 2022), as it better allows for detailed feedback and repetition compared to longer, improvised dialogues. between role-plays, the therapist completed a reaction rating of how challenging they had perceived the vignette. this rating guided the choice to make the next role-play easier or more difficult. for this reason, all vignettes were assigned difficulty levels. also, the participants were instructed in methods to decrease or increase the difficulty of the vignettes, such as by modulating their level of affect. the groups worked with each vignette until they felt they had exhausted it, between one and six repetitions. the participants switched roles to allow all participants to practice during every session. the facilitator alternated between the groups, giving them feedback and support and answering questions. the manual published by boswell and constantino (2021) instructs facilitators that the role-plays should be completed by two trainees and one supervisor with training in dp, where the supervisor is the one giving feedback. this study used peer feedback instead, allowing for a much larger number of participants, at the potential expense of the feedback quality and the facilitator’s ability to model responses. to ensure the study's focus and feasibility within an eight-week timeframe, a deliberate selection of skills was necessary from the comprehensive set outlined in the manual by boswell and constantino (2021), which details 10 core skills for effective cbt practice. given the pilot nature of this study and the constraints associated with an intensive, focused training program, we prioritized skills that we hypothesized would have the most imme­ diate impact on enhancing the therapist-patient working alliance our study's primary lagerberg, boswell, constantino et al. 9 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ outcome measure. consequently, we included seven skills, with particular emphasis on “responding to therapeutic alliance ruptures” by allocating two sessions to this area. this emphasis aligns with literature suggesting the pivotal role of managing alliance ruptures in therapy outcomes. the skills “explaining the treatment rationale for cbt”, “negotiating a session agen­ da”, and “adherence flexibility” were excluded. while these skills are fundamental to cbt and contribute to comprehensive therapist training, our decision to exclude them was twofold. first, it was based on the practical need to adapt the extensive content of the manual to a manageable scope that could be effectively covered within the limited duration of our intervention. second, considering the advanced training level of partici­ pating therapists and the study's specific focus on the working alliance, these skills were assessed to be less immediately relevant to the pilot study's objectives. this strategic exclusion allowed for a concentrated exploration of the selected skills, facilitating depth of learning and practice within the study's timeframe. this selection process reflects a strategic decision-making framework aimed at op­ timizing training effectiveness by focusing on skills with direct implications for our research objectives, within the practical constraints of an eight-week training program. such decisions are essential for the design of focused, feasible, and impactful training interventions in research settings. waitlist control group therapists that were randomized to the waitlist control group were informed that they had been allocated to the waitlist control group and that they would receive the study material at the end of the data-collection period. no blinding or control intervention was used. after the second data-collection, they received text and video-based material from the dp course curriculum. analyses linear mixed models (lmms) were chosen for the analysis. lmms allow for missing data points without listwise exclusion, allowing the principles of intention to treat to be followed. however, lmms assume that the data are missing at random, which is a potential weakness. the modeling was performed in ibm spss statistics for macintosh, ver. 27.0, using the mixed command. a restricted maximum likelihood was used as the sample was small (luke, 2017). fixed variables in the final fitted model were the main effects of time and group, as well as the interaction effect of time (preand post-measure­ ment) and group (randomization to dp or waiting list). the covariance structure was set to unstructured. assumptions were tested and data were found to be suitable for the planned analyses. deliberate practice and patient alliance: a pilot rct 10 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ results the therapists had difficulty recruiting patients for the study. of the 37 therapists, 29 managed to collect data during baseline, whereas only 23 collected data at post-measure. failure to collect data was greater in the control group; at baseline, seven (36.8%) partici­ pants failed to recruit any patients, growing to 10 (52.6%) at post-measure. the dp group had fewer therapists who failed to recruit any patients: two (11.1%) at baseline and four (22.2%) at post-measure. during the baseline measurement, a total of 128 session-level patient-reported alli­ ance ratings were obtained for the 29 therapists with baseline data. of these, we were unable to match eight ratings to a therapist, resulting in a mean of 4.14 ratings per therapist. at post-measure, only 71 session-level patient-reported alliance ratings were collected for the 23 therapists with post-measure data, of which seven ratings could not be matched to a therapist, resulting in a mean of 2.78 ratings per therapist. the variance between therapists was significant; during baseline, therapists collected between 1–12 ratings, and the corresponding number for the post-measure was 1–14. results from the lmm showed that the interaction effect of time and group was not statistically significant (f1,19.336 = 4.208, p = .054). however, we also conducted a visual inspection of the data and explored within-group effect sizes to better understand poten­ tial training effects. visual inspection of figure 2 and pairwise comparisons revealed that allocation to dp had a decreasing effect on patient-rated alliances, while allocation to the waiting list had an increasing effect on sai scores. the within-group effect sizes were moderate but in opposite directions for both conditions (d = -0.40 for the dp group and d = 0.49 for the control group). discussion this pilot study tested whether an eight-week role-play-based online course in dp for cbt therapists would increase therapist-level therapeutic alliance quality in a naturalis­ tic psychotherapy setting. the lmm did not find a significant effect of randomization to the dp course (p = .054). contrary to expectations, we observed a trend (p = .054) indicating that the average patient-rated alliance in the dp group decreased (d = -0.40) whereas the waiting list’s average patient-rated alliance increased (d = 0.49). the study had several limitations, such as missing data, risk that the therapists were biased in their recruitment of patients, and considerable attrition. the results should be interpreted with caution. to our knowledge, this is the first empirical study on dp for therapists to report potential negative effects. however, dp is a broad term, and this study only tested one specific approach to performing dp. the conclusions may not apply to the full manual or to other methods of executing dp. therapy works through a multitude of mechanisms that are still not well understood (cuijpers & cristea, 2016). this fact, combined with lagerberg, boswell, constantino et al. 11 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ the methodological issues previously mentioned, cause us to believe that speculation on specific mechanisms as to why the dp-groups alliance ratings did not improve, although thought-provoking, is of lesser importance, instead, the discussion will focus on confounders for future studies. in the dp course, expert mentorship was not applied which is a central tenet of dp (ericsson et al., 1993; miller et al., 2017). however, the original definition referred to “a teacher in a domain with a well-developed knowledge about effective methods for improving aspects of performance” (ericsson & harwell, 2019, p. 5). currently, uncertainty exists as to whether psychotherapy can be defined as such a domain, as evidenced by goldberg et al. (2016). nevertheless, the current study relied on peer feedback rather than expert mentorship. the mentor’s primary tasks in this format were to give brief feedback and to help the participants stay in the optimal learning zone by adjusting the difficulty—not too easy, not too difficult. the participants did not have any training in these specific dp coaching skills. the results of the study may indicate that an expert mentor is required for this form of dp to be effective, thus impeding the prospect of scaling up dp courses by increasing the ratio of participants to mentors. figure 2 change in composite scores on the session alliance inventory at baseline and post-measurement time postpre se ss io n al lia nc e in ve nt or y 4.8 4.6 4.4 4.2 4.0 3.8 group deliberate practice waitlist note. error bars represent 95% ci. deliberate practice and patient alliance: a pilot rct 12 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ a second tenet of dp is individualized learning goals (ericsson et al., 1993). this study used standardized vignettes and skills, adjusting the vignettes’ difficulty levels based on the previously described reaction ratings completed by the participants. partici­ pants may have spent time practicing skills at which they were already adept, resulting in no change, or practicing skills that were too difficult, which could lead to shame and withdrawal from the exercise and, ultimately, reduced self-efficacy. assessments of skills and weaknesses made by an expert or through other means may be crucial for the development of expertise through dp. the chosen skills may have been too demanding, leading to some of the aforementioned adverse effects. surprisingly, the control group increased their alliance ratings. asymmetrical dropout could reflect underlying differences between therapists, such as interest in dp or case­ load and thus caused a selection bias. furthermore, therapists in the control group, as in the dp group, may have been biased in some other way when recruiting patients. the finding that a manualized dp course with peer feedback led to no change in patient-rated alliances is noteworthy. therapy is a complex interpersonal process where the same actions can lead to wildly different results, while dp is a reductionistic activity that was developed for mechanistic tasks, such as playing the instruments or typing (clements-hickman & reese, 2020). there is growing evidence that the variance in expertise or performance explained by dp may vary greatly by domain (hambrick et al., 2016). although the study by chow et al. (2015) is frequently cited as an argument for the importance of dp, dp only explained 0.3% of the variance in performance, which paradoxically bolsters the argument that dp may play a smaller role in psychotherapist improvement than in other domains. previous studies have identified that specific psy­ chotherapy-related skills can be trained through dp (perlman et al., 2020; westra et al., 2021), but it remains uncertain whether these relatively simple skills translate to actual symptom improvement in patients. dp is an attractive method because it initially seems very logical: “practice makes perfect.” however, the criteria for the original definition of dp are difficult to attain (ericsson & harwell, 2019), and practice that does not meet these criteria may not yield the same effects as dp. at the same time, excessively strict boundaries around dp may impede innovation and advancements specific to the setting of psychotherapy (nurse et al., 2024). we argue that the dp course applied in the present study is an example of attempting to scale up dp by standardizing and reducing its complexity. future attempts to confirm or disconfirm the effectiveness of dp in the psychotherapy domain should adhere to the original definition and/or to particular modes of application (e.g., more individualized focus, or reliance on an expert supervisor rather than a peer). as goodyear and rousmaniere (2017, p. 84) wrote, “practice makes permanent, though not necessarily perfect.” the current study had several limitations. in the following section, limitations will be reviewed. lagerberg, boswell, constantino et al. 13 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ the therapists recruited their own patients. estimates suggest that sai-ratings were collected for about 10% of sessions during baseline and for about 6% during post-meas­ ure. this introduces a risk of bias. however, the data were collected anonymously via an encrypted website, and since no personal information was collected regarding the client, identification was impossible, reducing the risk that patients would inflate their alliance ratings due to social desirability. we do not have any data to explain the small percentage of recruited patients but speculate that it was caused by forgetfulness or lack of motivation on the therapists’ end, which would explain the drop in participation at the post-measure, as well as the control group recruiting fewer patients. there was asymmetrical attrition in the studied population due to difficulties recruiting patients. especially in the control group, five (26.3%) participants failed to recruit any patients during baseline or post-measure. furthermore, some therapists only recruited a single client, potentially causing issues with the lmm. the study used patient-rated alliance as the primary variable. preferably, a patientrated symptom scale would have been used, as it is possible that dp works through mechanisms other than alliance. this choice is further discussed in the introduction of the current article. the authors encourage future research to use symptom rating scales. of course, this necessitates using longitudinal within-patient data, which was unfortunately not possible with the current data set, where patients for privacy and ethical reasons, participated completely anonymously. within-patient data would enable researchers to use more powerful statistical analyses, such as multilevel modelling. also, it was not possible to include session number in the analysis, a factor that predicts alliance (meier & feeley, 2022). we suggest that future studies include within-patient data. a recent meta-analytical finding is that alliance measures are prone to moderate to large ceiling effects. there is a current debate as to whether these ceiling effects are caused by methodological issues or theoretical factors (meier & feeley, 2022). it is unclear as to what effect this may have had on the current study. the manual used was not explicitly focused on therapy alliance, but rather on overall therapist effectiveness. it is possible that a dp manual that more explicitly focused on alliance would have had a greater impact on this variable. however, several chapters focused specifically on alliance-related therapist behaviors. the study used a waitlist control group. in clinical psychological research this has been shown to inflate effect sizes of treatment groups (patterson et al., 2016). however, in this study the patients did not have to wait, only the therapists, so it is unclear wheth­ er the natural worsening effects that have been observed would apply. it could however explain the greater attrition in the wait-list control. a superior control condition would have been a placebo course as was employed in the excellent study by westra et al. (2021). deliberate practice and patient alliance: a pilot rct 14 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ finally, longitudinal data tends to be underpowered when only two time points are used. follow-up data would have increased the power of the study. conclusions this pilot study did not find a significant effect of a cbt-focused online group and manual-based dp course with peer-feedback on patient-rated alliance. however, a nonsignificant negative effect of dp on patients’ alliance ratings was observed. although the study had multiple limitations such as considerable asymmetrical attrition, missing data and risk of bias in the data collection, we found the results surprising enough to publish. the current study is also a step forward towards studying direct client outcomes, which has been missing in the literature on dp (nurse et al., 2024), and may serve as a foundation for future research. as dp is becoming an increasingly popular tool for therapist development, testing the effectiveness of the method is crucial. the authors conclude that future research should adhere more strictly to the original definition of dp and include patient outcomes. funding: the authors have no funding to report. acknowledgments: we thank all therapists and patients who volunteered their time and efforts in this study. we are especially grateful to elisabet rosén for generously allowing the first author to consult her during the dp course. competing interests: james f. boswell and michael j. constantino are the authors of the book “deliberate practice in cognitive behavioral therapy”. ethics statement: this study was approved by the swedish ethical review authority (id: 2021-05913-01). prior to the start of the study, informed consent was obtained from all participants, emphasizing their right to withdraw at any point without consequence. preregistration: this study was not pre-registered. the hypotheses, methodology, and analyses were developed before data collection; however, they were not officially recorded on a public preregistration platform prior to the commencement of the study. despite this, we have made efforts to conduct this research with transparency, scientific rigor, and integrity. reporting guidelines: the methodology, results, and interpretation of this study have been shaped and rigorously guided by the consolidated standards of reporting trials (consort) guidelines, enhancing the transparency, reliability, and replicability of our research findings. data availability: although the principles of open science guide our work, the sensitive nature of the data collected in this study precludes its open online availability. however, we fully support scholarly inquiry and collaboration. researchers interested in accessing the data may contact us directly. measures to protect participant privacy will be maintained during any data sharing. lagerberg, boswell, constantino et al. 15 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ references anderson, t., mcclintock, a. s., himawan, l., song, x., & patterson, c. l. 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(2021). testing a deliberate practice workshop for developing appropriate responsivity to resistance markers. psychotherapy, 58(2), 175–185. https://doi.org/10.1037/pst0000311 deliberate practice and patient alliance: a pilot rct 18 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://doi.org/10.1037/cou0000564 https://doi.org/10.1080/10503307.2024.2308159 https://doi.org/10.1016/j.jpsychires.2016.08.015 https://doi.org/10.1080/10503307.2020.1722862 https://drive.google.com/file/d/1mfdwu-frl-2ekn2rdvfsexpcj8-o0c_a/view https://doi.org/10.1016/j.invent.2016.09.006 https://doi.org/10.1037/pst0000311 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. lagerberg, boswell, constantino et al. 19 clinical psychology in europe 2024, vol. 6(3), article e12353 https://doi.org/10.32872/cpe.12353 https://www.psychopen.eu/ deliberate practice and patient alliance: a pilot rct (introduction) background method study design outcome measurements and data collection procedure and participants deliberate practice course waitlist control group analyses results discussion conclusions (additional information) funding acknowledgments competing interests ethics statement preregistration reporting guidelines data availability references competency-based training and assessment of listening skills: a waitlist-controlled study in european telephone emergency services research articles competency-based training and assessment of listening skills: a waitlist-controlled study in european telephone emergency services simone jennissen 1,2 , stefan schumacher 3, diana rucli 4, melinda hal 5,6 , andrás székely 7, derek de beurs 8 , ulrike dinger 1,2 [1] department of general internal medicine and psychosomatics, university hospital heidelberg, heidelberg, germany. [2] department of psychosomatic medicine and psychotherapy, medical faculty, heinrich heine university düsseldorf, düsseldorf, germany. [3] telefonseelsorge hagen-mark, hagen, germany. [4] studio rucli formazione e consulenza organizzativa, udine, italy. [5] department of applied psychology, faculty of health sciences, semmelweis university, budapest, hungary. [6] szent rókus hospital, psychiatry, baja, hungary. [7] végeken egészséglélektani alapítvány, budapest, hungary. [8] trimbos-instituut, utrecht, the netherlands. clinical psychology in europe, 2022, vol. 4(4), article e7933, https://doi.org/10.32872/cpe.7933 received: 2021-12-08 • accepted: 2022-03-13 • published (vor): 2022-12-22 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: simone jennissen, department of psychosomatic medicine and psychotherapy, medical faculty, heinrich heine university düsseldorf, moorenstraße 5, 40225 düsseldorf, germany. e-mail: simonejennissen@gmail.com supplementary materials: materials [see index of supplementary materials] abstract background: telephone emergency services (tes) provide an essential part of suicide prevention and emotional support services across different health care settings. tes are usually provided by paraprofessional counselors, who need specific training in listening skills to meet the demands of callers. method: this project developed a competency-based training for listening skills which was then evaluated in a randomized controlled waitlist study across four eu countries (germany, hungary, italy, and the netherlands). each country provided one training group and one waitlist group. across countries, a total of 71 (trained: n = 36, waiting: n = 35) counselor trainees were assessed in a standardized, simulated emergency call with an actor client either before or after training participation. calls were audiotaped and competencies in listening skills were evaluated by external raters using a standardized rating form. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.7933&domain=pdf&date_stamp=2022-12-22 https://orcid.org/0000-0002-9219-3641 https://orcid.org/0000-0002-3864-4472 https://orcid.org/0000-0002-0166-6897 https://orcid.org/0000-0002-4126-5676 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ results: trained counselors showed significantly better listening skills than participants from the waitlist condition. conclusion: results provide support for the efficacy of a competency-based training for listening skills in the field of tes across europe. furthermore, results demonstrated that a standardized competency-based assessment with an actor client is suitable to assess listening skills. keywords listening skills, training, telephone emergency services, helpline, paraprofessional counselors highlights • a competency-based training can improve paraprofessionals’ listening skills in a relatively short training time. • listening skills can be assessed in a simulation with an actor client. • the use of competency-based training and assessment methods could be expanded to the field of paraprofessional counseling. telephone emergency services (tes) form an important part of psychosocial health care, emotional support services, and suicide prevention (dinger et al., 2019). tes are usually free of charge, available at all times, and do not require help-seeking individuals to disclose their identity. thus, there is a small barrier for those in need to reach out to tes. this is also represented in the number of calls tes receive. in 2019, the german tes telefonseelsorge responded to 1.2 million calls (telefonseelsorge, 2019). similarly, the australian lifeline reports over one million calls yearly (lifeline, 2020), the united kingdom’s samaritans reported over 3.6 million calls in 2018 (samaritans, 2019), and the united states’ national suicide prevention lifeline reported more than 22 million calls in 2018 (the national suicide prevention lifeline, 2019), which underlines the widespread acceptance and need for tes. during the covid-19 pandemic, tes have gained even more importance since there were both needs for social distancing as well as increased mental health burdens. tes responds well to both needs as a low-threshold mental health service that can be accessed even by high risk patients during times of rigorous infection control measures (arenliu et al., 2020; humer et al., 2021; kavoor et al., 2020). as opposed to psychotherapists, psychiatrists, and social workers who participate in year-long professional training curricula before providing mental health services, tes counselors are paraprofessionals with limited and regionally different training. a study conducted on the german telefonseelsorge showed that tes counselors receive training over the course of seven to 24 months (m = 13.3 months; dinger & rek, 2017). the samaritans’ conduct their training in five to ten sessions over the course of a few months (samaritans, 2020). despite having no formal medical or psychological education, tes counselors frequently deal with highly stressed callers. in 2019, 43.7% of callers in germany presented suicidal thoughts, 6.6% stated an intent to commit suicide, and competency-based training and assessment of listening skills 2 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ 7.1% had formerly attempted suicide (telefonseelsorge, 2019). most callers repeatedly contacted tes for emotional support, which could be an indicator of high mental strain. frequently discussed topics included experiencing depression or anxiety, interpersonal difficulties, or physical health issues (telefonseelsorge, 2019). studies from the united kingdom (coveney et al., 2012), the united states (ingram et al., 2008; mishara et al., 2007), and australia (burgess et al., 2008) report similar contents. as such, the topics discussed in tes calls are comparable with the contents of psychotherapy sessions, despite tes counselors receiving far less formal training for handling difficult clients. training is important not only to provide adequate service to callers, but also for the well-being of tes counselors themselves. in a meta-analytic review, hattie et al. (1984) showed that the amount of training that paraprofessionals received was associated with their effectiveness as counselors on a variety of outcome measures such as clients’ selfreported change, clinical ratings by independent raters, information provided by signifi­ cant others, work performance, or therapist improvement ratings. paraprofessionals with “some experience” (e.g. hospital workers, medical students, or speech pathologists) were more effective than inexperienced paraprofessionals (e.g. college students, volunteer adults). a more recent review on the effectiveness of professional and paraprofessional counselors to deliver cognitive-behavioral treatment for depression and anxiety also concluded that training is important for paraprofessional counselors to deliver effective service (montgomery et al., 2010). furthermore, a qualitative survey suggests that par­ aprofessional counselors wish for more training in order to feel confident in dealing with difficult clients (skoglund, 2006). studies on psychotherapists show that training increases therapists’ self-efficacy (hess et al., 2006; pascual-leone & andreescu, 2013). note that while skills are defined as the ability to carry out an activity and competencies additionally include the knowledge of when and how to apply one’s skills, self-efficacy encompasses one’s confidence in one’s own capabilities, but not actual skills or compe­ tencies (bandura, 1977; butler, 1978; le deist & winterton, 2005). however, evidence from a systematic review suggests that counselor self-efficacy is related to counselor performance as assessed by trained raters and supervisors (larson & daniels, 1998). thus, training is necessary to both directly increase counselors’ efficacy as well as to boost their confidence in their own capabilities. within tes, as there are large numbers of callers and limited resources, paraprofessionals’ training is distinctively shorter than professionals’ training. since tes are local organizations without uniform training standards, there is a need for more research on time-efficient, focused training opportunities that equip volunteer counselors with the key competencies they require. listening skills form an integral part of many counselor trainings and are the core of tes trainings (hill, 2009; ivey et al., 1987). they comprise a variety of techniques such as active listening, showing empa­ thy, supporting clients’ self-efficacy, establishing rapport with the client, and exploring feelings of the client (hill, 2009; rogers & farson, 1957). listening skills may rather be jennissen, schumacher, rucli et al. 3 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ categorized as competencies, since they also include the knowledge about when and how to apply a specific skill and refer to the broader concept of being able to listen to, soothe, and help another person (butler, 1978; le deist & winterton, 2005). however, since listening skills is an established term, this term will be used throughout the paper. this study aimed to develop and evaluate a competency-based training for listening skills. to account for the heterogeneity of tes and extend the generalizability of our results, the study was conducted as an international multisite project in germany, ita­ ly, hungary, and the netherlands. furthermore, while research in psychotherapy and counseling mostly relies on self-report measures, these are likely biased due to limited introspectiveness of respondents. counselors, for instance, might overor underestimate their skills depending on their level of self-criticism (anderson et al., 2016). in psycho­ therapy research, recent studies have therefore employed competency-based assessments of therapist skills, such as the facilitative interpersonal skills (fis) performance test (anderson et al., 2009). the fis is used to assess therapists’ interpersonal behavior in a standardized test situation. therapists are asked to respond to challenging therapy situa­ tions that are presented to them either as video clips or with actor clients. therapists’ responses are filmed and later evaluated by trained judges according to a rating manual (munder et al., 2019). in this study we intended to employ a competency test methodolo­ gy similarly to the fis. specifically, we aimed to assess listening skills in a simulated tes call with an actor representing a typical tes client. as in the fis, trained judges evaluate participants’ listening skills based on recordings of the simulated calls using a standardized rating sheet. this allows a more objective assessment of paraprofessional counselors’ listening skills in an ecologically valid setting, while also directly assessing the competencies needed in a tes call. we hypothesized that trained participants would demonstrate better listening skills in the standardized simulated emergency call than participants who had not received the listening skills training. method the ethics committee (institutional review board) of the department of psychology at heidelberg university approved the study procedures (reference number: az jenn 2020 1/1). participants were informed about all study procedures by the local member of the research team and provided informed consent prior to participation. participants and procedure the study was designed as a randomized-controlled waitlist trial. participants were recruited at local tes posts in germany, hungary, italy, and the netherlands via partici­ pating institutions in the erasmus+ funded network empowering (educational path for emotional well-being). as a widely known organization, tes posts are regularly contac­ competency-based training and assessment of listening skills 4 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ ted by individuals who are interested in becoming a volunteer counselor for tes. during our study period from november 2016 to april 2017, those who contacted tes about becoming a volunteer counselor were informed about the study and the opportunity to participate in the listening skills training. those consenting to the study procedures were then cluster-randomized within site to start training either immediately (training group) or delayed (waitlist group). within each country, the research team randomized each individual to either an immediate training group or a waitlist group. participants in the training group immediately started the listening skills training. after the training groups had completed their training, listening skills of participants in both training and waitlist groups were assessed in a standardized, simulated emergency call with an actor client. after the assessment, the waitlist group received their listening skills training. due to the naturalistic recruitment, there is no information available on the number of individuals who decided against participating in our study. there were no dropouts after enrollment. participants had to be 18 years or older to be eligible. a total of n = 71 volunteer counselors (n = 12 from germany, n = 20 from hungary, n = 20 from italy, and n = 19 from the netherlands) participated in our study. each country provided on training group and one waitlist group. across countries, a total of n = 36 participants were randomized to the training group and n = 35 were randomized to the waitlist group. the majority of participants (82%) were female. participants’ mean age was 38.51 years (sd = 15.86). about half of the sample (48%) reported a school diploma and 52% a university degree as their highest level of education. participants were asked whether they had prior work experience as a “listener”, either volunteering for a counseling or emergency service or as a professional therapist or counselor before participating in this study. about half (45%) of participants reported prior professional or voluntary work experience as a listener for a mean duration of 6.96 years (sd = 8.76). descriptive characteristics by group (training vs. waitlist) are presented in table 1. there were no significant differences between study groups regarding descriptive characteristics. listening skills training a focus group of professionals in tes counseling and pastoral care developed a manual for the listening skills training. the 120 hr training is split into three parts: a 30 hr self-study online module to convey the theoretical basis of listening, a 40 hr practical group training in listening which is provided in 10 structured sessions, and a 50 hr module for in-depth practice and supervised training calls. table 2 provides a more detailed overview of the training modules. participants’ attendance was monitored for all in-class events and there were no missed sessions. attendance of the self-study online module was not assessed by the research team. jennissen, schumacher, rucli et al. 5 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ assessment listening skills were assessed in a standardized, simulated emergency call with a trained actor client. the actor role represented a typical tes caller. actors received a standar­ dized role script with a detailed description of their role as well as instructions for a 15-minute tes call. there was one native speaking actor in each country. before the assessment, actors prepared their role and practiced the simulated call with paraprofes­ sional counselors of different experience levels. this ensured that actors were trained to respond realistically to a variety of possible interventions by participants. furthermore, these practice calls were recorded and used as training material for the observer ratings of listening skills. during the assessment period, a local member of the research team listened to recordings of the standardized, simulated emergency call and gave feedback regarding role adherence to the trained actor client on a weekly basis. assessments were conducted by telephone to mimic a naturalistic tes setting. calls were recorded for assessment purposes. participants were called by blinded research assistants and instructed to be a good listener for an actor client for about 15 minutes. table 1 descriptive characteristics for the training and waitlist group characteristic training group n = 36 waitlist group n = 35 difference test m sd m sd t p age 40.1 15.7 36.9 16.1 -0.848 .400 former experience in listening (years) 2.4 6.0 3.8 7.5 0.832 .408 n % n % χ2 p gender 2.53 .112 male 4 11.1 9 25.7 female 32 88.9 26 74.3 highest educational level 1.283 .733 basic secondary school 5 13.9 7 20.0 high school 12 33.3 10 28.6 bachelor’s degree 10 27.8 12 34.3 master’s degree 9 25.0 6 17.1 former experience in listening 0.137 .712 yes 17 47.2 15 42.9 no 18 52.8 20 57.1 note. former experience in listening refers to prior work experience as a “listener”, either volunteering for a counseling or emergency service or as a professional therapist or counselor before participating in this study. competency-based training and assessment of listening skills 6 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ after assuring that the instructions were clear, the actor then took over the phone and presented herself as “laura”, a 27-year-old office clerk, who was struggling in her relationship and also stressed out by her current job workload. “laura” was calling tes when she was home alone in the evening and overwhelmed by her feelings. she was severely distressed, but not in an acute suicidal crisis. “laura” was struggling to identify her own emotions, but she was willing to respond to the paraprofessional counselor’s questions and able to benefit from the listening process. listening skills were assessed using an observer rating measure. the listening skills scale (lss) was developed by members of the research team (sj, ud) based on several validated psychotherapy process scales, i.e. the multitheoretical list of therapeutic inter­ ventions (multi; mccarthy & barber, 2009), the active empathetic listening scale (ael; drollinger et al., 2006), the working alliance inventory (wai-sr; hatcher & gillaspy, 2006), and the therapist empathy scale (tes; decker et al., 2014) and adopted the meth­ table 2 description of contents of the listening skills training modules module content 1. self-study (30 hrs) using an e-learning tool, participants are provided with 100 multiple choice questions regarding the theoretical basis of listening. after each question, participants receive feedback on their selected answer(s) and are presented with a brief theoretical explanation. topics include cognitive-behavioral, psychodynamic, systemic, and humanistic/client-centered theories. 2. practical group training (40 hrs) this part of the training is performed on site in groups of maximum 15 participants. session 1: introduction • focuses on a personal introduction of group members, self-reflection of training goals and motivations, and the assessment of existing knowledge and views on listening session 2: active listening • teaches the principles of active listening (how to ask for thoughts/feelings/ behaviors, give the other person space, and paraphrase meaningful contents) session 3: emotional stability • teaches ways to regulate one’s own and the other person’s feelings session 4: respect and boundaries • fosters acceptance of differences between people • teaches ways to set boundaries in the listening process session 5: empathy • fosters perspective taking and empathic responses to another person’s story session 6: mirroring • teaches ways to reflect the other person’s feelings or statements session 7: self-reflection • encourages reflection on own feelings, motivations, and resources session 8: structuring conversations • teaches the five-phase model of the listening process (welcome, exploration, goal setting, elaboration, conclusion) session 9: strengths and resources • teaches how to ask for resources and foster strengths of the other person session 10: feedback and conclusions • summarizes acquired listening skills and encourages reflection on personal progress 3. in-depth practice (50 hrs) having acquired the theoretical knowledge as well as practical experience in role plays and group exercises, the final part of the listening skills training is focused on supervised training cases. this module should be adapted to suit the needs of listeners in their specific work environment. jennissen, schumacher, rucli et al. 7 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ odology of the fis performance test (anderson et al., 2009). items were modified to suit the tes environment (i.e. “client” instead of “patient”; “listener” instead of “therapist”) and to reflect an observer perspective. the scale consisted of 33 items representing listening skills such as perspective taking, respect, active listening, resource activation, and structuring the conversation. higher values represent better listening skills. items include “the listener sometimes finds it difficult to see things from the other person’s point of view (inversed)” or “the listener appreciates their client as a person”. items are evaluated on a 5-point likert scale (1 – totally disagree; 5 – totally agree) with one additional n/a category in case an item cannot be assessed from the information in the audio recording of the standardized simulated emergency call. two items are reverse coded. higher values represent better listening skills. internal consistency of the scale was excellent in the present study (cronbach’s α = .94). the full scale is available in the online supplement. ratings were provided by at least on trained research assistant in each country. recordings of practice calls from the actor training were used to train raters in the appli­ cation of the lss. during the assessment period, at least once per week the local member of the research team listened to recordings of the standardized, simulated emergency calls, gave feedback to the actor (see above), and supervised the local research assistant in ratings on the lss. in the german subsample, all lss ratings were performed by two independent observers. interrater reliability of these two raters was excellent, icc(3,1) = .86. data analytic strategy as a first step, we explored missing data and investigated the factor structure of the listening skills scale as a basis for further analyses. we performed a principal component analysis (pca) using the scree criterion for factor retention to determine whether cal­ culating a mean score for listening skills was appropriate. next, we assessed whether our data was normally distributed. since each of the four countries provided one train­ ing group and one waitlist group, groups were nested within country. we therefore assessed whether this introduced dependency in our data by calculating the intraclass correlation (icc) within countries in a multilevel intercept only model. we intended to employ a multilevel model to assess group differences if there were an icc ≥ .05. an icc < .05 would indicate that country does not affect outcome and therefore single level multiple regression models would be appropriate (tabachnick & fidell, 2014). we employed a stepwise modeling procedure. the first model tested for group differences in listening skills without covariates. to assess the robustness of results, the second model introduced age and gender as common covariates and the third model adjusted for years of previous experience as a listener outside of the tes environment. effect sizes were calculated as standardized regression coefficients. a standardized regression coefficient competency-based training and assessment of listening skills 8 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ of b = .10 is considered small, b = .30 is considered moderate, and b = .50 is considered large (cohen, 1988). results preliminary analyses missing data analysis demonstrated more than 5% missing values in six items of the lss. we therefore excluded these items from the following analysis. next, we conducted a principal component analysis (pca) to explore the factor structure of the lss. the kaiser-meyer-olkin score of kmo = .86 and the significant bartlett’s test of sphericity, χ2(351) = 1562.15, p < .001, demonstrated the adequacy of the data for pca. the scree plot was slightly ambiguous and showed inflexions that would justify both retaining one or two components. inspections of the factor loadings indicated a higher-order general factor of “listening skills” which explained 48.58% of variance. we therefore decided to retain one component and calculate a mean value for listening skills as a basis for further analyses. factor loadings are available in the online supplement. based on a visual inspection of the histogram, negligible skew (-0.18) and kurtosis (-0.54), as well as a nonsignificant kolmogorov-smirnov test (p = .20), listening skills were normally distributed across participants. effect of the listening skills training since groups were nested within countries, we first assessed the dependency in our data by calculating the icc within countries in a multilevel intercept only model. with an estimated icc of .01, the model suggested negligible dependency in the data. hence, multiple regression was deemed an appropriate method to test for group differences. the first model predicted listening skills as measured by the lss from group (waitlist group vs. training group). group was a significant predictor of listening skills with a large standardized regression coefficient of b* = .52 (see table 3). participants in the training group (m = 3.99, sd = 0.69) demonstrated significantly better listening skills than participants in the waitlist group (m = 3.20, sd = 0.62, see figure 1). to assess the robustness of this effect, we next employed a hierarchical model introducing age and gender as covariates in the first step and group in the second step. while there was no significant effect of age or gender, group remained as a predictor of listening skills with a large standardized regression coefficient of b* = .54 (see table 3). lastly, we assessed whether previous experiences in listening affected the observed listening skills. the final hierarchical model introduced years of previous experiences in listening outside of tes in the first step and group in the second step. age and gender as nonsignificant predictors were dropped from this model. there was no significant effect of previous jennissen, schumacher, rucli et al. 9 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ experience, while group continued to significantly affect listening skills with a large standardized regression coefficient of b* = .52 (see table 3). table 3 linear regression models predicting listening skills parameter model 1 model 2 model 3 coefficient (se) 95% ci coefficient (se) 95% ci coefficient (se) 95% ci intercept 3.20 (0.11)* [2.97, 3.42] 3.46 (0.27)* [2.93, 4.00] 3.20 (0.12)* [2.96, 3.45] age -0.01 (0.01) [-0.02, 0.00] gender -0.06 (0.21) [-0.48, 0.35] experience -0.00 (0.01) [-0.03, 0.02] group 0.79 (0.16)* [0.48, 1.11] 0.82 (0.16)* [0.50, 1.14] 0.79 (0.16)* [0.47, 1.11] model fit r 2 0.27 0.28 0.27 adjusted r 2 0.26 0.26 0.25 note. n = 71; gender was dummy coded (0 – male, 1 – female). experience = years of previous experience in listening outside of telephone emergency services. group was dummy coded (0 – waitlist group, 1 – training group). listening skills were assessed in a standardized, simulated emergency call using the observer-rated listening skills scale (lss). *p < .05. figure 1 mean listening skills of participants in the training group and the waitlist group 1 1,5 2 2,5 3 3,5 4 4,5 5 waitlist group training group note. n = 71 (n = 36 participants were randomized to the training group and n = 35 were randomized to the waitlist group). error bars represent the standard error of the mean. listening skills were assessed in a standardized, simulated emergency call using the observer-rated listening skills scale (lss). scale values range from 1-5, where higher values indicate better listening skills. the difference between the groups is significant (p < .05), see result of the linear regression model in table 3. competency-based training and assessment of listening skills 10 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ discussion this study aimed to develop and evaluate a competency-based training for listening skills in an international multisite project across europe. results provide support for the efficacy of the 120 hr training. trained individuals demonstrated significantly better listening skills than their untrained counterparts. the effect size for this group differ­ ence was large, which implies that this relatively short training makes a meaningful difference in paraprofessional counselors’ abilities to adequately respond to tes calls. furthermore, the effect of the training was independent from participants’ age, gender, and previous experience as a listener in other contexts. although approximately half of the participants reported previous experiences in the field of “listening”, e.g. in their profession as social workers, nurses, or pastoral care workers, or as a volunteer for other services, these experienced participants benefitted as much from the training as inexper­ ienced participants. this implies that the training is suitable for groups with different levels of expertise and equips paraprofessional counselors with specific competencies needed within tes. listening on the telephone may require a different set of skills than listening in a face-to-face setting, such as the ability to fully rely on verbal expressions in understanding the client, without the option to consider nonverbal cues (sötemann, 2019). the counselors themselves also have to convey their interest in the client, their caring and respectful attitude, and the comfort they provide solely through speech and voice modulation. silence, which could serve a holding function in a face-to-face setting, might feel uncomfortable or even threatening to a client on the phone who has no means to determine whether the counselor is still with them. lastly, the anonymity of tes could be unfamiliar to those who have never worked in listening of the phone and make it difficult to build a relationship at the beginning (sötemann, 2019). these differences between face-to-face and telephone settings might explain while experiences in listening outside of the tes environment were not an advantage in our study and experienced participants also needed the training to acquire the specific competences needed to adequately respond to a tes call. in this study, the assessment of listening skills was realized with an actor patient in a simulated emergency call. this method was chosen not only for a more objective assessment, independent of participants’ ability to accurately report on their own listen­ ing skills, but also to tap into the exact competencies needed for the later task as a paraprofessional counselor in tes. competency-based assessment methods have gained increased popularity in medical education and psychotherapy over the last decades (anderson et al., 2016; dannefer & henson, 2007; lurie, 2012). they are based on the insight that neither factual knowledge, nor self-evaluation are sufficient to guarantee the mastery of a practical task (miller, 1990). to assure that trainees can perform their tasks competently, assessments should be performed in the context of the actual work­ place or in a realistic simulation (holmboe et al., 2010; issenberg et al., 2005). thereby, the assessment can include context factors from the real life setting and confirm that jennissen, schumacher, rucli et al. 11 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ trainees are prepared for authentic encounters. the employed assessment method of a standardized, simulated emergency call with an actor client fulfilled these requirements. participants were presented with a typical tes caller and could therefore demonstrate their competency as a paraprofessional counselor in tes. the assessment showed that the training sufficiently teaches listening skills as they a required in everyday practice at tes. limitations this study is limited in generalizability by the recruited sample. although we performed the study as a multisite project across four different european countries, tes operate internationally, and future studies will determine whether the listening skills training is effective in other than the investigated countries. however, investigating the training across four countries with very different local structures (germany, italy, hungary, and the netherlands) is a major strength of this study and the focus on european countries seems sensible since a large number of tes sites operate in europe (ifotes, 2020). another limitation of this study is the small sample size within each country. although the achieved power to detect the overall group difference was ≈ 1 (faul et al., 2007), drawing statistical inferences at the country level would have proven difficult. however, by calculating the icc we assured that outcomes did not differ depending on the country in which participants were assessed. next, although actors received a detailed role script, prepared their role thoroughly, and were trained and supervised frequently, the actors had to react flexibly to partic­ ipants’ interventions and therefore the assessment was not completely standardized. future studies could investigate whether presenting pre-recorded audio sequences is a viable alternative, although this comes at the cost of a less ecologically valid assessment situation. furthermore, although participants received a standardized training of 120 hrs in to­ tal, their attendance in the 30 hr online module was not monitored by the research team and thus may have varied. further evaluations of the training should assess attendance in all modules and control for missed classes in statistical analyses. next, though reliability measures within this study demonstrated excellent interrater agreement and internal consistency of the lss, further validation of the scale, preferably with listening skills measures from different perspectives, would be useful. lastly, due to limited resources we designed the study as a randomized controlled waitlist trial with a single assessment in each group. assuming randomization was successful, this procedure should result in correct effect size estimates for the training. however, a baseline assessment in the training group could have been used to examine the successfulness of randomization and could also have served as a more direct measure of existing knowledge than asking for previous experiences in listening. furthermore, competency-based training and assessment of listening skills 12 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ future evaluations of the listening skills training may want to include a follow-up assess­ ment to examine long-term effects of the training. implications and conclusion our findings have several implications. first and foremost, demonstrating the efficacy of the training in participants from several european countries suggests that the listening skills training can be used to train paraprofessional counselors at tes from different countries. the modular structure allows for flexibility while also providing an evaluated and effective basis. international tes sites may use the listening skills training as a basic curriculum and adapt it to their regionally different needs. to monitor their trainees’ development of competencies, they could also make use of the assessment method with the standardized acting role. although role-plays are typically part of the tes group training, introducing a standardized assessment could help trainers and trainees identify their specific needs while also providing a consistent background against which parapro­ fessional counselors’ listening skills can be evaluated. furthermore, the increased demand for mental health services during the covid-19 pandemic together with the necessity to reduce in-person contact between individuals has highlighted two core competencies of tes: they are widespread available and offer emotional support in a socially distant manner (humer et al., 2021; kavoor et al., 2020). although trainings such as the helping skills training or postgraduate training programs for psychotherapists, psychiatrists, and social workers are well-established (hill, 2009; hill & lent, 2006), the current rapid increase in demand for mental health services underlines the usefulness of short, effective trainings for listening skills. lastly, this study aimed to evaluate the use of competency-based training and assess­ ment methods in the field of paraprofessional counseling. although commonly accepted as beneficial in medical education (lane et al., 2001; scalese et al., 2008), competencybased methods are still rare in the field of psychotherapy and counseling. similarly to simulation patients in medical education, this study introduced an assessment with a standardized actor client to a paraprofessional counseling environment. future studies should investigate the use of an actor client to assess counseling competencies in the field of professional counseling and psychotherapy. to conclude, this international multisite study demonstrated the efficacy of a compe­ tency-based training for listening skills across europe. trainees successfully acquired listening skills in the 120 hr course, as demonstrated in a standardized simulated emer­ gency call with an actor representing a typical tes caller. findings encourage the appli­ cation of the training in tes to prepare volunteers for their tasks as paraprofessional counselors. furthermore, results suggest that competency-based assessment in a simula­ ted tes call is a suitable method to measure listening skills. jennissen, schumacher, rucli et al. 13 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://www.psychopen.eu/ funding: this research was supported by a grant from the erasmus+ program of the european union (2015-1-de02ka204-002492), which is gratefully acknowledged. acknowledgments: we thank our project partners frank ertel from ifotes europe, bence buza and linda engwau from magyar lelki elsosegely telefonszolgalatok szovetsege hungary, monica petra and christina rigon from telefono amico italia, ulrike dahme and ulrike zeller from telefonseelsorge münchen, noor bossers and cootje roosenboom from sensoor zuid-holland, luca rusi from studio rucli, and valeria puletti and silvia cordellini from scuola nazionale servizi italy for their support. competing interests: the authors have declared that no competing interests exist. supplementary materials provides an observer-rating measure of listening skills (listening skills scale). the listening skills scale (lss) was used by independent observers to rate listening skills of participants in simulated emergency calls (for access see index of supplementary materials below). index of supplementary materials jennissen, s., schumacher, s., rucli, d., hal, m., székely, a., de beurs, d., & dinger, u. 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(2019). the national suicide prevention lifeline—the nation’s mental health public safety net. https://988lifeline.org/wp-content/uploads/2019/04/nspl-overview-2019.pdf clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. jennissen, schumacher, rucli et al. 17 clinical psychology in europe 2022, vol. 4(4), article e7933 https://doi.org/10.32872/cpe.7933 https://doi.org/10.1521/bumc.2010.74.1.45 https://doi.org/10.1002/jclp.22846 https://doi.org/10.1080/14733145.2012.739633 https://media.samaritans.org/documents/samaritansimpactreport2018_19_web_low_res.pdf https://www.samaritans.org/support-us/volunteer/become-samaritans-listening-volunteer https://doi.org/10.1007/s11606-007-0283-4 https://doi.org/10.1093/hsw/31.3.217 https://www.telefonseelsorge.de/unsere-statistiken https://988lifeline.org/wp-content/uploads/2019/04/nspl-overview-2019.pdf https://www.psychopen.eu/ competency-based training and assessment of listening skills (introduction) method participants and procedure listening skills training assessment data analytic strategy results preliminary analyses effect of the listening skills training discussion limitations implications and conclusion (additional information) funding acknowledgments competing interests supplementary materials references mirror exposure training for adolescents with anorexia nervosa (miradan): cognitive mechanisms of body disturbance – a study protocol research articles mirror exposure training for adolescents with anorexia nervosa (miradan): cognitive mechanisms of body disturbance – a study protocol maarit pelzer 1 , jessica werthmann 1 , christian fleischhaker 2 , jennifer svaldi 3 , brunna tuschen-caffier 1 [1] department of psychology, clinical psychology and psychotherapy, university of freiburg, freiburg, germany. [2] department of child and adolescent psychiatry, psychotherapy and psychosomatics, freiburg university hospital, freiburg, germany. [3] faculty of science, clinical psychology and psychotherapy, eberhard karls university tübingen, tübingen, germany. clinical psychology in europe, 2023, vol. 5(4), article e11277, https://doi.org/10.32872/cpe.11277 received: 2023-02-03 • accepted: 2023-08-28 • published (vor): 2023-12-22 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: maarit pelzer, albert-ludwigs-university freiburg, department of psychology, clinical psychology and psychotherapy, engelbergerstraße 41, d-79106 freiburg, germany. e-mail: maarit.pelzer@psychologie.uni-freiburg.de abstract background: anorexia nervosa (an) is a severe mental illness, which typically develops in adolescence and, if left untreated, often becomes chronic. body dissatisfaction is a core characteristic of an. mirror exposure (me) is an effective therapeutic technique to tackle body dissatisfaction in adult patients with eating disorders, but there is limited evidence for the effects of me in adolescence. one potential mechanism underlying effects of me on body dissatisfaction is change in body-related attention bias. however, this mechanism remains to be empirically tested. accordingly, the aim of the current study is twofold: primarily, we aim to test if me can reduce body dissatisfaction and associated symptoms in adolescent patients with an. additionally, we aim to investigate whether change in biased body-related attention due to me is a possible mechanism of action. method: adolescent patients with an are randomized to either 12 sessions of me (3 me-sessions/ week) or wait-list within four weeks. main outcomes include body dissatisfaction and associated symptoms of an. moreover, body-related attention bias is assessed at baseline and post-treatment by means of eye-tracking with two paradigms. further, process variables are collected weekly. in addition, 12 weeks after end of the study, the acceptability of the me is assessed. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11277&domain=pdf&date_stamp=2023-12-22 https://orcid.org/0000-0002-6990-8557 https://orcid.org/0000-0002-2312-1249 https://orcid.org/0000-0002-4167-0014 https://orcid.org/0000-0001-9819-4752 https://orcid.org/0000-0002-2565-7792 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ discussion: the main aim of the study is to evaluate high-frequency and high-intense me for treating body dissatisfaction in adolescents with an. in addition, we would like to clarify whether change in attentional bias for body stimuli is a mechanism underlying change in body dissatisfaction due to me. keywords anorexia nervosa, body dissatisfaction, modifying attentional processes, mirror exposure, adolescence highlights • body dissatisfaction is a major risk factor for the development, maintenance, and relapse of an. • in this study we aim to test if mirror exposure reduces body dissatisfaction in young people with an. • a secondary aim is to test if change in body-related attention bias is a mechanism of change in body dissatisfaction. background eating disorders are highly prevalent among young women. for example, an 8-year lon­ gitudinal study found that 12% of female adolescents experienced some form of threshold or subthreshold eating disorder by age of 20 (stice et al., 2009). among people with a lifetime diagnosis of an with early onsets (< 25 years), about 40% were diagnosed within the age range of 15 to 18 years, making this a prominent age to receive an an diagnosis (grilo & udo, 2021). an has the lowest one-year remission rate (stice et al., 2013) and current treatments of an in adolescents show only moderate success, leaving room for further improve­ ments (e.g. for an overview of the treatment of an, brockmeyer et al., 2018; jansingh et al., 2020). this is particularly concerning because there was a highly significant increase of 40% in admission rates in the female children’s and the adolescents’ of typical and atypical an between the preand peri-covid-19 periods in 2019 and 2021, respectively, in germany (herpertz-dahlmann et al., 2022). this illustrates how important it is to improve treatment options for adolescents with an. a disturbed body image is a core characteristic of an. body image disturbance is characterized by dysfunctional attitudes and emotions toward one's body, such as body dissatisfaction or fear of weight gain (forrest et al., 2018; mitchison et al., 2018). research findings show that overaluation of shape and weight and the corresponding body dis­ satisfaction is a key risk factor for the development, maintenance, and relapse of an (glashouwer et al., 2019; jacobi et al., 2004). therefore, decreasing body dissatisfaction in an is an important treatment target (dubois et al., 2017). miradan – a study protocol 2 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ several meta-analytic reviews indicated that repeated confrontation with one's own body seems to have a positive influence on body image (alleva et al., 2015) and that body exposure is an effective intervention for body disturbance in eating disorders (griffen et al., 2018; hartmann et al., 2021). however, while in general me seems to treat body image disturbances well in people with clinical and subclinical groups, research on the effectiveness of me in patients with an is still limited. one uncontrolled study showed that eight weeks of body image therapy with me exercises in a group format (n = 9) compared to body image therapy without me exercises (n = 6) significantly reduced body dissatisfaction, body anxiety and avoidance behaviors (key et al., 2002). however, the reliability of these results is severely limited due to the particularly low power of the study (nestoriuc et al., 2012). a larger uncontrolled study of morgan et al. (2014) (n = 55) with exposure-based body image therapy (which included me in seven out of ten group sessions) yielded significantly lower levels of body-related anxiety and worry, dysfunctional body and eating behaviors compared to baseline. it should be noted here that the two uncontrolled therapy studies by key et al. (2002) and morgan et al. (2014) examined patients with an who were in partial remission with an almost healthy weight (bmi inclusion criterion ≥ 20.5 in key et al., 2002; bmi inclusion criterion ≥ 17.5 in morgan et al., 2014). additionally, a case study showed that patients with an (n = 3) in partial remission benefited from intensive acceptance and commitment (act) therapy with me exercises (up to three sessions of 17 therapy sessions in total) in terms of their general pathology, eating symptomatology and body acceptance (berman et al., 2009). additional evidence comes from studies investigating the therapeutic effects of me in a mixed group of women with an, bulimia nervosa and eating disorder not otherwise specified: results from these studies indicate that negative body-related thoughts and emotions decreased and overall body dissatisfaction and body-related avoidance behavior were reduced by confrontation-based body image therapies in women with eating disor­ ders compared to the control group without therapy (bhatnagar et al., 2013; vocks et al., 2008). however, in these studies, me exercises were part of a broader body image therapy (bhatnagar et al., 2013: one out of five sessions with predominantly imaginary body exposure exercises; vocks et al., 2008: three out of ten group therapy sessions), which makes it difficult to attribute effects to me, specifically. a functional magnetic resonance imaging (fmri) study (vocks et al., 2010) found no effects of body exposure (including me-sessions) in self-reported measures of an patients, but reported an increase in the activity of the extrastriate body area from preto post-treatment. the authors interpreted this finding as reduction of avoidant body-related processing in response to body image therapy, which may be one working mechanism of me. recently a randomized control trial (rct) was conducted in which young girls aged 11-17 years with a diagnosis of an (n = 15) received body image therapy, including six pelzer, werthmann, fleischhaker et al. 3 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ me sessions (out of a total of 14 sessions) as add-on to their inpatient eating disorder therapy; (biney et al., 2021). compared to a group without additional body image therapy (n = 16, treatment as usual (tau)), the experimental group showed significantly greater improvements in weight concerns, body-related avoidance behavior and fears of gaining weight. again, all patients had reached their individual minimum healthy weight prior to body image therapy, including me sessions. moreover, the effects, especially for body-related avoidance behavior, observed in this study cannot be attributed to me specifically, because other body image exercises were also included in the body image therapy received by the experimental group. to summarize, there are first indications for the effectiveness of me for patients with an. however, sample sizes of previous studies were considerably low (ranging between 9 and 15 participants per group) thereby limiting the power of observed effects. moreover, because me was mostly applied as a component of a comprehensive “body-related” treatment, there is a lack of reliable randomized controlled data on the specific effect of me in an, especially for adolescent patients. even though evidence is accumulating the me may be effective to target body dis­ satisfaction in an, it is still unclear why me may work. empirical evidence suggests that one potential mechanism underlying body dissatisfaction is an aberrant attention bias to negatively-valenced body parts (for an overview see jiang & vartanian, 2018; kerr-gaffney et al., 2019; rodgers & dubois, 2016) and me may specifically target this by changing attention processing of one own’s body during repeated confrontations with the own body in the mirror. accordingly, reducing body-related attention bias may be a working mechanism of me. however, experimental evidence for the causal relation of biased attention and body dissatisfaction as potential underlying mechanism of me remains sparse and contradicto­ ry so far (glashouwer et al., 2016; krohmer et al., 2022a; naumann et al., 2022). initial evidence comes from a study by smeets et al. (2011) demonstrating that directing atten­ tion towards subjectively positive body parts led to a reduction in body dissatisfaction in people with high body dissatisfaction. similarly, krohmer et al. (2022a) found that me improved on body-related attention bias in in the female patients with binge eating disorder compared to the waiting control group. in addition, change in attention bias correlated significantly with change in weight concerns. in a study by glashouwer et al. (2016), five weeks of me therapy (one session/week) in which women with high body dissatisfaction were instructed to focus on their subjectively attractive body parts also led to a reduction in self-reported body dissatisfaction. however, in this study, the instruction to direct attention towards subjective attractive body parts did not produce any changes in body-related viewing patterns (glashouwer et al., 2016), even though body dissatisfaction improved. this finding, in particular, questions whether change in attention is an important mechanism underlying the effects of me. as no clinical groups miradan – a study protocol 4 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ were examined in glashouwer et al. (2016), floor effects could have contributed to these results (naumann et al., 2022). thus, the question remains whether dysfunctional attentional processes are maintain­ ing mechanisms of body dissatisfaction and whether reducing this bias is a working mechanism of action of me. establishing whether changing biased attention towards the own body is a mechanism underlying the effects of me in reducing body dissatisfaction in people with an is therefore an important research target. in the present study, eye-tracking data, more specifically, tracking gaze on body stimuli, which has been successfully used in body image research as an objective measure of attentional bias (bauer et al., 2017; blechert et al., 2010; jansen et al., 2005), is used to test whether the assumed selective gaze pattern of patients with an on unattractive body parts can be successfully modified by a mirror exposure intervention, leading to a reduction in body dissatisfaction. in a study of bauer et al. (2017) all eating disorder subgroups had an attentive preference for body areas they find unattractive, with even longer fixation time on self-evaluated unattractive areas of one's own body compared to fixation time on the body of peer's. participants with an-r attended significantly longer to unattractive body areas in general and significantly shorter to attractive areas than the control groups (clinical control group with anxiety disorder and healthy controls). therefore, we aim to investigate attention bias in different variations (single presentation vs. simultaneous presentation of own/other bodies as well as neutral stimuli), analyzing the areas of the bodies (most unattractive/attractive) to which the participants allocate their visual attention. furthermore, we collect and analyze reaction times as an indirect measure of attentional biases through the cueing and dot-probe task (macleod et al., 1986; posner, 1980). aims the main aim of this randomized controlled trial is to test the efficacy of me in adoles­ cents with an. we expect that me significantly reduces body dissatisfaction compared to a waitlist control group. in addition, we will examine whether the change in body dissatisfaction relates to a reduction in the general eating disorder psychopathology. in exploratory analyses, we also aim to examine whether me compared to a waitlist control group leads to a change of the behavioral components of body image disturbance (body checking and body avoidance). secondly, we expect that me compared to a waitlist control group leads to a stronger reduction of body-related attention bias (pre-post comparison). finally, we expect that changes in body-related attention bias are associated with changes in body dissatisfac­ tion, body-related emotions and cognitions. additionally, we want to explore possible process variables and predictors of treatment success. pelzer, werthmann, fleischhaker et al. 5 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ method trial design this feasibility study is designed as rct (experimental: me, control: waitlist) with pre and post-comparison (6 weeks) and open follow-up (12 weeks). participants are random­ ly allocated to receive either 12 sessions of me (treatment group) in addition to tau or to waitlist (control group), who will receive tau only. tau includes behavioral therapy interventions and nutrition management according to the german s3 guideline for diagnosis and treatment of eating disorders. more detail regarding the randomization procedure is provided below. the study design is shown in figure 1. ethical approval and trial registration ethical approval has been obtained from the ethics committee of the albert-ludwigsuniversity in freiburg, germany (545/17). participants received verbal and written (con­ sent) information before participating. in the case of underage participants, their legal guardians are also informed and their consent to participate is obtained as well. the research is conducted in accordance with the declaration of helsinki. the study is regis­ tered on the german clinical trial register (drks; registration number: drks0019104). participants and recruitment participants are recruited via the department of child and adolescent psychiatry, psy­ chotherapy and psychosomatics of the freiburg university hospital (director: prof. dr. fleischhaker) and from the outpatient unit of the institute of psychology, department of clinical psychology and psychotherapy, university of freiburg (head: prof. dr. tuschencaffier). inclusion criteria girls and young women are eligible for participating if they are diagnosed with an icd-10 of an or atypical an, age > 12 < 21. in addition, participants are not allowed to be currently tube fed and their weight must be above the 10th bmi percentile at the time-point of inclusion. exclusion criteria exclusion criteria are high risk of suicide, co-occurring psychotic, bi-polar disorders, alcohol/substance dependence within the past six months, medical conditions that would affect the ability to participate, and pregnancy/lactation. miradan – a study protocol 6 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ figure 1 trial design clinician diagnostic appointment with patients and parents photography appointment baseline assessment + experimental attention paradigms (eye-tracking) me-group tau + mirror exposure 3 times/weekly (1h per session  overall 12 sessions) + survey of the process variables waitlist-control tau + 3 times/weekly survey of the process variables  overall 12 survey timeslots post assessment + experimental attention paradigms (eye-tracking) waitlist-control if participation is desired: me (up to 12 sessions) post-treatment assessment waitlist inclusion and randomization: treatment group (me-group) or waitlist-control w ith in fo ur w ee ks one week after last exposure session assessment for all participants sent by e-mail: survey of the outcome variables12 w ee ks af te r m e photography appointment w ith in o ne w ee k w ith in o ne w ee k figure 1 trial design pelzer, werthmann, fleischhaker et al. 7 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ me procedure and waitlist control group the me technique applied in the current study is based on the manual of hilbert and tuschen-caffier (2010) as well as on the me protocol used in trentowska et al. (2013). me sessions are delivered in an individual setting in standardized underwear (beige/ white panty and top) by one of two post-graduate psychologists, who are enrolled in clinical cbt-training to become a licensed therapist. participants are instructed to look in a full-length mirror with double winged doors. the therapist stands outside the participant’s view and asks her to describe her own body as precisely as possible from head to toe. during the me, participants can freely express their positive and negative feelings and the therapist encourages the participant to name and persevere any upcoming feelings as part of the exposure rationale. me sessions lasts 50-60 min and followed by a brief debriefing. the waitlist control group receives tau. tau entails integral cbt-based treatment about nutrition management, eating behavior, stress management, social competence training and body-image treatment. however, participants in the waitlist control retain from receiving any body-image related treatment during the four weeks of study partici­ pation to prevent confounding of me effects. therapist training and supervision all me therapists received an introduction to the me rationale and treatment manual as well as me practice sessions within the research group before starting with me in the study. regular supervision is provided to therapists by senior me therapists. to ensure treatment adherence, me sessions are video recorded and will be discussed during supervision. these are deleted after each supervision. outcome measures since this is a feasibility study, a broad range of outcome measures is included to determine which are most sensitive for detecting a treatment effect. table 1 provides an overview of outcome measurements. miradan – a study protocol 8 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ ta bl e 1 sc he du le o f a ss es sm en ts c on te nt a ss es sm en t sc re en in g ba se lin e w it hi nse ss io n po st po st tr ea tm en ta a ft er 3 m on th s pa rt ic ip an t’s in fo rm at io n, in fo rm ed c on se nt x c lin ic al a nd d em og ra ph ic in fo rm at io n x c he d e x k -s a d spl x a ff ec tiv e an d co gn iti ve c om po ne nt s of bo dy  im ag e  di st ur ba nc es ff b x x x x be ha vi or al c om po ne nt s of bo dy  im ag e  di st ur ba nc es bc q x x x x bi a q x x x x a tt en tio nbi as ex og en us c ue in g pa ra di gm x x ad ap te d ve rs io n of th e do t p ro be ta sk x x m oo d an d bo dy e va lu at io n ov er c ou rs e of m e pa n a s x x x x x “b od yq ue st io nn ai re ” x x x ot he rs bd iii x x x x rs e x x x x qu es tio ns a bo ut th e co nd iti on s x x tr ea tm en t e va lu at io n x n ot e. bd iii = b ec k d ep re ss io n in ve nt or y; b c q = b od y c he ck in g q ue st io nn ai re ; b ia q = b od y im ag e a vo id an ce q ue st io nn ai re ; c he d e = ea tin g d is or de r ex am in at io n fo r ch ild re n; c he d eq = c hi ld e at in g d is or de r ex am in at io n q ue st io nn ai re ; f fb = f ra ge bo ge n zu m f ig ur be w us st se in ; k -s a d spl = k id di e sc he du le fo r a ff ec tiv e d is or de rs a nd s ch iz op hr en ia l ife tim e ve rs io n; p a n a s = po si tiv e an d n eg at iv e a ff ec t s ca le s; r se = r os en be rg s el fes te em s ca le . a o nl y fo r w ai tli st c on tr ol w ho r ec ei ve d m e. pelzer, werthmann, fleischhaker et al. 9 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ primary outcome affective and cognitive components of body image disturbances — to assess body dissatisfaction, as affective-cognitive component of body image disturbance, the german version of the body shape questionnaire (bsq; cooper et al., 1987; german version: fragebogen zum figurbewusstsein, ffb; waadt et al., 1992) is used. the ffb includes 34 items and is a widely used measurement tool to record numerous aspects of dissatisfaction with one's body shape with good psychometric properties (pook et al., 2002). behavioral components of body image disturbances — exploratory, behavioral components of body image disturbances are assessed with the body checking question­ naire (bcq; reas et al., 2002; german version: vocks et al., 2008) and the body image avoidance questionnaire (biaq; rosen et al., 1991; german version: legenbauer et al., 2007). the bcq is a 23-item reliable and valid instrument for assessing body-related control behavior (steinfeld et al., 2017). the biaq is a 19-item self-assessment tool for body-related avoidance and eating-related control behaviors with good psychometric properties (legenbauer et al., 2007). general eating disorder pathology — ed symptomatology will be measured by the german version of the child eating disorder examination questionnaire (chede-q; today study group, 2007; german version: hilbert et al., 2008). this child version of the eating disorder examination-questionnaire by fairburn and beglin (ede-q, 1994, 2008; german-version: hilbert & tuschen-caffier, 2006, 2016) allows the assessment of the specific eating disorder psychopathology on four subscales (restraint, eating concern, weight concern and shape concern) with 28 items. the german translation of the chede-q proved to be good internal consistency, convergent validity and retest reliability over a period of 7.5 months (hilbert et al., 2008). secondary outcomes attention bias — attention bias will comprise eye-tracking based attention processing of individually self-defined unattractive versus attractive body parts. two attention paradigms (exogenous cueing paradigm and dot probe paradigm) are used to assess body-related attention biases. both paradigms rely on the assessment of eye-tracking to index overt spatial attention allocation to body stimuli. stimulus material — in both tasks, standardized photographs of the participants’ own body and a control body matched in bmi and waist-to-hip ratio are used as body stimuli. vases are used as neutral/non-body-related control stimuli (krohmer et al., 2022b). participants wear standardized underwear (beige/ white panty and top) and are photographed in standardized positions (hip wide stand, arms beside the body, back of miradan – a study protocol 10 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ the hands forward with fingers extended) from four perspectives (front, left, right, back) without the face and feet being visible. the photos are transferred in black and white and presented on a gray background. noticeable features (tattoos, scars) are removed. body-related exogenous cueing paradigm — in the exogenous cueing paradigm participants view their own body or a weight-matched control body on one side of the screen (either left or right) for 3000 ms and need to indicate the location of a cue appearing subsequently on either the left or right side of the screen (valid or invalid with the body’s position). accordingly, the paradigm consists of the following trial types: own body and other body in four perspectives (front, left, right, back) presented on right/left side with valid/ invalid cue = 32 trials, repeated in 4 blocks = 128 trials in total. the bias scores indexes attention allocation towards self-defined attractive and unattractive body parts of the own versus the other body without a direct competing stimulus. frequency and duration of fixations on areas of interest (self-rated attractive vs. self-rated unattractive body parts of the own and the other body) are extracted for further analyses. body-related version of the dot probe task — in this adapted version of the dot probe participants view stimulus pairs for 3000 ms and need to indicate the location of a cue appearing subsequently on either the left or right side of the screen, replacing one of the two stimuli. the following trial types are presented as stimulus pairs: own body/ vase, other body/vase, own body/other body (each pair in 4 perspectives), presented on right/left side with valid/ invalid cue = 48 trials, repeated in 2 blocks = 96 trials in total. gaze pattern during the presentation of these picture pairs indexes attention allocation towards the own body versus other body when a competing stimulus is presented at the same time. the bias scores of this paradigm indexes attention allocation towards own versus a direct competing neutral or another body stimulus. the frequency of the direction and the duration of the first and second fixation towards the own body when compared to a neutral stimulus or another body will be analyzed. mood and body evaluation over course of me — to explore other potential pro­ cesses of change during me, we assess mood and the evaluation of one's own body over the course of me. mood is assessed using the german version of the positive and negative affect scales (panas; watson et al., 1988; german version: krohne et al., 1996), which consists of 20 adjectives that describe different sensations and feelings (10 positive, 10 negative feelings). the german panas has very good psychometric properties (breyer & bluemke, 2016). the evaluation of one's own body is rated with the ‘body questionnaire’ (see e.g. tuschen-caffier et al., 2015), which assesses state body dissatisfaction and obtains attractiveness ratings of specific body parts based on photographs of participants as used in the attention paradigms. pelzer, werthmann, fleischhaker et al. 11 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ sample characteristics — age and duration of illness are measured. to assess severity of depression, the beck depression inventory (bdi-ii; beck et al., 1996; german version: hautzinger et al., 2006) is used, which is a 21-items self-report instrument for the severity of depressive mood over the last two weeks with high validity and reliability (keller et al., 2022). because self-esteem has been linked to body dissatisfaction and edsymptoms, we assess self-esteem at baseline validly and reliably using the 10-item rosenberg self-esteem scale (rse; rosenberg, 1965); german version: von collani & herzberg, 2003). procedure potential participants are referred to the study by their clinician/therapists. study researchers screen participants for eligibility. once eligibility has been established, pa­ tient’s and their parents’, in the case of underage patients, written informed consents are obtained. eligible participants are invited for a diagnostic session. eating disorder diagnoses are established by means of the german version of the chede (bryant-waugh et al., 1996; hilbert, 2016). other mental disorder diagnoses are assessed by means of the german version of the kiddie schedule for affective disorders and schizophrenia lifetime version (k-sads-pl; delmo et al., 2001; kaufman et al., 2000). if participants meet all inclusion criteria, participants are randomly allocated to the treatment or wait­ list control group. within one week, the photo appointment takes place, to create four standardized photos of participants, which are used as stimulus material in the attention paradigms. then, participants are invited to the baseline assessment, in which they complete the eye tracking paradigms and questionnaires on relevant outcome measures. if allocated to the me condition, an initial session to explain the rationale and procedure of me is scheduled first, followed by three sessions of me per week for four weeks. directly after each me session, participants answer questionnaires assessing their body dissatisfaction and mood. in the waitlist control, participants also have three appointments per week, during which only body dissatisfaction and mood are assessed. after completing 12 sessions of me or waitlist appointments, respectively, the post assessment takes place in the week following the last session. this outcome assessment of eye-tracking paradigms and questionnaires is identical to the baseline assessment. participants in the waitlist control group are offered me (at their own convenience) after completing post-treatment assessments. three months after the post assessment, participants who were allocated to the me group receive an email containing a link to an online-questionnaire asked about the individually experiences and evaluation of me regarding their subjective experiences of acceptability, satisfaction and recommendation. participants from the waitlist control group who took up me after post assessment evaluate their experience one week after their last me session and again after three months. miradan – a study protocol 12 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ randomization before the start of the study, a randomization list was prepared by the project manage­ ment. to ensure blinding during screening and diagnostics, the project management informs the researcher and the therapists on condition allocation only after inclusion of a patient. sample size and current trial status sample size calculation yielded with a power of (1-β) = .80, a moderate to large effect (cohen, 1988), based on previous results (key et al., 2002; morgan et al., 2014), of d = 0.8–1.3, α = .05 and a moderate correlation of within-effects the sample size – calculated over generic tests – at least around 42 patients with an should be included. the study was initiated in september 2018. by january 2023, 24 patients have participated. the study recruitment has been repeatedly interrupted for various reasons (e.g., the corona pandemic). with a study participation of 1-2 patients per month so far, the study is expected to run until december 2023. statistical analysis to determine quality, completeness and variability of the outcome measures, descriptive statistical analyses and graphical methods will be used. to test if me significantly reduces body dissatisfaction compared to waitlist control group (first hypothesis) 2 x 2 one-way analyses of variance (anova) with group (me/waitlist) as betweensubject factor, time (pre/post) as within-subject factor will be applied. in exploratory analyses we also aim to test if me significantly reduces body checking and body avoidance compared to waitlist control group 2 x 2 one-way analyses of variance (anova) with group (me/waitlist) as betweensubject factor, time (pre/post) as within-subject factor will be applied. for our secondary hypothesis (i.e. me compared to wait-list results in reductions of body-related attention bias), a mixed 2 (group: me/ waitlist) x 2 (time: pre/ post) x 2 (stimulus material: self/other) x 2 (body party: unattractive/attractive) anova for both attention paradigms is planned. we will define areas of interest (aoi) based on participants` ratings of the most attractive and unattractive body part (for own/other body respectively). bias scores for gaze duration, gaze frequency and number of initial fixations on each stimulus will serve as dependent variables. to clarify if change in attention bias is associated with change in body dissatisfaction, correlations between (changes) of attentional biases and body dissatisfaction, body checking and body avoid­ ance will be conducted. in exploratory analyses we also aim to capture processes of change in mood and body evaluation over the course of repeated me sessions and how potential change in these measures relates to changes in relevant outcome variables such as body dissatisfac­ tion, attention bias and global ed pathology. finally, we will also explore how possible pelzer, werthmann, fleischhaker et al. 13 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ participants’ characteristics, such as age or self-esteem, relate to improvements in body dissatisfaction after me. discussion dissatisfaction with one's own body is a major risk factor for the development, mainte­ nance, and relapse of an (glashouwer et al., 2019; jacobi et al., 2004). me is an effective technique for treating body dissatisfaction in adults (ziser et al., 2018). however, there is limited research on the effectiveness of me therapy in an, and even less research has been conducted on the effects of me in children and adolescents with an (biney et al., 2021). the aim of this study is to address this research gap by examining the effects of me on body dissatisfaction in children and adolescents with an. the secondary aim is to clarify whether the change in attentional bias for body stimuli is the mechanism underlying the change in body dissatisfaction due to me. in this feasibility rct we will also strive to explore additional variables of interest, such as body-related emotions and cognitions. strengths a strength of this study is conducting experimental psychopathology research in the field of adolescents with an and in residential facilities because this is particularly difficult context for experimental studies (glashouwer et al., 2020). considering the high prevalence of an among adolescents and minimal treatment effects in the treatment of an (e.g. zeeck et al., 2018), we know how important it is to conduct experimental research to test novel treatment options and to study working mechanisms of current treatment techniques as well as mechanisms contributing to the maintenance of an. the present study achieves a greater understanding of me as treatment technique for adolescents with an as well as providing initial evidence for a potential working mechanisms of this technique (change in body-related attention bias) and maintaining factor of body dissatisfaction in this sample (i.e. dysfunctional body-related attention patterns). in addition, this experimental study conducted as an add-on to tau offers the opportunity for patients to participate in and benefit from this treatment technique (me). another strength of the current study is combining a feasibility rct in this context with multimethodological outcome assessment, including the direct assessment of overt spatial attention allocation by means of eye-tracking. this multimethod approach can in­ form on subjective as well as relatively automatic cognitive changes due to the treatment (me). eye-tracking has been established as a valid instrument to index visual attention processing (blechert et al., 2009; van ens et al., 2019). miradan – a study protocol 14 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://www.psychopen.eu/ challenges one major challenge remains consistent recruitment – even though there is the high number of people affected by an in adolescence and in particular the prevalence of an in adolescents amid the covid epidemic and the demand for therapy are increas­ ing. consistent recruitment may also be challenging because facilitating research in an inpatient clinic during a pandemic has led to disruptions in concurrent recruitment procedures. in addition, the integration of a study in a clinical setting with a highly intensive therapy program for patients, is particularly challenging in the clinical context regarding logistics as well as time-planning organization. conclusion to conclude, this paper sets out a protocol for an rct that will enhance the current knowledge of the efficacy of me to target body dissatisfaction as central core symptom for an in adolescents. funding: the authors have no funding to report. acknowledgments: we thank the patients and their guardians for participating in our current study. we also thank the clinic team at clinic for psychiatry, psychotherapy and psychosomatics in childhood and adolescence for the continueing support during this study. competing interests: the authors have declared that no competing interests exist. ethics statement: ethical approval has been obtained from the ethics committee of the albert-ludwigs-university in freiburg, germany (545/17). study registration: the study is registered on the german clinical trial register (drks; 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(2018). effectiveness of body image directed interventions in patients with anorexia nervosa: a systematic review. international journal of eating disorders, 51(10), 1121–1127. https://doi.org/10.1002/eat.22946 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. pelzer, werthmann, fleischhaker et al. 21 clinical psychology in europe 2023, vol. 5(4), article e11277 https://doi.org/10.32872/cpe.11277 https://doi.org/10.1002/erv.825 https://doi.org/10.1024//0170-1789.24.1.3 https://doi.org/10.1037/0022-3514.54.6.1063 https://doi.org/10.3389/fpsyt.2018.00158 https://doi.org/10.1002/eat.22946 https://www.psychopen.eu/ miradan – a study protocol (introduction) background aims method trial design ethical approval and trial registration participants and recruitment inclusion criteria exclusion criteria me procedure and waitlist control group therapist training and supervision outcome measures procedure randomization sample size and current trial status statistical analysis discussion strengths challenges conclusion (additional information) funding acknowledgments competing interests ethics statement study registration references psychotherapy works – an inclusive and affirming view to a modern mental health treatment scientific update and overview psychotherapy works – an inclusive and affirming view to a modern mental health treatment christoph flückiger 1, ulrike willutzki 2, martin grosse holtforth 3,4, bruce e. wampold 5 [1] department of psychology, university of kassel, kassel, germany. [2] department of psychology, witten/herdecke university, witten, germany. [3] department of psychology, university of bern, bern, switzerland. [4] hospital insel, bern, switzerland. [5] department of counseling psychology, university of wisconsin-madison, madison, wi, usa. clinical psychology in europe, 2024, vol. 6(special issue), article e11971, https://doi.org/10.32872/cpe.11971 received: 2023-05-16 • accepted: 2023-07-17 • published (vor): 2024-04-26 handling editor: wolfgang lutz, department of psychology, university of trier, trier, germany corresponding author: christoph flückiger, university of kassel, department of psychology, clinical psychology ii, holländische straße 36 – 38, de-34127 kassel, germany. e-mail: christoph.fluckiger@uni-kassel.de related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract psychotherapy is a highly collaborative and individualized mental health practice developed in (post-) modern societies. the mental health outcomes of psychotherapy cover a broad range of psychological factors including the reduction of suffering/symptoms as well as the promotion of well-being, personal values, and personal strengths. there is extensive meta-analytic evidence that legitimate psychotherapy works remarkably well and robustly for most common mental disorders. in addition, there is a large body of meta-analytic evidence supporting the potential relevance of transdiagnostic relationship principles and transtheoretical psychotherapy factors. based on this ongoing empirical evidence, we propose four relevant implications for future training and practice in transdiagnostic psychotherapy: 1) the development of a transtheoretical legal framework for psychotherapeutic treatments, 2) the formulation of evidence-based transtheoretical interpersonal skills, 3) an orientation toward transtheoretical therapeutic factors, and 4) the exploration of comprehensive psychotherapy outcomes. we conclude with some more general guidance for future directions. keywords mental health, bona fide psychotherapy, transtheoretical psychotherapy, evidence-based psychotherapy this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11971&domain=pdf&date_stamp=2024-04-26 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • legitimate psychotherapy is remarkably effective. • the evidence-based consolidation process on psychotherapy key principles is progressing continuously. • there is robust empirical foundation of transtheoretical relationship factors and therapy skills. there is comprehensive meta-analytic evidence that psychotherapy works across the most common mental health conditions. surprisingly – and perhaps more controversially – there is robust evidence that various psychotherapy orientations work well, and when intended to be therapeutic (i.e., bona fide therapies) are approximately equally effective. that is, the ongoing controversy between psychotherapy orientations may make the potential differences between orientations appear larger than can be empirically suppor­ ted, which is particularly true for long-term follow-ups. in this commentary, we provide explicit definitions of psychotherapeutic treatments and their mental health outcomes. furthermore, we provide evidence-based examples of studies comparing the lasting ef­ ficacy at follow-up of particular legitimate psychotherapies vis-à-vis other legitimate psychotherapies. next, we provide examples of evidence-based psychotherapy principles and skills based on recently conducted meta-analytic summaries. last, we discuss impli­ cations for therapeutic practices and training, and conclude with some more general guidance for future directions. how can legitimate (bona fide) psychotherapy be characterized and why is it relevant to identify non bona fide psychotherapy conditions? psychotherapy is a highly collaborative and individualized mental health practice de­ veloped in (post-) modern societies (e.g., elias, 1978; huft, 2022). one of the main characteristics of psychotherapy is its collaborative nature. furthermore, patients have a proactive role and are engaged in therapy. the key point is that psychotherapy is a socioculturally embedded mental health practice, with patients and society expecting a highly custom-tailored and collaborative talking cure to reduce target complains and fostering well-being and psychosocial functioning to proactively work on the clients´ sufferings. one of the major challenges in psychotherapy research is that psychotherapy and its minimal standards are often not explicitly defined. we define the minimal standards of legitimate (bona fide) psychotherapy as follow (wampold et al., 1997; wampold & imel, 2015): psychotherapists with at least a master's degree provided treatment, and two of psychotherapy works 2 clinical psychology in europe 2024, vol. 6(special issue), article e11971 https://doi.org/10.32872/cpe.11971 https://www.psychopen.eu/ the following criteria are required: (a) treatment is generally recognized as legitimate psychotherapy, such as cbt or psychodynamic therapy, and therapists are not prohibited from using recognized therapeutic interventions, such as psychoeducation, empathy, a rationale for treatment, promotion of coping skills, or (b) the description of treatment includes a reference to a psychological mechanism (e.g., operant conditioning), or (c) a manual/guide is used, or (d) the treatment includes an active component that has appeared in the psychological literature. careful consideration of the minimum standards of legitimate psychotherapy is a prerequisite for including only such trials in meta-analy­ ses of psychotherapy comparisons to minimize research bias and triviality of findings. with respect to non bona fide psychotherapy conditions, such conditions often are constructed to not be fully therapeutic (e.g., westen et al., 2004; munder et al., 2019; flückiger et al., 2022). non bona fide psychotherapy conditions often can be identified by looking at what interventions are excluded or even “banned”. examples of non bona fide psychotherapy in the above-mentioned sense are: discussion group where the leaders were instructed to “not teach skills or differentially reinforce coping strategies” (wetherell et al., 2003, p. 33), psychoeducation where “instructors were asked, as best as they could, not to teach any skills in a way that may enhance mindfulness” (wong et al., 2016, p. 69), nondirective therapy where “direct suggestions, advice or coping methods were prohibited” (borkovec & costello, 1993, p. 613), three session contact control group to motivate patients “to wait for the start of the treatment” (linden et al., 2005, p. 37). in many cases such non bona fide “intent-to-fail”-interventions are used to demon­ strate the relevance of specific components of the favored treatment (westen et al., 2004). however, these conditions are not informative about the efficacy of the approach compared to legitimate psychotherapy and provide little information about specific in­ gredients. how can psychotherapy outcomes be defined? who defines mental health as follows: mental health is a comprehensive state of mental well-being that ena­ bles people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. it is an integral component of health and well-being that underpins our individual and collective abilities to make decisions, build relationships and shape the world we live in. (world health organization, who, 2022, june 17). consistent with the above-mentioned broad definition of the world health organiza­ tion (who), we understand mental health as a lifelong process of development and adaptation. most importantly, mental health has at least two constituents, including the reduction of suffering/symptoms as well as the promotion of well-being, personal values, flückiger, willutzki, grosse holtforth, & wampold 3 clinical psychology in europe 2024, vol. 6(special issue), article e11971 https://doi.org/10.32872/cpe.11971 https://www.psychopen.eu/ and strengths (e.g., schürmann-vengels et al., 2022). in psychotherapy, collaborative efforts toward symptom reduction and well-being represent psychotherapeutic outcomes that result from careful therapeutic exploration (grosse holtforth et al., 2004). the point relevant to this special issue on transtheoretical clinical training and practice is that psychotherapy outcomes go beyond the tailored ("primary") outcomes of a particular psychotherapy and should cover the broad spectrum of the who definition of mental health. does a particular bona fide psychotherapy have a more lasting effect than another? although somewhat arbitrary in nature, a threshold for a clinically relevant treatment effect in anxiety and mood disorders has been estimated to be about d = .25 (cuijpers et al., 2014). comparative meta-analyses report small to negligible relative differences in efficacy if two or more bona fide psychotherapies are compared directly in an rct design (wampold & imel, 2015). with respect to long-term outcomes, kivlighan and co-authors (2015) for example ex­ amined the long-term follow-ups of bona fide psychodynamic psychotherapies compared with non-psychodynamic bona fide psychotherapies (k = 25). they hypothesized that psychodynamic psychotherapies would perform better over time than other treatments (assuming a positive and statistically significant slope effect from assessment post-thera­ py to follow-up). however, they found an effect of dslope = .00 for disorder-specific targe­ ted outcomes, nontargeted outcomes, and personality outcomes. these results suggest that the efficacy of psychodynamic therapies is generally not more sustainable but also not less sustainable after active treatment compared with other bona fide psychothera­ pies. several other longitudinal multilevel meta-analyses on interventions for anxiety and depression did not show any significant increase or decrease in relative effects over follow-up time within studies, such as for cognitive interventions versus behavioral in­ terventions (podina et al., 2019), studies with additive components (flückiger et al., 2015), and established cognitive behavioral therapy or augmented integrative cognitive behav­ ioral therapy for generalized anxiety disorder under bona fide conditions (flückiger et al., 2022; for all studies dslope < .10). again, these meta-analytic findings show that differ­ ential long-term outcomes for particular bona fide psychotherapy approaches usually are not likely. the point relevant to the special issue for transtheoretical training and practice is that the enormous effort to specify psychotherapeutic effects through very specific approach explains surprisingly little on the long run. do we therefore face a shambles? no, we think not! on the contrary, as we will show in the following sections there is con­ siderable meta-analytic evidence for the outcome-relevance of multiple transtheoretical principles and skills. psychotherapy works 4 clinical psychology in europe 2024, vol. 6(special issue), article e11971 https://doi.org/10.32872/cpe.11971 https://www.psychopen.eu/ is there an evidence base for transtheoretical psychotherapy principles and skills? psychotherapy represents a cooperative course of action between therapist and patient during and between psychotherapy sessions. one of the most substantiated findings in psychotherapy research is that transtheoretical collaborative qualities are robustly linked to treatment outcomes across many psychotherapy conditions. based on an international meta-analytic summary of 295 studies representing more than 30,000 psychotherapies, there is a moderate predictive association of 8% explained variance (r = .278; confidence interval .256 ≤ r ≤ .299; flückiger et al., 2018) between alliance measured mostly once during therapy and therapy outcome (at the end of therapy) in face-to-face and inter­ net-mediated treatments. these statistically significant results confirm those of previous meta-analyses. a comparable predictive power of the working alliance could also be meta-analytically confirmed in therapies with children and adolescents (karver et al., 2018), in couple and family settings (friedlander et al., 2018) and groups (lo coco et al., 2022). there seem to be therapists who are comparatively more successful in building work­ ing alliances with their patients than others. these differences between therapists are relevant for treatment success, i.e., therapists who on average build better alliances also treat somewhat more successfully. these moderate effects have been meta-analytically confirmed (del re et al., 2021). it is hypothesized that the alliance-outcome relationship manifests itself in particular because of the patients' intake characteristics (e.g., feeley et al., 1999). however, based on 66 studies reporting both uncontrolled predictor models and predictor models control­ led for the intake variables, there is no systematic evidence that the alliance can be fundamentally understood as an epiphenomenon of the intake variables, arguing for the collaborative conception during treatment (r = .25 vs. .22; flückiger, del re, et al., 2020). furthermore, an individual participant data analysis of 17 studies indicated that in the early phase of therapy, symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions (flückiger, rubel, et al., 2020). overall, the available evidence across hundreds of studies indicates that the above-mentioned sociocultural key principle of psychotherapy as a highly collabora­ tive mental health treatment is robustly linked to psychotherapy outcomes. for other concepts that partly overlap with the alliance concepts comparable correlation patterns have been shown (for example empathy, goal agreement and group cohesion; norcross & lambert, 2018). with respect to particular therapist skills, a recent apa interdivisional effort investi­ gated 27 well-accepted basic psychotherapy skills and methods (hill & norcross, 2023). the results of the meta-analytic summaries revealed that some transtheoretical psycho­ therapy skills such systematic feedback in routine outcome monitoring (barkham et al., flückiger, willutzki, grosse holtforth, & wampold 5 clinical psychology in europe 2024, vol. 6(special issue), article e11971 https://doi.org/10.32872/cpe.11971 https://www.psychopen.eu/ 2023), emotion-regulation strategies (iwakabe et al., 2023) or strength-based methods (flückiger et al., 2023) were evaluated as “demonstrably effective” for post-treatment outcomes (published open access in the journal psychotherapy research; hill & norcross, 2023). overall, findings from process-outcome research have the potential to moderately improve psychotherapy interventions across psychotherapy orientations. clinical and training implications for future training and practice in transtheoretical psychotherapy based on the reviewed literature, the following transtheoretical, transdiagnostic and interdisciplinary implications can be summarized for future clinical practice and training. development of a legal framework for transtheoretical mental health treatments and psychotherapy we consider it a key societal achievement that legislators have prioritized mental health treatments that have a strong collaborative foundation. coercive measures are used only in extreme emergencies. psychotherapy is the best example of how the joint negotiation and decision-making process can be carefully elaborated within mental health systems. the alliance, as one of the most studied collaborative principles, emphasizes the overall meaning of therapy, which includes therapeutic goals, therapeutic tasks, and deeper bonds of trust in the confidentiality of psychotherapy. legitimate psychotherapy funda­ mentally requires consensual collaboration between therapist and patient. the relevant point for training and practice is that psychotherapy provides a socially protected setting where patients are allowed to express their innermost concerns and desires. psychotherapy is a cultural practice that promotes humane and free society. psychotherapy does not exclude people and brings individuals, couples, families and groups together. it offers understanding for diversity, cultural sensitivity, psychosocial exclusion and psychological strain. evidence-based transtheoretical interpersonal skills building on patients’ alliance potential and enhancing their alliance qualities at the beginning of a therapy is, on the one hand, central to ensuring that patients do not immediately discontinue the therapy. on the other hand, the early alliance (among other factors) lays the foundation for patients to engage in tasks of therapy. in the first phase of therapy, it is crucial that the methods of therapy are tailored to the patient's specific expectations, skills and abilities, and needs. the collaborative qualities of psychotherapy are crucial, namely that patients and therapists basically agree independently to the joint therapeutic tasks. the quality of the alliance may fluctuate within sessions. in principle, psychotherapy works 6 clinical psychology in europe 2024, vol. 6(special issue), article e11971 https://doi.org/10.32872/cpe.11971 https://www.psychopen.eu/ central tendency is more relevant to success than a single session. however, critical, negative to hostile reactions from patients are possible during sessions and interruptions of the alliance are not uncommon. adaptation of procedures to the patients’ motives and strengths can enhance the alliance quality. in addition, tears and ruptures in the therapeutic relationship can be explored in a non-catastrophizing way and, if necessary, used therapeutically (eubanks et al., 2023; also caspar & grosse holtforth, 2009; safran & muran, 1996). navigating transtheoretical therapeutic factors navigating and monitoring the patients´ views of psychotherapeutic factors is an impor­ tant therapist task to ensure that therapists do not take them for granted too quickly or become overly critical of themselves and the therapy. therapists differ in the quality of how they build and shape custom-tailored treatments. what basically counts is the overall collaborative quality of the therapeutic process and not the adherence to an ostensible therapeutic stereotype. broadening psychotherapy outcomes as the above-mentioned health definition exemplifies, mental health is a much more comprehensive condition than the absence of particular symptoms and related disorders. at the same time, well-being is not an exclusive goal for psychotherapeutic treatments. singing in a choir, sailing with friends, or listening to a punk rock band can similarly contribute to mental health depending on the individuals´ preferences. clearly, such activities may be highly relevant topics in the consolidation phase of a therapy to explore psychotherapeutic change. the critical point is that a wide range of mental health measures need careful consideration when evaluating mental health treatment. to promote effective learning and therapy practice, supportive psychotherapy train­ ing (e.g., fostering supportive supervision, positive trainee relationships, and group col­ laboration; heinonen et al., 2022) as well as structured practice on basic skills (e.g., anderson et al., 2020; eells et al., 2005) are essential. we expect a continuing psychother­ apy development of therapists over a career that comprises professional and personal progression as well as challenges (orlinsky et al., 2005). figure 1 shows an example of how an evidence-based transtheoretical model might be formulated (see wampold & flückiger, 2023), which is an extension of contextual model (wampold & imel, 2015). in the transtheoretical model, there are three pathways to the benefits of all mental health (as well as physical health) service: the care pathway (caring, attentive, real, empathic), the expectation pathway, and the specific pathway. in a sense, this model integrates the effects of relationship factors and specific ingredients, making it important for all psychotherapists, including those strongly affiliated with a particular treatment, as flückiger, willutzki, grosse holtforth, & wampold 7 clinical psychology in europe 2024, vol. 6(special issue), article e11971 https://doi.org/10.32872/cpe.11971 https://www.psychopen.eu/ well as for various healing domains, including psychotherapy, psychiatry, and medicine. the model is also transcultural as well as transtheoretical. figure 1 exemplification of an evidence-based transtheoretical model – the care-model of mental health treatments (adapted from wampold & flückiger, 2023) bond task goals exploration supportive skills empathy caring understanding reassurance trust warmth genuineness communication skills verbal fluency persuation competence relationship skills detecting needs and motives monitoring alliance and ruptures re-establishing goals and tasks meta-communication interpersonal skills broadening outcomes well-being values symptoms suffering expectancy hope bonding care specific navigating factors plausibility adherence engagement concluding comment for future directions mental health is a human right and a shared responsibility of societies that cannot be entirely delegated to particular professions nor achieved by certain treatments. at the same time, carefully conducted mental health treatments are cultural achievements. transtheoretical therapeutic factors such as collaborative qualities are relevant across orientations but also across professions and settings (wampold & flückiger, 2023). on the healthy side of mental health, there is openness, individuality, and basic human freedom in how we create our lives. accepting co-responsibility for psychotherapeutic outcomes is not only a critical interpersonal skill of therapists, but also entails an attitude of trust in joint exploration of what individual well-being means. psychotherapy works 8 clinical psychology in europe 2024, vol. 6(special issue), article e11971 https://doi.org/10.32872/cpe.11971 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references anderson, t., perlman, m. r., mccarrick, s. m., & mcclintock, a. s. 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(1997). a metaanalysis of outcome studies comparing bona fide psychotherapies: empirically, “all must have prizes.”. psychological bulletin, 122(3), 203–215. https://doi.org/10.1037/0033-2909.122.3.203 flückiger, willutzki, grosse holtforth, & wampold 11 clinical psychology in europe 2024, vol. 6(special issue), article e11971 https://doi.org/10.32872/cpe.11971 https://doi.org/10.1037/pst0000176 https://doi.org/10.1016/j.cpr.2015.05.003 https://doi.org/10.1159/000082025 https://doi.org/10.1037/ccp0000735 https://doi.org/10.1017/s2045796018000355 https://doi.org/10.1037/pst0000193 https://doi.org/10.1037/11157-000 https://doi.org/10.1016/j.cpr.2019.101774 https://doi.org/10.1037/0022-006x.64.3.447 https://doi.org/10.1002/jclp.23352 https://doi.org/10.1002/wps.21035 https://doi.org/10.1037/0033-2909.122.3.203 https://www.psychopen.eu/ westen, d., novotny, c. m., & thompson-brenner, h. (2004). the empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials. psychological bulletin, 130(4), 631–663. https://doi.org/10.1037/0033-2909.130.4.631 wetherell, j. l., gatz, m., & craske, m. g. (2003). treatment of generalized anxiety disorder in older adults. journal of consulting and clinical psychology, 71(1), 31–40. https://doi.org/10.1037/0022-006x.71.1.31 wong, s. y., yip, b. h., mak, w. w., mercer, s., cheung, e. y., ling, c. y., lui, w. w., tang, w. k., lo, h. h., wu, j. c., lee, t. m., gao, t., griffiths, s. m., chan, p. h., & ma, h. s. (2016). mindfulness-based cognitive therapy v. group psychoeducation for people with generalised anxiety disorder: randomised controlled trial. the british journal of psychiatry, 209(1), 68–75. https://doi.org/10.1192/bjp.bp.115.166124 world health organisation – who. (2022, june). mental health. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. psychotherapy works 12 clinical psychology in europe 2024, vol. 6(special issue), article e11971 https://doi.org/10.32872/cpe.11971 https://doi.org/10.1037/0033-2909.130.4.631 https://doi.org/10.1037/0022-006x.71.1.31 https://doi.org/10.1192/bjp.bp.115.166124 https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response https://www.psychopen.eu/ psychotherapy works (introduction) how can legitimate (bona fide) psychotherapy be characterized and why is it relevant to identify non bona fide psychotherapy conditions? how can psychotherapy outcomes be defined? does a particular bona fide psychotherapy have a more lasting effect than another? is there an evidence base for transtheoretical psychotherapy principles and skills? clinical and training implications for future training and practice in transtheoretical psychotherapy development of a legal framework for transtheoretical mental health treatments and psychotherapy evidence-based transtheoretical interpersonal skills navigating transtheoretical therapeutic factors broadening psychotherapy outcomes concluding comment for future directions (additional information) funding acknowledgments competing interests references the history of clinical psychology in greece: a brief review – legal deficiencies, practical dimensions and challenges for the future politics and education the history of clinical psychology in greece: a brief review – legal deficiencies, practical dimensions and challenges for the future katerina flora 1 [1] department of psychology, university of western macedonia, florina, greece. clinical psychology in europe, 2024, vol. 6(4), article e12515, https://doi.org/10.32872/cpe.12515 received: 2023-07-31 • accepted: 2024-08-28 • published (vor): 2024-12-20 handling editor: anton-rupert laireiter, university of vienna, vienna, austria corresponding author: katerina flora, kimonos voga 50, 54645, thessaloniki, greece. phone: 0030-6973238267. email: kflora@uowm.gr abstract background: the history of clinical psychology in greece spans more than 150 years. however, this branch of psychology concerned with the assessment and treatment of mental illness and psychological problems has not yet acquired the institutional and general recognition to which it is entitled. aims: this article intends to highlight, chronologically, the basic elements of the history of clinical psychology in greece, beginning with the important contribution of the work of philologist panagiota kazolea-tavoularis. results: from the first references in the context of medical studies during the 19th century, clinical psychology gradually develops through its application in pedagogical, laboratory, and clinical contexts to become an independent discipline alongside the consolidation of general psychology. special mention is made of the scientists who pioneered this direction. conclusion: the present review highlights historical milestones and concludes with the current situation, in which important steps have been taken. however, significant changes are needed at the institutional level. keywords clinical psychology, history, applied psychology, greece, review this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12515&domain=pdf&date_stamp=2024-12-20 https://orcid.org/0000-0002-4561-8555 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • during the 19th century elements of clinical psychology were formulated in the context of medical studies. • during the 20th century, clinical psychology developed more widely in pedagogical, laboratory and clinical contexts. • the formation of clinical psychology as an independent branch took place in parallel with the consolidation of general psychology. the purpose of this overview is to coherently present the history of clinical psychology, the branch of psychology concerned with the assessment and treatment of mental illness and psychological problems, in greece. the basic bibliographic source for the writing of this article is the doctoral thesis of panagiota kazolea-tavoularis (2001), titled “the history of psychology in greece (1830–1987)”. this particular thesis gathers rich and original material. what is described in this article is, by a significant part, an extraction from the thesis, specifically related to clinical psychology. it is worth noting that there are no specific sources for the history of clinical psychology in greece. therefore, the source material mainly concerned the history of psychology in greece in general, the history of applied psychology, and the history of psychiatry. processing of the found material resulted in five general origins and strands from which clinical psychology in greece is fed: medicine, especially neurology and psychiatry; philosophy and religion; educational science and pedagogy; psychoanalysis and psychotherapy; and the develop­ ment of american and european (experimental and applied) psychology in general, with its various fields and disciplines. this article follows a chronological order and concludes with a description of the current state of clinical psychology in greece. the chronological order follows the work of kazolea-tavoularis’ thesis, with the addition of older and modern sources added to the basic elements included in the historical review. the beginning – 19th century the development of clinical psychology in the 19th century was influenced mainly by medicine, particularly neurology and psychiatry, and its institutions (clinics, universities, and practitioners). since the 19th century, applied psychology subjects have been taught in medical departments throughout greece. psychological theories concerning mental disorders and shaping the early practice of clinical psychology appeared during the 19th century and were taught at medical schools in the context of general pathology, since psychiatry as a specialty was unestablished. the influence of psychological factors on physical health was emphasized, which equated with the harmony of body and soul. outside of a strict academic context, psychological issues were also referred to by history of clinical psychology in greece 2 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.psychopen.eu/ doctors, and an early use of the term “psychosis” was recorded with reference to the history of western psychiatry regarding the classification and treatment of phrenosis (kazolea-tavoularis, 2001). as early as 1885, scientific publications such as the journal medical had been established, in which doctors at the time – such as ioannis foustanos, a student of jean-martin charcot – referred to hypnosis, removing any metaphysical dimension from the behaviour of the hypnotized. apart from academic, theoretical psychology, an applied clinical psychology was practised in psychiatric institutions, and it may have been influenced, to some extent, by religious and philosophical currents. according to dimitris ploubidis (1995), practical psychiatry was practised in several monasteries through wishes, exorcisms, and incanta­ tions but also with more violent means such as binding with chains and confinement. these practices were succeeded from 1838 on by the establishment of the insane asylum of corfu and the dromokaiteio sanatorium of attica according to the standards of west­ ern european sanatoriums based on the theories of jean-etienne dominique esquirol (karamanolakis, 1998). these institutions were followed at the beginning of the 20th century by the aegineteio (athens) 1905, the public psychiatric hospital of athens in the 1920s, and the public psychiatric hospitals of thessaloniki and souda, chania (crete) (chartokollis, 1991). during that period, psychological theories and clinical practices that the greek doctors had learned from their studies in europe were applied in these institutions, following the french school of degeneration of valentin magnan or the german school of psychiatry, which, at the end of the century, ended up in the kraepelin classification of primitive dementia. there is a discrepancy in the diagnoses, as could be seen from the archives of the corfu psychiatric hospital (1880–1885) where diagnostic terms such as lysomania, bimorphous phrenitis, bimorphous paranoia, rationalized paranoia, isodemia, enteric frenzy, and exphylogenic frenzy were mentioned. it is worth mentioning the work of two greeks with international recognition, grigorios rosolimos in russia and konstantinos oikonomou in austria, in the field of neuropsychology during the same period. in greece in the 19th century, scientific events unfolded with a delay, as the state structures and educational ties were absent in the newly established state. therefore, beyond the above references, psychology remained largely philosophical and was slow to evolve into an applied field. clinical psychology in the 20th century overview and lines of development the 20th century saw a more intensive and heterogeneous development of psychology and clinical psychology in particular. the development of clinical psychology in greece flora 3 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.psychopen.eu/ came in two phases, the first lasting until about 1960 and the second following thereafter, as the discipline was largely established and consolidated as an independent scientific and practical field. the first phase: structure and development the first phase of the development of clinical psychology was strongly influenced not only by european and american psychology but also by pedagogy and psychotherapy. institutes and professorships of psychology were established in greece’s large cities and in institutions of applied clinical psychology in the fields of health and education. in 1964, the first chairs of psychology were established at the universities of ioannina and thessaloniki (kazolea-tavoularis, 2001). hypnosis and psychoanalysis were being practised elsewhere in europe, and greece imported knowledge about hypnotism for medical or parapsychological use. this sparked a dialogue that contributed to the awak­ ening of interest in the soul as an entity and, by extension, in psychic phenomena. ref­ erences to hypnosis, dreams, and parapsychological phenomena were noted in general psychology throughout the first half of the 20th century. some interested parties, howev­ er, leaned more towards mysticism, promoting religious beliefs and accusing scientific and research sources of being atheistic or materialistic. scientific psychology in universities and laboratories while psychology was taught as a general subject at the philosophical school of athens until 1908, as psychopathology at the medical school of athens, and as general psychol­ ogy in teaching and secondary education, it was still part of philosophy courses at the beginning of the 20th century. the first psychology laboratory, which provided impor­ tant services to student practice and research, was founded in 1926 at the university of athens by theophilos boreas. the second such laboratory was established in 1935 in thessaloniki, where the activities of professor georgios sakellariou were particularly noteworthy; he founded the magazine prometheus in 1951 and the hellenic psychological society in 1955. at the same time, psychopedagogical research was being conducted by alexandros delmouzos, a professor of pedagogy in thessaloniki and a student of wilhelm wundt. the psychological laboratory of athens was divided during the 1950s into four departments: psychological research, professional guidance, clinical psychology, and enlightenment of parents and young people; this was the first reference to clinical psychology at an academic level. the aims of the laboratory also included applied psychology. the work of s. paraskeva-sakka, who studied philosophy in thessaloniki and psychology in the united states and was a colleague of sakellariou, was noteworthy. paraskeva-sakka specialized in vocational guidance and psychoanalytic psychotherapy and translated and used many of the psychological tests still in use today. history of clinical psychology in greece 4 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.psychopen.eu/ applied psychology, the beginnings psychological scientists were sought after by the greek army early in the 20th century to help select and train conscripts in the most efficient use of new weapons and machines. in 1917–1918, a special committee drafted tests for the selection of aviators while selec­ tion methods were being implemented for conscripts and candidates for military schools. in 1948–1949, sakellariou trained army officers in the psychological laboratory at which intelligence tests were administered. since the 1950s, the army has used intelligence scales such as the terman–sakellariou scale and the nikolaos exarchopoulos progressive matrix test scale. additionally, applied psychology was used in the greek army until 1997, when the institution of psychosocial care was established to address conscripts’ problems. important contributions to the spread of psychology in greece were made by two female pioneers, sofia gedeon and aikaterini striftou-kriaras. they were collaborators of nikolaos exarchopoulos, the chair of pedagogy in the laboratory of experimental pedagogy, who was succeeded by spyridon kalliafas. kalliafas turned to the study of psy­ chological issues, as can be seen by his publication of characters or psychological types in 1935, in which he referred to older characterizations starting with plato and aristotle and continued with the psychoanalytic schools of freud, adler, and jung. his study mentioned the relevant psychology of individual differences of fechner, charcot, taine, binet, and stern and the contributions made by two greeks, nikolaos exarchopoulos and georgios sakellariou. kalliafas glorified jung’s typology and was perhaps the most basic and important exponent of his work in greece. konstantinos specieris succeeded kalliafas in 1953. in his work, the psychosynthesis of man, specieris attempted a philosophical approach to the psyche; however, he empha­ sized the therapeutic effects of the psychoanalysis of freud, adler, and jung. for the evaluation of the personality, he proposed his own psychograph type with 13 questions. specieris’ work, the mental life of man (specieris, 1960) was a revision of his previous work based on the latest scientific findings. it referred equally critically to behaviourism, psychoanalysis, individual psychology, and the philosophy of existence. he also directly questioned the method of psychological tests and, in general, quantitative measurements that provide only partial knowledge of phenomena. he argued that the totality of mental life was greater than the sum of its parts in accordance with morphological psychology, while insightful understanding and deepening introspection were required to understand the human psyche. applied psychology was introduced in greece at the beginning of the 20th century with the particularities that characterized greek scientific and social reality at that time. psychology was not clearly accepted as an independent scientific field, so discussion about freud’s theories of psychology and psychoanalysis took place within the circles of pedagogy. the first translations of freud’s works were published in the early 1900s, while at the same time the psychoanalytic movement was remembered mainly for its flora 5 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.psychopen.eu/ pedagogical application. beyond freud, adlerian principles of pedagogy were taught in selected schools of the country and also in special education through the work of the pioneering pedagogue roza imbrioti. the medical community in greece initially had a negative attitude towards psycho­ analysis, which favoured the demedicalization of psychoanalysis in greece during the first period of its introduction. however, dimitrios kouretas, a neurologist and psychia­ trist, delivered the first lecture on psychoanalysis in greece in 1927. he contributed to the creation of the first psychoanalytic nucleus in greece in 1947 with andreas empirikos, a poet and exponent of surrealism in greece, and georgios zavicsianos, a psychiatrist, under the supervision of princess marie bonaparte, a student and translator of freud and president of the paris psychoanalytic society. the name nikolaos drakou­ lides was also mentioned; he wrote a number of studies, including one on freud and psychoanalysis (1936) and another on the psychoanalytic interpretation of art (1948). psychoanalysis, however, was practiced clinically and was referred to as the new psycho­ therapeutic method with encouraging results since the 1930s. prominent practitioners were psychiatrist mihail vlastos, psychiatrist fotis skouras, and neurologist–psychiatrist konstantinos d. konstantinidis, a professor at the medical school of athens and director of the public psychiatry of athens. countering this group was georgios zouraris, a member of the institute for sexual research in berlin, who favoured psychobiology and criticized concepts of psychoanalysis such as childhood sexuality and the oedipus complex. given the interaction and mutual borrowing between disciplines and the theoretical issues of psychology and psychiatry (tzavaras, 1991), a reference to psychiatry in greece also concerned the history of psychology in the country, insofar as the conceptions of the “soul”, its functions, and its pathology were common points of concern for both. the popularity of psychological theories and therapeutic practices such as psychoanalysis and others, since it was only in 1963 that neurology and psychiatry were institutionally separated, erased the special characteristics of clinical psychology in institutions and as taught by university departments. after all, the concept of mental illness was part of a specific institutional framework, which, reflected the socio-economic conditions at the time as well as the ideological parameters in greece, as kazolea-tavoularis (2001) commented. mental health services: the treatment of the mentally ill of interest was the treatment of the mentally ill, which during the period of the ottoman empire – which is a long period for which there is not much evidence – was done in asylum-type institutions and sometimes in churches and monasteries. faith was thought to heal the mentally ill in a sense, while inhumane practices such as folk psychosurgery with red-hot irons were reported (ploubidis, 1995). history of clinical psychology in greece 6 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.psychopen.eu/ the first asylum was established in corfu, in 1838, by the british administration and was housed in the equestrian stables. the first doctors of the asylum were british, while the first greek doctor, christodoulos tsirigotis, took over as director in 1874. already in constantinople-during ottoman empirethere were several institutions that accepted the mentally ill. in the 16th century, we have the establishment of the hospital of galata of gemintzidon, which accepted the mentally ill. in 1780 the hospital of stadrodomiu, in 1839 of heptapyrgio, in 1855 the la paix asylum in constantinople was founded by catholic nuns, in 1748 the greek hospital with an insane asylum department. in constantinople, the ottomans founded two insane asylums in 1465, the fatih mosque hospital and in 1527 the second one in the suleiman mosque hospital. in 1583, sultana valide was founded and in 1850 the toptahi hospital, both of which received mental patients (madianos 1994; ploubidis, 1995). at the end of the 19th century and the beginning of the 20th century, some forms of psychiatric treatment were available, as it was reported that hospitals in chios, smyrna, and constantinople received mentally ill patients with various diagnoses such as primi­ tive dementia, progressive general paralysis, and mania-melancholia (ploubidis, 1995). opinions about mental illness in greece were shaped according to the studies of greek psychiatrists abroad. some followed the german school and others the french school. essentially, psychiatry was organized after 1930 and the founding of the neuro­ logical and psychiatric society. the prevailing opinion was that psychiatric diseases derived from organic causes, and the therapeutic practices were similar, including bed rest, electric shock, drugs, cold and hot water, occupational therapy, and hydrotherapy. public psychiatric hospitals, such as the university psychiatric clinic aeginetio foun­ ded at the start of the 20th century, were staffed by academic psychiatrists and treated patients using the well-known psychotherapeutic methods of the time. after the 1960s, psychosocial approaches such as drama groups, psychodrama, and group psychotherapy were also mentioned. more generally, however, the psychiatric world remained orien­ ted toward the neurobiological and organic basis of mental disorders while promoting chemical treatments and expressing doubts about the findings of the new science of psychology and psychoanalysis. over time, however, psychoanalysis was increasingly supported by a growing number of medical representatives. however, greek society at that time – characterized by its low level of education, conservatism, orthodox christian religion, and poor economic situation for large numbers of the population – generally maintained a negative attitude toward psychoanalysis and its emphasis on sexuality. in addition to academic psychology, a network of mental health services was created in the context of social welfare in the early days of the 20th century. associations promot­ ing mental health, institutions treating children’s psychosomatic health, and, since the mid-20th century, institutions for the blind and deaf, psycho–pedagogical centres, medi­ flora 7 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.psychopen.eu/ cal–pedagogical centres, psychotherapeutic clinics, vocational guidance centres, student perception centres, and psychological test institutes were established. an important development for community mental health was the establishment in the 1950s, following a proposal by psychoanalyst anna potamianou, of the centre for mental hygiene, which offered a series of counselling and therapeutic prevention and intervention services. a corresponding development was the psychological centre of northern greece in thessaloniki in the 1960s, which aimed to address the broader mental health problems in northern greece. its function was closely related to the scien­ tific activity of eftychia nanakou, a doctor and psychologist who treated children with mental retardation. in the 1960s, the athenian centre for the study of man was founded by psychiatrist georgios vassiliou and psychologist vaso vassiliou as the first institute of systemic and family therapy, with methods based on family and group dynamics such as those taught at loyola university of chicago. after 1960 – the consolidation of clinical psychology during the period 1964–1997, the above processes were been completed, and clinical psychology was consolidated and developed into various fields. hence, greece saw the consolidation of the science of psychology in both academic instruction and scientific activity. at the universities of ioannina, thessaloniki, and athens, psychology courses were taught within the faculty of philosophy in the departments of philosophy, peda­ gogy, and psychology. later the field of psychology became autonomous, and independ­ ent departments of psychology were created. clinical psychology was taught alongside the other subjects of psychology during these years. key representatives of applied psychology were maria nasiakou in ioannina as a school psychologist, mika haritou fatourou in thessaloniki as a clinical psychologist, and ioannis paraskevopoulos and anastasia kalantzi-azizi in athens in psychometry and clinical psychology, respectively. applied psychology, as we saw above, was taught as early as the 1930s in pedagogic departments, academies and teaching in the context of either general or special educa­ tion. educational and school psychology, developmental and evolutionary psychology, developmental psychopathology, assessment of intelligence and learning disabilities as well as therapeutic interventions are the main courses taught at this time, after 1960, in these schools. the 1970s saw the establishment of parenting schools through the work of psychologist maria khourdakis, which aimed to protect the mental health of both children and parents. these schools were based on the theories of family psychology, educational psychology, and school pedagogy. they had a significant impact on the public and 135 schools were operating nationwide by the 1980s. important in the consolidation and independence of the science of psychology in greece was the establishment of the association of greek psychologists in 1963 and the panhellenic psychological association in 1997, which defended the rights of licensed professional psychologists. however, despite continuous efforts, psychologists in greece history of clinical psychology in greece 8 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.psychopen.eu/ have not succeeded in establishing a single association that constitutes a legal entity under public law. additionally important is the presence of the hellenic psychological society, a scientific association founded in 1990, that includes branches of clinical psy­ chology and health psychology, among others. apart from this organization, there is no separate association of clinical psychology in greece. moreover, the connection between clinical psychology and psychotherapy lacks a clear framework in greece. psychotherapy is clearly a part of clinical psychology; for example, in the postgraduate programs of clinical psychology, psychotherapy is certainly a responsibility of the clinical psychologist. by contrast, many private institutes for the training of psychotherapists are not directly related to clinical psychology, as this disci­ pline is taught in universities. it is imperative to institutionally clarify the professions of clinical psychologist and psychotherapist, a distinction that remains unclear. additionally, in the context of social welfare, various institutions have been establish­ ed to accommodate children with various disabilities or those who have been removed from their families due to neglect or abuse. children’s psychological support and thera­ peutic interventions, occupational therapy, psychosocial support, and special vocational training have been broadly applied in these structures. at the same time, since the 1950s, various vocational orientation tests have been introduced in the psychological laboratories of athens and thessaloniki, while counsel­ ling for students has also been offered. from 2000 onwards, programs to remove social exclusion have been extended to various categories of people, such as prisoners, addicted people and disabled people, mainly with funding from the european union. clinical psychology, psychiatry, and psychiatric reform clinical psychology in greece remains a popular discipline among young psychologists. its relationship with psychiatric medicine was partly conflictual due to the different backgrounds of the two sciences and the therapeutic practices that each proposes. however, the psychological training of doctors should be noted, with the introduction of psychology courses in medical schools in 1970 and the increasing participation of psychiatrists in psychotherapeutic training programs. at the same time, the contribution of clinical psychologists to psychiatric reform, oriented towards deinstitutionalization, community psychology, and social psychiatry, was important. the work of psychiatrists kostas stefanis, panagiotis sakellaropoulos, petros hartokollis, stavroula berati, nikolaos tzavaras, charalampos hierodiakonou, and georgios anastasopoulos and psychologists anna kokkevi, alexandra routsoni, r. diakogianni, maria dolianiti, ilias fragos, and thaleia vergopoulou is important in this direction. the operation of psychiatric hospitals and the structure of psychiatric reform from the 1980s onwards contributed to the promotion of clinical psychology in greece. the same decade saw the establishment of the first addiction centres in greece, kethea and 18 ano, with the significant contributions of psychiatrists phoebus zafirides and flora 9 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.psychopen.eu/ katerina matsa, respectively. psychiatrists, psychologists, social workers, and psychiatric nurses worked at these centres, comprising the interdisciplinary teams. clinical child and adolescent psychology and psychiatry child psychiatry organisations have been established since 1950 to treat the mental health of children and adolescents. an important activity for the psychosomatic health of children was developed at the child psychiatric clinic of the agia sophia children’s hospital, founded in 1978. this department provides services such as diagnostic consul­ tation, short hospitalization and treatment, psychosocial support, and pre-professional training. the department trains doctors and psychologists and has prepared prevention programs. psychiatrists and psychologists gerasimos stefanatos, ioannis tsiantis, olga maratou, and anna kokkevi pioneered this effort. also related to the practice of clinical psychology in greece is the establishment of various organizations from 1960 onwards with the aim of providing psychotherapeutic services, the education and training of mental health professionals, and, sometimes, research. these groups followed various psychological approaches and practices and include the hellenic counselling society; hellenic psychoanalytic society; hellenic so­ ciety for dyslexia; hellenic society for research and behavior therapy; centre for family therapy; alcoholics anonymous; centre for individual psychology; centre for psychotherapy and gestalt training; hellenic society for community therapists, soci­ otherapy, and psychodrama; and the medical sexology institute. these societies have become widely associated with applied psychology, as many graduates of psychology departments have continued their education there to be trained in a psychotherapeutic approach, thus complementing the knowledge offered by academic study. the training in these organizations had a more practical orientation that psychology departments usually did not offer except at the postgraduate level. academic departments perhaps the most important event for the development of psychology in greece and, by extension, clinical psychology was the establishment in the mid-1980s of independent university departments of psychology. the first department of psychology was founded in 1987 at the university of crete. the contribution of psychologist maria khourdaki was important as, together with professors ioannis nestoros, nikos papadopoulos, and grigoris potamianos, she founded the new department. following the example of the university of crete, other psychology departments were established in athens and the­ ssaloniki. all departments arose from philosophical schools with the exception of the one at panteion university, which was rooted in the sociology department. the newly established department of psychology of panteion university was staffed by professors history of clinical psychology in greece 10 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.psychopen.eu/ of the department of sociology such as stamos papastamou, foteini tsalikoglou, and aimilios metaxopoulos. in 1992, a department (program) of psychology was established at the kapodistrian university of athens with professor george paraskevopoulos and assistant professors ilias bezevegis, nikolaos giannitsas, and anastasia kalantzi-azizi staffing this new de­ partment, which was part of the department of philosophy, pedagogy, and psychology. postgraduate programs were not initially offered. since 1993, an autonomous department of psychology has been operating at the aristotle university of thessaloniki, which also emerged from the department of phi­ losophy, pedagogy, and psychology. the department followed three directions – school– evolutionary, experimental–cognitive, and social–clinic – and was founded by professors maria maniou-vakali, anastasia euclides, dimitra papadopoulou, mika charitou-fatour­ ou, diomedes markoulis, dimitrios natsopoulos, and kostas bayraktaris. postgraduate studies have been offered almost from the beginning, while various scientific activities such as conferences, workshops, and seminars have been conducted. the map of psychology departments in greece was completed with the establishment of two new departments in 2019: the university of western macedonia, based in florina, and the university of ioannina, which also emerged from the older department of philosophy, pedagogy, and psychology. instead of an epilogue: clinical psychology in greece today in greece at the moment there are six psychology departments in public universities, four of which provide at least two years of postgraduate study in clinical psychology. additionally, at least 10 affiliates of foreign universities have been established in which undergraduate studies in psychology are taught, and at least five offer postgraduate studies in clinical psychology. private institutes providing training in various treatment approaches are numerous, and it is difficult to calculate their exact number. the professional training of clinical psychologists, as can be deduced from the above, is provided at the postgraduate level mainly at public universities but also at private colleges. these programs have an academic structure and also provide extensive practical training. as mentioned above, professional clinical psychology is not recognized officially and it is not institutionally protected. hence, there are no financial benefits for people who use the services of clinical psychologists through greece’s healthcare system. at the institutional level, there is the branch of clinical psychology in the hellenic psychological society that validates this specialty. clinical psychologists in greece work in both medical and psychiatric clinics, addic­ tion treatment programs, and other therapeutic settings as well as on an outpatient flora 11 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.psychopen.eu/ basis or in private practice. in recent years, the positions of clinical psychologists in public institutions have been scarce, leading to more clinicians to be employed in private practices. the work of clinical psychologists in medical and psychiatric clinics includes diagnosis, therapy, consultation, crisis intervention, and supervision. in private practices, it involves mainly therapy and consultation. another important issue is the unclear distinction between clinical psychology and psychotherapy. officially, neither is officially recognized as a profession in greece. how­ ever, psychotherapy is undeniably part of the work of a clinical psychologist. informally, psychotherapists are those who have completed training in a particular therapeutic approach, and their numbers are probably greater than clinical psychologists, but official figures are lacking. the public health system employs more clinical psychologists since academic qualifications, such as a master’s degree and a doctorate, are usually required. through the above-described developments, clinical psychology has established itself as a discipline in greece. however, there are institutional gaps in care that must be addressed to secure and further develop the field of clinical psychology (see kalantziazizi & karadimas, 2009). first and most importantly, the greek legislation regarding the profession of psychologist includes no mention of registered specializations such as clinical, school, or cognitive psychology. therefore, clinical psychology is taught at an academic level and practiced at a clinical level, but it does not have legal status as a specialization. a second deficiency that undermines the field of clinical psychology is the fact that the licence to practice the profession of psychologist in greece is issued directly after the completion of undergraduate studies, with only two months of practice. this is unprecedented, as a psychologist can typically undertake clinical work without having completed the necessary supervised clinical practice. the most basic requirement for a clinical psychologist should be supervised clinical practice for at least one year. in conclusion, clinical psychology in greece has a long history and has been served by notable scientists, initially from the field of medicine and later from psychology. however, the regulation by the state is needed to secure the field of clinical psychology in the present and to create the groundwork for its development in the future. funding: the author has no funding to report. acknowledgments: the author has no additional (i.e., non-financial) support to report. competing interests: the author declares that she has no relevant or material financial interests that relate to the research described in this paper. reporting guidelines: the author has followed the equator reporting guidelines (https://www.equator-network.org) and has used the prisma guidelines (http://prisma-statement.org). history of clinical psychology in greece 12 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://www.equator-network.org http://prisma-statement.org https://www.psychopen.eu/ references chartokollis, p. (1991). eισαγωγή στην ψυχιατρική [introduction to psychiatry]. themelio publications. kalantzi-azizi, a., & karadimas, e. (eds.). (2009). h σχέση της kλινικής ψυχολογίας με τους eφαρμοσμένους kλάδους της ψυχολογίας και την ψυχοθεραπεία [the relationship of clinical psychology with other applied fields of psychology and psychotherapy]. topos publications. karamanolakis, v. (1998). to δρομοκαϊτειο φρενοκομείο: 1887-1903. όψεις της εγκατάστασης ενός ιδρυματικού θεσμού [dromokaitio, the psychiatric hospital: 1887-1903. views of facility of one institutional institution]. mnimon, 20, 45–66. https://doi.org/10.12681/mnimon.666 kazolea-tavoularis, p. (2001). h ιστορία της ψυχολογίας στην eλλάδα (1830-1987) [the history of psychology in greece (1830-1987)]. [doctoral dissertation]. panteion university of social and political sciences. https://thesis.ekt.gr/thesisbookreader/id/15021#page/1/mode/2up madianos, m. (1994). h ψυχοκοινωνικη αποκατασταση απο το ασυλο στην κοινοτητα. παραρτημα: το νομικο πλαισιο της αποκαταστασης [psychosocial rehabilitation from the asylum to the community. annex: the legal framework of rehabilitation]. ellinika grammata. ploubidis, d. (1995). h ιστορία της ψυχιατρικής στην eλλάδα. θεσμοί, iδρύματα και kοινωνικό πλαίσιο [the history of psychiatry in greece: institutions and social context]. exantas publication. specieris, k. (1960). h ψυχική ζωή του ανθρώπου [the mental life of man]. typois mina myrtidi. tzavaras, t. (1991). oι σχέσεις ψυχολογίας και ψυχιατρικής από ιστορική-επιστημολογική άποψη [the relations between psychology and psychiatry from a historical-epistemological point of view]. psichologika themata, 4(2), 113–121. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. flora 13 clinical psychology in europe 2024, vol. 6(4), article e12515 https://doi.org/10.32872/cpe.12515 https://doi.org/10.12681/mnimon.666 https://thesis.ekt.gr/thesisbookreader/id/15021#page/1/mode/2up https://www.psychopen.eu/ history of clinical psychology in greece (introduction) the beginning – 19th century clinical psychology in the 20th century overview and lines of development the first phase: structure and development after 1960 – the consolidation of clinical psychology academic departments instead of an epilogue: clinical psychology in greece today (additional information) funding acknowledgments competing interests reporting guidelines references between-session homework in clinical training and practice: a transtheoretical perspective scientific update and overview between-session homework in clinical training and practice: a transtheoretical perspective truls ryum 1 , nikolaos kazantzis 2,3 [1] department of psychology, norwegian university of science and technology, trondheim, norway. [2] cognitive behavior therapy research unit, melbourne, victoria, australia. [3] beck institute for cognitive behavior therapy and research, philadelphia, pa, usa. clinical psychology in europe, 2024, vol. 6(special issue), article e12607, https://doi.org/10.32872/cpe.12607 received: 2023-08-15 • accepted: 2023-11-12 • published (vor): 2024-04-26 handling editor: wolfgang lutz, department of psychology, university of trier, trier, germany corresponding author: truls ryum, department of psychology, norwegian university of science and technology, 7491 trondheim, norway. e-mail: truls.ryum@ntnu.no related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract background: this paper defines and illustrates the ways in which between-session homework (bsh) may be integrated into clinical work with clients across various treatment approaches. in line with the focus of this special issue, we explore how clinical training and supervision can enhance therapist skills and competence in the use of bsh. method: after providing a brief historical overview and an integrative perspective on bsh, along with a review of empirical research supporting its efficacy, we delve into the discussion of bsh as a transtheoretical clinical method with heuristic value across different treatment approaches, such as cognitive-behavioral, psychodynamic, and humanistic-experiential therapies. results: there exists diversity in how bsh is incorporated into distinct treatment approaches. furthermore, we emphasize the significance of therapist skills and competence in utilizing bsh to facilitate client engagement and achieve positive treatment outcomes. finally, we address how clinical training and supervision contribute to the development of these essential skills and competence. conclusions: our findings highlight three main points: (1) substantial empirical support for the integration of bsh within cognitive-behavioral therapies, (2) the potential of bsh as a promising transtheoretical clinical method, even though research beyond cognitive-behavioral therapies remains limited, and (3) the imperative need for further research into how clinical training and supervision can effectively enhance therapist skills and competence in implementing bsh. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12607&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0001-7313-5879 https://orcid.org/0000-0001-9559-4160 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords homework, training, practice, trans-theoretical, evidence-based highlights • between-session homework (bsh) shows promise as a transtheoretical clinical method for clinical practice and training. • therapist skills and competence in utilizing bsh are essential to facilitate client engagement with bsh and treatment outcomes. • research into how clinical training and supervision can effectively enhance therapist skills and competence in implementing bsh is needed. a brief historical overview of between-session homework (bsh) the utilization of between-session homework (bsh) holds a substantial historical sig­ nificance within behavioral and cognitive-behavioral therapies (cbt). it was initially introduced as a systematic strategy for promoting and sustaining behavior change in behavior therapy (shelton & ackerman, 1974; shelton & levy, 1981). as cognitive thera­ py gained prominence, the significance of between-session assignments in achieving suc­ cessful outcomes gathered momentum. notably, aaron t. beck and colleagues dedicated a separate chapter to the use of bsh in their seminal clinical guide, "cognitive therapy of depression" (beck et al., 1979). while there has been a proliferation of training resources (e.g., beck, 2020) and treatment manuals for specific disorders since then, there has also been a recent shift towards more integrative and transtheoretical models (e.g., barlow et al., 2017; barlow et al., 2011). despite these changes, the importance of bsh remains a defining feature of cbt. this significance is underscored in the recent conceptual model proposed by kazantzis and miller (2022). in fact, the literature on homework is most advanced within cbt, with more research supporting its positive impact on outcomes compared to any other treatment component (see reviews in kazantzis et al., 2018; ryum et al., 2023a, 2023b). while bsh is considered a primary driver of change in cbt, it has received relatively less attention within psychodynamic (pdt) and humanistic-experiential therapies (het). in these approaches, bsh is typically assigned a more supportive role in the therapeutic process and outcome. however, even freud proposed the incorporation of between-ses­ sion activities in psychoanalysis (freud, 1952), and subsequent psychodynamic authors have advocated for integrating bsh into psychodynamic therapy (e.g., mccullough, 2003; stricker, 2006; wachtel, 1977). this notion is further supported by surveys of practicing therapists, indicating that bsh is commonly utilized by both cognitive-behavioral and psychodynamic therapists (fehm & kazantzis, 2004; kazantzis & dattilio, 2010; kazantzis, lampropoulos, et al., 2005). similarly, within humanistic-experiential therapies, the use a transtheoretical perspective on between-session homework 2 clinical psychology in europe 2024, vol. 6(special issue), article e12607 https://doi.org/10.32872/cpe.12607 https://www.psychopen.eu/ of bsh has been endorsed (e.g., brodley, 2006; greenberg & warwar, 2006; warwar & ellison, 2019), although a comprehensive survey among practicing therapists is lacking to our knowledge. it is worth noting that the journal of psychotherapy integration, vol. 16, no. 2, featured a dedicated special issue on the topic of homework across various psychotherapeutic models. we note that there has also been substantial interest in the affiliated concept of “intersession experiences/ processes” (orlinsky & geller, 1993; orlinsky et al., 1993), which builds upon psychodynamicand transtheoretical theories, and refers to the cli­ ent’s (and therapist’s) spontaneous or intentional processing of psychotherapy between session, including thoughts, feelings, memories, and fantasies about the therapy or the therapist (orlinsky et al., 1993). these experiences are internalized over the course of therapy, forming affect-laden representations, that influence on the therapeutic process and outcome (e.g., hartmann et al., 2010; hartmann et al., 2016; zeeck & hartmann, 2005). while both intersession processes and bsh concerns between-session activities, and client’s intersession experiences may relate to bsh, they differ fundamentally in the sense that bsh is planned, targeted, and negotiated between therapist and client through in-session dialogue, whereas intersession processes are not. we therefore refer interested readers to other sources for recent reviews on intersession processes (gablonski et al., 2023; stewart & schröder, 2015). for similar reasons, we avoid further discussion of between-session activities that are primarily client-initiated (e.g., spontaneous implemen­ tation of treatment-related content in stressful situations), although such activities would clearly be considered therapeutic (see discussion in brodley, 2006). furthermore, while our primary focus here centers on individual therapy, it is also imperative to acknowledge the enduring interest in the utilization of bsh within the contexts of couples and family therapies. this enduring interest is evidenced through surveys conducted among practicing therapists and their clinical applications (dattilio et al., 2011; kazantzis et al., 2023). the pervasive employment of bsh is thus discernible across various psychotherapeutic approaches, to the extent that it has been posited as a potential 'common factor' (kazantzis & ronan, 2006). nonetheless, disparities persist in the manner by which bsh is assimilated into clinical practices across these treatment ap­ proaches—an issue we shall expound upon. it is noteworthy to highlight that substantial endeavors have been undertaken to facilitate conciliation between therapeutic paradigms in the conceptualization of bsh as a transtheoretical method (a forthcoming special issue in the journal of clinical psychology – in session, 2024, delves into this matter). importantly, an enduring interest in the application of bsh endures, both within the framework of cognitive behavioral therapy (cbt) and across other diverse treatment methodologies (ryum et al., 2023a, 2023b), with mounting empirical support that sub­ stantiates bsh as an evidence-based, transtheoretical method of significance for clinical practice and the training of clinical psychologists. ryum & kazantzis 3 clinical psychology in europe 2024, vol. 6(special issue), article e12607 https://doi.org/10.32872/cpe.12607 https://www.psychopen.eu/ between-session homework: an integrative perspective numerous terms and definitions have been proposed to encapsulate the fundamental essence of between-session homework within the context of psychotherapy. these designations, encompassing a range of connotations such as “homework,” “extra-therapy assignment,” and “home practice activities,” among others, do not inherently signify a transformation in the content, nature, or essential essence of bsh. in this paper, we adopt the term “between-session homework,” recognizing the absence of a universally established terminology. nonetheless, it is imperative to underscore that bsh serves as a conduit for fostering therapeutic advancement and ultimate treatment objectives. a comprehensive generic definition of bsh may be formulated as “activities enabling clients to assimilate information and extrapolate newfound insights from the therapeutic milieu into their everyday life contexts, wherein their challenges transpire.” this defini­ tion encompasses both “insight-oriented” elements such as information and awareness, and “action-oriented” components like new learning and skill acquisition, which have been posited as universal mechanisms for change in psychotherapeutic contexts (e.g., mccullough et al., 2003; nelson et al., 2007; ryum et al., 2014; valen et al., 2011). furthermore, this elucidation underscores the inherent reality that, for each therapeutic hour dedicated, the remaining 23 hours of the day are lived beyond the counseling environment. thus, it intuitively follows that this time outside the therapy room should be harnessed to expedite the therapeutic process and advance toward ultimate treatment goals (kazantzis, deane, et al., 2005). diversity characterizes the content and nature of bsh across distinct treatment meth­ odologies. the timing, inclusion, and modality of bsh in psychotherapy necessitate adaptability, both within and across therapeutic approaches. the specific nature of bsh tasks and the procedural dynamics within a therapeutic session with a given client are contingent upon an array of factors, including the unique requirements of the client, the rationale underpinning the chosen therapeutic approach, the client's stage of change (e.g., precontemplation, contemplation, preparation, action, maintenance; prochaska & norcross, 2018) and contextual variables. to elaborate further, bsh might encompass ac­ tivities such as relaxation training, exposure exercises (in vivo, imaginal, interoceptive), activity scheduling, behavioral activation, integration of newly acquired skills (e.g., ex­ perimenting with novel interpersonal strategies or modes of interpersonal engagement), behavioral experiments, and the acquisition of information and heightened awareness (e.g., recording automatic thoughts, attending to dreams or emotional responses). bsh can effectively address behaviors and symptoms linked to specific settings or individuals in the client's daily life beyond the therapeutic encounter, as exemplified in various anxiety disorders (e.g., agoraphobia, obsessive-compulsive disorder) or maladaptive inter­ personal patterns or self-other relational dynamics (e.g., personality disorders). a transtheoretical perspective on between-session homework 4 clinical psychology in europe 2024, vol. 6(special issue), article e12607 https://doi.org/10.32872/cpe.12607 https://www.psychopen.eu/ amid this diversity, a central unifying rationale for bsh is the cultivation of learning in various forms (kazantzis & l’abate, 2007). bsh serves to inform, consolidate, expand, and reinforce the clinical work transpiring within the therapy session, enabling the con­ tinuation of therapeutic progress into the client's daily life where challenges most persist. the emphasis on bsh accentuates the client's active involvement in the therapeutic journey and may foster a sense of agency and responsibility for effecting positive change in their lives (dobson, 2022; dobson & kazantzis, 2023; strunk, 2022). inherent to this endeavor is the promotion of a mindset characterized by curiosity, interest in one’s thoughts and emotions, and the cultivation of self-care and self-acceptance. diverse perspectives arise when considering the in-session dynamics and therapist behaviors germane to the integration of bsh into psychotherapy. notably contentious is the question of whether bsh should predominantly emanate from the therapist (ellis, 1962), be initiated autonomously by the client (brodley, 2006), or emerge through collab­ orative negotiation between therapist and client (kazantzis et al., 2013; kazantzis et al., 2017). in most cognitive and behavioral therapeutic modalities, the delineation, planning, and review of bsh are explicitly incorporated into the session agenda, ideally arrived at through collaborative empiricism between client and therapist. homework assignments are meticulously tailored to the individual client, grounded in evidence-based therapeutic strategies and contextual considerations, often accentuating the specificity of the execu­ tion of bsh (e.g., how, when, where, duration, frequency, interpersonal involvement), thus augmenting the likelihood of successful outcomes (hildebrand-burke et al., 2023; kazantzis & miller, 2022). conversely, psychodynamic and humanistic-experiential therapies typically do not accord the same explicit prominence to the selection, design, and review of bsh within the session context. these therapeutic paradigms lean historically towards a less specific stance, emphasizing in-session processes such as the client-therapist relationship and the exploration of subjective experiences, emotions, and meaning, in contrast to activities external to the session. consequently, the introduction of bsh in these approaches is characterized by a more indirect and tentative manner; for instance, a humanistic-experi­ ential therapist might propose bsh as an optional experiment or as a potential avenue for the client's exploration if deemed beneficial (brodley, 2006), for example, with the use of tasks to increase self-soothing capabilities or the use of a diary to promote emotional awareness. meanwhile, a psychodynamic therapist might adopt a hypothetical approach to between-session assignments, such as positing, “i wonder what might have transpired had you...”, or even suggest more directively that the client tries out new interpersonal behaviors or ways of relating to others (dimaggio et al., 2015). it is important to high­ light that a cbt therapist might also choose to use similar language and express a level of tentativeness. this approach could be prompted by their ongoing case formulation, suggesting that a straightforward expectation regarding bsh may potentially result in an alliance rupture. for instance, this might occur in situations involving an active abuse/ ryum & kazantzis 5 clinical psychology in europe 2024, vol. 6(special issue), article e12607 https://doi.org/10.32872/cpe.12607 https://www.psychopen.eu/ mistrust schema being transferred to the therapist (refer to the discussion in kazantzis et al., 2017). as previously alluded to, current trends in the field indicate a burgeoning framework for bsh underscored by integration and assimilation. for instance, bsh may encompass endeavors aimed at heightening client awareness regarding latent thoughts and emotions or promoting self-compassion and self-acceptance (hayes, 2022). irrespective of the pre­ cise nature of the homework task, it is crucial to underscore that the effective and successful utilization of bsh hinges on the establishment of a reciprocal and collabora­ tive therapeutic relationship, where the therapist's facilitative interpersonal skills are indispensable, and consensus between therapist and client prevails regarding the specific objectives and tasks of the therapeutic process (kazantzis et al., 2017). these qualities appear to characterize the in-session process of integrating bsh across treatment ap­ proaches, as recently demonstrated (ryum et al., 2024a, 2024b). in summary, the panorama of bsh in psychotherapy is characterized by a mosaic of perspectives, encompassing diverse terms and definitions, multifaceted modalities, and a rich interplay between therapist and client. amid this diversity, a common thread of fostering learning and facilitating therapeutic progress emerges, with a recognition of the client's active engagement and empowerment. the process of integrating bsh into psychotherapy is contingent upon the treatment approach, necessitating nuanced consid­ erations, yet grounded in the shared commitment to advancing the client's well-being and progress towards treatment goals. empirical research on the relations between bsh and outcome numerous studies have extensively investigated the relationship between bsh and treat­ ment outcomes, and their findings have been synthesized in multiple meta-analyses and reviews (for a recent comprehensive overview, refer to ryum et al., 2023b). the majority of earlier publications have focused on three primary areas: (a) assessing the causal impact of homework on treatment outcomes by comparing interventions with and without homework (kazantzis et al., 2000; kazantzis, whittington, et al., 2010); (b) examining the correlation between client compliance with homework and treatment outcomes (kazantzis, whittington, et al., 2010; kazantzis et al., 2016; mausbach et al., 2010); and (c) investigating therapist skills and competence in assigning homework and their connection to engagement with bsh and treatment outcomes (therapist behaviors), see special issue in cognitive therapy and research (vol. 45, no. 2). causal effects analysis has reported a medium effect size (d = .53) (kazantzis et al., 2000; kazantzis, whittington, et al., 2010), while a significant linear association (r = .26) has been identified between client compliance with homework and treatment outcomes (mausbach et al., 2010; see also kazantzis, whittington, et al., 2010). recent meta-anal­ a transtheoretical perspective on between-session homework 6 clinical psychology in europe 2024, vol. 6(special issue), article e12607 https://doi.org/10.32872/cpe.12607 https://www.psychopen.eu/ yses have further validated these findings concerning both the quantity and quality of homework engagement in relation to treatment outcomes (kazantzis et al., 2016), including a specific examination of obsessive-compulsive disorder (wheaton & chen, 2021). collectively, these findings underscore that interventions incorporating bsh yield superior outcomes in contrast to those lacking bsh, and that greater client engagement with homework corresponds to better treatment results. more recent research has progressively highlighted the pivotal role of therapists' skills and competence in integrating bsh to facilitate client engagement with homework (as explored in research question c above). for instance, investigations have revealed that therapist competence in homework review (bryant et al., 1999; weck et al., 2013), as well as homework selection and planning (conklin et al., 2018; jungbluth & shirk, 2013; ryum et al., 2010), correlates with treatment outcomes. notably, these effects remain robust even when accounting for confounding variables like the therapeutic alliance (mcevoy et al., 2023; ryum et al., 2022), and studies have also incorporated client feedback in studies of therapist competence in using homework (hildebrand-burke et al., 2023; yew et al., 2021). these findings indicate that the positive impact of bsh extends beyond mere client compliance, emphasizing therapists' pivotal role in facilitat­ ing client engagement with homework. furthermore, a recent review conducted as part of the interorganizational task force on psychotherapy skills and methods that work (hill & norcross, 2023) comprehensively summarized findings on therapist behaviors affecting immediate (in-session) and intermediate (session-to-session) outcomes of bsh. the review observed favorable effects on intermediate outcomes, while results for imme­ diate outcomes were mixed and generally neutral (ryum et al., 2023b). the task force concluded that bsh demonstrates efficacy for ultimate treatment outcomes and likely effectiveness for intermediate outcomes (hill & norcross, 2023). however, amidst largely positive results, research has also illuminated challenges that clients may encounter with bsh, stemming from practical and emotional factors, which could impede therapeutic progress and potentially lead to premature discontinuation. some clients may exhibit adverse reactions to the term “homework” due to its educa­ tional connotations, invoking feelings of apprehension linked to evaluation, control, or failure (fehm & kazantzis, 2004; kazantzis, arntz, et al., 2010). consequently, the use of this term in clinical practice is not recommended (kazantzis, macewan, et al., 2005), and an alternative, “action plan,” has been proposed within cbt (kazantzis & miller, 2022). additionally, bsh may induce pressure, anxiety, resistance, or exacerbate mood-related issues for various reasons (e.g., lack of comprehension regarding homework rationale, overly demanding assignments due to symptom severity), with some clients identifying it as the foremost challenge in treatment. consequently, therapists should anticipate potential obstacles, maintain receptivity to client feedback, and establish a collaborative atmosphere where engagement with bsh is discussed through socratic dialogue and monitored via feedback on session-relevant aspects (kazantzis et al., 2017). ryum & kazantzis 7 clinical psychology in europe 2024, vol. 6(special issue), article e12607 https://doi.org/10.32872/cpe.12607 https://www.psychopen.eu/ it should also be recognized that (persistent) non-engagement with bsh may be a way for the client to oppose treatment and/ or the therapist (okamoto et al., 2019; okamoto & kazantzis, 2021; safran & muran, 2000; sijercic et al., 2016). strong needs for dominance or attachment may be evoked in certain clients, within a therapeutic relationship characterized by giving and receiving help and care, and client non-engage­ ment with bsh may therefore sometimes signal a rupture in the therapeutic alliance (kazantzis et al., 2023). although there is little conclusive research in this area, we may speculate if certain client populations are at a higher risk for non-engagement with bsh, for example, as for clients presenting with personality disorders or severe eating disor­ ders. however, in general, we caution against “blaming the client”, and rather suggest that therapists should examine their own contribution in the process when accounting for client’s non-engagement with bsh. notably, empirical investigations and reviews of bsh have mainly been conducted within cognitive and behavioral treatment frameworks, with rare exceptions emerging from psychodynamic (hilsenroth & slavin, 2008; nelson & castonguay, 2017; owen et al., 2012) and humanistic-experiential approaches. while research underscores bsh's clinical relevance for training and practice, as we will explore in the subsequent section, the generalizability of these findings to alternative treatment methodologies remains uncertain. clinical practice and training drawing upon theoretical writings and empirical research spanning five decades, our current understanding of the factors that can either facilitate or hinder the effective inte­ gration of homework into psychotherapy has become more comprehensive. these factors hold significant relevance for clinical training and practice. a comprehensive practical guide for the utilization of homework already exists in cbt (kazantzis, macewan, et al., 2005). additionally, an updated and comprehensive model was recently published (kazantzis & miller, 2022), which could provide valuable insights for integrating bsh into other therapeutic approaches. in the following sections, we delve into strategies that therapists can employ to enhance client engagement with bsh and discuss how clinical training and supervision can bolster therapist skills and competence in implementing bsh. clinical practice while the term "homework" is commonly associated with specific tasks assigned to cli­ ents, it also encompasses an in-session process reliant on a collaborative client-therapist relationship. therapist behaviors play a crucial role in helping clients establish realistic expectations about the role of bsh, fostering engagement with homework, and facili­ a transtheoretical perspective on between-session homework 8 clinical psychology in europe 2024, vol. 6(special issue), article e12607 https://doi.org/10.32872/cpe.12607 https://www.psychopen.eu/ tating symptom improvement. drawing from practical guides and empirical research, therapists should: (a) collaboratively design, plan, and review bsh in alignment with the client's goals and values; (b) link bsh with takeaways from the session; (c) provide a compelling rationale for homework; (d) address potential challenges and barriers to task engagement; (e) offer a written bsh summary including instructions and rationale; (f) incorporate client feedback when selecting, planning, and reviewing bsh; and (g) remain responsive to the evolving needs and context of the client (kazantzis, macewan, et al., 2005; kazantzis & miller, 2022; ryum et al., 2023a, 2023b). feedback here refers primarily to the therapist eliciting reactions and input from the client in the on-going therapeutic dialogue (e.g., beliefs about bsh; barriers to engagement; reactions to in-session practice; degree of skill acquisition or mastery), and not to more formal methods such as “routine outcome monitoring” (lambert & shimokawa, 2011). although “compliance” or “adherence” have historically been associated with bsh, the concept of “engagement” has been proposed as a more meaningful construct for research and clinical practice (kazantzis & miller, 2022). beyond merely measuring com­ pleted bsh tasks, a comprehensive assessment of client engagement should encompass potential practical obstacles, task-related difficulties (or perceived difficulties), activation of personal beliefs, and associated emotional distress (kazantzis, macewan, et al., 2005). for instance, a client might view a homework task as “too challenging” or “irrelevant,” leading to negative beliefs about themselves or the therapeutic process. while tracking homework completion remains informative (as compliance is linked to improvement), therapists should also explore client beliefs about bsh benefits, perceived progress contribution, skill acquisition, and encountered obstacles. the homework rating scalerevised (hrs-ii; kazantzis, deane, et al., 2005, available from www.cbtru.com) stands as a validated tool towards these goals, and is suitable for research, clinical training, and practice. regardless of the specific task, bsh should be framed as an opportunity for learning, even when tasks don't proceed as planned. therapists might harbor assumptions that hinder the integration of bsh into therapy (bunnell et al., 2021). negative attitudes, such as viewing homework as exclusively for distressed clients or fearing it might overstructure the client, should be treated as hypotheses rather than established facts. integrating bsh should entail socratic dialogue and feedback solicitation from clients. moreover, therapists' interpersonal styles or core schemas could impede effective bsh integration, manifesting as “demanding standards” or “excessive self-sacrifice” (haarhoff & kazantzis, 2007; kazantzis et al., 2017). clinical training although research supports the efficacy of bsh for treatment outcomes, empirical in­ vestigations into how clinical training and supervision enhance therapists' acquisition and proficient use of bsh are lacking. this gap mirrors the broader dearth of evidencebased training research in the field (callahan & watkins, 2018), and the need for future ryum & kazantzis 9 clinical psychology in europe 2024, vol. 6(special issue), article e12607 https://doi.org/10.32872/cpe.12607 http://www.cbtru.com https://www.psychopen.eu/ research utilizing controlled, longitudinal designs (see brattland et al., 2022). we propose recommendations for clinical training based on practice guidelines and insights from process-outcome research (kazantzis & miller, 2022; ryum et al., 2023a, 2023b). while reading materials and didactic courses grant trainee therapists a conceptual understanding of bsh integration, hands-on practical experiences hold even greater importance. clinical work necessitates practical skills and competencies, and direct en­ gagement with bsh is pivotal for novice and seasoned therapists alike (see kazantzis et al., 2017 for competence frameworks for collaborative work in cbt). competent and skillful bsh utilization hinges on the therapeutic approach, case conceptualization, contextual factors, and in-session dynamics. this complex clinical method defies full standardization but should be informed by practical guidelines. thus, learning “what works” with various clients and effectively addressing resistance or difficulties requires firsthand experience. although evaluating how well a therapist sets agendas is relatively straightforward, gauging skilled bsh implementation demands more nuanced expertise. role-plays and deliberate practice are effective tools for honing bsh skills in early therapists. developing standardized stimuli-clips depicting challenging integration sce­ narios could also enhance training. nonetheless, supervision of sessions with actual clients, whether through video recordings or direct observation, remains the optimal method for therapists to receive constructive feedback on bsh application. this process can be reinforced using validated measures of therapist behaviors pertinent to bsh, such as the homework adherence and competence scale (haacs; kazantzis, wedge, et al., 2005, available from www.cbtru.com) or the homework-specific therapist behaviors scale (hstbs; conklin et al., 2018). these tools aid trainees in identifying and addressing skill gaps related to task selection, planning, review, and overcoming obstacles, and could be used in supervision. complementing this, a validated measure of client engagement and beliefs, like the hrs-ii, could provide insights into client perspectives on bsh, and suggest areas that warrant further attention, exploration, and discussion between therapist and client (e.g., negative beliefs about a specific task; lack of comprehension, rationale, or specificity, etc.), although the scale does not have specific cut-offs. conclusions there has been more research on the use of bsh in cbt compared to that of other therapist interventions/ methods, and sufficient empirical evidence to consider bsh a demonstrable efficacious method for ultimate treatment outcomes. while empirical support is lacking for other treatment approaches, there is diversity in how bsh may be integrated into clinical work within and across treatment approaches, and we propose that bsh should be considered a transtheoretical method with heuristic value also for psychodynamic and humanistic-experiential therapies. for example, bsh may facilitate the treatment process and outcome by promoting experiential awareness, insight, or the a transtheoretical perspective on between-session homework 10 clinical psychology in europe 2024, vol. 6(special issue), article e12607 https://doi.org/10.32872/cpe.12607 http://www.cbtru.com https://www.psychopen.eu/ discovery of new meaning; behavior change and the acquisition of new adaptive skills; the generalization of new learning from the counseling room and into the everyday-life of the client; and a sense of agency and confidence in clients that they may play an active role in their own change-process. furthermore, empirical evidence highlights specific therapist behaviors linked to skillful bsh utilization, such as presenting a compelling rationale, collaborative planning, addressing challenges, and assigning personalized tasks. these behaviors should be cen­ tral in clinical practice and training. however, empirical research on how to enhance therapist competence and skill in bsh remains scarce, urging clinicians and researchers to prioritize this vital avenue of inquiry in the future. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: nikolaos kazantzis discloses his royalties from guilford, oxford, routledge, and springer nature publishers. truls ryum declares no conflict of interest. references barlow, d. h., farchione, d., bullis, j. r., gallagher, m. w., murray-latin, h., sauer-zavala, s., bentley, k. h., thompson-hollands, j., conklin, l. r., boswell, j. f., ametaj, a., carl, j. r., boettcher, h. t., & cassiello-robbins, c. 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(2005). relating therapeutic process to outcome: are there predictors for the short-term course in anorexic patients? european eating disorders review, 13(4), 245–254. https://doi.org/10.1002/erv.646 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. ryum & kazantzis 17 clinical psychology in europe 2024, vol. 6(special issue), article e12607 https://doi.org/10.32872/cpe.12607 https://doi.org/10.1007/s10608-020-10125-0 https://doi.org/10.1007/s10608-019-10059-2 https://doi.org/10.1002/erv.646 https://www.psychopen.eu/ a transtheoretical perspective on between-session homework a brief historical overview of between-session homework (bsh) between-session homework: an integrative perspective empirical research on the relations between bsh and outcome clinical practice and training clinical practice clinical training conclusions (additional information) funding acknowledgments competing interests references examination of gender differences: causal attributions of treatment-seeking individuals with overweight and obesity research articles examination of gender differences: causal attributions of treatment-seeking individuals with overweight and obesity carmen henning 1 , caroline seiferth 1,2 , tanja färber 1 , magdalena pape 2 , stephan herpertz 3 , sabine steins-loeber 2 , jörg wolstein 1 [1] department of psychopathology, university of bamberg, bamberg, germany. [2] department of clinical psychology and psychotherapy, university of bamberg, bamberg, germany. [3] department of psychosomatic medicine and psychotherapy, lwl-university hospital, ruhr university bochum, bochum, germany. clinical psychology in europe, 2024, vol. 6(4), article e12089, https://doi.org/10.32872/cpe.12089 received: 2023-05-31 • accepted: 2024-08-14 • published (vor): 2024-12-20 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: carmen henning, university of bamberg, markusstr. 8a, 96047 bamberg, germany. phone +49 951 863 2589. e-mail: carmen.henning@uni-bamberg.de supplementary materials: materials, preregistration [see index of supplementary materials] abstract background: addressing patients' perceptions of the causes of their overweight and obesity may be a promising approach to enhance treatment motivation and success. previous research suggests that there are gender differences in these aspects. the objective of this study was to investigate gender differences in causal attributions among individuals with overweight and obesity who participated in a cognitive-behavioral mobile health (mhealth) intervention. method: causal attributions were assessed using the revised illness perceptions questionnaire, which included a rated and open answering section. an ancova was conducted for each causal factor (behavioral, psychological, risk, external) as a dependent variable to determine gender differences, which were analysed with chi-squared tests for open-ended responses. results: the most frequently mentioned and highly rated cause was behavior for both genders (59.8% of 639 responses). the results indicated that women rated psychological causes, particularly stress-related causes, significantly higher, f(1,211) = 14.88, p < .001, η2 = .07, and were more likely to cite emotional eating than men, χ2(1, n = 639) = 15.06, p < .001. men rated alcohol stronger as cause than women, t(125.05) = 3.79, p < .001. conclusion: the findings of this study contribute to the understanding of the gender differences in causal attributions among individuals with overweight or obesity. implementing stress this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12089&domain=pdf&date_stamp=2024-12-20 https://orcid.org/0000-0002-8904-6130 https://orcid.org/0000-0001-7534-6151 https://orcid.org/0000-0003-4576-682x https://orcid.org/0000-0003-1952-8625 https://orcid.org/0000-0003-2087-5683 https://orcid.org/0000-0002-7651-0627 https://orcid.org/0000-0001-9338-8494 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ management interventions with a focus on emotion regulation is pivotal, especially for females. interventions should focus on sensitizing males to the association between emotions and eating behavior. the causal attributions should be assessed with different survey methods in order to match the patient’s view of their condition. keywords overweight, obesity, gender, causal attributions, physical activity, health behavior, mhealth highlights • causal attributions of overweight and obesity differ between males and females. • female participants attributed their overweight/obesity primarily to psychological causes. • awareness of the association between emotion and overweight or obesity for males is necessary. • for both genders, behavioral aspects and enhancing stress management should be focused on. nutrition and exercise programs for individuals with overweight or obesity (oo) are widely available, but the third pillar of evidence-based treatment, cognitive-behavioral interventions, is difficult to obtain at low-threshold. health insurance companies cover the costs of mobile health (mhealth) interventions in some countries (roth et al., 2023), which can adequately bridge the long waiting times for specialized in-person treatment. therefore, identifying the underlying mechanism of individuals with oo to engage with mhealth interventions that address cognitive-behavioral aspects of weight loss and weight-gain prevention is important. the perception of causes among individuals with overweight (body mass index, bmi = 25 – 29.99 kg/m2) or obesity (bmi ≥ 30 kg/m2) differs based on socio-cultural factors and self-perceived consequences. the media reinforces the ideal of thin women and the necessity of dieting for females (pedersen, 2010), which can lead to an inter­ nalization of a thin beauty ideal and social comparisons (lópez-guimerà et al., 2010). women who have internalized the thin beauty ideal or show a high exposure to such media tend to report greater body dissatisfaction, unhealthy eating (lópez-guimerà et al., 2010), and unrealistic weight goals (dutton et al., 2010). in contrast, men seem to be less concerned about their oo and less aware of the consequences than females (breland et al., 2023; mozumdar & liguori, 2011; tronieri et al., 2017). studies indicate that some males with oo do not perceive themselves as oo, whereas females with normal weight perceive themselves as overweight or obese (chang & christakis, 2003). several gender differences in oo have been reported: overall, 53.5% of the german population is affected by overweight, including obesity, with a clear gender difference of 60.5% men and 46.6% women (schienkiewitz et al., 2022). the prevalence of obesity is positively correlated gender differences causal attributions 2 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ with age and negatively correlated with socio-economic status (schienkiewitz et al., 2022). women are more likely to be affected by food craving (hallam et al., 2016) and emotional eating behavior, i.e., overeating when experiencing (negative) emotions, than men, whereby this overeating reinforces negative emotions and can create a vicious circle (breland et al., 2023). research indicates that there is a higher prevalence of weight loss intentions among females than males (houle-johnson & kakinami, 2018). both genders are motivated to lose weight to improve overall health, but women also tend to report more internal motivators, such as increased personal esteem (crane et al., 2017), while men tend to be more motivated by external factors, such as improved job performance (sabinsky et al., 2007). in general, males are under-represented in obesity research, which often leads to difficulties in the transfer of research findings (bramlage et al., 2004; cooper et al., 2021; pantalone et al., 2017). furthermore, research has demonstrated that women tend to associate obesity with more negative emotions and worse illness perceptions than men (henning et al., 2022), and that this mental image is negatively associated with dieting attempts and weight cycling (prill et al., 2021). gender differences have also been found in the assumptions about the causes of an illness, the so-called causal attributions of one’s own oo. these causal attributions have direct effects on therapeutic outcomes, coping, and goal-related behavior (mathieu et al., 2018; zhang et al., 2018). these causal attributions can be cate­ gorized into different factors, e.g., psychological or genetic. the structure varies depend­ ing on the disease and its aetiology, whether it is multifactorial or can be attributed to a specific trigger (e.g., hereditary in the case of trisomy 21). for oo, which is a multifacto­ rial disease, no unique structure has been identified (daigle et al., 2019). recent literature offers contradictory or non-comparable findings about the causal attributions of individ­ uals with obesity, and most of the studies report no gender specific results. a cohort study with 75 individuals with oo suggested that unfavourable health behavior (e.g., excessive eating) was the most often causal attribution (58.7%) of own obesity, but indi­ viduals also considered psychological causes (e.g., worries) (mathieu et al., 2018). strong behavioral attributions (e.g., sedentary behavior) were also found in an investigation of individuals seeking surgical or behavioral/pharmacological weight loss treatment (pearl et al., 2018). agüera and colleagues (2021) categorized causal attributions, particularly for individuals with eating disorders, into four distinct categories: eating disorder-specific, psychological, risk, and external causes. the psychological factor included self-reported own behavior, but not eating behavior. this was categorized within the domain eating disorder specific causal factor, which makes it difficult to compare the results with other studies. studies show that most of the individuals with oo named psychological causes, such as emotions, boredom, and low self-worth, followed by lifestyle aspects such as working environment (agüera et al., 2021; brogan & hevey, 2009). other causal attri­ butions contained childhood experiences, social environment, medical reasons, eating behavior, and media influence. brogan and hevey (2009) conducted a network analysis, henning, seiferth, färber et al. 3 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ which showed that trauma, family problems, and an “addictive personality” were distal causes for overeating and comfort eating. passive behavior, reduced physical activity levels, overeating, and comfort eating were proximal causes for obesity (brogan & hevey, 2009). to date, the majority of studies have not analysed results by gender. consequently, the investigation of patterns of gender disparities with regard to causal attributions is underrepresented. several studies have examined the link between bmi and causal attributions of oo, but the results have been inconsistent. lewis and colleagues (2010) suggested that the attribution of personal responsibility as a cause for obesity leads to powerlessness of the individuals with obesity grade iii (bmi ≥ 40kg/m2) and to empowerment of individuals with lower bmi, whereas another study found an association with age but not the bmi level (mathieu et al., 2018). individuals with oo showed stronger attributions to herita­ bility with their weight than normal weight individuals, which has been suggested to be associated with lower physical activity, decreased self-efficacy, and a low perception of personal control (hilbert et al., 2009; wang & coups, 2010). however, their assumptions that their obesity was caused by overeating could have led to greater reported levels of physical activity (wang & coups, 2010). the associations between causal attributions of oo and treatment outcomes or health behavior have been investigated by some studies. individuals with oo showed more negative health outcomes as well as emotional and disinhibited eating behavior when they assumed psychosocial causes of their obesity (mathieu et al., 2018). psychosocial attributions were associated with pathologic eating patterns, which was more often prevalent in females (mathieu et al., 2018). research showed that interventions that match individuals’ causal assumptions of their illness can be a strategy to individualize treatment in oo and lead to better weight loss results (bauer et al., 2020; broadbent et al., 2009; karekla et al., 2019). causal attributions are modifiable, disease and gender specific, and could lead to a change of health behavior (bonsaksen et al., 2015; surgenor et al., 2020; zhang et al., 2018). a gender-sensitive investigation about causal attributions of individuals with oo, who are motivated to lose weight and interested in using mhealth for weight loss is lacking. the results could give an insight in underlying mechanisms and help enhance mhealth interventions for men and women. the aim of the present study was to examine these gender differences in this group. given the contradictory or non-existent findings in the literature, we did not have directional hypotheses about gender-specific differences. gender differences causal attributions 4 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ materials and method design this cross-sectional study was part of the i-gendo project, which was approved by the ethics committee of the university of bamberg, germany and the institutional review board of the ruhr-university bochum (no. 18-6415) (pape et al., 2022). the study was conducted in accordance with the declaration of helsinki. the participants provided their informed consent to participate in this study. data collection took place via an online questionnaire between december 2019 and august 2020 within the pre-screening for the i-gendo project. the aim of the project was the development and evaluation of a gender-sensitive mhealth intervention with psychological contents for weight loss and self-tailoring elements (pape et al., 2022). after a telephone interview, individuals with suicidality or binge eating disorder were excluded. to avoid a systematic selection effect of a pseudo-random sample, we targeted especially males via press releases. con­ sequently, the sample is disproportionately stratified concerning gender, given that the proportion of males is still less than in the population. sample the study included 675 interested participants who were informed about the content of the project and screened for eligibility. the inclusion criteria of the participants were having overweight or obesity grade i and ii (bmi = 25.00 – 39.9 kg/m2), being motivated to lose weight and interested in using an mhealth application, at least 18 years old, not pregnant, and having no binge eating disorder or bulimia nervosa according to dsm-5-criteria (american psychiatric association, 2020) (see henning et al., 2024s, additional file 1 for recruitment process). individuals with a bmi greater than 40 kg/m2 often have comorbidities and drug therapy or bariatric surgery is advised (deutsche adipositas-gesellschaft e.v., 2014). consequently, they were excluded from the present study. the final sample compromised 213 participants (female: 143; male: 70) between 19 and 71 years old. power analyses were conducted using g*power version 3.1.9.7 (faul et al., 2007) and resulted in a sample size of 210 participants required to achieve 80% power for detecting a medium effect. more than half of the participants were married or in a partnership (55.4%), almost a third were single (31.4%) and 13.2% were divorced or widowed. males and females did not differ in bmi (min: 25.59kg/m2; max: 39.88kg/m2), age or education (see table 1). henning, seiferth, färber et al. 5 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ table 1 sample characteristics variable total (n = 213) females (n = 143) males (n = 70) group differences bmi m (sd) (kg/m2) 33.35 (3.79) 33.51 (3.71) 33.01 (3.95) t(211) = 0.301; p = .360 age m (sd) (years) 46.45 (12.13) 44.94 (12.58) 49.51 (10.59) t(160.05) = -2.78; p = .006 level of education (%) χ2(2,213) = 2.14; p = .343 low 13.62 13.29 14.28 middle 24.41 27.97 17.14 high 59.62 57.34 64.29 note. significance level p < .001. instruments we assessed the demographic variables such as age and gender at the beginning of the questionnaire. the causal attributions were assessed with the ipq-r (moss-morris et al., 2002). first, 19 potential causes of oo (e.g., “stress or worries”) were presented and participants were asked to rate the extent of personal agreement with each cause on a 5-point likert scale (1 = strongly disagree; 5 = strongly agree). subsequently, participants were requested to name three causes that are most relevant to them personally in an open answering form. statistical analysis rating of the causes — all analyses were conducted using ibm spss (version 26). a four-factor model for causal attributions was set based on moss-morris and colleagues (2002), which was adapted for oo in accordance with the recommendations for this questionnaire (see figure 1): psychological (6 items, cronbach’s α = .746), behavioral (2 items, α = .750), risk (6 items, α = .413), and external (5 items, α = .646) factor. the significance level was set at p < .05 and was maintained through a bonferroni correction for multiple testing (p < .001). for each of the four causal factors a one-way ancova was computed to analyse gender differences because the assumption of homogeneity of the regression slopes of gender for a mancova was not met. we controlled for bmi and age in the first step and added gender as an independent variable in the second step. additionally, we conducted two-sided t-tests for each item of the rated section. the assumptions for ancovas were checked: homogeneity of regression slopes was not violated for three of the four dependent variables: behavioral, psychological, and risk factors (p < .0125). this assumption was not met for the external factor, as indicated by the significant interaction term for gender and age (p = .001). consequently, we omitted age as a covariate in the ancova for the external factor. the residuals were normally gender differences causal attributions 6 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ distributed for the psychological and risk factors as determined by the shapiro-wilk test (p > .05). however, the shapiro-wilk test was significant for the behavioral and external factors. the kolmogorov smirnov test was not significant (p > .0125) and because of the sample size, we omitted bootstrapping in the analysis. the assumptions of homogeneity of variances were not violated (levene’s test: ps = .339 – .804). the leverage values (< .200) and values for cook’s distance (< 1) indicated no outliers to be removed. figure 1 the 4-factor model of causal attributions open statements — the open statements (n = 639) of the second questionnaire section were scalable, structured through deductive categorization according to mayring (2015, p. 68) by two independent raters. the categorization was based on the 4-factor-model of the rated items with further additions (see figure 1). for the 639 open statements, the degree of agreement by kappa was .946, which is an almost perfect interrater reliability (landis & koch, 1977). the analysis of the differences in frequencies for males and females were computed with chi-square tests. when expected cell frequencies were below five, we used the exact calculation option of spss. henning, seiferth, färber et al. 7 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ results a significant difference was found in the first part of the questionnaire for the psycho­ logical factor, with women rating the items as more likely to cause their obesity than men. in addition to psychological causes, men exhibited significantly stronger beliefs that alcohol was a possible cause. there was no significant gender difference at the factor level in the open response format. however, women were significantly more likely to report emotional eating as a cause of their obesity. table 2 presents the descriptive statistics of the four causal attribution factors (psychological, behavioral, external, and risk) for the total sample and for females and males separately as well as the results of the ancovas of the rated items section. all factors were weakly significantly correlated with each other (r = .177 – .228, ps < .001), but not with bmi or age. table 2 descriptive statistics of causal attributions and results of ancovas for gender factor means (standard deviations) f(1,211) p η2total females males femalesa malesa psy 3.23 (0.86) 3.40 (0.80) 2.88 (0.88) 3.39 (0.07) 2.91 (0.10) 14.883 < .001 .066 beh 4.54 (0.52) 4.56 (0.47) 4.50 (0.60) 4.56 (0.04) 4.51 (0.06) 0.440 .508 .002 ris 2.33 (0.53) 2.33 (0.53) 2.35 (0.53) 2.34 (0.05) 2.33 (0.06) 0.002 .966 0 ext 1.74 (0.55) 1.70 (0.54) 1.81 (0.57) 1.71 (0.05) 1.80 (0.07) 1.492 .223 .007 note. psy = psychological; beh = behavioral; ris = risk; ext = external factor. aadjusted for bmi at all factors and for age in the psychological, behavioral, and risk factor. psychological causes after controlling for age and bmi, a significant main effect of gender was found for the psychological causes. females showed a stronger inclination towards psychological causes, with 'stress or worries' being the highest rated item on the scale (m = 4.15; sd = 0.80) compared to males (m = 3.71; sd = 0.95) (see table 2). the approval rate for all items on the psychological scale (see henning et al., 2024s, additional file 2) was higher for females than for males. there was a significant effect of gender for the items 'stress/worries', t(118.14) = -3.34; p < .001, 'family problems', t(211) = 3.20; p < .001, and 'emotional state', t(211) = -4.79; p < .001 (see henning et al., 2024s, additional file 2). psychological causes were the second most frequently mentioned in the open-re­ sponse format, with 25.4% for females and 23.8% for males. however, no significant gender difference was found (see table 3). although 'family problems' were rated sig­ nificantly higher by females than males, men mentioned this cause more often than gender differences causal attributions 8 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ females in the open response section (refer to henning et al., 2024s, additional file 2 and table 3). table 3 frequencies, percentages, and results of the χ2(1; n = 639) tests of the open statement section factor / subcategory frequency percentages χ2 pa vtotal females males total females males emotional state 42 34 8 6.6 7.9 3.8 3.880 .049 .078 family problems 9 3 6 1.4 0.7 2.9 4.728 .030 .086 stress/worries 61 41 20 9.5 9.6 9.5 0 .989 .001 work stress 11 7 4 1.7 1.6 1.9 0.062 .803 .010 no discipline 36 24 12 5.6 5.6 5.7 0.004 .951 .002 psychological total 159 109 50 24.9 25.4 23.8 0.193 .661 .017 diet or eating habits 212 131 81 33.2 30.5 38.6 4.106 .043 .080 emotional eating 45 42 3 7.0 9.8 1.4 15.058 < .001*** .154 physical activity 117 68 49 18.3 15.9 23.3 5.277 .022 .091 my own behavior 3 2 1 0.5 0.5 0.5 0 .986 .001 habits (e.g., sleeping) 5 4 1 0.8 0.9 0.5 0.378 .539 .024 behavioral total 382 247 135 59.8 57.6 64.3 2.640 .104 .064 alcohol 16 5 11 2.5 1.2 5.2 9.579 .002 .122 (physical) illness 43 37 6 6.7 8.6 2.9 7.472 .006 .108 hereditary/past 13 10 3 2.0 2.3 1.4 .576 .448 .030 pregnancy in past 5 5 0 0.8 1.2 0 2.457 .116 .062 risk total 77 57 20 12.1 13.3 9.5 1.884 .170 .054 environment 6 4 2 0.9 0.9 1.0 0.001 .980 .001 external total 6 4 2 0.9 0.9 1.0 0.001 .980 .001 others total 15 12 3 2.3 2.8 1.4 1.152 .283 .042 note. v = cramer´s v, effect sizes of χ2 tests. asignificance level due to bonferroni correction p < .001 (***). behavioral causes the participants rated the behavioral factor as the most important cause (see table 2) and causes related to their behavior were most frequently mentioned in the open re­ sponse section, both by females (57.6%) and males (64.3%) (see table 3). although the chi-square test for the behavioral factor was nonsignificant, 'emotional eating' ('eating because i'm bored/frustrated') was reported as a cause of their oo significantly more often by women than men (see table 3). risk and external causes neither the risk nor the external factor were in an area of agreement (see table 2 for descriptive results and henning et al., 2024s, additional file 2 for single item agreement). males rated 'alcohol' (m = 2.64; sd = 1.24) significantly higher than females, m = 1.98; sd = 1.12; t(125.05) = 3.79, p < .001 (see henning et al., 2024s, additional file 2) and reported henning, seiferth, färber et al. 9 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ it as a possible cause more often (see table 3). causes of risk were reported more frequently by females (13.3%) than males (9.5%), mainly due to physical illness (64.9% of female vs. 30.0% of male responses in this category), but again the difference was not significant (see table 3). the number of statements categorized as external factors was less than 1% for both genders. discussion this study used an exploratory design to investigate the gender-related differences in self-perceived causes among individuals with oo. participants were permitted to rate pre-defined causes and provide open-ended responses. all participants wanted to lose weight and participated in a project involving a behavioral-cognitive mhealth interven­ tion. responses were analysed at both the factor level (psychological, behavioral, exter­ nal, and risk factors) and the item level. in summary, significant gender differences were observed in the agreement with the psychological causes. women considered stress, family problems and their emotional state to be significantly more important causes of their weight than men. behavioral cau­ ses were rated most highly by both genders, with significantly more women than men citing emotional eating as a cause in the open-ended responses. the only cause for which gender differences were observed in both survey methods was alcohol consumption. this was rated significantly more strongly and cited more frequently by men. the highest rated item on the psychological scale was 'stress/worries' for both gen­ ders, which emphasizes the importance of adaptive enhancing coping mechanisms in individuals with oo. stress management training should be an integral part of psycho­ logical interventions, especially for females who showed significant higher scores on stress-related causal beliefs than males. individuals with better coping strategies and competences to handle daily stresses are more successful in maintaining weight loss (elfhag & rössner, 2005). the high rating of the importance of behavioral aspects such as eating and physical activity behavior is in line with results of other studies, which showed that they are proximal causes and causal attributions of obesity (brogan & hevey, 2009; haslam & james, 2005; mathieu et al., 2018; pearl et al., 2018). unfavourable health behavior such as emotional eating or physical inactivity seem to be maladaptive coping strategies for stress. investigations of cardiac patients showed that individuals with beliefs in behavio­ ral causes were more likely to change their dietary or exercise behavior (weinman et al., 2000). based on our results, which focused on a psychological mhealth weight-loss intervention, and existing research, it appears that motivating patients to address their oo could be effective by emphasizing the behavioral and changeable aspects of the condition. gender differences causal attributions 10 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ this is supported by fleary and ettienne (2014) who found an association between the causal attribution of inactivity for males and their motivation to lose weight. research has shown that males tend to benefit more than females from exercise in terms of weight loss and prefer this method instead of dieting and restrictive eating, which is perceived as a 'female approach' of weight management (donnelly et al., 2003; kiefer et al., 2005). physical activity is not necessarily a prerequisite for weight-loss or maintenance because of compensatory behaviors and less discipline in attending sport programs regularly and on a long-term basis (foright et al., 2018). results about the effect of psychological intervention, such as behavioral change techniques on physical activity, are inconsistent (awoke et al., 2022; dombrowski et al., 2012). one possible approach could be to enhance self-efficacy by action planning, providing instruction and providing rewards to increase physical activity (williams & french, 2011). the aim of psychological interventions in oo therapy could be to strengthen perseverance and reduce reward behavior related to food intake or alcohol consumption after exercise, particularly for men. the results indicate that men are aware of the role of diet and eating behavior in causing their overeating but are not aware of emotional eating (e.g., eating because of frustration). interventions for males should focus on the association between emotions and overeating or alcohol consumption. alcohol consumption seems to be a pivotal causal attribution of males, which is not surprising given that males drink more alcohol than females (nolen-hoeksema, 2004). it is recommended that men be made aware of the association between their own maladaptive coping, emotion regu­ lation or self-rewarding behavior, which may manifest as alcohol consumption or eating, and their oo. psychoeducational elements regarding the influence of alcohol on weight management in men should be considered in the development of mhealth interventions. in addition, self-monitoring of alcohol consumption may be useful for men, as this behavior change technique has been shown to be effective in interventions for physical activity and healthy eating (samdal et al., 2017). such a diary is easy to integrate into mhealth interventions but should be optional for the user or practitioner to activate, as alcohol consumption, especially in women, was not often reported as a suspected cause of oo. it is suggested that emotional eating behavior for females should be focused on in interventions to target gender specific causal attributions. there is some evidence that females assume emotionally driven behavior such as emotional eating as a cause of their oo. emotional eating has also been shown to be associated with the concept of food addiction (pape et al., 2021) and eating addiction (hebebrand & gearhardt, 2021), to mediate the link between obesity, change in bmi and depression (konttinen, männistö, et al., 2010) and to be associated with less self-efficacy for the ability to maintain physical activity (konttinen, silventoinen, et al., 2010). thus, emotional eating may represent a barrier to successful treatment. our results are in accordance with other studies, which showed that females tend to engage in emotional eating behavior (löffler et al., 2015). henning, seiferth, färber et al. 11 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ our findings are also consistent with earlier observations, which showed that females had a much more 'emotional view' on their obesity and showed significantly stronger emotional illness representations than males (henning et al., 2022). this means that women associate their oo with anger and guilt. combined with the significant effect of gender at the second highest rated psychological factor, which was significantly more pronounced for women, the evidence emphasizes the importance of emotion-focused therapy in oo (mhealth) interventions, especially for females. however, the results of our study with the two different survey methods also suggest that while men recognise the psychological component of their illness, they do not see it as being as strongly responsible for oo as women do. this can be seen from the fact that the gender differences disappear almost completely in the open responses. this phenomenon may be due to the fact that women are more aware of obesity and its consequences, e.g., health consequences, and suffer more from it than men (audureau et al., 2016; breland et al., 2023). this greater awareness could also lead them to participate more in weight management programmes. we therefore recommend considering this as­ pect in questionnaires for men that measure the strength of the perception of causes and consequences and, if necessary, that the survey be optimised by adding open questions or interviews. to encourage men to participate in weight loss interventions or research projects, it may be beneficial to reduce the emphasis on the perceived threat associated with such initiatives in recruitment activities. instead, it may be more effective to focus on the elements of behavior that can be changed. in contrast to other studies (daigle et al., 2019), we did not find an association be­ tween causal attributions and bmi level. our results are also not consistent with previous findings that individuals with a bmi of less than 40 kg/m2 believe in causes such as social aspects or environment (daigle et al., 2019; lewis et al., 2010). one potential explanation is that our treatment-seeking sample was motivated to lose weight. consequently, they may have attributed their oo more often to changeable causes such as their behavior or coping mechanisms. the practical implication of this finding is that it is important to raise awareness of the impact of the environment, in order to enhance strategies to cope with these external stimuli. however, it is also important to emphasize their role, abilities, and potentials to meet these challenges, which in turn should enhance their self-efficacy to manage weight loss and maintenance. finally, a number of limitations need to be considered. the use of a cross-sectional design limits any causal conclusion. it is noteworthy that all respondents self-identified as either male or female, with no individuals selecting the "other" category. however, research in the domain of non-binary environments would be invaluable in order to facilitate the transfer of results to all individuals. apart from these limitations, the generalizability of these results is limited because the sample consisted of individuals who were motivated to attend an mhealth study, which could have led to desirability effects in answering. the rated section excluded hedonistic items (e.g., eating because it gender differences causal attributions 12 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ tastes good), physical diseases, and physical activity, which might have led to a priming effect or bias in responding to the open-statement section. as with other studies, the reliability of the factors is low (daigle et al., 2019), which is particularly evident in the "risk" factor, which in the context of oo encompasses a multitude of interrelated aspects. these include risky behaviors such as smoking, as well as external conditions, such as childhood experiences, which collectively contribute to a lack of internal consistency. we recommend an individualized view on a single item level respectively the subcategories of the open-statement section. the factorization seems to lead to a loss of information, which is needed for intervention planning. this might show the complexity and individ­ uality of oo but could also be a chance for mhealth interventions as these can be individualized economically and easily. the findings of this study contribute to the understanding of the gender differences in causal attributions among individuals with oo who are motivated to lose weight and interested in a psychological mhealth intervention. the practical implications are that implementing stress management interventions with a focus on emotion regulation is pivotal, especially for females. interventions should focus on sensitizing males to the association between emotions and eating behavior. mhealth interventions that promote strategies to increase health behavior, such as physical activity and reducing alcohol consumption, may be more effective in engaging men than dieting or the proclamation of the consequences of oo. furthermore, the causal attributions should be assessed with different survey methods in order to individualize (mhealth) interventions and to match the patient’s view of their overweight and target treatment options. henning, seiferth, färber et al. 13 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ funding: this work was supported by the german federal ministry of education and research (bmbf grant nr. 01gl1719a and 01gl1719b). acknowledgments: student assistants (bianca weishaupt and katja urwank) helped in part with data collection and acquisition of the sample. competing interests: the authors have declared that no competing interests exist. ethics statement: the design of the study was approved by the ethics committee of the university of bamberg, germany and the institutional review board of the ruhr-university bochum (no. 18-6415). the study was conducted in accordance with the declaration of helsinki. all participants were informed about the content of the entire project. preregistration: clinicaltrials.gov, nct04080193, september 6, 2019; german clinical trials register drks00016623, may 3, 2019 author contributions: ch was responsible for writing the paper, screening the literature, extracting, and analysing data, interpreting results, updating the reference lists and creating tables and figures. cs was a major contributor in discussing the results and collecting the data. tf and mp collected the data. all authors provided feedback on and approved the final manuscript. data availability: the datasets and codes used or analysed during the current study are available from the corresponding author on request. supplementary materials the supplementary materials contain the following items: • the preregistration at clinicaltrials.gov (nct04080193) (henning et al., 2019s-a) • the preregistration at the german clinical trials register (drks00016623) (henning et al., 2019s-b) • additional information (henning et al., 2024s): ◦ additional file 1: recruitment process ◦ additional file 2: single items analysis index of supplementary materials henning, c., seiferth, c., färber, t., pape, m., herpertz, s., steins-loeber, s., & wolstein, j. (2019sa). gender-sensitive enhancement of common weight loss strategies for overweight and obesity (igendo) [preregistration at clinicaltrials.gov; id: nct04080193]. clinicaltrials.gov. https://clinicaltrials.gov/study/nct04080193 henning, c., seiferth, c., färber, t., pape, m., herpertz, s., steins-loeber, s., & wolstein, j. (2019sb). gender-sensitive enhancement of common weight loss strategies for overweight and obesity: a gender differences causal attributions 14 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://clinicaltrials.gov/study/nct04080193 https://www.psychopen.eu/ personalized smartphone app [preregistration at the german clinical trials register; id: drks00016623]. german clinical trials register. https://drks.de/search/en/trial/drks00016623 henning, c., seiferth, c., färber, t., pape, m., herpertz, s., steins-loeber, s., & wolstein, j. 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(2011). what are the most effective intervention techniques for changing physical activity self-efficacy and physical activity behaviour – and are they the same? health education research, 26(2), 308–322. https://doi.org/10.1093/her/cyr005 zhang, l., schwarz, j., kleinstäuber, m., fritzsche, k., hannig, w., wei, j., yang, j., & zhang, l. (2018). confirmatory factor analysis of the causal illness attribution scale in chinese patients with multiple somatic symptoms. psychology, health & medicine, 23(sup1), 1056–1070. https://doi.org/10.1080/13548506.2018.1455983 henning, seiferth, färber et al. 19 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://doi.org/10.1007/s11695-018-3490-7 https://doi.org/10.1155/2021/8861386 https://doi.org/10.1002/oby.23744 https://doi.org/10.1038/sj.ejcn.1602537 https://doi.org/10.1186/s12966-017-0494-y https://doi.org/10.25646/10292 https://doi.org/10.1007/s10880-019-09624-4 https://doi.org/10.1007/s11920-017-0784-8 https://doi.org/10.1186/1479-5868-7-19 https://doi.org/10.1348/135910700168900 https://doi.org/10.1093/her/cyr005 https://doi.org/10.1080/13548506.2018.1455983 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. gender differences causal attributions 20 clinical psychology in europe 2024, vol. 6(4), article e12089 https://doi.org/10.32872/cpe.12089 https://www.psychopen.eu/ gender differences causal attributions (introduction) materials and method design sample instruments results psychological causes behavioral causes risk and external causes discussion (additional information) funding acknowledgments competing interests ethics statement preregistration author contributions data availability supplementary materials references mental flexibility and epistemic trust through implicit social learning – a meta-model of change processes in psychotherapy with personality disorders scientific update and overview mental flexibility and epistemic trust through implicit social learning – a meta-model of change processes in psychotherapy with personality disorders svenja taubner 1 , carla sharp 2,3 [1] institut für psychosoziale prävention, universitätsklinikum heidelberg, heidelberg, gemany. [2] university of houston, houston, tx, usa. [3] university of the free state, bloemfontein, south africa. clinical psychology in europe, 2024, vol. 6(special issue), article e12433, https://doi.org/10.32872/cpe.12433 received: 2023-07-18 • accepted: 2024-02-03 • published (vor): 2024-04-26 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: svenja taubner, institut für psychosoziale prävention, universitätsklinikum heidelberg, bergheimer str. 54, 69115 heidelberg, germany. tel.: 06221-56-4700. e-mail: svenja.taubner@med.uni-heidelberg.de related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, guest editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract this position paper follows the call for transtheoretical meta-models of general clinical change by concentrating on severe mental illness such as personality disorders (pds). we have identified a core process of change related to mental flexibility through implicit learning and propose recommendations for stance and technique that are informed by research on mentalization-basedtreatment (mbt) and the learning components as represented in the mediational intervention for sensitizing caregivers (misc). while the idea of corrective emotional experience as a general change mechanism involves discriminating between an old and new relationship to update relationship knowledge, the capacity to understand and process corrective emotional experiences may be limited and even iatrogenic in patients with pds. by integrating mbt and misc, a metamodel of change is created that allows training in and observation of the granular-level, behaviorally anchored, actions taken by the therapist to open up social learning. here, social learning is conceptualized as epistemic trust, increasing the client’s reflective functioning during sessions to ultimately enhance cognitive flexibility outside the therapy room. this opens the possibility to implement and observe micro changes in what should be termed now implicit cognitive and emotional corrective experiences. thus, we propose to shift towards implicit learning within professional relationships; that is, internalizing a new way of thinking about any life-event this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12433&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0001-8058-762x https://orcid.org/0000-0001-8349-4701 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ that requires adaption thereby creating adaptive capacities via mental flexibility as the general change mechanism of personality disorder (pd) treatment. keywords mentalization, mediated learning experiences, micro-process, corrective emotional experience, implicit learning highlights • the paper provides a transtheoretical change mechanism for the treatment of personality disorders such as mental flexibility. • mediational learning experiences translate the model of corrective emotional experience in psychotherapy into a clearly defined process of implicit learning. • using the model of mental flexibility and mediated learning enables helping professions to establish new competences in managing helping relationships. • for research on changes process, the model offers ways to investigate micro process in psychotherapy and helping professions. the treatment of personality disorders (pds) in the past two decades has been strongly influenced by three parallel developments. first, new expert treatment models have been established like mentalization-based treatment (mbt) (bateman et al., 2023), dialectic behavioral treatment (dbt) (linehan, 1993), transference-focused-psychotherapy (tfp) (kernberg et al., 2008) and schema therapy (st) (kellogg & young, 2006) that by now are regarded as evidence-based (storebø et al., 2020) and are commonly summarized as the “big 4” (rameckers et al., 2021) bearing in mind that there are other effective treatments for pds available. as stated in the respective treatment manuals, most of these treatments (mbt, dbt, st, tfp) have integrated techniques from different thera­ peutic traditions (psychodynamic, cognitive-behavioral, humanistic and systemic) and have further expanded ideas about the developmental pathways of personality problems and how best to address them. second, because specialized treatments are often timeand resource-intensive, a need was identified to also establish effective therapy for pds reflected in treatment protocols that address mental health problems related to impaired personality function­ ing (hutsebaut et al., 2020). to this end, treatment approaches like good psychiatric management (choi-kain & sharp, 2021; gunderson & links, 2014) have identified the common features that make pd treatment work and have packaged these features in a generalist approach that can be used in clinical practice. third, in parallel to these developments, the new classification systems of dsm-5 and icd-11 identified personality functioning as the common core of personality disorders, characterized by problems in self (identity and self-direction) and in interpersonal (empa­ thy and intimacy) functioning. interestingly, all “big 4” in the expert-treatments of pds address personality functioning in general while privileging different facets of disturbed mental flexibility 2 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://www.psychopen.eu/ personality functioning: tfp (identity), st (self-representation) and dbt (self-direction) focus on the functioning of the self, mbt concentrates on self with others (empathy, and self-and other understanding). all approaches work on intimacy problems by offer­ ing a secure attachment with the therapist and by working with varying degrees of directiveness and with the therapeutic relationship; from a more coach-stance in dbt to interpreting transference (enactment of dysfunctional relationship expectations) in tfp. despite these differences, none of the “big 4” appear to be superior to another in terms of treatment effectiveness (storebø et al., 2020). however, they have rarely been compared directly to each other and empirical proof for the exact mechanisms of change associated with each approach remains largely unknown. however, this is true for all specific and common factors in psychotherapy (cuijpers et al., 2019). furthermore, recent reviews on change mechanisms has revealed the non-specificity of change mechanism so that they are neither treatment-, nor disorder-specific. (lemmens et al., 2016; taubner et al., 2023). strikingly, there is almost no agreement in the research field which mediators should be assessed and which measures should be used. focusing on psychotherapy with adoles­ cents, taubner et al. (2023) identified 106 mediator rcts using 252 different mediator variables (grouped in cognitive, emotional, behavioral, family, therapy or peer-related domains) that were assessed with 181 different measures. for mechanisms of change in pd, keefe and derubeis (2019) evaluated changes in attachment-representations, men­ talization, core beliefs and defense-mechanisms as potential mediators. only changes in defense-mechanisms obtained enough empirical support to be regarded a mediator of change in pd treatment. in a recent systematic review on mediators of change in pd treatment, volkert et al. (2021b) identified 22 rcts in which the majority (k = 15) focused on the therapeutic alliance as the most important mechanism of change. however, inconclusive results were detected for specific mechanisms, e.g. change of schemas did not explain changes in symptoms whereas changes in mentalizing, defensive functioning and use of skills explained changes at least partially (volkert et al., 2021a, 2021b). furthermore, mentalization appears to be a general mechanism of change in psychotherapy – not limited to the treatment of pd – based on a systematic review that included 29 studies on this question (luyten et al., 2024). against this background, recent treatment developments are characterized by more modular, personalized and integrative interventions in the general field of psychothera­ py (lutz et al., 2022) calling for meta-models of general clinical change (eubanks & goldfried, 2019). meta-models of change can serve the purpose of overcoming conceptual inconsistencies in traditional psychotherapy traditions (lutz et al., 2021). meta-models of change also provide a framework to study transtheoretical change processes if a certain agreement can be reached in the field. this is consistent with the call from lancet psychiatry commission to move the field of psychotherapy to the level of mechanisms, starting with conceptual clarity, followed by experimental methods to isolate mediator candidates that should be rigorously tested in isolated treatment interventions (holmes taubner & sharp 3 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://www.psychopen.eu/ et al., 2018). therefore, with this statement we will argue for a meta-model in the treatment of pds (and psychopathology writ-large) that is transdiagnostic across pds and transtheoretical across different therapeutic orientations. we have identified a core process of change related to mental flexibility through implicit social learning and will propose recommendations for stance and technique that are informed by research on mbt and the learning components as represented in the mediational intervention for sensitizing caregivers (misc; klein, 1996; sharp & marais, 2022; sharp et al., 2020). evidence from developmental psychopathology conclusions from longitudinal research in developmental psychopathology (caspi et al., 2014) and large clinical samples (fonagy et al., 2017; sharp et al., 2015) established the idea of a general p-factor in psychopathology, meaning that instead of focusing on distinct categorical sets of mental disorders, we can model mental problems on a shared continuum of severity. although, the p-factor model has been challenged in the field (watts et al., 2022), we agree with caspi et al. (2024) that these concerns may be unwar­ ranted. moreover, fonagy et al. (2017) among others suggested that psychopathology can be conceptualized by the degree of absence of resilience, drawing our attention away from symptoms towards protective resources and mental capabilities or skills that evolve during childhood and adolescence. as such, developmental psychopathology serves as a strong foundation for meta-models of change in psychotherapy that shifts attention from current presentation of mental problems to etiologies of mental disorders that embrace complexity within a transactional, developmental and culturally sensitive frame. to facilitate resilience as a new goal in psychotherapy means to also shift therapeutic goals from adjustment to a certain cultural norm or definition of mental health to a more open way of creating mental flexibility in individuals. such flexibility is conditional not only for adaptation in adult role function as adolescents age into adulthood, but also in the pursuit of wellbeing, bearing in mind constantly changing socio-political circumstances and contexts. as such, mental (or cognitive) flexibility becomes that which reduces psychopathology while enhancing resilience. this has particular relevance for personality pathology which is characterized by rigid and maladaptive patterns of relat­ ing to self-and others and an inability to flexibly respond to the stochastic nature of interactions and relationships (sharp & bevington, 2022; sharp et al., 2012). central to the capacity for the flexible response and adaptation to a constantly changing environment is the ability to learn. learning takes place in all kinds of contexts (including psychotherapy), the first (and arguably the most potent) of which is within the serve-and-return with primary caregivers. it is within this context that the transmission of cultural knowledge first takes place. and it is within this context that epistemic trust is established in the child – that is, the notion that learning from others is worthwhile and in a person’s best interest. defined as “an individual’s willingness to consider com­ mental flexibility 4 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://www.psychopen.eu/ munication conveying the knowledge from someone as trustworthy, generalizable and relevant to the self” (fonagy et al., 2017, p. 766), epistemic trust develops in the context of secure attachment relationships (harris & corriveau, 2011). through repeated exchanges with the caregiver, the infant or child learns that their caregiver is a trusted source of knowledge enabling learning about the self, others and the world. the mechanics of how this learning takes place is not explained by attachment theory, but rather cognitive developmental theory. grounded in vygotsky’s (1978) theory of social learning, feuerstein’s (1979) theory of cognitive modifiability and klein’s (1996) extension thereof, the mechanics of learning rely on a set of prerequisites that allows the caregiver to create a mediated learning experience (mle) for a child. put differently, learning is enhanced when the environment or subjective experience of the child is intentionally, actively and non-intrusively mediated for the child. while intentionality is central to creating an mle, the learning that takes place is implicit in the sense that the caregiver is not actively teaching; rather, shared knowledge that is relevant to the unique characteristics and experiences of the child develops within the serve-and-return between caregiver and child. elsewhere we have argued that this implicit form of learning that takes place within the serve-and-return is essential for optimal learning – whether that learning takes place in the context of the caregiver-child interaction or the interaction between psychotherapist and client (sharp et al., 2020) – a thesis that we further elaborate here. explicit learning, corrective emotional experiences and micro-process many psychotherapies use psychoeducation and explicitly link behavior with thoughts and feelings to create new knowledge and perspectives to change symptoms. psychody­ namic approaches, for example, aim for insight into one’s wishes, anxieties and defenses to find better solutions for intraand interpersonal conflicts and use the therapeutic rela­ tionship as a stage to observe and interpret these phenomena. therefore, psychotherapy may use explicit learning by either teaching (e.g. psychoeducation, exercise, worksheets) or by explicitly interpreting ways of behaving in relationships (e.g. transference interpre­ tations). in contrast to specific techniques, the contextual model of psychotherapy has emphasized the role of common factors to explain variance in outcome such as thera­ peutic alliance, empathy, responsiveness, repairing ruptures, etc. (norcross & lambert, 2011; wampold, 2015). however, the general meta-models of change as proposed by grawe (1997) as well as orlinsky and howard (1987) remained too descriptive or not explaining the actual change process thereby still leaving unresolved the question as to what micro-processes between patient and therapist happen within and from session to session. following the convincing evidence about the impact of common factors, instead of explicit learning via psychoeducation and insight, we propose to consider implicit learning with the therapist as the starting-point to understand psychotherapeutic impact. taubner & sharp 5 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://www.psychopen.eu/ opposed to more instructional, interpretative learning or skill-based learning, implicit change involves the facilitation of a schema for reflection, a move from content (what) to process (how). implicit learning serves to create a mental capacity to learn how to resolve any life challenge in the future and thus leads to autonomy, agency and independence from teachers, experts and therapists to discover own solutions. therefore, in contrast to classic change models of explicit learning, this approach sug­ gests implicit learning as groundwork to create new resources to adapt to life challenges. alexander and french (1946) described the development of the psychodynamic technique from cathartic hypnosis, suggestion, free association to unlock the unconscious, working through transference neurosis until the emotional reeducation which can be seen as a meta-model of common factors and implicit learning. the authors emphasized that the classic psychoanalytic technique is to stress the repetition of the old conflict in the ther­ apeutic relationship and to emphasize the similarity of the old conflict situation to the current transference situation. the therapeutic significance of the differences between the original conflict situation and the present therapeutic situation is often overlooked. however, it is in this difference that the value of the therapeutic procedure lies. because the therapist's stance and role are different from that of the caregiving person of the past, the patient is given the opportunity to face again and again, under more favorable circumstances, those emotional situations which were formerly unbearable and to deal with them in a manner different from the old (alexander & french, 1946). this idea of discriminating between the old and the new relationship to update relationship knowl­ edge, create more mental flexibility and leave behind rigid maladaptive relationship patterns has been further developed in the control-mastery theory (silberschatz, 2005) discriminative exercises (mccullough, 2000), limited reparenting (kellogg & young, 2006) and the plan-based therapeutic relationship (caspar & goldfried, 2018). however, the capacity to understand and process corrective emotional experiences may be limited in patients with pds (fonagy & luyten, 2009). in pd treatment, clinicians are faced with a patient that appears unwilling or unable to learn from new relationships and also from the therapeutic relationship as negative expectations and low reflective functioning hinder the perception and internalization of new experiences. furthermore, mistrust in interpersonally transmitted knowledge is highly prevalent (termed as epistemic hyper­ vigilance). some patients with pd may also over-identify with the therapist and the method, bearing the risk of pretend mode and credulity which does not generalize to other relationships outside the consulting room as they simply adjust to or idealize the therapist. in this case, therapists may be perceived as the better or ideal parent which can lead to further alienation within families, loyalty conflicts, devaluation of parents, parent blaming as well as a dependency on the therapist. here, we propose that mistrust, credulity and low mentalizing within corrective emotional experiences can be helpfully addressed by using interventions and stance that rely on implicit learning such as mbt and misc. mental flexibility 6 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://www.psychopen.eu/ lessons learned from mbt mentalization-based treatment has reconsidered the role of insight and transference in the therapeutic work with pd patients as their vulnerability in mentalizing is often trig­ gered by the therapeutic relationship itself via attachment anxieties. thus, the two main functions of psychotherapy, getting support and having new perspectives by a helpful professional, are severely limited in pds. furthermore, epistemic trust is compromised for the same reason that mentalizing and attachment fail to be a resource, based on real or perceived histories of abuse and neglect in patients with pd. to facilitate mentalizing and epistemic trust, the mbt therapist adheres to a strict not-knowing stance and adjust all interventions to the current level of the ability to reflect upon self and others. mentalization which is related to mental flexibility is trained within the therapeutic relationship starting from mental exploration, clarification and challenging beliefs while sensitively keeping an eye on anxiety and arousal levels. if the anxiety/arousal increases, the mbt-therapist is asked to switch strategies from prompting mentalizing to suppor­ tive co-regulation and kick-starting mentalizing again by stop-and-rewind techniques as well as specific interventions for specific pre-mentalizing modes of thinking. mentalizing the relationship with the client is seen as a key component especially when the so-called “elephant in the room” is addressed – that is, affects in relation to the current session and the therapist. in contrast to classic psychodynamic therapies, the therapist engages in the “real” felt relationship with the patient instead of concentrating on the transference, i.e. the relationship as repetition of former relationships and tries to stay close to the patient’s current representation of the self (trying to see the world through their eyes). in so doing, the therapist discloses their own thoughts and feelings if this is helpful. in so doing, the patient learns new or other perspectives on relationships and perception of self and others, making explicit what normally stays hidden. as such, the mbt therapist models effective mentalizing and engages with curiosity and interest in the current, real therapeutic relationship with the patient, i.e. owning and actively repairing all misunderstandings, conflicts and lapses in empathy (maybe enactments) that are typical for real (authentic) relationships. all in all, this way of relating and intervening is thought to train the “mentalizing-muscle” instead of reaching a certain in­ sight into motivations for feelings, and thus serves a more implicit corrective emotional experience. the therapeutic goal is indeed to help patients learn to mentalize effectively through implicit learning instead of mentalizing for them, e.g. explaining behavior to them (which would be explicit learning). however, as mbt-training is mainly acquired through experts during supervision, it was recently criticized for being too abstract, too complex and not fine-grained enough in the planning (or evaluation) of minute-by-mi­ nute interventions or micro-processes. furthermore, sensitizing therapists to the implicit learning potential of the mbt-interactions may lead to an even stronger impact and may help therapists to better navigate the micro-processes involved. lastly, easier programs that enable changes in mental flexibility in patients and caregivers are needed to be taubner & sharp 7 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://www.psychopen.eu/ implemented for non-expert therapy in gpm models and for non-psychotherapeutic staff such as nurses, social workers as well as pedagogical (e.g. teachers) and early care professionals (georg et al., 2022). lessons learned from misc sharp et al. (2020) proposed that the misc offers the very minute-to-minute micro-pro­ cesses that culminate in social learning, and by extension, results in the recipient feeling mentalized. the starting point for the development of misc was klein’s (1996, 2001) observation that, notwithstanding significant differences between cultures, flexibility of mind and the capacity to learn from experience are evident in all cultures. klein identified the caregiver as pivotal in creating a predisposition for learning in taking on the role of the “mediator” who is responsible for the transmission of cultural knowledge (klein, 1996, 2001; klein & rye, 2004). to create a mediated learning experience (mle), an interaction must be intentional and reciprocal, must transcend the satisfaction of an immediate need, and must focus on conveying meaning, matching it to the child’s responses. the overlap with the concept of mentalizing is clear; however, misc extends the concept of mentalizing by describing concrete, behaviorally operationalized emotional and cognitive (learning/mediational) components that helps the caregiver take an inquir­ ing and curious not-knowing stance slowing down the interaction to ensure mutual understanding and learning. as displayed in figure 1 (the misc tree), the emotional com­ ponents of the misc are the roots of facilitating learning in others. these components are already part of the relational basis of all psychotherapies and include eye contact, smiles, vocalization, touch, physical closeness, turn-taking, sharing of joy, expression of positive affect, synchrony, length of communication chains, and excitement expressed toward things, people and experiences in the environment. however, the emotional com­ ponents are necessary, but not sufficient, for learning to take place. for learning to take place, cognitive components (also referred to as learning or mediational components) are necessary. these form the trunk of the misc tree (figure 1). here we describe the five mediational (learning/cognitive) components while providing examples of how they would be applied in psychotherapy: focusing: an act or sequence of acts that is directed toward gaining the client’s full attention (“wait… let’s pause for a minute – this seems really important”). through focusing, the therapist is communicating intention to teach. (2) providing/requesting meaning): the therapist names, describes, and gives meaning (without interpretation) to the client’s experience (“i see you are upset”). here, affect is important to convey additional meaning (“wow… this is tough…. he said that he wants to leave you?”. (3) expanding (transcendence): a therapist’s behavior directed toward broad­ ening of the client’s cognitive awareness extending the client’s understanding of what is in front of him/her by explaining, clarifying, comparing, or adding new experiences mental flexibility 8 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://www.psychopen.eu/ that go beyond the immediate content (“can we just pause for a moment to unpack this a bit… it sounds very much to me like a conversation we had two weeks ago… can you remember?”). (4) rewarding (mediated feelings of competence with explanation): any verbal or nonverbal behavior of the therapist that identifies specific components of the client’s behavior that the therapist considers successful (“you did very well in slowing down so we could talk about this in more detail….it helped me a lot to understand you better”). (5) regulating behavior (helping the client to plan before acting). the therapist brings to the client’s awareness the possibility of “thinking” before doing, of planning steps of behavior toward attaining a goal by modelling, demonstrating, or scheduling events in time and space, thereby regulating the pace and reducing the client’s impul­ siveness in perception, elaboration, and expression (e.g. “this is a very difficult topic to bring up with your mom… let’s first think together about how that might work out? what would be a good situation to set this up?”). as evident in the examples, the therapist is not explicitly teaching the misc components but instead use them to slow down the interaction in service of mutual understanding. over time, these processes are internalized and applied outside of the therapy room. evident in figure 1 are also the leaves of the misc tree. these are the outcomes for a person who was fortunate enough to experience emotional and cognitive components applied by someone interested in their wellbeing. if applied, the misc roots and trunk stimulate an individual’s needs system – the need to seek clarity of perception, to search for meaning and excitement, to have successful experiences and complete tasks, to seek information and to think before doing – in short, agency. these too are the outcomes that we want for our clients in psychotherapy. whereas the therapist’s role is to mediate the subjective experience for the client at the start of therapy, the end goal is for the client to foster that reflective capacity herself enabling her agency, independence and empowerment. in summary, the misc components represent the granular-level, behaviorally anch­ ored, and therefore observable actions taken by the therapist to open up the epistemic highway, flexing the client’s reflective mentalizing muscles during sessions to ultimately enhance cognitive flexibility outside the therapy room. these components can be coded frame-by-frame and moment-by-moment using the observing mediational interaction tool (omi; kerr et al., 2023; klein, 1996), thereby operationalizing the mechanisms of change in any psychotherapy assuming that we are correct in our thesis that learning and cognitive flexibility are inherent to all effective psychotherapy. because misc’s evidence base is grounded in work with laypersons as misc trainers (e.g. bass et al., 2017; boivin et al., 2013a, 2013b; boivin et al., 2017; sharp et al., 2022), its components can be learnt by paraprofessionals in healthcare thereby providing a much more scalable option to track, evaluate and teach this core and common feature of psychotherapy. taubner & sharp 9 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://www.psychopen.eu/ figure 1 the misc tree expanding affecting focusing it’s worthwile to act / i can do i’m with you / i’m safe i love you / i’m loved regulating rewarding needs to have successful experiences & to complete tasks turn-taking mutual engagement reciprocity mututal attention physical closeness basic elements of mediation basic messages roots of emotional development eye contact touch sharing of joy smiles vocalizations abc of love note. © paina s. klein, full copy right was granted for carla sharp to use this figure. future outline: fusion of mbt and misc to include misc in therapeutic processes, professionals would need to be sensitized to the emotional and cognitive components of the misc first and learn to observe and understand their micro-interactions with their clients through video-feedback of their own sessions. the emotional components of the misc (warmth, smiling, eye contact, synchrony, turn-taking, empathy, sharing happiness, etc.) are well in line with common factors in psychotherapy but go beyond some professional attitudes of abstinence or distance. however, in the treatment of pd emotional components alone are not strong enough to overcome epistemic mistrust. to open the gate to social learning, the client must feel understood and it is in the slowing down of the interaction through application mental flexibility 10 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://www.psychopen.eu/ of the mediational (cognitive/learning) components that the therapist signals a strong de­ sire to understand the client. as explained elsewhere (sharp et al., 2020) the mediational components powerfully cue to the recipient an interest in his/her mind, establishing a “royal road” to the formation of epistemic trust, because they necessarily involve recog­ nition of the recipient’s subjectivity and agency, and signal an interest in collaboration and cooperation. a strong interest in the client’s mind is communicated, while giving generous access to the therapist’s mind—marking the availability of the therapist’s mind for the client’s learning, as well as the investment and interest of the therapist’s mind in the client. these components may be especially useful in high emotional interactions where therapist mentalizing shuts down, as they help to structure the interaction giving the therapist time to recover their own mentalizing. mbt is already in line with many ideas from misc in its outline and has differentiated more clearly, as described above, that mentalizing the partner in an implicit learning interaction is the fundamental ingre­ dient to have a sensitive teaching moment. as such, the stance of not-knowing the exact mental states of the other, being mindful of the “teacher’s” own mentalizing and staying curious without interpreting, needs to be added to the misc intervention. bringing both approaches together opens the possibility to implement and observe micro changes in what should be termed now implicit cognitive and emotional corrective experiences. with all modesty, we try to argue that the here outlined implicit mediated learning in the social context of a professional relationship between therapist and patient has indeed been the core change mechanism of corrective emotional experiences. however, in former descriptions of corrective emotional experiences in psychotherapy, explicit naming of and insight in differences between now and then have been the focus of elabo­ rating this mechanism of change. thus, we propose to shift attention and understanding towards implicit learning within professional relationships, meaning internalizing a new way of thinking about any life-event that requires adaption and thus creating adaptive capacities via mental flexibility as the general change mechanism of pd treatment in any therapeutic setting that should be investigated in the future. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. taubner & sharp 11 clinical psychology in 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(2022). how robust is the p factor? using multitraittaubner & sharp 15 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://doi.org/10.1080/15374416.2021.1881903 https://doi.org/10.4324/9781003145899 https://doi.org/10.1016/j.biopsych.2012.02.029 https://doi.org/10.1111/cpsp.12334 https://doi.org/10.1037/abn0000033 https://doi.org/10.1002/14651858.cd012955.pub2 https://doi.org/10.1007/s00787-023-02186-9 https://doi.org/10.3389/fpsyg.2021.703095 https://doi.org/10.1002/wps.20238 https://www.psychopen.eu/ multimethod modeling to inform the meaning of general factors of youth psychopathology. clinical psychological science, 10(4), 640–661. https://doi.org/10.1177/21677026211055170 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. mental flexibility 16 clinical psychology in europe 2024, vol. 6(special issue), article e12433 https://doi.org/10.32872/cpe.12433 https://doi.org/10.1177/21677026211055170 https://www.psychopen.eu/ mental flexibility (introduction) evidence from developmental psychopathology explicit learning, corrective emotional experiences and micro-process lessons learned from mbt lessons learned from misc future outline: fusion of mbt and misc (additional information) funding acknowledgments competing interests references mind the gap – ideas for making clinical research more relevant for practitioners and patients editorial mind the gap – ideas for making clinical research more relevant for practitioners and patients max berg 1 , lea schemer 2 , lukas kirchner 1 , saskia scholten 2 [1] clinical psychology group, university of marburg, marburg, germany. [2] department of clinical psychology and psychotherapy, rptu kaiserslautern-landau, landau, germany. clinical psychology in europe, 2024, vol. 6(1), article e12419, https://doi.org/10.32872/cpe.12419 received: 2023-07-17 • accepted: 2024-03-06 • published (vor): 2024-03-28 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: max berg, university of marburg, gutenbergstraße 18, 35032 marburg, germany. e-mail: max.berg@uni-marburg.de randomized controlled trials (rcts) are widely considered to be the gold standard for demonstrating efficacy in psychotherapy research. however, the clinical utility of “typical” rcts for establishing routine care therapies has been a topic of long-standing debate in our field (persons & silberschatz, 1998). “typical” refers to a study with a small to moderate sample size that targets a disorder according to a standardized diagnostic manual and is often waiting-list controlled (carey & stiles, 2016). practitioners frequent­ ly express criticism about the external validity of such rcts (gyani et al., 2015; safran et al., 2011). in qualitative investigations, therapists describe the “unrepresentativeness of rcts” as a reason for why they do not regard clinical research as an important foundation for their everyday decision making (gyani et al., 2015). a review suggested that the perceived “inflexibility” of manuals could also be related to the lack of interest of many practitioners and that therapists wonder whether the “standardized instructions” provided in them are useful for their heterogeneous clinical use cases (speers et al., 2022). similarly, from a methodological point of view, the inference to intra-individual variability from group-level research was challenged (fisher et al., 2018). furthermore, the substantial heterogeneity in treatment effects suggests that even if patients with the same diagnoses are treated with the same treatment by the same therapist, they respond differently (herzog & kaiser, 2022). given the methodological challenges and the skepticism of therapists, we argue that the criticism regarding clinical science should be taken seriously. in this editorial, we present five ideas for improving psychotherapy research and for addressing the research practice gap. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12419&domain=pdf&date_stamp=2024-03-28 https://orcid.org/0000-0003-3060-7869 https://orcid.org/0000-0001-7830-4889 https://orcid.org/0000-0002-9564-1964 https://orcid.org/0000-0002-1439-8684 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ five ideas for psychotherapy research idea one: focus on transdiagnostic mechanisms diagnoses in clinical psychology typically do not present homogeneous entities, and comorbidity rates between “different” disorders are commonly high (rief et al., 2023). for example, different patients exhibit largely heterogeneous symptom dynamics in depression and novel clinical research is starting to acknowledge this (fried et al., 2023). also, we know from a large body of research that pathological mechanisms are not limited to a single disorder, but oftentimes pose transdiagnostic problems (dalgleish et al., 2020). transdiagnostic mechanisms include (but are not limited to), dysfunctional expectations with aberrant belief updating (kirchner et al., 2022), social impairments (lehmann et al., 2019), and reward insensitivity and its interplay with stress dysregula­ tion (martin-soelch, 2023). given the potential of transdiagnostic mechanisms, it seems worthwhile to allocate treatment based on them rather than solely based on diagnoses. for example, patients who exhibit a high tendency for repetitive negative thinking could be assigned to focused therapies that target this mechanism, regardless of whether they have been diagnosed with depression, generalized anxiety disorder, or both. idea two: dismantle treatment protocols a plethora of therapeutic techniques exist to target (transdiagnostic) mechanisms (schaeuffele et al., 2021). yet, we know little about their isolated effect because treatment manuals oftentimes with overlapping strategies – are evaluated as a treatment package. such “evidence-based black boxes” are effective for treating numerous mental disorders, but their respective effect sizes and response rates remain moderate (ormel et al., 2022). future research should dismantle treatment protocols and evaluate the effect of specific techniques. applying dismantled techniques instead of treatment protocols might be closer to clinical practice anyway, where the implementation of complex procedures is limited due to time, comorbidity patterns, and financial resources. the dismantling of treatment packages may also necessitate a departure from traditional therapy orienta­ tions. competence-oriented frameworks (rief, 2021), or process-based therapy (moskow et al., 2023) are two approaches that could promote a more “toolbox oriented” thinking. idea three: monitor individual trajectories with sufficient resolution in clinical research and practice, diagnostic instruments are usually collected at only a few points in time (e.g., before and after treatment). to date, few projects exist that collect intensive longitudinal data (i.e., session-by-session data or ecological momentary assessment) in clinical trials and routine care settings (lutz et al., 2022). these methods would allow to monitor individual trajectories, compare patients to similar cases and mind the gap 2 clinical psychology in europe 2024, vol. 6(1), article e12419 https://doi.org/10.32872/cpe.12419 https://www.psychopen.eu/ provide computerized treatment suggestions, while reducing therapist biases regarding outcome estimation (lutz et al., 2022). m-path and shiny apps are digital implementa­ tions of such efforts (mestdagh et al., 2023). however, just because appropriate tools are available does not mean they are already being frequently used. barriers, particularly in terms of usability and knowledge of digital technologies, can make it difficult for clinicians to use digital innovations. therefore, it is vital that the curricula of psychology students are expanded from scienceto practice-oriented use of data literacy and com­ puter science. idea four: use causal inference methods for routine care data large psychopathology data sets exist in routine care, but we need to sample and process them in a way that allows for causal inference. it was suggested that we can develop alternatives to rcts for estimating the causal effect of a given treatment on an outcome. in addition to established approaches like propensity score matching (lee & little, 2017), single-case experimental designs can be utilized as an ideographic alternative for rcts. these designs utilize an experimental manipulation that compares the individual response of a patient at different time points. (e.g., during treatment delivery versus waiting-periods). single-case experimental designs have the potential to empower practi­ tioners to become scientist-practitioners of their own clinical practice (kazdin, 2019). “synthetic waitlists” can also bring causal inference into psychotherapy research (kaiser et al., 2023). here, machine learning algorithms select patients from waiting lists, based on the multidimensional similarity to a given patient under treatment. this, in turn, allows to estimate the probability that a specific patient would have reached a certain outcome without receiving therapy. if this probability is low, then a significant part of the improvement can be attributed to the treatment. utilizing synthetic waitlists allow us to harvest routine data as an additional source of information and estimate the effect of therapeutic strategies under realistic, everyday conditions. idea five: utilize the expertise of practitioners and the lived experience of patients participatory science actively engages various stakeholders throughout the entire re­ search process (slattery et al., 2020). for example, patients should be involved as experts in the development of clinically relevant research questions (birnie et al., 2019), the optimization of treatment manuals (schemer et al., 2023), and for the planning of upcom­ ing research projects (slattery et al., 2020). similarly, practitioners can be involved to facilitate the clinical usefulness of technological advances or to find ways to overcome practical barriers to implement an effective therapeutic strategy. here, we face the challenge of involving practitioners who are distant or even skeptical about clinical research. yet, a participatory approach would help to address the research-practice gap berg, schemer, kirchner, & scholten 3 clinical psychology in europe 2024, vol. 6(1), article e12419 https://doi.org/10.32872/cpe.12419 https://www.psychopen.eu/ by involving groups for whom practically relevant and effective clinical science is in their vital self-interest. conclusion in conclusion, addressing the research-practice gap requires a shift towards dismantling the effect of specific therapeutic techniques on better-operationalized transdiagnostic mechanisms. monitoring individual trajectories and using innovative methods for infer­ ence can provide valuable insights into therapy effectiveness, if needed at an individual level. finally, an active involvement of non-scientists can create research that is interest­ ing and engaging for different stakeholders. funding: the post-doc position of max berg was funded by the psychange initiative (funding number: 56040018), by the hessian ministry of science and arts when this editorial was written. this work was also supported by the dynamic center, funded by the loewe program of the hessian ministry of science and arts (grant number: loewe1/16/519/03/09.001(0009)/98). acknowledgments: the psychange initiative by the hessian ministry of science and arts organized think-tanks, symposia, and expert interviews with the goal of conducting meta-science to improve psychological treatments. this work was endorsed and made possible by the initiative and max berg wants to thank all psychange members for the ongoing support. competing interests: all authors declare no competing interests, financial or otherwise. the ideas expressed in this editorial are solely based on the consensual personal opinions of the authors. preprint disclosure: a preprint can be found at the psyarxiv server: https://doi.org/10.31234/osf.io/2qvhy references birnie, k. a., dib, k., ouellette, c., dib, m. a., nelson, k., pahtayken, d., baerg, k., chorney, j., forgeron, p., lamontagne, c., noel, m., poulin, p., & stinson, j. 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(2011). does psychotherapy research influence the clinical practice of researcher–clinicians? clinical psychology: science and practice, 18(4), 357– 371. https://doi.org/10.1111/j.1468-2850.2011.01267.x schaeuffele, c., schulz, a., knaevelsrud, c., renneberg, b., & boettcher, j. (2021). cbt at the crossroads: the rise of transdiagnostic treatments. international journal of cognitive therapy, 14(1), 86–113. https://doi.org/10.1007/s41811-020-00095-2 schemer, l., hess, c. w., van orden, a. r., birnie, k. a., harrison, l. e., glombiewski, j. a., & simons, l. e. (2023). enhancing exposure treatment for youths with chronic pain: co-design and qualitative approach. journal of participatory medicine, 15, article e41292. https://doi.org/10.2196/41292 slattery, p., saeri, a. k., & bragge, p. (2020). research co-design in health: a rapid overview of reviews. health research policy and systems, 18(1), article 17. https://doi.org/10.1186/s12961-020-0528-9 speers, a. j. h., bhullar, n., cosh, s., & wootton, b. m. (2022). correlates of therapist drift in psychological practice: a systematic review of therapist characteristics. clinical psychology review, 93, article 102132. https://doi.org/10.1016/j.cpr.2022.102132 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. mind the gap 6 clinical psychology in europe 2024, vol. 6(1), article e12419 https://doi.org/10.32872/cpe.12419 https://doi.org/10.1016/j.cpr.2021.102111 https://doi.org/10.1037/0022-006x.66.1.126 https://doi.org/10.1136/ebmental-2020-300219 https://doi.org/10.32872/cpe.11699 https://doi.org/10.1111/j.1468-2850.2011.01267.x https://doi.org/10.1007/s41811-020-00095-2 https://doi.org/10.2196/41292 https://doi.org/10.1186/s12961-020-0528-9 https://doi.org/10.1016/j.cpr.2022.102132 https://www.psychopen.eu/ mind the gap (introduction) five ideas for psychotherapy research idea one: focus on transdiagnostic mechanisms idea two: dismantle treatment protocols idea three: monitor individual trajectories with sufficient resolution idea four: use causal inference methods for routine care data idea five: utilize the expertise of practitioners and the lived experience of patients conclusion (additional information) funding acknowledgments competing interests preprint disclosure references can a 1-item scale for psychotherapy outcomes be psychometrically robust? letter to the editor, commentary can a 1-item scale for psychotherapy outcomes be psychometrically robust? scott t. meier 1 [1] counseling, school and educational psychology, university at buffalo, buffalo, ny, usa. clinical psychology in europe, 2025, vol. 7(1), article e15207, https://doi.org/10.32872/cpe.15207 published (vor): 2025-02-28 corresponding author: scott t. meier, 80 londonderry ln, getzville, ny 14068, usa. phone: +1 716 906-9420. email: stmeier@buffalo.edu gonçalves et al. (2024) recently described the selection of a 1-item outcome scale for the european psychotherapy consortium. the field has been trending toward brief scales because of research indicating greater patient compliance with fewer items (miller et al., 2003; miller et al., 2005). from a psychometric perspective, however, the 1-item emotional and psychological outcomes (epo-1) measure is likely to produce low reliability and validity estimates. this results from measurement principles indicating that (a) reliability estimates increase with the number of items, and (b) validity estimates depend upon reliability. measurement error decreases with an increasing number of item responses because random error sources tend to balance or cancel (meier, 2013). if a patient misunderstands a question, for example, this error becomes a major influence on data in a single item self-report. because multiple factors typically influence responses to any psychological item, scores on 1-item scales are less likely to be sensitive to change resulting from psychotherapy than a multi-item scale that aggregates change-relevant variance (meier, 1997). other research suggests that many patients will not interpret the epo-1 as test developers intended (schwarz, 1999). labeling this problem as intracategory variability, dohrenwend (2006) observed that test-takers respond to item content on a self-report measure based on a wide range of personal experiences. when asked to report on a recent serious illness, for example, respondents will describe episodes that vary from simple flu to heart attacks. as a result, the basis on which individuals respond to health-related categories on self-report measures can range “from the catastrophic to the trivial” (dohrenwend, 2006, p. 479). the epo-1’s content is “at this moment, how well do you feel you are getting along emotionally and psychologically?” patients respond on a 5-point scale ranging from 0 ("very poorly; i can barely manage to deal with things") to 4 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.15207&domain=pdf&date_stamp=2025-02-28 https://orcid.org/0000-0001-5594-1332 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ ("very well; i have no important complaints"). for many individuals, these are cognitively complex tasks likely to lead to heterogeneous response processes and ratings. given that single item measures are inappropriate with ambiguous constructs (allen et al., 2022), future research should evaluate reliability and validity estimates for the epo-1. at a minimum, epo-1 scores should evidence (a) stability over time in the absence of any intervention, (b) change over time when the patient participates in a psychosocial intervention, and (c) moderate to high correlations with existing measures of outcome. if epo-1 scores fail to meet these standards, possible next steps include (a) augmenting epo-1 data with one or more item(s) related to common factors that have been shown to influence outcome and (b) developing a system that minimizes re­ spondent burden. regarding (a), working alliance would appear to be a strong candidate given that psychotherapy researchers consistently find a modest positive effect of the client/therapist alliance on outcomes (flückiger et al., 2018). regarding (b), recent studies suggest that ai could produce outcome information through analysis of text produced by client discourse recorded during therapy sessions as well as clinicians’ unstructured progress notes (chu et al., 2024). funding: the author has no funding to report. acknowledgments: the author has no additional (i.e., non-financial) support to report. competing interests: the author has declared that no competing interests exist. references allen, m. s., iliescu, d., & greiff, s. (2022). single item measures in psychological science: a call to action [editorial]. european journal of psychological assessment, 38(1), 1–5. https://doi.org/10.1027/1015-5759/a000699 chu, c., sun, t., zhang, b., & rounds, r. (2024). assessing vocational interests through chat: development and validation of the career guidance chatbot (cgc-bot) [unpublished manuscript]. university of illinois at urbana-champaign. dohrenwend, b. p. (2006). inventorying stressful life events as risk factors for psychopathology: toward resolution of the problem of intracategory variability. psychological bulletin, 132(3), 477–495. https://doi.org/10.1037/0033-2909.132.3.477 flückiger, c., del re, a. c., wampold, b. e., & horvath, a. o. (2018). the alliance in adult psychotherapy: a meta-analytic synthesis. psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172 gonçalves, m. m., lutz, w., schwartz, b., oliveira, j. t., saarni, s. e., tishby, o., rubel, j. a., boehnke, j. r., montesano, a., paiva, d., ceridono, d., zech, e., willemsen, j., saarni, s. i., kompan erzar, k., janeiro, l., gelo, o. c. g., errázuriz, p., holas, p., . . . barkham, m. (2024). can a 1-item scale for psychotherapy outcomes be psychometrically robust? 2 clinical psychology in europe 2025, vol. 7(1), article e15207 https://doi.org/10.32872/cpe.15207 https://doi.org/10.1027/1015-5759/a000699 https://doi.org/10.1037/0033-2909.132.3.477 https://doi.org/10.1037/pst0000172 https://www.psychopen.eu/ developing a european psychotherapy consortium (epoc): towards adopting a single-item self-report outcome measure across european countries. clinical psychology in europe, 6(3), article e13827. https://doi.org/10.32872/cpe.13827 meier, s. (1997). nomothetic item selection rules for tests of psychological interventions. psychotherapy research, 7(4), 419–427. https://doi.org/10.1080/10503309712331332113 meier, s. t. (2013). measuring change in counseling and psychotherapy. guilford press. miller, s. d., duncan, b. l., brown, j., sparks, j. a., & claud, d. a. (2003). the outcome rating scale: a preliminary study of the reliability, validity, and feasibility of a brief visual analog measure. journal of brief therapy, 2, 91–100. https://www.researchgate.net/publication/242159752 miller, s. d., duncan, b. l., sorrell, r., & brown, g. s. (2005). the partners for change outcome management system. journal of clinical psychology, 61(2), 199–208. https://doi.org/10.1002/jclp.20111 schwarz, n. (1999). self-reports: how the questions shape the answers. the american psychologist, 54(2), 93–105. https://doi.org/10.1037/0003-066x.54.2.93 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. meier 3 clinical psychology in europe 2025, vol. 7(1), article e15207 https://doi.org/10.32872/cpe.15207 https://doi.org/10.32872/cpe.13827 https://doi.org/10.1080/10503309712331332113 https://www.researchgate.net/publication/242159752 https://doi.org/10.1002/jclp.20111 https://doi.org/10.1037/0003-066x.54.2.93 https://www.psychopen.eu/ from theory to practice: a transtheoretical treatment and training model (4tm) scientific update and overview from theory to practice: a transtheoretical treatment and training model (4tm) wolfgang lutz 1 , brian schwartz 1 , anne-katharina deisenhofer 1 , jana schaffrath 1 , steffen t. eberhardt 1 , jana bommer 1 , antonia vehlen 1 , danilo moggia 1 , kaitlyn poster 1 , birgit weinmann-lutz 1 , julian a. rubel 2 , miriam i. hehlmann 1 [1] department of psychology, trier university, trier, germany. [2] department of psychology, osnabrück university, osnabrück, germany. clinical psychology in europe, 2024, vol. 6(special issue), article e12421, https://doi.org/10.32872/cpe.12421 received: 2023-07-17 • accepted: 2023-09-14 • published (vor): 2024-04-26 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: wolfgang lutz, wissenschaftspark 25+27, 54296 trier, germany. e-mail: lutzw@unitrier.de related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract background: in this paper, we present the conceptual background and clinical implications of a research-based transtheoretical treatment and training model (4tm). method: the model implements findings from psychotherapy outcome, process, and feedback research into a clinical and training framework that is open to future research. results: the framework is based on interventions targeting patient processes on a behavioral, cognitive, emotional, motivational, interpersonal, and systemic/socio-cultural level. the 4tm also includes a data-based decision support and feedback system called the trier treatment navigator (ttn). conclusion: we discuss important problems associated with clinical orientations solely based on one school of thought. we then contrast these concerns with a clinical and training framework that embraces ongoing research, serving as a guiding structure for process-based transtheoretical interventions. such research-based psychological therapy can take both traditional and novel clinical developments as well as findings from psychotherapy research into account and be adaptively disseminated to a variety of patient populations. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12421&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0002-5141-3847 https://orcid.org/0000-0003-4695-4953 https://orcid.org/0000-0001-5521-2535 https://orcid.org/0000-0003-0106-0243 https://orcid.org/0000-0002-9900-4671 https://orcid.org/0000-0002-8227-7761 https://orcid.org/0000-0002-6019-3161 https://orcid.org/0000-0001-6321-4450 https://orcid.org/0000-0002-1653-7772 https://orcid.org/0000-0002-8632-7113 https://orcid.org/0000-0002-9625-6611 https://orcid.org/0000-0002-1069-0813 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords transtheoretical clinical practice and training, psychotherapy outcome research, outcome monitoring, therapist effects, process research, clinical training, precision mental health highlights • we introduce a research-based transtheoretical treatment and training model (4tm). • the framework can serve as a guiding structure for process-based transtheoretical interventions. • it is targeting processes on a behavioral, cognitive, emotional, motivational, interpersonal, and systemic/socio-cultural level. • it includes a data-informed decision support and feedback system (i.e., trier treatment navigator, ttn). in this paper, our aim is to introduce the conceptual background and clinical implications of a research-based transtheoretical treatment and training model (4tm). we discuss important problems associated with clinical theoretical orientations solely based on one treatment approach (or school of thought). these challenges are then met with a clinical and training framework that is open to future research as a guide to process-based transdiagnostic and transtheoretical interventions. at the core of this framework is a data-informed decision system designed to facilitate therapists’ evidence-based clinical decision making throughout the entire treatment process. decades of research on treatment effects have provided substantial evidence for psy­ chotherapy as a (cost-)effective intervention for a wide range of psychological disorders (e.g., barkham & lambert, 2021). the widespread acceptance and integration of psycho­ therapy (now often referred to as psychological therapy to include the various newer theoretical concepts) into healthcare systems worldwide has led to the establishment of standardized training and certification requirements for therapists in numerous countries (e.g., lutz, castonguay, et al., 2021). in the introduction to the first edition of bergin and garfield’s handbook of psycho­ therapy and behavior change, urban and ford (1971) already noted that the evolution of psychotherapy was not a linear or continuous process. while the field emerged in the late 19th century, its development did not follow a simple linear progression towards ever more refined and effective psychological techniques, strategies, or principles of change. instead, with the introduction of numerous variations of psychotherapeutic treatments and orientations, progress took several lateral paths. therefore, it comes as no surprise that even a brief search on wikipedia using the term “list of psychotherapies” yields 171 variants. however, not all approaches have been empirically studied (barkham & lambert, 2021). regardless of the presence of an evidence base, a multitude of approaches and therapeutic schools have emerged, each with their own psychopathological and change a transtheoretical treatment and training model 2 clinical psychology in europe 2024, vol. 6(special issue), article e12421 https://doi.org/10.32872/cpe.12421 https://www.psychopen.eu/ concepts and corresponding professional organizations. as a consequence, the landscape of accepted approaches and regulations for clinical training and practice has become highly diverse, both within and between countries. decisions about which treatment approaches are available within a healthcare system or how many sessions per treatment are funded are often based on a mixture of empirical and political considerations (e.g., lutz, castonguay, et al., 2021). furthermore, for therapists, the different theories seem to constitute a narrative, which gives them a deep sense of meaning and identity and strong feelings of affiliation to a specific therapeutic orientation. simultaneously, the strong adherence to specific schools of thought within the different approaches has led to rigidity and ongoing disputes among colleagues, often resulting in a narrowed scientific and clinical perspec­ tive. it has been common for proponents of a particular therapy school to mistakenly assume that evidence of therapeutic effectiveness automatically validates the underlying theoretical assumptions pertaining to psychopathology and psychological processes of change. however, rosenzweig (1938) already pointed out this logical fallacy and the patients’ perspective seems to differ. while some patients may find it important to know the theoretical orientation of their therapist, for the majority of patients, their primary concern lies in their improvement through therapy. patients often recall having engaged in some form of talking therapy but tend not to retain specific details regarding their therapist’s treatment model. nevertheless, while this strong therapist identification with a single treatment ap­ proach is historically understandable, it is somewhat surprising from a scientific point of view. this is because heterogeneity within treatment schools is enormous, making it challenging to establish a unified set of concepts or mechanisms that are coherent across all variants within a specific treatment orientation. furthermore, none of the therapeutic orientations have yet established a scientifically grounded and clearly defined causal connection between their theoretically proposed mechanisms of change and treatment outcomes (e.g., crits-christoph et al., 2021; kazantzis et al., 2018). research guiding clinical practice and training in the following, six lines of psychotherapy research are described that can form the backbone of a clinical practice and training framework that is open to future devel­ opments: 1) comparative outcome research; 2) patient-focused feedback research; 3) research on therapist effects; 4) research on processes and mediators; 5) research on predictors and moderators; 6) research on dissemination and implementation. traditionally, outcome-oriented research in psychotherapy has focused on determin­ ing the average effectiveness or average comparative effectiveness of specific psycho­ therapeutic models for particular disorders. this line of research was essential to foster­ ing a widespread acceptance of psychological interventions worldwide. however, this lutz, schwartz, deisenhofer et al. 3 clinical psychology in europe 2024, vol. 6(special issue), article e12421 https://doi.org/10.32872/cpe.12421 https://www.psychopen.eu/ approach has limitations as it solely relies on average or comparative average effects between varyingly well-defined treatment models. categorizing the change processes in different variations or orientations of psychological therapy can be challenging and is often based on arbitrary boundaries rather than well operationalized theoretical dis­ tinctions. furthermore, the emphasis on specific change processes in certain treatment models and the assumptions regarding their prevalence in a model are often not well studied or understood (e.g., baldwin & imel, 2020; cohen et al., 2023). regardless of the long-running controversy surrounding the extent of small or nonexistent treatment differences between therapeutic models (e.g., barkham & lambert, 2021), for our purpose, two conclusions can be drawn from this line of research: a) com­ parative outcome research on treatment procedures and methods does not automatically lead to differentiated clinical knowledge about treatment options for a patient with a particular disorder; b) psychological treatments do not work for all patients and under all circumstances. negative treatment responses or patients at risk of unfavorable treatment outcomes are usually overlooked in clinical trials and meta-analytic reviews that focus on average effects (lutz, schwartz, & delgadillo, 2022). another line of outcome research, patient-focused feedback research, has been an influential research topic in psychotherapy research in the last two decades (e.g., lutz, schwartz, & delgadillo, 2022). over 50 studies on feedback and routine outcome monitor­ ing (rom) have been conducted during this period (barkham et al., 2023). the overall effect of feedback-informed treatments vs. evidence-based treatments without feedback is significant with an effect size of approximately d = 0.15 and 8% higher success rates in comparison to treatments not informed by feedback. the application of such a low-cost intervention as continuous measurement and feedback seems to result in improved treatment outcome, reduced dropout, and higher treatment efficiency than standard evidence-based treatments alone. it is important to note that these effects are additional to the effects of well-established evidence-based treatments. patients who benefited most from feedback systems were those who, at some point during treatment, indicated a higher risk for treatment failure. the effect can be en­ hanced when clinical support tools (csts) are used to personalize treatment for such “not on track” cases (with an effect size between 0.36 and 0.53 and an average success rate advantage of ~20% to 29%; barkham et al., 2023). these tools include additional clinical information to adapt treatment specifically to patients at risk for treatment fail­ ure by assessing potential problem areas (e.g., motivation, social support, etc.) and then directing therapists to additional interventions for identified risk profiles via a decision tree. new developments include machine learning prediction models and multimedia instruction materials to help therapists provide those interventions, which are the most promising for a particular patient (e.g., lutz, deisenhofer, et al., 2022). however, the effects of such systems seem to depend on the extent to which therapists make use of the information provided by feedback systems. a transtheoretical treatment and training model 4 clinical psychology in europe 2024, vol. 6(special issue), article e12421 https://doi.org/10.32872/cpe.12421 https://www.psychopen.eu/ as a summary, this line of research has important implications for clinical practice and training. feeding psychometric information back to therapists and integrating this procedure into clinical practice via modern technologies seems to have the potential to improve clinical practice, but the effects depend on the quality of its implementation. therefore, it is important to focus on the use of feedback in clinical training (e.g., barkham et al., 2023). another area of research relevant to transtheoretical interventions is the research on therapist effects, which has shown that therapists’ effectiveness differs systematically independent of their theoretical orientation. the impact of therapist effects on therapy outcomes is estimated to be 5–8% (e.g., wampold & owen, 2021), while about 1/8 of therapists have significantly better and 1/9 have significantly worse therapy outcomes than the average therapist. furthermore, therapist effects are particularly high for more distressed patients. besides outcomes, therapists also differ regarding therapy duration, dropout rates, and sudden gains (e.g., lutz, de jong, et al., 2021). in addition to therapy outcome, change processes and mediators associated with treatment outcome in psychological therapies have been studied (i.e., “process research”). the first empirically based taxonomies summarizing process–outcome research findings and mediators appeared as early as the 1970s. while it is beyond the scope of this paper to provide a comprehensive summary of the findings and challenges spanning five decades of research, for our purpose, it can be concluded that the outcomes of these investigations vary across different theories and treatment approaches. further, there is no consensus on the importance of specific core processes or mechanisms of change. moreover, there are measurement problems and the theoretical constructs have yet to be well validated. in summary, process–outcome research in psychological therapy has not yet been able to demonstrate clear causal relationships between specific mediators, mechanisms, or process variables and treatment outcome (e.g., cohen et al., 2023; critschristoph et al., 2021). until a clear causal link or network of interconnected strategies and processes is established, all clinical interventions experience some degree of empirical uncertainty. this also includes situations, in which certain interventions might affect multiple pro­ cesses, and in which some interventions might lack unique contributions, but could be substituted with others that produce a similar effect (see figure 1). however, numerous investigations have enabled the identification of a wide array of intensively-studied processes/interventions and change principles. while not firmly established in terms of causal connections, these processes and interventions have demonstrated empirical val­ idity (studied using experimental designs, correlational designs, or granger causality in time series) and maintain clinical relevance in the treatment of a wide range of disorders. the scope of this statement paper does not permit the description of detailed evidence for each of these processes and interventions. however, this line of research can provide general guidance within a clinical and training framework that remains open to future lutz, schwartz, deisenhofer et al. 5 clinical psychology in europe 2024, vol. 6(special issue), article e12421 https://doi.org/10.32872/cpe.12421 https://www.psychopen.eu/ investigations into mechanisms and processes (e.g., caspar, 2019; cohen et al., 2023; crits-christoph et al., 2021; eubanks & goldfried, 2019; grawe, 2004; hofmann & hayes, 2019; kazantzis et al., 2018; norcross & lambert, 2019; rubel et al., 2017; wolitzky-taylor et al., 2023). over the years, several transtheoretical and integrative frameworks have been developed following this line of research (several examples are given in papers within this special issue). the treatment strategies and clinical processes described in these models are hetero­ geneous in their conceptualization and application of research findings and do not stem from a fully empirically-defined network of causally linked elements. however, these concepts are all designed to move beyond the traditional view of categorical diagnosis as the sole basis for treatment selection. such broader conceptualizations can therefore help to unpack traditional treatment packages and understand clinical practice as a framework of scientifically grounded processes, mechanisms, and strategies, which is open to future research findings. these empirically studied processes and transtheoretical guidelines can also be rela­ ted to research on predictors and moderators of change (barkham & lambert, 2021). predictor and moderator models that support the assignment of patients to different treatment options have a long history in psychotherapy research. over the years, such efforts have become increasingly sophisticated, including new statistical tools based on machine learning algorithms that are closely linked to the development of personalized or precision mental health interventions (delgadillo & lutz, in press). finally, disseminating psychological treatments constitutes a challenge in many areas of the world, especially in lowand middle-income countries where access to mental health treatments is limited. transtheoretical concepts can be used to design cost-effi­ cient programs aimed to target specific mental health issues. various programs have been developed, which include low-intensity, single-session, or internet interventions. these treatment approaches are often rooted in transtheoretical concepts, emphasizing activities that foster engagement (e.g., collaboration, empathy, active listening), as well as addressing various domains of behavior, interpersonal relationships, emotions, and cognitions (e.g., singla et al., 2017). it is important to note that these lines of psychotherapy research, which form the foundation of a transtheoretical framework, are not a rigid set of findings and a corre­ sponding treatment approach, but rather a set of concepts that remains open to future research findings and further verifications. nonetheless, in our opinion, it provides sufficient guidance to structure clinical training and practice effectively. a transtheoretical treatment and training model 6 clinical psychology in europe 2024, vol. 6(special issue), article e12421 https://doi.org/10.32872/cpe.12421 https://www.psychopen.eu/ what could transtheoretical clinical practice and training look like? the open framework introduced above can be built on interventions targeting human experiences that facilitate change processes on a behavioral (e.g., behavioral activation), cognitive (e.g., cognitive restructuring), emotional (e.g., emotion-focused techniques), motivational (e.g., work on life goals), interpersonal (e.g., building a therapeutic rela­ tionship), and systemic/socio-cultural level (e.g., strength-based methods, cultural adap­ tations). figure 1 illustrates the core elements of such a clinical and training framework that is open to future research, showing the bio-psycho-social network of human experi­ ence and the web of associated problems and resources as the targets of evidence-based clinical interventions. each such intervention might therefore have a broader impact on the entire network (e.g., fried et al., 2022; orlinsky & howard, 1995). figure 1 core elements of a transtheoretical treatment and training model (4tm) a transtheoretical treatment and training model 12 figure 1: core elements of a transtheoretical treatment & training model (4tm) note. pi = psychological interventions; cbt = cognitive behavioral therapies; pd = psychodynamic therapies; sy = systemic therapies; he = humanistic-experiential therapies; nd = new developments/third wave (e.g., acceptance and commitment therapy, act; mindfulness-based stress reduction, mbsr; dialectical behavior therapy, dbt; emotion-focused therapy; mentalization; positive psychology); it = integrative treatment models (e.g., systematic treatment selection, sts; alliance-focused therapy, aft; schema therapy; cognitive behavioral analysis system of psychotherapy, cbasp); li = low-intensity treatments (e.g., brief treatments, one session treatments, online therapy). ttn = trier treatment navigator. note. pi = psychological interventions; cbt = cognitive behavioral therapies; pd = psychodynamic therapies; sy = systemic therapies; he = humanistic-experiential therapies; nd = new developments/third wave (e.g., acceptance and commitment therapy, act; mindfulness-based stress reduction, mbsr; dialectical behavior therapy, dbt; emotion-focused therapy; mentalization; positive psychology); it = integrative treatment models (e.g., systematic treatment selection, sts; alliance-focused therapy, aft; schema therapy; cognitive behavioral analysis system of psychotherapy, cbasp); li = low-intensity treatments (e.g., brief treatments, one session treatments, online therapy). ttn = trier treatment navigator. lutz, schwartz, deisenhofer et al. 7 clinical psychology in europe 2024, vol. 6(special issue), article e12421 https://doi.org/10.32872/cpe.12421 https://www.psychopen.eu/ figure 1 does not include details of evidence-based processes and interventions (see e.g., lutz & rief, 2022; lutz et al., in press), however this concept can guide research-based psychological therapy, while respecting the traditions of successful clinical developments and research within the specific orientations. it includes clinical skills on the micro level, techniques and strategies on the meso level, as well as principles of change on the macro level. the general clinical practice and training framework comprises several tasks and goals of therapy, such as facilitating the acquisition of cognitive, behavioral, and emo­ tional coping skills, strengthening patients’ resources, establishing a therapeutic alliance as a healing context, as well as fostering corrective experiences (on a motivational as well as an interpersonal/cultural/context level) and the acquisition of a more flexible and healthy view of the self and others. a corresponding model of psychological distress posits a transdiagnostic approach to psychopathology. of course, such a transtheoretical clinical practice and training framework must be continuously updated based on new research findings. example of a transtheoretical treatment and training model (4tm) over the last decade, we have tried to implement such a research-based transtheoretical treatment and training model (4tm) at the outpatient center at the university of trier. this 4tm aimed to realize one primary objective: integrating psychotherapy research in­ to clinical training and practice on an ongoing basis. this aim has led to the development of the trier treatment navigator (ttn), a tool that supports and enhances research, training, and practice, fostering synergistic effects between the three (right side of figure 1). the ttn was successfully evaluated in a recently published prospective randomizedcontrolled trial (lutz, deisenhofer, et al., 2022). it enables continuous monitoring of patient progress via psychometric questionnaires and provides therapists with valuable feedback and clinical decision support tools. therefore, rather than adhering to a predetermined manualized treatment for a particular diagnosis from the onset of therapy, our approach prioritizes patients’ realtime progress and continuously adapts treatment based on their specific needs (lutz, schwartz, & delgadillo, 2022). therefore, treatments integrate various therapeutic con­ cepts such as cognitive-behavioral, interpersonal, emotion-, motivation-, and alliance-fo­ cused as well as mindfulnessand strength-based interventions. as a result, therapists receive training in disorder-specific manuals, clinical guidelines, and transtheoretical concepts. when surveying our trainees (n = 102) about their therapeutic practice (see figure 2), 80.5%1 identified themselves as transtheoretical with an emphasis on embrac­ ing a variety of orientations, while acknowledging that cbt serves as the foundational concept, which, depending on the country, may need to be adapted to different contexts, health care traditions, or legal systems. a transtheoretical treatment and training model 8 clinical psychology in europe 2024, vol. 6(special issue), article e12421 https://doi.org/10.32872/cpe.12421 https://www.psychopen.eu/ figure 2 therapeutic orientation within n = 102 postgraduate trainees at the university of trier 3.97 3.15 3.03 2.80 2.77 2.76 2.73 2.38 2.21 2.12 1.35 0 1 2 3 4 5 note. 0 = not at all; 5 = very much; cbt = cognitive-behavioral therapy; eft = emotion focused therapy; hep = humanistic experiental psychotherapy; mbct = mindfulness-based cognitive therapy; act = acceptance and commitment therapy; syst = systemic therapy; ipt = interpersonal therapy; cbasp = cognitive behavioral analysis system of psychotherapy; pdt = psychodynamic therapy. finally, it is crucial to highlight that while there is a considerable level of flexibility in the theoretical portion of training, it is complemented by monitoring patient outcomes via feedback provided by the ttn. clinical training includes courses on psychotherapy research and its relation to clinical practice as well as the ttn. it is important to recog­ nize that ttn recommendations are data-based and provide probabilities. they must be evaluated with care in a case-specific manner (lutz et al., in press). this combination of decisions based on clinical and empirical knowledge enables trainees to cultivate their own therapist identity, while working within a framework that prioritizes patient outcomes and knowledge accumulated from psychotherapy research. 1) the following item, "to what extent would you assess your therapeutic work as transtheoretical?" was answered on a scale from 0 (not at all) to 5 (very much). the percentage provided reflects the combined number of trainees who answered 4 and 5 on the scale. lutz, schwartz, deisenhofer et al. 9 clinical psychology in europe 2024, vol. 6(special issue), article e12421 https://doi.org/10.32872/cpe.12421 https://www.psychopen.eu/ overall, the development of transtheoretical clinical concepts, as illustrated in this pa­ per, holds potential for the future of psychological therapy. by providing an overarching adaptable framework that accommodates both new and traditional schools of thought, along with findings from clinical research, we hope to enable therapists to move beyond the limitations of rigid schoolism and instead embrace a more comprehensive perspec­ tive. aligned with the development of a measurement-based approach to psychological therapy, this framework might improve the accessibility as well as outcome for a broader and more diverse patient population than previously achievable. funding: this work was supported by the german research foundation (dfg) under grant nr. lu 660/19-1 and lu 660/16-1. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the 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(2017). patients’ in-session experiences and symptom change: session-to-session effects on a withinand between-patient level. behaviour research and therapy, 90, 58–66. https://doi.org/10.1016/j.brat.2016.12.007 lutz, schwartz, deisenhofer et al. 11 clinical psychology in europe 2024, vol. 6(special issue), article e12421 https://doi.org/10.32872/cpe.12421 https://doi.org/10.1038/s44159-022-00050-2 https://doi.org/10.1177/2167702618772296 https://doi.org/10.1007/s10608-018-9920-y https://doi.org/10.1037/ccp0000642 https://doi.org/10.1146/annurev-clinpsy-071720-014821 https://doi.org/10.1080/00332747.1938.11022213 https://doi.org/10.1016/j.brat.2016.12.007 https://www.psychopen.eu/ singla, d. r., kohrt, b. a., murray, l. k., anand, a., chorpita, b. f., & patel, v. (2017). psychological treatments for the world: lessons from lowand middle-income countries. annual review of clinical psychology, 13(1), 149–181. https://doi.org/10.1146/annurev-clinpsy-032816-045217 urban, h. b., & ford, d. h. (1971). some historical and conceptual perspectives on psychotherapy and behavior change. in a. e. bergin & s. l. garfield (eds.), handbook of psychotherapy and behavior change (1st ed., pp. 3-35). wiley. wampold, b., & owen, j. (2021). therapist effects: history, methods, magnitude, and characteristics of effective therapists. in m. barkham, w. lutz, & l. g. castonguay (eds.), bergin and garfield’s handbook of psychotherapy and behavior change (7th ed., pp. 297–326). wiley. wolitzky-taylor, k., lebeau, r., arnaudova, i., barnes-horowitz, n., gong-guy, e., fears, s., congdon, e., freimer, n., & craske, m. (2023). a novel and integrated digitally supported system of care for depression and anxiety: findings from an open trial. jmir mental health, 10, article e46200. https://doi.org/10.2196/46200 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. a transtheoretical treatment and training model 12 clinical psychology in europe 2024, vol. 6(special issue), article e12421 https://doi.org/10.32872/cpe.12421 https://doi.org/10.1146/annurev-clinpsy-032816-045217 https://doi.org/10.2196/46200 https://www.psychopen.eu/ a transtheoretical treatment and training model (introduction) research guiding clinical practice and training what could transtheoretical clinical practice and training look like? example of a transtheoretical treatment and training model (4tm) (additional information) funding acknowledgments competing interests references translation and validation of the german 12-item obsessive-compulsive inventory (oci-12) in clinical and non-clinical samples research articles translation and validation of the german 12-item obsessive-compulsive inventory (oci-12) in clinical and non-clinical samples celina l. müller 1,2 , jakob fink-lamotte 3,4 , lena jelinek 5 , luzie lohse 5 , thomas ehring 1 , michael noll-hussong 6 , götz berberich 7 , andreas wahl-kordon 8 , jens borgelt 8 , dean mckay 9 , jonathan s. abramowitz 10 , amitai abramovitch 11 , barbara cludius 1,12 [1] department of psychology, lmu munich, munich, germany. [2] department of psychology, julius-maximiliansuniversität würzburg, würzburg, germany. [3] department of clinical psychology and psychotherapy, university of leipzig, leipzig, germany. [4] department of clinical psychology, university of potsdam, potsdam, germany. [5] department of psychiatry and psychotherapy, university medical center hamburg-eppendorf, hamburg, germany. [6] oberberg day clinic munich-westend, munich, germany. [7] oberberg hospital windach, windach, germany. [8] oberberg hospital schwarzwald, hornberg, germany. [9] department of psychology, fordham university, new york, ny, usa. [10] department of psychology and neuroscience, university of north carolina at chapel hill, chapel hill, nc, usa. [11] department of psychology, texas state university, san marcos, tx, usa. [12] department of psychology, university of bremen, bremen, germany. clinical psychology in europe, 2025, vol. 7(4), article e16165, https://doi.org/10.32872/cpe.16165 received: 2024-11-20 • accepted: 2025-04-15 • published (vor): 2025-11-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: celina l. müller, julius-maximilians-universität würzburg, department of psychology, clinical psychology and psychotherapy, marcusstraße 9-11, 97070 würzburg, germany. phone: +49 931 31-84124. email: celina.mueller@uni-wuerzburg.de supplementary materials: code, data, materials [see index of supplementary materials] abstract background: the obsessive-compulsive inventory-revised (oci-r) is widely used to assess symptoms of obsessive-compulsive disorder (ocd). despite its consistent factor structure, criticism on its syndromal validity has been raised. with the recent update of the commonly used diagnostic manuals, hoarding symptoms are now better captured by the diagnosis “pathological hoarding”. furthermore, the neutralising scale suffers from relatively low psychometric properties. consequently, a 12-item version of the scale (oci-12), excluding hoarding and neutralising items this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.16165&domain=pdf&date_stamp=2025-11-28 https://orcid.org/0000-0002-1639-8864 https://orcid.org/0000-0002-4384-4903 https://orcid.org/0000-0001-5292-350x https://orcid.org/0000-0002-1480-8145 https://orcid.org/0000-0001-9502-6868 https://orcid.org/0000-0002-9734-0161 https://orcid.org/0000-0001-8300-9294 https://orcid.org/0000-0002-1045-1994 https://orcid.org/0009-0004-8560-6614 https://orcid.org/0000-0003-1158-5043 https://orcid.org/0000-0002-1721-8060 https://orcid.org/0000-0001-9640-0970 https://orcid.org/0000-0003-4814-1497 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ was recently developed in english. the current study examined the psychometric properties of the german version of the oci-12. method: the psychometric properties of the translated german version of the oci-12 were investigated in a german-speaking sample, consisting of 102 participants with ocd, 69 participants with an anxiety-related disorder, and 248 non-clinical controls. results: the german version of the oci-12 replicated the four-factor structure of the original english version, with a higher order factor of general ocd symptoms. in addition, similar to the original version, the german oci-12 showed good internal consistency and test-retest reliability, moderate-to-good construct validity, and good-to-excellent diagnostic accuracy. conclusion: the german version of the oci-12 represents a syndromally valid and reliable inventory for assessing ocd symptoms. psychometric properties are good-to-excellent and comparable to the original english version. the diagnostic sensitivity is good-to-excellent and further supports using the oci-12 in clinical and research settings. keywords obsessive-compulsive disorder, obsessive-compulsive inventory, oci-12, validation, diagnostic accuracy highlights • the german version of oci-12 possesses good-to-excellent psychometric properties. • the oci-12 presents a syndromally valid measure to assess ocd symptoms in german. • integrating the oci-12 into routine clinical practice may improve ocd symptom assessment. over the last two decades, the most common questionnaire for the assessment of obsessive-compulsive disorder (ocd) symptoms has been the obsessive-compulsive inventory revised (oci-r; foa et al., 2002) and the german version of the oci-r (gönner et al., 2007). consisting of 18 items, the oci-r assesses ocd symptoms on six dimen­ sions (washing, checking, ordering, obsessing, neutralising, and hoarding). yet despite its consistent factor structure demonstrated across various languages (e.g., simos et al., 2019; solem et al., 2010; souza et al., 2011) and its frequent use, criticism on its syndromal validity has been raised. particularly, although hoarding symptoms can still contribute to an ocd diagnosis when driven by obsessions (dsm-5; american psychiatric association, 2013, p. 241), hoarding is no longer considered a core symptom of ocd and is now classified as separate disorder (dsm-5; american psychiatric association, 2013; icd-11; world health organization, 2019). moreover, the subscale “neutralising” is limited to phenomena involving numeric content and suffers from low psychometric properties compared to other oci-r subscales (abramovitch et al., 2021; abramowitz & deacon, 2006; hajcak et al., 2004). validation german version oci-12 2 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ with the aim to improve the syndromal validity of the oci-r and adjust it to the current changes in the dsm-5 and icd-11, abramovitch et al. (2021) developed a 12-item english version of the oci-r, called the oci-12. the oci-12 possesses good-to-excellent psychometric properties which were comparable to the original version of the oci-r. the factor analysis evidenced that the four factors of checking, ordering, washing, and obsessing could explain the data well, with a general factor of ocd being beneficial to account for the covariances between the factors. furthermore, the oci-12 was able to differentiate between individuals with ocd and those with an anxiety-related disorder (ard) or non-clinical (ncc) controls. in summary, the english version of the oci-12 represents a valuable update of the oci-r with a syndromally valid assessment of obsessive-compulsive symptoms and symptom dimensions. the current study aimed to assess the psychometric properties of the german version of the oci-12 to evaluate its utility in routine care and clinical research. we transla­ ted the oci-12 into german and examined its factor structure, internal consistency, test-retest reliability, construct validity, diagnostic accuracy, cut-off criteria, and severity benchmarks. method translation procedure the translation process of the oci-12 followed the translation-back-translation proce­ dure as described by cripps (2017) and added aspects of beaton et al. (2000). the process is described in supplement a. study procedure three groups of participants were assessed: ocd, ard, ncc. individuals in the clinical samples (ocd and ard) were assessed at a single timepoint (t1). for test-retest reliabili­ ty, the ncc sample was assessed at two timepoints (t1 and t2), with email invitations sent 14 days apart. at t1, all questionnaires were administered, whereas only the oci-12 was administered at t2. all questionnaires were administered online via the survey software redcap (harris et al., 2009). the study was approved by the ethics committee of the faculty of psy­ chology and educational sciences of the lmu munich (03_mueller_b). all participants provided informed e-consent for data collection. participants for determining the target sample size, we followed the suggestions for minimum sample sizes of maccallum et al. (1999) and hair et al. (2019) to ensure that the factor analyses of the oci-12 could be conducted in the total sample and the subsample of participants müller, fink-lamotte, jelinek et al. 3 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ with ocd. we also referred to previous studies that conducted analyses with similar clinical and non-clinical samples (e.g., ocd: n = 44, clinical control: n = 44, non-clinical: n = 287; aydin et al., 2014; ocd: n = 107, anxiety disorder: n = 30, depression: n = 40; fink-lamotte et al., 2021). therefore, we predefined samples sizes of 100 participants in the ocd group, 50 participants in the ard group, and 250 participants in the ncc group. the observed communalities (h 2 = .77 for the total sample; h 2 = .73 for the ocd sample) are on average larger than h 2 = .60, confirming that our sample sizes are adequate for conducting factor analyses in both the ocd and total samples (according to hair et al., 2019). participants were recruited between april 2022 and july 2024. general inclusion criteria were: minimum age of 18 years, no history of mania or psychotic disorders, and no acute suicidality. further group-specific inclusion criteria are described below. in and exclusion criteria were checked with dedicated questions and questionnaires in the survey’s start. clinical samples participants with a primary ocd/ard diagnosis within the previous six months, based on dsm-5 (american psychiatric association, 2013) or icd-10 (world health organization, 1992) criteria, or those undergoing treatment due to ocd/ard during this period, were recruited from collaborating clinics in germany and another research project at the lmu munich (https://osf.io/8gkjc). the diagnosis of ocd/ard was given by healthcare providers (for participants recruited through cooperating clinics) or with a structured interview (mini-dips, for participants recruited through another project; margraf & cwik, 2017). for ocd participants, inclusion required a yale-brown obsessive-compulsive scale (y-bocs; hand & büttner-westphal, 1991) total score > 12 or a subscale score ≥ 8 for obsessions or compulsions as an indicator for clinically relevant ocd symptoms (see also külz et al., 2014, 2019). the y-bocs was administered as self-rating (y-bocs-sr; baer, 1993) for participants recruited through cooperating clinics (n = 64) and as interview version (hand & büttner-westphal, 1991) for participants recruited through another project (n = 38). the final sample comprised 102 participants with ocd with y-bocs scores indicating moderate symptoms (m = 22.14, sd = 6.08; mobsessionsubscale = 11.25, sdobsessionsubscale = 3.39, mcompulsionsubscale = 10.88, sdcompulsionsubscale = 3.89). ard participants were excluded if they had a lifetime diagnosis of ocd. in total 69 participants with ard fulfilled the inclusion criteria and completed the assessment. the diagnoses were as follows: 28.99% social anxiety disorder, 13.04% generalised anxiety disorder, 31.88% panic disorder, 5.8% agoraphobia, 10.14% post-traumatic stress disorder, 42.03% specific phobia1. 1) as multiple anxiety disorders could be present at the same time, the percentages exceed 100%. validation german version oci-12 4 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://osf.io/8gkjc https://www.psychopen.eu/ non-clinical sample non-clinical participants were recruited via the german online panel psyweb (universität münster, 2025). participants were screened for major psychological disorders with the simple version of the web screening questionnaire (wsq; donker et al., 2009) and excluded if they exceeded any cut-off. of 906 participants that gave informed con­ sent to participate in the study and publication of their data, 383 filled out the screening questions and fulfilled the inclusion criteria. of those, a total of 248 participants comple­ ted the first assessment, with 163 eligible for test-retest analyses after completing both assessments. in summary, the final sample consisted of n = 419 participants, including n = 102 in the ocd group, n = 69 in the ard group, and n = 248 in the ncc group. sample characteristics are presented in supplement b. the dataset had also been used in a prior publication (müller et al., 2025), which in­ vestigated the psychometric properties of the four-item ultra-brief obsessive-compulsive inventory (oci-4) by extracting the items from the oci-12. measures the reliabilities of the questionnaires used in this study are provided in supplement c. the psychometric properties of the oci-12 will be elaborated below. 12-item obsessive-compulsive inventory (oci-12) the oci-12 is a 12-item self-report questionnaire measuring ocd symptoms and associ­ ated distress on a five-point likert scale [ranging from 0 (not at all) to 4 (extremely)]. each scale is assessed by three items, such as “i get upset if objects are not arranged properly.” for the ordering subscale, “i repeatedly check doors, windows, drawers, etc.” for the checking subscale, “i sometimes have to wash or clean myself simply because i feel contaminated.” for the washing subscale, and “i frequently get nasty thoughts and have difficulty in getting rid of them.” for the obsessing subscale. the german wording of each item and the associated subscales are displayed in supplement d. yale-brown obsessive-compulsive scale (y-bocs) the y-bocs was assessed as a 10-item interview (hand & büttner-westphal, 1991) for participants recruited through another project and as a 10-item self-report measure (ybocs-sr; baer, 1993) for participants recruited through cooperating clinics. the y-bocs assesses the severity of obsessions and compulsions over the past week. each item is rated on a five-point scale (0 to 4), with higher scores indicating higher symptom severity. while previous studies proposed that the two versions can be used interchange­ ably (steketee et al., 1996), more recent investigations showed slightly higher scores in the clinician administered version (federici et al., 2010; hauschildt et al., 2019). in müller, fink-lamotte, jelinek et al. 5 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ the current study, the y-bocs total scores did not differ significantly between the two administration modalities: y-bocs: m = 22.29, sd = 6.44 (completed by 38 participants recruited through another project); y-bocs-sr: m = 22.05, sd = 5.91 (completed by 64 participants recruited through cooperating clinics); t(71.61) = -0.19, p = .85. dimensional obsessive–compulsive scale (docs) the docs (fink-lamotte et al., 2021) assesses ocd symptom severity over the past month across four dimensions (i.e., contamination, responsibility for harm and mistakes, symmetry, and unacceptable/taboo thoughts). each dimension incorporates five items rated on a five-point scale (0 to 4), with higher scores representing higher symptom severity. anxiety sensitivity index-3 (asi-3) the asi-3 (kemper et al., 2011) assesses anxiety sensitivity with 18 items rated on a five-point likert scale [0 (very little) to 4 (very much)], with higher scores representing higher anxiety sensitivity. penn state worry questionnaire (pswq) the pswq (glöckner-rist & rist, 2014) assesses excessive and unrealistic worry using 16-items that are rated on a five-point likert scale [1 (not at all typical of me) to 5 (very typical of me)], with higher scores indicating higher worry. patient health questionnaire-9 (phq-9) the phq-9 (löwe et al., 2002) assesses the severity of depressive symptoms throughout the past two weeks with nine items rated on a four-point scale [0 (not at all) to 3 (nearly every day)]. higher scores indicate more severe depressive symptoms. web screening questionnaire (wsq) the adapted simple version of the wsq (donker et al., 2009) contains 13 questions that screen for the most common psychological disorders and acute suicidality. the original version of the wsq has been validated and deemed as an appropriate screening tool (donker et al., 2009; meuldijk et al., 2017). analytic plan the statistical analyses were performed in r statistics (version 4.4.1; r core team, 2024), with significance set at p < .05. the r-code is available at osf (müller & cludius, 2024s). validation german version oci-12 6 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ confirmatory factor analysis the factor structure of the oci-12 was investigated by confirmatory factor analyses (cfa) using the lavaan package (version 0.6-19; houben et al., 2015). both, the fourfactor structure (washing, checking, ordering, obsessing) and the four-factor structure including a higher-order factor of general ocd symptoms were investigated. we eval­ uated goodness of fit using the standardised root-mean-square residual (srmr), rootmean-square error of approximation (rmsea), the comparative fit index (cfi), and the tucker-lewis index (tli). the following criteria as indicator for good model fit (hu & bentler, 1999; schmitt, 2011): rmsea ≤ 0.06; srmr ≤ 0.08; cfi ≥ 0.95; tli ≥ 0.95. as the multivariate normality assumption was violated (for mean and variance), we decided to use the “maximum likelihood with robust standard errors and mean-variance adjusted test” in our cfas. therefore, all fit indices reported are robust fit indices. we further investigated in separate linear regression models whether each factor of the oci-12 could predict the corresponding subscale of the docs. construct validity to examine construct validity, correlation analyses were conducted between oci-12, y-bocs, and docs (convergent validity) and between oci-12, asi-3, pswq, and phq-9 (discriminant validity). pearson’s correlation coefficients were interpreted according to cohen (1988). reliability for internal consistency, both cronbach’s α and mcdonald’s ω were calculated (dunn, 2014; mcdonald, 1999) and interpreted according to hair (2009). the test-retest reliabili­ ty of the oci-12 was investigated with correlation analyses (interpreted according to cohen, 1988), paired t-tests, and the two-way mixed effect intraclass correlation coeffi­ cient (icc; interpreted according to koo & li, 2016) between t1 and t2 in the ncc sample. diagnostic accuracy we investigated group differences in the oci-12 total and subscale scores by means of univariate (anova) and multivariate analysis of variance (manova). furthermore, we conduced post-hoc tukey honest significant difference (tukey hsd). we investigated the diagnostic accuracy of the total score and each subscale with receiver operating characteristic (roc) analyses. the area under the curve (auc) was in­ terpreted according to the criteria by carter et al. (2016). cut-off scores were established with the youden index (j; youden, 1950). müller, fink-lamotte, jelinek et al. 7 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ results confirmatory factor analysis confirmatory factor analysis in the ocd sample figure 1a displays the cfa examining the four-factor solution. the chi-square test, χ2(48, n = 102) = 70.985, p = .017, rejected the hypothesis of a perfect fit. furthermore, the tli (0.945) did not support a good model fit while the rmsea indicated a marginal mod­ el fit (0.081; maccallum et al., 1996). the remaining goodness-of-fit indices supported a good fit of the four-factor model: srmr = 0.059; cfi = 0.960. the four-factor model including a higher-order factor of general ocd symptoms is shown in figure 1b. aside from the chi-square test, χ2(50, n = 102) = 71.181, p = .026, and the rmsea (0.076; reasonable fit; maccallum et al., 1996), all fit indices support a good model fit: srmr = 0.058; cfi = 0.963; tli = 0.951. the first-order factors loaded weakly to strongly on the higher-order factor of general ocd symptoms. the higher-order fac­ tor accounted for a significant proportion of variance in the first-order factors checking, ordering, and washing (rchecking 2 = .791, rordering 2 = .286, rwashing 2 = .148), but not obsessing (robsessing 2 = .023). confirmatory factor analysis in the total sample the path model of the four-factor solution in the total sample is displayed in figure 2a. as in the ocd sample, the chi-square test was significant, χ2(48, n = 419) = 80.558, p = .002) and the rmsea showed only a reasonable fit (0.065; maccallum et al., 1996). the remaining goodness-of-fit indices supported a good fit of the data: srmr = 0.043; cfi = 0.979; tli = 0.972. figure 2b presents the path model including the general ocd factor. except the chi-square test, χ2(50, n = 419) = 84.168, p = .002, and the rmsea (0.065; reasonable fit; maccallum et al., 1996), all fit indices support a good model fit: srmr = 0.046; cfi = 0.979; tli = 0.972. in the total sample, the first-order factors loaded strongly on the higher-order factor of general ocd symptoms. the higher-order factor accounted for a significant proportion of variance in all first-order factors (rchecking 2 = .796, rordering 2 = .433, rwashing 2 = .588, robsessing 2 = .557). correspondence of oci-12 subscales to docs factors the linear regression models of the four oci-12 factors predicting each docs subscale are presented in supplement e. each docs subscale significantly and strongly predicted by the corresponding oci-12 subscale (βs ranging from β = 0.44 for checking and ordering to β = 0.84 for washing). validation german version oci-12 8 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ figure 1 confirmatory factor analyses of the oci-12 in the ocd sample (n = 102) note. a. path diagram of the structural equation model in the ocd sample depicting the four-factor model. b. path diagram of the structural equation model in the ocd sample depicting the four-factor model including a higher order factor of general ocd symptoms. the factor loadings are presented between the lines, with thicker lines being indicative of higher factor loadings. residual variances are presented next to the observed items and factors. the shading corresponds to the strength of relationships. darker paths and values indicate stronger loadings or correlations. oci-12 = 12-item obsessive-compulsive inventory; che = checking subscale; ord = ordering subscale; was = washing subscale; obs = obsessing subscale; ocd = obsessive-compulsive disorder. müller, fink-lamotte, jelinek et al. 9 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ figure 2 confirmatory factor analyses of the oci-12 in the total sample (n = 419) note. a. path diagram of the structural equation model in the total sample depicting the four-factor model. b. path diagram of the structural equation model in the total sample depicting the four-factor model including a higher order factor of general ocd symptoms. the factor loadings are presented between the lines, with thicker lines being indicative of higher factor loadings. residual variances are presented next to the observed items and factors. the shading corresponds to the strength of relationships. darker paths and values indicate stronger loadings or correlations. oci-12 = 12-item obsessive-compulsive inventory; che = checking subscale; ord = ordering subscale; was = washing subscale; obs = obsessing subscale; ocd = obsessive-compulsive disorder. validation german version oci-12 10 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ reliability internal consistency the internal consistency for the oci-12 subscales in the ocd group ranged from good (obsessing) to excellent (washing; see table 1). the oci-12 total showed good internal consistency. in the ard subgroup, the internal consistency ranged from acceptable (washing) to good (ordering), while the oci-12 total demonstrated good internal consis­ tency. the ncc group showed the lowest internal consistency, ranging from not satis­ factory (checking) to acceptable (obsessing), with the oci-12 total showing acceptable internal consistency. table 1 internal consistency of oci-12 subscales per group oci-12 ocd n = 102 ard n = 69 ncc n = 248 α ω α ω α ω checking .85 .86 .78 .83 .40 .44 ordering .92 .92 .87 .87 .79 .70 washing .93 .93 .76 .76 .60 .61 obsessing .82 .84 .85 .85 .77 .77 total .82 .74 .84 .84 .72 .71 note. oci-12 = 12-item obsessive-compulsive inventory; ocd = obsessive-compulsive disorder; ard = anxiety-related disorders; ncc = non-clinical controls. test-retest reliability the test-retest reliability of the oci-12 was assessed over an interval of m = 13.42 (sd = 3.64) days in the ncc group. results are displayed in table 2. results of t-tests indicated no significant changes over the test-retest interval for oci-12 total and all subscales except for washing, which significantly increased from t1 to t2. a strong positive correlation between t1 and t2 was shown for the oci-12 total and a moderate (checking) to strong (ordering, washing, obsessing) positive correlation for the oci-12 subscales. the two-way mixed effect icc demonstrated moderate (checking) to good (ordering, washing, obsessing) reliability for the subscales and good reliability for the oci-12 total score. construct validity as shown in table 3, the oci-12 correlated moderately with the y-bocs in the ocd sample and strongly with the docs in all groups. the correlations with depressive symptoms, anxiety, and worry were moderate. müller, fink-lamotte, jelinek et al. 11 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ table 3 correlations between oci-12 and measures of ocd symptoms, depression, anxiety, and worry per group measure ocd ard ncc n r n r n r ocd symptoms (convergent validity) y-bocstotal 102 .45 – – – – docstotal 102 .74 69 .63 248 .50 other symptoms (divergent validity) phq-9 102 .48 69 .29 248 .44 asi-3 102 .47 69 .37 248 .39 pswqa 101 .48 65 .30 237 .46 amissing values in the dataset. note. ocd = obsessive-compulsive disorder; ard = anxiety-related disorders; ncc = non-clinical controls; oci-12 = 12-item obsessive-compulsive inventory; y-bocs = yale-brown obsessive-compulsive inventory; docs = dimensional obsessive-compulsive scale; phq-9 = patient-health questionnaire-9; asi-3 = anxietysensitivity index-3; pswq = penn-state worry questionnaire. diagnostic accuracy group differences descriptives and group differences on the oci-12 are presented in table 4. the total scores of the oci-12 significantly differed between groups, f(2, 416) = 373.1, p < .001, as indicated by a main effect of group in the anova. participants with ocd had significantly higher oci-12 scores than participants with ard and ncc, which showed table 2 descriptives and test-retest measures of the oci-12 oci-12 t1 t2 t-test pearson’s correlation consistency m sd m sd t p r p f icc checking 0.80 0.99 0.72 0.96 -1.151 .251 .52 < .001 3.2 .69 ordering 2.09 1.84 2.24 1.88 1.214 .227 .65 < .001 4.8 .79 washing 0.33 0.75 0.47 0.96 2.506 .013 .67 < .001 4.7 .79 obsessing 1.09 1.56 1.18 1.58 0.991 .323 .71 < .001 6.0 .83 total 4.32 3.42 4.61 3.57 1.323 .188 .67 < .001 5.1 .80 note. oci-12 = 12-item obsessive-compulsive inventory; icc = two-way mixed effect intraclass correlation coefficient. these measures were obtained in the sample of non-clinical controls (n = 163) only. validation german version oci-12 12 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ significantly higher oci-12 scores than the ncc group (all p’s < .001 in tukey’s hsd tests). table 4 descriptives and group differences of the oci-12 oci-12 ocd n = 102 ard n = 69 ncc n = 248 m sd mdn iqr m sd mdn iqr m sd mdn iqr checking 5.26 3.32 5 6 2.06 2.32 1 3 0.79 0.95 1 1 ordering 4.90 3.52 4 5.75 3.78 3.14 3 5 1.96 1.74 2 2 washing 5.83 4.41 6 8.75 1.59 2.16 1 3 0.34 0.85 0 0 obsessing 7.22 3.06 8 4 3.57 2.74 3 5 1.02 1.43 1 2 total 23.22 9.19 23 12 11.00 7.34 10 10 4.10 3.23 3 4 note. the values for each subscale can range from 0 – 12. the possible range for the total score is 0 – 48. oci-12 = 12-item obsessive-compulsive inventory; ocd = obsessive-compulsive disorder; ard = anxietyrelated disorders; ncc = non-clinical controls; mdn = median; iqr = interquartile range. when considering the oci-12 subscales, the manova showed a significant main effect of group across the subscales, pillai’s trace = 0.733, f(8, 828) = 59.837, p < .001. as for the oci-12 total score, separate anovas with post-hoc tukey hsd tests revealed that participants with ocd had significantly higher scores on each subscale than participants with ard, which showed significantly higher scores than the ncc group (all p’s < .001). diagnostic accuracy the diagnostic accuracy of the oci-12 to discriminate participants with ocd from participants with ard was good (auc = .85, 95% ci [.795, .909]; see figure 3a). the diagnostic accuracy for each subscale ranged from auc = .59 (ordering) to auc = .81 (obsessing; see figure 4a). considering the diagnostic accuracy of the oci-12 for distinguishing individuals with ocd from ncc’s, the oci-12 total score evidenced excellent accuracy (auc = .99, 95% ci [.976, .997]; see figure 3b). the diagnostic accuracy of the subscales ranged from auc = .75 (ordering) to auc = .96 (obsessing). overall, the oci-12 total score evidenced the best diagnostic accuracy for discriminating ocd participants from both, ard and ncc (see figure 4b). müller, fink-lamotte, jelinek et al. 13 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ figure 3 receiver operating characteristic curves for the oci-12 total note. a. receiver operating characteristic (roc) curve discriminating participants with obsessive-compulsive disorder (n = 102) from participants with anxiety-related disorders (n = 69). b. receiver operating characteristic (roc) curve discriminating participants with obsessive-compulsive disorder (n = 102) from non-clinical controls (n = 248). optimal cut-off table 5 summarises the youden indices, sensitivities, and specificities of the oci-12 total and each subscale for discriminating participants with ocd from ard and ncc partici­ pants. an oci-12 total score ≥ 17 was considered optimal to discriminate participants with ocd from participants with ard. when discriminating participants with ocd from ncc’s, a score of ≥ 11 was considered optimal. out of the subscales, the washing subscale could best discriminate ocd from ard participants, while the obsessing sub­ scale best discriminated ocd from ncc participants. the ordering subscale was suited worst to discriminate participants with ocd from ard and ncc participants. severity benchmarks oci-12 severity benchmarks were investigated in severity-groups based on y-bocs cut-offs (storch et al., 2015; see supplement f for oci-12 descriptives per severity group). the oci-12 total score fairly discriminated mild from moderate cases (auc = .73, 95% ci [.557, .900]), but only poorly distinguished moderate from moderate-severe cases (auc = .69, 95% ci [.576, .807]) and moderate-to-severe from severe cases (auc = .52, 95% ci [.059, .983]). validation german version oci-12 14 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ figure 4 receiver operating characteristic curves for the oci-12 subscales note. a. receiver operating characteristic (roc) curves for the oci-12 subscales discriminating participants with obsessive-compulsive disorder (n = 102) from participants with anxiety-related disorders (n = 69). b. receiver operating characteristic (roc) curves for the oci-12 subscales discriminating participants with obsessive-compulsive disorder (n = 102) from non-clinical controls (n = 248). table 5 optimal cut-offs for oci-12 subscales oci-12 subscale ocd vs. ard ocd vs. ncc cut-off j sensitivity specificity cut-off j sensitivity specificity checking 4 .47 65.69% 81.16% 3 .67 73.53% 93.55% ordering 9 .14 22.55% 91.30% 5 .42 49.02% 93.15% washing 5 .55 61.76% 92.75% 2 .63 70.59% 92.34% obsessing 5 .51 81.37% 69.57% 4 .81 85.29% 95.97% total 17 .52 76.47% 75.36% 11 .89 92.16% 97.18% note. oci-12 = 12-item obsessive-compulsive inventory; ocd = obsessive-compulsive disorder; ard = anxiety-related disorders; ncc = non-clinical controls; j = youden index; sensitivity = correct classification of ocd participants; specificity = correct classification of non-ocd participants. given that the severe group included only three individuals, moderate-to-severe and severe cases were combined, but discrimination from moderate cases remained poor (auc = .69; 95% ci [.577, .801]). an optimal cut-off ≥ 12 was suggested for mild vs. müller, fink-lamotte, jelinek et al. 15 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ moderate cases (j = .38), and a cut-off ≥ 24 for moderate vs. moderate-severe cases (j = .38). due to small sample sizes and limited discrimination, further research with a larger sample is needed to establish oci-12 severity benchmarks. discussion to utilise the oci-12 in german-speaking populations, we translated the original eng­ lish version (abramovitch et al., 2021) into german and investigated its psychometric properties. we replicated the original four-factor structure with a higher-order factor of general ocd symptoms. furthermore, our results on the reliability, validity, and diagnostic accuracy of the oci-12 are good-to-excellent and comparable to the original english version. more specifically, the four-factor model (washing, checking, ordering, and obsessing) including the higher-order factor of general ocd symptoms showed a good fit to the data according to the cfas. the higher-order factor also explained significant variance in the oci-12 subscales. of note, the chi-square test and the rmsea did not support a good model fit. however, both indices are criticised for being sensitive to the sample size (bollen, 2014; hu & bentler, 1999) and the degrees of freedom (kenny et al., 2015), respectively. as most of the approximate fit indices (i.e., srmr, cfa, tli) supported a good fit of the data, we conclude that the four-factor structure with a higher-order factor of general ocd symptoms is also evident in the german-speaking sample. moreover, each of the oci-12 subscale significantly and most strongly predicted the corresponding subscale of the well-established docs, providing further evidence for the four factors. the oci-12 total score’s internal consistency and test-retest reliability was good. in terms of construct validity, the current correlation analyses showed only a moderate cor­ relation between oci-12 scores and the y-bocs. this relatively low correlation has also been shown in previous studies (see abramovitch et al., 2021; aspvall et al., 2020) and may be related to idiographic nature of the y-bocs in measuring ocd symptom severity of individually assessed obsessions and compulsions as compared to the nomothetic approach of the oci-12. moreover, the format of administration seems to contribute to the relatively low correlation, hinting towards the common method bias (podsakoff et al., 2003). indeed, an exploratory correlation analysis showed that the correlation between the two self-reports, oci-12 and y-bocs-sr, was higher (r = .56, p < .001) than the correlation between the oci-12 and the y-bocs interview (r = .28, p = .090). however, in support of convergent validity, the correlation between the oci-12 and the docs is strong. therefore, we consider the comparably weak correlation with the y-bocs rather as a methodological/conceptual artefact. correlations between the oci-12 and measures of depression, anxiety, and worry have been moderate, highlighting that the oci-12 possesses discriminant validity but is not completely independent of these validation german version oci-12 16 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ symptom measures. given that the clinical samples present with comorbid diagnoses (e.g., depression), these results are, however, not surprising. when comparing the oci-12 scores between the three groups, the group of par­ ticipants with ocd showed significantly higher scores than both, participants with ard and ncc. the oci-12 can discriminate well between participants with ocd and ard when a cut-off of ≥ 17 is considered and can discriminate excellently between participants with ocd and ncc’s when a cut-off of ≥ 11 is used. of note, the oci-12 should not be considered as isolated diagnostic tool (i.e., the cut-off criteria should not replace a diagnostic interview). analyses of the severity benchmarks showed that the oci-12 could fairly discriminate mild from moderate cases, but only poorly discriminate between cases of mild or severe symptom severity. however, due to the small sample sizes within the severity groups, future research is needed to establish conclusive bench­ marks. limitations this study has some limitations. although participants were recruited within cooperat­ ing clinics, structured diagnostic interviews were not always possible, risking less precise diagnoses, particularly for comorbid disorders. likewise, the absence of structured inter­ views for the ncc population may have allowed the inclusion of participants with undiagnosed psychological disorders, not captured by dedicated questions or the wsq. furthermore, 63% of participants with ocd filled out the y-bocs as self-rating, whereas 37% completed the y-bocs interview. while both formats show strong correla­ tions and good reliability and may be used interchangeably (baer et al., 1993; rosenfeld et al., 1992; steketee et al., 1996), the weak correlation between the interview version and the oci-12 hints towards a common method bias, which should be taken into consid­ eration when interpreting the convergent validity. as the correlation between the oci-12 and the y-bocs is affected by the assessment modality, it may be worthwhile in future studies to investigate the correlation between the oci-12 and other interview-based measures. additionally, participants in the clinical samples presented with comorbid disorders. although this increases the ecological validity of the current validation, comorbid infor­ mation is not integrated into the psychometric analyses. therefore, comorbid symptoms may attenuate some of the reported measures (e.g., internal validity, discriminant validi­ ty). lastly, the sample size of the ocd group should be increased in future studies. while the average item communalities (h 2 = .73) indicate that a sample size of n = 100 is adequate for conducting the cfa according to rules of thumb (hair et al., 2019), a larger ocd sample may enhance the robustness of findings. the total sample size (n = 419), however, is adequate for conducting the cfa on the oci-12 which supports the four-fac­ tor structure, including the higher-order factor representing general ocd symptoms. a müller, fink-lamotte, jelinek et al. 17 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ valuable next step would be recruiting a large, representative sample, which would allow the development of norms for the oci-12. conclusion the german version of the oci-12 presents a syndromally valid self-report measure to assess ocd symptoms which can be used in research and clinical settings. the original four-factor structure with a higher-order factor of general ocd symptoms could be replicated and the oci-12 possesses good-to-excellent psychometric properties in terms of internal and test-retest reliability and construct validity. furthermore, the oci-12 possesses good-to excellent-diagnostic accuracy for its established clinical cut-off values. to enable a wide use of the oci-12, the german versions of this questionnaire, including the item numbering and scoring guidelines, can be found in supplement g and in müller and cludius, 2024s. as a next step, conducting a study with larger sample sizes would be valuable to establish norms, enabling an even more meaningful and precise interpretation of scores on the oci-12. validation german version oci-12 18 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.psychopen.eu/ funding: this study was supported by the german research foundation (project-id: 461724773). acknowledgments: the authors want to thank andreas kustermann, christiane treutler, sandra emmerich, katharina seifermann, katharina scharfstein, marena siegesleitner, and larissa wolkenstein for their on-site support in the recruitment of the clinical samples. the authors further want to thank lena ranftl and franziska ammer for their support throughout the data collection. lastly, the authors want to thank tonya frommelt, xenia schmalz, zoe ilona spock, and milena aleksić for their support in translating the items of the oci-12. competing interests: the authors have declared that no competing interests exist. author contributions: celina l. müller: conceptualisation, methodology, programming, validation, formal analysis, investigation, writing – original draft, project administration; jakob fink-lamotte: conceptualisation, validation, investigation, writing – review & editing; lena jelinek: conceptualisation, validation, investigation, writing – review & editing; luzie lohse: conceptualisation, validation, investigation, writing – review & editing; thomas ehring: conceptualisation, validation, investigation, writing – review & editing; michael noll-hussong: investigation, writing – review & editing; götz berberich: investigation, writing – review & editing; jens borgelt: investigation, writing – review & editing; andreas wahl-kordon: investigation, writing – review & editing; dean mckay: resources, writing – review & editing; jonathan s. abramowitz: resources, writing – review & editing; amitai abramovitch: validation, resources, writing – review & editing; barbara cludius: conceptualisation, methodology, validation, investigation, writing – review & editing, supervision, funding acquisition ethics statement: the study was approved by the institutional ethics committee of the faculty of psychology and educational sciences of the lmu munich. author note: the present manuscript details the psychometric properties of the german version of the oci-12. in a separate publication (müller et al., 2025), we conducted a first investigation of the german four-item ultra-brief obsessive–compulsive inventory (oci-4), which was derived from the dataset used in this study by selecting four items from the oci-12. social media accounts: celina müller: linkedin, bluesky preregistration: analyses were not preregistered. data availability: the research data, codebook, and code are provided at the open science framework (müller & cludius, 2024s). supplementary materials the supplementary materials contain the following items: • research data, codebook, and code (müller & cludius, 2024s) • additional information (müller et al., 2025s): ◦ supplement a: translation procedure müller, fink-lamotte, jelinek et al. 19 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://www.linkedin.com/in/celinamüller/ https://bsky.app/profile/celinalianemueller.bsky.social https://www.psychopen.eu/ ◦ supplement b: sample characteristics ◦ supplement c: internal consistencies of questionnaires ◦ supplement d: formulation of oci-12 items ◦ supplement e: oci-12 subscales predicting docs factors ◦ supplement f: severity benchmarks ◦ supplement g: 12-item obsessive-compulsive inventory (oci-12) index of supplementary materials müller, c. l., & cludius, b. 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(1950). index for rating diagnostic tests. cancer, 3(1), 32–35. https://doi.org/10.1002/1097-0142(1950)3:1<32::aid-cncr2820030106>3.0.co;2-3 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service provided by the leibniz institute for psychology (zpid), germany. validation german version oci-12 24 clinical psychology in europe 2025, vol. 7(4), article e16165 https://doi.org/10.32872/cpe.16165 https://doi.org/10.1016/0005-7967(96)00036-8 https://doi.org/10.1016/j.comppsych.2015.08.007 https://psyweb.uni-muenster.de https://icd.who.int https://doi.org/10.1002/1097-0142(1950)3:1<32::aid-cncr2820030106>3.0.co;2-3 https://www.psychopen.eu/ validation german version oci-12 (introduction) method translation procedure study procedure participants measures analytic plan results confirmatory factor analysis reliability construct validity diagnostic accuracy discussion limitations conclusion (additional information) funding acknowledgments competing interests author contributions ethics statement author note social media accounts preregistration data availability supplementary materials references scheduled support versus support on demand in internet-delivered cognitive behavioral therapy for social anxiety disorder: randomized controlled trial research articles scheduled support versus support on demand in internet-delivered cognitive behavioral therapy for social anxiety disorder: randomized controlled trial anton käll 1,2 , cecilia olsson lynch 3 , kajsa sundling 3, tomas furmark 3 , per carlbring 4 , gerhard andersson 1,2,5 [1] department of behavioural sciences and learning, linköping university, linköping, sweden. [2] department of biomedical and clinical sciences, linköping university, linköping, sweden. [3] department of psychology, uppsala university, uppsala, sweden. [4] department of psychology, stockholm university, stockholm, sweden. [5] department of clinical neuroscience, karolinska institutet, stockholm, sweden. clinical psychology in europe, 2023, vol. 5(3), article e11379, https://doi.org/10.32872/cpe.11379 received: 2023-02-14 • accepted: 2023-08-01 • published (vor): 2023-09-29 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: gerhard andersson, department of behavioural sciences and learning, linköping university, se-581 83 linköping, sweden. e-mail: gerhard.andersson@liu.se abstract objectives: clinician-supported internet-delivered cognitive behavioral therapy (icbt) can be an effective treatment option when treating social anxiety disorder (sad). unguided icbt is often found to be less effective. one possible solution to reduce the costs of clinician support is to provide support on demand. in this format of guidance, participants have the option to contact their clinician if needed. in a few studies, this mode of support has been compared favorably to scheduled support. method: participants in a previously reported controlled trial on sad who had been in a waitlist control group were randomly allocated to icbt with either on-demand guidance or scheduled weekly therapist guidance. a total of 99 participants were included. data were collected weekly on the primary outcome measure, the liebowitz social anxiety scale self-report (lsas-sr), and at preand post-treatment for secondary measures. data were analyzed in accordance with the intention-to-treat principle using mixed-effects models. results: both groups improved significantly during the treatment according to the lsas-sr ratings. the groups did not differ in their estimated change during the treatment period, with a between-group effect of d = 0.02, 95% ci [-0.37, 0.43]. both groups experienced similar this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11379&domain=pdf&date_stamp=2023-09-29 https://orcid.org/0000-0003-1579-8791 https://orcid.org/0009-0004-9175-3311 https://orcid.org/0000-0001-6821-9058 https://orcid.org/0000-0002-2172-8813 https://orcid.org/0000-0003-4753-6745 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ improvement also on the secondary outcome measures, with small between-group effect sizes on all outcomes. conclusions: the findings indicate that support on demand can be an effective way of providing guidance in icbt for sad, although more research on this topic is needed. a limitation of the study is that it was conducted in 2009, and the findings were in the file drawer. subsequent published studies support our initial findings, but more research is needed. keywords social anxiety disorder, icbt, internet-delivered treatments, guided icbt highlights • one way to handle the need for therapist support in internet-delivered cognitive behaviour therapy (icbt) is to offer support on demand. • a randomized controlled trial was conducted comparing scheduled versus support on demand when completing icbt for social anxiety disorder (sad). • both groups improved and there were no major differences in outcome. • support on demand can be an effective way of providing guidance in icbt for sad. social anxiety disorder (sad) is a common and debilitating mental health problem characterized by a persistent and intense fear of being evaluated in social situations (american psychiatric association, 2013). global estimates suggest that sad has an average lifetime prevalence of around 4%, often coupled with an early onset (stein et al., 2017) and, when left untreated, a chronic course (steinert et al., 2013). psychological treatments have been shown to assist people with this problem (acarturk et al., 2009). cognitive behavioral therapy (cbt) is often seen as the gold standard among these treatments, producing large effect sizes (mayo-wilson et al., 2014) and lasting effects that are maintained years after therapy termination (van dis et al., 2020). additionally, cbt targeting sad has been disseminated successfully using modes other than traditional individual therapy, for example, in group settings (barkowski et al., 2016) and via the internet (guo et al., 2021), most commonly in the form of internet-delivered cbt (icbt; andersson, 2018). icbt provides a resource-effective way of delivering psychological treatment, as it requires less time from the therapist and can increase access to cbt in underserved areas and populations (andersson, 2016). it has also been shown to be a cost-effective option (donker et al., 2015). specifically for sad, icbt has been shown to be an effective option in a regular care setting (el alaoui et al., 2015) and to have lasting effects five years after termination (hedman et al., 2011). icbt is often administered with scheduled support from a therapist (andersson, 2016), and studies suggest that this is more effective than pure self-help versions of icbt (baumeister et al., 2014). however, there are exceptions. for example, one study conduc­ ted in china reported that a pure self-help condition produced comparable results to a support on demand versus scheduled support in icbt 2 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ condition which received regular therapist guidance (kishimoto et al., 2016). furmark et al. (2009) also found that a bibliotherapy condition with minimal therapist contact led to similar improvement compared to a therapist-supported icbt condition, and that both active conditions outperformed a waitlist control group (furmark et al., 2009). one alternative to providing scheduled clinical support in icbt is to provide support on demand (also referred to as optional support). this requires clients to contact their clinician when they want feedback, support, or have questions regarding the treatment material. this resembles helplines and usually requires less clinician time. support on demand has been found to generate similar results to guided icbt interventions in the treatment of anxiety and depression in a routine care setting (hadjistavropoulos et al., 2017; hadjistavropoulos et al., 2019). additionally, the results indicated no significant dif­ ferences in satisfaction with the treatment. dear et al. (2015) did not find any significant differences between the optional support condition and scheduled therapist support in a trial on chronic pain, with high satisfaction and completion ratings across conditions (dear et al., 2015). support on demand has also been shown to have similar long-term outcomes compared to scheduled guidance in a study examining the outcomes of icbt for loneliness two years after treatment (käll et al., 2020). in a small factorial design trial on generalized anxiety disorder, the authors reported that support on demand was as effective as scheduled support, but that scheduled support was rated as more positive (dahlin et al., 2022). also, it has been suggested that scheduled guidance compared to optional guidance, is slightly more favorable at least in terms of adherence (koelen et al., 2022). in conclusion, controlled trials on clinician support on demand provides initial support for this guidance format. this way of disseminating icbt could increase access to icbt and reduce costs for the support function while still not sacrificing effects and safety. given the increasing interest in icbt and the need to make icbt scalable, the aim of the current study was to compare the support on demand mode with scheduled support in icbt treatment for sad. here we report findings from an unpublished part, i.e. a waiting list control group, of a previous randomized controlled trial (andersson et al., 2012). after initial waiting-time individuals were randomized to the two forms of guidance. we had originally hypothesized that the support on demand group would ex­ perience smaller reductions in symptoms of social anxiety and related psychopathology and smaller increase in quality of life. in addition, the support on demand group was expected to lead to less demand for therapist input. method the current study was part of the sofie-6 project, a study investigating the efficacy of icbt for sad (andersson et al., 2012). here, we report the results from the waitlist con­ käll, olsson lynch, sundling et al. 3 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ trol group, which received treatment directly following the first group in the controlled trial. participants and recruitment a flowchart of the recruitment and treatment processes is presented in figure 1. more information about the initial phase of the study can be found in andersson et al. (2012). participants were recruited via an email sent out to a waitlist who had registered interest on a public site hosted by the research group (www.studie.nu). an email invitation was sent to the first 600 names on the list. a total of 359 participants completed the screen­ ing questionnaires, and 272 completed the subsequent structured clinical interview for dsm-iv axis i disorders (scid-i) (first et al., 1997) via telephone. the scid-i interviews were conducted by 10 final-year students from the clinical psychologist program at uppsala university, sweden. they received training in administering the interviews before the study. inclusion criteria were: a) at least 18 years old, b) living in sweden, c) having access to a computer and an internet connection, d) meeting the criteria for sad on the social phobia screening questionnaire (spsq) (furmark et al., 1999), e) meeting the scid-i criteria for sad without meeting the criteria for a comorbid eating disorder or psychotic disorder, f) if applicable, having a stable dose of medication for the past two months, g) not undergoing current psychological treatment or having received psychological treatment during the past six months, h) providing informed consent via mail. in the original study, 204 participants met these criteria and were randomized to receive treatment either immediately during the autumn of 2008 or later. once the post treatment data were collected, the control group participants (n = 99 after accounting for dropout) were randomized once again using a true random number generator (www.random.org) to receive either scheduled support or support on demand. randomization during both phases was conducted by researchers not involved in other aspects of the study. treatment the treatment was divided into nine modules that were unlocked one at a time, given that the participants had completed the assignments in the previous module. modules were unlocked on a weekly basis, and participants were informed that this was the expected pace to keep during the treatment period. all unlocked modules were available for the duration of the treatment phase. each module consisted of a pdf containing texts and practical exercises to complete during the week. a quiz was placed at the end of the modules boost adherence to the important principles of the treatment. participants also provided a short written summary of the module in their weekly correspondence with the therapist (for the regular support group) or in a separate email to a non-specific therapist (in the support on-demand group). the content of the modules was identical support on demand versus scheduled support in icbt 4 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 http://www.studie.nu http://www.random.org https://www.psychopen.eu/ to those used in previous studies within the sofie project (furmark et al., 2009), which contained psychoeducation, cognitive restructuring, behavioral experiments, exposure exercises, and social skills training. an outline of the treatment is presented in table 1. the modules spanned 188 pages, ranging from 17 to 30 pages per module. figure 1 flowchart of the recruitment and assessments throughout the sofie-6 study figure 1. flochart of the recruitment and assessments throughout the sofie-6 study 359 participants completed the screening questionnaires 272 participants completed the diagnostic interview randomized for the current study (n = 99) • 3 participants declined participation allocation enrollment excluded at screening (n = 87) • declined participation (n = 1) • did not meet inclusion criteria (n = 10) • unable to contact for interview (n = 5) excluded after interview (n = 68) • did not meet inclusion criteria (n = 19) • did not send in informed consent sheet (n = 48) • declined participation (n = 1) 204 participants were randomized for the initial study allocated to the original control group (n = 102) allocated to the original treatment group (n = 102) analyzed for andersson, carlbring & furmark, 2012 (n = 102) allocated to treatment with guidance-on-demand (n = 49) • received allocated intervention (n = 49) allocated to treatment with scheduled guidance (n = 50) • received allocated intervention (n = 50) completed the post-treatment assessment (n = 49) • drop-out (n = 1) completed the post-treatment assessment (n = 42) • drop-out (n = 5) • lost to follow-up (n = 2) included in analysis (itt) (n = 49) • marked as missing at posttreatment (n = 1) included in analysis (itt) (n = 49)analysis the current study käll, olsson lynch, sundling et al. 5 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ table 1 content of the modules module content exercises number of pages (a4) 1 introduction and psychoeducation learning about symptoms, anxiety hierarchy 18 2 clarks and wells’ cognitive model of social anxiety personal model of social anxiety, thought record 20 3 cognitive restructuring i reality testing, cognitive distortions, goals for the treatment 30 4 cognitive restructuring ii negative automatic thoughts, behavioral experiments 23 5 exposure i exposure based on anxiety hierarchy 21 6 shifting focus safety behaviors, exposure 19 7 exposure ii safety behaviors, exposure 17 8 social skills social skills, exposure 19 9 relapse prevention summary, plan for relapse prevention 21 ten clinical psychologists served as clinicians during treatment. communication be­ tween the participants and the clinician was conducted via a messaging system on the encrypted study website (vlaescu et al., 2016). in addition to the messaging system, all participants had access to one of two anonymous discussion forums where they could write about the progress and experiences of the exercises conducted during the week. the scheduled support and support on demand groups had separate forums, and both forums were monitored by the study staff for safety. all participants received an introductory message, but for the group with scheduled support, this message was sent from their personal clinician, while the support on demand group participants received a generic message. the group with scheduled support received feedback on their exercises on a fixed day each week, which was the same day as when they received access to the next module. the support on demand group participants were told that they could contact the study staff via the messaging system. participants in this condition were not assigned a specific clinician; rather, the clinicians had a schedule with days during which support on demand versus scheduled support in icbt 6 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ they would monitor the activity of the participants and respond to requests for help and feedback. measures primary outcome measure liebowitz social anxiety scale – self report (lsas-sr) — the lsas-sr was the primary outcome measure. the lsas-sr measures fear and avoidance related to social situations using 24 items (fresco et al., 2001). respondents are asked to rate their fear and anxiety regarding a social situation on a scale between 0 (no fear or anxiety) and 3 (severe fear or anxiety). they also rate how often they avoid the situation or scenario, ranging from 0 (never) to 3 (usually). the ratings are summed up to provide a general rating of social anxiety, ranging between 0 and 144. the self-report version of the scale has been noted to have excellent internal consistency (cronbach’s α = 0.95) and a 12-week test–retest reliability of r = .83 (baker et al., 2002). it has been validated for internet administration (hedman et al., 2010). the questionnaire was administered online as a screening tool before the treatment began, weekly during the treatment (at a fixed day each week which was also the same time as participants were sent a new module if they had completed the previous module), and at post treatment. secondary outcome measures all secondary outcome measures were administered at the screening (before this part of the study took place), at the pretreatment time point (the start of the current study), and at the post treatment time point. social interaction anxiety scale (sias) — the sias consists of 20 items aimed at measuring the respondent’s anxiety during social interactions (heimberg et al., 1992). ratings are made on a likert scale from 0 (not at all characteristic or true of me) to 4 (extremely characteristic or true of me), with the total sum ranging from 0 to 80. psychometric properties include excellent internal consistency (cronbach’s α = .93) and a 12-week test–retest reliability of r = .92 (mattick & clarke, 1998). social phobia scale (sps) — the sps consists of 20 items administered with the intention of measuring respondents’ fear of evaluation in social situations (heimberg et al., 1992). ratings are made on a likert scale from 0 (not at all characteristic or true of me) to 4 (extremely characteristic or true of me), with a total sum range of 0 to 80. psychometric properties include an internal consistency (cronbach’s α = .94) and a 12-week test–retest reliability of r = .93 (mattick & clarke, 1998). beck anxiety inventory (bai) — the bai consists of 21 items that measure the physiological and cognitive symptoms of anxiety (beck et al., 1988). ratings are made käll, olsson lynch, sundling et al. 7 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ on a four-point likert scale, with possible sum scores ranging from 0 to 63. the instru­ ment’s psychometric properties include internal consistency (cronbach’s α = .92) and a one-week test–retest reliability of r = .75 (beck et al., 1988). montgomery åsberg depression rating scale – self report (madrs-s) — the madrs-s is a nine-item scale measuring symptoms of depression based on the 10-item clinician-administered version of the scale (montgomery & åsberg, 1979). respondents rate the frequency of cognitive, emotional, and physiological symptoms during the past three days on a seven-point scale. total sum scores can range from 0 to 54, with higher scores indicating an increased severity of symptoms. psychometric properties for the self-report version have been reported to include an internal consistency (cronbach’s α = .84) and a one-week intraclass correlation of .78 (fantino & moore, 2009). both bai and madrs-s are validated for internet use (thorndike et al., 2009). quality of life inventory (qoli) — the qoli is a 16-item instrument measuring respondents’ subjectively rated quality of life (frisch et al., 1992). the respondent is asked to indicate how important a specific domain is on a scale from 0 (not important) to 2 (very important), and then how satisfied they are with their current situation within that domain. the two ratings are multiplied and divided by the number of areas that the respondent considers to be somewhat or very important. the test–retest coefficient was measured between r = .80 and .91 (mean duration between measurements = 33 days) during the validation of the instrument. the range of values for internal consistency was reported as being between cronbach’s α = .77 and .89. the qoli, has been validated for internet use (lindner et al., 2013). power a formal power analysis was not conducted, as this was a spin-off study following the first phase of the trial. however, given the sample size and a power of 80% and p < .05, we had statistical power to detect an effect size of d = 0.40 on the lsas-sr. this would correspond to a clinically relevant effect, with the expected direction being the superiority of scheduled support over support on demand. statistical analyses statistical analyses were conducted using r version 4.0.3 (r core team, 2020) and spss version 25. across the analyses, the alpha level was set to .05. confidence intervals were reported at 95%. the assumption of normality was controlled using shapiro-wilks tests. tests of pretreatment differences and differences between responders and non-res­ ponders on the post treatment assessment were evaluated using independent sample t-tests, mann-whitney u tests (when the assumption of parametric data was not met) and fisher’s exact tests. independent t-tests were also used to investigate potential support on demand versus scheduled support in icbt 8 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ differences in the number of modules accessed (i.e., read) and completed (defined as completing the exercises in a module). a multiple regression model using residualized change scores as the dependent variable was used to investigate the relationship between completion of modules and change in the primary outcome measure. the data were analyzed according to the intention-to-treat principle (itt), meaning that all available data were included in the analysis and all randomized participants were included in the analysis. the post treatment data from one of the participants in the scheduled support condition was flagged, as the scores on all the outcome measures were 0 (including both symptom measures, such as the lsas and the quality-of-life ratings). due to this likely mistake/error the post treatment data for this participant were marked as missing. the model used to investigate the outcome of the primary outcome measure (lsassr) was a mixed-effects model fitted using the lme4 package (bates et al., 2015). model fit, including the form of change and covariance structure for the primary outcome where we had weekly measurements, was investigated iteratively using a likelihood ratio test (by using the anova function in r). the final model for the primary outcome measure incorporated a linear rate of change, random intercept and slope, and an unstructured residual variance structure. for the secondary outcomes with only two data points, we estimated a random intercept but not a random slope. q-q plots were used to assess the normal distribution of the residuals for all the mixed models. signifi­ cance for the fixed effects in the models was evaluated using the wald test, in which the estimate was divided by the standard error and compared against a z-distribution. inferences about the random effects of the model for the primary outcome measure are not evaluated by the wald test but rather from the estimated confidence intervals, where an interval not containing zero is interpreted in the same way as a significant p-value. confidence intervals were calculated using the confintmermod function with the profile method. the models were estimated using restricted maximum likelihood estimation, thus making use of all available data. the use of maximum likelihood estimation is one of two recommended approaches for dealing with missing data (schafer & graham, 2002). maximum likelihood estimators provide unbiased estimates in situations where data can be assumed to be missing at random (mar), meaning that the data are not missing systematically as a function of the would-be value. this is a less restrictive assumption than missing completely at random (mcar), where missingness is assumed to be independent of both the would-be value and the values of the other variables. due to differences in means between the conditions at pretreatment for the outcome measures, the parameter deemed to be of interest was the time x group interaction rather than the endpoint difference between the conditions. the conditions were coded as scheduled support = -0.5 and support on demand = 0.5. the cohen’s d between-group effect size for the estimated parameters of the models was calculated with the lme.dscore function using the satterwaites degrees of freedom according to the formula d = 2t/sqrt(df) (rosenthal, 1994). observed within-group ef­ käll, olsson lynch, sundling et al. 9 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ fect sizes were calculated with the pooled standard deviations from the preand post treatment measurements. between-group effect sizes were interpreted according to the recommendation provided by cohen, with 0.20, 0.50, and 0.80 corresponding to small, moderate, and large effect sizes, respectively (cohen, 1988). reliable change/deterioration was calculated according to the formula provided by jacobson and truax (1991), where the pretreatment mean was subtracted from the post treatment mean and divided by the pooled standard deviation adjusted for the instru­ ment’s test–retest reliability (jacobson & truax, 1991). the critical value for the lsas-sr was set at ± 28 points. results baseline characteristics the demographic characteristics of the sample are presented in table 2. the conditions did not differ significantly with regard to age, gender, civil status, or education level, all of which were p > .05. attrition, missing data, activity statistics, and adherence five participants in the support-on-demand group (10%) dropped out of the study during the treatment period. one of the participants from the scheduled support group dropped out during the treatment period (2%). there was no significant difference in the propor­ tion of dropouts between the two conditions, χ2(1) = 2.93, p = .087. for the sample as a whole, data were provided for 87% of the primary outcome measurements during the study. a total of 49 participants (98%) in the group with scheduled support completed all post treatment measurements. in the support on demand group, 42 participants (86%) completed all post treatment measures. the groups differed significantly in this regard, χ2(1) = 5.03, p = .025, suggesting that the support on demand group was less likely to complete the post treatment measurement. for the clinical and demographic variables, there were no significant differences between those who completed the post treatment assessment and those who did not (all p > .05). activity statistics are presented in table 3. for the support on demand group, the average total number of messages sent to the clinician during the treatment was 0.6 (sd = 1.10, range = 0–4), which was much lower than in the scheduled support group (m = 15.04, sd = 8.03, range = 0–45) (p < .001). on average, the support on demand group accessed 77.4% of the modules, while the scheduled support group accessed 83.3%. this difference was not significant, p = .359. however, participants with scheduled sup­ port completed significantly more modules (79.2% on average) than participants in the support on demand group (64.2% on average), p < .001. the group receiving scheduled support also posted more on the discussion forum (p < .001). as expected, clinicians support on demand versus scheduled support in icbt 10 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ supporting the scheduled support group also spent more time on average attending to their participants than the clinician responsible for the support on demand group (p < .001). table 2 demographic and clinical characteristics of the sample (n = 99) characteristic scheduled support support on demand m sd m sd t(97) p age 39.44 10.60 37.59 11.42 0.84 .33 n % n % χ2 p gender female 17 34.0 22 44.9 1.23 .32 male 33 66.2 27 55.1 civil status single 19 38.0 17 32.7 0.23 .63 in a relationship/married 31 62.0 32 65.3 highest educational degree primary school 1 2 3 6.1 5.98 .11 high school 12 24 13 26.5 university 31 62 20 40.8 other post-secondary education 6 12 13 26.5 m sd m sd t(97) p outcome measure lsas 58.76 24.14 69.71 21.99 -2.36 .020 sias 43.24 15.09 48.82 14.14 -2.74 .007 qoli 1.29 1.66 0.22 1.59 3.30 .001 m sd m sd u p sps 28.80 13.73 36.69 14.94 2.822 .005 bai 11.56 7.30 16.82 8.45 3.211 .001 madrs-s 12.50 6.12 17.02 7.63 3.007 .003 note. lsas = liebowitz social anxiety scale – self-rated; sias = social interaction anxiety scale; sps = social phobia scale; bai = beck anxiety inventory; madrs-s = montgomery-åsberg depression rating scale – self-rated; qoli = quality of life inventory; u = mann-whitney u-test statistic. käll, olsson lynch, sundling et al. 11 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ table 3 statistics on activity and comparisons between the conditions variable scheduled support support on demand t(97) pm (sd) m (sd) number of emails sent by participants to the clinician 15.04 (8.03) 0.44 (1.09) 12.48 < .001 number of posts made on the discussion forum 11.76 (7.99) 3.57 (5.24) 6.01 < .001 modules accessed during treatment (out of nine) 7.50 (2.49) 6.97 (2.82) 0.92 .359 modules completed during treatment (out of nine) 7.13 (2.48) 5.78 (2.89) 2.36 .020 clinician time per week and participant (minutes) 14.00 (6.08) 0.6 (1.10) 15.30 < .001 the multiple regression model showed no significant predictive value in residualized gain score for neither condition, β = -.33, p = .226, or the number of completed modules, β =.08, p = .585. there was, however, an interaction between condition and module completion for the gain scores, β =.55, p = .045. this suggests that the number of completed modules was significantly related to a greater reduction in symptoms but only in the support on demand group. the explained variance in the lsas-sr outcome was r 2 = 0.141. primary outcome liebowitz social anxiety scale – self report (lsas-sr) observed means including effect sizes are reported in table 4. for the lsas-sr ratings, the mixed-effects model revealed significant heterogeneity in both the intercept, sd = 23.26, 95% ci [19.99, 26.81], and the slope, sd = 2.43, 95% ci [2.05, 2.84], across the sample. additionally, the results showed a strong correlation between intercept and slope, r = -.53, 95% ci [-.67, -.35], suggesting that higher initial ratings were related to a steeper decline in symptoms during the treatment period. the fixed effects showed a significant difference between the groups at pretreatment, b = 11.40, 95% ci [2.02, 20.79], se = 4.79, p = .019, indicating that the support on demand group had significantly higher ratings on the lsas-sr at the start of the treatment. there was a significant linear decrease in symptoms over each unit of time (one week) for the entire sample, b = -2.61, support on demand versus scheduled support in icbt 12 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ 95% ci [-3.13, -2.09], se = 0.26, p < .001. the interaction between time and group was not significant, b = -0.07, 95% ci [-1.10, 0.97], se = 0.53, p = .898, suggesting that there was no significant difference in slope between the two conditions. the effect size for this comparison was d = 0.02, 95% ci [-0.37, 0.43], with the slight difference favoring the condition with support on demand. table 4 observed means for the outcome measures at preand post-treatment with within-group effect sizes outcome measure pre-treatment post-treatment observed within-group effect size m (sd) n m (sd) n d [95% ci] lsas scheduled 58.76 (24.14) 50 37.80 (22.79) 49 -0.89 [-1.31, -0.48] on demand 69.71 (21.99) 49 47.62 (22.43) 42 -1.00 [-1.43, -0.56] sias scheduled 43.24 (15.09) 50 32.90 (16.53) 49 -0.65 [-1.06, -0.25] on demand 48.82 (14.14) 49 38.43 (15.96) 42 -0.69 [-1.12, -0.27] sps scheduled 28.80 (13.73) 50 18.71 (13.27) 49 -0.75 [-1.16, -0.34] on demand 36.69 (14.94) 49 23.76 (15.11) 42 -0.86 [-1.29, -0.43] bai scheduled 11.56 (7.30) 50 8.18 (7.62) 49 -0.45 [-0.85, -0.05] on demand 16.82 (8.45) 49 11.05 (7.68) 42 -0.71 [-1.14, -0.29] madrs-s scheduled 12.50 (6.12) 50 7.86 (6.20) 49 -0.75 [-1.16, -0.35] on demand 17.02 (7.63) 49 10.76 (7.36) 42 -0.83 [-1.26, -0.40] qoli scheduled 1.29 (1.66) 50 2.04 (1.67) 49 0.45 [0.05, 0.85] on demand 0.22 (1.59) 49 0.88 (1.61) 42 0.41 [0.00, 0.82] note. lsas = liebowitz social anxiety scale – self-rated; sias = social interaction anxiety scale; sps = social phobia scale; bai = beck anxiety inventory; madrs-s = montgomery-åsberg depression rating scale – self-rated; qoli = quality of life inventory. secondary outcomes social interaction anxiety scale the model did not indicate a significant initial difference between the conditions in the sias ratings b = 5.08, 95% ci [-4.46, 14.62], se = 4.89, p = .301. overall, the sias scores decreased during the treatment, b = -10.12, 95% ci [-16.42, -4.26], se = 1.36, p < .001. the interaction between time and group was not significant, b = 0.50, 95% ci [-4.46, 5.81], käll, olsson lynch, sundling et al. 13 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ se = 2.71, p = .855. this difference in change equaled an effect size of d = 0.17, 95% ci [-0.35, 0.45] in favor of the group with scheduled support. social phobia scale the analysis showed a significant initial difference between the conditions on the sps, b = 10.04, 95% ci [1.32, 18.75], se = 4.47, p = .026. there was a significant overall average decrease from pre to post treatment, b = -11.03, 95% ci [-15.88, -4.29], se = 1.21, p < .001. the time x group interaction was not statistically significant, b = -2.15, 95% ci [-6.87, 2.59], se = 2.42, p = .377. this difference in change corresponded to an effect size of d = 0.18, 95% ci [-0.22, 0.59] in favor of the support on demand group. beck anxiety inventory the groups differed significantly in their initial bai ratings, b = 7.49, 95% ci [2.61, 12.38], se = 2.50, p = .003. there was an overall decrease in the bai scores, b = -4.36, 95% ci [-5.74, -2.99], se = 0.70, p < .001. the interaction between time and group was not statistically significant, b = -2.24, 95% ci [-6.83, 2.04], se = 1.40, p = .115. the corresponded to an effect size of d = 0.34, 95% ci [-0.31, 1.03] favoring the support on demand group. montgomery åsberg depression rating scale – self report there was a significant pretreatment difference in the madrs-s scores, b = 5.73, 95% ci [1.40, 10.07], se = 2.22, p = .011. after the treatment period, the analysis showed a significant decrease for the sample, b = -5.30, 95% ci [-6.54, -4.08], se = 0.63, p < .001. the interaction between time and group was again not significant, b = -1.21, 95% ci [-3.68, 1.24], se = 1.26, p = .338. the effect size for the difference in change between the groups was d = 0.20, 95% ci [-0.21, 0.61] favoring the support on demand group. quality of life inventory the groups did not differ significantly in their pretreatment qoli scores, b = -0.88, 95% ci [-2.46, 0.46], se = 0.47, p = .064. the sample showed a significant increase in the qoli during the treatment period, b = 0.66, 95% ci [0.23, 1.17], se = 0.12, p < .001. the groups did not differ significantly in their changes during this period, as indicated by the interaction between group and time, b = -0.20, 95% ci [-1.01, 0.86], se = 0.24, p = .423. the effect size for the difference in change between the groups during the treatment was d = 0.17, 95% ci [-0.76, 0.89] favoring the group with scheduled support. reliable change/deterioration in total, 27 of the respondents (27%) at post treatment met the criteria for reliably improving during the treatment period. none of the participants were classified as support on demand versus scheduled support in icbt 14 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ reliably deteriorated. the proportion of clinically significantly improved participants did not differ between the scheduled support group (n = 12) and the support on demand group (n = 15), fisher’s exact p = .504. discussion the aim of this study was to investigate the effects of a support on demand model for delivering icbt targeting sad relative to a standardized form of clinical support. results suggested overall significant reductions in symptoms of sad and related psycho­ pathology, along with an increase in quality of life with no significant between-group differences. the effect sizes for the estimated within-group pre-to-post comparisons on the measures of social anxiety were all large. the reduction in the symptoms of social anxiety is consistent with earlier findings indicating that icbt can be an effective alter­ native for treating sad (guo et al., 2021). results further suggest that active therapist guidance may be reduced with support-on-demand without significant loss of treatment gains. the lack of significant differences in change between the groups and the nonexistentto-small between-group effect sizes are in line with the notion that support on demand can be a way of delivering icbt for sad. the findings also add to the literature on com­ parisons between the support on demand format and traditional ways of administering icbt with weekly clinician support. like earlier studies (hadjistavropoulos et al., 2017; hadjistavropoulos et al., 2019), the analyses indicated that the two conditions did not differ significantly in change during the treatment. although the randomization “failed” as the groups differed at baseline, the lack of significant interactions between time and group suggests that support on demand can be a sufficiently effective way of delivering icbt compared to the more established clinician-guided format. that has positive impli­ cations for scalability (andersson et al., 2019). as expected, participants in the support on demand condition required significantly less clinician time per module than scheduled support participants. the average number of requests for help and/or feedback was low (m = 0.44), and none of the participants sent more than four messages to the clinician. extrapolating from this, it is likely that a support on demand model could be a resourceeffective way of disseminating icbt for sad, given that there are clinicians who are prepared to provide support when needed. this differentiates on demand icbt from fully self-guided versions in which contact with clinicians is not offered or only possible in urgent cases. however, the reduced need for clinician support gives credibility to the idea that icbt could be administered to a larger number of patients with relatively few clinicians, thus making it easier to disseminate in contexts where a lack of trained clinicians is a problem. as unguided interventions have sometimes been deemed less effective than interventions with scheduled support (ciuca et al., 2018), a support on käll, olsson lynch, sundling et al. 15 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ demand model could serve as a compromise, making it possible to disseminate more broadly with the decreased need for clinician support. while the two guidance conditions produced comparable reductions in social anxiety, there were some differences in the activity levels between them. participants in the group with scheduled support completed more modules, sent more emails to their clini­ cian, and made more posts on the discussion forum than participants with support on demand. it is unclear whether activity levels such as these are important in relation to the outcome of icbt in general, but the fact that module completion predicted a stronger reduction in symptoms in the support on demand group could be important. future studies could investigate this relationship and whether module engagement in the support on demand condition can be increased with the addition of optional components such as personalized reminders (hilvert-bruce et al., 2012). for unguided icbt, treatment credibility has also been noted as relevant to adherence (nordgreen et al., 2012), and this would be interesting to investigate in relation to the on-demand format. of note is that a significantly larger proportion of the participants in support on demand failed to complete the post treatment measures. this is likely due to a larger dropout rate during the treatment period. as the participants who provided post treatment ratings did have lower pretreatment scores on the bai, the results for this outcome measure should be interpreted with caution. inquiring about the reasons for dropout and non-adherence could be important going forward. such information may inform decisions about who the support on demand format is a good match compared to a scheduled and structured mode of clinician support. the results of the study should be viewed with some limitations in mind in addition to the fact that it is a file drawer study and hence could be less relevant even if technology in many ways has remained the same. first, the sample size was suboptimal for testing the differences between the two active treatment conditions. as cuijpers et al. (2019) noted, studies investigating the components of psychological treatments often have far too small a sample to serve as outright non-inferiority trials (cuijpers et al., 2019). it is important to note that the present study was not intended as such but rather a proof-of-concept trial regarding the ability to provide a new way of guiding participants through an icbt treatment. when the sofie-6 study was conducted, no such trials had been published apart from studies testing the added value of scheduled telephone calls (andersson et al., 2003; kenwright et al., 2005). the results should not be interpreted as conclusive but rather as an indication that support on demand can be feasible in the treatment of sad and possibly other conditions. additional, better-powered trials are needed, along with studies on change mechanisms, as we do not know what works for whom in terms of support. second, the randomization procedure did yield unbalanced group in terms of their pre-treatment differences. though the statistical analyses focused on the differences in support on demand versus scheduled support in icbt 16 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ change over time, rather than just the endpoint differences between the conditions, this should be kept in mind when interpreting the results and the outcome ratings. third, the study lacked data on some variables that might be of interest in addition to ratings of symptoms. for example, we did not measure treatment satisfaction or working alliance during and at post treatment. although the groups did not differ significantly with regard to changes in the outcome measures, such information could be valuable when seeking to understand other factors that might be important, such as adherence and module completion. fourth, data were not collected beyond the post treatment assessment. although the comparison of changes between the two conditions did not differ during the treatment period, the findings by ivanova et al. (2016) indicated that differences in effect may occur later (ivanova et al., 2016). while the long-term effects of icbt in general is favorable (andersson, 2018), future studies should strive to investigate the long-term effects of different support forms. lastly, though both the conditions had access to a forum, the condition with sched­ uled support made use of this function significantly more often. given that a similar forum may produce symptom reductions (griffiths et al., 2009), the fact that the design of the present study did not control for the specific effect of forum usage is a limitation. in conclusion, the present study provides support for the role of support on demand as a way of delivering icbt, and that the format is suitable in the treatment of sad. it can also serve as an example of the importance of still reporting studies in which the data (in this case, randomization group differences) do not fulfill expectations. the findings are important, as groups exhibited very similar symptom trajectories during the treatment period, regardless of whether they received scheduled weekly support, or had the option to contact a clinician when needed. additionally, no significant differences were found for any of the secondary measures. given the small number of studies testing the support on demand format, we look forward to replications and systematic reviews when a sufficient number of trials have been conducted. funding: this study was sponsored in part by a grant from the swedish research council to professor furmark, and a grant from linköping university to professor andersson. the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. acknowledgments: we thank members of sofie-6 research group for their help with the original study. competing interests: three of the authors (tf, pc, ga) have published a self-help book based on the material tested in the study. ethics statement: the study was approved by the ethics committee of uppsala university and registered (identifier: umin000001383). käll, olsson lynch, sundling et al. 17 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://www.psychopen.eu/ references acarturk, c., cuijpers, p., van straten, a., & de graaf, r. 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(2016). features and functionality of the iterapi platform for internet-based psychological treatment. internet interventions, 6, 107– 114. https://doi.org/10.1016/j.invent.2016.09.006 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. support on demand versus scheduled support in icbt 22 clinical psychology in europe 2023, vol. 5(3), article e11379 https://doi.org/10.32872/cpe.11379 https://doi.org/10.1186/s12916-017-0889-2 https://doi.org/10.1016/j.janxdis.2013.08.002 https://doi.org/10.1016/j.chb.2008.05.006 https://doi.org/10.1001/jamapsychiatry.2019.3986 https://doi.org/10.1016/j.invent.2016.09.006 https://www.psychopen.eu/ support on demand versus scheduled support in icbt (introduction) method participants and recruitment treatment measures power statistical analyses results baseline characteristics attrition, missing data, activity statistics, and adherence primary outcome secondary outcomes reliable change/deterioration discussion (additional information) funding acknowledgments competing interests ethics statement references harbingers of hope: scientists and the pursuit of world peace editorial harbingers of hope: scientists and the pursuit of world peace seithikurippu r. pandi-perumal 1,2 , willem a. c. m. van de put 3,4 , andreas maercker 5 , stevan e. hobfoll 6 , velayudhan mohan kumar 7 , corrado barbui 8 , arehally marappa mahalaksmi 9 , saravana babu chidambaram 9 , per olof lundmark 10,11 , tual sawn khai 12 , lukoye atwoli 13 , vitalii poberezhets 14 , ramasamy rajesh kumar 15 , derebe madoro 16 , hernán andrés marín agudelo 17 , samuel ratnajeevan herbert hoole 18 , luísa teixeira-santos 19,20 , paulo pereira 21 , konda mani saravanan 22 , anton vrdoljak 23 , miguel meira e cruz 24 , chellamuthu ramasubramanian 25 , alvin kuowei tay 26 , janne grønli 27 , marit sijbrandij 28 , sudhakar sivasubramaniam 29 , meera narasimhan 30 , eta ngole mbong 31 , markus jansson-fröjmark 32,33 , bjørn bjorvatn 34,35 , joop t. v. m. de jong 36,37 , mario h. braakman 38 , maurice eisenbruch 39 , darío acuña-castroviejo 40 , koos van der velden 41 , gregory m. brown 42 , markku partinen 43,44 , alexander c. mcfarlane 45 , michael berk 46 [1] saveetha medical college and hospitals, saveetha institute of medical and technical sciences, saveetha university, chennai, india. [2] division of research and development, lovely professional university, phagwara, punjab, india. [3] section of international health policy, institute for tropical medicine antwerp, antwerp, belgium. [4] institute of international humanitarian affairs (iiha), fordham university, bronx, ny, usa. [5] psychopathology and clinical intervention, university of zurich, zurich, switzerland. [6] star consultants – stress, anxiety and resilience, salt lake city, ut, usa. [7] kerala chapter, national academy of medical sciences (india), new delhi, india. [8] who collaborating centre for research and training in mental health and service evaluation, department of neuroscience, biomedicine and movement sciences, section of psychiatry, university of verona, verona, italy. [9] department of pharmacology, jss college of pharmacy, jss academy of higher education and research, mysuru, india. [10] department of optometry, radiography and lightning design, university of south-eastern norway, kongsberg, norway. [11] national centre for optics, vision and eye care, kongsberg, norway. [12] school of graduate studies, lingnan university, hong kong sar, china. [13] medical college east africa, brain and mind institute, the aga khan this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.13197&domain=pdf&date_stamp=2023-12-22 https://orcid.org/0000-0002-8686-7259 https://orcid.org/0000-0002-3306-5287 https://orcid.org/0000-0001-6925-3266 https://orcid.org/0000-0003-4136-0929 https://orcid.org/0000-0002-8477-6679 https://orcid.org/0000-0003-1073-9282 https://orcid.org/0000-0003-0966-8333 https://orcid.org/0000-0003-2357-056x https://orcid.org/0000-0001-8293-6184 https://orcid.org/0000-0003-4904-5421 https://orcid.org/0000-0001-7710-9723 https://orcid.org/0000-0003-2581-824x https://orcid.org/0000-0002-4351-0532 https://orcid.org/0000-0001-6901-2892 https://orcid.org/0000-0001-8050-2454 https://orcid.org/0000-0003-2552-6781 https://orcid.org/0000-0003-3110-7276 https://orcid.org/0000-0003-0227-2010 https://orcid.org/0000-0002-5541-234x https://orcid.org/0000-0002-0559-0981 https://orcid.org/0000-0001-6076-0878 https://orcid.org/0000-0002-0662-4688 https://orcid.org/0000-0002-9330-3929 https://orcid.org/0000-0002-2781-3533 https://orcid.org/0000-0001-5430-9810 https://orcid.org/0000-0002-1648-5474 https://orcid.org/0000-0002-7065-4435 https://orcid.org/0000-0001-8911-0684 https://orcid.org/0000-0003-2059-1621 https://orcid.org/0000-0001-7051-745x https://orcid.org/0000-0002-7652-7509 https://orcid.org/0000-0003-0314-5160 https://orcid.org/0000-0003-1734-3651 https://orcid.org/0000-0002-9680-1560 https://orcid.org/0000-0002-4002-3413 https://orcid.org/0000-0003-3222-9013 https://orcid.org/0000-0002-8182-9368 https://orcid.org/0000-0002-3829-9509 https://orcid.org/0000-0002-5554-6946 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ university, nairobi, kenya. [14] department of propedeutics of internal medicine, national pirogov memorial medical university, vinnytsya, ukraine. [15] all india institute of training and education (aiite), new delhi, india. [16] department of psychiatry, college of medicine and health sciences, dilla university, dilla, ethiopia. [17] behavioral sleep medicine institute, neumocenter, research department, medellín, colombia. [18] baldaeus theological college, adukubar, konesapuri, trincomalee, sri lanka. [19] center for health technology and services research, porto, portugal. [20] nursing school of coimbra, coimbra, portugal. [21] environmental management laboratory, mykolas romeris university, vilnius, lithuania. [22] department of biotechnology, bharath institute of higher education & research, chennai, india. [23] faculty of civil engineering, architecture and geodesy, university of mostar, mostar, bosnia and herzegovina. [24] centro cardiovascular da universidade de lisboa, lisbon school of medicine, lisbon, portugal. [25] division of community psychiatry, m. s. chellamuthu trust and research foundation, madurai, india. [26] discipline of psychiatry and mental health, school of clinical medicine, university of new south wales, sydney, nsw, australia. [27] department of biological and medical psychology, university of bergen, bergen, norway. [28] department of clinical, neuroand developmental psychology, who collaborating center for research and dissemination of psychological interventions, amsterdam public health research institute, vrije universiteit amsterdam, amsterdam, the netherlands. [29] department of biotechnology, manonmaniam sundaranar university, tirunelveli, tamil nadu, india. [30] department of neuropsychiatry and behavioral science, school of medicine, university of south carolina, columbia, sc, usa. [31] momentum integrated health resilience (mihr), ima world health, goma, north kivu, democratic republic of congo. [32] centre for psychiatry research, department of clinical neuroscience, karolinska institute, stockholm, sweden. [33] stockholm health care services, region of stockholm, stockholm, sweden. [34] department of global public health and primary care, university of bergen, bergen, norway. [35] norwegian competence center for sleep disorders, haukeland university hospital, bergen, norway. [36] cultural psychiatry and global mental health, amsterdam umc, amsterdam, the netherlands. [37] boston university school of medicine, boston, ma, usa. [38] transcultural forensic psychiatry, tilburg law school, department of criminal law, tilburg university, tilburg, the netherlands. [39] department of psychiatry, school of clinical sciences at monash health, monash university, clayton, victoria, australia. [40] centro de investigación biomédica, departamento de fisiología, facultad de medicina, instituto de biotecnología, universidad de granada, granada, spain. [41] public health, department of primary and community care, radboud university medical center, nijmegen, the netherlands. [42] centre for addiction and mental health, department of psychiatry, university of toronto, toronto, canada. [43] sleep medicine, helsinki sleep clinic, helsinki, finland. [44] department of clinical neurosciences, clinicum, university of helsinki, helsinki, finland. [45] psychiatry, faculty of health and medical sciences, the university of adelaide, adelaide, south australia, australia. [46] the institute for mental and physical health and clinical translation (impact), school of medicine, deakin university, barwon health, geelong, australia. clinical psychology in europe, 2023, vol. 5(4), article e13197, https://doi.org/10.32872/cpe.13197 published (vor): 2023-12-22 corresponding author: seithikurippu r. pandi-perumal, saveetha medical college and hospitals, saveetha institute of medical and technical sciences, saveetha university, chennai, india. e-mail: pandiperumal2023@gmail.com abstract the ongoing wars in many regions—such as the conflict between israel and hamas—as well as the effects of war on communities, social services, and mental health are covered in this special editorial. this article emphasizes the need for international efforts to promote peace, offer special editorial: harbingers of hope 2 clinical psychology in europe 2023, vol. 5(4), article e13197 https://doi.org/10.32872/cpe.13197 https://www.psychopen.eu/ humanitarian aid, and address the mental health challenges faced by individuals and communities affected by war and violence. keywords sdgs, un, unhcr, covid-19, global health diplomacy, hamas, israel, mental health, psychiatry, middle east, military invasion, palestine, peace, scientist, sustainable development goals, war “now i am become death, the destroyer of worlds” the bhagavad gita the world has recently endured covid-19, followed by the russian invasion of ukraine, the worldwide outrage about unprovoked invasions and subsequent deaths of civilians, and, currently, the deadly war between israel and hamas in gaza appears to have no end in sight. in the context of a long duration of bad blood between palestinians and israelis, hamas attacked israel in early october, an invasion which was evidenced by videos of murder, rape, torture, and kidnapping of civilian hostages. at the time of writing, while hamas continues its rocket attacks on israeli cities, israel has responded with a ground invasion and massive bomb strikes, activities that have resulted in incremental deaths among civilians, a particular heart-wrenching tragedy in gaza, with its very high population ratio of children and youth. the massive death and destruction have raised alarms among all nations. what is badly needed is humanitarian assistance in gaza, where the population lacks food, water, and fuel. israel, in the meanwhile, has lost the hostages in gaza but also many of its young men and young women who are now waging war on five fronts. fear reigns on both sides. more civilians are being killed every day, injured, displaced, bereaved, traumatized, and deprived of home and livelihood. fear of the outbreak of a re­ gional conflict has spread beyond gaza and israel, and large-scale public demonstrations are taking place around the world, especially on western university campuses where palestinians are viewed as the underdogs in an unequal war. we, as scientists and clinicians, have the means, whenever possible, of relieving anxiety and emotional distress. hence, we feel the need to make our voices heard in the midst of this crisis. there are turning points in history that require the dissemination of good sense. armed conflicts significantly undermine the economic vitality of conflict-affected nations (seleznova et al., 2023) and severely harm their social, physical, and human capital, both during and after the conflict is over. if international organizations are not given the opportunity and support to take urgent action, a humanitarian disaster will take place in gaza. amidst overwhelming despair and a general feeling of helplessness, we want to use our experience in researching the consequences of war and violence on mental health to lay out the facts regarding the impact of war on civilization. the effects of violence, from israel and gaza to afghanistan, cambodia, the demo­ cratic republic of congo, iraq, libya, syria, yemen, myanmar, nepal, rwanda, sri lanka, pandi-perumal, van de put, maercker et al. 3 clinical psychology in europe 2023, vol. 5(4), article e13197 https://doi.org/10.32872/cpe.13197 https://www.psychopen.eu/ syria, south sudan, sudan, and ukraine, have all been well studied (familiar et al., 2021; kienzler & sapkota, 2020; razjouyan et al., 2022; sá et al., 2022). history has supplied un­ ambiguous evidence of the lasting harm of warfare (hyseni duraku et al., 2023; leshem et al., 2023; saw et al., 2023; thomas et al., 2023). international wars, civil wars, proxy battles, conflicts, invasions, and insurgencies all end badly. they are all accompanied and followed by disruptions in the delivery of basic social services, especially access to healthcare, which has led to epidemics and spikes in infection and diseases, critical battle-related injuries, and chronic disability (blais et al., 2023), acute malnutrition, acute and chronic mental health conditions, and horrific deaths (sher, 2023). wars always re­ sult in widespread suffering, enduring stress, trauma, loss, and population displacement, which can reverberate and scar the well-being of future generations. this, in turn, leads to the continuation of violence across generations (betancourt, 2015; castro-vale et al., 2019; dashorst et al., 2019). in longstanding conflicts, past injustices are used as rationales for future retribution and aggression. human beings tend to ruminate over past grievances and, thus, view retaliation as justified. continued violence rips at the social fabric of society, and healing is difficult, but can be achieved (kapshuk & deitch, 2023). it was achieved, against all odds, in northern ireland (uluğ et al., 2023). living in war-torn countries has been associated with physical handicaps, and mental and psychological anguish (due to exposure to death). complaints such as post-traumat­ ic stress disorder (ptsd), anxiety, depression, sleeplessness, nightmares (birhan et al., 2023; pavlova et al., 2023; rogowska & pavlova, 2023), alcohol and substance abuse (dissanayake et al., 2023), suicidal thoughts, tendencies, and attempted suicides (blais et al., 2023; sher, 2023) sexual and non-sexual violence (hladik et al., 2023), and psychoso­ matic disorders all have been reported. these will have long-lasting effects on affected individuals. both aggressors and victims face immense mental challenges: war trauma, violations of human rights, social exclusion, discrimination, spiralling rates of family violence, poverty, and loss of social support. women and children are disproportionately impacted because they are unable to flee from danger due to their socioeconomic dependence on men (bendavid et al., 2021). parental loss and family disruption negatively affect children throughout their adult lives, partly because the memory of the terrors of war impairs the parenting abilities of survivors (ugurlu et al., 2016). children grow up with attachment difficulties and personality problems and remain, throughout life, at high risk of suicide. soldiers who serve in combat are increasingly reported as suffering from the often-catastrophic effects of injuries, medical problems such as chronic pulmonary disorders, as well as post-trau­ matic stress (jordans et al., 2009). decades of rehabilitation and rebuilding work are always required to aid in the recovery of individuals impacted by war as well as in the restoration of communities and the rebuilding of means of subsistence. many losses, not only of life but also of cultural traditions and meaningful religious symbols and structures, are irreversible. special editorial: harbingers of hope 4 clinical psychology in europe 2023, vol. 5(4), article e13197 https://doi.org/10.32872/cpe.13197 https://www.psychopen.eu/ when examining the effects of war on mental health and well-being, the results are invariably catastrophic whether for winners or losers, combatants or civilians. one of the most visible impacts of living in war-torn countries has been physical disability. wars disrupt the supply chain of food and potable water, contributing to mal­ nutrition, gastrointestinal and respiratory problems, as well as an increase in community infectious diseases. wars disrupt youth development and education (gómez-restrepo et al., 2023), leaving lasting transgenerational impacts on individuals and society. a notable concern is the mental health of first, second, and third generations of survivors. refugees are highly susceptible to trauma. as noted by the united nations high commissioner for refugees (unhcr), the main reasons for fleeing one’s country are related to war, the threat to survival, and the violation of human rights. these situations undermine mental health. fleeing brings with it the need to embrace a survival journey that involves abandoning one’s identity and self-worth, leaving one’s family and friends, subjecting oneself to dangerous, illegal crossings, and often needing to rely on unreliable human smugglers. parental loss and family disruption adversely affect migrants for life (raturi & cebotari, 2023). the inhumane conditions in which people seeking asylum are forced to live while awaiting international protection are disastrous for mental health. we know that human beings are resilient (purgato et al., 2020) but eventually, a limit to resilience is reached. in the present world situation, we need to prepare for the worst. specific physical, psychological, and mental health promotional help will be needed. psycho-education­ al, psychological, and other integrated health services will be required, as suggested by the recently released world mental health report (world health organization, noncommunicable diseases and mental health cluster, 2005). actions are needed to scale up interventions that are effective and sustainable in promoting mental health and preventing the development of mental disorders (tol et al., 2023). as proposed by who, in civil societies, basic training in mental health and mental health first aid for people in civil societies should be a concern of all governments. thousands of persons will be displaced and dispersed in host countries (teixeira-santos et al., 2023). there will be resource constraints and cost escalations. all sides in a conflict must make concessions, and this is difficult when there are wide differences in social, religious, and cultural norms, traditions, and values. a large influx of internally displaced people fleeing from violence at home is increasingly putting strains on the healthcare systems, other social services, and economies of countries that welcome refugees (somasundaram et al., 2023). there are compromises that civilians, host governments, and communities need to make so that refugees can integrate into the host society and contribute to their new country’s economic growth. if such an agenda fails, it will put pressure on the existing fabric of our global system and this usually leads to political unrest down the road. disinformation campaigns spread misinformation, disinformation, mal-information, tendentious information, and alternative facts on both sides of a war conflict. as a result, pandi-perumal, van de put, maercker et al. 5 clinical psychology in europe 2023, vol. 5(4), article e13197 https://doi.org/10.32872/cpe.13197 https://www.psychopen.eu/ even the well-intentioned fall prey to incorrect certainties, which they convey through their social networks. this results in unnecessary polarization and pitches neighbour against neighbour, destroying social networks that would be needed to re-establish the backbone of societies. the authors of this paper, as scientists and medical professionals, believe that our efforts are best focused on (i) averting conflicts among ourselves as a global community of scholars, scientists, and practitioners (not an easy feat); (ii) analyz­ ing the effects of war; (iii) assisting in the creation of relief efforts, (iv) developing and studying the beneficial effects of new mental health promotion and prevention strategies; and (v) planning for mental health resources for now and for the (ideally quick) return of peace. this special editorial has briefly highlighted some of the ramifications of war. when a conflict occurs in any part of the world, it triggers ripple effects that render us all vulnerable to fear. to combat fear, we unite as scientists to voice our opposition to war in general, as contrasted to protesting the rightness of one cause versus another. as scientists, we strongly encourage international leadership and diplomacy among statesmen as a path to enduring peace (pandi-perumal et al., 2022). scientific evidence has the power to improve the world's health, equality, justice, resilience, and prosperity for all. negotiations and compromise among partners in dialogue lead to far better out­ comes than mutual killings. international helping organizations and impartial, well-re­ spected international leaders are crucial agents in advancing peace initiatives and giving civilians in war-torn regions, refugees, and internally displaced persons the much-needed assistance they require. as nelson mandela pointed out: “negotiation and discussion are the greatest weapons we have for promoting peace and development.” the united nations (un) is the driving force behind the sustainable development goals (“addressing sustainable development through economic empowerment,” 2019); this is an intergovernmental set of objectives that advocates for 17 goals and 169 targets, cover­ ing a wide range of sustainable development issues and measured through 230 individual indicators that are inextricably linked to peace and stability (united nations, n.d.). the sdgs are imperiled by conflicts that derail the process and prevent the aspiration of achieving critical milestones; this affects not only the countries directly involved in the conflict, but all nations. peace means better quality of life and better mental health. there is abundant scien­ tific evidence that vulnerable populations, the public, planetary health and safety, global security, and the global economy must be protected in these very dangerous times. as scientists, we are mindful of the challenging, intricate, multifaceted, and malignant consequences of wars. apart from its impact on human health, it also hurts biodiversity, accelerates climate disasters, and intensifies social inequalities, inequities, and injustices. special editorial: harbingers of hope 6 clinical psychology in europe 2023, vol. 5(4), article e13197 https://doi.org/10.32872/cpe.13197 https://www.psychopen.eu/ let’s form a multi-stakeholder partnership involving scientists, policymakers, legislators, and regulators to facilitate a sustainable future for our planet earth. funding: the authors received no financial support for the research, authorship, and/or publication of this article. acknowledgments: mb is supported by an nhmrc senior principal research fellowship and leadership 3 investigator grant (1156072 and 2017131). competing interests: the views expressed in this article are those of the authors and do not reflect the official policy or stance of the department, institution, or the nation they represent. the authors declare no conflicts of interest. data availability: data sharing not applicable to this article as no datasets were generated or analyzed during the current study. references addressing sustainable development through economic empowerment. 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(n.d.). united nations annual report 2023. united nations. retrieved november 4, 2023, from https://www.un.org/en/annualreport?gclid=cjwkcajw15eqbhbzeiwabdomeupt9 qhwkrkw3zvlp1lcr5ouojibbvvxfv9p0gbivejqi1mielhaerocw9aqavd_bwe world health organization, noncommunicable diseases and mental health cluster. (2005). who steps stroke manual: the who stepwise approach to stroke surveillance. world health organization. https://apps.who.int/iris/handle/10665/43420 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. special editorial: harbingers of hope 10 clinical psychology in europe 2023, vol. 5(4), article e13197 https://doi.org/10.32872/cpe.13197 https://doi.org/10.1590/1980-220x-reeusp-2022-0447en https://doi.org/10.1111/aphw.12491 https://doi.org/10.1016/s2214-109x(23)00128-6 https://doi.org/10.1080/17450128.2016.1181288 https://doi.org/10.1111/bjso.12608 https://www.un.org/en/annualreport?gclid=cjwkcajw15eqbhbzeiwabdomeupt9qhwkrkw3zvlp1lcr5ouojibbvvxfv9p0gbivejqi1mielhaerocw9aqavd_bwe https://www.un.org/en/annualreport?gclid=cjwkcajw15eqbhbzeiwabdomeupt9qhwkrkw3zvlp1lcr5ouojibbvvxfv9p0gbivejqi1mielhaerocw9aqavd_bwe https://www.un.org/en/annualreport?gclid=cjwkcajw15eqbhbzeiwabdomeupt9qhwkrkw3zvlp1lcr5ouojibbvvxfv9p0gbivejqi1mielhaerocw9aqavd_bwe https://apps.who.int/iris/handle/10665/43420 https://www.psychopen.eu/ needs, modes, and stances: three cardinal questions for psychotherapy practice and training scientific update and overview needs, modes, and stances: three cardinal questions for psychotherapy practice and training eshkol rafaeli 1 , alexandra k. rafaeli 2 [1] department of psychology and gonda center for neuroscience, bar-ilan university, ramat-gan, israel. [2] unit for psychological services, ben-gurion university, beer-sheva, israel. clinical psychology in europe, 2024, vol. 6(special issue), article e12753, https://doi.org/10.32872/cpe.12753 received: 2023-09-05 • accepted: 2023-11-29 • published (vor): 2024-04-26 handling editor: wolfgang lutz, department of psychology, university of trier, trier, germany corresponding author: eshkol rafaeli, department of psychology, bar-ilan university, ramat-gan, 5290002 israel. phone: +972-3-531-8582. e-mail: eshkol@biu.ac.il related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, guest editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract background: advances in motivational science (dweck, 2017), personality dynamics (lazarus & rafaeli, 2023), and process-based psychotherapy (hofmann & hayes, 2019) converge into a pragmatic, integrative, and transtheoretical model of practice and training. method: the model comprises three elements: a formulation centered on clients’ psychological needs which provides guidance regarding the goals and processes most profitable to pursue; a recognition that such pursuit frequently requires contending with a multiplicity of clients’ internal self-states (i.e., modes); and an enumeration of pragmatic therapeutic stances likely to help address clients’ need-related goals in light of their modes. results: we distill these elements into three cardinal questions: what needs does this client have that are not currently met, and what are the most profitable ways of remedying that frustration? what mode or modes does this client manifest – both generally and at this very moment? and what stance should i adopt in response to the client’s current mode? we suggest that clinicians should be trained to continually pose these questions and seek to answer them collaboratively with their clients. conclusion: this model – illustrated here using schema therapy terms – offers a process-based approach which serves as a theoretically integrative starting point but is general enough to provide an assimilative integration roadmap for therapists anchored in most primary orientations. integrative or assimilative therapists trained to attend to needs, modes, and stances are likely to be this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12753&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0002-1226-9678 https://orcid.org/0009-0001-5610-0743 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ (and be perceived as) particularly responsive, and thus, to enact “common factor” practices known to be conducive to therapeutic alliance and gains. keywords process-based therapy, universal psychological needs, modes/self-states, therapeutic stances, psychotherapy integration highlights • we present three crucial tasks for facilitating effective clinical training and practice. • first, identify core psychological needs to set therapy goals and effective interventions. • second, recognize the multiplicity of clients' different self-states (or modes). • third, flexibly adopt specific stances to respond well to clients' needs and modes. people seek and enter psychotherapy because something is amiss. it is the role of psychotherapists to help formulate what that “something” is, translate it into identifiable goals for change, present possible pathways towards these goals, collaborate with their clients as they try out these pathways, respond to unforeseen obstacles and turns-ofevents along the way, and ultimately help their clients get their frustrated or thwarted needs more adequately addressed. in this article, we will argue for a model of practice (and thus, of training) that can help psychotherapists embody and enact this role well. this model emphasizes three key elements. the first element is a formulation of a client’s story (or their presenting complaints) in terms drawn from a universal taxonomy of psychological needs, which provide guidance regarding the goals and processes that would be most profitable to pursue in therapy. the second element is the recognition that such pursuit does not always follow a straight path, and often involves grappling with a multiplicity of clients’ internal self-states (or modes). the third element, which builds on these first two, is an enumeration of pragmatic therapeutic stances which help address the client’s need-re­ lated goals in light of their modes. in concluding, we will put forward the idea that therapists trained to attend to needs, modes, and stances and to make implicit – or better yet, explicit – use of these elements are likely to be (and to be perceived as) particularly responsive, and thus, to enact “common factor” practices known to be conducive to therapeutic alliance and gains. one note: the model we present is drawn from schema therapy (rafaeli et al., 2010; young et al., 2003), a theoretically integrative approach rooted in cognitive behavioral, psychodynamic, and experiential thinking. indeed, throughout the paper, we use schema therapy terms to illustrate the three elements discussed. however, as we hope to show, the key points presented here do not require one to subscribe to schema therapy per needs, modes, and stances: key questions for practice and training 2 clinical psychology in europe 2024, vol. 6(special issue), article e12753 https://doi.org/10.32872/cpe.12753 https://www.psychopen.eu/ se, or even to favor theoretical integration. instead, they may provide a roadmap for assimilative integration for therapists anchored in most primary orientations. let’s begin with the first element. recent years have brought a growing under­ standing that empirically supported treatments have probably gained much of what there is to gain from categorical identification of syndromes and from the development of syndrome-specific protocols or interventions (hofmann & hayes, 2019; insel, 2022). in their stead, the time seems ripe for process-based therapy – interventions that eschew diagnostic labels and focus instead on procedures most likely to change underlying biopsychosocial processes or mechanisms tied to desirable treatment outcomes or goals across diagnostic boundaries. but how should these processes or mechanisms be identified? we would argue that a straightforward taxonomy of change mechanisms, one that is most likely to make intuitive appeal to clients as well, is a taxonomy of universal psychological needs. after all, as our opening paragraph illustrated, the logical transition from saying that people enter therapy “because something is amiss” to viewing it as an issue of addressing “frustrated or thwarted needs” is quite seamless. in a way, most schools of psychotherapy have an explicit or implicit model of motives or needs at their core. some base this core, explicitly, on darwinian evolutionary princi­ ples (gilbert, 2019; hayes et al., 2020) and note the centrality of the broad needs for survival and reproduction, from which they draw more specific goals (e.g., social safeness; gilbert et al., 2008). others adopt the principles of bowlby’s attachment theory (e.g., davila & levy, 2006; goodwin, 2003; slade & holmes, 2019), itself strongly influenced by darwinian thinking, and focus on specific biobehavioral drives towards pair-bonding, care-giving, and (centrally) the formation and maintenance of attachment bonds. (nota­ bly, a wide range of approaches use the term “attachment” in their title, or identify it explicitly as a key part of their model; e.g., diamond et al., 2003; hughes, 2004; johnson, 2019; milrod et al., 2016; it’s interesting to consider why the same credit hasn’t been giv­ en to darwinian theory). and of course, many approaches to psychotherapy – especially those that gained prominence in the mid 20th century – place particular (explicit) premia on needs that may be more uniquely human: e.g., the need for authenticity (perls et al., 1951), meaning (frankl, 1959), self-actualization (rogers, 1963), and creativity (may, 1969). for various reasons (probably similar that those recognized in adjacent fields, like personality psychology; e.g., del giudice, 2018; zeigler-hill et al., 2019), motivational accounts within psychotherapy fell out of favor in the height of the cognitive revolution of the 1970s-1990s. a possible consequence has been that evidence-based psychotherapy approaches which came of age in those decades – including ones with which we strong­ ly identify (e.g., cognitive behavioral therapy; barlow, 2021; beck, 1970; interpersonal psychotherapy, markowitz & weissman, 2004) have stayed rather silent when it comes to discussing needs or other motivational constructs. this does not mean that motives rafaeli & rafaeli 3 clinical psychology in europe 2024, vol. 6(special issue), article e12753 https://doi.org/10.32872/cpe.12753 https://www.psychopen.eu/ or needs – e.g., for safety, connection, competence, or even simply for a world that can be adequately understood – aren’t implicitly present in these therapeutic models. it just means that they are not seen as key concepts within these approaches. thus, our first proposed element is that the practice of psychotherapy – and training in it – should adopt an explicit and transtheoretical language to describe psychological needs so as to help therapies achieve their most basic goal of addressing these needs. what should this language be? rather than pitting one theoretical school (say, hu­ manism) against another (say, attachment-based or evolutionary-based approaches), we would argue that psychotherapists should instead follow the lead of pioneers such as grawe (1997) in turning to vibrant work being done in the broader field of psychology. grawe turned to miller et al.’s (1960) work on plans to develop his consistency theory, which emphasized the role of need fulfillment in promoting well-being and facilitating positive therapeutic change. today, we can build on more modern motivational work, in which recently developed frameworks (e.g., del giudice, 2018; dweck, 2017; schaller et al., 2017) still lead to remarkably similar clinical conclusions. we’ll illustrate this with one particularly comprehensive framework – carol dweck’s (2017) recently-proposed model linking motivation, personality, and development. dweck's model synthesizes extensive literature on psychological needs from both basic and clinical research to provide a broad and inclusive taxonomy of needs, including three basic ones and 4 compound ones. the three basic needs – for acceptance/belonging, competence, and optimal predictability (i.e., sufficient order and stability) – are thought to be universal, present at birth, and non-derivative. the compound needs for control (or autonomy), trust, and status/self-esteem, though also universal, are thought to each emerge a bit later in development from the conjunction of two basic needs (e.g., trust integrating acceptance and optimal predictability) and to require meta-cognitive capacities not present at birth (e.g., self-awareness). finally, the ultimate compound need for self-co­ herence, encompassing meaning and identity, is thought to be fed by all other compound as well as basic needs and to serve as the “master sensor” of whether things are as they should be. dweck (2017) argues that needs give rise to goals, and that as people pursue these goals, they develop representations (which she refers to as beats: beliefs, representa­ tions of emotions and representations of action tendencies). understanding these needs and the ensuing beats is key to understanding human development, motivation, and personality. importantly, it is also key to understanding human distress and it’s amelio­ ration. specifically, thwarted or frustrated needs and their down-stream consequences (namely, ineffective or maladaptive goals or representations) are key determinants of poor psychological well-being and should therefore be the focus of psychotherapy. most clinicians find this basic idea of putting needs at the forefront entirely con­ sonant with the underlying assumptions driving their clinical work. yet, with few needs, modes, and stances: key questions for practice and training 4 clinical psychology in europe 2024, vol. 6(special issue), article e12753 https://doi.org/10.32872/cpe.12753 https://www.psychopen.eu/ exceptions (e.g., consistency theory: grawe, 1997; motivational interviewing: miller & rollnick, 2002; ryan et al., 2011; schema therapy: rafaeli et al., 2010; young et al., 2003), these assumptions typically remain silent, even when the therapy is guided by an other­ wise explicit case conceptualization (see gilboa-schechtman, 2024, this issue). we argue that by offering (or at least attempting to develop) a comprehensive model of psychologi­ cal needs, dweck’s (2017) framework provides us with an approach for organizing any therapeutic work we do. this would be relevant in relatively straight-forward situations, in which one of the basic needs (for optimal predictability, belonging/acceptance, or com­ petence) is unmet. and it would be even more relevant when later-appearing compound needs (for control/autonomy, trust, self-esteem/status, or self-coherence [i.e., meaning and identity]) are frustrated, or when multiple needs compete or become intertwined. indirect evidence that good therapy helps clients meet their needs, and thus, improve their ability to live meaningful, satisfying lives full of love and work (cf. freud, 1930) abounds. but despite the intuitive appeal of this model, and despite calls for the actual assessment of need satisfaction or frustration (e.g., vansteenkiste & sheldon, 2006), limited empirical work to date has explored need-satisfaction directly. even schema therapy, which expressly speaks about the recognition and importance of needs, rarely uses measures to directly assess need satisfaction or frustration. once needs are identified, understood, and explored, the ends (or “targets”) of therapy become much clearer. but what about the means to reach these therapeutic ends? with respect to this pragmatic question, the psychotherapy field is full of many effective/effi­ cacious therapeutic interventions, drawn from diverse orientations that can help clients satisfy specific needs. for example, a frustrated need for competence is often profitably addressed using behavioral interventions such as graded task assignment; a frustrated need for relatedness is often addressed with interpersonal therapy interventions such as communication analysis; and a frustrated need for self-worth or self-esteem, likely to be accompanied by harsh self-criticism, may be most amenable to techniques such as two-chair dialogues, drawn from greenberg's (2004) emotion-focused therapy, as well as to self-affirmation tools taken from gilbert's (2014) self-compassion therapy. the training implications of focusing on needs are clear: trainees should become familiar with need models and should be provided with at least a basic toolset of thera­ peutic interventions that could serve as “first-line” choices once a client’s core needs are identified. if we had to pare this entire element down to one supervisory point, it is that clinicians (and trainees) should strive to answer this first cardinal question: “what need or needs does this client have that are not currently met, and what are the most profitable ways of remedying that frustration?”. based on this logic, we (the first author together with aaron fisher at uc berkeley and gal lazarus at the hebrew university) are currently implementing a randomized clinical trial comparing brief intervention protocols that are personalized (or not) with respect to the client’s most glaring frustrated need. to do so, we adopted specific em­ rafaeli & rafaeli 5 clinical psychology in europe 2024, vol. 6(special issue), article e12753 https://doi.org/10.32872/cpe.12753 https://www.psychopen.eu/ pirically-supported techniques from a variety of models deemed to be good first-line need-focused interventions (see table 1 for our choice interventions). whether these will indeed prove efficacious with respect to need fulfillment is of course an empirical question; if they do not, others will. table 1 a listing of psychological needs, characteristic distress tied to their frustration, and suggested first-line intervention tools for each the need the characteristic distress (and most prominent schemas) high-likelihood first-line interventions (and the approaches from which they are drawn) optimal predictability worried, anxious (vulnerability to harm) acceptance and commitment (act) or mindfulness tools for emotion regulation acceptance/belonging lonely, rejected, isolated (social isolation, abandonment) interpersonal psychotherapy (ipt) tools to create change in the interpersonal sphere competence dependent, incompetent (dependence, failure, insufficient self-control) behavior therapy (bt) techniques to improve performance trust mistrustful, hurt (mistrust/abuse, emotion deprivation) schema therapy (st) tools, such as imagery work on trust violations autonomy/control outwardly focused or unmotivated (subjugation, enmeshment, undeveloped self, approval seeking) assertiveness training tools, decisional balance chair-work, motivational interviewing tools self-esteem/status ashamed, self-critical (defectiveness/shame, unrelenting standards, punitiveness) self-compassion therapy (sct) tools, emotion focused (eft) tools for combatting the self-critic self-coherence (meaning, identity) lost, identity-less, nihilistic (self-sacrifice, entitlement/ grandiosity) values (commitment) work from act which brings us to the second element. as many clinicians, including novice ones, quickly learn, the picture of clearly defined aims (whether they be fulfillment of frustra­ ted needs or removal of diagnostic symptoms) achieved through clearly defined means (including evidence-based ones, known to be effective on average), is an overly ideal­ ized version of many therapeutic processes. even when clinicians ask the first cardinal question noted above and reach well-founded answers for it, they often run up against substantial obstacles which require attention to the here-and-now of therapy. needs, modes, and stances: key questions for practice and training 6 clinical psychology in europe 2024, vol. 6(special issue), article e12753 https://doi.org/10.32872/cpe.12753 https://www.psychopen.eu/ one example of these obstacles can be observed within the context of the therapeu­ tic alliance. extensive research on alliance (see flückiger et al., 2018) attests to how important but non-trivial it is to establish therapeutic bonds, and to develop shared understanding of the goals to which therapy should aspire and the tasks that could lead there. but alliance fluctuates across therapists, clients, sessions, or even moments (zilcha-mano, 2021), and alliance ruptures, impasses, and interpersonal enactments are ubiquitous in therapy (safran & kraus, 2014). why do these occur? the state-like nature of alliance (and alliance ruptures, enactments, etc.) points to a likely culprit: namely, the fact that people themselves (including clients and therapists) are not fixed actors or agents, but rather a collection of multiple selves (markus & wurf, 1987), parts (bromberg, 1996), “i-positions” (hermans, 2001), modes (rafaeli et al., 2016), or as bill stiles poetically noted – “a community of internal voices” (stiles, 2011). as this (very partial) list of terms illustrates, many clinical models (and increasingly, social, developmental, and personality research findings) seem to converge on a similar idea: that humans move around between different “modes” (our preferred term) – co­ hesive, experientially distinct, state-like manifestations of personality characterized by specific profiles of affects, behaviors, cognitions, and desires (lazarus & rafaeli, 2023). explicit attention to these modes in theory and research – but also in clinical practice (rafaeli et al., 2014; ryle & fawkes, 2007; stiles, 2011) – can provide an organizing framework for understanding both "typical" personality and all (or at least most) forms of psychopathology. and as we’ll show in a minute, they also play an outsized role in the here-and-now of therapy. thus, our second proposed element is that practice and training of psychotherapy must prepare clinicians to see multiplicity within their clients (and themselves). the idea that modes are present to some degree in every person’s phenomenology is easily intelligible to most people, who know, viscerally, how different it feels to be hurt, angry, self-critical, detached, reflective, playful, and so on. but therapists and trainees who become attuned to such modes (or voices, or selves, or parts, etc.) can use this attunement to facilitate therapist-client communication, practice more effective empathy, and repair alliance ruptures more effectively. they can also have (and share with their clients) an experience-near understanding of the clients’ varying and often distressing psychological states. not every client requires mode-based work. certainly, some clients enter therapy with sufficient reflectiveness and self-compassion (referred to, in schema therapy, as a “healthy adult mode”; young et al., 2003) and/or with sufficient playfulness and creativi­ ty, so that even if they do manifest some vulnerable modes (marked by pain or distress), they are relatively unencumbered by introjected voices (marked by self-criticism or self-punishment) or maladaptive coping parts (marked by avoidance, surrender, or overcompensation). with such clients, answering the first cardinal question posed earlier could suffice; after the focal needs are correctly identified, and a well-suited targeted rafaeli & rafaeli 7 clinical psychology in europe 2024, vol. 6(special issue), article e12753 https://doi.org/10.32872/cpe.12753 https://www.psychopen.eu/ response implemented, we should see their pain or distress abate. for example, a client with a relatively simple dilemma regarding a specific life decision may be accurately seen as lacking in (say) autonomy or internal motivation; these could probably be augmented by using (say) assertiveness training, decisional balance, or acceptance-and-commitment tasks. often, however, broad personality traits and/or more specific pernicious modes (which may reflect such traits) are so prominent that therapy invariably must address them or at least take them into account. for example, trait perfectionism (e.g., zinbarg et al., 2008), as well as state or trait self-criticism (e.g., löw et al., 2020; werner et al., 2019) have been tied to poorer treatment response; the same is true for avoidance (e.g., grosse holtforth, 2008). to address these, therapists should be prepared to ask a second cardinal question: “what mode or modes does this client manifest – both generally and at this very moment?”. answering this question helps conceptualize the client’s presentation in mode terms and brings this awareness of modes into clinical work. mode-aware clinical work (e.g., rafaeli et al., 2014; ryle & fawkes, 2007; stiles, 2006) aims to achieve better integration among modes through three broad processes: identifying and labeling individuals’ nota­ ble or recurrent modes; giving voice to adaptive and vulnerable modes over maladaptive or introjected ones; and creating adaptive boundaries between modes in ways that alter the relative dominance or power of specific modes. these processes frequently involve psychoeducation about the universality of modes coupled with cognitive, behavioral, and experiential methods. quite often, though, the best way to advance these processes is by implementing the third element of our model – the idea that mode-aware clinical work calls for the flexible adoption of different therapeutic stances depending on the client’s active mode. explicit or implicit therapeutic stances are present in many clinical approaches, and function as general rules for how therapists using that particular approach should engage with their clients. examples include using an open/accepting stance in acceptance and commitment therapy (e.g., o’neill et al., 2019), engaging in collaborative empiricism in cbt (tee & kazantzis, 2011), maintaining neutrality in transference-focused therapy (e.g., clarkin et al., 2021), experiencing and expressing empathy in self-psychology (e.g., kohut, 1981/2010), etc. though each of these stances may have its merits, they are often contradictory (e.g., acceptance vs. change, neutrality vs. empathy); moreover, there’s little reason to think that any one stance necessarily fits all clinical circumstances. rather than adhering to a single therapeutic stance, therapists attentive to modes have the opportunity to address their clients differentially – i.e., to ask themselves the third cardinal question: “what stance should i adopt in response to the client’s current mode?” to illustrate this idea, we consider the recommendations made within schema thera­ py (e.g., rafaeli et al., 2014) regarding the stances that would be most effective vis-à-vis needs, modes, and stances: key questions for practice and training 8 clinical psychology in europe 2024, vol. 6(special issue), article e12753 https://doi.org/10.32872/cpe.12753 https://www.psychopen.eu/ different categories of client modes (see table 2). we use these schema therapy categories because we see them as striking a good balance between optimal distinctiveness (i.e., minimizing definitional overlap among modes) and parsimony (i.e., limiting the number of modes as much as possible); for more discussion on adjudicating the number and identity of modes or mode categories, see lazarus and rafaeli (2023). table 2 mode categories, relevant example modes, and suggested therapeutic stances mode category relevant mode(s) in schema therapy suggested therapeutic stance reflective and self-compassionate mode healthy adult joining and mirroring this mode’s behavior when it is present. modeling such behavior when it needs strengthening. child modes (i.e., basic emotional need states) distressed mode, vulnerable child, angry child using limited reparenting to directly meet client emotional needs (e.g., appropriate nurturance, protection, limit-setting, encouragement, playful joining). maladaptive coping modes detached/avoidant protector, hopeless surrenderer, perfectionistic over-controller, etc. using the dialectic stance of empathic confrontation (empathy plus confrontation of maladaptive behaviors). dysfunctional introjected voices self-critic, punitive parent mode, etc. using straightforward confrontation to make the voice ego-dystonic; siding with the healthy adult against it; providing psychoeducation in less severe instances. let’s begin with the simplest stance, relevant to moments in which clients present with a strong, reflective (“healthy adult”) mode. in such moments, therapists are free to employ various evidence-based tools (and possibly adopt therapeutic stances such as cbt’s collaborative empiricism or act’s openness and acceptance). in broader terms, the therapeutic stance can be thought of as joining and as modeling of adaptive problem solving. in other moments, clients’ activated modes clearly reflect basic emotional need states: distress of various sorts (which schema therapy refers to as the “vulnerable child”), anger over unmet needs (“angry child”), impulsivity (“impulsive child”), but also con­ tentment/play (“content/happy child”). schema therapy’s reference to these as “child rafaeli & rafaeli 9 clinical psychology in europe 2024, vol. 6(special issue), article e12753 https://doi.org/10.32872/cpe.12753 https://www.psychopen.eu/ modes” is meant to evoke the idea that when clients (of whatever age) are in such modes, the most viable and appropriate response is often to try and meet the emotional needs directly – within the ethical boundaries of therapy – in ways that simulate a good-enough parent or attachment figure. thus, activated modes marked by intense primary emotions occasion a therapeutic stance referred to as limited reparenting, which aims to address the client’s hyper-arousal, help soothe them back into a window of tolerance (ogden & minton, 2000), and (ultimately) serve as a model for healthy self-care. intriguing evidence in support of this idea comes from recent work (fisher et al., 2023) showing that therapists’ oxytocin responses (a marker of caregiving system activation) following genuine displays of client distress mediate the association between client negative emotion activation and symptomatic change. quite often, clients manifest maladaptive coping modes, in which they attempt – knowingly or not – to avoid the distress of unmet needs using coping behaviors (e.g., avoidance, over-compliance, over-compensation) and/or cognitions (e.g., detachment, surrender, self-aggrandizement). these may bring short-term relief, but come with a hefty long-term cost: coping modes impede both raw emotional need states (i.e., the vulnerable child mode which evokes limited reparenting) and healthy (i.e., reflective, compassionate) states that would permit real engagement. to address coping modes, st calls for a third therapeutic stance, a dialectic balance of empathy and confrontation referred to as empathic confrontation. in this stance, therapists strive for empathy (or at least curiosity) for the need itself, for the distress that accompanies its frustration, and for the short-term relief brought about by the coping behaviors/cognitions; at the same time, they directly confront the specific behaviors or cognitions which are deemed maladaptive, and help clients develop healthier alternative behaviors/cognitions. finally, therapists may come face-to-face with clients’ introjected voices (e.g., voices of parents, other significant others, peers, or the society at large) that are a root cause of distress. these include punitive, self-critical, neglectful, and self-denigrating voices, and they call for yet another stance: one in which the therapist sets limits or directly confronts the introjects to help clarify their ego-dystonic nature and thus weaken them. the terminology and clinical guidelines above are drawn from schema therapy (e.g., rafaeli et al., 2016), an approach documented by a growing body of research to offer effective treatment for a range of relatively complex and chronic conditions (e.g., peeters et al., 2022; zhang et al., 2023). other mode-aware approaches may delineate the modes somewhat differently (e.g., stiles, 2006) or offer somewhat different guidelines for choos­ ing differential stances to address them (e.g., fosha, 2000; gilbert, 2019; greenberg, 2004). arbitrating which of these stances would work best remains an open empirical issue. conclusion. we presented a model of practice and training containing three ele­ ments, translated into the three cardinal questions: “what unmet needs are most promi­ nent for this client and how could they be addressed?”, “what mode is the client in right now?”, and “what stance would work best to address this client’s needs while in this needs, modes, and stances: key questions for practice and training 10 clinical psychology in europe 2024, vol. 6(special issue), article e12753 https://doi.org/10.32872/cpe.12753 https://www.psychopen.eu/ mode?”. these elements distill integrative ideas from schema therapy (rafaeli et al., 2010; young et al., 2003), but we believe they are general enough to serve as a starting point for a unifying language for most, if not all, therapists – and for clients. specifically, though cognitive-behavioral, emotion-focused, and psychodynamic therapists may quibble about the etiology of distress, the pros and cons of alleviating distress through direct interven­ tion (i.e., meeting vs. frustrating needs), or the merits of adopting flexible therapeutic stances, they are less likely to find cause for disagreement regarding the existence – and importance – of the first two elements discussed: needs and modes. establishing a formulation based on needs and (when needed) on modes as an explicit starting point, and using intuitive and experience-near terms to share this formulation with one’s client, empowers the client to have greater agency within their therapy. it also sets the stage for therapeutic work that harnesses contemporary understanding about both specific and common/nonspecific factors that exert beneficial therapeutic effects (see hofmann & barlow, 2014). specifically, therapists attentive to the three elements described here are likely to be implementing transtheoretical “common factors” known to be conducive to therapeutic gains. consider the widely-studied common factor of therapeutic alliance, responsible for a substantial portion of therapy’s benefits (e.g., flückiger et al., 2018). two strong (though understudied) predictors of alliance are responsiveness (reis & gable, 2015) and high-quality listening (itzchakov et al., 2022). both involve getting a clear picture of the client’s real as well as perceived needs (refoua & rafaeli, 2023), and being attuned to their present "mode". therapeutic alliance, and repair of ruptures in this alliance, require such responsiveness. specifically, in addressing clients’ core needs, a responsive therapist needs to identify whether, at the moment, they are mostly overwhelmed with pain/sadness/fear and can (at most) absorb some comfort (i.e., limited reparenting); too defended (detached, avoidant, compliant, argumentative, over-controlling, etc. – i.e., in a coping mode) to do any productive work and need to be coaxed away from these coping modes into more productive modes; truly toxic towards themselves (i.e., in an introjected negative mode) and need some limit-setting; or else are present, reflective, integrative, and self-compassionate enough (i.e., in a healthy adult mode) and thus able to work, shoulder-to-shoulder, towards their goals. interestingly, transtheoretical work on rupture resolution (e.g., safran et al., 2011) touches on these three elements as well. in particular, it recognizes that different needs (e.g., for communion vs. agency) may underlie disagreements regarding tasks or goals, and/or deterioration in the therapeutic bond. additionally, it adopts a similar “what to do when” approach, and thus calls for specific stances in response to different states. interestingly, whereas rupture repair work focuses on alliance states and views them predominantly intersubjectively, our model allows for, but does not assume, such inter­ subjectivity. rafaeli & rafaeli 11 clinical psychology in europe 2024, vol. 6(special issue), article e12753 https://doi.org/10.32872/cpe.12753 https://www.psychopen.eu/ of course, as the reviewers of an earlier draft correctly noted, even if we as clinicians and supervisors converge on this universal starting point of needs, modes, and stances, many questions remain to be explored: what instruments or procedures should be used to assess these? should interventions to address specific needs be selected primarily based on empirical evidence or guided by theoretical principles? should these choices be made uniformly across all therapeutic schools, or should we expect variation in the selection process within these schools? and would prospective trainees be expected to develop expertise in all distinct first-line interventions and/or in all the approaches from which they are drawn? coda. the approach outlined here is decidedly integrative in several respects (castonguay et al., 2015). it can serve as a theoretically integrative starting point; it adopts technical eclecticism in addressing specific needs (see table 1); it speaks (as we’ve shown) to the issue of common/nonspecific factors; and it is general enough to provide those clinicians who choose to remain anchored in a primary orientation (be it cbt, experiential, dynamic, or systemic therapy) a roadmap for assimilative integration of concepts that may not be endemic to their approach, but are also not likely to be too foreign. after all, the elements presented here tend to be consistent with most people's (including clinicians’) lay understanding of what distress is about (i.e., unmet needs) and of what phenomenology is about (i.e., "parts" or "selves" or "modes"). the model includes a healthy dose of therapist humility and is deliberately jargon-free. consequently, it can help engage clients in collaboratively posing and answering the cardinal questions presented, developing a shared language for talking about their needs, goals, and modes, and ultimately reaching desired outcomes. funding: this work was funded in part by a us—israel binational science foundation grant (# 2020289) awarded to the first author. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. twitter accounts: @arlabbiu references barlow, d. h. 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[2] university clinic and outpatient clinic for psychiatry, psychotherapy and psychosomatics, university hospital halle (saale), halle, germany. §these authors contributed equally to this work. clinical psychology in europe, 2024, vol. 6(2), article e13751, https://doi.org/10.32872/cpe.13751 received: 2024-01-18 • accepted: 2024-05-01 • published (vor): 2024-06-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: cara limpächer, hohe str. 53, 01187 dresden, germany. telephone: +49 351 463 36956. email: cara.limpaecher@tu-dresden.de supplementary materials: materials, preregistration [see index of supplementary materials] abstract background: anhedonia is a risk factor for a severe course of depression but is often not adequately addressed in psychotherapy. this study presents the training to enhance reward experience (t-rex), a novel self-help approach that uses savoring and mental imagery to target impairments in reward experience associated with anhedonia. we aimed to examine feasibility and acceptability of t-rex and exploratively investigated its effects on anhedonia and other clinical variables. method: in an online, randomized controlled trial, 79 subjects participated for five days in t-rex or the active control condition gratitude writing (gw). we assessed changes in anhedonia, depression, and active behavior at inclusion, after the waiting period, post-intervention and at follow-up. the intervention effects were examined for the full sample and an anhedonic subsample. results: t-rex and gw were equally feasible and clearly accepted by the sample. both interventions significantly reduced depressive symptoms and increased behavioral activation. although there was no significant main effect of the interventions, between-group differences were observed for depressive symptoms and active behavior at post-intervention and follow-up, favoring t-rex. further, within-group changes for t-rex were larger than for gw. the observed this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.13751&domain=pdf&date_stamp=2024-06-28 https://orcid.org/0000-0001-7349-7255 https://orcid.org/0000-0003-4014-0916 https://orcid.org/0000-0002-1697-6732 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ effects had a greater magnitude in the anhedonic sub-sample, suggesting that individuals with more pronounced anhedonic symptoms derived greater benefit from the interventions. discussion: this first study of t-rex provides promising results that should prompt further investigations of t-rex in clinical samples. the results suggest that t-rex has a positive effect on depression symptoms and active behavior. further, its potential as a valuable adjunct to behavioral activation interventions is discussed. keywords depression, reward experience, behavioral activation, savoring, gratitude writing highlights • we theoretically deduced, developed, and examined a novel treatment option for anhedonia based on savoring and mental imagery. • the training to enhance reward experience (t-rex) reduces depression and increases active behavior. • t-rex proves to be a promising extension of behavioral activation or other cbt treatments. depression is one of the most frequent mental disorders worldwide and among the three leading causes of non-fatal health loss and years lived with disability (gbd 2017 disease and injury incidence and prevalence collaborators, 2018). psychotherapeutic approaches including cognitive-behavioral therapy are generally successful and recommended in treatment guidelines (e.g., national institute for health and care excellence [nice], 2022). however, patients often experience relapses (36 – 54%, steinert et al., 2014) and residual symptoms like sleep problems, fatigue, and loss of interest endure even after other symptoms of depression have already subsided (nierenberg, 2015). problems of reward experience and loss of interest are frequent. of those affected by major depressive disorder, up to 75% report to suffer from anhedonia, i.e., inability to experience pleasure or enjoyment from activities that would normally be pleasurable (franken et al., 2007). further, 37% endure severe, chronic anhedonic symptoms, which coincide with higher severity of depression (pelizza & ferrari, 2009). higher anhedonia predicts a poor longi­ tudinal course of depression (kessler et al., 2017). it is postulated to be a predictor of suicidal ideation (ducasse et al., 2018) and the presence of anhedonia might ease the progression from ideation to action (auerbach et al., 2022). most conceptualizations of anhedonia converge upon three main subcomponents: (1) anticipatory pleasure represents the motivation to expend effort for rewards and includes implicit and explicit wanting processes, (2) consummatory pleasure refers to the responsivity towards rewards, (3) reward learning is defined as probabilistic and reinforcement learning of stimulus-reward contingencies (craske et al., 2019). the dys­ function of any of the three components of the reward process may lead to the disruptive training to enhance reward experience 2 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ effects that anhedonia may have for psychotherapy (rømer thomsen et al., 2015; wang et al., 2021). in recent decades, psychotherapy research has primarily focused on developing strategies to reduce psychopathology, such as sadness and anxiety. improvements in well-being are often viewed as by-products of symptom reduction. however, patients indicate the restoration of positive affect as their primary treatment goal (demyttenaere et al., 2015). despite the growing interest in positive psychology (seligman et al., 2006), treatment options aiming to re-establish positive affect are scarce (boumparis et al., 2016; sandman & craske, 2022). on a positive note, current treatment programs can likely be improved by incorporating techniques that focus on positive affect (dunn et al., 2020). in view of the reduced responsiveness of reward processing in anhedonic patients, recent approaches suggest improving activation and mood by targeting the reward system more specifically (forbes, 2020; nagy et al., 2020). to this end, we want to introduce the training to enhance reward experience (t-rex), a new self-help approach that focuses on restoring and actively creating positive affect. training to enhance reward experience the training to enhance reward experience (t-rex) was derived from the literature on mechanisms underlying anhedonia. it takes an integrative approach and incorporates techniques such as savoring and mental imagery, that have already been shown to be effective in increasing positive affect. savoring is a meta-cognitive process that refers to the process of “generating, intensifying, and prolonging enjoyment through one’s own volition” (bryant, 2003, p. 176). it describes the ability to regulate positive emotions by looking forward to an upcoming positive event, savoring the moment while the positive event takes place and looking back on positive experiences (bryant, 1989). the process of savoring intensifies and prolongs the experienced pleasure and reward. in the training, mental imagery is used to facilitate savoring of positive experiences in the past and also to vividly anticipate positive moments and emotions elicited by positive experiences in the future. the training is not a novel intervention per se but rather a new approach that is intended to be simple, effective within a short period of time, and a valuable adjunct to existing interventions, notably behavioral activation (ba) treatments (e.g., hoyer & vogel, 2018). purpose of the present study in a pilot randomized controlled trial we compared t-rex with gratitude writing (gw), an empirically supported positive psychology intervention known for enhancing positive affect and well-being (jans-beken et al., 2020). the study focused on assessing the effec­ tiveness, acceptability, and feasibility of t-rex in comparison to gw as an active control condition. as our main research question, we wanted to examine the intervention's limpächer, kindt, & hoyer 3 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ effect on symptoms of anhedonia, depression, and active behavior. while taking part in t-rex, participants train the ability to savor positive moments in the past, when they regularly and repeatedly reminisce about positive experiences. consequently, the positive affect that has been felt is intensified and prolonged to counteract anhedonic and depressive symptoms. therefore, we expected that participation in the t-rex group results in a significantly greater reduction of anhedonic and depressive symptoms than in the gw group, across all measurement points. further, we expected a significantly greater increase in active behavior for t-rex compared to gw, because mental imagery of future activities has shown to increase the motivation to actually engage in those activities (heise et al., 2022). additionally, we expected improvements in anhedonia, depression, and active behavior for both groups from preto post-intervention, but not during the waiting period. method sample participants were recruited through online forums and websites with a focus on depres­ sion, psychology, or mental health, and in lectures at several universities in germany. inclusion criteria were an age between 18 and 65 years, being able to write using a pc, and having at least good german language skills. exclusion criteria were obsessions or compulsions, acute suicidality, psychotic symptoms, substance abuse, currently receiving psychotherapeutic counseling, started or changed dose of antidepressant medication during the past 3 months. all inclusion and exclusion criteria were assessed using single items. informed consent was obtained before participation, and the study was conducted in accordance with the declaration of helsinki. procedure the web-based longitudinal study was conducted online via sosci survey (leiner, 2021); all questionnaires and instructions for the interventions were delivered on this platform. directly after study inclusion, participants completed the baseline questionnaire (t1). we randomly assigned participants to either t-rex or gw. both groups were compared to a within patient waitlist control group. after a waiting time of one week the respective intervention started and participants completed the pre-intervention questionnaires (t2). after participating in the interventions for five days, participants filled in post-interven­ tion questionnaires at the last intervention day (t3) and follow-up questionnaires two weeks afterwards (t4). training to enhance reward experience 4 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ material interventions both interventions were designed as online self-guided approaches. for comparability, the time required for the interventions was similar, with both interventions taking approximately 15 minutes per day. each day of the intervention, participants received an email with a link that took them directly to the intervention’s instructions, provided in both written and audio format. t-rex consists of four parts. the initial phase on day one consists of psychoeduca­ tional information about the training rationale (reward sensitization). the latter three parts of the training target components of the reward system and thus aim to enhance reward experience by building on the three time orientations of savoring. participants are encouraged to focus their attention on experiences (activities, perceptions, etc.) that they perceive as pleasant. therefore, their task for the next days is to collect positive moments in everyday life. in the standardized instructions, we provide two examples of methods for collecting these moments (e.g., a smartphone to take a picture of something representative of the experience), however, participants are free to choose their own method (reward registration). each evening, participants are asked to recall the positive moments they collected during the day and to reminisce about them by mentally visual­ izing these moments (reward reliving). lastly, participants are asked to think of positive experiences that could occur the next day (reward anticipation). audio-instructions for positive mental time travel are used as reinforcing enjoyment experience strategies for recalling and anticipating rewards. instructions for mental imagery were adapted from renner et al. (2019). we opted for mental imagery as it has demonstrated superior effectiveness as a motivational amplifier in activity scheduling when compared to verbal reasoning, as evidenced by ji et al. (2021). the comparator intervention gw consists of two parts. similar to t-rex, participants receive a psychoeducational introduction to the intervention on the first day. every eve­ ning on the following four days, subjects receive an instruction to write about something they are grateful for. within this exercise, gratitude can be directed to people as well as to experiences, situational circumstances, or other personal topics. once participants identify something they are grateful for, they are instructed to write about it in as much detail as possible, including any feelings or thoughts that arise. the instructions for gw have been developed after reviewing the instructions of magyar-moe (2009) and rupp et al. (2018). primary outcome measures we used the snaith-hamilton-pleasure-scale (shaps; snaith et al., 1995; german ver­ sion: franz et al., 1998) to assess anhedonic symptoms. the questionnaire consists of 14 items and subjects are instructed to imagine whether they might feel pleasure during limpächer, kindt, & hoyer 5 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ certain experiences. snaith et al. proposed to recode the four response categories into dichotomous categories, that is, agree and disagree (score 0 and 1). more recent papers have used a continuous scoring method to increase sensitivity to change (franken et al., 2007), producing scores ranging from 14 (not at all anhedonic) to 56 (severely anhedonic). the present study adopts this continuous scoring approach. the internal reliability of the continuously scored shaps has been found to be adequate in both non-clinical (α = 0.91) and clinical (α = 0.94) samples (franken et al., 2007). the internal reliability for the continuously scored shaps was also adequate in the current sample (α = 0.79). the beck’s depression inventory ii (bdi-ii; beck et al., 1996; german version: hautzinger et al., 2006) is a widely used questionnaire in both clinical and non-clinical samples, includes 21 items that can be rated on a 4-point scale (0 – 3) and assesses somatic-affective and cognitive dimensions of depression. the total score can range between 0 and 63 and indicates mild (≥ 16), moderate (20-28) or severe (≥ 29) depressive symptoms. psychometric properties and validity are well-established (herzberg et al., 2008; kühner et al., 2007), the bdi-ii showed high internal consistency (α = .92-.93) and high test-retest reliability (r = .93, beck et al., 1996), comparable to this study (α = .95). the 9-item short form of the behavioral activation for depression scale – short form (bads; manos et al., 2011; german version: teismann et al., 2016) assesses concepts of ba (activity and avoidance) by measuring behavioral activity in the past week with statements that can be rated on a 7-point scale ranging from 0 (not at all) to 6 (complete­ ly). the summated score ranges from 0 to 54 and higher scores refer to greater activity (kanter et al., 2007). the bads showed good internal consistency in previous studies (α = .85, teismann et al., 2016), and in this study (α = .80). the primary outcome measures reported here differ from those outlined in the preregistration, where initially more outcome measures were planned. due to space constraints, we opted to report only the most pertinent outcomes. additional measures to examine acceptability, we applied a feedback questionnaire with three items that were rated on a 4-point scale (adapted from robichaud et al., 2020). participants provided feedback on their overall satisfaction with the intervention, the quality of the study material, and whether the time effort was worth it. a fourth item asked participants if they would recommend the intervention to a friend who suffers from loss of pleasure or interest. to address the feasibility of the interventions we examined retention and attrition rates, as measured by the percentage of dropout between baseline (t1) and follow-up (t4). we separately assessed adherence rates as measured by the relative number of subjects who completed all five days of the respective intervention. to account for potential attrition bias (dumville et al., 2006), we included comparisons of baseline characteristics training to enhance reward experience 6 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ between dropouts and completers using t-tests for continuous variables and chi-square tests of independence for categorical variables. statistical analysis intent-to-treat analyses were performed using multilevel modeling (mlm), assuming data were missing at random. as one cannot prove that data is missing at random, we first examined whether participants with missing data differed from those with complete data on any demographic or pretreatment level of the study variables. a linear mixed model for each of the three outcome measures was implemented with a random intercept for subject. the models included shaps-score, bdi-ii score, or bads-score, respectively, as the outcome variable, the level 1 predictor time (t1, t1, t3, t4), the level 2 predictor group (t-rex vs. gw), and a cross-level interaction between time and group. we tested the interaction of time and group by comparing the full to reduced models without the respective interaction term via likelihood ratio tests (lrts). we specified t-rex and baseline measurement (t1) as reference categories and parameters were estimated with the maximum likelihood estimation method. differences from t1 to t2 represent waiting time, differences from t1 to t3 post-intervention differences and from t1 to t4, the fol­ low-up-period. estimated marginal means, planned contrasts, within and between-group effect sizes (expressed as cohen’s d), and confidence intervals (cis) were derived from the mixed-modeling analysis. in accordance with cohen (1988), effect sizes of d = 0.2 were interpreted as small, of d = 0.5 as medium and of d ≥ 0.8 as large. in all analyses α was set to .05. we used r (r core team, 2023) with the following packages: lme4 (bates et al., 2015) to perform a linear mixed effects analysis, and em­ means (lenth et al., 2022) to calculate the statistical significance of pairwise differences. results participant flow and characteristics in total, 251 individuals attempted to participate in the study. of these, 172 were excluded as ineligible or declined to participate. following the screening, 79 participants (65 females, mage[sd] = 26.44[9.31]) in total were randomized to either t-rex (n = 39) or gw (n = 40) and provided baseline data (see figure s1 for consort flowchart in the online supplementary materials). table s1 in the supplementary materials shows the demographic and clinical characteristics. at baseline, the groups did not significantly differ in demographic characteristics and clinical variables (all ps > .05, see table s1 in the supplementary materials). limpächer, kindt, & hoyer 7 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ feasibility and acceptability analysis the overall retention rate from baseline to follow-up was 72% (n = 57), thus n = 22 subjects dropped out of the study before completing the last assessment. looking at t-rex and gw separately, the retention rates (including follow-up) were 82% (n = 32) and 63% (n = 25), respectively. the dropout was higher for gw than for t-rex, although this difference was not statistically significant χ2 = 3.76, p = .053. adherence for t-rex was 90% and 75% for gw. to identify potential baseline factors that might have affected whether participants dropped out by the two weeks follow-up, and whether this varied between interventions, a series of factorial anovas (group by dropout) were conducted. participants who dropped out were on average older than completers (m = 31.8 vs. 24.4, f[1,75] = 12.88, p < .001, ηp2 = < 0.01), but this did not differ by group, with a non-significant interaction (f[1, 75]= 0.006, p = .938, ηp2 < 0.01). there were no differences on clinical outcomes or demographic variables for those who dropped out by two weeks follow-up, nor interactions with group (all ps > .05). on average, participants indicated their satisfaction regarding the interventions, qual­ ity of study materials, and time effort between 3,00 – 3,29 from 4. all subjects who completed t-rex would recommend the intervention to a friend suffering from a loss of pleasure or interest. within completers of gw 90% would recommend the intervention to a friend, although this difference was not statistically significant (χ2 = 3.67, p = .055). changes in anhedonia, depression, behavioral activation we compared the mixed effect models with and without the interaction term for all primary outcome measures. for all three outcome measures the null-hypothesis could not be rejected: the models with the interaction term did not explain significantly more variance than the reduced models (shaps: χ2[3] = 1.14, p = .768; bdi-ii: χ2[3] = 2.80, p = .423; bads: χ2[3] = 2.58, p = .461), hence there was no significant difference in average slope between the two groups. since the interaction of time and group was not significant, we consider main effects of time and group in the following. as predicted, the change in shaps, bdi-ii and bads-score over the one week waiting time was small and not significant (all ps > .05). there was no significant main effect of time or group on the shaps-score at any of the measurement occasions (all ps > .05). however, we found a significant main effect of time for bdi-ii at post-training (β = -3.12, se = 0.96, p = .001) and follow-up (β = -3.96, se = 0.99, p < .001), meaning that compared to baseline, after the intervention and at two weeks follow-up, bdi-ii in both groups was roughly three to four points lower than at baseline. we found no significant main effect of group (β = 2.65, se = 2.41, p = .275), while data inspection revealed that participants in t-rex have on average three bdi-ii points less than participants in gw. again, we found a significant main effect of time for bads at post-training (β = 4.05, se = 1.22, p = .001) and follow-up (β = 5.65, se = 1.26, p < .001), indicating that after training to enhance reward experience 8 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ both interventions and at two weeks follow-up, bads scores were on average roughly four to five points higher than at baseline. further, we found no main effect of group on bads-scores (β = -0.66, se = 2.16, p = .757). in addition, we rerun the analyses excluding the items of the bdi-ii that cogan et al. (2024) recently identified as assessing anhedonia (items 4, 12, 15, 21). however, results for the models with and without the interaction term and for within and between group changes were only marginally different, when this reduced version of the bdi was used. observed and estimated marginals means based on the multilevel models, as well as contrasts and between-group effect sizes are presented in table 1. note that the confidence interval of cohen's d includes zero for all between-group effect sizes. table 1 means and standard deviations/standard errors for observed and estimated data, contrasts and cohen’s d for the full sample outcome observed estimated contrast [95% ci] d m (sd) m (se) t-rex gw t-rex gw shaps t1 24.4 (5.97) 24.7 (8.46) 24.4 (1.07) 24.7 (1.05) -0.32 [-3.28, 2.65] -0.07 t2 24.9 (6.39) 23.9 (6.58) 24.9 (1.07) 23.9 (1.05) 0.93 [-1.99, 3.94] 0.23 t3 24.1 (5.28) 23.1 (7.00) 23.8 (1.10) 22.9 (1.15) 0.87 [-2.28, 4.02] 0.20 t4 23.5 (5.06) 22.8 (7.65) 23.2 (1.13) 23.0 (1.22) 0.14 [-3.14, 3.43] 0.03 bdi-ii t1 11.2 (8.06) 13.8 (13.7) 11.18 (1.74) 13.82 (1.72) -2.65 [-7.50, 2.21] -0.65 t2 11.0 (7.89) 14.0 (13.0) 11.03 (1.74) 14.03 (1.72) -3.00 [-7.85, 1.85] -0.74 t3 8.57 (6.77) 10.7 (11.7) 8.06 (1.76) 10.98 (1.78) -2.92 [-7.88, 2.04] -0.72 t4 7.19 (5.98) 11.5 (14.0) 7.22 (1.78) 12.15 (1.82) -4.93 [-9.97, 0.12] -1.21 bads t1 30.8 (8.71) 30.1 (11.0) 30.8 (1.56) 30.1 (1.54) 0.67 [-3.66, 5.00] 0.13 t2 31.6 (8.72) 30.0 (10.6) 31.6 (1.56) 30.0 (1.54) 1.59 [-2.74, 5.92] 0.31 t3 34.1 (8.24) 33.2 (10.6) 34.8 (1.59) 32.9 (1.64) 1.91 [-2.61, 6.42] 0.37 t4 35.7 (6.86) 33.4 (11.9) 36.4 (1.62) 32.8 (1.71) 3.65 [-1.00, 8.31] 0.71 note. t-rex = training to enhance reward experience; gw = gratitude writing; shaps = snaith-hamiltonpleasure-scale; bdi-ii = beck’s depression inventory ii; bads = behavioral activation for depression scale; t1 = baseline (n = 79); t2 = pre-intervention (n = 79); t3 = post-intervention (n = 65); t4 = two-week follow-up (n = 57). exploratory analysis in anhedonic sub-sample the participants from this study were recruited from the general population. however, since we focused on including patients with self-reported depressive symptoms, some individuals in the sample exhibited stronger anhedonic symptoms. to see whether the interventions would be effective if anhedonia is more severe, we carried out the limpächer, kindt, & hoyer 9 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ same analyses for an anhedonic sub-sample. subjects with a cut-off score ≥ 2 in the shaps original coding at baseline, were classified as anhedonic. we decided to use a slightly more liberal cut-off score than recommended by snaith et al. (1995) to ensure an adequate sample size for analysis. given the complexity and multifaceted nature of anhedonia, a stringent cut-off could have led to the exclusion of individuals who still exhibit clinically relevant symptoms, albeit to a lesser extent. this criterion applied to n = 17 (44%) subjects in the t-rex group and n = 18 (45%) in the gw group. the following analyses were based on the anhedonic sub-sample (n = 35, 28 females, mage[sd] = 26.09[8.25]). neither for shaps, bdi-ii, nor bads the models with the interaction term (time x group) explained significantly more variance than the reduced models (all ps > .05). therefore, there was no significant difference in the average slope between the two groups. since the interaction of time and group did not yield significance, we focus on the main effects of time and group in subsequent analyses. regarding shaps, in the anhedonic sub-sample, the main effect of time was not significant at post-training (β = -2.69, se = 1.73, p = .124) but significant at follow-up (β = -5.51, se = 1.77, p = .002). we found significant effects of time on bdi-ii at post-training (β = -6.41, se = 1.67, p < .001) and follow-up (β = -5.99, se = 1.71, p < .001). likewise, we found a main effect of time on bads at post-intervention (β = 8.75, se = 1.78, p < .001) and follow-up (β = 9.08, se = 1.82, p < .001). figure 1 shows the mean values of all measures for baseline, pre-intervention, post-intervention, and follow-up for the full sample and the anhedonic sub-sample respectively. observed and estimated marginals means based on the multilevel models, as well as contrasts and between-group effect sizes for the anhedonic sub-sample are presented in table 2. we found large between-group effect sizes for bdi-ii and bads scores at post-intervention and at follow-up (all ds > .80). note that the ci includes zero for all contrasts and ds presented in table 2. within-group effect sizes for the full sample and the anhedonic sub-sample are depicted in table 3. discussion this is the first study investigating the effects of t-rex, a new self-help intervention targeting anhedonia. in an online randomized controlled trial, we used gw, hence an em­ pirically tested intervention, as comparison. we examined the interventions’ feasibility, acceptability, and treatment effects on anhedonia, depression, and behavioral activation – both in the full sample as well as in an anhedonic sub-sample. training to enhance reward experience 10 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ figure 1 mean values of bdi-ii, shaps and bads for each assessment in both groups (t-rex, gw) for the total sample (n = 79) and anhedonic sub-sample (n = 36) note. t-rex = training to enhance reward experience; gw = gratitude writing; shaps = snaith-hamiltonpleasure-scale; bdi-ii = beck’s depression inventory ii; bads = behavioral activation for depression scale; cut-off scores for bdi-ii (total score of > 13 = mild depression, beck et al., 1996) included as dotted line. limpächer, kindt, & hoyer 11 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ table 2 means and standard deviations/standard errors for observed and estimated data, contrasts and cohen’s d for the anhedonic sub-sample outcome observed estimated contrast [95% ci] d m (sd) m (se) t-rex gw t-rex gw shaps t1 29.1 (4.30) 30.1 (9.05) 29.1 (1.54) 30.1 (1.49) -0.94 [-5.19, 3.31] -0.19 t2 29.5 (4.76) 26.6 (5.37) 29.5 (1.54) 26.6 (1.49) 2.92 [-1.33, 7.16] 0.59 t3 26.3 (5.76) 27 (6.80) 26.4 (1.58) 27.0 (1.57) -0.56 [-4.97, 3.85] -0.11 t4 23.5 (5.34) 26.8 (8.07) 23.6 (1.62) 26.8 (1.71) -3.21 [-7.87, 1.45] -0.65 bdi-ii t1 14.7 (7.58) 17 (13.2) 14.71 (2.60) 17.00 (2.53) -2.29 [-9.57, 4.98] -0.48 t2 14.5 (7.26) 16.8 (12.5) 14.47 (2.60) 16.78 (2.53) -2.31 [-9.58, 4.97] -0.49 t3 8.25 (5.79) 13.9 (13.8) 8.30 (2.62) 13.34 (2.57) -5.04 [-12.41, 2.33] -1.06 t4 8.27 (6.37) 15.5 (16.2) 8.72 (2.65) 15.22 (2.66) -6.50 [-14.01, 1.02] -1.37 bads t1 26.8 (7.78) 26.9 (11.2) 26.8 (2.20) 26.9 (2.14) -0.12 [-6.24, 6.00] -0.02 t2 29.2 (5.23) 27.8 (10.7) 29.2 (2.20) 27.8 (2.14) 1.34 [-4.78, 7.47] 0.26 t3 35.9 (6.5) 29.8 (11.8) 35.6 (2.23) 30.2 (2.20) 5.34 [-0.91, 11.59] 1.05 t4 36.2 (5.05) 31.7 (12.0) 35.9 (2.26) 31.4 (2.31) 4.49 [-1.95, 10.94] 0.89 note. t-rex = training to enhance reward experience; gw = gratitude writing; shaps = snaith-hamiltonpleasure-scale; bdi-ii = beck’s depression inventory ii; bads = behavioral activation for depression scale; t1 = baseline (n = 35); t2 = pre-intervention (n = 35); t3 = post-intervention (n = 32); t4 = 2-weeks follow-up (n = 28). table 3 within-effect sizes (cohen’s d) and 95% cis for the full sample and the anhedonic sub-sample outcome condition within-group ds [95% ci] full sample within-group ds [95% ci] anhedonic sub-sample baseline to post-intervention baseline to follow-up baseline to post-intervention baseline to follow-up shaps t-rex 0.13 [-0.34, 0.59] 0.28 [-0.21, 0.76] 0.54 [-0.17, 1.26] 1.11 [0.38, 1.84] gw 0.40 [-0.09, 0.90] 0.38 [-0.15, 0.92] 0.62 [-0.09, 1.33] 0.65 [-0.11, 1.41] bdi t-rex 0.77 [0.29, 1.24] 0.97 [0.48, 1.46] 1.35 [0.62, 2.07] 1.26 [0.51, 2.00] gw 0.70 [0.19, 1.20] 0.41 [-0.12, 0.95] 0.77 [0.05, 1.49] 0.37 [-0.40, 1.15] bads t-rex -0.78 [-1.26, -0.31] -1.09 [-1.58, -0.61] -1.72 [-2.45, -1.00] -1.79 [-2.53, -1.05] gw -0.54 [-1.04, -0.04] -0.52 [-1.05, 0.02] -0.65 [-1.37, 0.07] -0.88 [-1.65, -0.11] note. t-rex = training to enhance reward experience; gw = gratitude writing; shaps = snaith-hamiltonpleasure-scale; bdi-ii = beck’s depression inventory ii; bads = behavioral activation for depression scale; d is printed in bold if the ci does not contain 0. training to enhance reward experience 12 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ both interventions significantly reduced depressive symptoms and increased behavioral activation from baseline measurement to post intervention. the observed favorable ef­ fect persisted until the follow-up measurement and appeared to become subsequently amplified. we found medium to high between-group effect sizes in favor of t-rex for depressive symptoms and active behavior at post-intervention and at follow-up, but the main effect of intervention was not statistically significant. in the full, as well as in the anhedonic subsample, within-arm changes in the t-rex group from baseline to post-intervention and to follow-up were consistently larger than in the gw group (especially for bdi-ii and bads). the observed effects had a greater magnitude within the anhedonic sub-sample, suggesting that individuals with more pronounced anhedonic symptoms derived greater benefit from the interventions. relatively higher retention and thus lower attrition rates in t-rex as well as a favorable adherence rate, suggests a great­ er preference for t-rex. participants’ feedback on the interventions was predominantly good to excellent. further, the dropout rates can also be interpreted in terms of accepta­ bility (feeley et al., 2009), thereby supporting the acceptability of both interventions. subsequently, a more detailed examination is conducted to explore the effects of the interventions on depression symptoms, behavioral activation, and anhedonia, respective­ ly. after participating in the interventions, the estimated means for both groups were below the cut-off score for mild depression (bdi-ii < 13, beck et al., 1996). we found medium to large effect sizes in diminishing depressive symptoms from baseline to postintervention and sustained through follow-up for t-rex, while only small to medium effect sizes were noted for gw. our findings indicate that a brief 5-day intervention combining reward sensitivity training, savoring exercises, and mental imagery effectively mitigates depressive symptoms. these data corroborate findings of previous studies that showed that savoring is a protective factor for depression as higher savoring was associated with lower depressive symptoms (chiu et al., 2020; ford et al., 2017). future studies are needed to observe which temporal savoring domain is likely to reduce depres­ sion symptoms most. research so far indicates that momentary savoring has stronger negative association with depressive symptoms than do reminiscing and anticipating (bryant, 2003; kahrilas et al., 2020). behavioral activation was effectively increased even though t-rex did not include activity planning, a core element of ba (kanter et al., 2009). this is consistent with other studies suggesting that mental imagery of activities serves as a “motivational amplifier” for engaging in activities (ji et al., 2021; renner et al., 2019). hence, it is likely that t-rex, especially reward anticipation, may prompt a more active behavior, i.e., increases the motivation to engage in pleasurable activities, and that t-rex therefore has the potential to be optimally combined with ba interventions. our results are in line with the pattern of co-occurrence of increased behavioral activation and decreased depressive symptoms previously found in response to behavioral activation interventions (hoyer & vogel, 2018; limpächer et al., 2023; melicherova et al., 2024). albeit we did not gather limpächer, kindt, & hoyer 13 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ data regarding the implementation of imagined activities for the subsequent day; this aspect could be explored in a future study. such an investigation would yield an objective measure of behavioral activation, surpassing mere reliance on self-reported data. surprisingly, despite t-rex being specifically designed to alleviate anhedonia, the shaps was the sole outcome measure where no significant effect of time was observed. one potential explanation for the missing effect in the full sample, could be attributed to the low baseline scores, suggesting little room for improvement. moreover, it is conceiva­ ble that anhedonia may require a longer time to repair, gradually resolving as depressed mood recovers and individuals consistently engage in potentially rewarding activities. the validity of this assumption is supported by the results of the anhedonic sub-sample, where a significant improvement in anhedonic symptoms was observed in both groups at follow-up. these findings align with the results reported by alsayednasser et al. (2022), who conducted a comparison of cognitive-behavioral-therapy and ba treatments for individuals with depression: across all measurement points and for both conditions anhedonia was repaired to a lesser extent than depression. limitations and future research a number of methodological limitations need to be considered. first, due to the pilot nature of this study, our sample size was rather small. thus, the design was likely underpowered, especially for the confirmation of interactions between group and time, leading to a decreased chance of detecting treatment differences. moreover, generaliza­ bility of our findings is limited given the sociodemographic profile of our sample that is of young age and mostly female. we note that the sample was a healthy or rather subclinical sample, as, for example, no cut-off regarding anhedonia or depression was set for participation, and, because the study took place online, a detailed clinical assessment was not possible. hence, our results provide a proof of concept and call for further replications with larger (clinical) samples. second, we acknowledge that the positive changes observed may be attributed to other factors than the online interventions, which include the attention of the study team, the neutral course of symptoms related to depression, or other variables that may impact symptom burden but are unrelated to t-rex or gw (e.g., stress associated with school/work, additional coping attempts). third, although we countered systematic bias by randomly assigning interventions, our research on primary and secondary outcomes relies on self-report measures, which are known to be prone to several types of bias, including confirmation bias, retrospective recall bias, and social desirability bias. naturally, new research questions arise from these limitations. given the encouraging results, the next step should be to proceed from this pilot study to a large-scale trial. future studies are essential to examine how well the observed effects translate to, or even increase in clinical samples and other settings (i.e., offline). furthermore, it would training to enhance reward experience 14 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://www.psychopen.eu/ be valuable to conduct a more in-depth analysis of the dose-response relationship of savored moments. this analysis would explore whether the effects of t-rex intensify as more positive events are collected, reminisced upon, and imagined for the next day. moreover, given that sharing positive experiences with others is considered a savoring strategy associated with greater well-being (gable et al., 2004; lambert et al., 2013), it seems plausible to assume that group therapies could be a particularly potent setting for implementing t-rex. in conclusion, this study offers encouraging evidence supporting the feasibility and acceptance of t-rex as an intervention to alleviate depression symptoms and enhance behavioral activation over a brief intervention period. nevertheless, the findings once again emphasize the challenging nature of treating anhedonia through psychotherapeu­ tic interventions. funding: the authors have no funding to report that is related to this article. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have no competing interests to report. ethics statement: all participants gave informed consent, and the procedure was approved by the local ethics committee (ek 152032021). data availability: the data that support the findings of this study are available from the corresponding author, cl, upon reasonable request. supplementary materials the supplementary materials include the following items: • the preregistration for this study (see limpächer et al., 2021s) • additional information (see limpächer et al., 2024s): ◦ a consort flow chart of participants ◦ a table with pretreatment and demographic characteristics of the intent-to-treat sample index of supplementary materials limpächer, c., kindt, t., & hoyer, j. (2021s). supplementary materials to "counteract anhedonia! introducing an online-training to enhance reward experiencing – a pilot study" [preregistration]. german clinical trials register. https://drks.de/search/en/trial/drks00025758 limpächer, c., kindt, t., & hoyer, j. (2024s). supplementary materials to "counteract anhedonia! introducing an online-training to enhance reward experiencing – a pilot study" [additional information]. psychopen gold. https://doi.org/10.23668/psycharchives.14656 limpächer, kindt, & hoyer 15 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://drks.de/search/en/trial/drks00025758 https://doi.org/10.23668/psycharchives.14656 https://www.psychopen.eu/ references alsayednasser, b., widnall, e., o’mahen, h., wright, k., warren, f., ladwa, a., khazanov, g. k., byford, s., kuyken, w., watkins, e., ekers, d., reed, n., fletcher, e., mcmillan, d., farrand, p., richards, d., & dunn, b. d. 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(2021). anhedonia as a central factor in depression: neural mechanisms revealed from preclinical to clinical evidence. progress in neuropsychopharmacology & biological psychiatry, 110, article 110289. https://doi.org/10.1016/j.pnpbp.2021.110289 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. training to enhance reward experience 20 clinical psychology in europe 2024, vol. 6(2), article e13751 https://doi.org/10.32872/cpe.13751 https://doi.org/10.1037/0003-066x.61.8.774 https://doi.org/10.1192/bjp.167.1.99 https://doi.org/10.1016/j.jad.2014.06.043 https://doi.org/10.1002/cpp.1948 https://doi.org/10.1016/j.pnpbp.2021.110289 https://www.psychopen.eu/ training to enhance reward experience (introduction) training to enhance reward experience purpose of the present study method sample procedure material statistical analysis results participant flow and characteristics feasibility and acceptability analysis changes in anhedonia, depression, behavioral activation exploratory analysis in anhedonic sub-sample discussion limitations and future research (additional information) funding acknowledgments competing interests ethics statement data availability supplementary materials references psychological clinical science: meeting the challenge of public mental health scientific update and overview psychological clinical science: meeting the challenge of public mental health richard j. mcnally 1 [1] department of psychology, harvard university, cambridge, ma, usa. clinical psychology in europe, 2024, vol. 6(special issue), article e12067, https://doi.org/10.32872/cpe.12067 received: 2023-05-15 • accepted: 2023-07-28 • published (vor): 2024-04-26 handling editor: wolfgang lutz, department of psychology, university of trier, trier, germany corresponding author: richard j. mcnally, department of psychology, harvard university, 1230 william james hall, 33 kirkland street, cambridge, ma 02138 usa. tel.: 1+(617) 495-3853. e-mail: rjm@wjh.harvard.edu related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract the purpose of this article is to provide a brief overview of how clinical psychology evolved in the united states as a prelude to discussing the emergence of psychological clinical science in the closing years of the 20th century. despite the growth of clinical psychology, mental disorders remain highly prevalent, compelling us to envision new ways to deliver services in an effective but efficient manner. topics include the dissemination gap, the affordable access gap, and the psychological clinical science accreditation system (pcsas). examples of novel methods for addressing the problem of public mental health in the 21st century are discussed. finally, i close by considering the potential relevance of our experience in america for european clinical psychology. keywords clinical science, psychological clinical science accreditation system, pcsas, public mental health this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12067&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0002-5228-8777 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • the history of clinical psychology in america is traced. • the clinical science movement emerged from struggles with the apa’s accreditation system. • the development of the psychological clinical science accreditation system (pcsas) is described. • can the clinical science model flourish in europe? the origins of clinical psychology in america the founder of experimental psychology, wilhelm wundt, was an immensely productive man. he was the author or co-author of 503 publications (simonton, 2002, p. 37) and the supervisor of 186 ph.d. dissertations, including those of 16 americans who had traveled to the university of leipzig to study under his direction (benjamin et al., 1992). one of these students, lightner witmer, coined the term clinical psychology (witmer, 1907/1996). like many of wundt’s american students, witmer was eager to apply the new science of psychology to practical problems. upon his return from germany, he established the first psychological clinic in 1896. based at the university of pennsylvania, the clinic aimed to help children who were struggling in school, had difficulties with attention or memory, or who exhibited disruptive behavior. witmer and his assistants worked closely with physicians, social workers, and schoolteachers (witmer, 1909). meanwhile, three faculty members in the precursor to harvard university’s depart­ ment of psychology – william james, morton prince, and hugo münsterberg – were engaging in psychotherapy, often involving hypnosis, to treat adult patients with psycho­ neuroses (taylor, 2000). each of them had an m.d. and münsterberg also had a ph.d. earned under wundt’s mentorship. however, president charles eliot of harvard advised münsterberg to cease “the hypnotic treatment of women” after one of münsterberg’s patients smuggled a pistol into a therapy session and threatened to shoot him, causing a bit of a scandal.1 despite these early beginnings, psychotherapy was not the main role for clinical psychologists during the first half of the 20th century (benjamin, 2005). indeed, psychia­ trists treated patients with psychosis, and neurologists, such as freud in austria and münsterberg in the united states, treated patients with neuroses. although some selfdescribed clinical psychologists began practicing psychotherapy, physicians vigorously and effectively opposed them, claiming that psychotherapy was solely the province of medicine. the upshot was that clinical psychologists were largely confined to develop­ ing, administering, and interpreting what another american mentee of wundt, james 1) i thank ludy t. benjamin, jr. for providing me with a copy of president eliot’s letter to professor münsterberg, dated april 30, 1909. psychological clinical science 2 clinical psychology in europe 2024, vol. 6(special issue), article e12067 https://doi.org/10.32872/cpe.12067 https://www.psychopen.eu/ mckeen cattell, called mental tests. tests of cognitive ability, personality, and psychopa­ thology (e.g., minnesota multiphasic personality inventory) figured prominently in the careers of clinical psychologists who often worked closely with educators, the military, and psychiatry. the golden age of clinical psychology world war ii changed everything. despite psychiatric screening of military inductees designed to eliminate the psychologically vulnerable, psychiatric battle casualties were very common and some never recovered. approximately 60% of the men receiving medical treatment from the veterans administration (va) in the late 1940s were suffering from the psychiatric consequences of warfare (levenson, 2017). there were far too few psychiatrists to treat the tsunami of cases, and so the va asked the american psycholog­ ical association (apa) to establish a formal curriculum to train clinical psychologists capable of delivering psychotherapy to troubled veterans. leaders of the field convened at the university of colorado and formulated an educational and training curriculum known as the boulder or scientist-practitioner model of clinical psychology (committee on training in clinical psychology of the american psychological association, 1947). clinical psychologists were to be hybrids. they conducted research worthy of the schol­ arly ph.d. and they received clinical training, including an internship, thereby qualifying them to join psychiatrists as psychotherapists. in the late 1940s, the apa assumed the responsibility of evaluating clinical psychol­ ogy ph.d. programs and giving its stamp of approval for those that met its accredita­ tion criteria. the federal government poured vast amounts of money into the va and university departments of psychology to support the training of clinical psychologists. the number of accredited clinical psychology programs grew, and graduates joined the ranks of va practitioners, others became professors, and very many others commenced lucrative careers in the private practice of psychotherapy. in the united states today, 44.7% of clinical psychologists are in private practice, 17% practice in hospitals, and 11% work in universities. the profession of clinical psychology grew immensely in the following decades, but so did dissatisfaction with the apa’s scientist-practitioner model. a group of 14 prominent practitioners who called themselves “the dirty dozen” transformed clinical psychology in america (wright & cummings, 2001). the reference to dirt in their self-applied moniker denotes their willingness to engage in political lobbying on behalf of their profession as well as “all sorts of psychologically unseemly acts” (wright, 2001, p. 2). they wrote a revelatory book describing how they gained control over the apa and used it as a vehicle for “professionalizing” clinical psychology. their volume is a self-congratulatory tale of triumph over both psychiatry and over the science-oriented, academic clinical psychologists whose attitudes regarding practice, they argued, ranged mcnally 3 clinical psychology in europe 2024, vol. 6(special issue), article e12067 https://doi.org/10.32872/cpe.12067 https://www.psychopen.eu/ from benign neglect to hostile contempt. the dirty dozen believed programs accredited by apa were biased toward research at the expense of preparing graduates for clinical practice – the chief career goal for most graduates. utterly clueless about the intensely competitive healthcare marketplace, academic clinicians, they said, were wholly inept at lobbying congress in defense of the professional and economic interests of clinical psychologists in private practice who were struggling to compete against social workers and psychiatrists for healthcare dollars in the 1980s as managed care in the health insurance industry began to curb reimbursement for mental health. the politically astute dirty dozen and their allies in private practice secured control of state psychological associations and eventually the power structure of apa itself. four of them were elected president of apa: theodore h. blau in 1977, nicholas a. cummings in 1979, max siegel in 1983, and jack g. wiggins in 1992. among their achievements was ensuring that clinical psychologists could obtain acceptable reimbursement for their services from insurance companies governed by managed care. rejecting the scientist/practitioner model, some dirty dozen members established proprietary professional schools of clinical psychology awarding the doctor of psychol­ ogy degree (i.e., the psy.d.) which does not require a research-based dissertation. fol­ lowing a conference held in vail, colorado in 1973, their practitioner-scholar model of clinical training was recognized by the apa as an accreditation-eligible approach to clinical training. yet there are ironies to the dirty dozen’s approach to professionalizing clinical psy­ chology (mcnally, 2003). in the early 20th century, physicians professionalized medicine by strengthening the connection between practice and science (starr, 1982, pp. 112-127), whereas the dirty dozen strive to do the opposite. unfortunately, their gambit will likely undermine the professional status of our field. as sociologists emphasize (e.g., freidson, 2001, pp. 152-176), a profession must possess epistemic authority to survive. practitioners acquire prestige when they possess specialized knowledge and expertise unavailable to those outside the profession. a clinical psychology increasingly divorced from science will cease to command the allegiance of clients, congress, or society at large. moreover, as medicine professionalized by bolstering its scientific base in the ear­ ly 20th century, many free-standing proprietary medical schools vanished (starr, 1982, p. 118). they folded because they lacked funds for laboratories, libraries, and the tech­ nology that were available to university-based medical schools, such as those at johns hopkins and harvard. ironically, members of the dirty dozen have been among the most enthusiastic supporters of proprietary professional schools. the emergence of clinical science the dirty dozen repudiated the scientist-practitioner model because they believed that it overemphasized often-irrelevant science at the expense of training for a successful career psychological clinical science 4 clinical psychology in europe 2024, vol. 6(special issue), article e12067 https://doi.org/10.32872/cpe.12067 https://www.psychopen.eu/ in the private practice of psychotherapy. yet another group of clinical psychologists were also dissatisfied with the model, but for precisely the opposite reason. their views were canonically captured in mcfall’s (1991) essay, “manifesto for a science of clinical psychology” (see also, mcfall, 2000). mcfall argued that the scientist-practitioner model implied that a clinical psychologist can be either a scientist or a practitioner, thereby suggesting that scientific reasoning, empirical principles, and evidence-based assessment and treatment are not necessarily relevant for a practitioner of psychotherapy. he argued that the ph.d. first and foremost confirms the psychologist as a scientist regardless of whether he or she works in a lab or in a clinic. mcfall emphasized that scientific clinical psychology is – or should be – the only clinical psychology. just as patients rightly expect that their cardiologists, oncologists, and internists will always base their practice on the best available science, patients of clinical psychologists have every right to expect the same. unfortunately, in the years since mcfall’s manifesto, our field has remained cluttered with popular interventions whose efficacy remains empirically untested (e.g., bessel van der kolk’s ‘the body keeps the score’ approach to treating trauma; mcnally, 2023); tested, but ineffective (e.g., psychological debriefing for trauma; mcnally et al., 2003); or downright harmful (for a review, see lilienfeld, 2007). mcfall’s call to arms resonated with many directors of clinical training (dcts) of the scientifically strongest clinical psychology ph.d. programs and clinical internship programs, resulting in the founding of the academy of psychological clinical science in 1994 (benjamin, 2005). academy members struggled within apa to strengthen the role of science in the training of psychotherapists and managed to convince apa to recognize the clinical science as the third accreditable training model. as of this writing, the apa has accredited 108 psy.d. and 256 ph.d. programs in clinical psychology, and 68 of these ph.d. programs are members of the academy of psychological clinical science. hence, of the three models of training – scientist-practitioner, practitioner-scholar, and clinical scientist – clinical scientist programs are in the minority. continued frustration with the apa accreditation system motivated the academy to development an alternative, science-based clinical psychology accreditation system to rival that of the apa. a vote of academy members overwhelmingly supported and authorized this system in 2007, named the psychological clinical science accreditation system (pcsas). the founding executive director was richard m. mcfall. the goal of pcsas is to foster excellent, science-centered education and training in university programs granting the ph.d. in clinical psychology and to advance the knowl­ edge base for disseminating and delivering the safest, most cost-effective psychological health services to the public. note that clinical science is transtheoretical. although many programs favor a cognitive-behavioral approach to training and treatment, such an orientation is independent of the empirical, scienced-based focus of pcsas. mcnally 5 clinical psychology in europe 2024, vol. 6(special issue), article e12067 https://doi.org/10.32872/cpe.12067 https://www.psychopen.eu/ also, diverse meta-theoretical perspectives are compatible with the clinical science approach including categorical diagnostic (e.g., american psychiatric association, 2013; haeffel et al., 2022), dimensional (e.g., kotov et al., 2017; kotov et al., 2021), and network analytic (e.g., borsboom, 2017; mcnally, 2021) ones. hence, the guiding questions regard­ ing an intervention are: “does it work?” and if so, “how do we know?” one major difference between apa and pcsas accreditation procedures concerns input versus output. that is, the apa has a checklist of course and content coverage essential for accreditation, whereas pcsas emphasizes the outcomes of training. are graduates of clinical science programs functioning as clinical scientists? for example, the criteria for classifying a graduate as functioning as a clinical scientist in the department of psychology at harvard university is as follows: 1. the graduate of our clinical science program is generating new knowledge via research. evidence of this may be employment as a postdoctoral fellow, faculty member at a college or university, or scientist at a research facility or hospital affiliated with a medical school. 2. their position involves the widespread dissemination of clinical science research. this may be accomplished through scholarly publications, conference presentations, teaching of clinical science related courses, or research supervision. any publications are expected to go beyond work done solely in graduate school. 3. leadership role in a clinical setting involving program development, new initiatives in training or assessment, or public policy work where the graduate is clearly using clinical science skills. simple application of evidence-based assessment and treatment in a clinical setting (e.g., a va) is not sufficient. for accreditation, pcsas requires that at least 50% of a program’s graduates qualify as clinical scientists. as of this writing, pcsas has accredited 46 ph.d. programs in clinical psychology at universities in the united states and canada. these are among the finest programs. u.s. news & world report ranks the top clinical psychology programs in america, and 40 of the top 50 programs are accredited by pcsas as are all 20 of the top-ranked programs. the challenge of public mental health the academy sponsored the summit on clinical science training at washington univer­ sity in st. louis on may 4-5, 2023. the purpose was to address pressing issues concerning our field. most participants were dcts or representatives of other relevant stakeholders (e.g., national institute of mental health). the videos of the major talks and summaries of the intensive breakout discussion groups are now available online as are the lists of participants for each of these groups.2 psychological clinical science 6 clinical psychology in europe 2024, vol. 6(special issue), article e12067 https://doi.org/10.32872/cpe.12067 https://www.psychopen.eu/ the summit covered a range of topics including how best to select ph.d. students for clinical science training, concerns about how to streamline course curricula, mentoring models, ensuring the mental health of our ph.d. students3, underrepresentation of racial minorities in clinical science,4 and occupational opportunities for psychological clinical scientists outside academia (e.g., in government, in think tanks). some of these issues have been thoughtfully discussed by gee et al. (2022). however, the chief challenge was how to improve public mental health. despite the emergence of evidence-based treatment protocols for many common mental disorders (e.g., barlow, 2021), epidemiologic data indicate that we failing to move the needle regarding their incidence and prevalence (insel, 2022). why? one explanation is a failure of clinical scientists to disseminate treatments established as efficacious in randomized controlled trials (rcts). the assumption is that clinical training programs, including clinical practicum and internship sites, are failing to teach these interventions to their clinical psychology trainees. a related explanation is there is insufficient time for students to master all the evidence-based treatment programs that have been confirmed as efficacious in rcts. david h. barlow and his team have addressed this problem by developing and confirm­ ing the efficacy of their unified protocol for treating the often-comorbid syndromes of depression, panic disorder, and so forth (barlow et al., 2017). this transdiagnostic approach targets problems that often co-occur in different disorders (e.g., avoidance behavior, emotion regulation problems), thereby obviating the need to master many disorder-specific, evidence-based treatment manuals. although the dissemination gap is surely a problem, there is also a treatment access gap, at least in the united states (mcnally & mcnally, 2016). because practitioners who are expert in evidence-based psychotherapy possess a relatively rare set of skills, their services are in high demand. accordingly, they can set their fees as a function of the market and need not accept insurance. relatively affluent patients can afford to write 2) the videos summarizing the content of the summit on clinical science training can be viewed here: https://www.acadpsychclinicalscience.org/summitproceedings.html. the topics and members of the workgroups can be viewed here: https://drive.google.com/file/d/1_gzopkqml1iwhmczyrhw0-ia7yjhcvmj/view?usp=sharing. 3) my research group has devised a brief, scalable workshop for teaching emotion regulation skills to help ph.d. students manage stress and counteract burnout, modified to accommodate the stressors characteristic of diverse departments (e.g., physics, economics, psychology, philosophy, etc.). our pre-post data are favorable (bernstein et al., 2021; bernstein et al., 2023). 4) for the past several years, harvard’s department of psychology have offered a free, intensive weekend workshop delivered nationally via zoom providing mentoring guidance for college students keen on obtaining a ph.d. in psychology (including clinical science) at universities throughout the country. the enrollees are from throughout the united states, and are members of underrepresented minority groups, first-generation college students, and others who are unlikely to acquire the tacit knowledge about the educational and other experiences enabling applicants to gain admission to graduate school. our aim is to level the playing field by transmitting key knowledge, which is readily available to upper-middle class undergraduates, to potential applicants who are otherwise unlikely to be acquainted with it. the link to our program is here: https://psychology.fas.harvard.edu/pprep mcnally 7 clinical psychology in europe 2024, vol. 6(special issue), article e12067 https://doi.org/10.32872/cpe.12067 https://www.acadpsychclinicalscience.org/summitproceedings.html https://drive.google.com/file/d/1_gzopkqml1iwhmczyrhw0-ia7yjhcvmj/view?usp=sharing https://psychology.fas.harvard.edu/pprep https://www.psychopen.eu/ a check to pay for such expert care, but less affluent patients who rely on their health insurance are out of luck. this problem is less common in european countries with comprehensive health insurance coverage. as kazdin and blase (2011) emphasized, the mental health needs in the united states far exceeds the capacity of clinical psychologists trained to deliver face-to-face interventions over the course of several months of weekly 50-minute sessions. the clinical psychologist david m. clark and the behavioral economist richard layard joined forces to solve this problem in england. they developed a remarkable program entitled improving access to psychological therapies5 (iapt; clark, 2018). clark and layard lobbied labor and the tories, respectively, making the case that we now have evidenced-based cbt treatments that can ameliorate the suffering of people struggling with depression and anxiety disorders, enabling them to recover and rejoin the work force of productive english citizens. moreover, layard calculated, by enabling these patients to return to the workforce as tax-paying, productive citizens who no longer require financial support for psychiatric disability, the program would pay for itself. by 2018, the senior clinical psychologists had trained over 10,500 new nondoctoral therapists to deliver cbt protocols for depression and anxiety disorders. data were collected for each session to enable progress to be tracked. when frontline therapists encountered difficulties, senior doctoral clinicians were available to provide supervisory guidance. the iapt program treats more than 560,000 patients per year, and about 50% recover and two-thirds of the remaining patients experience worthwhile progress. the data tracking and feedback mechanisms built into the computerized database enable fine-tuning of clinical practice. indeed, the effectiveness of the therapeutic interventions has thereby improved over the years since the program was launched in 2008. clark and layard’s remarkable achievements were built on the preexisting national health service (nhs). in effect, they made the nhs both more effective and efficient by mandating evidence-based treatment and tracking progress via standardized systematic data collection. i suspect that clark and layard’s counterparts in european countries with comprehensive national health coverage could replicate these positive results. unfortunately, it would be challenging to accomplish this throughout the united states without a nationwide healthcare system. however, bradley c. riemann, ph.d., has established a conceptually similar program for treatment of ocd in oconomowoc, wisconsin at the nonprofit rogers behavioral health system. riemann, an expert in the behavioral treatment of ocd established inpatient and outpatient services for ocd 28 years ago, and then established an intensive training program for individuals with a b.a. or b.s degree in psychology to conduct intensive in vivo exposure and response pre­ vention under the supervision of senior ph.d. clinical psychologists. frontline therapists 5) the program has been renamed the nhs talking therapies for anxiety and depression. psychological clinical science 8 clinical psychology in europe 2024, vol. 6(special issue), article e12067 https://doi.org/10.32872/cpe.12067 https://www.psychopen.eu/ “shadow” expert clinicians conducting behavior therapy and must read a considerable amount of scientific literature on the psychopathology and treatment of ocd, including passing examinations on the material they must master. they, in effect, become highly expert in a narrow area of specialization. like clark and layard, riemann has a standard ongoing, computerized assessment of ocd, depression, and related symptoms. working with expert colleagues throughout the united states, riemann has now established similar programs at 20 other hospital sites. strikingly, these paraprofession­ al therapists for ocd are just as effective as ph.d. clinicians who are expert in the behavioral treatment of ocd. the upshot is that the number of patients receiving stateof-the-art therapy has vastly increased. in a talk he gave in paris at the international convention of psychological science (riemann, 2019), he presented data showing that the percentage of patients receiving intensive treatment increased by 168% and that was when he had established “only” eight additional program in addition to his original one in wisconsin. what are the prospects of others replicating riemann’s achievements elsewhere in america? the essential ingredients appear to be a nonprofit facility keen to offer disorder-specific, efficacious psychological therapy for a relatively common mental dis­ order (e.g., bulimia nervosa, panic disorder, non-melancholic major depression). when riemann launched his program, there were only a handful of facilities in the country providing intensive exposure and response prevention for ocd despite its prevalence being much greater than most specialists surmised. another possibility for improving public mental health is expansion of training in barlow’s unified protocol. given its wide applicability, it has the potential of transform­ ing the practice of scientific clinical psychology, especially among “generalist” practition­ ers. barack obama’s affordable care act (“obamacare”) was a significant step toward enhancing access to health services in the united states. further advances, including those specific to mental health, will require considerable political efforts. although some politicians regard spending on mental health as merely a cost, it is truly an investment in the future. early detection and efficacious treatment of mental health problems saves money in the long run. unfortunately, steps that successfully prevent disasters in the distant future seldom seize the attention of politicians preoccupied with the immediate future. conclusion the most important question, especially for an author writing for clinical psychology in europe, is how well favorable trends in america generalize to countries in europe. i am grateful for two anonymous peer reviewers whose comments partly mitigated my ignorance of the european scene. mcnally 9 clinical psychology in europe 2024, vol. 6(special issue), article e12067 https://doi.org/10.32872/cpe.12067 https://www.psychopen.eu/ clinical psychology ph.d. programs in the usa integrate coursework, research, and clinical assessment and treatment practica within departmental clinics or in affiliated clinics (e.g., specialized practica in treating certain disorders in clinics at harvard medical school teaching hospitals). ph.d. programs with a clinical science orientation confine practica to evidence-based sites as well as involve more research activity than do programs with a scientist-practitioner focus. accredited full-time, 12-month clinical internships complete the requirements for the ph.d. the best internship sites are those with a compatible clinical science orientation. the course load, the clinical work, and sheer amount of research and writing that students do in a clinical science program hones their time and task management skills, enabling then to flourish despite the heavy workload. the entire process including the internship takes about 6-7 years. apparently, in some european countries, students complete a research-oriented ph.d. and then apply to a diversity of clinical training sites to do receiving supervised clinical training in various schools of therapy. i was surprised to learn how influential psychoanalytic psychotherapy remains in italy and germany as well as in france. psychoanalysts and apparently humanistic psychotherapists vigorously oppose policies confining public spending to mental health services having a solid evidential basis. moreover, i learned, that when clinical psycholo­ gists address the public through the media, they are usually psychoanalytic practitioners, and seldom clinical scientific ones. this is strikingly different from america where main­ stream journalists from the new york times, the washington post, the wall street journal, national public radio, cnn, msnbc, and other prestigious outlets almost invariably rely on clinical scientists for comment. apparently, we have a much better chance of influencing public opinion than do many of our continental european counterparts. alas, dissemination of “pseudoscientific” therapies abounds on social media (e.g., youtube videos), and thus has a popular platform. another route to educating the public other than through the mainstream media is through public policy think tanks concerned with health care. this option was favorably discussed at the st. louis summit on clinical science training as a career option for clinical scientists who do not plan to work in clinical or academic settings. clark and layard’s program in england is unquestionably the most important clinical science success story in public mental health. by making the case for evidence-based clinical psychology to both the political left and political right, they succeeded in gain­ ing bipartisan support for incorporating clinical science into the nhs. the patchwork character of mental health services in the united states poses serious challenges to repli­ cating the english program here. however, i suspect that the public health systems in european countries may be far more amenable of translating clark and layard’s system to their respective nations especially as it is just as cost effective as it is efficacious. in conclusion, clinical science has made major strides in developing treatments for mental disorders, established as efficacious by randomized controlled trials. yet the need psychological clinical science 10 clinical psychology in europe 2024, vol. 6(special issue), article e12067 https://doi.org/10.32872/cpe.12067 https://www.psychopen.eu/ for mental health services is immense. the challenges we face are daunting but are beginning to inspire innovative ways of reaching more people as never before. ultimate­ ly, the prospects for progress are bright if we continue to base our efforts on the best science available. funding: the author has no funding to report. acknowledgments: i thank two anonymous peer reviewers for their excellent and helpful comments and suggestions. competing interests: the author has declared that no competing interests exist. references american psychiatric association. 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(2001). the practice of psychology: the battle for professionalism. tucker and theisen. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. mcnally 13 clinical psychology in europe 2024, vol. 6(special issue), article e12067 https://doi.org/10.32872/cpe.12067 https://doi.org/10.1146/annurev-clinpsy-081219-092850 https://doi.org/10.1111/tops.12638 https://doi.org/10.1111/1529-1006.01421 https://doi.org/10.1037/0003-066x.55.9.1029 https://doi.org/10.1037/0003-066x.51.3.248 https://doi.org/10.1037/h0072263 https://www.psychopen.eu/ psychological clinical science the origins of clinical psychology in america the golden age of clinical psychology the emergence of clinical science the challenge of public mental health conclusion (additional information) funding acknowledgments competing interests references process-based therapy as a novel treatment approach and framework for classifying psychopathology letter to the editor, commentary process-based therapy as a novel treatment approach and framework for classifying psychopathology stefan g. hofmann 1 , steven c. hayes 2 [1] translational clinical psychology group, department of psychology, philipps university of marburg, marburg, germany. [2] department of psychology, university of nevada, reno, nv, usa. clinical psychology in europe, 2024, vol. 6(1), article e13727, https://doi.org/10.32872/cpe.13727 published (vor): 2024-03-28 corresponding author: stefan g. hofmann, philipps-university of marburg, department of psychology, translational clinical psychology group, schulstraße 12, 35032 marburg, germany. e-mail: stefan.hofmann@unimarburg.de in a recent article, one of us co-authored a discussion paper comparing prominent classi­ fication frameworks (rief et al., 2023). in the discussion, the article noted the following: “pbt is primarily a treatment approach, while the systems perspec­ tive is a broader framework for understanding mental disorders. while pbt draws on the systems perspective to inform its under­ standing of mental disorders, it is primarily focused on developing and implementing novel interventions. the systems perspective, on the other hand, seeks to provide a comprehensive understanding of mental disorders that can inform the development of a wide range of future treatments” (p. 27). we would like to correct and clarify these statements. in fact, pbt is not primarily a specific treatment approach, and it does seek a broader understanding of mental and behavioral health. in essence, pbt provides a different and more idiographic perspective on systems approaches to clinical science. it begins with an idiographic focus on how processes of change combine in complex networks and can best be altered case by case, which is extended to nomothetic principles if and only if doing so maintains or increases idiographic fit: what we term an “idionomic” approach. as we noted in one of our first publications introducing pbt (hofmann & hayes, 2019), we contend that modern clinical science needs to focus on the following question: “what core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed?” (p. 38). this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.13727&domain=pdf&date_stamp=2024-03-28 https://orcid.org/0000-0002-3548-9681 https://orcid.org/0000-0003-4399-6859 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ our proposed answer was an idionomic understanding of “the contextually specific use of evidence-based processes linked to evidence-based procedures to help solve the problems and promote the prosperity of particular people” (p. 38). in the context of evolutionary science, adaptation or maladaptation is a function of variation, selection, and retention of biopsychosocial processes in given contexts. any process can be helpful or hurtful depending on the person’s history, goals, or circumstan­ ces. processes are often functionally interconnected, forming a complex network that may differ in degree of abstraction and complexity. we contend that a broader and more functional approach to mental health will come by viewing psychopathology as a complex system – evolution gone awry within networks of biopsychosocial processes in the life trajectories of individuals, that may then be corrected with intervention. when such knowledge is extended in an idionomic fashion pbt argues it will provide a comprehensive understanding of mental disorders that can inform the development of a wide range of future treatments. we hope this clarifies the distinguishing features of pbt and other frameworks discussed in the article by rief et al. (2023). funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: dr. hofmann receives financial support by the alexander von humboldt foundation (as part of the alexander von humboldt professur) and the hessische ministerium für wissenschaft und kunst (as part of the loewe spitzenprofessur). he also receives compensation for his work as editor from springernature and royalties and payments for his work from various publishers. references hofmann, s. g., & hayes, s. c. (2019). the future of intervention science: process-based therapy. clinical psychological science, 7(1), 37–50. https://doi.org/10.1177/2167702618772296 rief, w., hofmann, s. g., berg, m., forbes, m. k., pizzagalli, d. a., zimmermann, j., fried, e., & reed, g. m. (2023). do we need a novel framework for classifying psychopathology? a discussion paper. clinical psychology in europe, 5(4), article e11699. https://doi.org/10.32872/cpe.11699 letter to the editor, commentary 2 clinical psychology in europe 2024, vol. 6(1), article e13727 https://doi.org/10.32872/cpe.13727 https://doi.org/10.1177/2167702618772296 https://doi.org/10.32872/cpe.11699 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. hofmann & hayes 3 clinical psychology in europe 2024, vol. 6(1), article e13727 https://doi.org/10.32872/cpe.13727 https://www.psychopen.eu/ clinical psychology in transition: taking responsibility and broadening the scope editorial clinical psychology in transition: taking responsibility and broadening the scope cornelia weise 1 , winfried rief 1 [1] division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, marburg, germany. clinical psychology in europe, 2023, vol. 5(4), article e13465, https://doi.org/10.32872/cpe.13465 published (vor): 2023-12-22 corresponding author: cornelia weise, division of clinical psychology and psychotherapy, department of psychology, philipps-university of marburg, gutenbergstrasse 18, 35032 marburg, germany. e-mail: weise@unimarburg.de for many of us, december is the time to look back to what happened during the year. very often we end up remembering all the challenges, difficulties, worries and burdens that have accompanied us throughout the year. this is also the case this year and not without a reason: the world is full of wars, there are crises and unstable political conditions in many countries around the globe, and not to forget the climate change that is speeding toward catastrophe (lenton et al., 2023). but… should we really leave this editorial’s review of the year at that? we don’t think so. even if we have seen a lot of miserable things happen in 2023, there are also a lot of positive activities going on. or in the words of haruki murakami: “where there is light, there must be shadow, and where there is shadow there must be light. there is no shadow without light and no light without shadow.” (haruki murakami, 1q84) in the ever-evolving landscape of clinical psychology, 2023 has witnessed remarkable strides that signal a paradigm shift in the discipline. this year has been marked by an expanded scope that addresses global challenges such as climate crises and wars, a heightened emphasis on patient and public involvement, and the establishment and fortification of crucial research initiatives. these positive developments not only signify the forward-thinking nature of clinical psychology but also underscore its relevance and adaptability in addressing contemporary societal issues. addressing global challenges: in response to the psychological impact of global challenges, the field of clinical psychology has expanded its purview. we are delighted this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.13465&domain=pdf&date_stamp=2023-12-22 https://orcid.org/0000-0001-5216-1031 https://orcid.org/0000-0002-7019-2250 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ to see that researchers in clinical psychology are taking responsibility and suggest ways how to improve mental health. in this issue, an editorial by pandi-perumal and research­ ers from an impressive number of 22 different countries points to the consequences of war on mental health (pandi-perumal et al., 2023). the authors clearly express the need for international efforts to promote peace, humanitarian aid and mental health care. in an earlier issue, asbrand, michael, and colleagues (2023) discussed the impact of current challenges such as wars, societal polarization, and climate crisis on mental health in adolescents. the key recommendations of their paper include not only developing and expanding effective prevention and intervention programs, but also making a joint effort at various levels of society to enable effective changes. but also the activities of the field to overcome vaccination hesitancy to improve covid-19 management indicated that clinical psychological concepts and intervention approaches are more and more considered relevant for tackling global challenges (asbrand, gerdes, et al., 2023; bagarić & jokić-begić, 2022; hysing et al., 2023; lincoln & rief, 2021; wilson et al., 2022) emphasizing patient and public involvement: the commitment to patient and public involvement in clinical psychology research is exemplified by initiatives mandated by renowned institutions such as the european research council (erc) or the national institute for health research (nihr). for instance, the erc, as a driving force in funding cutting-edge research across europe, has been instrumental in promoting patient and public involvement as an integral component of research applications. researchers seek­ ing erc grants are now required to demonstrate how they actively engage with patients and the public throughout the research process. similarly, leading academic journals encourage researchers to engage with patients in the design, conduct, and dissemination of studies, recognizing the value of incorporating diverse perspectives to enhance the relevance and impact of medical and psychological research. these international initia­ tives not only elevate the standard of clinical psychology research but also align the discipline with a global ethos of inclusivity, ensuring that the voice of the patient and the public resonates in the development and implementation of mental health interventions. establishing and strengthening research initiatives: this year has also seen the fortification of several research initiatives fostering mental health. these initiatives are characterized by their collaborative and cross-european nature, bringing together experts from diverse fields to tackle complex issues. notable examples include projects focusing on the intersection of technology and mental health, initiatives aimed at reduc­ ing mental health disparities, and endeavors exploring the long-term impact of the global pandemic on mental well-being. the backbone of clinical psychology and psychiatry, namely the classification of mental disorders, is more and more challenged with sugges­ tions for improvement or revision (see also our special issue “innovations in icd-11”, (maercker, 2022a, 2022b) and the manuscript in this paper (rief et al., 2023)). intervention techniques and trainings in psychological treatments are searching for new frameworks, that help to overcome barriers of traditional psychotherapy theories (see our special editorial 2 clinical psychology in europe 2023, vol. 5(4), article e13465 https://doi.org/10.32872/cpe.13465 https://www.psychopen.eu/ issue on “transtheoretical psychological treatments” that will be published early 2024). our association, the european association of clinical psychology and psychological treatment (eaclipt) has emerged as a central force in promoting collaboration and advancing clinical psychology practices across europe. most importantly, the eaclipt campaigns for better policies at a european level (e.g. by reporting to and building a direct exchange with members of the european parliament). in addition, the series of eaclipt webinars featuring renowned experts who present research on hot topics in clinical psychology and psychological treatment. in 2023, o’connor talked about the psychology of suicide risk and neuner focused on trauma treatment in refugees (neuner, 2023; o’connor, 2023). as the year draws to a close, we are pleased to announce the completion of the fifth volume of clinical psychology in europe. this milestone is a proof of the vibrant landscape of clinical psychology and would not have been possible without the collective support of our community. our heartfelt thanks go to our brilliant publisher, whose commitment to excellence and open science has been fundamental to our success. our thanks also go to the reviewers for their careful evaluations and to the authors who entrust us with their groundbreaking work. we look forward with enthusiasm to the forthcoming cpe volumes. thank you for being an essential part of our journey. funding: the authors have no funding to report that is related to this editorial. acknowledgments: the authors wish to thank the editorial assistant ania hoffmann salán for her support. competing interests: winfried rief and cornelia weise are editors-in-chief of clinical psychology in europe. wr reports honoraria from boehringer ingelheim for workshops on post-covid. twitter accounts: @corneliaweise, @wrief1 references asbrand, j., gerdes, s., breedvelt, j., guidi, j., hirsch, c., maercker, a., douilliez, c., andersson, g., debbané, m., cieslak, r., rief, w., & bockting, c. (2023). clinical psychology and the covid-19 pandemic: a mixed methods survey among members of the european association of clinical psychology and psychological treatment (eaclipt). clinical psychology in europe, 5(1), article e8109. https://doi.org/10.32872/cpe.8109 asbrand, j., michael, t., christiansen, h., & reese, g. (2023). growing (up) in times of multiple crises – a call for mental health (research) action. clinical psychology in europe, 5(3), article e12713. https://doi.org/10.32872/cpe.12713 weise & rief 3 clinical psychology in europe 2023, vol. 5(4), article e13465 https://doi.org/10.32872/cpe.13465 https://twitter.com/corneliaweise https://twitter.com/wrief1 https://doi.org/10.32872/cpe.8109 https://doi.org/10.32872/cpe.12713 https://www.psychopen.eu/ bagarić, b., & jokić-begić, n. (2022). fear of becoming infected and fear of doing the wrong thing – cross-cultural adaptation and further validation of the multidimensional assessment of covid-19-related fears (mac-rf). clinical psychology in europe, 4(1), article e6137. https://doi.org/10.32872/cpe.6137 hysing, m., petrie, k. j., harvey, a. g., lønning, k.-j., & sivertsen, b. (2023). loneliness across the covid-19 pandemic: risk factors in norwegian young people. clinical psychology in europe, 5(3), article e10483. https://doi.org/10.32872/cpe.10483 lenton, t. m., armstrong mckay, d. i., loriani, s., abrams, j. f., lade, s. j., donges, j. f., milkoreit, m., powell, t., smith, s. r., zimm, c., buxton, j. e., laybourn, l., ghadiali, a., & dyke, j. g. (2023). the global tipping points report 2023. https://global-tipping-points.org lincoln, t. m., & rief, w. (2021). (how) can clinical psychology contribute to increasing vaccination rates in europe? clinical psychology in europe, 3(3), article e7525. https://doi.org/10.32872/cpe.7525 maercker, a. (2022a). the icd-11 diagnoses in the mental health field – an innovative mixture. clinical psychology in europe, 4(special issue), article e10647. https://doi.org/10.32872/cpe.10647 maercker, a. (guest ed.) (2022b). special issue: innovations in icd-11. clinical psychology in europe, 4. https://doi.org/10.32872/cpe.v4.si neuner, f. (2023). reaching out to refugees: lessons for trauma treatment and psychotherapy delivery. https://www.eaclipt.org/post/webinar-trauma-treatment-with-refugees o’connor, r. (2023). when it is darkest: understanding the psychology of suicide risk. https://www.eaclipt.org/post/when-it-is-darkest-understanding-the-psychology-of-suicide-risk pandi-perumal, s. r., van de put, w. a. c. m., maercker, a., hobfoll, s. e., mohan kumar, v., barbui, c., mahalaksmi, a. m., chidambaram, s. b., lundmark, p. o., khai, t. s., atwoli, l., poberezhets, v., rajesh kumar, r., madoro, d., andrés marín agudelo, h., hoole, s. r. h., teixeira-santos, l., pereira, p., saravanan, k. m., . . . berk, m. (2023). harbingers of hope: scientists and the pursuit of world peace. clinical psychology in europe, 5(4), article e13197. https://doi.org/10.32872/cpe.13197 rief, w., hofmann, s. g., berg, m., forbes, m. k., pizzagalli, d. a., zimmermann, j., fried, e., & reed, g. m. (2023). do we need a novel framework for classifying psychopathology? a discussion paper. clinical psychology in europe, 5(4), article e11699. https://doi.org/10.32872/cpe.11699 wilson, e., onwumere, j., & hirsch, c. (2022). psychological processes associated with resilience in uk-based unpaid caregivers during the covid-19 pandemic. clinical psychology in europe, 4(4), article e10313. https://doi.org/10.32872/cpe.10313 editorial 4 clinical psychology in europe 2023, vol. 5(4), article e13465 https://doi.org/10.32872/cpe.13465 https://doi.org/10.32872/cpe.6137 https://doi.org/10.32872/cpe.10483 https://global-tipping-points.org https://doi.org/10.32872/cpe.7525 https://doi.org/10.32872/cpe.10647 https://doi.org/10.32872/cpe.v4.si https://www.eaclipt.org/post/webinar-trauma-treatment-with-refugees https://www.eaclipt.org/post/when-it-is-darkest-understanding-the-psychology-of-suicide-risk https://doi.org/10.32872/cpe.13197 https://doi.org/10.32872/cpe.11699 https://doi.org/10.32872/cpe.10313 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. weise & rief 5 clinical psychology in europe 2023, vol. 5(4), article e13465 https://doi.org/10.32872/cpe.13465 https://www.psychopen.eu/ competence-based trainings for psychological treatments – a transtheoretical perspective scientific update and overview competence-based trainings for psychological treatments – a transtheoretical perspective winfried rief 1 , marcel wilhelm 1 , gaby bleichhardt 1 , bernhard strauss 2 , lisbeth frostholm 3 , pia von blanckenburg 1 [1] division of clinical psychology and psychotherapy, university of marburg, marburg, germany. [2] institute of psychosocial medicine, psychotherapy and psychooncology, university hospital jena, university of jena, jena, germany. [3] department of clinical medicine, aarhus university, aarhus, denmark. clinical psychology in europe, 2024, vol. 6(special issue), article e13277, https://doi.org/10.32872/cpe.13277 received: 2023-11-20 • accepted: 2023-12-19 • published (vor): 2024-04-26 handling editor: wolfgang lutz, department of psychology, university of trier, trier, germany corresponding author: winfried rief, gutenbergstraße 18, 35032 marburg, germany. e-mail: rief@uni-marburg.de related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si supplementary materials: materials [see index of supplementary materials] abstract background: although in most countries psychotherapy trainings focus on one treatment orientation, such an approach is associated with systematic shortcomings. the priorities from teaching one theoretical framework should be moved to a more rigorous orientation in science and evidence-based practice, and to the needs of patients, even if strategies of different theoretical approaches need to be combined. method: we discuss whether competence-based trainings in psychological treatments offer a better framework to facilitate the progress of psychological treatments to a professional academic discipline with transtheoretical exchange, and we provide an example of a transtheoretical education in the basic competences of psychological treatments. a transtheoretical education program requires an umbrella model for case formulation and a transtheoretical definition of intervention goals. results: we provide an adaptation of the traditional model distinguishing vulnerability/resilience, exacerbation, and maintenance of clinical problems for case conceptualization. dynamic network models offer a further perspective for developing modern, transtheoretical case formulations. treatment methods should be better classified according to their transtheoretical goals, which this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.13277&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0002-7019-2250 https://orcid.org/0000-0001-8055-9346 https://orcid.org/0000-0003-4685-993x https://orcid.org/0000-0001-5971-038x https://orcid.org/0000-0002-9683-7416 https://orcid.org/0000-0001-7899-9828 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ offers opportunities to better compare or combine them. we report a case example of how to transform a general competence-based approach in the training of psychological treatments in the academic education system, which found exceptional acceptance from participating students. conclusion: thus, a rigorous competence-based approach to training early clinicians in applying psychological treatments helps to bridge the artificial divide between psychotherapeutic traditions. it also supports the evolution of psychological treatments into an academically robust and highly professional, integrative discipline. keywords psychological treatments, psychotherapy, training, competence, transtheoretical highlights • effective psychotherapy depends on basic transtheoretical competences of the clinician. • a competence-based approach helps to overcome barriers caused by the artificial separation of different treatment schools and stimulates better, research-based exchange of findings and intervention effects. • a case example of training in psychological treatment exemplifies the potential of a transtheoretical training approach and is supported by the exceptional satisfaction ratings of participating students. in most countries, the training of early career clinicians in providing psychological treatments is highly linked to one treatment tradition (e.g. psychodynamic, cognitive-be­ havioral therapy cbt) or one newer development in psychotherapy (e.g., acceptance and commitment therapy act). thus, the typical education goal is to become an expert in one of these theoretical frameworks and its practical applications. however, defining psychotherapy as the application of one specific treatment orientation is associated with a series of problems and shortcomings. first, this is in sharp contrast with medical spe­ cializations, which have the goal of training upcoming specialists to be able to provide best evidence guideline-oriented treatments for most clinical conditions in the specific field, instead of limiting the training to one specific theory. such a system, like in medicine, is transparent for cooperating health care providers with other specializations and allows adaptation of training programs according to changes that are based on new evidence, even if other theoretical orientations are necessary to understand and use the new guidelines. as long as psychotherapy is defined through separated theoretical orientations, the transtheoretical stimulation and inspiration of treatment experiences are hampered, and a consequent transition of scientific evidence to clinical application (and back) is limited. even for the blockbuster of scientific evaluation in psychological treatments, cbt, an exclusive perspective on its own concepts hinders dynamic progress that would allow for benefits from other experiences outside its own theoretical world. competences for psychological treatments 2 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ defining psychological treatments as a family of non-linked theoretical orientations is also in opposition to research results that highlight that successful treatments and successful therapists have shared features that are not limited to one single theory (norcross & lambert, 2019). common factors explain major parts of the variance of outcome (wampold et al., 2017). further, there seems to be a benefit if therapists have options to switch to interventions from other theoretical backgrounds, or, as fonagy has pointed out: “recent studies indeed suggest that adherence flexibility ([...] using interventions from other treatment approaches and modalities) may be associated with superior outcomes” (p. 270, fonagy & luyten, 2019). however, the typical trainings of early career clinicians do not sufficiently address this full potential of scientifically based knowledge about the delivery of effective treatments, and improved education in transtheoretical competences can provide a pathway to more successful treatments in clinical practice. the lack of a common language for psychological treatments further hinders fruitful exchanges between representatives of different treatment approaches. overcoming these restrictions offers new potential for improving training for psychological intervention and for shaping the personal competence profiles of upcoming psychotherapists. in addition, this leads to more transparency in what patients can expect from an expert pro­ viding psychological treatments. it seems barely acceptable that patients have to inform themselves before they choose psychological treatments about whether the treatment provider has a good training, is able to offer guideline-oriented treatments, or has some specialization that does not fit the patient`s problem. like in other fields of healthcare specialization, patients have a right to expect that experts providing treatments for mental health should be qualified to address most clinical problems in this field with the best evidence intervention. competence-based training as a new framework for education in psychological treatments what are the competencies that patients can expect if they search for an expert offer­ ing psychological treatments? it is surprising that many groups trying to define basic competences for clinical psychologists came up with a list of general competences that are not linked to one specific orientation but rather take into consideration the clinical needs and experiences with patients suffering from mental and behavioral disorders. the university college of london has done impressive work in defining competence profiles, some of them being linked to clinical conditions (such as psychosis), and some of them being linked to providing specific treatment approaches (ucl, 2020). the problem-spe­ cific definitions of competences needed to professionally treat this condition summarize a long list of general factors before defining the specific competences that are necessary rief, wilhelm, bleichhardt et al. 3 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ to provide a specific treatment approach (see example for persistent physical symptoms; supplementary materials, figure s1). the european association of clinical psychology and psychological treatments (eaclipt) also provided a list of general competences of professional clinical psychologists (eaclipt task force on “competences of clinical psychologists”, 2019) that was the result of a discussion group with members represent­ ing different treatment orientations (for an excerpt, see supplementary materials, table s1). we can use such competence profiles as a starting point for the systematic develop­ ment of a self-learning system (rief, 2021): trainings for therapists can better focus on these competences, and the consequences for patients and other involved people can be evaluated. the results of this evaluation can be fed back into the competence list, leading to refinements and changes. therefore, comparable to the english “talking therapies” program (clark, 2018), such a living system can lead to the detection of weaknesses in current mental health care, and the ability to respond with methods to improve the system. a competence-based approach typically indicates that people providing professional psychological treatments need to have general academic knowledge that is relevant for understanding the clinical condition (e.g., from basic psychology or neuroscience), mainly to have a basic understanding of evidence-based change processes during treat­ ments, and they need the personal competences to apply this knowledge in the current patient-clinician-interaction. however, moving from a theory-specific training of clinicians to a transtheoretical, competence-based training has some requirements. first, we need a general, transtheor­ etical framework for case conceptualization. second, we need some agreement about the necessary competences and how interventions from different treatment orientations can contribute to the training of these competences. transtheoretical case conceptualization transtheoretical case conceptualizations are necessary to provide a framework for un­ derstanding mental disorders and to identify foci for personalized treatment decisions. one of the oldest transtheoretical concepts for case conceptualization is the diathesisstress model which distinguishes vulnerability/resilience factors (distal factors) from factors that led to symptom exacerbation (proximal factors), while symptom persistence and chronicity is closer linked to maintaining factors. this model has been modified by rief and strauß (2018; figure 1) to better integrate person-environment interactions, the self-perpetuating capacity of mental disorders (disorder-specific dynamics), and the specific role of patient expectations as a maintaining factor (rief & glombiewski, 2017). problems in social interaction are a scientifically proven risk factor for the development of mental disorders (starting from attachment experiences in early life; see predisposition competences for psychological treatments 4 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ box in figure 1), but social interaction problems can also develop or intensify after the establishment of mental disorders, thereby contributing to maintaining mechanisms (see person x environment interaction and maintenance boxes in figure 1). figure 1 transtheoretical case conceptualization (adapted from rief & strauß, 2018) a generic model for case conceptualization predisposition; vulnerability (e.g., genetics, early childhood adversities, skills development, attachment, ressources maintenance; expectation of future developments and events exacerbation (e.g., proximal stressors and conflicts; memories; sociocultural influences) disorder-specific dynamics person x environment interaction the model presented in figure 1 offers a guidance for designing training programs for psychotherapists: they need to acquire competences to address problems of every single box, and they have to decide which box requires most attention according to the individual case conceptualization. it also highlights that mental disorders can have their own intrinsic dynamics, and typically this needs to be addressed directly. although the classification of mental disorders is under discussion (rief et al., 2023), therapists need specific competencies to address different mental disorders (disorder-specific dynamics). while models such as the one in figure 1 are still mainly static, dynamic network models for understanding mental disorders have been published to overcome the limita­ tions of our traditional case conceptualizations (see figure 2). these models identify “nodes” with high centrality to understand the clinical condition, and these nodes can vary from patient to patient. therefore, network models do not only overcome the rief, wilhelm, bleichhardt et al. 5 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ gap between group-oriented (nomothetic) concepts and person-oriented (idiographic) conceptualizations, but they also explain why sometimes different treatments can lead to the same results, while in other cases the same treatments can lead to very different re­ sults (depending on the network status of the patient). further, such a network approach rejects the illusion of separated clinical disorders, takes it as given that symptoms and clinical problems can be highly interlinked and that mental disorders do not represent isolated entities. while applying network models to clinical decisions and treatments is just at its beginning, first attempts show highly promising results, open the view to a more transtheoretical understanding, and enable us to define new pathways for treat­ ment planning (betz et al., 2020; fried & robinaugh, 2020). of note, clinical information can be integrated into data-driven developments of individual network models (burger et al., 2022; scholten et al., 2022). figure 2 a network approach as a common framework for transtheoretical treatments (lutz & rief, 2022) kognition appraisals needs, goals, expectations physiological processes behavior affect & emotions cultural context, socioeconomic status mental health and psychopathology attention, memory self (-value, -acceptance) predispositions early life events; genetic and epigenetic vulnerabilities; resilience current challenges current psychosocial stressors and trauma affecting components of the network the psychological network of mental health systemic and interpersonal relationships to ensure a comprehensive competence-based training, clinicians are trained to integrate both the traditional diathesis-stress model and the evolving network models, recognizing the unique contributions and insights each brings to understanding and treating mental disorders. trainings of clinicians should qualify to address every single node (see boxes in blue, figure 2) if it is considered a critical part of the network. competences for psychological treatments 6 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ transtheoretical categorization of psychological interventions instead of describing treatment goals with the words of one specific treatment approach, we recommend categorizing treatment techniques according to more general aims using the basic concepts of psychology and neuroscience. this helps to bundle treatments from different treatment theories, thereby indicating the potential for comparing, stimulating and evaluating similar approaches and accelerating their developments to better achieve the common goal. the selection of these treatment goals is grounded in a transtheoret­ ical framework, emphasizing the importance of versatile skills that transcend specific theoretical orientations, thereby ensuring clinicians are well-equipped to address the complex needs of their patients. beyond integrating academic knowledge into clinical work and considering disorder-specific recommendations, clinicians providing professio­ nal psychological treatments should be trained to develop the competencies according to the following treatment goals. establishing a therapeutic relationship it is not only common sense that the quality of the therapeutic relationship is able to predict treatment outcome, but it is also an everyday experience in the context of clinical encounters that the trustworthiness of the clinician is a major predictor of a patient’s behavior and whether a patient accepts and complies with a therapist´s recommendation. while this is not part of the case conceptualizations in figure 1 and figure 2, nearly all general models of psychotherapy emphasize the role of a therapeutic relationship as a precondition for treatment success, although much of its evidence goes back to correla­ tional analysis (grawe, 2004; norcross & lambert, 2019; wampold & imel, 2015). there is ambiguity regarding how to define the relevant features of therapeutic relationship. in social psychology, one of the most prominent concepts on social perception is the model of fiske and others (fiske et al., 2007; fiske et al., 2002), summarizing that the major features of social perception can be grouped into the two factors of warmth and compe­ tence. in one of the few studies using an experimental approach to investigate the role of therapeutic relationships, we were able to show that both warmth and competence determine whether participants make use of new information provided by a therapist (seewald & rief, 2023). this does not only determine explicit change processes but also implicit attitudes (seewald et al., 2023). this means that the new experiences triggered during treatment sessions can only be integrated if patients consider the therapist as someone with warmth (empathy, perspective taking, non-aggressive) and competence (e.g., well-trained, providing convincing explanations, structuring treatment sessions). a first step in training early career clinicians should be how to establish a relationship with a patient that leads to the patient’s perception of a therapist as being warm and competent. rief, wilhelm, bleichhardt et al. 7 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ consideration of patient´s goals and values in the past, motivation for psychotherapy and motivation for change have been typically considered as preconditions for treatment. this has substantially changed over the last two decades, and working with motivation is considered a part of the psychological treatment process, in particular if the motivation for treatment and for change is fragile, ambiguous, or varies because of conflicting needs. therapists need the competence to reflect the patient´s motivation and needs, and to consider the patient´s life goals during the treatment process, to finally arrive at shared treatment goals to select intervention techniques that are in accordance with the patient’s general values. acceptance and commitment therapy (act; hayes et al., 2006) has reinvented the consideration of existential life goals to establish commitment as part of the treatment process, but the tradition of working with patient´s life goals and values is much older (e.g., frankl, 1955). psychodynamic treatments often focus on the conflict between different motives of patients. but also roger´s non directive intervention aims to clarify patient´s needs, help to find solutions in conflicts, and to increase the motivation to follow them. thus, people offering professional psychological treatments need the competence to analyze, reflect and work with the patient´s motives, taking into consideration general life goals and values of patients, to clarify different aspects of conflicts, and to improve patient´s motivation for change. motivational interviewing is just one of the examples of how to directly focus on aspects of motivation (miller & rollnick, 2002); originally developed for people with addiction problems, it can be used for nearly all decision problems, as a tool to improve motivation for change in particular with patients with stable, dysfunctional states (e.g., a patient with anorexia suffering from chronic underweight; long-year persisting depressive states; dysfunctional aggressive and impulsive behavior). this strategy can be easily combined with other treatment techniques. improving tolerance for unpleasant sensations and feelings emotion regulation refers to the process of understanding, managing, and effectively coping with feelings and sensations. it involves developing skills to identify and respond to emotions in a healthy manner. this can include recognizing triggers, understanding the intraand interpersonal context of feelings, and implementing strategies to manage intense feelings. the rise of concepts on emotion regulation and their relevance in psychological treatments also brought another insight into the field that has its roots in the buddhist wisdom “living is suffering”. every person needs competence in tolerating aversive states and not to change strategies because of single unpleasant disruptions. people suffering from chronic aversive states (e.g., chronic pain) need to develop accept­ ance strategies, if they want to improve their quality of life. therefore, clinicians should be able to support patients how to better tolerate unpleasant feelings. competences for psychological treatments 8 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ improving skills the counterpart of accepting aversive situations and memories is trying to change them. this often requires the improvement of skills, and improving skills is a major component of nearly all treatments. the history of training how to improve communica­ tion skills started before behavior therapy was officially introduced (salter, 1949), and psychodynamic treatments wanted to overcome “structural deficits” (e.g., deficits in emo­ tion regulation, communication of needs, self-concepts) by working with the patient´s psychological skills during the therapeutic encounter. other skills were added to the portfolio of skills improvements in psychological treatments: improving problem solving skills, relaxation skills, emotion regulation, and mentalization competence (reflection of motives and emotions of others and self). these interventions focusing on improving skills have some specific characteristics in common. they typically follow a step by step approach, trying to induce some smaller successful changes as soon as possible, before aiming for broader goals. they typically follow a communicable rationale and are rooted in the principles of learning. exposing to new and feared situations although exposure is often defined as a pure cbt intervention, the overall goal is broader: how to expose a patient to a new situation, a feared situation, or an aversive inner stressful experience if this is necessary to achieve the treatment goals? with such a definition, it is obvious that every psychological treatment will arrive at such a point because either implicitly or explicitly most patients have to face the fact that exposure is a prerequisite for change. most treatment frameworks require exposure to new situations and/or behaviors (foa & mclean, 2016). further, there are few psychological interven­ tions with as much scientific evidence and scientifically based principles as exposure. therefore, knowing about the basic principles of exposure interventions and being able to motivate and guide patients through such a process is a basic requirement for all therapists. working with the therapeutic relationship as an example of interactions for many years, psychodynamic treatments focused exclusively on working with the therapeutic relationship, considering aspects such as transference and counter-transfer­ ence. even if this exclusiveness could be questioned and was modified in many subse­ quent psychodynamic developments, the work with the therapeutic relationship still offers a splendid option to reflect on and modify interaction patterns and problems in social relationships. one could argue that as long as warmth and competence are established in therapeutic relationships, there is no need for further relationship-oriented interventions. however, other experts brought attention to the fact that ruptures in rief, wilhelm, bleichhardt et al. 9 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ the therapeutic alliance are a common phenomenon (eubanks, muran, & safran, 2018), and trying to repair these ruptures can be a helpful experience not only to establish a pre-condition for a successful treatment, but also as an example of how to deal with interaction problems in everyday life (eubanks, muran, & safran, 2018). a consensus between different therapists was reached on how typical ruptures during the therapeutic interaction can be categorized (eubanks, burckell, & goldfried, 2018), and a portfolio on how to intervene when ruptures occur was put together (eubanks, muran, & safran, 2019). detecting and reflecting on these ruptures, and being able to use strategies from a broad portfolio how to deal with them can help further to professionalize psychotherapy. reattribution and mentalization reattribution takes place in all forms of successful psychological treatments. it starts with providing a new framework for understanding the clinical problem, continues with changing cognitive evaluations of one’s own feelings and behaviors, of motives of other’s behavior, and also includes reformulations of the self-concept and self-esteem. in recent years, it has been emphasized that the overall goal of all psychological treatment is to improve psychological and cognitive flexibility (doorley et al., 2020). psychotherapists should be sensitive and even able to trigger these reattributions. also, models of affect regulation and its connection to psychopathology (gross et al., 2019) emphasize the crucial role of appraisal processes. supporting patients to be able not only to consider one explanation for problems but to choose between different views is a major step in problem solving. cognitive therapy offers a broad spectrum of ways to deal with this topic, but it can be enriched with other approaches as well. mentalization-based treatments (bateman & fonagy, 2010) also address improved perspective-taking, more variety in interpreting the motives of others and oneself, and a better understanding of emotional reactions through new appraisals. working in multi-person settings for many interventions, it is necessary to work with several people together. often, the inclusion of significant others who might play a role in maintaining the problems is nec­ essary. but also providing group therapy (which may be more economical than individual treatments) or even working with communities belongs to the competence profile of clinical psychologists. all professional psychotherapists should be aware that the single patient always lives in a social environment with other people who interact and can ei­ ther support or hamper successful changes. therefore, working in multi-person settings is also a precondition for the broad competence profiles of psychotherapists. systemic therapies have suggested multi-person interventions (pinquart et al., 2016; riedinger et al., 2017), but nearly all other major traditions of psychotherapies have developed ways to deal with it. competences for psychological treatments 10 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ personal competences of the therapist during the last decade, more emphasis has been put on the role of the persons offering psychological treatments and their personal competences. therapist’s personality char­ acteristics can predict parts of the treatment outcome (norcross & lambert, 2019). still, there is no good and broadly accepted framework for self-reflection and self-experience and how to achieve these personality features. while the evidence for this field does not allow well-proven recommendations, there is some clinical agreement at least about one position: it is helpful if psychotherapists have the abilities they want to teach their patients (emotion regulation, communication, problem solving, self-reflection, mentaliza­ tion, psychological flexibility, and even humor; ziede & norcross, 2020). an example of training basic competencies for psychological treatments in a university setting after legal regulations for providing psychological treatments in germany changed in 2019, more practice-oriented master programs were introduced, and the university of marburg established an example of training in basic and transtheoretical competences for psychological treatments. hereby, the ideas of subchapter 2-4 were the basis for planning the program. in a block seminar attended by a maximum of 15 students, various modules covering basic competencies are taught (see figure 3). each module begins with a brief theoretical overview and repetition about one basic competence and watching an example video or a demonstration of the instructor. this is followed by a short exercise in the group and a discussion about possible difficulties and pitfalls. the main part is on role plays featuring different vignettes or personal experiences. during the first sessions, all students are required to provide a personal problem, while later, written clinical examples are the basis for the role plays. they take place in groups of three: one acting as the patient, one as the therapist, and one as the observer who provides feedback using a structured feedback form. the instructor, a licensed psychotherapist, also gives feedback. afterwards, students rotate roles to ensure that every student has the opportunity to learn each role. students are tasked with a homework assignment in regard to the last competence learned. they are required to create and film another role play, which is then submitted via the university's secure platform. two randomized fellow students subsequently provide feedback on the performance and demonstrated competences of these videos. rief, wilhelm, bleichhardt et al. 11 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ figure 3 seminar structure 8. module defining and improving social relationships 1. module establishment of treatment relationship short theoretical input example video/ demonstration of the instructor group discussion and short practice roleplay with personal problem or vignette role rotation: patient, therapist, observer homework: videotape role play and give feedback 3. module motivational interviewing 2. module definition of treatment goals short theoretical imput example video or demonstration of the instructor group discussion and short practice roleplay with personal problem or vignette role rotation: patient, therapist, observer seminar structure „training of basic competences in psychological treatments“ 4. module perspective taking, mentalization 5. module exposing to new, unused or fearful situations 6. module broadening cognitive appraisals 9. module working with the therapeutic relationship 10. module treatment setting: couples and families 11. module treatment setting: group therapy 7. module detachment: relaxation, mindfulness, acceptance the modules encompass a range of essential topics, including: 1. initial establishment of a treatment relationship: in this module, students learn how to create a treatment relationship. this involves active listening, empathetic understanding, and creating a safe, non-judgmental space, allowing the patient to feel heard and supported. 2. definition of treatment goals: students should proactively assess both explicit treatment goals and personal objectives (life goals and values). treatment goals should be attainable, clear, and congruent with the patient's emotional preferences. additionally, a hierarchical approach, distinguishing between general goals (such as overall well-being and personal growth) and specific goals (like overcoming specific challenges or behaviors), allows for a comprehensive approach, addressing both immediate concerns and the broader context of the patient's life (e.g., michalak & holtforth, 2006). 3. treatment motivation, motivational interviewing: the module “motivational interviewing” employs a guiding approach to engage with patients, elicit their motivations for behavior change, and foster autonomy in decision-making; it can be learned through practicing “change talk” and “confidence talk” (e.g., rollnick et al., 2010), and can be applied in addiction problems, but also all other ambivalence conflicts. competences for psychological treatments 12 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ 4. perspective taking, mentalization: in this module, students learn to get a deeper understanding of mentalization. it refers to the capacity to understand and interpret one's own and others' thoughts, feelings, and intentions, particularly in emotionally significant interpersonal relationships, and is viewed as a learnable skill crucial for maintaining stable relationships (e.g., bateman & fonagy, 2010). 5. exposing to new, unused, or fearful situations: this module provides students with specific strategies, such as expectancy violation and deepened extinction, to optimize the exposition to new situations, adding these strategies to traditional cognitivebehavioral approaches like 'fear habituation' and 'belief disconfirmation' (e.g., craske et al., 2014). 6. broadening cognitive appraisals: in this module, students learn how to expand the patients´ perspective and how to consider alternative interpretations of situations to gain more balanced perspectives and constructive thinking patterns. developing psychological flexibility is a major goal. 7. detachment: this module trains the integration of detachment, encompassing relaxation, mindfulness, and acceptance, as an important aspect of psychological treatments with a focus on emotion regulation (shapiro et al., 2006). techniques such as progressive muscle relaxation, mindfulness meditation, and self-compassion practices are employed to help patients cultivate detachment from thoughts and emotions (wells, 2005). 8. defining and improving social relationships: in this module, understanding and improving social behavior is trained with the help of the interpersonal circumplex model (kiesler, 1983). this framework visualizes interpersonal behavior along two axes: agency (ranging from dominance to submissiveness) and communion (ranging from friendliness to hostility), creating a circular space. this model categorizes behavior into eight segments, providing a comprehensive representation of an individual's interpersonal profile and serving as a valuable tool for understanding psychopathology within social contexts (guhn et al., 2019). 9. working with the therapeutic relationship; complimentary relationship expectations; ruptures and repair: in this module, the students learn the concept of complementary therapeutic relationship, in which therapists should offer each patient a customized relationship tailored to their most significant goals, as determined through plan analysis and case conceptualizations. this approach suggests that a therapist's behavior should align with and complement the patient's needs and objectives in therapy (e.g., caspar et al., 2005). moreover, students train to recognize and effectively address ruptures in therapy (e.g., eubanks et al., 2019). 10. treatment setting couples and families: this module stresses the importance of integrating the partners and children into the psychological treatments. it offers strategies for enhancing positive interactions and components for communication, and it also trains the therapist in multi-perspectivity and impartiality. additionally, it rief, wilhelm, bleichhardt et al. 13 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ outlines therapeutic approaches for various psychological disorders within the framework of couple and family therapy (e.g., hahlweg & baucom, 2008). 11. treatment setting group interventions: in this module, students learn to conduct different types of group therapy (e.g., psychoeducational, disorder-specific, individual case-oriented). the main focus of the module is on individual caseoriented group therapy addressing the specific psychological issues or predetermined theme of a protagonist. the selection of the topic is tailored to the individual's personal situation and life history, with the assumption that most group participants may have similar problems or life situations (sipos & schweiger, 2019). the goal is to work on the individual situation of the protagonist, while other group members serve as sources of information, experiences, feedback, and practice partners for role-playing exercises. all of the students get different vignettes about their role as trainer or participant, and large role plays follow (see supplementary materials, table s2 for an example vignette). the described seminar is evaluated regularly, using standardized questions that are sim­ ilar in most german universities. the evaluations consistently show that students rate the quality of the seminar very high. figure 4 shows the students' assessment regarding the three most relevant items for evaluating seminar quality (satisfaction, understanding of the material, increase of learned content). the results of the training of basic compe­ tences for psychological treatments include 15 teaching evaluations (2012-2023) from six different instructors. for comparison, n = 4,829 teaching evaluations from non-practical events in psychology from the same years are depicted. figure 4 teaching evaluation of the training of basic competences for psychological treatments 1 2 3 4 5 how much have you learned at this seminar? the way the seminar is structured contributes to the understanding of the material. overall, i am very satisfied with the seminar. non-practice-oriented seminars in psychology. (n=4829) training of basic competences for psychological treatments (n=288) note. legend: the items are rated on a five-point response scale ranging from 'strongly disagree' = 1 to 'strongly agree' = 5, or 'very little' = 1 to 'very much' = 5. competences for psychological treatments 14 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ taken together, the seminar integrates theoretical knowledge with hands-on practice. it empowers students to apply basic competences in practical settings and receive feedback from both instructors and peers. such active learning strategies equip students for realworld applications of their psychological treatment skills. shortcomings of this approach the competence-based training approach in psychotherapy, while valuable in many respects, is not without its limitations. it is important to acknowledge that this approach is not intended to replace comprehensive postgraduate trainings in psychotherapy, but it is meant to offer an alternative to current trainings in particular as a starting approach early in the career, e.g., offering a “common trunk” before specialization takes place. here are some of the key shortcomings associated with this approach: lack of disorder-specific approaches: one significant limitation is its generalist nature. it may not sufficiently cater to the unique needs and nuances of specific psycho­ logical disorders and problems. tailoring interventions to address specific conditions like depression, anxiety, or trauma requires additional training and expertise. incomplete coverage of competences: while the competence-based approach covers important therapeutic skills, it may not encompass the full spectrum of competences that could be beneficial in psychotherapy, and it will always represent a selection. factors such as cultural sensitivity, advanced assessment techniques, or specialized interventions for severe psychopathologies might not receive adequate attention. the complexities of transference and countertransference, which are crucial aspects of the therapeutic rela­ tionship, may not be fully addressed in a competence-based framework, similar as some other specific approaches (such as schema therapy or specialized exposures). emotion regulation training could be strengthened compared to this proposal. there are limita­ tions in a transtheoretical approach to integrating highly specialized abilities from all different approaches. however, we want to understand our approach as a dynamic model that invites modifications, adaptations, and improvements and also allows variations. in contrast to being bound to one single approach, a strength of our approach is that it can be flexibly adapted to improve identified shortcomings and integrate new evidence-based acknowledgements stemming from different fields. in summary, while the competence-based approach provides a valuable foundation for psychotherapists, it should be viewed as a starting point rather than a final com­ prehensive training in itself. supplementing this approach with specialized knowledge, disorder-specific techniques, and a nuanced understanding of complex therapeutic dy­ namics is essential for providing high-quality, tailored care to clients with diverse needs. rief, wilhelm, bleichhardt et al. 15 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://www.psychopen.eu/ concluding remarks many early career clinicians using psychological treatments receive training that focu­ ses on one of the traditional or current frameworks, such as psychodynamic, cbt, or act. focusing on one of these approaches, often accompanied by developing a strong identification for it, typically neglects other experiences, new developments in other contexts, and/or basic findings on disorders or treatment mechanisms. overcoming these limitations requires a transtheoretical approach for case conceptualization and treatment. this can create a platform for a true academic and scientific field of psychological treatment. we provide such transtheoretical frameworks for case conceptualization, and we suggest a competence-based framework for training early career clinicians in how to use psychological treatments. these concepts should not be understood as fixed or new truth, but as a flexible framework that can be continuously adapted according to new scientific or practical experiences and local needs. we established a basic training of competences for upcoming psychotherapists that integrated treatment approaches of different theoretical orientations. students’ satisfaction was very high, and negative aspects (e.g., being confused; not being able to integrate the different approaches to an overall understanding) were not observed. broadening the science of psychological treatments to a transtheoretical approach helps to overcome artificial differences and im­ proves the integration of our knowledge and experiences into an overall transtheoretical framework. funding: no special funding beyond the public university funding for the study program. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: winfried rief is an editor-in-chief for clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. twitter accounts: @wrief1 supplementary materials the supplementary materials include the following items (for access, see rief et al., 2024): • the first supplemental material outlines a framework detailing essential competencies for psychological interventions with individuals facing persistent physical health conditions. these include professional stance, values, and assumptions; core knowledge about the illness; a good assessment and planning ability; generic therapeutic competences such as the ability to foster and maintain a good therapeutic alliance; knowledge about specific interventions; and metacompetences. competences for psychological treatments 16 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://twitter.com/wrief1 https://www.psychopen.eu/ • the second supplement provides an excerpt of a competence list, as outlined by the eaclipt task force on "competences of clinical psychologists" in 2019. meta-competences for clinical psychologists encompass proficiency in providing interventions aligned with treatment aims and scientific knowledge. moreover, meta-competences include the ability to motivate patients, explain interventions to stakeholders, demonstrate perspective-taking and empathy, regulate their own emotions, and address treatment and therapeutic relationship issues. • the third supplemental material introduces a case vignette illustrating therapeutic objectives aimed at addressing relationship ruptures and understanding patient motives to enhance therapeutic engagement and flexibility. this case features a patient with an affective disorder and can be used in the training of clinical psychologists. index of supplementary materials rief, w., wilhelm, m., bleichhardt, g., strauss, b., frostholm, l., & von blanckenburg, p. 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(2020). personal therapy and self-care in the making of psychologists. the journal of psychology, 154(8), 585–618. https://doi.org/10.1080/00223980.2020.1757596 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. competences for psychological treatments 20 clinical psychology in europe 2024, vol. 6(special issue), article e13277 https://doi.org/10.32872/cpe.13277 https://doi.org/10.1177/21677026221094331 https://doi.org/10.1007/s10608-023-10413-5 https://doi.org/10.1002/jclp.20237 https://www.ucl.ac.uk/pals/research/clinical-educational-and-health-psychology/research-groups/competence-frameworks https://www.ucl.ac.uk/pals/research/clinical-educational-and-health-psychology/research-groups/competence-frameworks https://doi.org/10.1007/s10942-005-0018-6 https://doi.org/10.1080/00223980.2020.1757596 https://www.psychopen.eu/ competences for psychological treatments (introduction) competence-based training as a new framework for education in psychological treatments transtheoretical case conceptualization transtheoretical categorization of psychological interventions establishing a therapeutic relationship consideration of patient´s goals and values improving tolerance for unpleasant sensations and feelings improving skills exposing to new and feared situations working with the therapeutic relationship as an example of interactions reattribution and mentalization working in multi-person settings personal competences of the therapist an example of training basic competencies for psychological treatments in a university setting shortcomings of this approach concluding remarks (additional information) funding acknowledgments competing interests twitter accounts supplementary materials references reduction of pathological skin-picking via expressive writing: a randomized controlled trial research articles reduction of pathological skin-picking via expressive writing: a randomized controlled trial carina schlintl 1 , anne schienle 1 [1] clinical psychology, university of graz, biotechmed, graz, austria. clinical psychology in europe, 2023, vol. 5(2), article e11215, https://doi.org/10.32872/cpe.11215 received: 2023-01-24 • accepted: 2023-04-11 • published (vor): 2023-06-29 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: anne schienle, clinical psychology, university of graz, universitätsplatz 2/iii, a-8010, graz, austria. phone: +43 (0)316 380 – 5086. e-mail: anne.schienle@uni-graz.at supplementary materials: materials, preregistration [see index of supplementary materials] abstract background: expressive writing (ew: a personal form of writing about emotional distress, without regard to writing conventions) can improve physical and mental health. the present study investigated whether ew can reduce pathological skin-picking. in addition, the effects of two modalities of writing were contrasted with each other: computer vs. paper/pencil. method: a total of 132 females with self-reported pathological skin-picking participated in a twoweek intervention. they either carried out six ew sessions or wrote about six abstract paintings (control condition), using either paper/pencil or a computer. before and after each session, participants rated their affective state and the urge to pick their skin via a smartphone application. questionnaires for assessing skin-picking severity were completed before and after the two-week intervention. results: the urge for skin-picking decreased directly after a writing session. the reduction was more pronounced in participants of the ew group, who also experienced reduced tension and increased feelings of relief at the end of a writing session. ew also reduced the severity of focused skin-picking after the two-week intervention. the writing modality had no differential effect on skin-picking symptoms. conclusions: this study identified beneficial effects of ew on pathological skin-picking. a future study could investigate ew as a potential tool in the context of (online) psychotherapy for skinpicking disorder. keywords skin-picking, expressive writing, app-assisted approach, tension, relief this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11215&domain=pdf&date_stamp=2023-06-29 https://orcid.org/0000-0002-2285-0650 https://orcid.org/0000-0003-2173-6626 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • expressive writing (ew) reduces pathological skin-picking. • ew reduces the urge for skin-picking. • ew increases feelings of relief. • the beneficial effects of ew are associated with trait anxiety. skin-picking is a common behavior in the general population. while occasional manipu­ lation of the skin in the form of picking at scabs, bumps, or the cuticles around finger­ nails can be considered normal and generally as not having any negative consequences, more frequent and intense skin-picking can lead to somatic problems (skin lesions, infections, scars) and impaired socio-emotional functioning. in this case, excessive skinpicking has developed into a mental disorder, labeled as skin-picking disorder (spd; american psychiatric association, 2013). research suggests that (benign as well as pathological) skin-picking often occurs in reaction to the experiencing of negative affective states (e.g., anger, anxiety). it usually provides short-term relief of tension and elicits positive feelings (bohne et al., 2002). indeed, many people who pick their skin report that they find it soothing, satisfying, and/or rewarding (gallinat et al., 2021; schienle & wabnegger, 2020). thus, skin-picking can be seen to serve emotion regulation, which can be functional (as in occasional skin-picking), or dysfunctional (as in spd). several studies have shown associations between excessive skin-picking and difficul­ ties in emotion regulation (prochwicz et al., 2018; schienle et al., 2018; snorrason et al., 2010). for example, snorrason et al. (2010) demonstrated that difficulties in emotion regulation (e.g., difficulties engaging in goal-directed behavior under distress), as well as increased emotional reactivity, predicted pathological skin-picking. a study by schienle et al. (2018) also found strong associations between excessive skin-picking and emotion dysregulation. more specifically, the severity of focused skin-picking (i.e., skin-picking performed with full awareness, in contrast to automatic skin-picking) was predicted by difficulties in controlling impulsive behaviors, self-disgust (the tendency to feel disgusted by one's behavior), and disgust proneness (the tendency to experience disgust towards potential transmitters of disease). further, prochwicz et al. (2018) investigated a non-clin­ ical sample (university students) and also found an association between a strategy for emotion regulation and skin-picking severity. it was shown in that study that those who used cognitive reappraisal more often (i.e., re-evaluation of emotion-eliciting situations/ cognitive distancing) reported a lower skin-picking severity. the studies mentioned above suggest that excessive skin-picking might be used as an alternative strategy for controlling one’s negative emotions when other effective strategies are not at hand. along this line of reasoning, the emotion regulation model of spd (e.g., snorrason et al., 2010) holds that skin-picking is an emotion regulation reduction of pathological skin-picking via expressive writing 2 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ strategy used by people who have difficulties in applying more adaptive strategies. based on these findings, it would appear important to offer alternative methods for emotion regulation to those who pick their skin excessively. one possible approach is expressive writing (ew). ew can be described as personal and emotional writing without regard to form or writing conventions (e.g., spelling, punctuation, grammar). ew was first introduced by pennebaker and beall (1986) who asked students to write about their thoughts and feelings associated with a stressful/traumatic or neutral event. the protocol in that inves­ tigation included four writing sessions, each lasting 15 minutes. it was found that ew fostered favorable physical and mental health-related outcomes: a reduction of visits to the university health center during a 6-month follow-up period and improved well-being. further, two meta-analyses support the notion that ew about upsetting experiences produces improvements in mood as well as in indicators of quality of life (pavlacic et al., 2019; reinhold et al., 2018). the mechanisms underlying the positive effects of ew are still under investigation. pennebaker et al. (1990) have suggested that the process of ew can help one to better understand a distressing event that has taken place (gaining insight), and further, that ew can promote better problem-solving. ew has also been suggested to support disin­ hibition (catharsis), self-regulation, social integration, and acceptance of the negative experience (frattaroli, 2006; pavlacic et al., 2019). finally, other authors have emphasized the role of exposure in ew (frattaroli, 2006). participants subject to ew interventions repeatedly confront themselves with thoughts and feelings regarding an upsetting event. similarities can be drawn between this approach and exposure (or flooding) therapy, which promotes habituation, extinction, and cognitive restructuring. based on meta-ana­ lytical findings, frattaroli (2006) concluded that exposure theory has received the most empirical support for explaining ew effects. in the case of excessive skin-picking, it is very likely that ew possesses an additional positive component: the mechanical requirements of writing (either by hand or by com­ puter) make skin-picking difficult to perform at the same time. thus, ew incorporates a form of ‘stimulus control’ (by reducing the opportunity to perform skin-picking), which has been identified as a successful psychological treatment strategy for skin-picking disorder (snorrason et al., 2017). further, the process of writing – holding the pen and performing up and down movements – is somewhat similar to the physical movements involved in skin-picking. along these lines, patients with spd have reported that draw­ ing (e.g., pencil sketches) can be a replacement behavior for skin-picking (atkin, 2017). thus, it is assumed that the process of writing in ew, particularly in the paper/pencil form, may contribute to its effectiveness in reducing skin-picking. the present study investigated whether a two-week intervention with ew (including six writing sessions) could reduce pathological skin-picking. short-term effects of ew (e.g., changes in the urge to pick one’s skin directly after a writing session), as well schlintl & schienle 3 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ as mid-term effects (e.g., changes in self-reported skin-picking severity), were assessed. further, the effects of two modalities of writing on the urge for skin-picking were contrasted with each other: computer vs. paper/pencil. the following hypothesis had been preregistered: expressive writing (particularly paper/pencil writing) reduces skinpicking behavior. in addition, an exploratory regression analysis was carried out to identify variables (e.g., number of completed writing sessions, trait anxiety) that were associated with the effectiveness of expressive writing (in terms of reduction in the urge for skin-picking). method participants participants with self-reported pathological skin-picking were invited to participate in a study on the effects of different writing interventions (this was carried out via postings on social media, and self-help groups for skin-picking disorder). the invitation included a link to an online survey that checked that participants met inclusion/exclusion crite­ ria. inclusion criteria were female sex, because of a higher prevalence of skin-picking behavior in the female population (apa, 2013), and scores ≥ 7 on the skin picking scale-revised (sps_r, gallinat et al., 2016). exclusion criteria included an existing diag­ nosis of a psychotic disorder, substance dependence, posttraumatic stress disorder, or depression with severe symptoms. furthermore, participants who reported skin diseases were excluded. a total of 308 participants were eligible; of them, 158 could be contacted and agreed to participate in the study. twenty-six participants (16%) dropped out of the study during the intervention. data from 132 participants were included in the analyses (see supplementary figure 1: consort flow diagram). 34% of the females participated in self-help groups during the course of the study. the participants were randomly allocated to one of four groups: (a) expressive writing (paper/pencil), (b) expressive writing (computer), (c) picture description (pa­ per/pencil), (d) picture description (computer). the four groups did not differ in the number of participants, mean age, years of education, and reported symptom severity of skin-picking as assessed by the skin picking scale (sps_r; gallinat et al., 2016) and the milwaukee inventory for the dimensions of adult skin-picking (midas; walther et al., 2009; m = 22.36, sd = 4.56). moreover, participants did not differ in trait anxiety and trait depression according to the state-trait anxiety and depression inventory (stadi; laux et al., 2013). for group characteristics see table 1. reduction of pathological skin-picking via expressive writing 4 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ table 1 group characteristics (means, standard deviations, f/chi-square statistics) characteristic expressive writing (paper/ pencil) expressive writing (computer) picture description (paper/pencil) picture description (computer) statistics m (sd) m (sd) m (sd) m (sd) mean age (years) 28.21 (8.13) 27.71 (10.69) 30.29 (11.80) 27.50 (6.98) f(3,128) = .61, p = .608, ηp2 = .014 years of education 14.09 (2.14) 13.68 (2.17) 13.68 (2.26) 14.03 (2.16) f(3,128) = .34, p = .796, ηp2 = .008 sps_r 14.58 (4.15) 14.58 (3.78) 14.11 (4.13) 14.47 (4.04) f(3,128) = .11, p = .954, ηp2 = .003 midas (focused) 22.88 (4.97) 22.55 (3.84) 21.50 (5.28) 22.70 (3.81) f(3,128) = .661, p = .578, ηp2 = .015 stadi_depression 20.70 (5.75) 21.45 (6.07) 21.58 (6.04) 22.00 (5.87) f(3,128) = .268, p = .849, ηp2 = .006 stadi_anxiety 23.97 (5.55) 23.55 (5.41) 23.74 (6.32) 25.20 (5.19) f(3,128) = .530, p = .662, ηp2 = .012 n n n n number of participants 33 31 38 30 χ2(3) = 1.15, p = .765 dropout rate 9 3 8 6 χ2(3) = 2.23, p = .527 note. sps_r = skin picking scale revised; midas (focused) = subscale focused picking of the milwaukee inventory for the dimensions of adult skin picking; stadi_depression = subscale trait depression of the state trait anxiety and depression inventory; stadi_anxiety = subscale trait anxiety of the state trait anxiety and depression inventory. all participants provided written informed consent before participating. this study was preregistered on the german register for clinical studies (drks00029224; 2022/06/07) and approved by the ethics committee of the university (gz. 39/79/63 ex 2021/22). questionnaires before and after the two-week intervention participants filled out the following ques­ tionnaires via online surveys: a. german version of the skin picking scale-revised (gallinat et al., 2016), which assesses symptom severity and impairment due to skin-picking during the last week. the eight items (e.g., how strong was your urge to pick your skin?) are answered on schlintl & schienle 5 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ 5-point scales (0 = no urge; 4 = very strong urge). an overall score (total sps_r; cronbach’s alpha = .81) was computed that reflects the severity of skin-picking. a score of 7 represents the clinical cut-off (gallinat et al., 2016). b. the milwaukee inventory for the dimensions of adult skin-picking (midas; walther et al., 2009) is a self-report questionnaire with two subscales: automatic skin-picking (cronbach’s α = 0.62; e.g., i don't notice that i have picked my skin until after it's happened.) and focused skin-picking (cronbach’s α = 0.75; e.g. i experience an extreme urge to pick before i pick). the six items of each subscale are judged on 5-point likert scales (1 = not at all; 5 = very much). due to the low cronbach’s α of the automatic skin-picking subscale, no further analyses were performed with this subscale. c. the trait version of the state-trait anxiety and depression inventory (stadi; laux et al., 2013) has two subscales: depression (α = .913) and anxiety (α = .866), with ten items each (e.g., depression: “i am sad”; anxiety: “i worry that something might happen”) that are scored on a four-point likert scale ranging from 1 (not at all) to 4 (very much). app-assisted interventions all participants of the four intervention groups were asked to set aside at least 10 minutes for each writing session in a quiet place without disturbance. in total, six writing sessions had to be completed within a two-week period (with a maximum of one writing session per day). the participants had the option to write more than six times during the two weeks if they felt to do so. before and after each writing session, the participants rated their affective state (pleasantness, tension, relief, urge to pick the skin) via a smartphone app on 100-point likert scales (0 = i do not feel good, tense, relieved, no urge to pick my skin; 100 = i feel good, tense, relieved, a strong urge to pick my skin). the rating interval (pre vs. post-writing) was set to 10 minutes (it was not possible to provide the app ratings earlier). the group-specific instructions for the writing sessions were as follows: a. expressive writing: expressive writing is an intervention in which people spend a few minutes writing about specific, personally relevant topics over several days. let your thoughts and feelings wander freely while writing. expressive writing has been studied since the 1980s and offers a beneficial way to engage with one's emotions and manage them. write for at least 10 minutes about a topic that is currently on your mind. explore your thoughts and emotions openly that you perceive while writing. spelling, syntax, or grammar are irrelevant. it is desirable to get into a flow of writing. choose a time of the day that suits you best and find a quiet place where you will not be disturbed (e.g., put your mobile phone in flight mode). reduction of pathological skin-picking via expressive writing 6 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ b. picture description: a picture description is a visual representation translated into language. it is meant to be a reproduction of what is seen in the picture. for example, image descriptions enable visually impaired people to find access to pictorial representations such as paintings or photographs. the detailed descriptions train analytical and structural thinking, which are important skills for problemsolving and finding new solutions. choose a time of the day that suits you best and find a quiet place where you will not be disturbed (e.g., put your mobile phone in flight mode). describe for at least 10 minutes one of the abstract pictures that you have received from us. write about the appearance of the image as factually and neutrally as possible, as if you were describing it to a visually impaired person. half of the participants were asked to use paper and pencil to complete the task, while the other half of the participants were assigned to the computer-writing groups. the written texts remained with the participants; the experimenters had no access to the texts. procedure after the first online survey (checking of inclusion/exclusion criteria), eligible partici­ pants were scheduled for a personal meeting where they were randomly allocated to one of four interventions: (a) expressive writing (paper/pencil), (b) expressive writing (computer), (c) picture description (paper/pencil), (d) picture description (computer). all participants received further information about the study, including instructions for using the smartphone app. after participants completed the two-week writing interven­ tion, they were asked to fill out a second online survey (questionnaires). moreover, participants were asked to count the words written in each session. we consider the number of written words as a proxy for the time spent writing. further, we chose this measure to detect potential noncompliance (e.g., refusal to engage in writing). the procedure is depicted in figure 1. statistical analysis self-reports assessed via the smartphone app: mixed-model analyses of variance (anovas) were conducted to compare the two interventions (expressive writing (ew) vs picture description (pd)) and the two writing modalities (paper pencil (pp) vs computer (c)), before vs after a writing session (factor: time). this was done for the dependent measures: urge to pick one’s skin, feelings of tension, relief, and pleasantness. the ratings were averaged across the number of writing sessions during the two weeks. moreover, word count (number of written words) was compared between the inter­ ventions via an anova. schlintl & schienle 7 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ questionnaires: mixed-model analyses of variance (anovas) were computed to com­ pare the questionnaire scores (sps-r; midas; stadi_depression, stadi_anxiety) be­ tween interventions and time (before and after the two-week intervention). exploratory regression analyses: to identify variables (number of completed writing sessions, word count, trait anxiety, trait depression) that are associated with the effec­ tiveness of expressive writing (reduction in the urge to pick one’s skin before vs. after a writing session), a multiple linear regression analysis was conducted. the model was assessed for multicollinearity (all variance inflation factors (vifs) < 1.5; tolerance > 0.7) and residual distribution (cook’s distance < 0.3, durbin watson > 1.5 and < 2.5). all analyses were conducted with spss version 28. figure 1 procedure note. sps-r: skin-picking scale (revised); midas (milwaukee inventrory of the dimensions of adult skinpicking); stadi: subscales trait anxiety/ depression of the state trait anxiety and depression inventory. reduction of pathological skin-picking via expressive writing 8 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ results self-reports assessed via the smartphone app number of completed writing sessions on average, participants completed four writing sessions (range: 1-12). the number of sessions did not differ between the intervention groups, mewpp = 3.88, sd = 2.71; mewc = 4.55, sd = 2.49, mpdpp = 3.76, sd = 2.39, mpdc = 2.97, sd = 2.54; f(3,128) = 2.003, p = .117, ηp2 = .045. word count the anova that was carried out revealed that the four intervention groups differed in the number of written words per writing session, f(3,128) = 14.36, p < .001, ηp2 = .252. tukey post-hoc comparisons (see supplementary table s1) showed that the ewc group had the highest word count (m = 316, sd = 154), followed by the ewpp group (m = 210, sd = 84), the pdc group (m = 205, sd = 135), and the pdpp group (m = 142, sd = 51). urge to pick one’s skin the anova revealed a significant main effect of time, f(1,128) = 50.64, p < .001, ηp2 = .283, and a significant interaction time x intervention, f(1,128) = 8.75, p = .004, ηp2 = .064. all other effects were non-significant (all p > .05; see supplementary table s2). after a session of expressive writing, participants reported a reduced urge to pick their skin compared to before the session, t(63) = 7.02, p < .001. after a session of picture description, the urge to pick was less intense compared to before the pd session, t(67) = 3.12, p = .003; figure 2. the reduction in the urge to pick was more pronounced in the expressive writing groups (mdiff = -15.19, sd = 17.30) than in the picture description groups (mdiff = -6.43, sd = 16.97; t(130) = 2.94, p = .004). relief the anova revealed a significant main effect of time, f(1,128) = 10.07, p = .002, ηp2 = .073, and a significant interaction time x intervention, f(1,128) = 9.83, p = .002, ηp2 = .071. post hoc comparisons showed that participants felt more relieved after expressive writing than before, t(63) = 4.02; p < .001. in the picture description groups, the participants did not significantly differ in their ratings for relief before and after a writing session, t(67) = .04; p = .979; figure 2. all other effects were non-significant (all p > .005; also see supplementary table s2). schlintl & schienle 9 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ tension the anova revealed a significant main effect of time, f(1,128) = 29.95, p < .001, ηp2 = .190, and a significant interaction time x intervention, f(1,128) = 4.52, p = .036, ηp2 = .034. post hoc comparisons showed that after both expressive writing, t(63) = 5.23; p < .001, and picture description, t(67) = 2.52; p = .014, participants reported reduced feelings of tension compared to before writing. the reduction of tension was more pronounced in the expressive writing groups, mdiff = -12.60, sd = 19.28, than in the picture description groups, mdiff = -5.61, sd = 18.35; t(130) = 2.14, p = .035. for means and standard deviations see figure 2. all other effects were non-significant (all p > .005; also see supplementary table s2). pleasantness the anova revealed a significant interaction effect time x intervention, f(1,128) = 7.88, p = .006, ηp2 = .058. all other effects were non-significant (all p > .005, see supplementary table s2). post hoc comparisons revealed that participants in the picture description groups felt more pleasant than participants in the expressive writing groups figure 2 means and standard deviations for the app-data note. ewpp = expressive writing paper/pencil; ewc = expressive writing computer; pdpp = picture description paper pencil; pdc = picture description computer; ew = expressive writing; pd = picture description. reduction of pathological skin-picking via expressive writing 10 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ before the session t(130) = 2.31; p = .023. after the session, the groups did not differ in valence ratings, t(130) = .12; p = .905. in the picture description groups, participants felt more unpleasant after the writing than before, t(67) = 2.56; p = .013. in the expressive writing group, participants did not significantly differ in their pleasantness ratings before and after the session, t(63) = 1.41; p = .165. for means and standard deviations see figure 2. questionnaire data skin picking scale (revised) the anova revealed a significant main effect of time, f(1,128) = 28.53, p < .001, ηp2 = .182. after the two-week intervention, participants scored lower on the sps-r (m = 12.89, sd = 4.72) than before (m = 14.42, sd = 4.00) independent of intervention and writing modality. all other effects were non-significant (all p < .005; see supplementary table s3). milwaukee inventory for the dimensions of adult skin-picking (focused) the anova revealed a significant main effect of time, f(1,128) = 5.56, p = .020, ηp2 = .042, and an interaction effect time x intervention, f(1,128) = 7.46, p = .007, ηp2 = .055. post hoc comparisons showed that participants of the expressive writing groups scored lower on the focused picking scale of the midas after the intervention (m = 21.47, sd = 4.65) than before, m = 22.72, sd = 4.42; t(63) = 4.04, p < .001. in contrast, participants of the picture description groups did not differ in their scores before (m = 22.03, sd = 4.69) and after the two-week intervention, m = 22.10, sd = 4.46; t(67) = .20; p = .842. all other effects were non-significant (all p > .05; see supplementary table s3). state-trait anxiety depression inventory the anova revealed no significant effects for trait anxiety and trait depression (all p > .05; see supplementary table s3). regression analysis the regression equation for the dependent variable ‘reduction in the urge to pick one’s skin’ (before minus after a session of ew) with the predictors number of writing ses­ sions, word count, depression, and anxiety, was significant, r 2 = .17; f(4,63) = 2.98, p = .026. trait anxiety was a significant positive predictor. participants with a higher level of trait anxiety showed a greater reduction in the urge to pick their skin due to expressive writing (for statistics see table 2). schlintl & schienle 11 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ table 2 results of the multiple linear regression analysis for the association between “reduction in the urge to pick” (before minus after a writing session) and “number of writing sessions,” “wordcount”, “stadi_anxiety” and “stadi_depression” variable b se b β t p 95.0% ci b r srll ul (constant) -13.973 10.913 -1.280 .205 -35.810 7.864 wordcount .005 .016 .036 .303 .763 -.026 .036 .014 .039 frequency -.751 .800 -.113 -.939 .352 -2.352 .850 -.106 -.121 stadi_anxiety 1.091 .461 .344 2.368 .021 .169 2.014 .390 .295 stadi_depression .244 .431 .083 .567 .573 -.618 1.106 .263 .074 note. se b = standard error of b; 95% ci b = 95% confidence interval for b; r = bivariate correlation, and sr = partial correlation; wordcount = average number of written words per writing session; frequency = number of writing sessions; stadi_anxiety = subscale trait anxiety of the state trait anxiety and depression inventory; stadi_depression = subscale depression of the state trait anxiety and depression inventory. discussion this study investigated the effects of expressive writing (using an app-assisted approach) on excessive skin-picking behavior. each participant was asked to complete six writing sessions over two weeks that either focused on emotional experiences with personal rele­ vance (expressive writing), or the description of abstract paintings (control condition). the main findings of this study were that expressive writing (ew) produced posi­ tive short-term and mid-term effects on skin-picking behavior. directly after a writing session, the two ew groups (computer, paper/pencil) reported a reduced urge to pick their skin. interestingly, the control groups also expressed less of an urge to manipulate their skin after describing a painting. this latter finding implies the positive effects of distraction on skin-picking behavior. this is in line with clinical recommendations which suggest, for example, distracting one’s hands with stress balls, fidgets, or tangle toys to reduce skin-picking (e.g., snorrason, goetz, & lee, 2017). similarly, cognitive-behavioral therapy for skin-picking disorder typically includes stimulus control techniques as well as habit reversal training: this involves those affected being taught to engage in harm­ less motor behaviors (like clenching one’s fists), which in turn prevent skin-picking (e.g., snorrason, goetz, & lee 2017). importantly, the effects of ew on skin-picking go beyond distraction and motor control. in the present study, ew was associated with a more pronounced reduction in the urge to pick one’s skin than picture description (a reduction of -15 vs. -6 points on a scale ranging from 0 to 100). moreover, only ew was associated with the reduction of focused skin-picking as indexed by the midas. whereas the control groups showed no change, the ew groups showed an average reduction of one point in their midas scores. reduction of pathological skin-picking via expressive writing 12 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ thus, ew and picture description exhibited differential effects on skin-picking symptoms (with small to moderate effect sizes). ew also demonstrated immediate effects on participants’ affective states. directly after a writing session, participants in the ew groups reported a greater reduction of tension than those in the control groups. in addition to this, those in the ew groups also experienced increased feelings of relief (this positive emotion occurs as a response to a threat that has abated or disappeared). previous findings have suggested that ew exerts its effects through habituation, and/or through the (re)structuring of anxious feelings (sabo-mordechay et al., 2019; pennebaker & chung, 2011; perry & ward-smith, 2018). in this sense, the findings of the present study imply that ew may have assisted participants in reducing their emotional distress, which in turn reduced the need for skin-picking (i.e., the emotional distress may have no longer been pronounced enough to trigger skin-picking). this interpretation is also in line with exposure theory: when pa­ tients repeatedly confront themselves with negative feelings, this repetition and exposure can eventually lead to extinction of those feelings and associated thoughts (see frattaroli, 2006). an exploratory analysis was carried out which attempted to identify variables associ­ ated with the effectiveness of ew. this regression analysis showed that the number of writing sessions completed and the number of words written during a session did not contribute significantly to the positive effects of ew. in the present study, participants completed on average four writing sessions; this was below the six sessions they were originally instructed to carry out. nonetheless, this amount of writing was sufficient to reduce skin-picking behavior. this finding is also in line with recommendations based on a meta-analysis by frattaroli (2006) who investigated optimal conditions for ew effects; these conditions included completing a minimum of only three writing sessions. thus, the average of four writing sessions carried out in the current study can be seen as sufficient to produce positive results. a further finding of the current study was that there was a general trend toward more words being written on the computer compared to handwriting. this appears to reflect different writing speeds for each modality. an unexpected finding was that the writing modality had no differential effect on the reduction of skin-picking symptoms. we had assumed that the process of writing (performing up and down movements) would be similar to the physical movements involved in skin-picking, and could there­ fore be an efficient replacement behavior. the null findings of the current study, howev­ er, are in line with results reported in the meta-analysis by frattaroli (2006). in that study, it was concluded that the mode of disclosure did not moderate ew outcomes; studies using handwritten disclosure did not produce larger effects than studies using typed disclosure. the present investigation also showed that high levels of reported trait anxiety were associated with more positive effects of ew (in terms of a greater reduction in the urge schlintl & schienle 13 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ to pick one’s skin). anxiety has been shown to be a typical elicitor of skin-picking episodes (e.g., yeo & lee, 2017). further, patients with skin-picking disorder report elevated trait anxiety and show elevated rates of comorbid anxiety disorders (schienle et al., 2022). other studies have demonstrated that ew is effective at reducing anxiety and associated problems (e.g., test anxiety; see park et al., 2014; robertson et al., 2021; shen et al., 2018). for example, park et al. (2014) showed that highly math-anxious individuals performed significantly worse on a math test than individuals with low anxiety. notably, a subsequent ew intervention significantly reduced the group difference in test scores. the authors of that study proposed that the ew might have enabled participants to more effectively identify and differentiate their emotional experience, which may have led to the use of better emotion regulation strategies. further, the use of specific words in the ew task related to anxiety, cause, and insight, was positively related to math performance (also see shen et al., 2018). thus, confrontation with anxious feelings, as well as cognitive restructuring, appear to be important components involved in the positive effects of ew on anxiety and related problems; both components are elements of exposure therapy, which is a highly effective method for reducing symptoms of anxiety and other negative emotions (e.g., hollon & beck, 1994; margraf & schneider, 1990; ruhmland & margraf, 2001). in the current study, while trait anxiety was not found to be reduced on average after the ew intervention, trait anxiety was however identified as a moderator for the effects of ew on the urge to perform skin-picking (i.e., participants high in trait anxiety were found to benefit more from ew). considering this, in future ew studies that focus on excessive skin-picking, text analyses could be implemented to further elucidate anxiety-associated mechanisms of ew in the context of this dysfunc­ tional behavior. further, additional trait variables associated with affective processing in the context of pathological skin-picking (e.g., disgust propensity, difficulties in emotion regulation) should be investigated (schienle et al., 2018). it is important to mention the potential limitations of the present study. first, we only studied females. therefore, the results cannot be generalized to males or other groups. second, some of the participants took part in self-help groups during the study; this could have biased results. however, none of the participants received any other form of psychological treatment during the course of the study. third, observed changes in skin-picking behavior were based on the self-reports of participants. in future studies, objective measures could be introduced (e.g., photos of affected skin before and after the ew intervention). finally, participants received a brief intervention lasting only two weeks. the implementation of ew as an additional component in a (longer-lasting) psychotherapy would very likely enhance its effectiveness. further, this type of psycho­ therapy would not have to be based on conventional face-to-face interactions but could be provided via online counseling. the present study underlines how technologies such as app-assisted interventions can be used to promote beneficial effects for reducing psy­ chological symptoms, in this case, pathological skin-picking. such e-therapy approaches reduction of pathological skin-picking via expressive writing 14 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ might also enhance the effectiveness of ew interventions, since larger effects of ew have been obtained when participants have disclosed at home vs. in other (non-private) settings (frattaroli, 2006). conclusion this study revealed positive immediate effects of ew on skin-picking, including a re­ duced urge for skin-picking and increased feelings of relief. mid-term effects of ew on skin-picking were also found, relating to a reduction in focused skin-picking (according to self-reports). the beneficial effects of ew were independent of the writing modality (paper/pencil vs. computer) and were also found to be associated with trait anxiety. funding: the authors have no funding to report. acknowledgments: we would like to thank hannah fink and carla danczewitz for their help in conducting this study. competing interests: the author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article. ethics statement: all procedures performed in studies involving human participants were in accordance with the ethical standards of the university of graz and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. informed consent was obtained from all individual participants included in the study. the study was approved by the ethics committee of the university of graz (gz. 39/79/63 ex 2021/22). data availability: the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): 1. the pre-registration protocol for the study. 2. follow-up tests (tukey post-hoc comparisons) for the analysis of variance (anova) that compared the four interventions (expressive writing: paper/pencil; expressive writing: computer; picture description: paper/pencil; picture description: computer) concerning word count (number of written words during a session) are provided in the supplementary table s1. 3. f-statistics (f, df, p, part η2) for the mixed-model analyses of variance (anovas) to compare the two interventions (expressive writing (ew) vs picture description (pd)) and the two writing modalities (paper pencil (pp) vs computer (c)), before vs after a writing session schlintl & schienle 15 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://www.psychopen.eu/ (factor: time) concerning the app ratings (urge to pick one’s skin, feelings of tension, relief, and pleasantness) are provided in supplementary table s2. 4. f-statistics (f, df, p, part η2) for the mixed-model analyses of variance (anovas) to compare the questionnaire scores (sps-r; midas; stadi_depression, stadi_anxiety) between interventions and time (before and after the two-week intervention) are provided in supplementary table s3. 5. supplementary figure s1 depicts the consort flow diagram. index of supplementary materials schlintl, c., & schienle, a. 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(2017). the relationship between adolescents’ academic stress, impulsivity, anxiety, and skin picking behavior. asian journal of psychiatry, 28, 111–114. https://doi.org/10.1016/j.ajp.2017.03.039 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. reduction of pathological skin-picking via expressive writing 18 clinical psychology in europe 2023, vol. 5(2), article e11215 https://doi.org/10.32872/cpe.11215 https://doi.org/10.1016/j.jocrd.2017.10.006 https://doi.org/10.1371/journal.pone.0191779 https://doi.org/10.1002/9781118890233.ch56 https://doi.org/10.1016/j.jbtep.2010.01.009 https://doi.org/10.1016/j.jbtep.2008.07.002 https://doi.org/10.1016/j.ajp.2017.03.039 https://www.psychopen.eu/ reduction of pathological skin-picking via expressive writing (introduction) method participants questionnaires app-assisted interventions procedure statistical analysis results self-reports assessed via the smartphone app questionnaire data regression analysis discussion conclusion (additional information) funding acknowledgments competing interests ethics statement data availability supplementary materials references towards a 21st century definition of mental health – emerging trends in bringing practice and research together editorial towards a 21st century definition of mental health – emerging trends in bringing practice and research together christoph flückiger 1 , jan schürmann-vengels 2 , nadine messerli-bürgy 3 [1] clinical psychology, department of psychology, university of kassel, kassel, germany. [2] school of psychology and psychotherapy, witten/herdecke university, witten, germany. [3] family and development research center, institute of psychology, university of lausanne, lausanne, switzerland. clinical psychology in europe, 2025, vol. 7(3), article e18657, https://doi.org/10.32872/cpe.18657 published (vor): 2025-08-29 corresponding author: christoph flückiger, department of psychology, holländische straße 36 – 38, de-34127 kassel, germany. e-mail: christoph.fluckiger@uni-kassel.de mental health is typically defined in clinical contexts through categorical systems such as the dsm (diagnostic and statistical manual of mental disorders) or icd (international classification of diseases). these categorical systems are based on medical standards, where a specific diagnosis is either met or not met (e.g., a major depressive episode is ei­ ther present or absent). despite the potential communicative benefits of categorical sys­ tems in clinical settings, these classification systems fall short in capturing the complex, multi-faceted nature of mental health (rief et al., 2023), thereby leading to frustration among practitioners who struggle to reconcile the nuances of human experience with the limitations of existing diagnostic frameworks (e.g., jensen-doss & hawley, 2011). in the context of the rapid advancements in information processing and data sciences, the limitations of existing classification systems are becoming increasingly pronounced. a gap is emerging between the precision in measuring and representing mental health and the above-mentioned, rather crude categorical classification systems for mental disorders. recent innovations can be illustrated by three developments, among others: the transition from categorical to dimensional, hierarchically structured understanding of mental health severity; the definition of mental health with both individual problems and strengths; and the representation of mental health in a psychosocial and structural context. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.18657&domain=pdf&date_stamp=2025-08-29 https://orcid.org/0000-0003-3058-5815 https://orcid.org/0000-0002-8963-1129 https://orcid.org/0000-0001-8619-5950 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ transition from categorical to dimensional, hierarchically structured understanding of symptom severity while a multidimensional understanding of personality disorders has become well es­ tablished in classification systems, mental health diagnoses with high prevalence rates in the anxiety and depression spectrum continue to be strongly categorical in nature. the hitop model presents a counterpoint to this approach and proposes a hierarchical understanding of mental health (kotov et al., 2021). at a higher level of this hierarchy, internalizing and externalizing behaviors can be defined – a distinction that has been established in the field of child and adolescent psychology for some time (vergunst et al., 2023). the newer hierarchical understanding of mental health can be illustrated by pathological worrying, for example. in contrast to the dsm and icd models, which categorize pathological worrying as a primary symptom of generalized anxiety disorder (gad), the hitop model assumes that this symptom may be a key feature of a more general stress factor that crosses traditional diagnostic categories. this view is suppor­ ted by meta-analytic evidence summarizing the association between worry and mental health based on 138 correlational studies (vîslă et al., 2022). notably, the link between worry and mental health was not significantly different between samples of individuals with gad and those with major depressive disorder, supporting the notion that worry is a common symptom of a broader, generalized distress factor. these findings have important implications for the treatment of worry, suggesting that interventions focusing on worry may be beneficial for a wider range of psychopathologies. this example serves as one of several illustrations demonstrating how a dimensional understanding of mental health can inform the nuanced and sophisticated clinical thinking of practitioners (hopwood & sharp, in press). definition of individual mental health problems and strength mental health is more than merely a response to individual distress. two-dimensional models of mental health postulate that mental health is more accurately described by two related, but still distinct overall dimensions: psychological burden (assessed by the degree of psychopathological suffering) and positive mental health, which includes various facets of patient strengths and resources such as subjective life satisfaction, hedonic pleasure, positive affect in everyday life, self-acceptance, personal growth, or finding purpose in life (schürmann-vengels et al., 2023). the two affect-related dimensions are not opposites and not strongly related, as two recent meta-analyses demonstrate. individ­ uals with severe psychological impairments also experience positive states, relatively towards a 21st century definition of mental health 2 clinical psychology in europe 2025, vol. 7(3), article e18657 https://doi.org/10.32872/cpe.18657 https://www.psychopen.eu/ independent of the severity of their anxiety symptoms (flückiger et al., 2025) or of depressive moods (schürmann-vengels et al., 2025). traditional psychotherapies consistently emphasize the importance of strengths and resources as catalysts for therapeutic progress. moreover, many practitioners acknowl­ edge the limitations of a solely problem-focused understanding of the individuals who come into therapy. a current intersectional task force evaluates capitalization of patient strengths and resources as a 'demonstrably effective' method in terms of therapeutic progress through to treatment termination (flückiger et al., 2023). this systematic review and meta-analysis examined the effectiveness of strength-based methods in psychother­ apy and revealed an association with more favorable immediate outcomes, as well as a small but significant effect on post-treatment outcomes compared to psychotherapy conditions without strength-based personalization. the findings indicate a potential benefit in capitalizing on patient strengths and resources while working on the problems and challenges, specifically by virtue of the systematic and regular assessment of an individual's abilities and motivational readiness, and the corresponding adjustment of mental health interventions. this approach fundamentally redefines the clinical concept of mental health, emphasizing the importance of leveraging an individual's inherent strengths and capacities in the pursuit of psychological well-being. representation of mental health in psychosocial and structural contexts mental health encompasses more than the symptoms and abilities of an individual person. mental suffering is caused and experienced in and with others. mental health issues develop and are maintained within a social context where factors like relationship dynamics (e.g. within families, peers, at work or school) and chronic social stress expo­ sure (ex. conflicts, social exclusion, discrimination, low socioeconomic status) negatively influence an individual’s well-being. severe stress exposure of family members such as critical life events (e.g. the birth of a child or physical health issues of a family member) can not only increase the risk of mental health issues in individuals but also in their partners and children. in turn, developed mental health issues can negatively impact an individual’s social environment by straining relationships, perpetuating stigmatization and/or provoking social exclusion. as another example, numerous studies have shown that marginalized groups experience disproportionate levels of mental distress due to additional stressors, such as discrimination, arising both from their immediate social environments and from broader societal structures (hatzenbuehler et al., 2024). these examples demonstrate that the definition of mental health should not just be reduced to individual-level factors and instead reflect a complex psychosocial phenomenon that needs to be captured in future mental health assessments (chronister et al., 2021). flückiger, schürmann-vengels, & messerli-bürgy 3 clinical psychology in europe 2025, vol. 7(3), article e18657 https://doi.org/10.32872/cpe.18657 https://www.psychopen.eu/ the above-mentioned three trends highlight the need for a reciprocal exchange of knowledge between research and practice to define mental health, where practice is informed by current research, and research, in turn, is grounded in the everyday realities and challenges of clinical practice. these developments, however, also provide compel­ ling evidence that the convergence of research and practice is considerably advancing. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: nadine messerli-bürgy is editor-in-chief of clinical psychology in europe. references chronister, j., fitzgerald, s., & chou, c. c. (2021). the meaning of social support for persons with serious mental illness: a family member perspective. rehabilitation psychology, 66(1), 87–101. https://doi.org/10.1037/rep0000369 flückiger, c., mahlke, f., john, g., daus, p., zinbarg, r. e., allemand, m., & schürmann-vengels, j. (2025). how strongly are trait positive and negative affectivity associated with anxiety symptoms? a multilevel meta-analysis of cross-sectional studies in anxiety disorders. journal of anxiety disorders, 109, article 102956. https://doi.org/10.1016/j.janxdis.2024.102956 flückiger, c., munder, t., del re, a. c., & solomonov, n. (2023). strength-based methods – a narrative review and comparative multilevel meta-analysis of positive interventions in clinical settings. psychotherapy research, 33(7), 856–872. https://doi.org/10.1080/10503307.2023.2181718 hatzenbuehler, m. l., lattanner, m. r., mcketta, s., & pachankis, j. e. 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(2023). association of childhood externalizing, internalizing, and comorbid symptoms with long-term economic and social outcomes. jama network open, 6(1), article e2249568. https://doi.org/10.1001/jamanetworkopen.2022.49568 vîslă, a., stadelmann, c., watkins, e., zinbarg, r. e., & flückiger, c. (2022). the relation between worry and mental health in nonclinical population and individuals with anxiety and depressive disorders: a meta-analysis. cognitive therapy and research, 46(3), 480–501. https://doi.org/10.1007/s10608-021-10288-4 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. flückiger, schürmann-vengels, & messerli-bürgy 5 clinical psychology in europe 2025, vol. 7(3), article e18657 https://doi.org/10.32872/cpe.18657 https://doi.org/10.32872/cpe.11699 https://doi.org/10.1016/j.brat.2025.104789 https://doi.org/10.32872/cpe.8041 https://doi.org/10.1001/jamanetworkopen.2022.49568 https://doi.org/10.1007/s10608-021-10288-4 https://www.psychopen.eu/ towards a 21st century definition of mental health (introduction) transition from categorical to dimensional, hierarchically structured understanding of symptom severity definition of individual mental health problems and strength representation of mental health in psychosocial and structural contexts (additional information) funding acknowledgments competing interests references developing a brief cognitive task intervention to reduce long-standing intrusive memories of trauma: a feasibility study with remote delivery for women in iceland research articles developing a brief cognitive task intervention to reduce long-standing intrusive memories of trauma: a feasibility study with remote delivery for women in iceland johann palmar hardarson 1 , beau gamble 2 , kristjana thorarinsdottir 1 , elín sjöfn stephensen 1 , marie kanstrup 2 , thorsteinn gudmundsson 1 , unnur valdimarsdóttir 3,4,5 , arna hauksdottir 3 , andri s. bjornsson 1 , michelle l. moulds 6 § , emily a. holmes 7 § [1] department of psychology, university of iceland, reykjavik, iceland. [2] department of psychology, uppsala university, uppsala, sweden. [3] the center of public health sciences, university of iceland, reykjavik, iceland. [4] department of epidemiology, harvard th chan school of public health, boston, ma, usa. [5] the national university hospital of iceland, university of iceland, reykjavik, iceland. [6] school of psychology, unsw sydney, sydney, australia. [7] department of women’s and children’s health, uppsala university, uppsala, sweden. §these authors contributed equally to this work. clinical psychology in europe, 2024, vol. 6(1), article e11237, https://doi.org/10.32872/cpe.11237 received: 2023-01-27 • accepted: 2023-11-17 • published (vor): 2024-03-28 handling editor: cornelia weise, philipps-university of marburg, marburg, germany corresponding author: johann palmar hardarson, department of psychology, university of iceland, sæmundargata 12, 102 reykjavik, iceland. phone: +354 525 4240. e-mail: jph6@hi.is supplementary materials: code, data, materials, preregistration [see index of supplementary materials] abstract background: there is emerging evidence that a brief cognitive task intervention may reduce the frequency of intrusive memories, even long-standing memories of older trauma. however, evaluations to date have involved in-person researcher contact. we investigated the feasibility and acceptability of remote delivery to women (n = 12) in iceland who had experienced trauma on average two decades earlier. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11237&domain=pdf&date_stamp=2024-03-28 https://orcid.org/0000-0002-3598-0526 https://orcid.org/0000-0001-8284-9371 https://orcid.org/0000-0002-9939-1333 https://orcid.org/0000-0001-7472-7112 https://orcid.org/0000-0003-2060-5288 https://orcid.org/0000-0003-4183-7563 https://orcid.org/0000-0001-5382-946x https://orcid.org/0000-0002-4253-1059 https://orcid.org/0000-0003-0307-2512 https://orcid.org/0000-0001-7064-4248 https://orcid.org/0000-0001-7319-3112 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ method: participants monitored intrusive memories in a daily diary for one week (i.e., baseline phase), completed (at least) two guided, remote intervention sessions (e.g., via secure video platform), and were encouraged to continue to use the intervention self-guided. results: eight participants completed the primary outcome and reported fewer intrusive memories in week 5 (m = 6.98, sd = 5.73) compared to baseline (m = 25.98, sd = 29.39) – a 68% reduction. intrusions decreased at each subsequent time point; at 3-months (n = 7) there was a 91% reduction compared to baseline. other psychological symptoms reduced and functioning improved. importantly, participant ratings and qualitative feedback support feasibility and acceptability. conclusion: findings suggest the feasibility of remote delivery of the brief imagery-competing task intervention by non-specialists (who were not mental health professionals) and hold promise for developing psychotherapeutic innovations supporting women with intrusive memories even decades after trauma. keywords trauma, intrusive memories, intervention, feasibility study, mental imagery highlights • there is a high global prevalence of trauma exposure and mental health resources are limited. • the intervention delivered remotely by non-specialists to women in iceland was feasible and acceptable. • participants reported fewer intrusive memories at 5 weeks post-intervention relative to the baseline phase. • this method could complement existing therapies, in cases of long waitlists or lack of access. effective brief, low intensity interventions are needed to address mental health problems on a global scale. such an intervention has been developed to target intrusive trauma memories (holmes et al., 2009; iyadurai et al., 2018; kanstrup, singh, et al., 2021). the intervention draws on cognitive neuroscience (monfils & holmes, 2018), specifically targeting the potential effect of taxing working memory on altering re-consolidation of trauma memories (visser et al., 2018). it comprises three components: (1) briefly bringing a trauma memory to mind, (2) engaging in a visuospatial task such as the computer game ‘tetris’ for approximately 20 minutes, whilst (3) employing mental rotation during gameplay. studies in the laboratory (using trauma analogues; e.g., james et al., 2015) and with trauma exposed samples (e.g., women who experienced traumatic childbirth, horsch et al., 2017; emergency department patients, iyadurai et al., 2018; kanstrup, singh, et al., 2021) demonstrate that receiving the intervention in the initial hours and days posttrauma results in fewer intrusive memories relative to receiving a placebo control. reducing intrusive memories of trauma: feasibility study 2 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ there is also emerging evidence that this intervention reduces long-standing intru­ sive memories up to decades old; e.g., in people with chronic ptsd (kanstrup, kontio, et al., 2021; kessler et al., 2018). further, a pilot case study (thorarinsdottir et al., 2021) and brief case series (n = 3; thorarinsdottir et al., 2022) with icelandic women with a chronic trauma history provided preliminary evidence of its capacity to reduce intrusive memo­ ries in this group. not only were treatment gains (i.e., reduced intrusions) maintained at 3 month follow-up, other clinical symptoms (e.g., depression, anxiety) reduced and functioning (e.g., concentration, sleep) improved. essential to an intervention’s scope for scalability is its capacity for effective re­ mote delivery, eliminating the need for in-person contact. ideally, scalable interventions should be deliverable by non-specialists who have received remotely-delivered training. whilst the abovementioned case study (thorarinsdottir et al., 2021) and case series (thorarinsdottir et al., 2022) provide encouraging preliminary evidence of the cognitive task intervention’s effectiveness, both studies included some aspects of in-person recruit­ ment and/or intervention delivery, and the intervention was delivered by a qualified clinical psychologist. in line with the goal of establishing scalability, the current study (i) investigated the feasibility of a fully remote delivered, researcher-guided form of the intervention, and (ii) explored preto post-intervention changes in the number of intrusive memories. in addition, we delivered some aspects of the intervention in digitalized format; i.e., via brief animated film-clips (e.g., to explain the target symptom). we investigated feasibility in a sample of trauma-exposed women in iceland who reported intrusive memories of long-standing trauma. we assessed the feasibility of delivering the intervention in a fully remote format based on the number of sessions completed, dropout rates and reasons, and adverse events. we also investigated the feasibility of conducting remote training and supervision of non-specialists (psychology students) to train them to deliver the intervention. finally, we assessed intervention acceptability via participants’ ratings and qualitative feedback. consistent with previous studies (e.g., kanstrup, singh, et al., 2021), we predicted that, compared to the baseline phase (week -1), participants would report fewer intrusive memories in the fifth week after the second intervention session, as assessed via a daily diary (primary outcome). second, we predicted that the intervention would lead to reductions in related psychological symptoms (e.g., anxiety, depression), and improved functioning (e.g., in concentration, sleep, social relationships) (secondary outcomes). we also aimed to explore whether the frequency of targeted intrusive memories decreased relative to the frequency of non-targeted intrusive memories. hardarson, gamble, thorarinsdottir et al. 3 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ method participants women in a sub-study of the stress and gene analysis (saga) cohort (a populationbased longitudinal study of icelandic women investigating trauma history, www.áfallasa­ ga.is) were screened for eligibility. the sub-study (the social trauma project) involves a comparative analysis of two sub-samples extracted from the saga cohort (i.e., wom­ en with likely ptsd or no ptsd). participants were assessed (in person) with the clinician-administered ptsd scale for dsm-5 (caps-5; weathers et al., 2018) and the mini international neuropsychiatric interview for dsm-4 (mini; sheehan et al., 1998). these diagnostic interviews were adminstered by fully qualified clinical psychologists and students who were completing their masters in clinical psychology. inclusion criteria were: (a) having experienced at least one criterion a trauma ac­ cording to the diagnostic and statistical manual of mental disorders (5th ed.; dsm–5; american psychiatric association, 2013); (b) reporting at least two intrusive memories in the previous week (consistent with the criterion of a minimum of 1-2 intrusions per week required to endorse this symptom on the caps-5); (c) reporting being bothered by intrusive memories over the past month (i.e., scoring at least a moderate score on pcl-5 item 1); (d) able and willing to complete 3-9 sessions with the researcher; (e) willing to monitor intrusive memories; (f) having access to a smartphone; (g) able to speak icelandic and read study materials in icelandic. exclusion criteria (assessed with the mini) were: (a) current psychotic disorder; (b) current manic episode; (c) being acutely suicidal. twelve women were enrolled in the study (mean age = 42.42 years, sd = 12.03; mean duration since time of trauma (target memory) = 20.73 years, sd = 14.65). primary traumas were sexual violence (n = 5), witness to death or serious injury (n = 3), physical violence (n = 3), and motor vehicle accident (n = 1). eight participants completed the intervention and the primary outcome; 7 participants completed the 3-month follow-up. design participants monitored intrusive memories of trauma in a daily diary for one week (i.e., baseline phase, week -1), followed by at least two guided intervention sessions with a researcher remotely (via telephone or secure video platform) over the following week (week 0). participants could opt to complete up to four additional guided intervention sessions (i.e., maximum of 6 sessions), until the completion of the primary outcome (i.e., week 5). after the first guided session, participants were encouraged to use the intervention on their own throughout the study. participants continued to monitor their intrusive memories in the daily diary throughout weeks 0-5. follow-up questionnaires were completed at week 1, 1-month, and 3-months after the second intervention session. the primary outcome was the reducing intrusive memories of trauma: feasibility study 4 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ change in total number of intrusive memories from the baseline week (week -1) to the fifth week after the second intervention session (week 5). participants also monitored (in a daily diary) the number of intrusive memories they experienced for one week, beginning the day of completing the 3-month follow-up questionnaires. the study had a repeated ab design, such that the length of baseline (‘a,’ preinter­ vention, monitoring only) and intervention (‘b’) phases differed across each intrusive memory; i.e., depending on when it was targeted. the baseline phase could thus be used as a control period for each individual memory – i.e., to compare the number of intrusive memories before and after the intervention. training and supervision of psychology students to deliver the intervention the intervention was delivered to the first participant by kt, a licensed clinical psychol­ ogist who had received training in delivering the intervention via two workshops led by eah and mk, and had experience in intervention delivery (thorarinsdottir et al., 2021). the intervention was delivered to the next 11 participants by four msc students in clinical psychology and two bsc students at the university of iceland who received remotely-delivered training and ongoing supervision. to allow remote training during the covid-19 pandemic, we developed a beta ver­ sion of an online training course (via the platform www.talentlms.com) in the style of a ‘mooc’ (massive open online course), which included material in the form of text, images, animated videos, video roleplay assignments, quizzes, and written reflec­ tions (oakley & sejnowski, 2019). alongside the mooc, training was delivered by kt, jph, and mk (all with intervention delivery experience [kanstrup, kontio, et al., 2021; kanstrup, singh, et al., 2021; thorarinsdottir et al., 2021, 2022]) and supervised by asb and eah. a training group (trainees, trainers, facilitator (bg) and supervisors) met via zoom for seven one-hour weekly sessions (sept-nov 2020), as trainees worked through the on­ line course. trainees could discuss the mooc, observe experienced trainers roleplaying and ask questions. trainees uploaded video roleplays online, assessed by kt and jph with rating scales ranging from 0 (‘absence’) to 6 (‘excellence’) covering nine components (e.g., ‘explanation of the target symptom (intrusive memories)). trainees were required to score at least 4 (‘competent’) on all scales before delivering the intervention. the group continued to attend weekly zoom supervision meetings (jan-july 2021) with the option of individual supervision (from kt). hardarson, gamble, thorarinsdottir et al. 5 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 http://www.talentlms.com https://www.psychopen.eu/ measures primary outcome measure intrusive memory diary. participants monitored their intrusive memories in a daily paper diary used in previous research (e.g., iyadurai et al., 2018; kanstrup, singh, et al., 2021) and validated (singh, ahmed pihlgren, et al., 2023). primary outcome was the change in total number of intrusive memories of the traumatic event recorded in the diary (morning, afternoon, evening and night) from baseline week (week -1) to the fifth week after the second intervention session (week 5). secondary outcome measures in line with the goal of investigating feasibility and in the interest of brevity, we report data for the first five pre-registered ‘secondary outcome measures’ which examine symptoms of ptsd, depression, and anxiety along with intrusive memories. findings for the remaining measures including functional measures are presented in appendix a of the supplementary materials. intrusive memory diary. change in the total number of intrusive memories recorded in the diary daily during the week of receiving the first two intervention sessions (week 0), the subsequent four weeks (weeks 1-4) and at 3-month follow-up, compared to the baseline week (week -1). unwanted memories of trauma (umt; hackmann et al., 2004). six items measuring the frequency of unwanted memories of the trauma in the previous week, the level of distress, nowness, reliving, disconnectedness associated with intrusions, and the degree to which different triggers are associated with memories of the trauma. posttraumatic stress disorder checklist 5 (pcl-5; weathers et al., 2013). a 20-item measure assessing the severity of ptsd symptoms. patient health questionnaire-9 (phq-9; kroenke et al., 2001). a 9-item measure of the severity of depression symptoms. generalized anxiety disorder-7 (gad-7; spitzer et al., 2006). a 7-item screening tool assessing the presence and severity of gad symptoms. sheehan disability scale (sds; leon et al., 1997). a measure of functional impairment in work/school, social and family life domains. items were adapted to assess functional impairment associated with intrusive memories. world health organization disability assessment schedule 2.0 (whodas 2.0; world health organization, 2010). a 12-item questionnaire measuring difficulties due to health conditions, including mental problems. lower scores indicate better functioning. impact of intrusive memories on concentration, sleep and stress – ratings. self-rated items assessing the impact of intrusive memories on concentration, sleep and stress in the past week. two items assess general concentration difficulties and impairments in reducing intrusive memories of trauma: feasibility study 6 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ concentration, two items assess sleep disturbances, and one item assesses the impact of intrusive memories on stress. rating of how long intrusive memories disrupt concentration. a single item assessing the estimated average duration of disruption to concentration, rated on a 6-point scale (from 0 = <1 minute to 6 = > 60 minutes). impact of intrusive memories on functioning. a 2-item measure assessing the impact of intrusive memories on daily functioning. the first question is: "have the intrusive memories affected your ability to function in your daily life in the past week? (from 0 = not at all to 10 = affected very much), followed by the open-ended question: "if yes, how?". general impact of intrusive memories – ratings. two items assessing the impact of intrusive memories. other outcome measures only data for the pre-registered ‘other outcome measures’ that examine feasibility, adherence, and acceptability are reported and described, in the interest of conciseness. for a comprehensive review of the remaining other outcome measures, please refer to the ctr (nct04709822); the corresponding findings can be found in appendix b of the supplementary materials. self-guided intervention adherence – usage of the gameplay intervention in daily life. two items assessing participants’ use of the gameplay intervention in everyday life: "how many times did you manage to play tetris after you experienced an intrusive memo­ ry?" if relevant participants were asked a follow-up open-ended question, i.e.: "which of your intrusive memories did you target when you played on your own?". intrusion diary adherence. a single item assessing participants’ adherence to complet­ ing the intrusion diary accurately. acceptability ratings. acceptability of the intervention was assessed with two rating items. acceptability was also assessed with two open-ended questions ("how did you feel about playing tetris after you had an intrusive memory?" and "did you find the intervention helpful? if yes, how?"). credibility/expectancy scale. prior to completing the intervention for the first time, participants provided ratings of treatment expectancy1 as well as the degree to which they found the rationale for intervention credible. wording of the items was adapted for the current study. 1) the ctr states that this scale contained 5 items, but only 4 items were included owing to an administrative error. hardarson, gamble, thorarinsdottir et al. 7 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ procedure participants were recruited between january and may 2021. women who participated in the social trauma project sub-study of the saga cohort who met the inclusion criteria were contacted (described in thorarinsdottir et al., 2021). baseline session eligible participants were invited to a remote meeting (i.e., baseline session) with a researcher. participants were given a brief verbal description of the study, presented with an information sheet containing study details, and provided informed consent by signing an e-consent form in the electronic registration system redcap. all but one participant indicated that they had a printer and were emailed the diary. a paper diary was delivered to the remaining participant. participants then watched a brief video titled what are intrusive memories? the researcher asked a series of questions to check their understanding of the content, then sent a link to a second video, identifying your intrusive memories. participants were then asked to generate a list of intrusive memories they were experiencing. the researcher emphasised that they should not provide a detailed description of each intrusion, but rather summarise each briefly in only a few words (e.g., “dark room”). the researcher recorded each intrusive memory in redcap and shared the screen containing the list of intrusive memories with each participant. next, participants watched the third video, keeping count of your intrusive memories, which explained how to monitor intrusive memories. the researcher then explained how to use the intrusive memory diary to monitor their daily intrusions in the week ahead (i.e., baseline, week -1). participants also completed baseline questionnaires, and an appointment was scheduled for the first intervention session. first intervention session at the start of the session, the researcher explained that the session would involve using the intervention to target one of the participant’s intrusive memories, then sent them a link to the fourth video (what is the intervention?) which provided a rationale. together the participant and researcher then chose an intrusion to target (typically the most frequent or distressing). next, the researcher asked participants to briefly bring the memory to mind so they could ‘see it in their mind’s eye’, but without discussing its content. the researcher sent a link to a fifth video (how to play tetris using mental rotation), which included instructions about how to play tetris, and emphasised the importance of mental rotation (i.e., mentally rotating upcoming blocks in the game to visualise how to best place them). after viewing, the researcher directed participants to open www.tetris.com in their web browser and share their screen with the researcher. participants then had the opportunity to practice playing tetris (if they wanted to) and were then instructed to engage in gameplay using mental rotation for at least 20 reducing intrusive memories of trauma: feasibility study 8 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 http://www.tetris.com https://www.psychopen.eu/ minutes. next, an appointment was scheduled for the second intervention session, and participants were also given instructions as to how to use the intervention at home. the last three participants also watched a final video, tetris and the brain, which re-iterated the rationale for the intervention and its hypothesised mechanisms. second intervention session participants received a second intervention session approximately one week later, target­ ing the same intrusion (i.e., if intrusions persisted) or a different intrusive memory that they wished to reduce. participants were informed that they had the choice of continu­ ing to use the intervention alone (i.e., self-guided) or scheduling further intervention session/s (up to 6 sessions) with researcher support. participants continued to monitor the frequency of both targeted and non-targeted intrusive memories in the daily diary throughout weeks 0-5. follow-up assessments participants completed follow-up questionnaires at week 1, 1-month, and 3-months after the second intervention session. participants also monitored their intrusive memories for one week at the 3-month follow-up. at each intervention session and assessment, participants were asked about the occurrence of any adverse events since the previous contact. this study was registered on clinicaltrials.gov (nct04709822) on 14/1/2021. it was approved by the national bioethics committee in iceland (id: no. vsnb2017110046/03.01, dated 1/10/2019; amendments: (i) 17-238-v23, dated 23/6/2020; (ii) 17-238-v27, dated 24/11/2020; (iii) 17-238-v29-s1, dated 2/3/2021; (iv) 17-238-v30, dated 30/3/2021; (v) 17-238-v31, dated 13/4/2021). participants provided their informed consent digitally. all sessions followed a written protocol. no serious adverse events or adverse events related to the intervention were reported. results analytic approach as a feasibility trial, we adopted a descriptive approach to reporting the results. whilst we collected both qualitative and quantitative data, only quantitative findings are repor­ ted here. analyses were conducted (by bg) using r, version 4.0.242 (‘psych’ package, version 2.0.8, for descriptive analyses). de-identified summary data, codebook and r scripts are available on the open science framework (gamble et al., 2022). whilst descriptive statistics for all participants are reported below, we also provide data for completers only (i.e., per protocol analyses) on the osf (gamble et al., 2022). hardarson, gamble, thorarinsdottir et al. 9 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ figure 1 presents the number of intrusive memories reported in the daily diary for each participant. table 1 reports the means, sds, and effect sizes (as cohen’s d along with 95% cis) for (i) number of intrusive memories reported in the daily diary at each assessment point, and (ii) secondary outcome measures at each assessment point. table 2 reports measures of adherence and credibility. figure 1 number of intrusive memories for all participants (n = 12): treatment completers (n = 8) and non-completers (n = 4) primary outcome the primary outcome was the change in the total number of intrusive memories recor­ ded in the daily diary from baseline (week -1) to week 5. participants reported fewer intrusive memories of the traumatic event in the fifth week after the second intervention session (m = 6.98, sd = 5.73, range: 0-15) compared to the baseline week (week -1; m = reducing intrusive memories of trauma: feasibility study 10 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ 25.98, sd = 29.39, range: 2-92) – a difference that reflected a 68% reduction in the number of intrusions (i.e., for participants who completed the primary outcome, n = 8). secondary outcomes we explored whether participants reported fewer intrusive memories in the daily diary at week 0, weeks 1-4 and at 3-month follow-up (relative to week -1, baseline phase), as well as reductions in other psychological symptoms (e.g., anxiety, depression) over the course of the study (see table 1 for means). table 1 number of intrusive memories reported in the daily diary and self-report measures of posttraumatic stress symptoms, depression and anxiety for all participants (n = 12) outcome n m sd cohen’s d comparison to baseline cohen’s d 95% ci ll ul number of intrusive memories (daily diary) baseline (week -1) 11 25.98 29.39 week 0 10 17.46 16.01 -0.27 -0.55 0.00 week 1 10 14.20 21.21 -0.52 -1.05 0.02 week 2 10 10.00 8.91 -0.22 -0.39 -0.05 week 3 9 10.81 11.69 -0.38 -0.66 0.10 week 4 8 9.62 7.19 -0.64 -1.22 -0.07 week 5 8 6.98 5.73 -1.16 -2.47 0.15 3-month 7 3.71 4.35 -0.81 -1.52 -0.11 umta (frequency) baseline 12 3.25 1.14 week 1 9 3.56 1.33 0.09 -0.71 0.89 1-month 8 2.38 0.74 -1.52 -2.98 -0.06 3-month 7 1.29 0.76 -2.36 -3.59 -1.14 umta (distress) baseline 12 45.42 15.08 week 1 9 41.33 19.40 -0.28 -0.79 0.24 1-month 8 28.50 22.58 -0.94 -1.69 -0.18 3-month 7 24.00 29.45 -0.76 -1.52 0.01 umta (nowness) baseline 12 38.83 25.46 week 1 9 25.56 22.56 -0.63 -1.50 0.25 1-month 8 23.00 23.86 -0.77 -1.75 0.22 3-month 7 10.43 26.72 -1.10 -2.32 0.12 hardarson, gamble, thorarinsdottir et al. 11 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ outcome n m sd cohen’s d comparison to baseline cohen’s d 95% ci ll ul umta (reliving) baseline 12 40.58 24.83 week 1 9 39.22 29.53 -0.20 -1.12 0.73 1-month 8 30.38 29.40 -0.36 -1.40 0.69 3-month 7 17.71 26.02 -0.83 -1.91 0.26 umta (disconnectedness) baseline 12 61.42 24.99 week 1 9 72.78 17.37 0.38 -0.60 1.35 1-month 8 59.88 17.11 -0.03 -0.97 0.92 3-month 7 32.14 37.81 -0.81 -2.30 0.68 umta (triggers) baseline 12 55.67 24.63 week 1 9 52.89 28.87 -0.36 -1.04 0.32 1-month 8 35.88 27.76 -0.65 -1.29 -0.01 3-month 7 28.71 28.62 -0.79 -1.77 0.18 pcl-5b baseline 12 36.42 16.81 week 1 9 28.89 16.83 -0.42 -0.77 -0.07 1-month 8 28.50 21.27 -0.31 -0.73 0.10 3-month 7 18.71 17.53 -0.71 -1.37 -0.05 phq-9c baseline 12 11.83 5.70 week 1 9 9.89 4.76 -0.20 -0.53 0.13 1-month 8 8.62 3.46 -0.37 -0.71 -0.02 3-month 7 8.29 5.71 -0.46 -0.98 0.07 gad-7d baseline 12 8.75 6.17 week 1 9 6.00 4.39 -0.16 -0.34 0.02 1-month 8 5.62 4.00 -0.30 -0.57 -0.03 3-month 7 5.00 4.62 -0.44 -1.18 0.31 aunwanted memories of trauma. bposttraumatic stress disorder checklist 5. cpatient health questionnaire-9. dgeneralized anxiety disorder-7. change in total number of intrusive memories participants recorded fewer intrusive memories in the diary during the week of receiving the first two intervention sessions (week 0), the subsequent four weeks (weeks 1-4) and at 3-month follow-up, relative to the baseline week (i.e., week -1). at 3-month follow-up, reducing intrusive memories of trauma: feasibility study 12 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ there was a 91% reduction in the number of intrusive memories reported relative to baseline (week -1) (i.e., for participants who completed the 3-month follow-up, n = 7). symptoms of ptsd unwanted memories of trauma (umt). overall, participants reported increased frequency of intrusive memories from baseline to week 1; however, ratings of frequency declined across subsequent time points. similarly, ratings of disconnectedness increased from baseline to week 1, but progressively diminished at each subsequent time point. for the remaining items (distress, nowness, reliving, triggers), participants’ ratings steadily decreased from baseline to 3-month follow-up. posttraumatic stress disorder checklist 5 (pcl-5). pcl-5 scores decreased at each time point, from baseline to 3-month follow-up. depression and anxiety symptoms patient health questionnaire-9 (phq-9). phq-9 scores decreased at each successive time point, from baseline to 3-month follow-up. generalized anxiety disorder-7 scale (gad-7). anxiety symptoms decreased at each assessment point, from baseline to 3-month follow-up. functioning sheehan disability scale (sds). ratings of functional impairment decreased at each assessment point for all domains, indicating improved self-reported functioning from baseline to 3-month follow-up. world health organization disability assessment schedule 2.0 (whodas 2.0). consis­ tent with the sds, participants reported improvements in functioning at each timepoint, across the course of the study. impact of intrusive memories on concentration, sleep, and stress – ratings. participants reported improved concentration at each timepoint. ratings of the impact of intrusive memories on sleep decreased at each timepoint from baseline to 1-month follow-up. however, participants rated an increased impact of their intrusions on sleep from the 1-month to 3-month follow-up. notably, the mean rating at 3-month follow-up was lower than that reported at baseline. regarding nightmares, ratings indicated an increased impact of intrusions on nightmares from baseline to week 1, with decreased ratings at each subsequent timepoint (with a mean of 0 at 3-month follow-up). finally, although participants reported an overall reduction in the impact of intrusive memories on stress across the study, the means fluctuated across assessment points. specifically, ratings reduced (indicating that intrusions had less impact on stress) from baseline to week 1, then increased at 1-month follow-up, and subsequently decreased at 3-month follow-up. rating of how long intrusive memories disrupted concentration on average. ratings indicated that the duration of time that intrusive memories disrupted concentration hardarson, gamble, thorarinsdottir et al. 13 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ decreased from baseline to 3-month follow-up. whilst duration of disruption increased from baseline to 1 week, it decreased at each subsequent timepoint. impact of intrusive memories on functioning. ratings of the impact of intrusive memo­ ries decreased at each assessment point, from baseline to 3-month follow-up. general impact of intrusive memories – ratings. ratings of the vividness of intrusive memories and intrusion-related distress reduced from baseline to 3-month follow-up. despite these overall reductions there was some fluctuation across assessment points. we also planned to explore the relative differences in the number of intrusive memo­ ries (reported during the baseline phase and week -1) targeted by the intervention and non-targeted intrusive memories. however, we were unable to conduct these planned exploratory analyses because participants’ untargeted intrusive memories were not suf­ ficiently frequent to conduct the comparisons. whilst such analyses have been carried out in a previous investigation (kessler et al., 2018), we note that participants in that study were inpatients with complex ptsd who reported frequent intrusive memories of multiple traumas. by comparison, in the current feasibility trial participants reported a smaller number of key intrusive memories, which were the focus of the intervention – and non-targeted intrusions were less frequent. feasibility feasibility of delivering the intervention in fully-remote format. twelve participants com­ menced the trial, of whom 8 completed the primary outcome. seven treatment complet­ ers completed the required two intervention sessions, and one completed four sessions. of the four non-completers, two completed two intervention sessions, one completed one session, and one completed zero sessions. two completed the week 1 follow-up but could not be contacted to obtain the primary outcome. the other two dropped out before the week 1 follow-up due to unrelated stressors. no adverse events were reported. feasibility of remote training and supervision to deliver the intervention. all four msc students and the two bsc students attended all remote training sessions and completed the online training course. online supervision sessions proved feasible, enabling interac­ tions between the students and trainers in real-time, and the opportunity for practical teaching components such as role-plays. feasibility of training non-specialists (i.e., bsc and msc students) to deliver the interven­ tion to a competent standard. all trainees were judged to reach competence (defined as scoring a ‘4’ or greater on all competency rating scales), demonstrating the feasibility of training non-specialists to deliver the intervention. the median competency score across trainees for all rating scales was 5.00, based on the final round of video roleplays completed prior to delivering the intervention to participants. reducing intrusive memories of trauma: feasibility study 14 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ adherence participants’ ratings of self-guided intervention adherence (i.e., usage in everyday life) indicated that (across all time points) the average number of times participants played tetris after experiencing an intrusive memory was 3.54 (sd = 2.95). these ratings were relatively consistent from week 1 to 3-month follow-up (range = 2.86 – 4.00; see table 2). there were high levels of adherence to completing the daily diary: of the 8 participants who completed the primary outcome, the mean percentage of missing days (across all weeks) was 2.27% (sd = 4.02%). in addition, participants’ self-rated accuracy in complet­ ing the diary indicated consistently high levels of accuracy (m = 7.96, sd = 1.19) across all time points. table 2 self-report measures of ratings of adherence and credibility/expectancy for all participants (n = 12) outcome n m sd self-guided intervention adherence baseline week 1 9 3.67 3.20 1-month 8 4.00 3.38 3-month 7 2.86 2.34 intrusive memory diary adherence baseline 11 8.27 1.01 week 0 10 7.70 1.42 week 1 10 7.90 1.10 week 2 10 8.00 1.15 week 3 9 7.44 1.33 week 4 8 8.06 1.02 week 5 8 7.94 1.21 week 12 6 8.67 1.37 credibility/expectancy – how logical baseline 12 74.67 20.03 credibility/expectancy – how useful baseline 12 75.42 18.42 credibility/expectancy – how strongly recommend to a friend baseline 12 65.50 17.96 credibility/expectancy – how much improvement expected baseline 12 69.67 16.52 hardarson, gamble, thorarinsdottir et al. 15 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ acceptability participants’ ratings indicated acceptability. specifically, participants indicated that they would recommend the intervention to a friend (m = 6.50, sd = 3.51), and considered gameplay an acceptable way to reduce intrusive memories (m = 6.25, sd = 3.20). credibility/expectancy overall, participants rated high levels of intervention expectancy and credibility (m = 71.31, sd = 14.43). discussion we investigated the feasibility and acceptability of a remotely delivered, researcher-gui­ ded imagery-competing task intervention targeting intrusive memories of long-standing trauma in a sample of women in iceland. twelve participants commenced the trial, of whom 8 completed the primary outcome. no intervention related adverse events were reported. these data confirm the feasibility of remote delivery of the researcher-guided form of the intervention and good client engagement. the trial also confirmed the feasibility of conducting remote (i.e., fully online) training for non-specialists without clinical psychology qualifications. finally, participants’ ratings indicated acceptability of the remote version of this brief guided intervention. another goal was to explore preto post-intervention changes in the number of intrusive memories reported in a daily diary. as predicted, participants reported fewer intrusive memories in week 5 relative to baseline; specifically, a 68% reduction. by 3-month follow-up, there was a 91% reduction relative to baseline. this pattern of improvement was also observed across other psychological outcomes: depression and anxiety symptoms reduced, and self-reported functioning improved. these encouraging results extend the findings of our previous case series’ using the same imagery compet­ ing task intervention, in which participants (n = 1, n = 3) reported a reduced frequency of intrusive memories by 38% to 56% in the intervention phase, with continued reductions observed at 1and 3-month follow-ups (thorarinsdottir et al., 2021, 2022). notably, in the current study a similar pattern of outcomes was achieved despite having fewer sessions and remote delivery of the intervention by non-specialists (i.e., individuals without pro­ fessional training in mental health). current data complement existing evidence of the efficacy of this intervention when delivered in acute settings in the initial hours and days following traumatic events (e.g., in women who experienced traumatic childbirth, horsch et al., 2017; emergency department patients, (iyadurai et al., 2018; kanstrup, singh, et al., 2021), and also in targeting established memories of trauma in frontline healthcare workers (iyadurai et al., 2023; ramineni et al., 2023). we highlight that these findings are preliminary and come with several limitations, including a small sample size and (in keeping with the aims of a feasibility trial) the reducing intrusive memories of trauma: feasibility study 16 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ absence of a control condition. we note that intrusions increased from baseline to week 1, and cannot rule out the possibility that the frequency of intrusive memories may have increased during the baseline phase due to participants being asked to monitor their occurrence, particularly in the context of long-standing trauma. this is an aspect that future studies may wish to carefully monitor and explore further – potentially through employing a larger sample size and extending the study period. incorporating a longer baseline could also be beneficial to ascertain whether any observed increase is maintained or is transient. further, this feasibility study cannot clarify the underlying mechanisms of the intervention; specifically, whether intrusions reduce owing to memo­ ry reconsolidation (astill wright et al., 2021), mental imagery interference (baddeley & andrade, 2000), a combination of the two, or other factors. should these beneficial outcomes be replicated and extended in randomised control­ led trials, they will have important applied implications. specifically, removing the need for in-person contact will increase the capacity to deliver the intervention at scale, and disseminate it to vulnerable traumatised populations (e.g., refugees), potentially overcoming challenges related to geographical location, language, and other barriers to access (holmes et al., 2017; kazlauskas, 2017). similarly, eliminating the need for highly qualified trauma specialists to deliver the intervention competently will further increase scope for scalability. hardarson, gamble, thorarinsdottir et al. 17 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ funding: eah received funding from the oak foundation (ocay-18-442) in main support of this study; asb received funding from the icelandic research fund (11709-0270) and ah as well (200095-5601; 2106-0365). eah also receives funding from the swedish research council (2020-00873), afa insurance (200342), and the wellcome trust (223016/z/21/z). funders were not involved in the study design, collection, analysis, and interpretation of data; writing of the report; and/or decision to submit the report for publication. acknowledgments: the authors thank bergrun mist johannesdottir, freyja agustsdottir, marianna hlif jonasdottir, and roshildur arna olafsdottir for their involvement in data collection. we also thank berglind gudmundsdottir, edda bjork thordardottir, and thorhildur olafsdottir for assistance with study design. finally, we thank katy metcalf for producing the animated videos. competing interests: eah has written books on mental imagery with guilford press and oxford university press and receives occasional honoraria for conference keynotes and clinical workshops. eah is on the board of trustees of the mq foundation. eah has developed the intervention approach to reduce intrusive memories and training in using it (anemone ™). eah salary is part funded by the wellcome trust (223016/z/21/z) via consultancy to p1vital products ltd (a study not part of the current work). author contributions: conceptualization (eah, asb, bg, jph), methodology (all), formal analysis, data curation, visualization (bg, jph, mm), writing – original draft (bg, mm, tg), supervision (asb, eah, jph, mk, mm, kt), funding acquisition (eah, asb, ah). all authors critically revised the manuscript approved the final version for publication. ethics statement: this study was approved by the national bioethics committee in iceland (id: no. vsnb2017110046/03.01, dated 1/10/2019; amendments: (i) 17-238-v23, dated 23/6/2020; (ii) 17-238-v27, dated 24/11/2020; (iii) 17-238-v29-s1, dated 2/3/2021; (iv) 17-238-v30, dated 30/3/2021; (v) 17-238-v31, dated 13/4/2021). data availability: participants provided their consent for de-identified summary data to be made openly available for secondary research; this data can be accessed at the osf (gamble et al., 2022). we have aimed to follow fair data principles; i.e., such that data are findable, accessible, interoperable, and reusable. study materials may be made available upon reasonable request with an appropriate materials transfer agreement (mta) with eah (uppsala university). we note delivery of this intervention requires training and supervision. supplementary materials the supplementary materials include the following items: • the pre-registration protocol for the study, registered on clinicaltrials.gov (nct04709822) on 2021-01-14 (see bjornsson, 2021) • de-identified summary data, codebook and r scripts (see gamble et al., 2022) • online appendices (see hardarson et al., 2024) reducing intrusive memories of trauma: feasibility study 18 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ index of supplementary materials bjornsson, a. s. (2021). remote delivery of a brief visuospatial interference intervention to reduce intrusive memories of trauma (clinicaltrials.gov id nct04709822) [pre-registration protocol]. clinicaltrials.gov. https://clinicaltrials.gov/study/nct04709822 gamble, b., kanstrup, m., stephensen, e. s., bjornsson, a. s., holmes, e. a., singh, l., hardarson, j. p., þórarinsdóttir, k., & moulds, m. l. (2022). remote delivery of a brief visuospatial interference intervention to reduce intrusive memories among trauma exposed women: a feasibility study / deidentified data and analysis scripts [de-identified summary data, codebook and r scripts]. osf. https://osf.io/2b6nh hardarson, j. p., gamble, b., thorarinsdottir, k., stephensen, e. s., kanstrup, m., gudmundsson, t., valdimarsdóttir, u., hauksdottir, a., bjornsson, a. s., moulds, m. l., & holmes, e. a. 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(2010). measuring health and disability: manual for who disability assessment schedule whodas 2.0. world health organization. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. reducing intrusive memories of trauma: feasibility study 22 clinical psychology in europe 2024, vol. 6(1), article e11237 https://doi.org/10.32872/cpe.11237 https://www.psychopen.eu/ reducing intrusive memories of trauma: feasibility study (introduction) method participants design training and supervision of psychology students to deliver the intervention measures procedure results analytic approach primary outcome secondary outcomes discussion (additional information) funding acknowledgments competing interests author contributions ethics statement data availability supplementary materials references effectiveness of empower-grief for relatives of palliative care patients: protocol for an exploratory randomized controlled trial research articles effectiveness of empower-grief for relatives of palliative care patients: protocol for an exploratory randomized controlled trial david d. neto 1,2 , alexandra coelho 1,2 , sara albuquerque 3 , ana nunes da silva 4,5 [1] school of psychology, ispa – instituto universitário, lisbon, portugal. [2] appsyci – applied psychology research center capabilities & inclusion, lisbon, portugal. [3] hei‐lab: digital human‐environment interaction labs, lusófona university, lisbon, portugal. [4] faculdade de psicologia, universidade de lisboa, lisbon, portugal. [5] cicpsi, lisbon, portugal. clinical psychology in europe, 2025, vol. 7(1), article e14307, https://doi.org/10.32872/cpe.14307 received: 2024-04-02 • accepted: 2024-10-02 • published (vor): 2025-02-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: david d. neto, ispa – instituto universitário, rua jardim do tabaco 42, 1100-081, lisbon, portugal. phone: +351 218811700. e-mail: dneto@ispa.pt abstract background: grief reactions of relatives of palliative care patients are seldom addressed. most interventions focus on prolonged grief disorder (pgd) and not on its prevention. this is particularly relevant in palliative care, in which death is the result of a difficult period of a terminal illness, making caregivers particularly vulnerable to psychological distress. the purpose of the present exploratory trial is to test the efficacy of a selective intervention (empower-grief) for the initial problematic grief reactions and to study potential predictors of adherence and efficacy. method: this is an exploratory randomized controlled trial (rct) studying empower-grief compared with treatment as usual (tau). participants will be relatives or caregivers of palliative and oncological patients with initial indicators of risk of developing pgd and will be randomly allocated to empower-grief and tau. participants will be assessed prior, at the end and six months after the intervention. the primary outcome considered will be symptoms of pgd. the assessment includes measures of anxiety and depression, coping, attachment, psychological flexibility, posttraumatic growth, social support and therapeutic alliance. results: the trial is ongoing. forty-four participants will be invited to participate. conclusion: this study addresses the need for the development of empirically grounded and feasible interventions aimed at dealing with initial problematic reactions in grief, exploring this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.14307&domain=pdf&date_stamp=2025-02-28 https://orcid.org/0000-0002-3129-262x https://orcid.org/0000-0002-2883-415x https://orcid.org/0000-0003-0687-1352 https://orcid.org/0000-0001-7125-716x https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ potential predictors and possible venues for personalizing intervention and understanding the mechanism through which these interventions operate. keywords prolonged grief disorder, palliative care, empower-grief, psychological intervention, bereavement highlights • caregivers of deceased cancer patients are particularly vulnerable to prolonged grief disorder. • there is a significant need to develop low-intensity interventions for emotional reactions to grief. • the current protocol aims to test the efficacy of empower-grief and to identify predictors of outcome. background prolonged grief disorder (pgd), recognized as a mental illness in the icd-11 (world health organization, 2019) and more recently in the dsm-5-tr (american psychiatric association, 2022), consists of intense grief along with significant social and occupational dysfunction persisting for an extended period (with the inclusion in the dsm-5-tr, the temporal criterion was extended from 6 to 12 months). caregivers of patients with advanced cancer are particularly vulnerable to elevated psychological distress. in a caregiver sample, pgd prevalence was 40% at six months, 28% at 13 months, and 27% at 18 months (guldin et al., 2012), thus supporting the idea that end-of-life caregiving increases the risk of mental health disturbance. high levels of pgd were also found in a portuguese population of palliative care caregivers (coelho et al., 2022). considering the elevated prevalence of disordered reactions, the goal of providing dif­ ferent interventions according to the risk of developing pgd has the potential to provide care to more individuals. these interventions range from psychoeducation (i.e., univer­ sal interventions) to low-intensity selective and high-intensity indicative interventions. very few low-intensity interventions have been proposed. lichtenthal and colleagues (lichtenthal et al., 2022) developed a brief manualized cognitive-behavioural, acceptancebased intervention for critically ill patients´ caregivers called empower (enhancing and mobilizing the potential for wellness and resilience). empower is a psychological intervention composed of six modules based on cognitive-behavioural and acceptancebased interventions: 1) initial assessment, rationale and adherence to the intervention; 2) resources for stabilization; 3) psychoeducation on grief and the cognitive-behavioural model; 4) promoting experiential acceptance; 5) imagined dialogue; 6) coping training. this intervention has been shown to be feasible, acceptable and effective in reducing empower-grief study protocol 2 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.psychopen.eu/ psychological symptoms, including pgd, depression and anxiety. this program, designed initially for intensive care contexts, emphasizes the detrimental role of experiential avoidance (i.e., the tendency to avoid unpleasant feelings) in decision-making and the grieving process. as opposed to acceptance, this coping mechanism has been associated with higher anticipatory grief (davis et al., 2017) and the persistence of complicated grief in palliative care (eisma & stroebe, 2021). the majority of the family caregivers will require selective intervention, oriented at people identified as being at risk of developing pgd. the differentiation of interventions allows combining need-based timely interventions to prevent pgd while increasing ac­ cess through rationalization of service delivery. despite the recommendations, no studies have matched the intensity of interventions to the severity of psychological reaction to death in preventing prolonged grief. the present research intends to implement and evaluate the effectiveness of the empower-grief intervention (coelho et al., 2024; lichtenthal et al., 2022) in the population of family caregivers of patients accompanied in the palliative medicine unit of the centro hospitalar universitário lisboa norte (chuln). empower-grief is an adaptation of the original empower to the current palliative care context and post-mortem stage. it consists of the same six modules of the original intervention, but a 50-minute session is devoted to each of the modules, with two booster sessions done after treatment. it is a manualized treatment in which each session is structured. this research project has two objectives. first, to evaluate the effectiveness of em­ power-grief intervention compared to treatment as usual (tau) in terms of symptoms of prolonged grief and psychological distress in relatives or caregivers of palliative and oncological patients. the second objective is to identify predictors, among the factors consistently found in the literature, of response to intervention. this second objective is crucial, considering the low-intensity level of the intervention. in addition to the risk of prolonged grief, other factors such as prior mental health, the nature of the death, social support, attachment style and psychological flexibility may be relevant in explaining the response to this intervention and serve as essential variables in adapting the intervention to the needs of the participants. this research is crucial to influence national policy to­ wards a greater emphasis on prevention and early intervention, making the allocation of cost-effective bereavement support services the most efficient and sustainable approach for a significant public health impact in bereavement care. method design the present study is an exploratory randomized controlled trial (rct) with two parallel groups (figure 1) comparing the experimental treatment conditions, empower-grief, and neto, coelho, albuquerque, & nunes da silva 3 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.psychopen.eu/ treatment as usual (tau) in a medical centre. all study procedures have been approved by the local and central institutional review boards. the project was approved by the ethics committee of ispa (i-138-2-24). setting and participants treatment is offered at chuln lisboa norte to family members or other caregivers of patients, followed by the palliative care unit and oncology service. inclusion criteria involve individuals more than 18 years old, having experienced the death of a close person (e.g., relative, partner, friend) due to cancer in a palliative or oncological con­ text from three to 12 months, and sufficient cognitive abilities and proficiency in the portuguese language who provide written informed consent. participants are invited from the service registry, where the reference caregiver is identified. exclusion criteria include individuals reporting a diagnosis of pre-existing severe or active mental disorder predating the loss (e.g., schizophrenia, bipolar disorder, major depression). participants currently undergoing psychological intervention will also be excluded. while medication will be monitored, it will not be an exclusion criterion. recruitment, enrollment, and randomization family members will be contacted by phone from the chuln. the number of par­ ticipants who refuse to participate, change their address, or are unreachable will be registered. unreachable participants are considered those who are not reached after one month of attempts. second, the protocol of contact is established and will be revised to address any concerns participants may have. non-participation data will be controlled monthly (weekly at the beginning of the data-gathering period). participants will undergo assessment for pgd risk and then be randomly assigned to one of the two conditions. those considered at risk, using the cut-off values (i.e., 7 or more) of risk assessment for grief (ministry of health, 2017) to be at a moderate level, will be invited to additional intervention and participation in the current study. all participants will provide informed consent before initiating one of the two interventions. the informed consent process will cover the study's purpose, procedures, potential risks, and benefits, and it will be obtained from each participant before any data collection or randomization occurs. participants will be informed that their data will be anonymized and securely stored. the analysis follows an intention-to-treat principle, ensuring the inclusion of every randomized participant. participants who do not meet the criteria will be carefully referred to an appropriate service. in cases where participants refuse, do not adhere to, or do not benefit from a particular intervention, they will be offered the intervention at a higher level in the referred services. empower-grief study protocol 4 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.psychopen.eu/ randomization is independently conducted by a research assistant. participants will be randomly assigned to empower-grief vs. tau. randomization occurs after a partic­ ipant meets eligibility criteria, provides consent, and undergoes risk assessment. a ran­ dom sequence of numbers or allocation codes will be generated using a randomization tool. this sequence will determine the allocation of participants to the two intervention groups. the participants will be allocated to each branch of the rct through block randomization. clinicians will not be aware of any research assessments, including the initial risk assessment, and will not be involved in assessing participants' outcomes. throughout the study, the project team will continuously monitor the randomization process to ensure it is executed as planned, with any deviations documented and ad­ dressed. the study protocol was written in accordance with the spirit 2013 statement (standard protocol items: recommendations for interventional trials (chan et al., 2013). strategies to enhance participant retention and minimize attrition will be employed, including regular check-ins, reminders for follow-up assessments, and flexible scheduling options. also, a feedback system for participants to express concerns or provide input on the study's procedures will be put in place, and this will be used to make necessary adjustments. throughout their participation, we will emphasize participants’ contribu­ tion to improving grief support for others and the rigorous privacy and confidentiality measures in place. treatment conditions tau treatment as usual (tau) consists of supportive psychotherapy based on a non-struc­ tured and integrative method that focuses on developing more adaptive coping strategies and understanding and working on the patient's internal models of self, others, and the world (winston & lujack, 2015). for the present investigation, tau will be considered during the same period as the empower-grief intervention – that is, 12 weeks – as the frequency of sessions may differ slightly from case to case. psychologists with specific training for each intervention will administer both interventions. empower-grief empower-grief (coelho et al., 2024) is a cognitive-behavioural and acceptance-based intervention divided into six modules adapted from empower (lichtenthal et al., 2022) to a post-mortem application. it consists of six in-presence or online 50-minute sessions and two booster sessions 2 and 4 weeks after the final intervention. it is a manualized treatment in which each session has a specific goal: 1) welcome, initial assessment and adherence to the intervention; 2) psychoeducation and transmission of resources for stabilization; 3) psychoeducation on trauma, grief and cognitive-behavioral model; 4) promoting experiential acceptance; 5) imagined dialogue; 6) coping training; and two neto, coelho, albuquerque, & nunes da silva 5 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.psychopen.eu/ final boosting sessions. in every session, the impact of the previous consultation and evolution is evaluated. treatment fidelity various strategies will be employed to ensure the effective delivery of the intervention and maintain consistency among psychologists. the standardized intervention protocol for "empower-grief" (coelho et al., 2024) will be utilized (manualized intervention). the implementation team for the empower-grief will comprise four psychologists, all with master's degrees in clinical and health psychology and at least one year of clinical experience. this group underwent a comprehensive 20/30-hour training in the empower-grief intervention model. in addition to the standardized training provided to all psychologists, model sessions were conducted where experienced psychologists, each with a minimum of 10 to 15 years of clinical experience in grief intervention, demonstrated how to deliver interventions effectively. these experienced psychologists will serve as valuable resources in ensuring the fidelity and quality of intervention delivery across the team. the implementation team of tau will include three licensed psychotherapists or ma-level psychologists in advanced postgraduate clinical training. all therapists will have at least five years of experience and at least two years of experience working with complicated grief. during the trial, empower-grief psychologists will have weekly group supervision, while tau psychologists will have their usual practices that include team reunions to discuss cases. ongoing supervision and monitoring of psychologists in the experimental group will include regular check-ins, feedback sessions, and opportunities for providers to seek guidance or clarification. all providers will have access to the same materials, resources, and tools required for their sessions. fidelity checks will be conducted to ensure quality and consistency across psycholo­ gists. purposely constructed fidelity assessment tools will include a checklist with inten­ ded tasks, content, format, and psychologists' behaviour, completed after each session and discussed in supervision. records will be maintained for each fidelity check, includ­ ing dates, psychologist names, and fidelity assessment results, along with any corrective actions taken. the primary goal of these procedures is to ensure treatment adherence, maintain low non-participation rates, and control differential non-participation rates, particularly between follow-up times and types of termination. the expected outcomes include overall low non-participation rates, specifically in the considered conditions. empower-grief study protocol 6 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.psychopen.eu/ figure 1 overview of the study design assessments and instruments three measurement points will be considered (table 1). considering the context of data gathering, care has been taken to avoid overburdening participants with excessive questionnaires. the screening will include sociodemographic data and rag. the first as­ sessment, before the first session, includes some additional sociodemographics, pg13-r, hads, brief cope, ecr-rs, aaq-ii, and mspss. the second assessment will include pg13-r, hads and the working alliance measure (wai-s). the follow-up assessment pe­ riod (3rd assessment) will occur six months after the last assessment. these will include all outcomes (pg13-r, hads, ptgi). the interventions will share the same assessment neto, coelho, albuquerque, & nunes da silva 7 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.psychopen.eu/ periods and instruments. the follow-up assessment ensures that all participants are evaluated one year after the death, enabling a pgd diagnosis. table 1 time points for measurement instrument screening t1 t2 6 mths sociodemographics x x risk assessment for grief (rag) x pg-13-r x x x the hospital anxiety and depression scale (hads) x x x the posttraumatic growth inventory (ptgi) x brief cope x experiences in close relationships (ecr-rs) x acceptance and action questionnaire ii (aaq-ii) x the multidimensional scale of perceived social support (mspss) x the working alliance inventory-short form (wai-s) x note. t1 = pre-treatment; t2 = 12 weeks/post-treatment; 6 months = follow up. participants will be contacted sensitively to inquire about the reasons for discontinuing the intervention. clinical teams will receive supervision for each intervention, and ad­ herence to treatment measures will be monitored. screening sociodemographic data, such as participants' gender, age, marital status, education, em­ ployment, and mental health and treatment history, are also collected. risk assessment for grief (rag) — rag is a hetero-assessment scale of pgd risk developed by the new zealand ministry of health (ministry of health, 2017) and adapted for the dgs norm 003/2019 (dgs, 2019). it includes four items (anger, accusation/guilt, current relationships and general coping with grief) evaluated on a 5-point likert scale. this instrument classifies the degree of pgd risk as low (<7 points), moderate (7-10 points) and high (≥ 10 points). primary outcome prolonged grief scale – revised (pg13-r) — the pg13-r is a self-report scale devel­ oped by prigerson and colleagues (prigerson et al., 2021) based on dsm-5-tr criteria for pgd. pg-13-r includes 13 items, evaluated on a 5-point likert scale. pg-13-r grief symp­ toms represent a unidimensional construct with high degrees of internal consistency in research conducted at yale (cronbach's α = .83), utrecht (cronbach's α = .90), and oxford (cronbach's α = .93) universities. pgd diagnosis is attributed when the person obtains a total value greater than 30 and meets the temporal (12 months) and impairment criteria. empower-grief study protocol 8 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.psychopen.eu/ secondary outcome the hospital anxiety and depression scale (hads) — the hads, originally de­ veloped for individuals with somatic diseases in hospitals (zigmond & snaith, 1983), measures anxiety and depression symptoms. the scale was developed for non-psychiat­ ric populations and includes 14 items evaluated on a 4-point (0-3) likert scale. values higher than eight in each subscale suggest clinically relevant symptomatology. in the portuguese adaptation (pais-ribeiro et al., 2007), cronbach alpha values were .76 in anxiety and .81 in depression. predictors and other relevant variables posttraumatic growth inventory (ptgi) — the ptgi (tedeschi & calhoun, 1996) evaluates the extent of perceived positive transformations following a challenging event. comprising 21 items, it encompasses five subscales: personal strengths, appreciation of life, new possibilities, spiritual changes, and relation to others. participants were instructed to assess each item on a 6-point likert scale, ranging from 1 to 6. the overall ptgi score represents the sum of all items and higher scores indicated higher levels of posttraumatic growth. the original version of the ptgi has shown excellent internal reliability (cronbach's α = 0.90) and acceptable test-retest reliability (r = .71). the ptgi has also shown good psychometric properties in breast cancer portuguese samples (silva et al., 2009). brief cope — the brief cope (carver, 1997) is composed of 28 items organized into 14 coping strategies. each coping strategy is measured using two items (humour, positive reframing, emotional and social support, acceptance, religion, instrumental sup­ port, planning, active coping, behavioural disengagement, self-blaming, substance use, venting, self-distraction, and denial). participants were asked to answer each item with a likert-type response scale ranging from 0 (i never do this) to 3 (i always do this). mean scores were calculated for each coping factor. the study of internal consistency for each factor using cronbach's alpha shows adequate values (in general α ≤ .60), taking into account there are only two items per factor for the original (carver, 1997) and the portuguese version (ribeiro & rodrigues, 2004). experiences in close relationships (ecr-rs) — the ecr-rs (fraley et al., 2011) is a self-report instrument that measures adult attachment to relevant persons – in this case, the deceased – rated on a seven-point likert scale that ranges from 1 (strongly disagree) to 7 (strongly agree). its nine items are grouped into two dimensions: attachment-rela­ ted anxiety (items 1-6) and avoidance (items 7-9). the total subscale score consists of the mean of the items and ranges from 1 to 7, with higher scores indicating higher attachment avoidance or anxiety. the portuguese version showed adequate reliability (α ranged from .72 to .91) and construct validity (moreira et al., 2015). neto, coelho, albuquerque, & nunes da silva 9 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.psychopen.eu/ acceptance and action questionnaire ii (aaq-ii) — the aaq (bond et al., 2011) is a 7-item questionnaire with a single-factor structure measuring acceptance, experiential avoidance, and psychological inflexibility. in the portuguese validation (pinto-gouveia et al., 2012), results from a confirmatory factor analysis showed the goodness of fit of the model, and this version also demonstrated an excellent level of internal consistency (α = .90) and good convergent and discriminant validity. individuals are asked to rate each statement on a 7-point likert scale ranging from 1 (never true) to 7 (always true). this scale reflects the single domain of psychological inflexibility, with higher scores indicating greater psychological inflexibility. the multidimensional scale of perceived social support (mspss) — the mspss (zimet et al., 1988) measures perceived social support from family, friends, and others. the 12 items are grouped into three factors (family, friends and significant others), each with four items, using a 7-point likert scale (0 = strongly disagree, 7 = strongly agree). examples of items include “there is a special person who is close by when i need him/ her"; "i can talk about my problems with my family”. the portuguese version of the mspss (carvalho et al., 2011) demonstrated good psychometric qualities (α ranged from .85 and .95). the working alliance inventory-short form (wai-s) — the wai-s (tracey & kokotovic, 1989) is a widely studied 12-item self-report that measures how the client perceives the therapeutic alliance with the therapist, with a 7-point likert scale ranging from 1 (never) to 7 (always). in addition to the overall alliance score, the wai-s includes three specific subscales: bond, tasks, and goals (four items, respectively). internal consis­ tency for the portuguese version is .89 for the patient version and .85 for the therapist version (machado & horvath, 1999). statistical analysis to evaluate the impact of empower-grief relative to tau on the primary outcome (prolonged grief symptoms) and secondary outcome (anxiety and depression), we will use a mixed-effects model. a mixed-effects model for longitudinal data (pre-post and a 6-month follow-up) accounts for the hierarchical structure of the data, with participants nested within treatment groups and the correlation between repeated measurements within subjects. the intention-to-treat principle will be followed in the analysis, ensuring that all participants randomized to each treatment condition are included in the analy­ sis, regardless of whether they completed all assessments or adhered to the treatment protocol. to address missing data, multiple imputations will be employed, a statistical method that generates multiple plausible values for missing data points based on the observed data. this method preserves the relationships between variables and reduces the potential for bias due to missing data. empower-grief study protocol 10 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.psychopen.eu/ before drawing inferences, a preliminary examination of model assumptions, includ­ ing checks for the normality of residuals and homogeneity of variances, will be conduc­ ted. the primary outcome, prolonged grief severity, will be modelled using a linear mixed-effects model with fixed effects for treatment condition (empower-grief vs. tau), time point (pre-treatment, post-treatment, and 6-month follow-up), and their interaction, and random effects for participants and treatment groups. secondary outcomes, anxiety and depression symptoms, will be analyzed using similar mixed-effects models. the sample size for this research project was estimated using g*power software, employing a repeated measures analysis with a mixed-effects model. assuming a low effect size of d = 0.25, a significance level of α = 0.05, and a power of 1-β = 0.80. with two treatment groups, empower-grief and treatment as usual, and measurements taken at three moments (baseline, post-treatment, and 6-month follow-up), the resulting estimated sample size for the study was 44 participants for both treatments, representing a robust size to detect the anticipated effect with high statistical power. to assess the predictive value of the considered predictors (i.e., posttraumatic growth, coping, attachment to the deceased, psychological flexibility, social support, and thera­ peutic alliance) on treatment outcomes, separate regression analyses will be conducted for each outcome measure (prolonged grief, anxiety, and depression). for each outcome, we will fit a mixed-effects model with the baseline variable as a fixed effect, adjusting for treatment condition, time, and their interaction. the random effects’ structure will remain the same as in the primary analysis. results the rct is ongoing. we have contacted 294 potential participants and recruited 44 to this moment. recruitment will close in april 2024. we plan to complete data analyses by december 2024. discussion this study responds to a lack of research in grief interventions, which is relevant consid­ ering the high prevalence of pgd and the general delay in providing care. assessing the differentiation of intervention leads to increases and equality in access to empirically based interventions. by empowering caregivers to respond to a challenging grief process, the intervention may contribute to preventing pathological long-term psychological reac­ tions. the present research project aims to assess the efficacy of a low-intensity selective intervention compared with tau in terms of prolonged grief symptoms and distress. the project's second goal is to identify potential predictors of the outcome and adherence to these treatments – considering the matching conditions. neto, coelho, albuquerque, & nunes da silva 11 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.psychopen.eu/ this research has several strengths. first, the study of low-intensity interventions – recommended by international and national bodies (shear et al., 2017) – has a good cost-benefit ratio and increases access to psychological interventions in this social con­ text. second, empower-grief is flexibly delivered so that it can be adapted to caregivers’ dynamic needs and post-mortem context. third, it was developed and refined using stakeholder feedback to optimize its acceptability and fit for its recipients’ specific needs. also, identifying predictors of adherence and change serves to increase sensitivity in aligning interventions to the needs of clients. the fact that the current study is conducted in a practice setting leads to some constraints – namely, the lack of manualization of tau or the need to keep the research questionnaire relatively small. however, the practice-based nature of the context of data gathering provides a demonstration of how a structured intervention such as empow­ er-grief can be useful. results from this study will, therefore, provide a pathway for improving clinical decision-making and tailoring treatments to an individual's specific needs, which is crucial to meeting citizens’ needs in the context of the rational provision of services. this research is situated in the field of intervention personalization and psychological services research. it can inform and enrich the predicting process by considering other dimensions of patient characteristics, such as psychological flexibility or attachment, thus fostering new research and informing bereavement support practice. funding: this study was supported by funding from appsyci–applied psychology research center capabilities and inclusion (fct/uidb/05299/2020). acknowledgments: we would like to acknowledge the clinicians involved in the present research: andrea mendes, cristina pereira, daniela nogueira, inês minhós, joana semedo dos santos, mário nascimento, and tatiana tavares. competing interests: the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. ethics statement: ethics approval for the study was provided by the ethics committee of the ispa – instituto universitário (portugal), approval no. i-138-2-24. all participants provided written informed consent. trial registration: trial registered at clinicaltrials.gov, identifier: nct06270381 (registered february 21, 2024). reporting guidelines: the present report was written in accordance with the spirit 2013 statement (standard protocol items: recommendations for interventional trials). social media accounts: david d. neto: linkedin, researchgate empower-grief study protocol 12 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.linkedin.com/in/ddneto/ https://www.researchgate.net/profile/david-dias-neto https://www.psychopen.eu/ references american psychiatric association. 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(1988). the multidimensional scale of perceived social support. journal of personality assessment, 52(1), 30–41. https://doi.org/10.1207/s15327752jpa5201_2 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. neto, coelho, albuquerque, & nunes da silva 15 clinical psychology in europe 2025, vol. 7(1), article e14307 https://doi.org/10.32872/cpe.14307 https://www.redalyc.org/pdf/4596/459645444007.pdf https://doi.org/10.1002/jts.2490090305 https://doi.org/10.1037/1040-3590.1.3.207 https://doi.org/10.1002/9781118753378.ch92 https://icd.who.int/ https://doi.org/10.1111/j.1600-0447.1983.tb09716.x https://doi.org/10.1207/s15327752jpa5201_2 https://www.psychopen.eu/ empower-grief study protocol (introduction) background method design setting and participants recruitment, enrollment, and randomization treatment conditions treatment fidelity assessments and instruments statistical analysis results discussion (additional information) funding acknowledgments competing interests ethics statement trial registration reporting guidelines social media accounts references associations and interactions between neuroticism, adverse life events and health anxiety: results from a large representative cohort research articles associations and interactions between neuroticism, adverse life events and health anxiety: results from a large representative cohort thomas tandrup lamm 1,2 , mimi yung mehlsen 3 , tina birgitte wisbech carstensen 1,2 , kaare bro wellnitz 1,2 , eva ørnbøl 1,2 , thomas meinertz dantoft 4 , per fink 1,2 , marie weinreich petersen 1,2 , lisbeth frostholm 1,2 [1] research clinic for functional disorders, aarhus university hospital, aarhus, denmark. [2] department of clinical medicine, aarhus university, aarhus, denmark. [3] department of psychology, aarhus university, aarhus, denmark. [4] center for clinical research and prevention, bispebjerg and frederiksberg hospital, the capital region of denmark, denmark. clinical psychology in europe, 2025, vol. 7(2), article e14441, https://doi.org/10.32872/cpe.14441 received: 2024-04-22 • accepted: 2025-03-08 • published (vor): 2025-05-28 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: thomas tandrup lamm, research clinic for functional disorders, aarhus university hospital, palle juul-jensens boulevard 11, aarhus n 8200, denmark. phone: +0045 61147069. e-mail: thlamm@rm.dk supplementary materials: materials [see index of supplementary materials] abstract purpose: adverse life events and neuroticism have been shown to be associated with health anxiety (ha), but their interaction has not been studied. this study aimed to examine the separate associations as well as the possible interaction effect of neuroticism and adverse life events with ha. method: cross-sectional self-report data originated from a representative danish population cohort (danfund) (n = 7,493, 18-72 years, 53% females). primary measures were ha (whiteley index 6 revised), neuroticism (neo personality inventory revised short form), and adverse life events (cumulative lifetime adversity measure, clam). the clam was split into illness/death related life events (ide) and other adverse life events (oae) to test the specificity of ides. results: adjusted ordinal logistic regression models showed positive associations with ha for ides (or = 1.05, ci [1.03, 1.08]), oaes (or = 1.05, ci [1.03, 1.07]) and neuroticism (or = 1.08, ci this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.14441&domain=pdf&date_stamp=2025-05-28 https://orcid.org/0009-0001-4335-5640 https://orcid.org/0000-0001-5820-8937 https://orcid.org/0000-0001-5086-4331 https://orcid.org/0000-0001-5882-5118 https://orcid.org/0000-0002-5915-9839 https://orcid.org/0000-0001-7437-7052 https://orcid.org/0000-0003-2921-4099 https://orcid.org/0000-0001-8141-2792 https://orcid.org/0000-0002-9683-7416 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ [1.07, 1.09]). a wald's test revealed no difference in association with ha for ides and oaes (p = .82). adjusted models showed an interaction effect for neuroticism*ides (or = 1.002, ci [1.000, 1.004]), but not for neuroticism*oaes (or = 0.999, ci [0.996, 1.002]). conclusion: associations with ha were found for both adverse life events and neuroticism. size of association did not differ for ides and oaes. only ides interacted with neuroticism. keywords health anxiety, neuroticism, adversity, diathesis stress model, cohort study, effect moderation highlights • neuroticism and adverse life events are associated with health anxiety. • no difference in effect size between illness/death and other types of adversity was found. • illness/death related adversity interact with neuroticism in their association with health anxiety. • interaction between illness/death related adversity and neuroticism was small. health anxiety (ha) refers to the experience of recurrent, excessive preoccupations with bodily symptoms and fear of having a serious illness in spite of relatively sparse evidence of illness (fink et al., 2004). the term covers both mild and transient health-related worries as well as severe and debilitating ha (longley et al., 2010). experiences with ha frequently occur in the general population (sunderland et al., 2013) and if untreated, severe ha has been shown to persist (fink et al., 2004; olde hartman et al., 2009) with dire consequences, such as reduced quality of life, more sick leave, more disability pensions, and increased health expenditure (eilenberg et al., 2015; fink et al., 2010). models of severe health anxiety one foundational model to explain why mental disorders occur is the diathesis-stress model (monroe & simons, 1991). this model states that mental disorders develop when a pre-disposed individual (individual specific factors) is exposed to an adequate stressor (environmental specific factors). some studies have tested this model on disorders such as depression and social anxiety, finding significant interactions between adverse life events and diathesis factors such as neuroticism and genetic profiles (arnau-soler et al., 2019; brown & rosellini, 2011; howe et al., 2017). in relation to ha, elements of the diathesis-stress model are reflected in the cogni­ tive model of ha, which is the most widely used etiological model of ha (salkovskis & warwick, 2001). here, adverse life events associated with illness and death are thought to contribute to an individual forming inflexible or negative schematic assumption about health and illness. this predisposes individuals to react in catastrophizing ways to future neuroticism, adversity and health anxiety 2 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ health-related stressors, which can ultimately increase the risk of developing the more severe forms of ha. according to the cognitive model of ha, illness/death related life events (ides) play a special role in the development of severe ha and should thus have a stronger association with ha than other adverse life events (oaes) (e.g. social adversity, natural disasters, violence), which may be associated with increased anxiety and distress but are not specifically linked to health related anxiety. experiences with illness and death the association between adverse life events and ha has been examined in several studies, which indicate higher rates of adverse life events among people that report more ha (mertz et al., 2023; reiser et al., 2014; weck et al., 2014). the specificity of ides nevertheless remains unclear (thorgaard et al., 2018). some studies indicate a degree of specificity for ides (bailer et al., 2014; sandin et al., 2004), whereas others show that it is adverse life events, irrespective of type, which are associated with ha (mertz et al., 2023; reiser et al., 2014; weck et al., 2014). some studies have even indicated a lack of association between ha and ides (barsky et al., 1994; gehrt et al., 2022). neuroticism while the cognitive model of ha emphasizes the role of stress factors, such as ides, less emphasis is placed on the role of predisposing/diathesis factors (salkovskis & warwick, 2001). neuroticism is a trait that reflects an individual’s largely heritable tendency to experience negative emotions (barlow et al., 2014). it has been argued that neuroticism acts as a central diathesis factor for mood and anxiety disorders (barlow et al., 2014), and studies have demonstrated that neuroticism can interact with and amplify the effect of adverse life events in relation to depression and stress (brown & rosellini, 2011; howe et al., 2017). moderate to large associations have furthermore been found between neuroti­ cism and ha (cox et al., 2000; taillefer et al., 2003). however, while there are several studies relating severe ha to neuroticism and various types of adverse life events, no studies have examined if these factors interact in their association with ha, as suggested in the diathesis-stress model. aim of the current study to provide insight into the development of ha, the current study aimed to 1) examine the association between ha, neuroticism, and adverse life events related to illness/death (ides) as well as other types of adverse life events (oaes), and 2) to examine if neuroti­ cism and adverse life events interact in the association with an individual’s level of ha. we hypothesized that: 1) higher levels of neuroticism would be associated with higher levels of ha, 2) higher numbers of adverse life events (both ides and oaes) lamm, mehlsen, carstensen et al. 3 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ would be associated with higher levels of ha, 3) ides would be more strongly associated with ha than oaes, 4) there would be an interaction effect between adverse life events (both ides and oaes) and neuroticism in their association with ha, so that scoring higher on adverse life events would cause the association between neuroticism and ha to be amplified. method design and participants data originates from the danish study of functional disorders (danfund), which is a representative danish general population cohort study (dantoft et al., 2017). 25,368 adults living in the western part of the greater copenhagen area of denmark were ran­ domly drawn from the danish civil registration system based on social security number and invited to participate in the study. they received the invitation via mail to their postal address. 7,493 participants (29.53% of the invited) were included between 2012 and 2015. participants were excluded if they were 1) pregnant, 2) not born in denmark, 3) not danish citizens. participants answered a large battery of validated questionnaires, covering a variety of biological, psychological, and social domains and underwent a physical health examination. only measures of relevance to this study will be described (for all measures, see dantoft et al., 2017). all participants gave written informed consent. ethical approval was granted from the ethical committee of copenhagen county (ethics committee: 3-2012-0015) as well as the danish data protection agency (2012–58006, 1–16–02-227-16), and the study was conducted in accordance with the helsinki ii declaration. the current study was not pre-registered. measures the following measures were used: dependent variable health anxiety was measured with a revised and abbreviated 6-item version of the whitely index (pilowsky, 1967), called the whitely index 6 revised (wi6-r) (carstensen, ørnbøl, fink, pedersen, et al., 2020). the wi6-r is a self-report measure, where items are scored on a 0-4 rating scale (from ’not at all’ to ‘a great deal’), with a range of 0-24. higher scores indicate more ha. this measure has been validated in the danish general population, using the danfund cohort (carstensen, ørnbøl, fink, pedersen, et al., 2020). neuroticism, adversity and health anxiety 4 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ independent variables neuroticism was measured by the neo-pi-r short form (sf) (hansen & mortensen, 2004). this is an abbreviated version of the danish 240-item neo-pi-r. the neo-pi-rsf consists of 60 items, which measure the big five traits (neuroticism, conscientiousness, extraversion, agreeableness, openness), though in the current study, only the neuroticism scale was used. in the neo-pi-rsf, each trait is measured with 12 items. answers are given on a 5-point rating scale (‘clearly disagree’ to ‘clearly agree’) with a range of 0-48. higher scores indicate more neuroticism. the neo-pi-rsf has been validated in a sample of the danish population showing that the instrument has acceptable psychometric properties (hansen & mortensen, 2004). adverse life events were measured using a danish version of the cumulative life-time adversity measure (clam) (seery et al., 2010). this version was translated and validated in a danish sample using the danfund cohort (carstensen, ørnbøl, fink, jørgensen, et al., 2020). the clam is a formative instrument that estimates the occurrence of adverse life events throughout the life span via 37 items, which are divided into 7 categories: 1) own-illness or injury, 2) loved one’s illness or injury, 3) violence, 4) bereavement, 5) social/environmental stress, 6) relationship stress, 7) disaster. for each event, three instances of the event and one period can be recorded (from time point a to b). one self-described event can also be recorded. for each item, a score is calculated by adding all recorded instances into a single score (max 4 events per item). higher scores indicate more adverse life events. a total score for each category of adverse life events can be formed by combining the scores of items for the specific event category. a total lifetime adversity score can also be constructed by summing the total scores from all event categories. for the current study, an “illness/death related life events” (ides) variable was computed by combining the categories: “own-illness or injury”, “loved one’s illness or injury” and “bereavement” into a single score (13 items, range 0-52). to assess the effect of the remaining adverse life events, an “other adverse life events” (oaes) variable was computed by combining the remaining clam categories, including “violence”, “social/environmental stress”, “re­ lationship stress”, “disaster” (26 items, range 0-104). covariates covariates were chosen based on directed acyclic graphs (moffa et al., 2017). this is further elaborated upon in the following section ‘analysis’. the following covariate measures were used: self-reported social status was measured with a validated item asking individuals how they would rate their own social position in society on a ranking scale from 1-10, which was scored on an ordinal scale from 1 to 10, with 10 representing the highest possible self-reported social status (demakakos et al., 2008). lamm, mehlsen, carstensen et al. 5 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ physical fitness was tested using the danish step test (aadahl et al., 2013), which is a validated measure of cardiorespiratory fitness. the test is conducted by asking participants to step up and down on a step bench for a maximum of 6 minutes following instructions from a computer. maximal oxygen consumption (vo2max) is estimated based on how long participants can keep up with the pace of instructions and is then calculated based on known principles of the energy costs. physical fitness was scored from 0-20, where a higher score indicated better physical fitness (aadahl et al., 2013; dantoft et al., 2017). sleep problems were measured using 2 items (“how often do you have problems falling asleep?” and “how often do you wake up too early compared to how long you would like to sleep?”), which have been used in a previous population cohort (byberg et al., 2012; dantoft et al., 2017). both items were scored from 1-4 using the following categories: 1 = “once per month or rarer”; 2 = “two to four times per month”; 3 = “once or more times a week”; 4 = “daily”. in the current study, sleep problems were binarily rated as having “sleep problems” if participants scored above 2 on either of the items, and “no sleep problems” if they did not. analysis descriptive analyses consisted of counts (%), range, mean (sd), or median (iqr) depend­ ing on the variables and their empirical degree of skew. because of long tails on the distribution of ides and oaes, the tails were shortened by reducing all values above a given threshold to the threshold value (ides threshold = 10; oaes threshold = 7). all hypotheses were analyzed using both crude and adjusted ordinal logistic regres­ sion models with ha as an ordered outcome. hypotheses were tested based on the adjusted estimates as they provide minimally confounded estimates, but crude estimates were also reported to facilitate comparison with other studies. adjustment variables were chosen based on directed acyclic graphs (dags) (moffa et al., 2017), and the minimal set of adjustment variables was found using the free online software daggity (textor et al., 2016). dags were drawn by a subset of the author group (ttl, tc, kbw, mwp, lf) and included neuroticism, ides, oaes, age (in years), physical activity, physical symptoms, sex (male/female), sleep problems, and socio-economic status. the minimal set of adjustment variables consisted of sleep prob­ lems, physical activity, and self-reported social status as well as neuroticism, ides, and/or oaes depending on primary predictor. thus, hypotheses 1, 2, and 3 were all evaluated based on parameters from the same adjusted ordinal logistic regression analysis. syntax for the dags can be found in appendix a. odds ratio (or) was used as a measure of association, and hypotheses were evaluated at alpha level .05 by interpreting 95% confidence intervals (ci) and whether or not ci overlapped with 1. neuroticism, adversity and health anxiety 6 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ hypotheses 1 and 2 that ha was associated with neuroticism, ides, and oaes were evaluated based on the adjusted ci for the associations of neuroticism, ides, or oaes with ha. or > 1 indicated that higher neuroticism or more ides/oaes were associated with greater odds of ha. hypothesis 3 that ides were more strongly associated with ha than oaes was evaluated by direction and degree of overlap of the adjusted cis of ides and oaes and was formally tested using wald's test. hypothesis 4 that neuroticism and ides or oaes interacted in the association with ha was tested by adding either neuroticism*ides or neuroticism*oaes to the adjusted model used for hypotheses 1, 2, and 3. it was furthermore examined to which degree ides had a specific association with ha, or if similar associations could be found in relation to more general measures of anxiety or depression. to do this, supplementary analyses were conducted using the scl-90 depression and anxiety scales as the dependent variables (description of measures in appendix b), and ides, neuroticism and their interaction as the independent variables. both crude and adjusted models were estimated, using the same set of covariates as the ordinal logistic regression model predicting ha. all independent variables and covariates were median centered. proportional odds as­ sumptions were tested using brant tests (brant, 1990). linearity of continuous covariates was checked by expanding the model with natural cubic splines with five knots at the 5th, 27.5th, 50th, 72.5th, and 95th percentiles, following the recommendations by (harrell, 2015). all analyses were run in stata version 18.0 (statacorp, 2023). results the studied population consisted of n = 7,493 participants aged 18-72, of which 53% were females. rates of missing data were below 1.7% for all measures with a completion rate of 99.4% for ha, 98.2% for neuroticism, and 98,8% for adverse life events. further descriptive statistics for the analyzed cohort can be found in table 1. testing hypotheses 1 and 2, which stated that there would be a positive association between ha and oaes, ides, and neuroticism, revealed a positive association with ha for neuroticism, ides, and oaes. this indicated that having a higher score on these variables was associated with higher odds of reporting more ha (see table 2). the size of these effects varied. to enhance interpretability, the standard deviation (sd) and interquartile range (iqr) were used to estimate the difference in odds of scoring higher on ha between two individuals where one scored one sd or quartile above the other on the dependent variables. for neuroticism, it was estimated based on the adjusted model that an individual scoring one sd higher on neuroticism would have 74% higher odds of scoring higher on ha. for ides, it was estimated based on the adjusted model that an individual scoring lamm, mehlsen, carstensen et al. 7 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ one quartile higher would have a 10% higher odds of scoring higher on ha. for oaes, this was 5%. hypothesis 3 was examined by testing to which degree there was a difference in the strength of the association with ha for the ides and oaes variables. a wald's test (χ2(1) = 0.05, p = .82) indicated that there was no difference in the effect sizes between ides and oaes and that both variables had similar ors and almost identical cis (see table 2). testing hypothesis 4 regarding the interactions between neuroticism and the two types of adverse life events (ides and oaes), a small interaction effect between neuroti­ cism and ides in their association with ha was found. no interaction was found for neuroticism and oaes (see table 2). this indicates that ides amplified the association between neuroticism and ha, rather than the effect of ides and neuroticism simply being additive. a more tangible effect size was calculated by using the model parameters to estimate the difference in odds of scoring higher on ha for two individuals where one individual scored one sd higher on neuroticism and one quartile higher on ides. the table 1 sample characteristics variable n (%) m (sd)a/ median (iqr)b range n missing (%) sex males 3456 (46) females 4037 (54) ageb 7493 54 (44-63) 18-72 self-rated social statusa 7407 6.62 (1.40) 1-10 86 (1.15) sleep problems 60 (0.80) no 6371 (86) yes 1062 (14) physical fitnessa 6419 9.52 (2.73) 1-19 1074 (14.33) health anxietyb 7454 2 (0-5) 0-24 39 (0.52) neuroticisma 7365 16.47 (7.48) 0-46 128 (1.71) adverse life events, totalb 7405 5 (3-8) 0-35 88 (1.17) illness/death related eventsb 7361 4 (2-6) 0-19 132 (1.76) other adverse life eventsb 7405 1 (0-2) 0-25 88 (1.17) note. mean (standard deviation) or median (interquartile range) was reported selectively based on the empirical distribution of each variable. for variables that were normally distributed, mean (sd) was reported. for variables that were non-normally distributed, median (iqr) was reported. reporting format is denoted in the superscript. amean, sd. bmedian, iqr. neuroticism, adversity and health anxiety 8 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ higher scoring individual was estimated to have a 2% higher odds of scoring higher on ha. to further ascertain the specificity of the interaction between ides and neuroticism for ha, similar ordinal logistic regression models were run with depression and anxiety measures as the outcome instead of ha (see appendix d). these models indicated that both neuroticism and ides were associated with anxiety and depression scores. the effect sizes of the associations were slightly larger for neuroticism than what was found in the model predicting ha, and slightly smaller for ides. in contrast to models table 2 ordinal logistic regression models and interaction effects for the association between neuroticism, adverse life events, and health anxiety independent variable or [95% ci] z p n neuroticism, cru 1.09 [1.09, 1.10] 31.22 < 0.01 7362 neuroticism, adja 1.08 [1.07, 1.09] 24.24 < 0.01 6169 illness/death related life events, cru 1.05 [1.03, 1.07] 6.59 < 0.01 7348 illness/death related life events, adjb 1.05 [1.03, 1.07] 5.74 < 0.01 6169 other adverse life events, cru 1.12 [1.10, 1.15] 11.02 < 0.01 7391 other adverse life events, adjc 1.05 [1.03, 1.08] 4.48 < 0.01 6169 illness/death*neuroticism, cru 1.002 [1.000, 1.005] 2.60 < 0.01 7261 illness/death*neuroticism, adjd 1.002 [1.000, 1.004] 1.96 0.05 6169 other adverse*neuroticism, cru 1.000 [0.997, 1.002] 0.08 0.93 7303 other adverse*neuroticism, adje,f 0.999 [0.996, 1.002] -0.25 0.82 6169 note. cru = crude; adj = adjusted; or = odds ratio. or values should be interpreted as the cumulative odds of scoring higher on the wi6-r for each additional point on neuroticism (range: 0-48), other adverse life events (range: 0-104), illness/death related life events (range: 0-52). brant tests for proportional odds were non-significant in all cases except for the crude model for the interaction between neuroticism and illness/death related life events, where a brant test showed a p = .023 for the overall model. nevertheless, variable level tests were all p > .05. consequently, we chose to regard the assumption of proportional odds as sufficiently fulfilled. aillness/death related life events, other adverse life events, physical activity, sleep problems, self-reported social status. bneuroticism, other adverse life events, physical activity, sleep problems, self-reported social status. cillness/death related life events, neuroticism, physical activity, sleep problems, self-reported social status. dother adverse life events, physical activity, sleep problems, self-reported social status. eillness/death related life events, physical activity, sleep problems, self-reported social status. finteraction effects in the last four rows are based on ordinal logistic regression models with interaction terms included. to see the estimated parameters of all variables included in these models, see appendix c. lamm, mehlsen, carstensen et al. 9 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ predicting ha, no interaction effect was found when predicting anxiety or depression from the interaction between neuroticism and ides (p > .05). discussion summary of findings this population-based study found positive associations between health anxiety and illness/death related life events, other adverse life events, and neuroticism (hypotheses 1 and 2). it further indicated that illness/death related life events did not have a stronger association with ha than other types of adverse life events (hypothesis 3). finally, a small interaction effect was shown for illness/death related life events, which amplified the effect of neuroticism on health anxiety. no such interaction with neuroticism was found for other adverse life events (hypothesis 4). associations between health anxiety, adverse life events, and neuroticism the finding that both neuroticism and adverse life events were positively associated with ha is in line with other studies on the association between ha and different types of adverse life events (mertz et al., 2023; reiser et al., 2014; thorgaard et al., 2018; weck et al., 2014) and neuroticism (cox et al., 2000; taillefer et al., 2003). it should also be noted that the positive associations between neuroticism and adverse life events have been found for other types of mental disorders in previous studies and is thus not likely to be specific to ha (hogg et al., 2023; kotov et al., 2010). similarly, in the current study, ides had associations to depression and anxiety which were comparable in size to what was found in relation to ha. it should also be considered that the estimated effect of neuroticism appeared to be larger than the effects of both oaes and ides. this difference in effect may indicate that dispositional factors could be more strongly associated with the development of ha than adverse life events. the specificity of ides the lack of specificity for ides found when testing hypothesis 3 is in line with the few other studies that have not been able to identify difference in the size of the association with ha for oaes and ides (barsky et al., 1994; mertz et al., 2023; reiser et al., 2014; weck et al., 2014). this is also reflected in the review by thorgaard et al. (2018) which showed that several studies demonstrate associations with ha for both event types. the inconsistency of the association between ides and ha could be interpreted as neuroticism, adversity and health anxiety 10 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ incongruent with the cognitive model of ha, which proposes that ides should play a specific causal role in the development of severe ha. interactions between adverse life events and neuroticism the current study is the first to test for an interaction effect between neuroticism and adverse life events in relation to ha, finding an interaction between neuroticism and ides, which does not appear for the association between neuroticism and oaes. this appears to be consistent with other studies examining diathesis-stress interactions for other mood and anxiety disorders that have found similar significant interaction effects (arnau-soler et al., 2019; brown & rosellini, 2011; howe et al., 2017) and aligns with what would be expected based on the diathesis-stress model. furthermore, supplementary analyses showed that an interaction between ides and neuroticism could not be identified when examining the association with more general depression and anxiety. thus, the interaction effect between neuroticism and ides seemed to only occur in relation to ha. importantly, the size of the interaction effect was small. scoring highly on both neuroticism and ides resulted in only 2% higher odds of scoring higher on ha. the size of this association puts the theoretical and clinical implications of this finding into question. implication and future work the results of this study indicate that both diathesis and stress factors are associated with ha, consistent with the diathesis-stress model (monroe & simons, 1991), though inconsistent evidence was found for the specificity of ides in relation to ha, which is implied in the cognitive model of ha (salkovskis & warwick, 2001). to more robustly establish the causal role of oaes, ides and neuroticism in relation to ha, future studies should preferably use prospective designs. current findings do not support the importance of future studies examining ides as a separate category instead of measures of cumulative adversity (seery et al., 2010). furthermore, the current model supports the importance of dispositional factors in relation to ha, as neuroticism was shown to have the strongest association with ha. future theoretical work could focus on integrating these factors in the cognitive model of ha (salkovskis & warwick, 2001). the knowledge about the relative importance of neuroticism and adverse life events could inform clinical work with ha patients and may be integrated in case formulation, psychoeducation or during psychotherapy (bagby et al., 2016; buwalda & bouman, 2008). lamm, mehlsen, carstensen et al. 11 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ strengths and limitations the strength of the current study is its use of validated self-report measures in a large representative sample of the general population. all analyses are theoretically driven, testing popular models within the field, and the current study is also the first to test the interactions between neuroticism and adverse life events in relation to ha. the study is limited by its cross-sectional design, which inhibits causal inference (kraemer et al., 1997). while it is well established that both adverse life events and neuroticism are prospective risk factors for various types of mental disorders (jeronimus et al., 2016; li et al., 2016), bi-directional effects have also been shown, where mental disorder can increase both rates of stressful life events (rnic et al., 2023) and levels of neuroticism (ormel et al., 2013). the retrospective nature of the clam also makes it vul­ nerable to recall bias, whereby current state effects may modify the reported frequency or significance of past events (lalande & bonanno, 2011). another limitation is related to the use of a self-reported measure for ha, as distress reported via self-report may not always correspond to actual clinically significant dis­ tress (hedman et al., 2015). thus, the current findings could be supplemented in future studies using dichotomous classifications of ha set via clinical interviews to better estimate the clinical implication of findings. finally, the aggregated adverse life event variables used in the current study (ides and oaes) were created by combining specific subscales from the clam for this specific study (carstensen, ørnbøl, fink, jørgensen, et al., 2020). as such, these subdivisions have not been formally validated. however, as the clam is a formative measure, this should not pose a threat to validity. conclusion using data from the large representative danfund cohort, the current study has found positive associations between health anxiety and neuroticism, illness/death related life events and other adverse life events. the findings show that illness/death related life events did not have a stronger relation to health anxiety than other adverse life events. while a specific interaction effect was found between illness/death related life events and neuroticism in relation to health anxiety, the size of this interaction was small, and the clinical significance of this finding remains unclear. neuroticism, adversity and health anxiety 12 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ funding: the current publication did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the danfund study was supported by trygfonden (7-11-0213), the lundbeck foundation (r155-2013-14070). funders were not involved in the collection, analysis and interpretation of data, the writing of the current article, or the decision to submit for publication. acknowledgments: thanks are given to maja cosedis strand for proofreading the publication. the authors would also like to extend our gratitude to all participants in the danfund cohort for contributing data to the study and to the staff from center for clinical research and prevention, bispebjerg and frederiksberg hospital, for their work in relation to collecting the data. competing interests: the authors have declared that no competing interests exist. furthermore, the authors have no additional (i.e., non-financial) support to report. ethics statement: all participants gave written informed consent. ethical approval was granted from the ethical committee of copenhagen county (ethics committee: 3-2012-0015) as well as the danish data protection agency (2012–58006, 1–16–02-227-16), and the study was conducted in accordance with the helsinki ii declaration. reporting guidelines: the current manuscript was formatted according to the jars-quant reporting guidelines for quantitative research designs. preregistration: the current study was not pre-registered. the current study is not a replication study. data availability: all data collected in the current study are confidential, and data can therefore not be made available. the code used for statistical analysis and other study materials can be shared upon reasonable request. supplementary materials the supplementary materials contain the following items (for access, see lamm et al., 2025s): • appendix a: syntax of directed acyclic graphs (dags) • appendix b: ordinal logistical regression models of the association between neuroticism, adverse life events, and health anxiety with interactions • appendix c: description of measures used in supplementary analyses and descriptive statistics • appendix d: results of supplementary analyses index of supplementary materials lamm, t. t., mehlsen, m. y., carstensen, t. b. w., wellnitz, k. b., ørnbøl, e., dantoft, t. m., fink, p., petersen, m. w., & frostholm, l. (2025s). supplementary materials to "associations and interactions between neuroticism, adverse life events and health anxiety: results from a large representative cohort" [online appendices]. psychopen gold. https://doi.org/10.23668/psycharchives.16215 lamm, mehlsen, carstensen et al. 13 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://doi.org/10.23668/psycharchives.16215 https://www.psychopen.eu/ references aadahl, m., zacho, m., linneberg, a., thuesen, b. h., & jorgensen, t. 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(2014). previous experiences with illness and traumatic experiences: a specific risk factor for hypochondriasis? psychosomatics, 55(4), 362–371. https://doi.org/10.1016/j.psym.2013.10.005 lamm, mehlsen, carstensen et al. 17 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://doi.org/10.1016/j.cpr.2013.04.003 https://doi.org/10.1192/bjp.113.494.89 https://doi.org/10.1016/j.chiabu.2013.08.007 https://doi.org/10.1037/bul0000390 https://doi.org/10.1080/10615800310001637134 https://doi.org/10.1037/a0021344 https://doi.org/10.1192/bjp.bp.111.103960 https://doi.org/10.1016/s0022-3999(02)00332-x https://doi.org/10.1093/ije/dyw341 https://doi.org/10.1080/02739615.2017.1318390 https://doi.org/10.1016/j.psym.2013.10.005 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. neuroticism, adversity and health anxiety 18 clinical psychology in europe 2025, vol. 7(2), article e14441 https://doi.org/10.32872/cpe.14441 https://www.psychopen.eu/ neuroticism, adversity and health anxiety (introduction) models of severe health anxiety experiences with illness and death neuroticism aim of the current study method design and participants measures analysis results discussion summary of findings associations between health anxiety, adverse life events, and neuroticism the specificity of ides interactions between adverse life events and neuroticism implication and future work strengths and limitations conclusion (additional information) funding acknowledgments competing interests ethics statement reporting guidelines preregistration data availability supplementary materials references web-based imagery behavioral activation (wimba): study protocol for a randomized controlled trial testing the effects, acceptability, and feasibility of a mental imagery activity scheduling training delivered online research articles web-based imagery behavioral activation (wimba): study protocol for a randomized controlled trial testing the effects, acceptability, and feasibility of a mental imagery activity scheduling training delivered online max heise 1 , sanne j. e. bruijniks 1,2 , fritz renner 1 [1] clinical psychology and psychotherapy unit, institute of psychology, university of freiburg, freiburg, germany. [2] department of clinical psychology, utrecht university, utrecht, the netherlands. clinical psychology in europe, 2024, vol. 6(2), article e12133, https://doi.org/10.32872/cpe.12133 received: 2023-06-09 • accepted: 2024-03-21 • published (vor): 2024-06-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: max heise, clinical psychology and psychotherapy unit, institute of psychology, university of freiburg, engelbergerstr. 41, 79106, freiburg, germany. phone: +49 761 203 9446. e-mail: max.heise@psychologie.uni-freiburg.de supplementary materials: preregistration [see index of supplementary materials] abstract background: behavioral activation (ba) is an effective and efficacious treatment for depression. activity scheduling is the central treatment component of ba and involves planning of potentially enjoyable and rewarding activities. evidence from non-clinical studies suggests that mental imagery simulations of planned activities can increase motivation and anticipated pleasure for these activities. method: we describe a randomized controlled trial testing a mental imagery activity scheduling training delivered online in four weekly sessions (total training duration approximately 90 minutes) in a sample meeting diagnostic criteria of a major depressive episode, as indicated by the diagnostic short-interview for mental disorders (mini-dips), and not currently receiving treatment. participants (n = 140) will be randomized to either mental imagery activity scheduling or a wait-list control condition. depressive symptoms (bdi-ii) and behavioral activation (bads) are the primary outcomes; bdi-ii will be measured at session 1, session 4, and at two-week followup, bads at sessions 1-4 and at two-week follow-up. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12133&domain=pdf&date_stamp=2024-06-28 https://orcid.org/0000-0003-2650-8681 https://orcid.org/0000-0003-3448-5192 https://orcid.org/0000-0002-1692-449x https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ discussion: it is discussed how the expected results may reflect mechanisms and effects of a mental imagery activity scheduling training delivered online in a sample of individuals with depression. concluding we outline next steps for future research and highlight the potential of this novel treatment for dissemination in the wider community and integration into routine care. keywords mental imagery, mental simulation, behavioral activation, activity scheduling, depression highlights • preliminary data suggest that mental imagery can be used to enhance behavioral activation (ba). • we describe a rct testing the effects of web-based imagery-enhanced ba in a depressed sample. • online imagery-enhanced ba is easy to disseminate and may improve depression treatment. a deficit in reward processing is one of the core clinical features of major depressive disorder (mdd). according to early behavioral models, mdd is associated with a de­ creased engagement in potentially rewarding activities, which leads to reduced reward experiences and a worsening of mood (lewinsohn, 1974). a number of studies support this theoretical account. behavioral and neuroimaging findings have suggested that patients with mdd are hyposensitive to reward and hypersensitive to punishment (alloy et al., 2016; eshel & roiser, 2010). in addition, compared to healthy controls, patients with mdd show a reduced expectation of how rewarding or pleasant a future stimulus will be (gorka et al., 2014). this phenomenon, also referred to as low anticipation of reward, has been related to less active behavior and less positive affect (bakker et al., 2017). one effective psychotherapy that aims to target these deficits in reward processing is behavioral activation (ba; dimidjian et al., 2006, 2011; for a meta-analysis, see cuijpers et al., 2023). ba can consist of different procedures, of which activity scheduling (i.e., scheduling activities with the aim to increase positive reinforcement) and skill training (i.e., such as social or problem-solving skills) have received most support (kanter et al., 2010). multiple studies on ba procedures have linked these interventions to increases in self-reported levels of behavioral activation and to decreases of depressive symptoms (stein et al., 2021), and even suggested that behavioral activation may play a role across different types of psychotherapies (bruijniks et al., 2022). although research that links ba procedures or self-reported behavioral activation to changes in reward functioning is still scarce (forbes, 2020; janssen et al., 2021), some studies did already point to a positive association between reward anticipation and increased activation (bakker et al., 2017; dichter et al., 2009) and showed that procedures focused on behavioral activation seem to increase neural activity related to motivation (mori et al., 2018). however, patients wimba: study protocol 2 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ with mdd often suffer from low energy levels (schuch et al., 2017) and poor motivation (treadway & zald, 2011) that can act as a barrier towards engaging in behaviors (i.e., activation) that might facilitate reward experiences. as there is still an urgent need to improve treatments for mdd (cuijpers et al., 2021), identifying ways to optimize ba procedures to improve reward processing in patients with mdd might be a promising way forward. recent pre-clinical studies suggest that ba treatment might be facilitated by combin­ ing activity scheduling with mental imagery based procedures (heise et al., 2022; holmes et al., 2016; renner et al., 2019). mental imagery refers to the multi-sensory experience of information from memory (kosslyn et al., 2001). imagery-based procedures have a long tradition in many forms of psychotherapy. prospective mental imagery involves the simulation of future situations or activities. in non-clinical samples, mental imagery of planned activities has been linked to increased motivation for engaging in these activities (renner et al., 2019). mental imagery of positive future events has also been shown to increase the estimated likelihood of future events (boland et al., 2018) and to decrease depressive symptoms and perceived stress (marciniak et al., 2024). recently, we showed that affective mental imagery leads to higher motivation for completing activities compared to neutral mental imagery or no mental imagery, suggesting that an affective mental imagery component may be crucial to enhance motivation. these findings however did not translate to the actual performance of activities, possibly due to a ceiling effect within this non-clinical sample (heise et al., 2022). in a sub-clinical sample, participants who were instructed to generate positive images showed better performance on a behavioral task compared to participants who were instructed to generate negative images (pictet et al., 2011). positive imagery has been shown to mod­ ulate early attention allocation towards stimuli associated with the imagined activities (bär et al., 2023). in sum, these studies suggest that individuals with depression, who typically have lower activation levels compared to healthy controls (manos et al., 2011; pinto-meza et al., 2006), might benefit from prospective mental imagery interventions. indeed, a recent pilot randomized clinical trial that compared imagery-enhanced ba with a wait-list control condition in a sample of patients with late-life depression confirmed that adding mental imagery to ba is feasible and depressive symptoms decreased more in the imagery ba condition, including at 6-month follow-up (pellas et al., 2022, 2023). however, in this trial the sample size was small (n = 41) and restricted to elderly patients with mdd. while the effects observed by pellas et al. (2022, 2023) are promising, there is a clear need for additional studies on the clinical utility of imagery-enhanced ba. accordingly, we propose to test the effects of an unguided, online-delivered imagery ba intervention in a sample of individuals meeting diagnostic criteria for mdd. the change in study format from telephone-based, as in pellas et al. (2022), to online-based facilitates easier dissemination, potentially expanding access to an empirically-supported treatment. fur­ heise, bruijniks, & renner 3 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ thermore, we believe it is also highly relevant to investigate the role of individual differ­ ences for the effectiveness of imagery-enhanced ba. research suggests that imagery viv­ idness is reduced in persons experiencing symptoms of depression (holmes et al., 2016). since the intervention builds on imagery of planned, potentially rewarding activities we aim to investigate if individual differences in the ability to generate reward imagery moderate treatment effects. likewise, some empirical data suggest that symptoms of anhedonia (webb et al., 2023) and avoidance tendencies (nasrin et al., 2017) might limit the effectiveness of ba. by investigating how imagery ability, anhedonia, and avoidance tendencies influence the effectiveness of the imagery-enhanced ba interventions we hope to gain a better understanding for whom this intervention works best, paving the way for treatment individualization in the future. additionally, it may also shed some light on the mechanisms underpinning imagery ba effects, thus enabling potential increases in efficiency by focusing on the ‘active ingredients’. the present study will test the acceptability, feasibility, and effects of a 4-session imagery ba intervention delivered over the internet on behavioral activation and depres­ sive symptoms in individuals meeting diagnostic criteria for mdd. while results from several studies have already supported the use of ba in online settings (e.g., muellerweinitschke et al., 2023; potsch & rief, 2024; puspitasari et al., 2017; weitzel et al., 2022), the presented study will be the first to test the acceptability, feasibility, and effects of an imagery-enhanced ba intervention in an online setting. besides, the present study will include multiple measurements of potential mechanisms of change, thereby providing insights into the relationship between the procedure (imagery-enhanced activity sched­ uling), potential mechanisms of change (reward anticipation, motivation, and behavioral activation), and outcome (depressive symptoms). in addition, the present study will explore the moderating effects of imagery ability, anhedonia, and avoidance tendencies. specifically, we expect to find (1) an increase in behavioral activation, measured with the behavioral activation for depression scale (bads; kanter et al., 2007) weekly from baseline to session 4 and at two-week follow-up, and (2) a decrease in depressive symptoms, measured with the beck depression inventory-ii (bdi-ii; beck et al., 1996) at baseline, session 4, and at two-week follow-up, for participants in the imagery ba condition, compared to participants in the wait-list control condition. we expect that this difference between conditions in behavioral activation and depressive symptoms will be present at the end of the intervention (session 4) and will be maintained at two-week follow-up. wimba: study protocol 4 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ method design the study is a two-arm randomized controlled trial with one active intervention condi­ tion (imagery ba) and one wait-list control condition. participants in both conditions are invited to complete questionnaires at baseline (session 1), weeks 1-3 after baseline (sessions 2-4) and at follow-up (week 5 after baseline). the study has been pre-registered (see heise et al., 2022s). participants inclusion criteria are (a) meeting the diagnostic criteria for a current major depressive disorder (mdd) as indicated by the diagnostic short-interview for mental disorders (mini-dips; margraf et al., 2017), (b) a bdi-ii score ≥ 14, indicating at least mild levels of depression, and (c) age between 18 and 65 years. participants will be excluded if (1) they are currently in treatment for a mental health condition (psychotherapy and/or medication), (2) they present high levels of suicidality (as indicated by answers > 1 for item 9 of the bdi-ii or the respective section in the mini-dips), or (3) if they are meeting diagnostic criteria for one or more of the following disorders: bipolar disorder, psychotic disorders, or substance dependence. sample size. our aim is to obtain a dataset containing n = 140 complete observations, that is, with measurements for all four sessions and follow-up. this sample size was pre-registered (heise et al., 2022s) and determined a priori using gpower (faul et al., 2009). we assumed a small effect size (as observed in initial pilot testing), 95% power, and α = 0.05. to account for attrition as observed in initial pilot testing, in which approximately 26% of baseline participants did not complete the follow-up assessment, we plan to recruit a total of n = 192 participants from the general population. procedure screening process to inform potential participants about the present study, advertisements and leaflets will be distributed through various online (social media groups, forums focusing on depression) and offline (general practitioners, psychotherapists, psychiatrists, outpatient clinics, university student counseling services) channels. anyone interested in the study will be referred to an online screening website, where detailed information about the study’s procedures are provided and informed consent is obtained from interested poten­ tial participants. next, participants complete the bdi-ii and screening questions for the mini-dips. if complying with inclusion and exclusion criteria, participants may book an appointment for a telephone interview by choosing a suitable date/time from a list displayed online. heise, bruijniks, & renner 5 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ telephone interview in the telephone interview, trained interviewers complete the mini-dips including sec­ tions on major depression and current suicidality as well as any other section identified through the respective screening question. this procedure allows assessing whether diagnostic criteria for inclusion/exclusion diagnoses are met as well as for any other diagnoses covered in the mini-dips. measurements participants complete questionnaires at baseline, weeks 1-3, and follow-up (week 5; see table 1 for a complete list of measures, forms, and sampling points) as part of the respective online sessions. session invitations will be sent out via email. if participants fail to respond to a given session invitation by accessing the provided link within 24 hours, a reminder message is sent out. the link in the reminder message is valid for another five days; if this period elapses without response, the respective participant is excluded from further participation in the study. randomization and recruitment stop block randomization will be used, where each participant will be randomly assigned to one of two equally sized, predetermined blocks. randomization is performed using the respective function provided by the survey platform formr (arslan et al., 2020) used in this online study. recruitment will stop if either of the following two criteria is met: (a) the number of recruited participants, i.e. participants who have completed at least the baseline questionnaires and have been randomized, has reached n = 192 or (b) the number of complete observations, i.e. datasets containing measurements for all four sessions and follow-up, has reached n = 140. as a compensation for taking part in the study, participants will receive a 25 € online retailer voucher. intervention: imagery ba session content — the present study’s intervention consists of four sessions. in session 1 (duration approximately 20 minutes), participants are familiarized with information about prevalence and symptoms of depression, the general rationale of cbt and, more specifically, of ba. at the end of session 1, and following standard ba procedures (e.g., addis & martell, 2004), participants are instructed to monitor the kind of activities they engage in and how these activities influence their mood during the following week. to this end, participants receive email invitations to complete an activity monitoring form (for details, see below) at 6 pm on day 3 and day 5 after completion of the first session. during session 2 (duration approximately 25 minutes), participants will receive short, standardized, constructive written and personalized graphical feedback on their activity monitoring forms. next, to facilitate the identification of idiosyncratic and meaningful activities, participants will be asked to identify three meaningful life areas from a list wimba: study protocol 6 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ (see appendix), rank these based on personal significance, and nominate personal values pertaining to each of these areas. participants will be instructed to choose two activities they would like to engage in over the following week from their highest-ranked life area. in preparation for the following mental imagery tasks, participants complete a standard imagery training exercise (see paragraph ‘imagery training’ below). participants then proceed to schedule a time and date within the following seven days for each previously chosen activity. importantly, and differing from standard ba procedures, participants complete a guided mental imagery task presented via audio recording in which participants are instructed to simulate engagement in the respective activity (for further details, see paragraph ‘imagery-enhanced activity scheduling’ below). in session 3 (duration approximately 35 minutes), participants fill out activity monitoring forms table 1 measures and sampling points measure screening session 1/ baseline session 2 session 3 session 4 follow-up primary outcomes bads x x x x x bdi-ii x x x x secondary outcomes items on acceptability and feasibility x wemwbs x x x activity data activity monitoring form x x x activity ratings x x potential mediators (measured as activity ratings) reward anticipation x x motivation x x potential moderators cbas x x x x fris x x suis x teps x note. bads = behavioral activation for depression scale (kanter et al., 2007); bdi-ii = beck depression inventory-ii (beck et al., 1996); cbas = cognitive behavioral avoidance scale (ottenbreit & dobson, 2004); fris = freiburg reward imagery scale (https://osf.io/9y64q); suis = spontaneous use of imagery scale (kosslyn et al., 1998); teps = temporal experience of pleasure scale (gard et al., 2006); wemwbs = warwick-edinburgh mental wellbeing scales (tennant et al., 2007). heise, bruijniks, & renner 7 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://osf.io/9y64q https://www.psychopen.eu/ corresponding to their activities scheduled in session 2 and receive standardized, con­ structive written and personalized graphical feedback on this. next, participants choose three activities (+1 compared to session 2) and once again complete imagery-enhanced activity scheduling for each of these activities. while participants are encouraged to try out new activities, previously chosen activities may also be re-scheduled. in session 4 (duration approximately 20 minutes), following completion of activity monitoring forms and having received feedback on these, the intervention concludes with a summary of the study’s rationale. participants are encouraged to continue planning positive activities and are reminded of the follow-up assessment two weeks later. study format — throughout all sessions, content materials are presented on interactive slides using text, pictures, and audio recordings. apart from the telephone screening interview, the present study is conducted completely online and unguided. however, participants are encouraged to contact the study team if questions or problems related to the study arise. participant adherence is encouraged through personalized graphical feedback on activity completion, reminder messages, and individualization (focus on idiosyncratic values). furthermore, the study team continuously monitors participants’ progress and will contact individual participants if necessary. the current version of the intervention incorporates adaptations made in response to participant feedback received in a pilot trial. for a graphical overview of the study’s procedure, see figure 1. imagery-enhanced activity scheduling — in the present study, standard ba activity scheduling is enhanced by adding a guided mental imagery task, in which participants are instructed to generate emotionally rich, multisensory mental imagery of how they engage in their previously chosen rewarding activity. participants are guided through the consecutive stages of initiating, engaging in, and completing the activity. throughout the latter two stages, emphasis is placed on experiencing the positive emotional impact of the activity. finally, participants are instructed to create a ‘mental snapshot’ of the positive emotional consequences attributed to the activity. the standardized script used in the present study was based on previous studies (heise et al., 2022; renner et al., 2019), adapted to the requirements of the present online study format, and pilot-tested. the audio recordings used for the guided imagery task last 2:51 min (female voice) and 2:46 min (male voice) respectively. imagery training — prior to engaging in the imagery-enhanced activity scheduling for the first time, participants in the imagery ba condition will complete a standard imagery training task (cf. holmes & mathews, 2005). in this training task, participants are instructed to generate vivid, first-person mental imagery while making use of all sensory modalities (vision, sound, smell, and so forth). the audio recordings used for the imagery training last 2:35 min (female voice) and 3:00 min (male voice) respectively. wimba: study protocol 8 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ figure 1 procedure note. bads = behavioral activation for depression scale (kanter et al., 2007); bdi-ii = beck depression inventory (beck et al., 1996); cbas = cognitive behavioral avoidance scale (röthlin et al., 2010); fris = freiburg reward imagery scale (https://osf.io/9y64q); mini-dips = diagnostic short-interview for mental disorders (margraf et al., 2017); suis = spontaneous use of imagery scale (kosslyn et al., 1998); teps = temporal experience of pleasure scale (gard et al., 2006); wemwbs = warwick-edinburgh mental wellbeing scales (tennant et al., 2007). heise, bruijniks, & renner 9 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://osf.io/9y64q https://www.psychopen.eu/ wait-list control condition for participants in the wait-list control condition, the number and frequency of sessions is identical to those of participants in the imagery ba condition. however, session contents are restricted to the collection of questionnaire data only. participants in the wait-list control condition can choose to complete the imagery ba intervention starting one day after the follow-up assessment. materials the present study has been implemented on the formr platform (arslan et al., 2020). this online survey platform will be used to collect questionnaire data, perform block ran­ domization of participants, distribute the audio-visual session contents (including guided imagery scripts) to participants, send out email invitations, and reminder messages. to take part in this study, participants require access to a digital device with internet access and the ability to playback audio files (e.g., smartphone, tablet, or laptop). measures primary outcomes behavioral activation — behavioral activation will be assessed weekly from baseline (session 1) to session 4, and at two-week follow-up using the behavioral activation for depression scale (bads; kanter et al., 2007; german version: teismann et al., 2016). the bads conceptualizes behavioral activation as comprising four distinct factors (acti­ vation, avoidance/rumination, work/school impairment, social impairment) measured by asking respondents to indicate agreement with 25 statements (e.g., “i did something that was hard to do but it was worth it.”) on a seven-point scale ranging from 0 “not at all” to 6 “completely”. reliability and validity of the bads have been supported (teismann et al., 2016). depressive symptoms — depressive symptoms will be assessed at baseline (session 1), session 4, and at two-week follow-up using the beck depression inventory-ii (bdi-ii; beck et al., 1996). the bdi-ii measures depressive symptom severity across 21 symptoms by letting respondents choose from four (for two symptoms, seven) statements (e.g., “i blame myself all the time for my faults.”) ranked by increasing severity (scoring 0-3 points per symptom). total scores can range from 0 to 63, with 0-13 indicating minimal depression, 14-19 mild depression, 20-28 moderate depression, and 29-63 severe depression. reliability and validity of the bdi-ii are well supported (kühner et al., 2007; wang & gorenstein, 2013). wimba: study protocol 10 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ secondary outcomes acceptability and feasibility — acceptability and feasibility of the newly developed online imagery ba intervention tested in this study will be measured by dropout rate during the intervention and by a number of questions on acceptability and feasibility (e.g., “i liked the online format of the study”, “i found it difficult/unpleasant to engage with the study.”, “i would recommend the training to friends”). responses will be recor­ ded on seven-point likert scales with end points labelled 0 “not at all” and 6 “very much” and will be obtained at follow-up or – in the case of drop-out – via an additional questionnaire sent to dropped-out participants. furthermore, open-ended questions are included to encourage participant feedback on this newly developed intervention. monitoring of potential adverse effects — potential adverse effects of the interven­ tion will be assessed in terms of symptom deterioration (bdi-ii) as well as through questions on acceptability and feasibility. to minimize the occurrence of adverse effects such as suicidal thoughts and behaviors, extra care is taken to identify persons at risk during the screening procedures and intake telephone interview (for details see inclusion criteria in the participants section above). in addition, a safety protocol to deal with suicidal ideation that includes consultation with a clinical psychologist has been imple­ mented. mental well-being — mental well-being will be assessed at baseline, session 4, and follow-up using the warwick-edinburgh mental wellbeing scales (wemwbs; tennant et al., 2007; german version: lang & bachinger, 2017). respondents rate frequency of occurrence for 14 statements (e.g., “i’ve been feeling confident.”) during the past two weeks. answers are recorded on a five-point scale ranging from 1 “none of the time” to 5 “all of the time”. reliability and validity of the wemwbs has been confirmed in a german speaking sample (lang & bachinger, 2017). activity data activity ratings — to assess individual differences and changes in reward anticipation and motivation, participants in the imagery ba condition will be asked to provide ratings of the following items pre and post intervention, that is, before and after the imagery-en­ hanced activity scheduling procedure: (a) how pleasant they expect the activity to be, (b) how rewarding they expect the activity to be, and (c) how motivated they are to engage in the activity. to control for potential differences in activity characteristics, ratings of activity importance, procrastination tendency, and previous engagement with the activity will be obtained pre intervention. as a manipulation check, allowing to infer whether participants succeeded in generating mental imagery, participants in the imagery ba condition will rate mental imagery vividness and anticipatory pleasure (i.e., pleasure experienced while imagining the activity) post intervention. heise, bruijniks, & renner 11 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ activity monitoring forms — to track whether and how participants engage in (scheduled) activities, they are asked to fill out activity monitoring forms in the week between sessions 1 and 2, as well as in sessions 3 and 4. in these forms, participants indicate which activities they engaged in (week after session 1) or whether they engaged in their scheduled activities (sessions 3 and 4). while inviting participants to fill out the activity monitoring form during the week, as implemented between sessions 1 and 2, more closely matches standard ba procedures, where activity monitoring is typically given as a homework assignment, it was decided to deviate from this procedure after ses­ sion 2 to avoid confounding behavioral intervention effects with the potential reminder effect of activity monitoring invite messages sent in between sessions. for each activity, participants note the duration of their engagement in the activity, how enjoyable/reward­ ing they experienced the activity to be, and to what extent the activity influenced their mood. in case of non-engagement, participants can note a putative reason for this. the activity monitoring form is presented online and uses an interactive format that adapts to participants’ answers by displaying only relevant elements (e.g., depending on the initial answer whether or not participants engaged in a given activity). potential moderators avoidance tendencies — avoidance tendencies will be measured from baseline to session 4 using the cognitive behavioral avoidance scale (cbas; ottenbreit & dobson, 2004; german version: röthlin et al., 2010). in the cbas, respondents rate appropriate­ ness of 31 statements (e.g., “i quit activities that challenge me too much.”) on a five-point scale ranging from 1 “not at all true for me” to 5 “extremely true for me”. excellent internal consistency of α = 0.92 has been reported for the german version (röthlin et al., 2010). the ability to generate reward imagery — the ability to generate reward imagery will be measured at baseline and session 4 using the freiburg reward imagery scale (fris), a newly developed scale assessing individual differences in the ability to generate mental imagery of future activities including the associated positive emotional outcomes (for details, see pre-registration at https://osf.io/9y64q). for this scale, respondents are in­ structed to imagine engaging in a rewarding activity and subsequently rate the resulting mental image (subscales include vividness, anticipatory pleasure, anticipated pleasure, and motivation). respondents rate their agreement with 12 statements (e.g., “this activi­ ty would make me happy.”) on an eleven-point scale ranging from 0 “not at all” to 10 “completely”. everyday imagery use — everyday imagery use will be measured at baseline using the spontaneous use of imagery scale (suis; kosslyn et al., 1998; german version: görgen et al., 2016). in the suis, respondents rate the appropriateness of 12 statements (e.g., wimba: study protocol 12 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://osf.io/9y64q https://www.psychopen.eu/ “when i think about visiting a relative, i almost always have a clear mental picture of him or her.”) on a five-point scale ranging from 1 “never appropriate” to 5 “always completely appropriate”. acceptable (α = 0.72 0.76; nelis et al., 2014) to good (α = 0.83; mccarthy-jones et al., 2012) reliability has been reported for the english version. for the german version, cronbach’s alpha has been reported to be lower (α = 0.66 in both studies; görgen et al., 2016; heise et al., 2022). symptoms of anhedonia — symptoms of anhedonia will be measured at baseline using the temporal experience of pleasure scale (teps; gard et al., 2006). in the teps, anhedonia is assessed as two subcomponents, namely anticipatory pleasure (10 items, e.g. “looking forward to a pleasurable experience is in itself pleasurable.”) and consum­ matory pleasure (8 items, e.g. “i really enjoy the feeling of a good yawn.”). respondents rate agreement with items on a six-point scale ranging from 1 “very false for me” to 6 “very true for me”. acceptable reliability indices for the anticipatory (α = 0.74 – 0.81) and consummatory (α = 0.69 – 0.74) subscales have been reported (ho et al., 2015). statistical analyses we will regard p-values less than .05 as criteria for statistically significant results. all reported p-values will be two-tailed. hypothesis 1 – behavioral activation to test for differences between the imagery ba condition and the wait-list control condi­ tion in change in behavioral activation across the five measurement points (sessions 1–4, follow-up), we plan to conduct a repeated-measures anova on the bads score with condition (imagery ba vs. wait-list control) as between-subject factor and time (sessions 1–4, follow-up) as within-subject factor in an intention-to-treat analysis. hypothesis 2 – depressive symptoms to test for differences between the imagery ba condition and the wait-list control con­ dition in change in depressive symptoms across the three measurement points (session 1, session 4, follow-up), we plan to conduct a repeated-measures anova on the bdi-ii score with condition (imagery ba vs. wait-list control) as between-subject factor and time (session 1, session 4, follow-up) as within-subject factor in an intention-to-treat analysis. exploratory analyses to assess feasibility and acceptability, we will report the drop-out rate and descriptive data on acceptability and feasibility. using structural equation modelling that will allow us to model change over time, we will explore whether reward anticipation and motiva­ heise, bruijniks, & renner 13 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ tion mediate the relation between treatment and behavioral activation and treatment and depressive outcome, respectively. baseline scores on everyday mental imagery use, symptoms of anhedonia, avoidance tendencies, and the ability to generate reward im­ agery will be tested as potential moderators of the effect of treatment on outcomes (behavioral activation, depressive symptoms). discussion we presented a study protocol of a randomized controlled trial testing the effects of an online-delivered imagery ba intervention on behavioral activation and depressive symp­ toms in individuals with depression. the imagery ba intervention will be compared to a wait-list control group. while there are promising pre-clinical studies testing the impact of the imagery-en­ hanced activity scheduling procedure on motivation and reward anticipation (heise et al., 2022; renner et al., 2019) and one pilot randomized controlled trial testing the effects of an imagery ba intervention in a sample of patients with late life depression (pellas et al., 2022), the present study will be the first to test an imagery ba intervention in an online setting with an adequately powered sample of individuals with depression. this study includes at least two innovative aspects: first, the intervention that is tested in this study combines two evidenced-based therapeutic procedures (ba activity scheduling and mental imagery) into a new intervention. although ba activity schedul­ ing is an effective intervention in itself, not all patients with depression benefit from activity scheduling and symptoms of depression, such as a lack of energy and loss of pleasure from activities, might be barriers to successful application of activity scheduling. the mental imagery component might offer an opportunity to overcome these barriers by providing a “pre-experience” of the positive aspects of planned activities in the here-and-now while they are planned in. as several studies have shown that ba can be successfully implemented in an online format (for meta-analyses, see alber et al., 2023; huguet et al., 2018; recent studies involving online ba include mueller-weinitschke et al., 2023; potsch & rief, 2024), it will be interesting to see if the same is true for this novel intervention. if confirmed, this would potentially enable broad dissemination to reach individuals with depression who do not have access to other therapy resources or who are on waiting lists for treatment. also in a face-to-face context, the imagery ba intervention is relatively straightforward to learn and does not require a high degree of training which would potentially foster further dissemination. the second innovative aspect of the present study is the concurrent measurement of outcome (depressive symptom severity) and the putative mechanism underlying po­ tential changes in this outcome, that is, behavioral activation. in a study testing an internet-delivered ba intervention in a sample of clinically depressed individuals, fu et al. (2021) found that improvements in symptom severity were mediated and preceded wimba: study protocol 14 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ by increases in activation levels. the present study should provide further insights into whether a similar pattern emerges if ba is augmented with mental imagery. we expect that the imagery ba intervention is not associated with any risks or adverse effects. previous studies in non-clinical (heise et al., 2022; renner et al., 2019) and clinical samples (pellas et al., 2022, 2023) suggest that the intervention can be delivered in a safe way and is well accepted and tolerated. one aspect that needs to be considered when interpreting the results of this study is the fact that we plan to compare the intervention to a wait-list control group. due to the nature of the control condition, we will not be able to test the added effects of the new mental imagery component on top of the effects of ba activity scheduling alone. however, given that this is the first adequately powered trial in this context, starting with a wait-list control condition seems appropriate. subsequent research should test the added effect of mental imagery simulation in activity scheduling by comparing an imagery-enhanced activity scheduling intervention to a standard ba activity scheduling intervention. results of pre-clinical work already suggest that the imagery component does have an added value on motivation and reward anticipation for planned activities (renner et al., 2019) specifically when the imagery component focusses on pre-experi­ encing pleasant aspects of planned activities (heise et al., 2022). the added value of the mental imagery component on depressive symptom severity in patients with depression should be tested in subsequent studies. in conclusion, although a number of evidence-based treatments for depression exist, including behavioral activation treatment, about half of the patients with depression do not get better in treatment and there is room for treatment innovation and improvement (cuijpers et al., 2021). it is therefore important to explore new procedures to deliver and to amplify established evidenced-based interventions, such as ba activity scheduling. the imagery ba intervention that is tested in the present study is an example of this approach. the results of this study will provide the first empirical evidence of an image­ ry-enhanced ba intervention in an online setting for individuals with depression. heise, bruijniks, & renner 15 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ funding: this work was supported by the sofja kovalevskaja award from the alexander von humboldt foundation and the german federal ministry for education and research awarded to fritz renner. acknowledgments: the authors would like to thank luisa treiss and leonhard morrissey for their conceptual contributions and assistance in the creation of study materials. competing interests: the authors have declared that no competing interests exist. ethics statement: the present study will be performed in line with the principles of the declaration of helsinki (world medical association, 2013) and has been approved by the ethics committee of the german society for psychology (dgps; 2020-10-07va/2021-08-04am). informed consent will be obtained from all participants in this study. x accounts: @_mxhs, @sbruijniks, @fritz_renner data availability: upon completion of recruitment and data analysis, the data of the presented study will be made available via the open science framework. alternatively, data will be made available by the authors on reasonable request. supplementary materials the supplementary materials contain the pre-registration protocol for the study (see heise et al., 2022s). index of supplementary materials heise, m., bruijniks, s. j. e., & renner, f. 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(2013). world medical association declaration of helsinki: ethical principles for medical research involving human subjects. journal of the american medical association, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 heise, bruijniks, & renner 21 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://doi.org/10.1016/j.brat.2019.02.002 https://doi.org/10.1026/0012-1924/a000008 https://doi.org/10.1016/j.jad.2016.10.050 https://doi.org/10.1017/s0033291720000239 https://doi.org/10.1002/cpp.1948 https://doi.org/10.1186/1477-7525-5-63 https://doi.org/10.1016/j.neubiorev.2010.06.006 https://doi.org/10.1590/1516-4446-2012-1048 https://doi.org/10.1038/s41386-022-01481-4 https://doi.org/10.1016/j.jad.2022.04.090 https://doi.org/10.1001/jama.2013.281053 https://www.psychopen.eu/ appendix: list of life areas • relationships (family / friends / romantic) • sports & outside activities • hobbies / creativity / activities alone • self-care / recreation / spirituality • education & profession • everyday tasks clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. wimba: study protocol 22 clinical psychology in europe 2024, vol. 6(2), article e12133 https://doi.org/10.32872/cpe.12133 https://www.psychopen.eu/ wimba: study protocol (introduction) method design participants procedure materials measures statistical analyses exploratory analyses discussion (additional information) funding acknowledgments competing interests ethics statement x accounts data availability supplementary materials references appendix: list of life areas overall anxiety severity and impairment scale (oasis) and overall depression severity and impairment scale (odsis): adaptation and validation in buenos aires, argentina research articles overall anxiety severity and impairment scale (oasis) and overall depression severity and impairment scale (odsis): adaptation and validation in buenos aires, argentina rodrigo lautaro rojas 1 , camila florencia cremades 1 , milagros celleri 1 , cristian javier garay 1 [1] faculty of psychology, universidad de buenos aires, buenos aires, argentina. clinical psychology in europe, 2023, vol. 5(2), article e10451, https://doi.org/10.32872/cpe.10451 received: 2022-10-11 • accepted: 2023-02-15 • published (vor): 2023-06-29 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: rodrigo lautaro rojas, roma 2641 – buenos aires – argentina. e-mail: lautarorojas@psi.uba.ar supplementary materials: materials [see index of supplementary materials] abstract background: the oasis and odsis scales are two transdiagnostic brief 5-item instruments designed to assess the severity and functional impairment associated with symptoms of anxiety and depression, respectively. the present study aimed to adapt and validate the online versions of both scales in buenos aires, argentina. method: a sample of 344 women and men from the general population of buenos aires completed a test battery consisting of the oasis, the odsis, the beck depression inventory (bdi), the beck anxiety inventory (bai), the positive and negative affect scale (panas) and the multicultural quality of life index (mqli). descriptive statistics and item discrimination of both scales were analyzed, as well as their factorial structure, internal consistency, and convergent and discriminant validity, using the r programming language. results: the results showed a unidimensional factorial structure, excellent internal consistency, and adequate construct validity for both the oasis and the odsis. conclusion: these results supports the use of both scales as valid and reliable instruments to assess severity and interference due to anxiety and depression in the general population of buenos aires, argentina. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.10451&domain=pdf&date_stamp=2023-06-29 https://orcid.org/0000-0002-7153-5155 https://orcid.org/0000-0002-1051-6073 https://orcid.org/0000-0002-0102-339x https://orcid.org/0000-0003-4082-8876 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords anxiety, depression, adaptation, validation, psychometrics highlights • both scales are valid and reliable instruments for the assessment and detection of anxiety and depressive symptoms. • their availability is important for the reliable application of the unified protocol in our country. • they can be used in our context in an online format without compromising their psychometric properties. emotional disorders (barlow, 1991) are the most frequent psychological problems in the argentinian population. the lifetime prevalence of anxiety disorders reaches 16.4% and for major depressive disorder it reaches 8.7%, while their annual prevalence reaches 9.4% and 3.8%, respectively (stagnaro et al., 2018). additionally, both groups of disorders are costly (parés-badell et al., 2014; ruiz-rodríguez et al., 2017), interfering (kazdin & blase, 2011; olatunji et al., 2007) and highly comorbid problems (brown et al., 2001; brown & barlow, 2009). there are multiple tools to assess general anxiety and depression, such as the beck anxiety inventory (bai; beck et al., 1988; argentinian adaptation by vizioli & pagano, 2020) or the beck depression inventory (bdi; beck et al., 1996; argentinian adaptation by brenlla & rodríguez, 2006). similarly, there are also numerous instruments to assess symptoms associated with specific anxiety disorders, such as the penn state worry questionnaire (pswq; meyer et al., 1990; argentinian adaptation by rodríguez biglieri & vetere, 2011) for generalized anxiety disorder, and the panic disorder severity scale (pdss; shear et al., 1997) for panic disorder, not yet adapted to our setting. however, all of these instruments are limited to assessing the frequency and intensity of specific symptoms and do not offer a global measure of the severity and interference associated with these symptoms, either in established disorders or at subclinical levels (gonzález robles et al., 2018; norman et al., 2006). scales of this type do not adequately reflect the impact of symptoms on functioning (bentley et al., 2014) and are of little use in assessing the overall impact of treatment (ito, oe, et al., 2015). similarly, while scales designed to assess specific symptoms of specific diagnoses are ideal for detailed assessments, they are less useful in clinical settings when assessing comorbid cases (campbell-sills et al., 2009). additionally, the use of different scales can be time-consuming and impractical in settings such as primary care (campbell-sills et al., 2009; osma et al., 2019). in view of these problems, two scales have been developed to capture the severity and interference of anxious and depressive symptomatology in a brief and transdiagnostic manner–that is, regardless of the diagnostic category of these symptoms: the overall validation of oasis and odsis in argentina 2 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ anxiety severity and impairment scale (oasis; norman et al., 2006) and the overall depression severity and impairment scale (odsis; bentley et al., 2014). the oasis is a brief scale designed to assess the severity and interference associated with anxiety. it can be used with individuals with one or more anxiety disorders or with anxiety symptoms below the diagnostic threshold. it consists of 5 items referring to the past week and it’s scored on a likert-type scale ranging from 0 to 4. higher scores indicate greater anxiety-related severity and impairment. severity is captured by items that ask for the frequency and intensity of anxiety symptoms (e.g., "2. in the last week, when you have felt anxious, how intense or severe was your anxiety?"), while interference is measured by items that assess the impact of these symptoms on work/ school and social life. it also includes an item that evaluates avoidance as a specific symptom of anxiety. in its original version, it yielded a mean of 7.16 (sd = 3.05), excellent internal consistency (α = .80), a unifactorial structure and excellent convergent validity in a non-clinical sample (norman et al., 2006). the scale was developed to capture common domains of all anxiety disorders in a fast and simple way in demanding clinical settings such as primary care (gonzálezrobles et al., 2018), and to monitor changes in symptoms over the course of treatment (campbell-sills et al., 2009). it was validated in both clinical and non-clinical samples and in paper-and-pencil and online formats, showing excellent internal consistency and good convergent and discriminative validity (bragdon et al., 2016; campbell-sills et al., 2009; farrahi et al., 2020; gonzález-robles et al., 2018; hermans et al., 2015; ito, oe, et al., 2015; moore et al., 2015; norman et al., 2006; norman et al., 2011; osma et al., 2019; osma et al., 2021; sandora et al., 2021). different cut-off scores have been proposed to discriminate between people with clinical and subclinical anxiety in their different validations (see table 1). the odsis was developed based on the oasis in order to capture the severity and interference associated with depressive symptoms. it maintains the same structure of 5 items, which refer to the last week and are scored on a likert-type scale ranging from 0 to 4, with higher scores indicating greater severity and functional interference associated with depression (bentley et al., 2014). like the oasis, its items assess the frequency and intensity of depressive symptoms and their interference with work/school and social life (e.g., "5. in the past week, how much has depression interfered with your social life and relationships?"). the most notable difference is that the oasis item assessing avoidance was replaced by one assessing interference due to loss of interest and difficulty experiencing pleasure as a symptom of depression. in its original version, it yielded a mean of 5.50 (sd = 5.04), excellent internal consistency (α = .94), a unifactorial structure, and adequate convergent and discriminant validity in the clinical subsample (bentley et al., 2014). rojas, cremades, celleri, & garay 3 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ table 1 validations of the oasis authors country sample format m (sd) cutoff points bragdon et al. (2016) usa clinical sample (n = 202) paper-and-pencil ad: 9.63 (sd = 4.69) wad: 4.96 (sd = 4.26) – campbell-sills et al. (2009) usa clinical sample (n = 1036) paper-and-pencil 10.77 (sd = 4.02) 8 farrahi et al. (2020) iran students sample (n = 464) paper-and-pencil 4.83 (sd = 3.68) – gonzález-robles et al. (2018) spain clinical sample (n = 583) online 8.69 (sd = 4.21) 7.5 hermans et al. (2015) netherlands clinical sample (n = 257) paper-and-pencil ad: 8.46 (sd = 3.96) wad: 3.00 (sd = 3.51) 5 ito, oe, et al. (2015) japan clinical (n = 1667) and non-clinical sample (n = 1163) online clinical: 9.69 (sd = 5.55) non-clinical: 5.56 (sd = 4.91) 9 moore et al. (2015) usa clinical sample (n = 347) paper-and-pencil 9.35 (sd = 4.38) 8 norman et al. (2006) usa students sample (n = 711) paper-and-pencil 7.16 (sd = 3.05) – norman et al. (2011) usa students sample (n = 171) paper-and-pencil 6.61 (sd = 4.01) 8 osma et al. (2019) spain clinical sample (n = 339) paper-and-pencil 10.45 (sd = 4.49 10 osma et al. (2021) spain students sample (n = 382) online 3.92 (sd = 4.13) 4 sandora et al. (2021) czech republic non clinical sample (n = 2912) online 9.50 (sd = 4.25) 15 note. ad = anxiety disorders; wad = without anxiety disorders; sd = standard deviation. this scale was designed to be used across mood disorders and with depressive symptoms below the diagnostic threshold (bentley et al., 2014). it was validated in clinical and nonclinical samples and in paper-and-pencil and online formats, showing excellent internal consistency and good convergent and discriminative validity (bentley et al., 2014; ito, bentley, et al., 2015; mira et al., 2019; osma et al., 2019; osma et al., 2021; sandora et al., validation of oasis and odsis in argentina 4 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ 2021). different cut-off scores have been proposed to discriminate between people with clinical and subclinical depression in their different validations (see table 2). table 2 validations of the odsis authors country sample format m (sd) cutoff points bentley et al. (2014) usa 1. clinical sample (n = 100) 2. students sample (n = 566) 3. community sample (n = 189) paper-and-pencil 1. 5.50 (sd = 5.04) 2. 2.57 (sd = 3.36) 3. 5.16 (sd = 4.81) 8 ito, bentley, et al. (2015) japan clinical (n = 1667) and non-clinical sample (n = 1163) online clinical: 8.68 (sd = 6.32) non-clinical: 3.67 (sd = 4.87) 5 mira et al. (2019) spain clinical sample (n = 474) online 7.83 (sd = 4.90) 5 osma et al. (2019) spain clinical sample (n = 339) paper-and-pencil 9.87 (sd = 5.14) 10 osma et al. (2021) spain students sample (n = 382) online 2.79 (sd = 4.06) 5 sandora et al. (2021) czech republic non-clinical sample (n = 2912) online 8.73 (sd = 4.34) 12 note. m = mean; sd = standard deviation. the administration of instruments in online format has increased in recent years, due to advantages such as accessibility and ease of administration and scoring (van ballegooijen et al., 2016). although paper and online versions of the same instrument often correlate strongly, mean scores and psychometrics may differ (alfonsson et al., 2014), so specific validations need to be conducted for online administration. both the oasis and odsis were developed in paper-and-pencil format, and their online use requires specific valida­ tion in this format, as was conducted in other media (gonzález-robles et al., 2018; mira et al., 2019). considering that both anxiety disorders and depression are highly prevalent, comor­ bid and often associated with significant distress and interference, it is necessary to have transdiagnostic measures to capture the severity and interference associated with anxious and depressive symptomatology in our local environment. although there are rojas, cremades, celleri, & garay 5 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ instruments designed to assess symptoms of anxiety and depression that have been adapted and validated in our setting, none of them can quickly capture the severity and social and occupational interference associated with such symptomatology. the present study aims to carry out the linguistic, cultural and psychometric adaptation of the online versions of the oasis and odsis scales in the population of buenos aires, argentina. method linguistic and cultural adaptation the adaptation of both instruments was carried out taking into consideration the rec­ ommendations of the international test commission (ict) for the adaptation of tests to other cultures (muñiz et al., 2013). the translation into spanish was carried out following a direct translation method by five independent translators and five judges who evaluated the quality of the translations on a likert scale from 1 (quite different) to 4 (identical). the translations that received the highest number of high scores (3 or 4) on the likert scale from the judges were selected to form the preliminary versions of both scales. with the preliminary version of the instrument, a pilot test was carried out with a sample of 12 individuals using google forms, in which the comprehension of the items was evaluated and a first analysis of the items was carried out. participants signed an informed consent form expressing their voluntary participation. the final adapted versions of both instruments can be found in appendices a and b (see supplementary materials). procedure the psychometric properties of the translated and culturally adapted versions of the oasis and the odsis were analysed. the recruitment of participants was non-probabil­ istic using the snowball method through the dissemination of flyers on social media. all participants gave their consent to participate in the study in which the confidentiality of the data, the purposes of the research and the possibility of withdrawing from the study at any time were clarified. all participants then completed a set of scales through a virtual google forms questionnaire. participants the sample consisted of 344 adults (18-65 years old) from the general population residing in the city of buenos aires (26.7%, n = 92), greater buenos aires (49.1%, n = 169) and the province of buenos aires (24.1%, n = 83), argentina. the mean age of the sample was 29.44 (sd = 10.62). the 80.5% identified with the female gender (n = 277), 19.2% with the male gender (n = 66) and the remaining 0.3% with a fluid gender (n = 1). in terms of validation of oasis and odsis in argentina 6 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ educational level, 56.1% had completed secondary school (n = 193), 43.3% had completed university (n = 149) and 0.6% had completed primary school (n = 2). instruments socio-demographic questionnaire as part of the test battery, an ad-hoc questionnaire was included in which the partici­ pants' age, gender, place of residence and level of education were asked. beck depression inventory ii (bdi ii) the bdi-ii (beck et al., 1996; argentinian adaptation by brenlla & rodríguez, 2006) is an inventory designed to assess depressive symptoms. it consists of 21 items referring to the past week and is scored on a likert-type scale from 0 (not at all) to 3 (severely). the higher the score, the greater the severity of the depressive symptomatology. the validation in our setting showed an adequate internal consistency with a cronbach's alpha coefficient of .88. beck anxiety inventory (bai) the bai (beck et al., 1988; argentinian adaptation by vizioli & pagano, 2020) is com­ posed of 21 items that assess the severity of anxiety symptoms. each item refers to specific anxiety symptoms and is scored on a likert-type scale from 0 (not at all) to 4 (it bothered me a lot). higher scores indicate greater severity of the anxiety symptomatolo­ gy. its validation in the local setting yielded a cronbach's alpha coefficient of 0.93. brief positive and negative affect schedule (panas) the panas (thompson, 2007; argentinian adaptation by moriondo et al., 2012) is an in­ strument designed to dimensionally measure positive and negative affect. in the present study, the short version of the instrument designed by thompson (2007) and adapted to argentina by moriondo et al. (2012) was selected, consisting of four subscales: trait positive affect (five items), trait negative affect (five items), state positive affect (five items) and state negative affect (five items). each item is scored on a likert-type scale from 1 (very little or not at all) to 5 (very much or completely). it was adapted in our context with a cronbach's alpha coefficient of .73 (.84 for negative affect and .75 for positive affect). multicultural quality of life index (mqli) the mqli (mezzich et al., 1996; argentinian adaptation by jatuff et al., 2007) is a self-administered instrument designed to assess quality of life in a brief, multicultural and multidimensional way. it consists of 10 items assessing different aspects of quality of life, each of which is scored on a likert-type scale from 1 (poor) to 10 (excellent). rojas, cremades, celleri, & garay 7 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ all sub-dimensions are summed to produce the global quality of life index. the higher the score, the higher the quality of life perceived. it was adapted to our setting with a cronbach's alpha of .85. overall anxiety severity and impairment scale (oasis) the oasis (norman et al., 2006) is a brief scale designed to measure the severity and interference associated with anxiety symptoms. it consists of 5 items inquiring about the frequency and intensity of anxiety symptoms, the interference caused by anxiety symptoms in school/work and social life and avoidance as a specific symptom of anxiety. each item consists of 5 response options on a likert-type scale from 0 (little or none) to 4 (extreme). it was adapted to spanish in spain with a cronbach's alpha of .86 (gonzález-robles et al., 2018). overall depression severity and impairment scale (odsis) the odsis (bentley et al., 2014) is a brief scale designed to measure the severity and interference associated with depressive symptoms. it consists of 5 items inquiring about the frequency and intensity of depressive symptoms, the interference caused by depres­ sive symptoms in school/work and social life and the difficulty experiencing pleasure and/or interest as a specific symptom of depression. each item consists of 5 response options on a likert-type scale ranging from 0 (little or none) to 4 (extreme). it was adapted to spanish in spain with a cronbach's alpha of .92 (mira et al., 2019). data analysis all analyses were carried out using the r programming language. first, the sociodemo­ graphic characteristics of the sample (n = 344) and the descriptive statistics (mean, variance, skewness and kurtosis) of both oasis and odsis items were analysed. prior to the analysis of the internal structure of both scales, the existence of adequate intercorrelation between items was assessed using the kaiser-meyer-olkin measure of sampling adequacy and bartlett's test of sphericity. to analyse the factor structure, a confirmatory factor analysis was carried out. following norman et al. (2006) and bentley et al. (2014), a one-factor model was tested for both scales. the fit of the models was assessed using the comparative fit index (cfi), the tucker-lewis index (tli) and the standardised mean squared error (srmr) as criteria. the following cut-off scores were used to determine a good fit: cfi and tli around .90 and srmr below 0.08 (marsh et al., 2004). for the analysis of internal consistency, both cronbach's alpha and omega coeffi­ cients were calculated (dunn et al., 2014). convergent and discriminant validity was explored by calculating pearson's r correlations between the oasis and odsis and well-established measures of anxiety (bai), depression (bdi), positive and negative affect validation of oasis and odsis in argentina 8 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ (panas) and quality of life (mqli). to interpret the correlation values, the p-value was calculated and the benchmarks for r-values proposed by hinkle et al. (2003) were used. r-values between .90 and 1.00 were considered very high, those between .70 and .90 were considered high, those between .50 and .70 were considered moderate and those between .30 and .50 were considered low. corrected item-total correlations were also calculated to analyze the discrimination of the items of both scales. we also wanted to explore the existence of differences in the scores of both scales regarding gender. for this purpose, a student's t-test for independent samples was per­ formed. because the criteria of normality and homoscedasticity of variances were not met in all groups, a wilcoxon test was also performed. finally, a linear regression was performed to determine whether age was a good predictor of change in severity levels of depression and anxiety. results descriptive analysis of the items the mean score of the oasis in the sample analysed was 6.52 (sd = 3.90). the mean, variance, skewness and kurtosis of each item were analysed. all items had skewness and kurtosis values between -1 and 1, suggesting a normal distribution (see table 3). table 3 mean, standard deviation, skewness, and kurtosis of oasis items item m sd skewness kurtosis 1 1.88 0.96 0.38 -0.43 2 1.62 0.86 0.01 -0.32 3 0.96 1.03 1 0.54 4 1.98 0.95 0.75 0.06 5 0.99 1.04 0.83 -0.06 as for the odsis, the mean score in the sample analysed was 4.48 (sd = 4.40). all items had skewness and kurtosis values between -1 and 1.03, suggesting a normal distribution (see table 4). item discrimination analysis item discrimination was calculated using corrected item-total correlations. all oasis items showed to discriminate adequately (r > .30) [item 1 (r = .66), item 2 (r = .68), item 3 (r = .65), item 4 (r = .73), item 5 (r = .67)]. similarly, the odsis items also showed rojas, cremades, celleri, & garay 9 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ adequate discrimination (r > .30) [(item 1 (r = .84), item 2 (r = .83), item 3 (r = .87), item 4 (r = .84), item 5 (r = .81)]. internal structure analysis first, the existence of adequate intercorrelation between items was assessed using the kaiser-meyer-olkin measure of sampling adequacy and bartlett's test of sphericity, ob­ taining evidence suggesting the feasibility of conducting a factor analysis for both the oasis (kmo = .83; χ2 = 227.86, gl = 10, p < .001) and the odsis (kmo = .87; χ2 = 452.48, gl = 10, p < .001). confirmatory factor analysis (cfa) was then conducted on the one-factor model proposed in previous research for the oasis (norman et al., 2006) and odsis (bentley et al., 2014). model fit was determined by the comparative fit index (cfi = .991 for the oasis; cfi = .999 for the odsis), the tucker-lewis index (tli = .982 for the oasis; tli = .997 for the odsis) and the standardised root mean square error (srmr = .061 for the oasis; srmr = .031 for the odsis), obtaining adequate goodness-of-fit indices. internal consistency analysis for the analysis of internal consistency, cronbach's alpha coefficient was calculated, obtaining a value of α = .90 for the oasis and α = .97 for the odsis. the omega coefficient yielded a value of ω = .93 for the anxiety scale and ω = .93 for the depression scale. convergent and discriminant validity pearson's r correlations between the oasis, the odsis and related scales are shown in table 5. a high and significant positive association was found between the oasis and the odsis, r(343) = .70, p < .01, the bdi, r(343) = .70, p < .01, and between the oasis and the bai, r(343) = .73, p < . 01. a moderate and significant positive association was table 4 mean, standard deviation, skewness, and kurtosis of odsis items item m sd skewness kurtosis 1 0.96 0.98 0.92 0.45 2 0.88 0.92 0.72 -0.19 3 0.89 1.05 1.02 0.2 4 0.77 0.93 1.03 0.15 5 0.77 1 1.02 1 validation of oasis and odsis in argentina 10 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ found between the oasis and the negative trait affectivity, r(343) = .61, p < .05, and state, r(343) = .54, p < .05, subscales of the panas. on the other hand, a moderate and significant negative association was found between the oasis and the mqli, r(343) = -.66, p < .01, and a low and significant negative association between the oasis and the positive trait affectivity, r(343) = -.46, p < .05, and state, r(343) = -.42, p < .01, subscales of the panas. table 5 correlations between oasis and odsis and other scales oasis odsis bdi bai mqli panast na panast pa panass na panass pa oasis – .70** .70** .73** -.66* .61* -.46* .54* -.42** odsis .70** – .73** .62** -.65** .51** -.49** .46** -.40** note. oasis = overall anxiety severity and impairment scale; odsis = overall depression severity and impairment scale; bdi = beck depression inventory; bai = beck anxiety inventory; mqli = multicultural quality of life index; panast = positive and negative affect scale trait; panass = positive and negative affect scale state; na = negative affect; pa = positive affect. *p < .05. **p < .01. a high and significant positive association was found between odsis and bdi, r(343) = .73, p < .01, a moderate and significant positive association between odsis and bai, r(343) = .62, p < .01, and the negative trait affectivity subscale, r(343) = .51, p < .01, of the panas and a low and significant positive association with the negative state affectivity subscale, r(343) = .46, p < .01. on the other hand, a moderate and significant negative association was found between the odsis and the mqli, r(343) = -.65, p < .01, and a low and significant negative association between the odsis and the positive trait, r(343) = -.49, p < .01, and state, r(343) = -.40, p < .01, subscales of the panas. differences according to gender and age differences in oasis and odsis scores were assessed regarding gender. a t-test was conducted to compare the oasis and odsis scores of those who reported identifying with the female gender and those who reported identifying with the male gender to explore the existence of significant gender differences. it was found that females scored significantly higher than males on both the oasis, t(107) = -2.76, p < .01, and odsis, t(117) = -2.91, p < .01. considering that the assumption of normality in the groups was not met, a wilcoxon test was also performed, which also yielded statistically significant differences for oasis, w = 10935, p < .05, and odsis, w = 10783; p < .05. finally, to assess whether age functioned as a good predictor of anxiety severity and interference, a linear regression was performed taking the oasis score as the dependent rojas, cremades, celleri, & garay 11 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ variable and age as the predictor variable. it was found that the higher the age, the lower the severity and interference due to anxiety, β = -0.10, f(1, 342) = 27.75, p < .001, r 2 = .07. the same procedure was performed to determine whether age functioned as a good predictor of severity and interference due to depression, finding that the older the age the lower the severity and interference due to depression, β = -0.10, f(1, 342) = 23.13, p < .001, r 2 = .06. discussion the aim of the present study was to carry out the adaptation and validation of the oasis and odsis in the argentine population in an online format. the psychometric validation included the analysis of item discrimination, factorial structure, internal con­ sistency, convergent and discriminant validity, and differences in scores as a function of sociodemographic variables for both scales. considering only those adaptations that took participants from the general popula­ tion, both the oasis (m = 6.52; sd = 3.90) and the odsis (m = 4.48; sd = 4.40) yielded mean scores higher than those obtained in the japanese (ito, oe, et al., 2015; ito, bentley, et al., 2015) adaptations, but lower than those obtained in the czech study (sandora et al., 2021). the latter may be due to the fact that in the czech study the data were collected during the covid-19 pandemic, which may have influenced the scores obtained. also, the odsis yielded higher mean scores than those obtained in the non-clinical subsample of the original validation (bentley et al., 2014). the higher scores obtained in local adap­ tations compared to japanese or american ones may be linked to the high prevalence of problems linked to anxiety and depression in argentina (stagnaro et al., 2018). on the other hand, taking into account the adaptations that were performed in online format, as expected the local adaptations presented lower scores than those that took a clinical sample (gonzález-robles et al., 2018; mira et al., 2019) but higher than the one that took a sample of students (osma et al., 2021). however, all the above comparisons should be taken with caution because there have been no studies investigating the cross-cultural measurement invariance of these scales. the 5 items of both scales were found to discriminate adequately (r > .30), indicating that they allow to distinguish between people with different levels of severity and interference due to anxiety and depression, respectively. as in previous research (bentley et al., 2014; norman et al., 2006; osma et al., 2019), confirmatory factor analysis revealed a unidimensional factor structure with strong factor loadings for all items of both scales. regarding reliability, both the oasis and the odsis demonstrated excellent internal consistency in the sample of argentinian participants (α = .90 and ω = .93. for the oasis and α = .97 and ω = .93. for the odsis), showing values similar to those of previous validations performed in the general validation of oasis and odsis in argentina 12 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ population (bentley et al., 2014; ito, bentley, et al., 2015; ito, oe, et al., 2015; sandora et al., 2021). regarding construct validity, significant positive correlations were found between the oasis and the bai and between the odsis and the bdi, providing evidence for the convergent validity of both scales with two of the most widely used instruments for the assessment of anxiety and depression. the fact that significant positive correlations were also found between the oasis and the odsis, the bdi and the panas subscales of trait and state negative affect, but lower than that found for the bai, is interpreted as evidence of the discriminant validity of the instrument. likewise, the fact that significant positive correlations were also found between the odsis and the oasis, the bai and the negative trait and state affect subscales of the panas, but lower than that found in relation to the bdi, is interpreted as evidence of the instrument's discriminant validity. taken together, these findings provide evidence of adequate construct validity for both the oasis and the odsis, in agreement with previous research (gonzález-robles et al., 2018; mira et al., 2019; osma et al., 2019; osma et al., 2021). in contrast to previous adaptations (gonzález-robles et al., 2018; ito, bentley, et al., 2015; ito, oe, et al., 2015; mira et al., 2019), significant differences were found in the oasis and odsis total scores as a function of gender and age. individuals who identified with the female gender scored significantly higher on both scales than males, which is consistent with previous literature that indicates that argentinian women are 85% more likely to suffer from anxiety disorders than men (stagnaro et al., 2018). furthermore, in line with the research by stagnaro et al. (2018), which reported a higher prevalence of emotional disorders in younger individuals, it was found that the levels of severity and interference due to anxiety and depression decrease with increasing age. the older the age, the lower the severity and interference due to anxiety and depression. in sum, the results of the present study are consistent with those obtained in previous validations performed in the general population (bentley et al., 2014; ito, bentley, et al., 2015; ito, oe, et al., 2015; sandora et al., 2021), and support the oasis and odsis scales as valid and reliable instruments to assess the severity and functional interference due to anxiety and depression in the general population of buenos aires, argentina. this is the first study to evaluate the psychometric properties of the oasis and odsis scales in argentina. having instruments adapted to our environment that allow us to measure the severity of anxiety and depression and their level of interference in daily functioning is essential to assess and detect both groups of disorders, which are highly prevalent in our population (stagnaro et al., 2018), whether they occur in isolation or in comorbidity, both in clinical and non-clinical settings. their availability is also a first step for the reliable application of the unified protocol, a transdiagnostic treatment designed to address emotional disorders that uses both scales to measure the patient's change in anxiety and depressive symptomatology on a weekly basis (barlow et al., 2011). rojas, cremades, celleri, & garay 13 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ furthermore, and in line with previous research (gonzález-robles et al., 2018; ito, bentley, et al., 2015; ito, oe, et al., 2015; mira et al., 2019), the results also suggest that both the oasis and the odsis can be used in our setting in an online format without compromising their psychometric properties. having adapted instruments in online format is important because it enables their use in the context of internet-based interventions, which have proliferated in recent decades in the field of cognitive-be­ havioral therapies (andersson et al., 2019). the development of these interventions is especially important in argentina, where access to evidence-based treatments is difficult and the inclusion of the technology in academia is still scarce (distéfano et al., 2015). the availability of both scales in online format represents a contribution to this promising field in argentina. limitations limitations of the study include the fact that the sample consisted of people from the general population of buenos aires, which limits the generalizability of the results to clinical settings and people from another regions of the country. in addition, no methods were used to guarantee whether the participants were receiving psychological treatment or have an actual mental disorder. also, the mean age of the participants was very young and the educational level very high, which may have been related to the method chosen to reach them. another limitation was that the proportion of males and females was not balanced, which may have affected the representativeness of the results. unlike previous studies (sandora et al., 2021), the comparison between men and women was performed without having calculated measurement invariance between both genders because the sample size was smaller than recommended in the literature (<100) to calculate it (meade & bauer, 2007; putnick & bornstein, 2016). finally, unlike previous adaptations, test-retest reliability, sensitivity to change and cut-off scores for both scales could not be established in our population. it would be desirable for future research to consider these aspects and analyse them in a clinical sample. funding: research institute, university of buenos aires. acknowledgments: we would like to thank all the people who served as translators and judges, and who kindly collaborated with this adaptation: arias, ricardo; bendinger, mayra; bregman, claudia; fabrissin, javier; facio, alicia; gallagher, paula; korman, guido; rutsztein, guillermina; sarudiansky, mercedes; tenreyro, cristina; vizioli, nicolás; wolfzun, camila. competing interests: the authors have declared that no competing interests exist. data availability: materials and analysis code for this study are available by emailing the corresponding author. validation of oasis and odsis in argentina 14 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://www.psychopen.eu/ supplementary materials the supplementary materials contain the following items (for access see index of supplementary materials below): • appendix a: presents the argentine version of the overall anxiety severity and impairment scale (oasis) • appendix b: presents the argentine version of the overall depression severity and impairment scale (odsis). index of supplementary materials rojas, r. l., cremades, c. f., celleri, m., & garay, c. j. 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(2021). the abbreviated overall anxiety severity and impairment scale (oasis) and the abbreviated overall depression severity and impairment scale (odsis): psychometric properties and evaluation of the czech versions. international journal of environmental research and public health, 18(19), article 10337. https://doi.org/10.3390/ijerph181910337 shear, m. k., brown, t. a., barlow, d. h., money, r., sholomskas, d. e., woods, s. w., gorman, j. m., & papp, l. a. (1997). multicenter collaborative panic disorder severity scale. american journal of psychiatry, 154(11), 1571–1575. https://doi.org/10.1176/ajp.154.11.1571 stagnaro, j. c., cía, a., vázquez, n., vommaro, h., nemirovsky, m., serfaty, e., sustas, e., medina mora, m. e., benjet, c., aguilar-gaxiola, s., & kessler, s. (2018). estudio epidemiológico de validation of oasis and odsis in argentina 18 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://doi.org/10.1016/j.jpsychires.2010.06.011 https://doi.org/10.1002/da.20182 https://doi.org/10.1371/journal.pone.0105471 https://doi.org/10.1016/j.cpr.2007.01.015 https://doi.org/10.3390/ijerph19010345 https://doi.org/10.1016/j.jad.2019.03.063 https://doi.org/10.1016/j.dr.2016.06.004 https://doi.org/10.5209/rev_sjop.2011.v14.n1.41 https://doi.org/10.1016/j.anyes.2017.10.003 https://doi.org/10.3390/ijerph181910337 https://doi.org/10.1176/ajp.154.11.1571 https://www.psychopen.eu/ salud mental en población general de la república argentina [epidemiological study of mental health in the general population of argentina]. vertex. revista argentina de psiquiatría, 29(142), 275–299. https://apsa.org.ar/docs/vertex142.pdf thompson, e. r. (2007). development and validation of an internationally reliable short-form of the positive and negative affect schedule (panas). journal of cross-cultural psychology, 38(2), 227–242. https://doi.org/10.1177/0022022106297301 van ballegooijen, w., riper, h., cuijpers, p., van oppen, p., & smit, j. h. (2016). validation of online psychometric instruments for common mental health disorders: a systematic review. bmc psychiatry, 16(1), article 45. https://doi.org/10.1186/s12888-016-0735-7 vizioli, n. a., & pagano, a. e. (2020). adaptación del inventario de ansiedad de beck en población de buenos aires [adaptation of the beck anxiety inventory in a buenos aires population]. interacciones, 6(3), article e171. https://doi.org/10.24016/2020.v6n3.171 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. rojas, cremades, celleri, & garay 19 clinical psychology in europe 2023, vol. 5(2), article e10451 https://doi.org/10.32872/cpe.10451 https://apsa.org.ar/docs/vertex142.pdf https://doi.org/10.1177/0022022106297301 https://doi.org/10.1186/s12888-016-0735-7 https://doi.org/10.24016/2020.v6n3.171 https://www.psychopen.eu/ validation of oasis and odsis in argentina (introduction) method linguistic and cultural adaptation procedure participants instruments data analysis results descriptive analysis of the items item discrimination analysis internal structure analysis internal consistency analysis convergent and discriminant validity differences according to gender and age discussion limitations (additional information) funding acknowledgments competing interests data availability supplementary materials references health scares: tracing their nature, growth and spread scientific update and overview health scares: tracing their nature, growth and spread kate mackrill 1 , michael witthöft 2 , simon wessely 3 , keith j. petrie 1 [1] department of psychological medicine, faculty of medical and health sciences, university of auckland, auckland, new zealand. [2] department of clinical psychology, psychotherapy and experimental psychopathology, johannes gutenberg university of mainz, mainz, germany. [3] department of psychological medicine, institute of psychiatry, psychology & neuroscience, king’s college london, london, united kingdom. clinical psychology in europe, 2023, vol. 5(4), article e12209, https://doi.org/10.32872/cpe.12209 received: 2023-06-19 • accepted: 2023-10-18 • published (vor): 2023-12-22 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: kate mackrill, department of psychological medicine, faculty of medical and health sciences, university of auckland, 28 park ave, grafton, auckland 1023, new zealand. e-mail: k.mackrill@auckland.ac.nz abstract background: health scares are highly publicised threats to health that increase public concern and protective behaviours but are later shown to be unfounded. although health scares have become more common in recent times, they have received very little research attention. this is despite the fact that health scares often have negative outcomes for individuals and community by affecting health behaviours and causing high levels of often unnecessary anxiety. method: in this paper we undertook a review and analysis of the major types of health scares as well as the background factors associated with health scares and their spread. results: we found most health scares fell into seven main categories; environmental contaminants, food, malicious incidents, medical treatments, public health interventions, radiation from technology and exotic diseases. for most health scares there are important background factors and incident characteristics that affect how they develop. background factors include conspiracy theories, trust in governmental agencies, anxiety, modern health worries and wariness of chemicals. incident characteristic include being newly developed, not understood or unseen, man-made rather than natural and whether the incident is out of personal control. we also identified the aspects of traditional and social media that exacerbate the rapid spread of health scares. conclusion: more research is needed to identify the characteristics of media stories that intensify the levels of public concern. guidelines around the media’s reporting of health incidents and potential health threats may be necessary in order to reduce levels of public anxiety and the negative public health impact of health scares. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12209&domain=pdf&date_stamp=2023-12-22 https://orcid.org/0000-0002-8128-0678 https://orcid.org/0000-0002-4928-4222 https://orcid.org/0000-0002-6743-9929 https://orcid.org/0000-0002-6337-2480 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords health scares, media, environmental incidents, technology, nocebo effect highlights • most health scares can be categorised into one of seven types. • underlying environment and social factors influence the development of health scares. • traditional and social media could reduce the negative public health impact of health scares. we live in the age of health scares, defined as a highly publicised threat (or perceived threat) to health that causes increases in public concern, avoidance or protective behav­ iour but is substantially disproportionate to the risk involved (mackrill, 2021). news stories frequently appear in the media that raise concern about common household products, food or medication. while the respective health risk appears frighteningly large initially, it turns out to be comparatively low or unfounded in retrospect (hooker, 2010). the early stage of a health scare is characterised by an increase in concerns and public anxiety which is followed by the gradual reduction in the frequency and tone of coverage, until the event is no longer newsworthy. consequently, it is the response of the public and the media that elevates a health incident into a scare (whitworth et al., 2017). many health scares involve the unexpected dangers of modern or new technology, such as 5g or wi-fi. others, such as in modern food production, are concerned with chemical additives, processing or colourings. most countries have experienced some form of scare over artificial sweeteners, the overuse of antibiotics in food, and genetically modified ingredients. modern medicine has also been implicated, with drugs and other medical treatments always being a prominent source of public concern. anxieties about vaccination are as old as the intervention itself but have recently gained more visibility with the covid-19 pandemic. understanding the nature of health scares has become more important with increas­ ing recognition and numerous examples of the public health consequences they can have. for example, the covid-19 crisis has provided many unfortunate illustrations of how unfounded health scares about the virus and its control can cause negative outcomes for individuals and communities. these included the belief that covid-19 was spread by 5g towers, which lead to a number of towers being damaged (ahmed et al., 2020). a related scare was that covid-19 vaccines alter people’s dna and that the vaccine was developed to control individuals by placing a microchip inside them for easy tracking (sanders, 2020). this has contributed to a greater hesitancy for some individuals to be vaccinated and consequently affected uptake and community immunity. health scares can be rapidly transmitted on informal social networks spreading fur­ ther anxiety and negative expectations in a community (southwell et al., 2019). research health scares 2 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ suggests that individuals who hold strong conspiracy beliefs also are more likely to be­ lieve that some of the same factors that are commonly associated with health scares also cause cancer, such as eating genetically modified food and microwave ovens (paytubi et al., 2022). the transmission of these beliefs can establish negative expectations that may subsequently produce a nocebo effect when the individual has been exposed to the focus of concern (crichton, dodd, et al., 2014). a nocebo effect is defined as adverse effects that are caused by negative expectations rather than any physical effects from exposure to an object of concern (petrie & rief, 2019). in this paper we start by providing a taxonomy of common health scares, followed by an analysis of the background factors and circumstances associated with their devel­ opment, as well factors involved in their spread. we end with a discussion of areas for future research on health scares. taxonomy of health scares research on health scares identifies particular health interventions, consumer goods or features of modern life that are often the subject of unexplained adverse reactions or unfounded concerns. from our analysis of this literature, we found that health scares fell into seven main categories; environmental contaminants, food, malicious incidents, medical treatments, public health interventions, radiation from technology and exotic diseases (table 1). consistent across many health scares is the fact that they can arise from a legitimate concern but what distinguishes health scares is the disconnect between the level of perceived and actual risk. the first category of environmental contaminants involves instances where the pub­ lic believe they have been exposed to a noxious substance in the environment, such as infrasound from wind turbines or chemicals in drinking water. these exposures are unlikely to have a physical effect on health but people report symptoms due to the perception of harm (crichton, chapman, et al., 2014; david & wessely, 1995). health scares relating to exotic diseases occur when it is retrospectively determined that the catastrophic outcomes initially predicted when the disease first appeared did not occur. for example, the world health organisation (who) warned in 2004 that the bird flu virus could kill millions of people (bird, 2005), however, to date there has been 457 deaths globally (who, 2023). potentially this category represents an important dilemma that robust and effective prevention strategies that are used to contain an outbreak or virus could potentially increase anxiety and contribute to the creation of a health scare, as the public may see preventative measures as a sign of a severe and imminent health threat. food scares involve concerns that additives in food or genetic modification cause health problems. scares may also occur when there is a confirmed contamination case but the public responds by avoiding foods unrelated to the incident (whitworth et al., mackrill, witthöft, wessely, & petrie 3 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ 2017). on a broader level various foods containing gluten, dairy, flavourings, lactose, and various additives, such as sulphites can also cause avoidance and anxiety from time to time (haen, 2014; vernia et al., 2010). a further category is comprised of scares involving malicious incidents. this category is characterised by targeted attacks on individuals that involve methods like radiation that could potentially impact the wider community and cause significant public anxiety, even if the actual risk of harm to the wider public is low. after the poisoning of the former russian secret service agent alexander litvininko in london in 2006, a survey found 12% of londoners believed their own health was at risk due to the polonium table 1 taxonomy of common health scare areas with examples of health concerns and evidence for the scare health scare reference examples environmental contaminants building ventilation/sick building kinman & griffin, 2008; mendelson et al., 2000; ooi & goh, 1997 water scares banner, 2018; david & wessely, 1995; petrie & wessely, 2004; roy et al., 2023 wind turbine infrasound chapman et al., 2013; crichton, chapman, et al., 2014 exotic diseases swine flu klemm et al., 2016 sars hooker, 2008; tausczik et al., 2012 food scares genetically modified food frewer et al., 2002; shaw, 2002 food contamination jacob et al., 2011 additives bearth et al., 2014; haen, 2014 malicious incidents anthrax leask et al., 2003; wills et al., 2008 deliberate chemical or radiation poisoning rubin et al., 2007; rubin & dickmann, 2010; rubin et al., 2020 medical treatments amalgam fillings dodes, 2001; flanders, 1992; molin, 1992 generic drugs and medicine reformulation boone et al., 2018; faasse et al., 2009; faasse et al., 2012; mackrill et al., 2019 hormone replacement therapy bluming & tavris, 2009; haas et al., 2007 public health interventions vaccination programmes burgess et al., 2006; mackrill, 2023; petts & niemeyer, 2004 water fluoridation armfield, 2007; carstairs & elder, 2008; howat et al., 2015 radiation from technology electromagnetic fields rubin et al., 2010 wi-fi bräscher et al., 2017; bräscher et al., 2020; witthöft & rubin, 2013 5g foster, 2019 mobile phones and towers burgess, 2004; drake, 2006; interphone study group, 2010 note. adapted from mackrill (2021). health scares 4 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ poisoning (rubin et al., 2007). more recently following the deliberate poisoning of an ex-russian intelligence officer and his daughter with novichok in salisbury, 19% of a sample of salisbury locals reported avoiding the city despite it being a targeted rather than random event (rubin et al., 2020). a large number of people with anxiety and dis­ tress-induced symptoms seek medical care following a terrorist attack or other malicious incident (engel et al., 2007). two categories relate to medical interventions, namely concerns about medical treatments, and worries about public health interventions. scares involving medical treatments typically involve existing patient groups, where the treatment is subsequently revealed to have unexpected side effects or undergoes changes in ingredient formulation or appearance, which can elicit a nocebo response due to negative expectations (faasse et al., 2009; faasse et al., 2016). in regards to scares relating to public health interventions, these occur in non-patient groups receiving a medical treatment, such as in the case of large vaccination campaigns. this can foster worries and reluctance, as people experi­ ence no visible benefit, such as symptom reduction, and are instead exposing themselves or vulnerable others (such as in childhood vaccinations) to potential adverse reactions or the risk of unforeseen negative effects (martin & petrie, 2017; petts & niemeyer, 2004). scares involving radiation from technology centre on the perceived harm of invisible electromagnetic fields, such as those from mobile phones, wi-fi or 5g, which do not have a physical effect no health (rubin et al., 2010). a previous study has shown that when highly anxious participants are shown a television documentary about the possible health effects of wi-fi they are more likely to report symptoms after exposure to a sham wi-fi signal and to decide they were sensitive to electromagnetic fields (witthöft & rubin, 2013). the health scare taxonomy differentiates the primary areas of concern in seven main categories. table 1 provides an illustration of the common health scares in each category, references to specific examples of health concerns, and evidence for the scare. however, we recognise this is to some extent an arbitrary categorisation. the categories could easily be divided further, which has been done for food scares by page and colleagues (2006) and whitworth et al. (2017) for environmental contaminations. it is important to note that health scares are typically wider and affect a greater number of people than incidents of mass psychogenic illness (mpi), which occur after a discrete event involving a closed community, such as a school or office building. background factors health scares do not occur in a vacuum and are instead produced through the environ­ ment and social context that effects their development and spread. we term these the background factors, which shape an individual’s interpretation of threat and expectations about how their health may be affected. in this section we discuss a number of factors in mackrill, witthöft, wessely, & petrie 5 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ the contemporary social environment as well as individual factors that influence the im­ pact and spread of health scares, specifically: conspiracy theories, trust in governmental agencies, anxiety, modern health worries, and a wariness of chemicals. conspiracy theories while it is clear that conspiracy theories have been with us for as long as there have been theories, there is evidence that they increase during periods of uncertainty and threat as has been the experience for many during the covid-19 pandemic (van prooijen & douglas, 2017). often conspiracy theories, which ascribe events to malevolent people or powers, provide a ready-made explanation of events that may be threatening or anxiety provoking, providing a simplistic, albeit wrong, explanation of complex events (aaronovitch, 2010). a conspiracy mentality, or the tendency to believe conspiracy theories, has impor­ tant health consequences and is likely to influence the spread of health scares. oliver and wood (2014) found medical conspiracy theories, such as the fda is deliberately suppressing evidence about natural cures of cancer because of pressure from drug com­ panies, to be common in the us population. conspiracy beliefs are associated with a wide range of health behaviours, such as preferences for organic food and avoidance of mainstream medicine (oliver & wood, 2014). there is evidence that the acceptance of conspiracy theories is associated with a shunning of vaccination (jolley & douglas, 2014) and lower adoption of recommended preventative actions against covid-19 such as wearing a face mask (romer & jamieson, 2020). trust in governmental agencies a similar influential factor is the degree to which people trust governmental agencies. suspicion and distrust of government institutions makes reassurance from official chan­ nels less effective following a health scare (uscinski et al., 2016). distrust in the health­ care system is associated with a greater tendency to believe health misinformation (scherer et al., 2021). in the salisbury novichok incident, lower trust in governmental agencies was associated with greater anxiety, perceived risk to self, and an increased likelihood of avoiding salisbury (rubin et al., 2020). trust can also affect side effect reporting. in an experimental study, lower trust in pharmaceutical regulatory agencies was associated with a greater number of side effects being attributed to a placebo tablet (webster et al., 2018). in a medicine brand change, lower trust in pharmaceutical agencies was associated with a lower belief in the efficacy of a new generic medicine (mackrill & petrie, 2018). health scares 6 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ anxiety anxiety is, by definition, associated with health scares. the publicization of health threats increases the general public’s anxiety but existing trait anxiety can be an impor­ tant background to factor in the development of health scares. anxiety has a close relationship with the tendency to notice physical symptoms and to interpret them more negatively (barsky et al., 2002; watson & pennebaker, 1989). it is this misattribution process that is key in health scares and research suggests individuals higher in anxiety not only experience a greater number of symptoms but there is a greater tendency to misattribute these to the effects of any given health scare (faasse et al., 2009; petrie et al., 2004; witthöft & rubin, 2013). modern health worries concerns related specifically to modernity or new technology have also been identified as a risk factor for health scares generally (petrie et al., 2001). modern health worries are surprisingly prevalent with a large proportion of people acknowledging concerns about the safety of food or the health effects of chemicals in household products. a german study found that 94% of people report some concerns about the effect of modernity on health and that this was associated with greater symptom reporting (rief et al., 2012). other studies have found higher levels of modern health worries to be associated with a greater use of organic food and alternative medicine (devcich et al., 2007; furnham, 2007). the influence of modern health worries in a particular health scare was exam­ ined in a prospective study looking at the health effects of an aerial pesticide spray programme to control an invasive moth species in new zealand. individuals with higher levels of modern health worries were found to attribute more symptoms to the spray programme and to also believe the spray caused more health problems for themselves, their children and pets compared to those with lower levels of modern health worries (petrie et al., 2005). wariness of chemicals a related factor is an increase in the fear of chemicals or the association of chemicals with cancer, death and toxicity (siegrist & bearth, 2019). this has been called “toxico­ histrionics” (banner, 2018) and is often associated with the belief that modern manufac­ turing produces products that have dangerous levels of chemical substances that are hazardous to health (saleh et al., 2019) and may be particularly associated with water and food-related health scares. negative attitudes towards chemicals are associated with a greater preference for natural foods (dickson-spillmann et al., 2011). people with high levels of concerns about chemical substances that are present in food or the environment often do not consider the importance of dose (the dose makes the poison) or that the dis­ tinction between synthetic and natural chemicals is irrelevant when assessing chemical mackrill, witthöft, wessely, & petrie 7 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ risk in food (paarlberg, 2021) or water (roy et al., 2023). it seems that this concern is increasing while the risk of such exposures has decreased over time (entine, 2011). incident characteristics background factors are only one part of the foundation required to develop health scares. health-related worries on their own will not manifest symptoms, rather a threatening event is also required to influence bodily awareness and the misattribution of symptoms to a particular category of scare. for instance, worry about power lines did not influence symptom reporting for people who did not live next to high voltage transmission lines, whereas for those living in these areas, the most worried respondents were more likely to report health problems (mcmahan & meyer, 1995). it seems logical that background factors alone can’t create a health scare and that a threatening event is also necessary. however, not all health interventions or environmental events will be perceived as threatening. incidents that often develop into larger health scares have certain character­ istics that instil worry. these characteristics include: being newly developed, not well understood or unseen threats, natural versus man-made, and out of personal control (mackrill, 2021). newly developed a frequent unifying factor of many common examples of health scares is that the event or medical intervention is modern or newly developed. through history it is evident that health scares often follow the advent of a new form of technology. when the bicycle was created in the 1880s it was believed that the riding position would cause hernias and curvature of the spine and that women in particular could become possessed by ‘cyclemania’ (whorton, 1978). as the novelty of the technology begins to decline so does concern; it is now accepted that cycling conveys many health benefits. anxiety and concerns surrounding modernity still exist but the focus has shifted towards the latest technological advancement such as 5g (elwood & wood, 2019). it should be noted that this can also include changes to existing familiar interventions, such as medications, that take on a new form or colour (faasse et al., 2009). not understood and unseen it is often the case with newly developed technology that the underlying science is not be well understood by lay people. the general public may believe that the safety of the intervention has not been proven and unidentified negative effects might still occur. an example here is the new mrna covid-19 vaccines that use new technology to produce an immune response. the public’s confusion and concern about the potential unknown effects of these interventions can be fuelled by the perception of ‘unseen’ harms. for health scares 8 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ example, these interventions are often described as an invisible danger and people can be concerned that they are being unknowingly exposed to a perceived health threat (e.g., owens & feldman, 2004; reekie, 2017). this has also been the case for health scares about electromagnetic fields (emfs), such as those from wi-fi, mobile phones and microwave ovens. public discussion about the health effects of emfs has focused on the radiation emitted, with claims that mobile phones or wi-fi can cause cancer (swerdlow et al., 2011). despite the widespread use of phones there has actually been a decrease in the diagnosis of brain and other nervous system cancers over the last 15 years in the united states (united states food and drug administration, 2020). confusion can be further exacerbated through factually correct albeit unclear information like the world health organisation (who) classifying mobile phones as “possibly carcinogenic” (who, 2014). while this sounds alarming to the general public, there are other normal, everyday things, like pickled vegetables and carpentry, that also share this classification. man-made versus natural in a similar vein is the differing perception of harm from natural versus man-made interventions. there is a common misconception that synthetic chemicals, at any con­ centration, are harmful (entine, 2011). chemicals of natural origin are perceived to be healthier and safer than synthetic chemicals, since the latter involve human intervention (saleh et al., 2019). even though a medicine’s efficacy and safety may be clinically proven, patients can be fearful of putting ‘unnatural chemicals’ into their bodies and instead turn to untested ‘natural’ remedies (petrie & wessely, 2002). low personal control if a situation is perceived to be out of an individual’s control then this can also promote health scares. the perception of threat can be high when an incident is uncontrollable (slovic, 1987). a feeling of lacking personal agency can occur through the government acting on behalf of the public. this is the case with water fluoridation, which despite the overwhelming evidence that fluoride is safe and effective at reducing tooth decay, is viewed as a violation of people’s rights not to be subjected to compulsory medication (reekie, 2017). when compulsory vaccination was introduced in britain in the mid-19th century, opponents claimed that people’s freedoms were being invaded by parliament (hussain et al., 2018). in mandatory medication switches from branded to generic medi­ cines there are often backlash as patients fear side effects from the new brand and per­ ceive their medicine options being removed due to a government cost-cutting strategy (faasse et al., 2009). as a result, the nocebo effect frequently occurs in medicine brand changes (weissenfeld et al., 2010). mackrill, witthöft, wessely, & petrie 9 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ health scare spread the concerns about and nocebo reactions to a perceived health threat initially start as an individual response. however, these issues can grow and be spread to a wider population through traditional and social media. as will be discussed in the next sections, it is this spread and publicity that transforms a health incident to a health scare. traditional media it has been claimed that the traditional media, such as newspapers and television, can turn a health incident into a crisis (doeg, 1995). the media is central in the dissemination of health alarms (burgess, 2008) and health scares are frequently characterised by mass media reporting creating panic about a health issue or intervention (guillaume & bath, 2004). observational studies clearly illustrate the impact of the media on spreading worry and adverse event reporting. negative media coverage of the mmr vaccine by a local newspaper in the united kingdom was associated with a decrease in vaccination rates by almost 14% in the area covered by the newspaper (mason & donnelly, 2000). newspaper coverage of side effects was also found to be associated with an increase in adverse event reports from the hpv vaccination (faasse et al., 2017). media coverage discussing side effects from a generic antidepressant was associated with an increase in adverse event reporting, with television increasing the reporting rate by more than 210% compared to print media (mackrill et al., 2019; mackrill et al., 2020). recently, the discussion of rare covid-19 vaccine side effects in the media resulted in increased reporting of cardiac complaints, which were likely self-diagnosed (mackrill, 2023). we identified two key factors responsible for the media’s ability to spread nocebo responding and anxiety about a health event: 1) the faming of the news item; and 2) the process of social modelling. the way the media frames issues can influence the public’s expectations about a health event. the media is often people’s first source of information about a health threat and because it is considered to be a trusted source, the reporting has the ability to shape long-lasting expectations (guillaume & bath, 2004). however, it is usually negative expectations that are developed, as the media is more interested in stories about an intervention causing harm than stories about benefit (kitzinger, 1999). tobert and newman (2016) give the example of how “statins have very few adverse effects” is not newsworthy, but “cholesterol drugs taken by millions are dangerous” often is. this media focus has resulted in strong expectations in the general public that statins are associated muscle pain and other side effects, resulting in high discontinuation rates (matthews et al., 2016). there is often an imbalance between how much media attention a health issue receives and its actual public health significance (cooper & roter, 2000). news articles about health threats disproportionately discuss toxic and environmental causes of illness, health scares 10 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ while neglecting lifestyle factors that are more common causes of illness (frost et al., 1997). even if experts or officials deny a link between a health event and an adverse reaction, the media have been known to report on an individual personal account of harm, allowing the perceived risk to enter public awareness (kitzinger, 1998). almost three quarters of british newspaper reports presented a mainly electromagnetic cause for complaints of symptoms from emfs and used the experiences of particular people as examples (eldridge-thomas & rubin, 2013). repeated reporting of a health issue can also be detrimental. the availability heuris­ tic can influence people’s estimation of the probability of events due to how readily confirmatory examples can be brought to mind (kahneman et al., 1982). when the media continuously highlights a health issue, examples of harm can be readily recalled causing people to overestimate its incidence (gollust et al., 2019). additionally, artificial balance can be created by the media. in the united kingdom, the media often gave equal coverage to both sides of the mmr-autism debate, which led the public to assume there was equal evidence for each argument (hargreaves et al., 2003). news stories often simplify a health issue (seale, 2003). in the case of genetically modified food, media coverage reduced the complexity of this issue into a simple conflict between organic versus processed foods. organic food has been framed as safe, natural and nutritious, while the alternatives that are created through new technology are artificial, threatening and untrustworthy, which has been linked to a rising anti-genetic modification attitude in the general public (lockie, 2006). media coverage is also able to spread adverse reaction reporting through the process of social modelling. it has been well documented in experimental placebo studies that seeing another person report side effects can influence the treatment outcome in the observer (faasse & petrie, 2013). seeing a study confederate report side effects from a placebo tablet results in a reduced placebo effect as well as increased side effect reporting (faasse et al., 2015). similarly, after inhaling an inert substance described as a toxin, female participants reported more side effects if they saw a model also report side effects (lorber et al., 2007; mazzoni et al., 2010). watching a model display more pain after a placebo cream was applied resulted in participants also reporting greater pain (vögtle et al., 2013). media coverage replicates this social modelling effect on a larger scale. the act of seeing someone in a media story report medication side effects can lead to increased expectations in the observer that they too will experience this response (faasse & petrie, 2016). when participants were shown television coverage of people reporting negative health effects from wind turbine noise, they reported more symptoms and of higher intensity than those who watched a neutral information video (crichton, dodd, et al., 2014). this effect has also been found in research investigating emfs (bräscher et al., 2017; witthöft & rubin, 2013; witthöft et al., 2018). this can also occur with written information. participants who read a leaflet containing media warnings about environ­ mackrill, witthöft, wessely, & petrie 11 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ mental pollution and a case example of someone with multiple chemical sensitivity, reported more side effects after inhaling an inert substance than those who did not receive prior warning (winters et al., 2003). social media more recently, social media has been a key medium in the spreading of negative beliefs about health interventions. unlike traditional media, social media has allowed opponents of medical interventions to directly share their concerns, which are not required to factually accurate (wilson & keelan, 2013). for example, the vaccine-autism link has been shown to be discussed more frequently on social media than in online mainstream news sites (jang et al., 2019). similarly, in the 2014 ebola crisis, news shared on the social media platform reddit amplified panic and uncertainty surrounding ebola, while traditional newspaper coverage was significantly less likely to produce panic-inducing coverage (brown et al., 2019). in another study, mothers who do not support childhood vaccination were more likely to share opinions and negative information on social media compared to those who did support vaccination (mckeever et al., 2016). negative health information appears to spread more readily on social media than accurate or positive public health appeals. an analysis of news stories on twitter found that false stories spread faster and more broadly than true stories, potentially due to them containing more novel information (vosoughi et al., 2018). exposure to misinforma­ tion on the internet about health threats can lead to negative expectations, which further reinforces opposition (crichton & petrie, 2015). conclusion and future directions this review provides the basis for how health scares are likely to develop and spread to wider populations. when a threatening incident occurs, background factors unique to an individual become more salient and influence expectations and health behaviours. through examining health scare and nocebo effect literature, we identified specific influ­ ential background factors, namely conspiracy theories, trust in governmental agencies, anxiety, modern health worries, and a wariness of chemicals. additionally, characteristics of incidents that appear to influence threat appraisals include being newly developed, not well understood or unseen threats, natural versus man-made, and out of personal control. past research clearly shows that health concerns and adverse reactions can spread rapidly to a wider group of people through the attention of traditional and social media. this review has also provided a taxonomy to aid the grouping of health scares into common areas of concern. it is hoped that this taxonomy will help researchers differentiate between different types of health scares and encourage a greater analysis health scares 12 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ of how different factors way be involved in the development and resolution of specific scares. it is evident that more research is needed on interventions to reduce the development and spread of health scares, in particular identifying the characteristics of media stories that intensify the levels of public concern and increase the likelihood a story will be shared widely. a cardinal characteristic of health scares is the perceived level of risk is disproportional to the actual level of risk. unlike many areas of health where researchers wish to increase the public’s attention to risky behaviour or substances, in the case of health scares the need is to develop effective strategies to increase reassurance and alleviate public concern. it may be beneficial to provide an additional explanation of how beliefs and concerns can manifest symptoms and be misattributed to a treatment or other exposure, as this has been shown to be effective at reducing anxiety and symptom reporting (crichton, chapman, et al., 2014; mackrill et al., 2021). social media has taken some steps to curb the spread of misinformation and scares by attaching a warning to posts that contain inaccurate information. in a similar vein, guidelines around the media’s reporting of side effects and potential health threats may be necessary in order to reduce the effect of social modelling and the spread of anxiety. there needs to be a balance between creating a newsworthy story but not needlessly exacerbating worries. future research will further our understanding of the role of psychology in intensifying perceived health threats, which will aid the development of strategies to reduce the likelihood of health scares occurring in the future. funding: the authors have no funding to report. acknowledgments: the authors have no 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(2023, january 6). avian influenza weekly update number 877. https://iris.who.int/bitstream/handle/10665/365675/ai-20230106.pdf health scares 22 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://doi.org/10.1016/j.pain.2013.04.041 https://doi.org/10.1126/science.aap9559 https://doi.org/10.1037/0033-295x.96.2.234 https://doi.org/10.1111/bjhp.12298 https://doi.org/10.1691/ph.2010.9749 https://doi.org/10.1108/bfj-06-2016-0263 https://doi.org/10.1007/bf03160961 https://doi.org/10.2196/jmir.2409 https://doi.org/10.1097/01.psy.0000041468.75064.be https://doi.org/10.1080/08870446.2017.1357814 https://doi.org/10.1016/j.jpsychores.2012.12.002 https://www.who.int/news-room/fact-sheets/detail/electromagnetic-fields-and-public-health-mobile-phones https://www.who.int/news-room/fact-sheets/detail/electromagnetic-fields-and-public-health-mobile-phones https://iris.who.int/bitstream/handle/10665/365675/ai-20230106.pdf https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. mackrill, witthöft, wessely, & petrie 23 clinical psychology in europe 2023, vol. 5(4), article e12209 https://doi.org/10.32872/cpe.12209 https://www.psychopen.eu/ health scares (introduction) taxonomy of health scares background factors conspiracy theories trust in governmental agencies anxiety modern health worries wariness of chemicals incident characteristics newly developed not understood and unseen man-made versus natural low personal control health scare spread traditional media social media conclusion and future directions (additional information) funding acknowledgments competing interests references dropout from trauma-focused treatment for ptsd in a naturalistic setting research articles dropout from trauma-focused treatment for ptsd in a naturalistic setting verena semmlinger 1 , keisuke takano 2 , larissa wolkenstein 1 , antje krüger-gottschalk 3 , sascha kuck 3 , anne dyer 4 , andre pittig 5 , georg w. alpers 6 , thomas ehring 1,7 [1] department of psychology, lmu munich, munich, germany. [2] human informatics and interaction research institute (hiiri), national institute of advanced industrial science and technology (aist), tsukuba, japan. [3] institute of psychology, wwu münster, münster, germany. [4] central institute of mental health, zisg mannheim, mannheim, germany. [5] translational psychotherapy, institute of psychology, georg-august-university of göttingen, göttingen, germany. [6] department of psychology, school of social science, university of mannheim, mannheim, germany. [7] german center for mental health (dzpg), munich, germany. clinical psychology in europe, 2025, vol. 7(1), article e14491, https://doi.org/10.32872/cpe.14491 received: 2024-04-26 • accepted: 2024-09-15 • published (vor): 2025-02-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: verena semmlinger, department of psychology, lmu munich, 80802 munich, germany. phone +49 89 2180 5171; fax: +49 89 2180 5224. e-mail: verena.semmlinger@psy.lmu.de supplementary materials: materials [see index of supplementary materials] abstract background: although evidence-based interventions for posttraumatic stress disorder (ptsd) are highly effective, on average about 20% of patients drop out of treatment. despite considerable research investigating ptsd treatment dropout in randomized controlled trials (rcts), findings in naturalistic settings remain sparse. objective: therefore, the present study investigated the frequency and predictors of dropout in trauma-focused interventions for ptsd in routine clinical care. method: the sample included n = 195 adults with diagnosed ptsd, receiving trauma-focused, cognitive behavioral therapy in routine clinical care in three outpatient centers. we conducted a multiple logistic regression analysis with the following candidate predictors of dropout: patient variables (e.g., basic sociodemographic status and specific clinical variables) as well as therapist’s experience level and gender match between therapist and patient. results: results showed a dropout rate of 15.38%. age (higher dropout probability in younger patients) and living situation (living with parents predicted lower dropout probability compared to this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.14491&domain=pdf&date_stamp=2025-02-28 https://orcid.org/0000-0001-9201-7464 https://orcid.org/0000-0003-0406-8654 https://orcid.org/0009-0008-1954-9518 https://orcid.org/0000-0002-3095-4732 https://orcid.org/0000-0003-3022-2766 https://orcid.org/0000-0001-5374-1206 https://orcid.org/0000-0003-3787-9576 https://orcid.org/0000-0001-9896-5158 https://orcid.org/0000-0001-9502-6868 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ living alone) were significant predictors of dropout. dropout was not significantly associated with the therapist’s experience level and gender match. conclusions: in conclusion, routinely assessed baseline patient variables are associated with dropout. ultimately, this may help to identify patients who need additional attention to keep them in therapy. keywords treatment dropouts, posttraumatic stress disorder, prediction, psychotherapy, clinical practice, naturalistic setting highlights • about 15% of patients receiving ptsd treatment in routine clinical care dropped out. • this rate is lower than found in previous studies. • age and living situation were the only variables related to dropout. evidence-based interventions for posttraumatic stress disorder (ptsd) have been shown to be highly effective (e.g., mavranezouli et al., 2020). however, about 20% of patients receiving an intervention for ptsd drop out of treatment (e.g., varker et al., 2021). as treatment dropout can lead to lower treatment effectiveness and reduced probability of improvement (barrett et al., 2008; varker et al., 2021), ptsd treatment dropout is an important clinical challenge. on a general level, dropout can be defined as termination of an initiated treatment before the symptoms that had caused the patient to seek treatment have been alleviated (swift et al., 2009; swift & greenberg, 2012). despite repeated efforts to establish a common standard, there remains a lack of consensus in the literature regarding the operationalization of dropout, resulting in different variants being observed (e.g., barrett et al., 2008; imel et al., 2013). one criterion that is common in many different operationalization methods is that dropout is a unilateral decision by the patient without mutual agreement or discussion of the decision with the therapist (swift et al., 2012). in clinical practice, therapist judgement has been discussed for many years as a preferred operationalization method (swift & greenberg, 2012; wierzbicki & pekarik, 1993) that can be combined with an objective measure to ensure reliability and comparability (semmlinger & ehring, 2022). previous research has focused on estimating the prevalence of dropout from psy­ chological treatment in randomized controlled trials (rcts). across different mental disorders, a large-scale meta-analysis found a weighted average dropout-rate of 19.7%, 95% ci [18.7, 20.7] (swift & greenberg, 2012). the average dropout rate reported from evidence-based treatments for ptsd is comparable to this general dropout rate. in a recent meta-analysis investigating dropout from guideline-recommended psychological treatments for ptsd in rcts, varker et al. (2021) reported an average dropout rate of 20.9%, 95% ci [17.2, 24.9]. similar dropout rates have been estimated by other previous dropout in ptsd treatment 2 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ meta-analyses that focus on a wider range of treatment orientations and settings (e.g., imel et al., 2013: 18.3%, 95% ci [14.8, 21.8]; lewis et al., 2020: 16%, 95% ci [14, 18]). while there is a vast body of research investigating dropout in rcts, less is known about dropout rates from treatment for ptsd in routine clinical care. in a systematic review investigating dropout from outpatient treatment for ptsd in a sample of veterans with combat-related ptsd, goetter et al. (2015) estimated a dropout rate of 36%, 95% ci [26.2, 43.9]. a recent meta-analysis including both rcts and non-rcts reported a weighted average dropout rate of 41.5% from trauma-focused cbt for ptsd (mitchell et al., 2022). it is worth noting that, due to the focus of their analysis, mitchell et al. (2022) only reported the average dropout rate across all studies and did not include information on the weighted dropout rates for rcts and non-rcts separately. dropout rates for the included non-rct studies were 35%, 67.5%, and 72.2% (mitchell et al., 2022). for dropout from ptsd treatment a number of predictors have been discussed. first, baseline ptsd symptom severity might influence dropout, evidence however is mixed. while varker et al. (2021) did not find a significant effect, mitchell et al. (2022) showed higher clinician-rated baseline ptsd symptom severity scores in patients dropping out of treatment compared to completers (hedge’s g = .50, 95% ci [-.95, -.04], p < .05). it is worth noting that this effect applied only to clinician-rated but not to self-rated ptsd severity. zandberg et al. (2016) added to these findings by examining the influence of the rate of improvement on dropout as a function of symptom severity. the authors showed that for patients with high baseline severity, high dropout rates were associated with both very fast and very slow ptsd improvement, in contrast to patients with low baseline severity, who showed high dropout rates only with fast improvement. the loss of motivation and reduction in the credibility of treatment caused by slow improvement of ptsd symptoms might result in a higher risk of dropout in patients with high ptsd severity (zandberg et al., 2016). second, comorbidity is often discussed as a possible predictor, especially comorbid depression, generalized anxiety disorder (gad), alcohol disorder, and borderline person­ ality disorder (bpd) (e.g. steindl et al., 2003). however, the findings are contradictory and potential mechanisms are still unknown (e.g., angelakis & nixon, 2015; mitchell et al., 2022; snoek et al., 2021). as possible explanations, different studies have discussed depressed patients’ reduced ability for emotional processing (angelakis & nixon, 2015) or the possible exacerbation of ptsd symptomatology and the increase of psychosocial impairment as a result of comorbid bpd (frías & palma, 2015). specifically, with regard to dropout, a handful of studies have reported an effect of co-occurring depression (e.g., zayfert et al., 2005), anxiety (e.g., mcdonagh et al., 2005; van minnen et al., 2002), or comorbid personality disorder (e.g., mcdonagh et al., 2005) on dropout. however, recent large-scale meta-analyses did not find a significant relationship between comorbidity and dropout from ptsd treatment (mitchell et al., 2022; snoek et al., 2021; varker et al., 2021). semmlinger, takano, wolkenstein et al. 3 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ third, other pretreatment clinical variables might be associated with dropout in ptsd treatments. however, results to date are inconsistent and findings only rely on few studies. possible predictors are difficulties in emotional regulation (no effect: belleau et al., 2017; shnaider et al., 2022; effect: bremer-hoeve et al., 2023; gilmore et al., 2020), anger (no effect: hinton et al., 2022; van minnen et al., 2002; mixed results: rizvi et al., 2009), impaired social functioning (effect: zayfert et al., 2005), dissociative symptoms (no effect: hagenaars et al., 2010), and childhood trauma (effect: miles & thompson, 2016; mixed results: resick et al., 2014; no effect: van minnen et al., 2002). in addition, the patient’s trauma response and maladaptive processing (e.g. avoidance, rumination, overgeneralization) may be associated with dropout (alpert et al., 2020; shayani et al., 2023). alpert et al. (2020) found that more negative emotions and ruminative processing predicted lower dropout, whereas overgeneralization was associated to higher dropout. in contrast, shayani et al. (2023) did not find an effect of overgeneralization, ruminative processing, and negative emotions, but did find that higher levels of avoidance were associated with higher dropout. concerning sociodemographic variables, only for the variable age is there a reason­ able indication that younger age might be predictive for dropout in ptsd treatment (garcia et al., 2011; goetter et al., 2015; rizvi et al., 2009). however, in two recent meta-analyses, none of the sociodemographic variables (including age) was found to be a consistent predictor across studies (lewis et al., 2020; varker et al., 2021). the majority of studies investigating dropout in ptsd treatment have used an rct design. therefore, much less is known about dropout in naturalistic settings. to our knowledge, there is only one review with a veterans sample (goetter et al., 2015) and few studies (garcia et al., 2011; van minnen et al., 2002) specifically investigating dropout in routine clinical care. transferring results from efficacy studies (rcts) to naturalistic therapeutic settings might be problematic (leichsenring, 2004; schindler et al., 2011). despite the well-known strength of rcts it has been discussed whether randomization in rcts and the strict use of diagnosis specific treatment manuals impose artificial conditions that do not reflect the complexities of clinical practice. therefore, naturalistic studies are required (leichsenring, 2004). the aim of the present study was to investigate the frequency and predictors of dropout in trauma-focused, guideline-recommended interventions for ptsd in routine clinical care. due to the lack of research on the prevalence and predictors from ptsd treatment in naturalistic settings, our analyses followed an exploratory approach. dropout in ptsd treatment 4 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ method participants data was assessed at three university-based outpatient centers providing treatment for ptsd in germany, located at lmu munich (dataset 1) as well as the university of mün­ ster and the otto selz institute at the university of mannheim (dataset 2). the sample consisted of 195 adult patients receiving treatment for ptsd. all data was collected as part of effectiveness studies evaluating trauma-focused cognitive behavioral therapy (tf-cbt) for ptsd in routine clinical care (previous, different analysis only on dataset 2: krüger-gottschalk et al., 2024; schumm et al., 2022, 2023). at pretreatment, all patients met dsm-5 diagnostic criteria for ptsd assessed via the clinician-administered ptsd scale for dsm-5 (caps-5) (weathers, blake, et al., 2013), and were between 18 and 65 years old. only participants who had already terminated their treatment at the respective institution and had attended at least one treatment session were included in the study. exclusion criteria included current psychotic disorder, current substance dependence, or current suicidal intent (first, williams, karg, & spitzer, 2016). sociodemographic and clinical characteristics of the sample are presented in table 1. treatment treatment in all outpatient centers consisted of trauma-focused cognitive behavioral therapy following the same treatment manual. due to the naturalistic setting of the study, no randomization took place and there was no control condition. the treatment manual is based on empirically tested therapy concepts (especially ehlers & clark’s cognitive therapy approach, ehlers & wild, 2022, as well as dbt-ptsd principles, bohus et al., 2020) and follows a modularized phase-based approach (see also ehring, 2019). it includes three consecutive phases. phase 1 can be summarized as preparation for trauma-focused therapy, including providing a theoretical rationale, increasing treatment motivation, or reducing risky or self-destructive behavior where needed. phase 2 con­ sisted of the trauma-focused interventions. therapists could choose between different trauma-focused interventions, including prolonged exposure, cognitive therapy, imagery rescripting, trigger analyses and discrimination training, as well as cognitive interven­ tions targeting dysfunctional assumptions. phase 3 was the final phase of treatment and focused on improving quality of life, resuming activities, and relapse prevention. the treatment plan was intended to take each patient through all three phases, with the number of sessions required for each phase and the selection of modules within each phase varying from patient to patient. depending on the current symptomatology, deviations from this phase structure had to be made in individual cases. treatment sessions were usually provided on a weekly basis, with a regular session duration of 50 minutes. the overall average treatment length was m = 36.6 sessions (sd = 23.4). the average treatment length for dropout cases was m = 23.3 sessions semmlinger, takano, wolkenstein et al. 5 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ (sd = 17.5) and m = 39.3 (sd = 23.5) for patient who did not drop out. on average patients underwent m = 5.0 (sd = 1.3) preparatory sessions. this is higher than typically reported in rcts for ptsd, whereas 12 – 16 sessions are more frequently used. in the german healthcare system patients are permitted to receive up to 80 treatment sessions. therefore, the reported number of sessions used in our study is typical of the german healthcare system. second, ptsd treatment in rcts is often provided in 90-100 min sessions, which means that the treatment dose received in the current study is not that different to typical rct settings. the treatments were conducted by either licensed cbt therapists (39.2%) or psychotherapists in training (60.8%) employed at the outpatient centers. supervision by a cbt therapist with expertise in ptsd treatment was regularly provided, on average at every second session. given the naturalistic nature of the study, it was not feasible to implement formal fidelity checks. the majority of the therapists were female (86.4%). measures the baseline assessment included sociodemographic data, namely age, gender, marital status, living situation, and education. clinical variables were assessed using clinical interviews and psychometric questionnaires. in addition, two therapist variables, i.e., experience level and gender match, were coded as potential predictors of dropout. for each patient, we revised the patient files, analyzing the therapeutic session protocols. dropout dropout was operationalized using the therapist’s judgement, and the termination had to be initiated by the patient, without a mutual agreement that termination was the best choice. therapists routinely documented this information in patient files on a treatment termination form. in exceptional cases, where no information was provided, we used an elaborate file analysis, i.e., analyzing the three last session protocols for each respective patient, to retrieve the information needed. if no or only ambiguous information could be obtained, the patient was excluded from the study. clinician-administered ptsd scale for dsm-5 (caps-5) the caps-5 (weathers, blake, et al., 2013; german translation by schnyder, 2013) is a structured diagnostic interview that assesses posttraumatic stress symptoms in the past month. symptoms are rated on a five-point likert scale ranging from 0 = absent to 4 = extreme, with a rating of 2 or higher indicating the presence of a symptom (weathers et al., 2018). the presence of at least one symptom per cluster “intrusive symptoms” and “avoidance”, and at least two symptoms per cluster “changes in mood and cognition” and “hyperarousal” indicated the presence of a ptsd diagnosis. the caps-5 is a gold-stand­ ard clinical interview with good reliability and validity (weathers et al., 2018). dropout in ptsd treatment 6 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ structured clinical interview for dsm (scid) the scid (first, williams, karg, & spitzer, 2016; wittchen et al., 1997) was used to assess the presence of comorbid disorders. the scid for personality disorders (first, williams, smith benjamin, & spitzer, 2016; fydrich et al., 1997) was administered to assess the pres­ ence of comorbid personality disorders. the scid is a gold-standard clinical interview to assess diagnostic criteria according to the dsm. for each disorder, interview questions along the dsm criteria allow the rating of diagnostic symptoms as present or absent. ptsd-checklist for dsm-5 (pcl-5) the pcl-5 (weathers, litz, et al., 2013; german version by krüger-gottschalk et al., 2017) was used to assess posttraumatic symptom severity. the assessment consists of 20 items, corresponding to the dsm-5 ptsd criteria. distress caused by each symptom is rated on a five-point likert scale ranging from 0 = not at all to 4 = extremely. symptom severity was obtained as a sum score of all 20 items (range 0 to 80). the german pcl-5 has demonstrated high internal consistency (cronbach’s α = .95) (krüger-gottschalk et al., 2017). in the current study, internal consistency was also high (α = .87). please note that cronbach’s alpha for all analyzed questionnaires was calculated on the non-imputed dataset. childhood trauma questionnaire (ctq-28) exposure to traumatic childhood experiences was assessed with the ctq-28 (bernstein et al., 2003; german version by klinitzke et al., 2012). the ctq-28 is a self-report question­ naire consisting of 28 items, rated on a five-point likert scale ranging from 1 = never true to 5 = very often true. a sum score for all items (range 25 to 128) was calculated. the german ctq-28 shows overall good psychometric properties. the internal consistency for the four subscales without physical neglect is high (α ≥ .80), while the physical neglect subscale shows weak internal consistency (α = .55) (klinitzke et al., 2012). in the current study, internal consistency was good (α = .95) for the total ctq score. inventory of interpersonal problems (iip-32) the iip-32 was used to assess interpersonal problems (horowitz et al., 2000; german ver­ sion by thomas et al., 2011). the self-report questionnaire contains 32 items, assessing interpersonal behavior that the participant either finds difficult or shows in excess. the items are rated on a five-point likert scale ranging from 0 = not at all to 4 = extremely. in the parent studies, different item versions of the questionnaire were used (iip-127, iip-64, iip-32). for the main analyses, we used the iip-32 version and narrowed the long versions down to the iip-32. we calculated the iip-32 total score as the mean of the eight scale scores (horowitz et al., 2000). the internal consistency of the german iip-32 was rated as satisfactory to good; for the individual scales it ranged from α = .60 to α = .83 (thomas et semmlinger, takano, wolkenstein et al. 7 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ al., 2011). in the current study the internal consistency for the total iip-32 was high (α = .90). dissociative experience scale (des) dissociative symptoms were assessed with the dissociative experience scale (des) (bernstein & putnam, 1986; german version by spitzer et al., 2004, called fds-20). the des is a 20-item self-report questionnaire. items are rated on a scale ranging from 0% (never) to 100% (all the time). we used the total mean score to determine the overall dissociation. the des showed good psychometric measures and the internal consistency was α = .93 (spitzer et al., 2004). in the current study internal consistency was high α = .93. posttraumatic cognitions inventory (ptci) and interpretation of symptoms inventory (ipsi) posttraumatic cognitions were assessed using a combined version of the ptci (foa et al., 1999) and the ipsi (dunmore et al., 1999) (german versions by ehlers & boos, 2000). the self-report questionnaire assesses negative cognitions and beliefs in response to a traumatic experience (ptci) and to posttraumatic symptoms (ipsi). the 48 items are rated on a seven-point likert scale ranging from 1 = totally disagree to 7 = totally agree. we used the total sum score for ptci and the ipsi mean (ehlers, 1999). the german ptci has demonstrated high internal consistency of α = .95 and good overall psychometric properties (müller et al., 2010). the internal consistency reported for the ipsi was α = .84 (dunmore et al., 2001). in the current study internal consistency was high for ptci (α = .92) and ipsi (α = .92). difficulties in emotion regulation scale (ders) emotional dysregulation was assessed with the self-report questionnaire ders (gratz & roemer, 2004; german version by ehring et al., 2008). the 36 items are rated on a five-point likert scale ranging from 1 = almost never to 5 = almost always. we used the ders sum score (range 36 to 180) to determine possible difficulties in emotion regulation. the german version of the ders has an excellent internal consistency of α = .96 (for the sum score) (kruse et al., 2024). in the current study, internal consistency was excellent, α = .94. procedure the studies were approved by the local ethics committees at the lmu munich, university of münster, and the university of mannheim. all three outpatient centers are specialized in the treatment of patients with trauma-related disorders. participants referred to these centers were screened for eligibility. if eligible, participants received detailed information about the respective study, and written informed consent was obtained. due to the dropout in ptsd treatment 8 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ naturalistic setting, participants were not randomized to different conditions but received standard care (see treatment). after the baseline assessment had taken place, the treat­ ment was initiated at the next possible date. all candidate predictor variables were assessed at baseline. the baseline assessment session consisted of clinical interviews (caps-5; scid) as well as sociodemographic and clinical questionnaires. as treatment was delivered in a naturalistic setting, a substantial effort was made to prevent premature termination of treatment as part of the standard procedure. in the case of excused absence, a new appointment offer was made; in the case of unexcused absence, patients were called by the therapists to make a new appoint­ ment. if no contact could be made after several attempts, a letter was sent asking the patient to get in contact within a defined period of time to guarantee continued access to treatment. if the patient clearly expressed the desire to discontinue treatment, no further attempts to contact them were made. statistical analyses all statistical analyses were conducted using r (version 4.2.0). datasets from two parent studies were merged for the current analyses. the dropout rate was calculated as the proportion of the patients who dropped out to the total number of patients who had star­ ted the treatment. there was a notable amount of missing data in some questionnaires (m = 7%, sd = 4%, max = 27%). the missing data was assumed to be missing at random (mar) (bhaskaran & smeeth, 2014), and was imputed using the iterative procedure of conditional multiple imputation technique on an item level, i.e., before calculating the respective sum score. conditional multiple imputation was realized by the five-step procedure proposed by rubin (1976) and kropko et al. (2014), using the r multivariate imputation by chained equations (mice) package (van buuren & groothuis-oudshoorn, 2011). the number of multiple imputations as well as the number of iterations were set to five (m = 5, maxit = 5), and we used predictive mean matching (pmm) as the imputation method for continuous variables and the logistic regression (logreg) as the imputation method for dichotomous variables. we conducted a sensitivity analysis to ensure that the results were not affected by multicollinearity due to highly correlated items in the dataset or by the use of the multiple imputed dataset for our main analysis. first, we tested the differences in demographics and baseline symptom levels between patients who dropped out and those who did not. next, zero-order associations were ex­ amined between dropout and the predictors of interest using point-biserial correlation on the imputed data. we then conducted a multiple logistic regression analysis (maximum likelihood estimation; imputed data) to investigate the unique effects of the variables on dropout after controlling for the effect of the other variables in the model. the level of significance was set as α = .05. we included the following variables as potential predictors of dropout (all assessed at the beginning of treatment): age, gender, marital status, living situation, education, posttraumatic symptom severity (pcl), exposure to semmlinger, takano, wolkenstein et al. 9 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ traumatic childhood experiences (ctq), interpersonal problems (iip), overall dissociation (des), posttraumatic cognitions in response to the traumatic experience (ptci) and to posttraumatic symptoms (ipsi), emotional dysregulation (ders), number of previous treatments (outpatient and inpatient), number of comorbid disorders (all comorbid disor­ der), comorbid personality disorder, therapist’s experience level (registered vs. in train­ ing), and gender match. although our primary focus was on the effects of each predictor on dropout, we were interested in how well the logistic regression model would predict dropout. we evaluated the prediction performance using leave-one-out cross-validation on the imputed datasets. the following three performance measures were computed (as medians across imputed datasets): accuracy (i.e., the number of patients who were correctly identified by the model as dropouts or non-dropouts divided by the total number of patients), sensitivity (i.e., the number of dropouts correctly identified as dropouts by the model divided by the number of dropouts), and specificity (i.e., the number of non-dropouts correctly identified as non-dropouts divided by the number of non-dropouts). in addition, receiver operating characteristic (roc) analysis was performed to evaluate the discriminatory power of the logistic regression model. the area under the roc curve (auc) was calcu­ lated to summarize the overall performance of the model, again as median auc across the multiple imputed datasets. the auc typically ranges from 0 to 1, with 1 indicating the perfect separation and with 0.5 meaning random separation (or poor prediction performance). results descriptives and demographics the sample consisted of 195 patients, with a mean age of 36.14 years (sd = 13.02 years). the majority of patients were female (75.9%). ninety-six patients (56.8%) had at least one comorbid disorder. the mean baseline ptsd symptom severity (pcl) was m = 46.2 (sd = 14.5), indicating a high severity of ptsd symptoms. patients in the sample experienced a variation of traumatic events, including accidental trauma, victimization, or trauma predominantly related to death threat. there was a significant association between dropout and age (see table 1), but not with respect to the other variables studied. the descriptive statistics for all demographic and clinical measures of the sample are presented in table 1. dropout in ptsd treatment 10 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ table 1 descriptive statistics of the sample, of dropouts, and of no dropout at baseline variable total dropout no dropout t or χ2 (p)n (%) / m (sd) n (%) / m (sd) n (%) / m (sd) gendera 0.35 (.56) female 148 (75.9%) 21 (70.0%) 127 (77.0%) male 47 (24.1%) 9 (30.0%) 38 (23.0%) age in yearsb 36.1 (13.02) 29.97 (10.11) 37.28 (13.21) 3.40 (.001) marital statusc 0.73 (.70) single 112 (59,6%) 19 (65.5%) 93 (58.5%) married 58 (30.8%) 7 (24.1%) 51 (32.1%) divorced/widowed 18 (9.6%) 3 (10.4%) 15 (9.4%) living situationb 3.90 (.27) alone 41 (21.9%) 7 (24.1%) 34 (21.4%) with partner 106 (56.7%) 14 (48.3%) 92 (57.9%) with parents 23 (12.3%) 2 (10.3%) 21 (13.2%) other 17 (9.1%) 5 (17.2%) 12 (7.5%) highest education leveld 4.15 (.25) university degree 35 (18.5%) 3 (10.0%) 32 (20.1%) high school† 35 (18.5%) 9 (30.0%) 26 (16.4%) secondary school‡ 102 (54.0%) 16 (53.3%) 86 (54.1%) other 17 (9.0%) 2 (6.7%) 15 (9.4%) previous treatmente 0.63 (.43) yes 106 (58.6%) 14 (50.0%) 92 (60.1%) no 75 (41.4%) 14 (50.0%) 61 (39.9%) comorbid pdf < .001 (1.0) yes 15 (8.6%) 2 (6.9%) 13 (8.9%) no 160 (91.4%) 27 (93.1%) 133 (91.1%) number of cdg 0.98 (1.1) 0.89 (0.91) 0.99 (1.13) 0.54 (.60) gender matchh 0.02 (.89) match 107 (73.3%) 19 (70.4%) 88 (73.9%) no match 39 (26.7%) 8 (29.6%) 31 (26.1%) approval therapisti 0.02 (.89) licensed 56 (39.2%) 11 (42.3%) 45 (38.5%) non-licensed 87 (60.8%) 15 (57.7%) 72 (61.5%) semmlinger, takano, wolkenstein et al. 11 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ variable total dropout no dropout t or χ2 (p)n (%) / m (sd) n (%) / m (sd) n (%) / m (sd) clinical measuresa pcl-5 46.2 (14.5) 47.0 (12.2) 46.1 (15.1) -0.33 (.74) ctq-28 55.2 (22.9) 49.6 (15.9) 56.2 (24.2) 1.46 (.15) iip-32 1.6 (0.6) 1.6 (0.5) 1.7 (0.7) 0.54 (.59) des 2.0 (1.8) 2.2 (1.5) 2.0 (1.9) -0.55 (.58) ptci 131.7 (36.3) 135.3 (33.2) 131.0 (37.6) -0.59 (.55) ipsi 3.5 (1.5) 4.0 (1.2) 3.5 (1.5) -1.77 (.08) ders 103.8 (27.4) 103.3 (23.9) 103.9 (28.1) 0.11 (.91) an = 195, bn = 187, cn = 188, dn = 189, en = 181, fn = 175, gn = 167, hn = 146, in = 143. †high school: 12-13 years of schooling, according to the german school system; ‡secondary school: 9-10 years of schooling, according to the german school system; with partner = with partner and/or child(ren) in own apartment; with parents = with parents/one parent; previous treatment = previous psychological treatment (inpatient and/or outpatient); comorbid pd = comorbid personality disorder; number of cd = number of comorbid disorders; m, sd, and t values for the clinical measures were calculated on the imputed dataset; significant effects are displayed in bold. dropout in trauma focused-treatment for ptsd a total of 30 out of 195 patients (15.38%) were classified as dropouts according to our criteria. analysis of dropout prediction association between dropout and predictor variables point-biserial correlations were calculated on the imputed dataset to examine the zeroorder associations between dropout and the predictor variables. results revealed a signif­ icant positive correlation between dropout and age (r = -.19, p = .02) but not between dropout and any other variable. see supplementary materials, table s.1 for a complete correlation matrix of all variables studied. prediction of dropout to examine the unique influence of the variables of interest on dropout (0 = no dropout, 1 = dropout), a multiple logistic regression was performed on the imputed data. the results indicated that age (β = 0.07, p = .04) and living situation (β = -2.16, p = .04) were significant predictors of dropout (see table 2). results showed that younger individuals were more likely to drop out of treatment, with an or of 0.94. patients who lived with their parents were at lower risk of dropout compared to those who lived alone (or = 0.12). dropout in ptsd treatment 12 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ table 2 results of the logistic regression analysis variable β se t or ll ul p intercept -0.46 2.13 -0.22 0.63 0.01 47.31 .82 gender (ref. = female) 0.87 0.65 1.34 2.39 0.67 8.59 .18 age -0.07 0.03 -2.12 0.94 0.88 1.00 .04 marital status (ref. = single) married -0.33 0.67 -0.49 0.72 0.19 2.73 .63 divorced/widowed 0.35 0.91 0.39 1.42 0.23 8.79 .70 living situation (ref. = alone) with partner -0.11 0.68 -0.17 0.89 0.23 3.42 .87 with parents -2.16 1.02 -2.11 0.12 0.02 0.88 .04 other 0.05 0.83 0.06 1.05 0.20 5.41 .95 highest education level (ref. = uni. degree) high school 1.12 0.83 1.35 3.07 0.59 15.90 .18 secondary school 0.45 0.79 0.57 1.57 0.33 7.43 .57 other 0.99 1.10 0.90 2.68 0.31 23.41 .37 previous treatment (ref. = no) -0.39 0.54 -0.73 0.68 0.23 1.97 .47 comorbid pd (ref. = yes) 0.92 0.93 0.99 2.52 0.39 16.30 .33 number of cd 0.03 0.31 0.08 1.03 0.52 2.02 .93 gender match (ref. = match) -0.20 0.62 -0.33 0.82 0.24 2.80 .74 approval therapist (ref. = licensed) -0.02 0.51 -0.05 0.98 0.36 2.66 .96 clinical measures pcl-5 -0.01 0.02 -0.34 0.99 0.95 1.04 .73 ctq-28 -0.01 0.01 -0.81 0.99 0.96 1.02 .41 iip-32 0.02 0.58 0.04 1.02 0.32 3.26 .97 des -0.04 0.19 -0.22 0.96 0.66 1.40 .83 ptci 0.01 0.01 0.66 1.01 0.99 1.03 .51 ipsi 0.47 0.27 1.72 1.60 0.93 2.76 .09 ders -0.02 0.02 -1.12 0.98 0.95 1.01 .26 note. ref. = reference category; with partner = with partner and/or child(ren) in own apartment; with parents = with parents/one parent; uni. degree = university degree; previous treatment = previous psychological treat­ ment (inpatient and/or outpatient); comorbid pd = comorbid personality disorder; number of cd = number of comorbid disorders; or = odds ratio; lower and upper ci refer to the corresponding 95% confidence intervals of the or; significant effects are displayed in bold. prediction performance using leave-one-out cross-validation on the imputed datasets, we evaluated the predic­ tion performance of the logistic regression model in distinguishing between people who semmlinger, takano, wolkenstein et al. 13 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ dropped out vs. those who did not dropout from the treatment. the model showed an accuracy of 80.5%. this accuracy score should be interpreted carefully as the data was not balanced between dropout (15.38%) and no dropout (84.62%). indeed, the specificity was excellent (95.2%) although the sensitivity was poor (3.3%), meaning that the model is not good at identifying dropouts. roc analysis showed an auc value of 0.58, indicating the marginal discriminatory power of the logistic regression model. discussion the first aim of the present study was to investigate the frequency of dropout in traumafocused, guideline-recommended interventions for ptsd in routine clinical care. 15.38% of patients unilaterally decided to prematurely terminate a started ptsd treatment. the dropout rate found in our study was considerably lower than previous estimates in routine clinical care. this applies for a sample of veterans (e.g., 36%, goetter et al., 2015), as well as for a joint consideration of trauma-focused treatments for ptsd in rcts and non-rcts (e.g., 41.5%, mitchell et al., 2022). the present findings are further accentuated by the fact that the estimated dropout rate is comparable or even slightly lower than mean dropout rates reported in meta-analyses of highly standardized rcts, e.g., 16% for a wide range of ptsd treatments (lewis et al., 2020) and 20.9% from guideline-recom­ mended ptsd treatment (varker et al., 2021). this finding on the low dropout rate is of particular importance as in clinical practice it is a major therapeutic goal to develop not only effective but also acceptable and feasible treatments. a number of possible explanations for the low dropout rate in our study are conceivable. first treatment was delivered in university-based outpatient centers which provide a well-structured treatment approach along with close supervision, while also allowing for some flexibility in treatment provision. thus, it could be argued that the present setting combines the strengths of both, rcts and a naturalistic setting. note, however, that in rcts across disorders higher dropout rates were found in university-based institutions (swift & greenberg, 2012). second, therapists in training might invest more time and effort to tailor treatment to their patients’ needs than it is usually observed in regular care. third, the manualized tf-cbt provided as a treatment may have been a particularly suitable form of treatment for the ptsd patients who participated in the current study. conceiva­ ble explanations include the modularized phase-based approach with high flexibility in the selected modules per phase and flexibility in the sessions provided per module and phase. it is further conceivable that the specialization of the outpatient centers in ptsd treatment has an additional effect. forth, we used well defined criteria to operationalize dropout (therapist decision combined with patient-initiated dropout). the second aim of the study was to investigate predictors of dropout in trauma-fo­ cused, guideline-recommended interventions for ptsd in routine clinical care. a multi­ ple logistic regression revealed age and living situation to be significant predictors, with dropout in ptsd treatment 14 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ higher risk of dropout in younger individuals and lower risk of dropout in patients who lived with their parents as opposed to living alone. the finding of younger age being predictive for dropout adds to previous findings on predictors of dropout in the general and ptsd-specific literature (goetter et al., 2015; swift & greenberg, 2012), with only few studies not replicating these findings (e.g., varker et al., 2021). note, that all patients in the study were adults (between 18 and 65 years). possible explanations include the fact that young patients may have more competing time demands (goetter et al., 2015), treatment may not sufficiently match their needs, or young patients may face a lack of stability in their living environments (de soet et al., 2024). in addition, it is conceivable that young adults have not yet experienced that ptsd symptoms in most cases do not simply disappear on their own over time (morina et al., 2014). to our knowledge, no previous study has investigated the influence of living situation on premature termination of treatment. note that although patients living with their parents probably tend to be younger, the significant findings on lower risk of dropout in patients who lived with their parents compared to living alone had a unique effect, i.e., when controlling for the influence of age. to explain our findings, it appears important to address the influence of parental support on treatment outcomes. in their review of dropout in adolescents, de soet et al. (2024) showed that parental approval, participation, and support were associated with lower risk of dropout. therefore, young patients living with their parents might perceive more parental support and thus dropout becomes less likely than if these patients were living alone. however, more research is needed to understand the influence of living situation on premature termination of treatment. we also examined the possible role of several clinical variables as predictors of dropout. results showed that baseline symptom levels and associated clinical variables were overall not predictive of dropout. this is in line with earlier findings (mostly based on data collected using rct designs) showing that e.g., symptom severity (varker et al., 2021) or comorbidity (mitchell et al., 2022; snoek et al., 2021; varker et al., 2021) were not predictive of dropout. a notable exception is a study by mitchell et al. (2022), which did find higher ptsd symptom severity at baseline predicted dropout; however, this was only the case for clinician-rated ptsd severity and not for self-rated ptsd scores. thus, the role of baseline ptsd symptom severity on dropout needs to be examined in further research focused on a possible role of methodological variables. with regard to the impact of therapist characteristics on dropout our findings in­ dicate that neither the experience level nor the gender match of the therapist has a significant influence on the dropout rate. this contradicts previous findings on treatment dropout across disorders. there is substantial evidence for the so-called therapist effect, which states that differences between therapist influence dropout rates (deisenhofer et al., 2024; saxon et al., 2017; zimmermann et al., 2017). in addition, research has indicated an effect of therapist experience level on dropout (roos & werbart, 2013; swift & greenberg, 2012). for ptsd treatment in particular, evidence is sparse, with initial semmlinger, takano, wolkenstein et al. 15 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ evidence for a therapist effect on dropout (sayer et al., 2022). in the present study possible influences of therapist characteristics might have been minimized by the fact that patients were treated in a highly specialized service with close supervision, and the fact that most therapist were at an early-career stage. therefore, the variability of therapist characteristics may have been rather low in the current study. in line with this reasoning, deisenhofer et al. (2024) found that the therapist effect on dropout was significantly reduced by such institution effects. although it was not the primary focus of the current study, we additionally tested how well the logistic regression model would predict dropout. taking the given imbal­ ance between dropout and no dropout into account, the model comprising different pretreatment variables was not successful in predicting whether a patient who just started treatment would dropout during the course of treatment. our results are in line with vöhringer et al. (2020) who reported poor results on the discriminative power of pretreatment variables to distinguish between dropouts and completers. however, bremer-hoeve et al. (2023) were able to predict dropout in ptsd treatment using ma­ chine learning techniques. in sum, only very few variables assessed in the current study were significant predic­ tors of dropout, and the overall model could not predict dropout to a practically useful level. this is broadly in line with the majority of earlier findings. thus, therapists and researchers should be cautious about making confident predictions about retention based on baseline data. limitations this study has a number of important strengths. one major strength is the naturalistic setting of the study, which allows for flexibility and variance in the trauma-focused, guideline-recommended treatment provided. in addition, the naturalistic setting contrib­ utes significantly to an increase in external validity and generalizability of the results to clinical practice. nevertheless, there are a number of noteworthy limitations. first, the number of participants included in the analysis was limited, potentially leading to reduced statistical power. even though we combined data from three outpatient centers, we had to exclude a substantial number of participants. this was due to the strict inclusion criteria regarding ptsd diagnosis and missing data for the assessment of dropout despite extensive file analysis. second, treatments were not standardized but allowed for some flexibility based on a manual delineating key treatment principle. on the one hand, this can be regarded as a strength of the study as it is typical for routine clinical practice, where manuals are usually less strictly applied than in rct research. on the other hand, however, we cannot rule out the possibility that the variability in the composition and timing of the use of different treatment modules may have obscured effects of certain variables in predicting dropout, as therapists may have counter-acted these variables in treatment. third, results could be limited by the method used to dropout in ptsd treatment 16 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ operationalize dropout. forth, the uncontrolled study design allows a more naturalistic investigation of dropout. however, in contrast to an rct design the internal validity of effects of different variables on dropout is low. specifically, it remains unclear whether confounding variables that were not controlled may have influenced on the occurrence of dropout. last, although we examined a wide range of variables, potentially important aspects are missing in our dataset. these include type of trauma experienced, treatment characteristics (e.g., session frequency), and patterns of change during treatment (e.g., rate of improvement). conclusion and future directions in conclusion, this study provides important knowledge about the dropout rate and predictors of dropout in trauma-focused, guideline-recommended interventions for ptsd in routine clinical care. results show that the dropout rate in this naturalistic study was comparable to dropout rates found in rcts. in addition, two baseline predictors of dropout were identified, suggesting that young adults with ptsd may need close, supportive care, especially when they are no longer living with their parents. therapists can act as supportive guides, build and strengthen hope (swift & greenberg, 2012), and be aware of urgent crises and the social needs of their young patients. possibly most importantly, however, our findings replicate earlier results showing that identifying patients at risk of dropping out of treatment early-on by baseline varia­ bles is challenging and currently not possible at a practically useful level. a number of implications can be drawn from this finding. first, from an applied perspective, these findings contradict widespread clinical beliefs about trauma-focused interventions being less acceptable to patients with high symptom severities, high comorbidity, or complex symptom presentations (e.g., emotion dysregulation, dissociation, interpersonal difficulties). neither earlier research nor our current findings suggest that patients with these particularly severe and/or complex presentations are more likely to drop out of treatment. however, larger samples may provide more power and enable us to examine even a broader scope of potential predictor variables with modern machine learning ap­ proaches (see taubitz et al., 2022). second, the cumulated findings may suggest that it is necessary to look beyond pretreatment factors when predicting dropout and to addition­ ally include variables investigating processes occurring in the course of treatment. for example, zandberg et al. (2016) found that the rates of symptom change had a significant influence on dropout in patients with comorbid ptsd and alcohol dependence. patients with low baseline symptom severity showed low risk for dropout in slow improvement and higher risk in fast improvement. when baseline symptom severity was high, the effect was u-shaped, with high risk of dropout in both slow and fast improvement (zandberg et al., 2016). third, further research should focus on investigating additional variables characterizing the treatment process, in particular the frequency of sessions provided. in a large-scale meta-analysis hoppen et al. (2023) showed lower dropout semmlinger, takano, wolkenstein et al. 17 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://www.psychopen.eu/ rates for trauma-focused treatments delivered in high intensity. these findings are in line with levinson et al.’s (2022) meta-analytical findings on dropout from pe provided in an outpatient setting. finally, as earlier evidence has been inconsistent, we followed an exploratory research approach. therefore, further studies are needed to test specific hypotheses based on theory. in addition, it appears recommendable to systematically assess subjective reasons from the patients’ perspective (vöhringer et al., 2020). expanding research into dropout from ptsd treatment in these ways appears highly relevant since dropout continues to be an important clinical challenge preventing a con­ siderable subgroup of treatment-seeking ptsd sufferers from receiving effective treat­ ment. a better understanding of predictors of – and ultimately causal factors involved in – dropout may ultimately help to develop preventive strategies to reduce dropout and keep patients with severe symptoms in effective treatment. funding: this research received no specific grant from any funding agency, commercial or not-for-profit sectors. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors report there are no competing interests to declare. ethics statement: the studies were approved by the local ethics committees at the lmu munich, university of münster, and the university of mannheim. written informed consent was obtained for all participants. reporting guidelines: we report how we determined our sample size, all data exclusions (if any), all manipulations, and all measures in the study, and we follow jars. related versions: this publication forms part of the doctoral thesis of verena semmlinger at the lmu munich. semmlinger, v. (2024). the complexity of treatment failure – prevalence and predictors of dropout and non-response in psychological treatment for traumatized populations [doctoral dissertation, lmu munich]. electronic theses repository of lmu munich. https://doi.org/10.5282/edoc.34387 preregistration: this study’s design and its analysis were not pre-registered. social media accounts: @thomasehring.bsky.social data availability: the authors have no permission to share the data. the code is available upon reasonable request. supplementary materials the supplementary materials contain a full correlation matrix of all variables studied (see semmlinger et al., 2025s). dropout in ptsd treatment 18 clinical psychology in europe 2025, vol. 7(1), article e14491 https://doi.org/10.32872/cpe.14491 https://doi.org/10.5282/edoc.34387 https://bsky.app/profile/thomasehring.bsky.social https://www.psychopen.eu/ index of supplementary materials semmlinger, v., takano, k., wolkenstein, l., krüger-gottschalk, a., kuck, s., dyer, a., pittig, a., alpers, g. w., & ehring, t. 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[2] ggz nhn, amsterdam, the netherlands. [3] department of gastroenterology and hepatology, olvg west, amsterdam, the netherlands. [4] department of health psychology, university medical center groningen, groningen, the netherlands. [5] amsterdam public health research institute, mental health, amsterdam, the netherlands. [6] department of psychiatry, amsterdam university medical centers, location amc, amsterdam public health, university of amsterdam, amsterdam, the netherlands. [7] centre for urban mental health, university of amsterdam, amsterdam, the netherlands. clinical psychology in europe, 2025, vol. 7(3), article e14717, https://doi.org/10.32872/cpe.14717 received: 2024-05-27 • accepted: 2025-02-09 • published (vor): 2025-08-29 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: floor bennebroek evertsz’, department of medical psychology, amsterdam university medical center/ location amc, meibergdreef 15, 1105 az amsterdam, the netherlands. tel.: +31 20 566 4661. email: f.bennebroek@amsterdamumc.nl supplementary materials: preregistration [see index of supplementary materials] abstract background and aims: ‘inflammatory bowel disease (ibd)-specific-cognitive-behavioral therapy’ (cbt) is effective in improving quality of life (qol) and in decreasing anxiety and depression in ibd-patients with poor mental qol, one month after completing cbt. main aim was to examine the sustainability of treatment effects up to three years after treatment with cbt. method: participants (n = 118) of a previously conducted randomized-control-study on the effects of ‘ibd-specific-cbt’ for ibd-patients were contacted for a long-term follow-up assessment on main outcomes: generic and ibd-specific-qol (sf-36, ibdq), anxiety and depression (hads, ces-d) and dsm-iv disorders (scid-i). change over time was examined with multilevelregression-analyses. results: three years after finishing ‘ibd-specific-cbt’, 61 ibd-patients (response rate 52%) completed the follow-up scid-i assessment and 52 patients (response rate 44%) completed the this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.14717&domain=pdf&date_stamp=2025-08-29 https://orcid.org/0000-0002-1851-2819 https://orcid.org/0009-0005-5919-0288 https://orcid.org/0009-0003-9925-5758 https://orcid.org/0000-0002-0823-1159 https://orcid.org/0000-0002-2479-8817 https://orcid.org/0000-0002-3728-6933 https://orcid.org/0000-0002-9220-9244 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ assessments for symptomatology. there were no differences between dropouts and participants at three year follow-up, except for a longer disease duration in dropouts. at three-year follow-up the chance of patients having a dsm-disorder significantly decreased with an estimated 48% (from 87% at baseline to 38% at follow-up). multilevel analyses showed a significant improvement between baseline (n = 118) and follow-up measurements (n = 52) on outcomes: ibdq-total (cohen’s d effect-size = .89), sf-36 physical (d = .54), and sf-36 mental (d = .69), hads-a (d = -.77), hads-d (d = -.65) and ces-d (d = -.55); all p < .01. qol outcomes showed further improvement between completion (n = 90 for ibd-specific qol and n = 91 for generic qol) and follow-up measurements, with significant improvements for ibdq-total (d = 0.31) and sf-36 physical (d = 0.32). conclusions: sustainable positive effects of ‘ibd-specific-cbt’ for ibd-patients with poor mental qol were found and the prevalence of mental conditions substantially decreased over three year follow-up. keywords cognitive behavioral therapy, inflammatory bowel disease, three year follow-up, quality of life, anxiety, depression highlights • ibd-specific-cbt showed lasting benefits on qol, anxiety, and depression three years post-treatment. • patients further improved, even after completion of therapy regarding ibd-specific qol and generic physical qol. • comorbid psychiatric disorders at baseline had decreased at long-term follow-up three years after ending ‘ibd-specific-cbt’. • larger studies are needed to confirm these findings. the unpredictability of the chronic relapsing and remitting inflammatory bowel diseases (ibd) ulcerative colitis (uc) and crohn’s disease (cd), may impact psychological wellbeing profoundly. whereas the exact mechanisms by which ibd is developed remains unclear, it is assumed that the disease develops due to an interaction of genetic predispo­ sitions, enviromental and dietary factors, gut microbiome and a dysregulated immune response (lee & chang, 2021). patients with ibd report a poor quality of life (qol) and psychiatric complaints such as anxiety and depressive disorders (bennebroek evertsz’, thijssens, et al., 2012). moreover, a recent systematic review and meta-analysis demonstrated a high prevalence of symptoms of common mental health disorders in patients with ibd. according to validated screening instruments, one-third of ibd-patients are affected by symptoms of anxiety and a quarter by symptoms of depression in the previous 10-15 years (barberio et al., 2021). moreover, patients with active ibd were also found to have a higher probability of experiencing both anxiety and depression symptoms compared to patients with inactive ibd (barberio et al., 2021). although the causal pathway remains unclear, follow-up of ibd-specific cognitive behavioral therapy 2 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://www.psychopen.eu/ associations between depression, anxiety and disease activity are well demonstrated (mikocka-walus et al., 2016). additionally, anxiety and depression were found to exacer­ bate disease outcomes in ibd patients (i.e. higher rates of surgery, hospitalization and corticosteroid use) (keefer, 2021). moreover, anxiety related irrational beliefs may lead ibd patients to disengage from regular restrictive physical activity (gravina et al., 2023) and anxiety itself may reduce their therapeutic adherence, as was documented during the covid pandemic (pellegrino et al., 2022). various studies point to a bidirectional link between the brain-gut axis (gracie et al., 2018). this bidirectional link has been proven to affect the natural course of the disease along with mental health (fairbrass et al., 2022; peppas et al., 2021). furthermore, individuals with a history of depression may show an increased risk of developing subsequent new-onset ibd (piovani et al., 2024). a recent study found that ibd patients with anxiety and depressive symptoms have a higher risk of developing steroid resistance and ibd related poor outcomes (duan et al., 2023). additionally, two recent systematic reviews and meta-analyses (naude et al., 2023; seaton et al., 2024) have shown that psychological treatments, including cbt addressing mood disorders, also improve inflammatory biomarkers in ibd (i.e. faecal calprotectin and c-reactive protein). consequently, an effective psychological intervention to target both anxiety and depression in ibd patients is important. hence, we designed an ‘ibd-specific cognitive behavioral therapy (cbt)’ (bennebroek evertsz’, bockting, et al., 2012), that targets anxiety, depression, post traumatic stress disorder (ptsd) and adjustment disorders for ibd patients with poor mental qol. the beneficial effects were measured one month after ‘ibd-specific-cbt’ treatment as studied in a multi-center randomized control trial (ql!c study) (bennebroek evertsz’ et al., 2017). the ql!c-study consisted of an experimental group receiving immediate cbt (n = 59), and was compared with a wait-list control group receiving standard medical care followed by cbt (n = 59) (bennebroek evertsz’ et al., 2017). at baseline, (before starting the ‘ibd-specific-cbt’) we measured the prevalence of psychiatric disorders (scid i), generic and disease specific qol (sf-36, ibdq), anxiety and depression (hads, ces-d) in this ibd-patient group with poor mental qol (bennebroek evertsz’ et al., 2017, 2020). we found a positive effect of ‘ibd-specific-cbt’ on disease specific qol, generic qol, depression and anxiety symptoms, one month after completion. currently, the evidenced based ‘ibd-specific-cbt’ intervention for ibd patients has been implemented and disse­ minated in several hospitals in the netherlands and showed comparable positive short– term effects on ibd-specific qol, anxiety and depression (bennebroek evertsz’ et al., 2024). study aims the primary aim was to investigate whether treatment gains of ‘ibd-specific-cbt’ (bennebroek evertsz’ et al., 2017) were sustained up to three years after treatment with bennebroek evertsz’, goes, stokkers et al. 3 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://www.psychopen.eu/ cbt, particularly with respect to psychiatric disorders, disease specific qol, generic quality of life, anxiety and depressive symptoms. materials and method procedures three years after completion of the ‘ibd-specific-cbt’ from the ql!c-study (bennebroek evertsz’ et al., 2017), ibd-patients ‘who participated in the qlic-study’ were asked to participate in a follow-up study during the period july 2013 and june 2015. before participating in the previous ql!c study (bennebroek evertsz’ et al., 2017), all the participants had provided written informed consent, including permission to be approached for follow-up research measuring the long-term effect of ‘ibd-specific-cbt’. the patients met the criteria of the diagnoses of crohn’s disease or ulcerative colitis at the start of the original study. ibd was diagnosed based on the usual clinical criteria, comprising clinical history, physical examination, laboratory findings, negative stool cultures, radiological imaging and endoscopic and histological examinations as assessed by ibd-experts, at least 3-6 months before entry in the ql!c-study (maaser et al., 2019). potential participants of the former ql!c study (n = 118) were contacted by telephone by a research assistant. if they were interested in receiving more information, we sent them a letter with information about the follow-up study and an invitation for participation. the invitation letter was sent without an initial phone call, if only a postal e-mail address was known. once patients agreed to participate, an appointment was made for a telephone interview to administer the scid-i. the questionnaires were sent by mail or e-mail (with a link to the online version of the questionnaires). a reminder was sent if the participant did not return the completed questionnaires by post or e-mail within two weeks. when participants declined participation, they were asked for their permission by phone to fill in the declaration form with the reasons for refusal, demographicand clinical characteristics. the ql!c study was approved by the local medical ethics committee of the amster­ dam university medical centre (location amc: dossier number: mec 08/295) and the long term follow-up study was approved as an amendment of the ql!c study (location amc: dossier number: mec nl22948.018.08). outcomes psychiatric disorders were assessed with the structural clinical interview for dsm-iv disorders (scid-i) (first et al., 1999), by psychologists who received a specific training. all other assessments were based on self-report questionnaires, which are the same as the questionnaires used in the original trial (ql!c-study) (bennebroek evertsz’ et al., 2017). the primary outcome was the total score on the inflammatory bowel disease follow-up of ibd-specific cognitive behavioral therapy 4 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://www.psychopen.eu/ questionnaire (ibdq) – 32 items assessing four domains; bowel symptoms, systemic symptoms, and emotional and social functioning (russel et al., 1997). where higher scores indicate a better health related qol. secondary outcome was generic qol assessed with the sf-36 (ware, 1992). the sf-36 items can be aggregated into a physical-com­ ponent-summary (pcs) score and a mental-component-summary (mcs) score. with higher scores indicating better health related qol. tertiary outcomes were depression and anxiety, which were assessed using the hospital anxiety and depression scale (hads) (zigmond & snaith, 1983). the hads is considered to be unbiased by the presence of a somatic illness. its 14 items were combined to form an anxiety (7 items) and depression scale (7 items), without including physical symptoms. with higher scores indicating more symptoms. the depression scale (ces-d) consisting of 20 items, assess­ es depressive symptomatology in the general population was also used to examine the difference between these two questionnaires on depression (radloff, 1977). statistical analysis data analyses were performed using ibm spss (version 28.0.1.1 (15)). the threshold for significance was p < .05 (two tailed). demographic and clinical characteristics were analyzed using frequencies, percentages and median scores. baseline differences between the group responders and non-responders were compared with chi-square or wilcoxon tests. normality assumptions were checked using the shapiro-wilk test and inspection of histograms, appropriate non-parametric tests (i.e. wilcoxon tests) were applied if needed. scores on disease specific and generic qol, anxiety and depression symptoms at baseline (before starting the ibd-specific-cbt) were compared with scores one month after com­ pletion and three years after cbt. additionally, the prevalence of mental condition and co-morbid mental conditions at baseline and three years after cbt were compared. to analyze differences over time we used multilevel regression analyses (heck & thomas, 2020). multilevel modeling takes into account the relationship between measures of the same individual across time and allows for including all available data (i.e. also data from participants who did not complete all measurements). multilevel logistic regression was used to assess the difference between psychiatric disorders (dsm-iv) as assessed at baseline and the three-year follow-up measurements. the analysis yields estimated prob­ ability of having a psychiatric disorder at both measurements, where the odds-ratio (or) is used to assess the difference between these two probabilities. when the upper bound of the 95% confidence interval of the estimated odds-ratio is below “1” this indicates that the chance of having a psychiatric disorder has significantly decreased with p < .05. differences between scores on baseline, completion (post-cbt) and three-year follow-up measurements of ibd-specific and generic qol, anxiety and depression symptoms were assessed with multilevel regression analysis. comparison between baseline and threeyear follow-up was used to measure change over time, and between cbt completion and follow-up was used to assess whether the treatment effectiveness was sustained after bennebroek evertsz’, goes, stokkers et al. 5 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://www.psychopen.eu/ three years. this analysis yields estimated mean differences between assessments, where confidence intervals of the estimated effects can be used to assess statistical significance of the difference. when the 95% confidence interval does not include zero, this indicates that the estimated difference is statistically significant at alpha = .05. the estimated effects can also be used to calculate a cohen’s d effect size (es with 0.3, 0.5 and 0.8 indicating a small, moderate and large effect, respectively) while taking into account the correlation between measurements using the design-effect (hox et al., 2018). the multilevel analyses were performed using the package lme4 (v1.1-34) (bates et al., 2015) in r (r core team, 2021). assumptions of homogeneity of variances and normality of residuals were assessed using an anova on squared residuals within participants and by inspecting qq-plots respectively. assumption of (log)linearity does not apply as the comparisons involves only two measurement occasions. we added an ad-hoc analyses to measure the effect of gender, age and disease type. results of the 57 (48%) ibd-patients who did not participate in this follow-up study (dropouts), 42 (74%) refused participation with no reason, 9 (16%) did not respond to letters and/or telephone calls, 2 (3%) persons indicated to be physically not able to participate and 4 (7%) persons were not able to participate due to time constraints. the dropout analyses (comparing baseline measures of the 61 patients participating at three-year follow-up vs the 57 dropouts) showed no significant differences regarding demographic and clinical characteristics and psychiatric disorders (dsm-iv) (data not shown). dropouts had a significantly longer median disease duration of 11 years at time of baseline while partici­ pants who participated at follow-up’ had a ‘median’ disease duration of 5 years (p = .03). the demographicand clinical characteristics of 61 ibd-patients (response rate 52%) who completed the three year follow-up scid-i telephonic interview assessment, are summarized in table 1. median age at long term follow-up was 36 years (iqr 28-47), 35 patients are female (57.4%) and almost more than two-fifth of our participants are married or living together (44.3%). of the 61 participating ibd-patients there were 52 (85%) ibd-patients who also completed ibd-specific and generic qol, anxiety and depression symptoms at three-year long-term follow-up. median age was 35 years (iqr 28-47), 30 patients were female (57.7%) and nearly half of them were married or living together (43.4%) (see also table 1). there were also no significant differences regarding demographic and clinical characteristics (and neither disease duration; p = .07) between the n = 52 participants who completed follow-up and patients lost to follow-up (data not shown). assumptions of homogeneity of variances and normality of residuals were met for all multilevel analyses. follow-up of ibd-specific cognitive behavioral therapy 6 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://www.psychopen.eu/ table 1 demographic and clinical characteristics variable ibd (n = 61) baseline and 3 year follow-up ibd (n = 52) baseline, post-cbt and 3 year follow-up completion of psychiatric disorders completion of ibdq, sf-36, hads, ces-d gender female 35 (57.4%) 30 (57.7%) age in years (median [iqr]) 36 (28-47) 35 (28-47) marital status in a relationship 27 (44.3%) 23 (43.4%) level of education low (primary or secondary) 24 (39.4%) 23 (40.4%) high (college or university) 32 (52.5%) 26 (50%) otherwise 5 (8.2%) 3 (5.7%) employment employed or studying 34 (55.7%) 28 (53.8%) unemployed 27 (44.3%) 24 (46.2%) sickleave 12 (19.7%) 10 (19.2%) hospital type academic 36 (59%) 29 (55.8%) diagnosis ulcerative colitis 26 (42.6%) 22 (42.3%) crohn’s disease 35 (57.4%) 30 (57.7%) disease duration in years (median iqr) 5 (3 – 13) 6 (3 – 13) number of operations none 43 (70.5%) 36 (69.2%) ≥1 18 (29.5%) 16 (30.8%) stoma 1 (1.6%) 0 (0%) medication with side-effect depression prednisone 12 (19.7%) 9 (17.3%) none 49 (80.3%) 43 (82.7%) multilevel regression analyses showed a significant decrease in estimated probability of overall psychiatric disorders (baseline 86.7% (n = 51), follow-up 38.3% (n = 24), p < .01), mood disorders (baseline 45.4% (n = 25), follow-up 20% (n = 13), p < .01), anxiety disorders (baseline 35.1% (n = 21), follow-up 10.7% (n = 8), p < .01) and adjustment disorders (baseline 30.6% (n = 23), follow-up 11.5% (n = 7), p < .01) (see table 2). for the other psychiatric disorders, including eating disorder, alcohol related disorder and psychotic disorder, the number of participants with the disorder at baseline was very low (n < 5), precluding further analyses. bennebroek evertsz’, goes, stokkers et al. 7 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://www.psychopen.eu/ table 2 frequencies of psychiatric disorders of ibd patients at baseline and at 3 year follow-up psychiatric disorder baseline (n = 118) 3 year follow-up (n = 61) or [95% ci]n %a n %a dsm-iv 51 86.7 24 38.3 0.10 [0.02, 0.23]** mood 25 45.4 13 20.0 0.30 [0.13, 0.62]** anxiety 21 35.1 8 10.7 0.22 [0.07, 0.52]** adjustment 23 30.6 7 11.5 0.30 [0.11, 0.68]** note. psychiatric disorders were only assessed at baseline and at 3 year follow-up and are not available immediately at post-cbt. apercentages are based on the estimated odds from the multilevel logistic regression model. **p < .01. additionaly, analyses showed a significant improvement in ibd-specific qol between baseline and follow-up among 52 patients after three years (ibdq total score: cohen’s d = .89, ibdq bowel: cohen’s d = .69, ibdq systemic: cohen’s d = .79, ibdq emotional: cohen’s d = .79, ibdq social: cohen’s d = 73). also there was a significant positive long-term effect on generic qol (sf-36 physical: cohen’s d = .54 and sf-36 mental: cohen’s d = .69). strikingly, patients showed significantly further improvement three years after completion of ‘ibd-specific-cbt’, concerning ibd-specific qol total, ibdq bowel, ibdq social and generic physical qol (completion versus follow-up ibdq total score: cohen’s d = .31; ibdq bowel: cohen’s d = .34, ibdq social: cohen’s d = .33, sf-36 physical: cohen’s d = .32) (see table 3). anxiety and depression symptoms remained decreased three years after completion of ‘ibd-specific-cbt’ (baseline versus follow-up hads-a: p < .01, cohen’s d = -.59; hads-d: p < .01, cohen’s d = -.41 and ces-d: p < .01, cohen’s d = -.66). however, these results did not further significantly improve after completion of the therapy (completion versus follow-up hads-a: p = .42, cohen’s d = -.12; hads-d: p = .67, cohen’s d = -.06; ces-d: p = .20, cohen’s d = -.19). ad hoc explorative analyses showed that there were some effects of disease-type (i.e., uc versus cd). participants with cu showed a larger improvement between base­ line and three year follow up on ibdq total (p < .05), and the improvement between completion and three-year follow up for sf36-mh was only statistically significant for participants with cu (but not for participants with cd). there were no effects of age and gender. there were also no effects of gender, age and disease-type on the decrease of psychiatric disorders over time. follow-up of ibd-specific cognitive behavioral therapy 8 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://www.psychopen.eu/ discussion we found a sustainable positive effect up to 3 years follow-up of ‘ibd-specific-cbt’ on ibd-specific and generic qol, anxietyand depressive symptoms among ibd patients with a priori poor mental qol. moreover, comorbid psychiatric disorders at baseline had decreased at long-term follow-up three years after ending ‘ibd-specific-cbt’. recent meta-analyses and reviews did find short term effectiveness of cbt for ibd on mental health problems (such as anxiety and depression) (chen et al., 2021; li et al., 2019). however, to date, positive sustainable effects of ‘ibd-specific-cbt’ have not been demonstrated. after 24 months of observation, mikocka-walus et al. (2017) did not find a significant longterm effect of cbt on qol, mental health or coping. a study of mccombie et al. (2016), that examined the long-term effect of computerized cbt, found an increased qol at 12 weeks but the effect was not maintained after 6 months. in patients with other medical illnesses, little is known about the sustainable effects on mental symptomatology and mental condition as well as qol after cbt (van straten et al., 2010). however, sustainable effects of cbt have been reported for depressive disorder (cuijpers et al., 2013, 2023; furukawa et al., 2021; legemaat et al., 2023). table 3 comparison of qol, anxiety and depression between baseline (n = 103) and 3 year follow-up (n = 52), and completion (post-cbt; n = 91 (ibdq) or n = 90 (other proms)) and follow-up assessments (total n = 106) assessment baseline vs follow-up completion (post cbt) vs follow-up mda [95% ci] cohen’s db mda [95% ci] cohen’s db ibdq total 25.11 [17.92, 32.31]** 0.89 8.85 [1.60, 16.05]** 0.31 ibdq bowel 6.8 [4.26, 9.33]** 0.69 3.41 [0.86, 5.95]** 0.34 ibdq systemic 4.53 [3.00, 6.06]** 0.79 1.34 [-0.19, 2.87] 0.23 ibdq emotional 10.1 [7.01, 13.19]** 0.79 2.32 [-0.79, 5.42] 0.18 ibdq social 3.72 [2.37, 5.07]** 0.73 1.67 [0.32, 3.02]** 0.33 sf-36 physical 2.07 [1.01, 3.14]** 0.54 1.22 [0.16, 2.28]* 0.32 sf-36 mental 3.75 [2.49, 5.03]** 0.69 0.8 [-0.48, 2.08] 0.15 hads anxiety -3.23 [-4.29, -2.18]** -0.77 -0.85 [-1.90, 0.21] -0.20 hads depression -2.39 [-3.39, -1.39]** -0.65 -0.67 [-1.66, 0.33] -0.18 ces-d -3.83 [-5.52, -2.14]** -0.55 -1.56 [-3.26, 0.15] -0.22 note. cohen’s d .3 is small, .5 is medium and .8 is large. ibdq = inflammatory bowel disease questionnaire; sf-36 = mos 36-item short form health survey; hads = hospital anxiety and depression scale; ces-d = the center for epidemiologic studies depression scale. amean difference (md) is based on the estimated effect in the multilevel regression model. bcohen's d is based on the estimated parameters from the multilevel regression model. *p < .05. **p < .01. bennebroek evertsz’, goes, stokkers et al. 9 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://www.psychopen.eu/ we would recommend a number of amendments for future research to investigate the sustainable effects of ‘ibd specific cbt’. first, employment of a larger sample size that would accommodate dropout, enabling the study of long-term effects. furthermore, inclusion of multiple assessment points (e.g., 3, 6 and 12 months after completion) would enable a closer examination of the treatment effects over time. even more so, in the first phase of this study we randomized cbt to a wait-list control group. therefore we have no control group for the three year follow-up. we would recommend to use a different type of control-group. namely comparison of ‘ibd-specific-cbt’ with ibd patients receiving only treatment as usual for longterm follow-ups. fortunately, this research will be repeated with due observance of these recommendations. given these promising short-term and long-term results of ‘ibd-specific-cbt’ in ibd patients with poor mental qol and the positive results of the aforementioned imple­ mentation study of ‘ibd-specific-cbt’ in four hospitals in the netherlands (bennebroek evertsz’ et al., 2024), there is an urgent need to disseminate standard stepwise screening and treatment of mental health disorders in ibd patients. as mentioned before cbt for patients living with ibd not only enhances psychological benefit, but may also improve their physical health (e.g. inflammation) (naude et al., 2023; seaton et al., 2024). moreover, providing integrated psychological care to ibd patients in need for mental health can reduce costs, particularly by decreasing visits to emergency departments (lores et al., 2021). however, untill now the integration of mental health care in general ibd care is still insufficient and a challenge in daily clinical practice (fairbrass & gracie, 2021; peppas et al., 2021). conclusions ibd patients with initial poor mental qol were found to experience a sustainable positive effect of the ‘ibd-specific-cbt’ on ibd-specific and generic qol, anxiety and depressive symptoms, three years after ending cbt. morover, a significant reduction of the prevalence of mental conditions was found (83.6% 1 month after cbt to 39.3% with a mental health condition at three year follow-up). the prophylactic effect of cbt seems also to hold for ibd-specific problems, since patients further improved, even after completion of therapy regarding ibd-specific qol and generic physical qol. this gives an indication that this therapy may not only have sustainable positive effects, but also generate further improvement over years after completion. this is in line with other findings on preventive cognitive therapy in depression (bockting et al., 2018; furukawa et al., 2021; legemaat et al., 2023) and cbt in anxiety disorders (van dis et al., 2020). we can therefore conclude this ‘ibd-specific-cbt’ was found to have sustainable effects in decreasing mental health problems and mental conditions in ibd-patients on the long term. moreover this study shows the first indications of long-term sustainable effects. larger studies are needed to confirm these findings. follow-up of ibd-specific cognitive behavioral therapy 10 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: first, we would like to thank all participating patients with ibd who took place in this three year follow-up study. we thank all medical specialists (gastro enterologists), support staff, managements of the departments of medical psychology of the amsterdam umc/location amc. additionally, we thank all psychologists and research assistents: laura de vries and eva ten brink for administering the structural clinical interview at three years follow-up and gathering the data. finally, we thank ria rochelle d’abreo for her help with editing the manuscript. competing interests: the authors (fbe, flsg, pcfs, rs, mv, mags and clhb) declare that they have no competing interests. author contributions: fbe was the chief investigator grant holder of the three years follow-up ql!c study. she drafted the final manuscript (which was added and modified by all other authors), wrote the original treatment manual ‘ibd-specific-cbt’ (which was added to and modified by clhb) and she was responsible for the training and supervision of the psychotherapists. mags was the study’s principal investigator. the statistical analysis plan was set up by fbe, mv and flsg. mv is responsible for the statistical analysis and reporting (adviser statistical analyses). mags, pcfs, rs, and clhb supervised the study and contributed to its design and analytic strategy. flsg supported in literature searches, reference preparation and reviewed early drafts of the article. fbe, mags and clhb reviewed early drafts of the article. all authors read and approved the final manuscript. fbe had full access to all data in the study and had final responsibility for the decision to submit for publication. ethics statement: this long term follow-up study design has been approved by the medical ethics committee of the amsterdam umc as an amendment of the qlic study (location amc: dossier number: mec nl22948.018.08). participants of the follow up study were properly instructed and they gave informed consent. the manuscript has been read and approved by all authors. reporting guidelines: clinical trial, intervention study following the consort statement. preregistration: before start of the study the trial was registered at the overview of medical research in the netherlands (omon), the formerly dutch trial register. trial registration number of the original randomized control trial (tc = 1869) (see bennebroek evertsz’, 2025s). data availability: the corresponding author fbe had full access to the study data and material. the data underlying this article will be shared on request to the corresponding author. code availability: non applicable. supplementary materials the supplementary materials contain the preregistration for the study (see bennebroek evertsz’, 2025s). bennebroek evertsz’, goes, stokkers et al. 11 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://www.psychopen.eu/ index of supplementary materials bennebroek evertsz’, f. (2009). enhancing the quality of life of patients with inflammatory bowel disease: a multi-center study investigating cognitive behavioral therapy [preregistration; trial registration number = 1869]. overview of medical research in the netherlands (omon). https://www.onderzoekmetmensen.nl/nl/trial/19981 references barberio, b., zamani, m., black, c. j., savarino, e. v., & ford, a. c. (2021). prevalence of symptoms of anxiety and depression in patients with inflammatory bowel disease: a systematic review and meta-analysis. the lancet gastroenterology & hepatology, 6(5), 359–370. https://doi.org/10.1016/s2468-1253(21)00014-5 bates, d., mächler, m., bolker, b., & walker, s. 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(1983). the hospital anxiety and depression scale. acta psychiatrica scandinavica, 67(6), 361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. follow-up of ibd-specific cognitive behavioral therapy 16 clinical psychology in europe 2025, vol. 7(3), article e14717 https://doi.org/10.32872/cpe.14717 https://doi.org/10.1111/j.1600-0447.1983.tb09716.x https://www.psychopen.eu/ follow-up of ibd-specific cognitive behavioral therapy (introduction) study aims materials and method procedures outcomes statistical analysis results discussion conclusions (additional information) funding acknowledgments competing interests author contributions ethics statement reporting guidelines preregistration data availability supplementary materials references loneliness and distress in the aftermath of the covid-19 pandemic: a cross-sectional study of german university students research articles loneliness and distress in the aftermath of the covid-19 pandemic: a cross-sectional study of german university students joanna j. hunsmann 1 , florian weck 1 , julia wendt 2 , franziska kühne 1 [1] department of clinical psychology and psychotherapy, university of potsdam, potsdam, germany. [2] department of emotionand biopsychology, university of potsdam, potsdam, germany. clinical psychology in europe, 2025, vol. 7(2), article e14365, https://doi.org/10.32872/cpe.14365 received: 2024-04-10 • accepted: 2025-01-19 • published (vor): 2025-05-28 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: joanna j. hunsmann, division of clinical psychology and psychological treatment, lmu munich, leopoldstr. 13, 80802 munich, germany. phone: +49 89 2180 5199. e-mail: joanna.hunsmann@psy.lmu.de supplementary materials: code, data, materials, preregistration [see index of supplementary materials] abstract background: characterized by uncertainty and recurring periods of social isolation, the covid-19 pandemic resulted in increases of loneliness and distress in young adults, such as university students. despite the lifting of the last restrictions in germany in april 2023, the state of mental health in vulnerable groups after the three-year global crisis remains to be investigated. therefore, we aimed to assess university students’ mental health after the pandemic. method: between april and july 2023, n = 886 university students throughout germany participated in a fully anonymous cross-sectional online survey. psychological distress (bsi; brief symptom inventory), loneliness (ls-soep; loneliness scale), and emotion regulation strategies (erq; emotion regulation questionnaire) were assessed by standardized questionnaires, and mental health was compared to a survey of students in april 2020 (n = 1,062). results: unexpectedly, we found higher levels of distress in 2023 than in 2020. overall, r2 adj = 41% of variance in psychological distress was accounted for in a multiple linear regression, with loneliness emerging as the most important predictor. additionally, emotion regulation, gender identity, and health behaviors such as keeping daily routines, sufficient sleep, and regular exercise were significant predictors. analyses of variance (anovas) revealed that students with past or present mental health conditions were significantly lonelier than those without. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.14365&domain=pdf&date_stamp=2025-05-28 https://orcid.org/0009-0002-3439-9200 https://orcid.org/0000-0001-9621-3227 https://orcid.org/0000-0003-2299-5881 https://orcid.org/0000-0001-9636-5247 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: these findings highlight the ongoing mental health challenges of university students in the aftermath of the covid-19 pandemic, identifying non-binary and female students, as well as students with current or past mental health conditions as particularly lonely and distressed. keywords mental health, psychological distress, loneliness, emotion regulation, health behaviors, covid-19 pandemic, university students highlights • this study is among the first to investigate post-pandemic mental health in german university students. • differences in loneliness were found by gender, with non-binary students particularly affected. • students with current or past mental health conditions reported more loneliness and more distress. • health behaviors and adaptive emotion regulation predicted better mental health. impacting various domains of life, the covid-19 pandemic has been widely recognized not only as a threat to physical, but also to mental health (bower et al., 2023; gruber et al., 2021; world health organization, 2020). across borders, it was accompanied by increases in psychological distress and symptoms of depression and anxiety (benke et al., 2020; bower et al., 2023). characterized by periods of social isolation, the covid-19 pandemic has also seen a notable rise in loneliness (ernst et al., 2022). university stu­ dents, often confronted with financial instability, academic pressures, and instability in social networks, are considered particularly vulnerable to mental health deterioration (auerbach et al., 2018; ochnik et al., 2021). in germany, university students’ mental health was affected by frequently changing study conditions (matos fialho et al., 2021). typically associated with older age, a rise in loneliness in young adults in germany during the covid-19 pandemic has been high­ lighted (lepinteur et al., 2022; werner et al., 2021). this is alarming since social contacts are considered especially important in this life phase. defined as subjective experience of distress resulting from perceived deficiencies in the quantity and quality of social connections (hawkley & cacioppo, 2010), loneliness has been tied to a variety of adverse health outcomes (cacioppo et al., 2010; hawkley et al., 2009). early longitudinal studies reported responses of recovery after the lifting of lockdown restrictions, however, levels of loneliness remained notably high (ahrens et al., 2021; chandola et al., 2022; entringer et al., 2020). in germany, pandemic restrictions (e.g., mask-wearing) were maintained comparatively long, with final regulations ending in early 2023 (bundesregierung, 2023; see also appendix a in the supplementary materials). loneliness and distress after covid-19 2 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ mauz and colleagues (2023) provide evidence for the deterioration of mental health during later waves of the pandemic, highlighting the negative effect of the war in ukraine. given the pandemic duration, added stressors, and the serious threat for mental health given prolonged loneliness, monitoring university students’ mental health in the aftermath of the covid-19 pandemic remains relevant. during the pandemic, identifying as female (benke et al., 2020; lepinteur et al., 2022), younger age (benke et al., 2020; bower et al., 2023), and prior mental health conditions (benke et al., 2020; bower et al., 2023; shevlin et al., 2023) were consistently associated with greater distress. individuals belonging to a risk group for covid-19 or experiencing lasting consequences (e.g., post-covid) were more distressed (houben-wilke et al., 2022). meanwhile, in line with recommendations by health organizations (inter-agency standing committee, 2020), better mental health was associated with behaviors such as keeping daily rhythms, regular physical exercise, healthy nutrition, and sufficient sleep (mata et al., 2021; shanahan et al., 2022; voltmer et al., 2021). furthermore, adaptive emotion regulation was associated with less distress and loneliness (ahrens et al., 2021; preece et al., 2021). policymakers and university staff would benefit from understanding which students may be particularly burdened after covid-19. in this study, we examined german university students’ mental health in the after­ math of the covid-19 pandemic. specifically, we hypothesized that students would report lower levels of psychological distress in spring 2023, after restrictions ended, com­ pared to the lockdown period in 2020. we expected correlations between psychological distress and loneliness, as well as emotion regulation strategies. we hypothesized that loneliness and emotion regulation strategies would be significant predictors for psycho­ logical distress, beyond the impact of person-related factors and health behaviors. finally, we examined the role of students’ prior mental health conditions and hypothesized that students with current or past mental health conditions would report more loneliness, demonstrate less adaptive emotion regulation, and engage less in health-related behav­ iors compared to others. method procedure a total of n = 886 university students in germany participated in the cross-sectional online study between april and july 2023. the survey was conducted using the survey tool of the university of potsdam. participants were recruited nationally via email through universities’ student councils, with requests to spread the survey link among their students, as well as locally at the university of potsdam via the participant pool of the cognitive sciences and by distribution of flyers at key locations on campus during mental health awareness days. hunsmann, weck, wendt, & kühne 3 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ inclusion criteria were student status, studying in germany, age 18 and above, and giving informed consent. the latter was obtained from all participants, ensuring thor­ ough understanding of their rights, the study's objectives, risks, and benefits. abiding by institutional guidelines of the university of potsdam, data collection maintained complete anonymity, strictly limiting sociodemographic information asked, and adhering rigorously to national and eu data protection laws. participant characteristics can be found in table 1. measures the questionnaire commenced with a brief assessment of sociodemographic variables, namely gender (female, male, non-binary), age (in categories to further ensure anonymi­ ty, e.g., 21-25), relationship status, and study term. covid-19-related variables participants were asked how often they had been infected with the covid-19 virus and whether they belonged to one of the following three groups, later referred to as covid-related group status: at-risk for severe infection, having experienced a severe infection, and experiencing lasting effects of a past infection. participants were also asked about the extent to which they felt burdened by the covid-19 pandemic, the war in ukraine, the energy crisis, and the climate crisis. answers were given on a 5-point likert scale, ranging from 1 (not at all) to 5 (very strongly). psychological distress psychological distress was assessed with the german version of the brief symptom inventory (bsi; derogatis & melisaratos, 1983; franke, 2000). consisting of 53 items, it measures distress on nine dimensions. general psychological distress is indicated by a global score, the general severity index (gsi). the instrument uses a 5-point likert scale, ranging from 0 (not at all) to 4 (extremely). higher levels reflect greater distress. to calculate the gsi, the sum of all item scores is divided by 53, the number of items. in the present study, cronbach’s α was .96. loneliness the german version of the 3-item loneliness scale (ls-soep; hawkley et al., 2015; hughes et al., 2004) was used to assess loneliness, which is derived from the ucla loneliness scale (russell, 1996). responses to the items were given on a 5-point likert scale, ranging from 0 (never) to 4 (very often). we used the mean value of given responses (luhmann & hawkley, 2016), with higher values indicating greater loneliness. in this sample, cronbach’s α was .77. loneliness and distress after covid-19 4 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ emotion regulation emotion regulation was measured with the german version (abler & kessler, 2009) of the emotion regulation questionnaire (erq; gross & john, 2003). it contains 10 items that measure how a person deals with positive and negative emotions. the scale suppression consists of six items and the scale reappraisal consists of four items rated from 1 (strongly disagree) to 7 (strongly agree). in our sample, cronbach’s α was .81 for reappraisal and .75 for suppression. health-related behaviors six items regarding health behaviors were self-developed by adapting recommendations of the of the inter-agency standing committee of the united nations (2020). in line with previous studies during the covid-19 pandemic, self-reported regularity of exercise, daily living rhythms, sufficient sleep, healthy dietary habits, mindfulness practices, and alcohol consumption were recorded (chen et al., 2020; koob et al., 2021; mata et al., 2021; petzold et al., 2020). answers were given on a 4-point scale, ranging from 1 (disagree) to 4 (agree), with higher values indicating stronger practice of health behaviors (see appendix c, supplementary materials, for full item list). mental health conditions students were queried regarding prior mental health conditions (1 = yes, i am currently undergoing treatment for it; 2 = yes, i received treatment for it in the past; 3 = no). if affirmed, participants were asked to specify whether there had been a worsening of symptoms since the pandemic. comparison data to compare post-pandemic levels of psychological distress to students’ mental health in the beginning of the covid-19 pandemic, we used data from a survey conducted at our university in april 2020 (löscher, 2020). a total of n = 1,062 (n = 706, 66.5% female; n = 345, 32.5% male; n = 11, 1% non-binary) university students in germany participated in this cross-sectional online survey. participants were aged 18 to 51 years (m = 24.01; sd = 4.68). the procedure was analog to the assessment detailed for 2023, except for the distribution of flyers on campus. statistical analysis all analyses were conducted in r (r core team, 2023). there were no missing data. however, for the study term question, some exclusions were made due to non-digit entries (e.g., “bachelor”, 23 cases). the level of significance for all analyses was α = .05. analyses were conducted as previously registered, with minor deviations detailed below due to unmet assumptions (hunsmann & kühne, 2023s, march 31). first, we computed hunsmann, weck, wendt, & kühne 5 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ descriptive statistics. in exploratory manner, we examined the correlations between perceived burdens and psychological distress, applying the bonferroni correction for multiple comparisons (armstrong, 2014). we also explored differences in loneliness by gender. proceeding with our hypotheses, we examined the relationships between psycho­ logical distress, loneliness, and emotion regulation strategies, using spearman’s rank correlations due to violations of the assumption of normality. to better understand how distressed students were in the aftermath of the covid-19 pandemic, we used a mann-whitney u-test to compare students’ levels of psychological distress in both samples. the mann-whitney u-test was conducted due to violations in the assumptions of equal variances and normality. effect sizes are reported, with r = .1 considered a small, r = .3 a moderate, and r = .5 a large effect (cohen, 1988). next, we conducted hierarchical multiple regression analyses to predict psychological distress from loneliness and emotion regulation strategies, while controlling for health behaviors and person-related factors. first, we considered a baseline model with health behaviors and person-related factors. in a second step, we added the emotion regulation strategies suppression and reappraisal as predictors. similarly, we added the predictor loneliness to the baseline model. finally, we computed a multiple regression model pre­ dicting psychological distress from all variables. as the assumption of homoskedasticity was not confirmed for all regression models, we employed heteroskedasticity-consistent, robust estimations using the hc3 method in all regression analyses (hayes & cai, 2007; long & ervin, 2000; white, 1980). where the assumption of normality of residuals was violated, we conducted bootstrapped regression analyses with 5000 bootstrap samples to assess the stability of the original regression models’ results. if not specified otherwise, the bootstrapped regression analyses supported the initial models. finally, we conducted analyses of variance (anovas) to investigate differences in loneliness, emotion regulation strategies, and health behaviors between participants de­ pending on their history of mental health conditions. post hoc contrasts were computed using the tukey honestly significant difference (hsd) test. effect sizes were calculated using omega squared (ω2) as recommended by kroes and finley (2023). field’s (2013) recommendation for interpreting ω2 was used (ω2 ≥ 0.01 small, ω2 ≥ 0.06 medium, ω2 ≥ 0.14 large). results sample an overview over sociodemographic information is provided in table 1, experiences related to the covid-19 pandemic in table 2. loneliness and distress after covid-19 6 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ table 1 sample characteristics characteristic overall n = 886 n (%) female n = 551 n (%) male n = 307 n (%) non-binary n = 28 n (%) age 18-20 165 (18.6%) 108 (19.6%) 51 (16.6%) 6 (21.4%) 21-25 498 (56.2%) 311 (56.4%) 171 (55.7%) 16 (57.1%) 26-30 155 (17.5%) 94 (17.1%) 57 (18.6%) 4 (14.3%) 31-35 32 (3.6%) 17 (3.1%) 15 (4.9%) 0 (0.0%) 36-40 22 (2.5%) 11 (2.0%) 10 (3.3%) 1 (3.6%) 41-45 6 (0.7%) 5 (0.9%) 1 (0.3%) 0 (0.0%) 46-50 3 (0.3%) 1 (0.2%) 2 (0.7%) 0 (0.0%) 51+ 5 (0.6%) 4 (0.7%) 0 (0.0%) 1 (3.6%) education (in semesters) m (sd) 6.13 (3.56) 6.09 (3.43) 6.25 (3.78) 5.59 (3.40) range 1.00, 24.00 1.00, 18.00 1.00, 24.00 1.00, 14.00 marital status divorced 1 (0.1%) 1 (0.2%) 0 (0.0%) 0 (0.0%) married 32 (3.6%) 27 (4.9%) 4 (1.3%) 1 (3.6%) relationship 355 (40.1%) 243 (44.1%) 103 (33.6%) 9 (32.1%) single 497 (56.1%) 280 (50.8%) 200 (65.1%) 17 (60.7%) widowed 1 (0.1%) 0 (0.0%) 0 (0.0%) 1 (3.6%) mental health condition no 634 (71.6%) 383 (69.5%) 241 (78.5%) 10 (35.7%) current 123 (13.9%) 88 (16.0%) 27 (8.8%) 8 (28.6%) previous 129 (14.6%) 80 (14.5%) 39 (12.7%) 10 (35.7%) of those students who had a history of mental health conditions (n = 252; 28.4%), either currently or previously received psychotherapy, 58.3% (n = 147) reported worsening symptoms since the covid-19 pandemic. furthermore, 44.5% (n = 394) of participants were classifiable as psychologically distressed. as can be seen in figure 1, 10.1% of students reported feeling strongly or very strongly burdened by the covid-19 pandemic. in comparison, the percentage of students reporting to feel strongly or very strongly burdened by the other stressors were 17.6% for the war in ukraine, 26.9% for the energy crisis, and 45.8% for the climate crisis. yet, there was a small but significant correlation between students’ distress and how burdened they felt by the covid-19 pandemic (r = .26, p < .001). likewise, there were small correlations between psychological distress and perceived burdens due to the energy crisis (r = .28, hunsmann, weck, wendt, & kühne 7 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ p < .001), the war in ukraine (r = .25, p < .001), and the climate crisis (r = .22, p < .001, bonferroni correction p < .0125). table 2 covid-19-related variables characteristic n = 886, n (%) number of infections with covid-19 0 165 (18.6%) 1 450 (50.8%) 2 227 (25.6%) 3 40 (4.5%) 4 4 (0.5%) at-risk group 75 (8.5%) severe course 65 (7.3%) lasting consequences (e.g., post-covid) 84 (9.5%) descriptive statistics for psychological distress, loneliness and emotion regulation are provided in table 3. a one-way anova revealed a small yet significant difference in loneliness by gender, f(2, 883) = 8.37, p < .001, ω2 = .016, 95% ci [.004, .039]. post hoc contrasts showed that participants identifying as non-binary were significantly lonelier (m = 3.5, sd = 0.98) than participants identifying as female (m = 2.92, sd = 0.88) or male (m = 2.79, sd = 0.96). as for differences in loneliness by covid-19 related group status, a t-test revealed that participants at risk for a severe course of infection reported significantly higher loneliness (m = 3.21, sd = 0.92) than participants not belonging to a risk-group (m = 2.86, sd = 0.91; t(884) = -3.19, p = .001, d = 0.39), and that participants who reported lasting consequences of a past infection reported significantly higher loneliness (m = 3.09, sd = 0.95) than participants without post-covid ramifications (m = 2.87, sd = 0.91), t(884) = -2.10, p = .036, d = 0.24. difference in psychological distress the mann-whitney u-test revealed a significant difference in psychological distress between students in 2020 and 2023, u = 332516, z = -8.211, p < .001, r = .19, with students in 2023 reporting significantly higher distress (mdn = 0.74) than students in 2020 (mdn = 0.45). loneliness and distress after covid-19 8 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ psychological distress in relation to loneliness and emotion regulation there was a large positive correlation between psychological distress and loneliness, rs(884) = .56, p < .001. a small negative correlation was found between psychological distress and reappraisal, rs(884) = -.18, p < .001, whereas distress and suppression were positively correlated, rs(884) = .23, p < .001. the baseline multiple linear regression model predicting psychological distress from health behaviors and person-related factors was statistically significant, explaining 17% of variance, see table d1 (appendix d, supplementary materials). adding the emotion regulation strategies to the baseline model resulted in a statistically significant model ex­ plaining 24% of variance in psychological distress, see table d2 (appendix d). the model was better than the baseline model, δr 2 = .066, f(2, 866) = 38.5, p < .001. the strategy of suppression predicted higher psychological distress, and the strategy of reappraisal figure 1 perceived burdens due to current events note. extent to which participants indicated to feel burdened: 1 = not at all, 2 = slightly, 3 = somewhat, 4 = strongly, 5 = very strongly. hunsmann, weck, wendt, & kühne 9 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ lower distress. the bootstrapped regression analysis closely aligned with initial model, however, belonging to the age group 36-40 was corrected as a nonsignificant predictor. similarly, the predictor loneliness was added to the baseline model, resulting in a statistically significant model accounting for 39% of the variance in psychological distress, see table d3 (appendix d). here, an increase in loneliness was associated with an increase in psychological distress. the model with loneliness was significantly better than the baseline model, δr 2 = .209, f(1, 867) = 301.87, p < .001. lastly, an exploratory regression model with all predictors accounted for r 2 = 41% of variance in psychological distress, see table 4 (see also table d4, appendix d). while being the strongest of the models predicting distress, it only explained 2% more variance in distress than the model with loneliness (table d3, appendix d), δr 2 = .024, f(2, 865) = 17.99, p < .001. this underscores the importance of loneliness as a predictor for distress. the role of prior mental health conditions the anova revealed a small effect of prior mental health in loneliness, f(2, 883) = 20.00, p < .001, ω2 = .041, 95% ci [.02, .071]. post hoc comparisons revealed that participants table 3 descriptive statistics characteristic overall n = 886 mental health conditions no n = 634 current n = 123 previous n = 129 psychological distress (gsi) m (sd) 0.88 (0.62) 0.79 (0.57) 1.17 (0.67) 1.05 (0.68) range 0.00, 3.58 0.00, 3.23 0.08, 3.58 0.04, 3.00 loneliness (ls-soep) m (sd) 1.89 (0.92) 1.77 (0.88) 2.28 (0.95) 2.09 (0.93) range 0.00, 4.00 0.00, 4.00 0.00, 4.00 0.00, 4.00 reappraisal (erq) m (sd) 4.30 (1.08) 4.32 (1.06) 4.21 (1.15) 4.33 (1.08) range 1.00, 7.00 1.00, 7.00 1.50, 6.50 1.00, 7.00 suppression (erq) m (sd) 3.72 (1.28) 3.73 (1.27) 3.85 (1.30) 3.55 (1.31) range 1.00, 7.00 1.00, 7.00 1.00, 6.75 1.00, 6.50 note. gsi = general severity index; ls-soep = 3-item loneliness scale; erq = emotion regulation question­ naire. loneliness and distress after covid-19 10 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ with current (m = 3.28, sd = 0.95) and past mental health conditions (m = 3.09, sd = 0.93) were significantly lonelier than those without (m = 2.77, sd = 0.88). as for differences in emotion regulation by mental health status, no significant differ­ ence was found in suppression, f(2, 883) = 1.78, p = .169. there was also no significant difference in reappraisal, f(2, 883) = 0.59, p = .556. table 4 multiple regression analysis: predictors of psychological distress (n = 886) variable standardized β se t p (intercept) 0.17 3.454 < .001 loneliness .44 0.02 13.225 < .001 suppression -.10 0.02 -3.407 < .001 reappraisal .13 0.01 4.659 < .001 health behaviors daily structure -.07 0.02 -2.244 0.025 healthy nutrition .02 0.03 0.757 0.449 regular exercise -.06 0.02 -2.086 0.037 mindfulness practice .05 0.02 1.630 0.104 sufficient sleep -.16 0.02 -5.128 < .001 limiting alcohol -.03 0.02 -1.241 0.215 agea 21-25 -0.02 0.04 -0.708 0.479 26-30 0.02 0.06 0.456 0.648 31-35 0.00 0.10 0.151 0.880 36-40 -0.04 0.11 -1.420 0.156 41-45 0.00 0.13 -0.196 0.845 46-50 -0.02 0.18 -1.429 0.153 51+ 0.01 0.48 0.226 0.821 genderb male -.13 0.04 -4.564 < .001 non-binary .02 0.15 0.508 0.612 therapyc current .08 0.06 2.654 0.008 previous .09 0.05 2.960 0.003 r 2 (radj 2 ) .442 (.409) f 31.630 p < .001 areference category: 18-20. breference category: female. creference category: no therapy. hunsmann, weck, wendt, & kühne 11 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ as for the overall score regarding health behaviors, there was no significant differ­ ence between participants with past, current, or no mental health conditions, f(2, 883) = 0.57, p = .564. investigating each behavior individually, we found a small difference in exercising regularly between participants depending on their mental health history, f(2, 883) = 6.73, p = .001, ω2 = .013, 95% ci [.002, .033]. post hoc comparisons revealed that participants with no mental health conditions (m = 2.9, sd = 0.99) reported to exercise more regularly than participants with current (m = 2.65, sd = 1.05) or past (m = 2.6, sd = 1.03) mental health conditions. there was also a small difference in mindfulness practice by mental health group, f(2, 883) = 11.05, p < .001, ω2 = .022, 95% ci [.007, .047]. however, participants with no mental health conditions (m = 1.88, sd = 0.9) reported significantly less mindfulness practice than participants with current (m = 2.2, sd = 0.91) or past (m = 2.19, sd = 1) mental health conditions. discussion our first hypothesis, anticipating lower psychological distress in 2023 compared to 2020, was not supported. confirming the second hypothesis, loneliness and emotion regulation emerged as significant predictors for distress. the third hypothesis, positing differences by prior mental health, was only partially confirmed. comparing levels of psychological distress in a three-year interval, we found that students reported higher distress in 2023 than in 2020, with 44.5% of students psychologically distressed, as compared to 27% in 2020. certain health behaviors, i.e., keeping regular routines, getting sufficient sleep, and exercising regularly, were associated with lower distress. identifying as male was asso­ ciated with lower distress, experiencing past or current mental health conditions with higher distress. beyond person-related variables and health behaviors, suppression and loneliness were predictive of higher psychological distress, while reappraisal predicted lower distress. overall, loneliness was the most influential predictor for psychological distress and 41% of variance in distress was explained. students identifying as non-binary reported the highest levels of loneliness, followed by female students. students with prior or current mental health conditions reported more loneliness than others. there were no differences in emotion regulation by mental health history. regarding health-related behaviors, students without prior mental health issues reported to exercise more regu­ larly. however, students with previous and current mental health conditions reported practicing more mindfulness. our research design does not allow for causal attributions. however, our results are in line with existing research suggesting a deterioration of mental health in germany during the later pandemic (mauz et al., 2023; walther et al., 2023). a us study highlighted an increase in severe levels of depression, anxiety, and stress among university students compared to previous years (emmerton et al., 2024). however, the authors report this as part of a longer-term trend and identify academic performance as key stressor alongside loneliness and distress after covid-19 12 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ several non-pandemic stressors (emmerton et al., 2024). our results might also capture differences in daily stressors, as the 2020 assessment occurred during lockdown and the semester break. furthermore, global stressors beyond the pandemic must be considered (mauz et al., 2023). our exploratory analyses indicate that students in 2023 felt markedly burdened by stressors such as the climate crisis and the war in ukraine. however, the reliance on self-developed self-report measures is a limitation. another limitation of this study lies in the use of a convenience sample. the study may have particularly attracted the interest of students struggling with mental health. however, a similar prevalence of mental disorders has been reported in other studies (e.g., auerbach et al., 2018). age distributions in both samples were comparable and in line with nationwide representative surveys (e.g., statista, 2024). a notable 62% of participants identified as female (67% in 2020) and 3% as non-binary (1% in 2020). as the percentages of female and male students in germany are approximately equal (kroher et al., 2023) and since the pandemic had differential effects on male, female, and non-binary individuals (flor et al., 2022), this limits the generalizability of our findings. furthermore, demographic variables that may explain differences in mental health were not assessed due to anonymity considerations, thereby limiting comparability. such variables could be financial status (e.g., chandola et al., 2022), ethnic minority status (plenty et al., 2021), and geographical location, as covid-19 measures varied across regions in germany. finally, almost 10% of students reported being impacted by lasting consequences of a prior infection with covid-19 (see appendix b, supplementary materials). the central role of loneliness in predicting psychological distress loneliness was the strongest predictor for psychological distress. one explanation is to understand loneliness as a persisting consequence of the pandemic. werner and colleagues (2021) reported loneliness being highly predictive of mental health issues in a longitudinal study, with loneliness during the pandemic only marginally predicted by pre-pandemic loneliness. greater loneliness was reported in regions with more pandem­ ic-related restrictions in a norwegian study among students, however, the study also found that loneliness was linked to time spent on campus and declined again from 2021 to 2022 (hysing et al., 2023). conversely, loneliness could stem from existing mental health conditions. students with diagnosed mental health conditions might struggle to seek social support or engage in fulfilling interactions (perese & wolf, 2005). as mental health conditions remain a sensitive topic, they may hesitate to confide in others (schnyder et al., 2017; schomerus et al., 2019). regarding gender differences in loneliness, our results align with existing findings (hysing et al., 2023; werner et al., 2021). a rise in female loneliness during covid-19 has been linked to declining wellbeing (lepinteur et al., 2022), likely due to gender gaps in other areas, e.g., finances or caretaking (flor et al., 2022). however, the 3% non-binary students in our sample reported the highest loneliness. this percentage is in line with hunsmann, weck, wendt, & kühne 13 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ other german and international surveys (e.g., ipsos, 2021). transgender and non-binary individuals are more likely to experience discrimination and violence (aparicio-garcía et al., 2018), with social support and lgbtqia+ communities playing a vital role in mitigating negative mental health outcomes (weinhardt et al., 2019). thus, they may have been disproportionately affected by social restrictions. alternatively, loneliness may have been high in this group before the pandemic (aparicio-garcía et al., 2018). despite the importance of emotion regulation in psychopathology, we found no differences by mental health status. this may reflect the limitations of our narrow assessment, with adaptive emotion regulation increasingly seen as flexible (e.g., aldao et al., 2015) and influenced by factors like strategy access and emotional awareness (gratz & roemer, 2004). in line, cognitive control and flexibility moderated the association between uncertainty intolerance and emotion regulation difficulties in a multi-wave pandemic study, affecting mental health (godara et al., 2023). our finding that health behaviors served as adaptive coping strategies generally aligned with previous research (chen et al., 2020; mata et al., 2021; oftedal et al., 2019). conclusion psychological distress was high in this university student sample even after the pandem­ ic, with loneliness notably prevalent in the most distressed individuals. this underscores the importance of addressing loneliness in young adults. we also found that adaptive emotion regulation and specific health behaviors, such as adequate sleep, exercise, and maintaining daily routines, were associated with better mental health cross-sectionally. future research should monitor loneliness among university students longitudinally. specific interventions could address loneliness (ma et al., 2020; masi et al., 2011). targe­ ted programs in universities would benefit from particularly focusing on non-binary and female students. counseling services could facilitate support groups and therapy referrals, and universities could expand practical assistance for challenges commonly faced by female students, such as caregiving responsibilities. by addressing mental health openly and fostering support systems, significant strides may be made towards reducing loneliness among university students. loneliness and distress after covid-19 14 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. ethics statement: abiding by institutional guidelines of the university of potsdam, data collection maintained complete anonymity, strictly limiting sociodemographic information asked. the survey strictly followed the apa ethical principals of psychologists and code of conduct (2017) and the ethical guidelines of the federation of german psychologist associations (dgps, 2022). informed consent was obtained from all participants, ensuring thorough understanding of their rights, the study's objectives, risks, and benefits. preregistration: the study and analyses were conducted as previously registered (hunsmann & kühne, 2023s, march 31). reporting guidelines: jars-quant reporting standards for studies using no experimental manipulation data availability: the analysis code and data from this study are available on osf (hunsmann & kühne, 2024s), the comparison data is available from the corresponding author upon request. no further materials were used. supplementary materials the supplementary materials contain the following items: • preregistration (hunsmann & kühne, 2023s) • research data and analysis code (hunsmann & kühne, 2024s) • online appendices (hunsmann et al., 2025s): ◦ appendix a: covid-19 pandemic restrictions in germany ◦ appendix b: lasting consequences of prior covid-19 infections ◦ appendix c: item list of health behaviors ◦ appendix d: regression tables with detailed statistics for multiple regression models: a baseline model, a model with emotion regulation, a model with loneliness, and a model with all predictors index of supplementary materials hunsmann, j. j., & kühne, f. 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(2020). mental health and psychosocial considerations during the covid-19 outbreak, 18 march 2020. world health organization; who iris. https://apps.who.int/iris/handle/10665/331490 loneliness and distress after covid-19 22 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://doi.org/10.1017/s003329172000241x https://doi.org/10.1017/s0033291721001665 https://de.statista.com/statistik/daten/studie/1166109/umfrage/anzahl-der-studenten-an-deutschen-hochschulen-nach-alter/ https://de.statista.com/statistik/daten/studie/1166109/umfrage/anzahl-der-studenten-an-deutschen-hochschulen-nach-alter/ https://doi.org/10.25646/10598 https://doi.org/10.1186/s12889-021-11295-6 https://doi.org/10.3238/arztebl.m2023.0180 https://doi.org/10.1080/1550428x.2018.1522606 https://doi.org/10.1038/s41598-021-02024-5 https://doi.org/10.2307/1912934 https://apps.who.int/iris/handle/10665/331490 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. hunsmann, weck, wendt, & kühne 23 clinical psychology in europe 2025, vol. 7(2), article e14365 https://doi.org/10.32872/cpe.14365 https://www.psychopen.eu/ loneliness and distress after covid-19 (introduction) method procedure measures comparison data statistical analysis results sample difference in psychological distress psychological distress in relation to loneliness and emotion regulation the role of prior mental health conditions discussion the central role of loneliness in predicting psychological distress conclusion (additional information) funding acknowledgments competing interests ethics statement preregistration reporting guidelines data availability supplementary materials references a process-based approach to transtheoretical clinical research and training scientific update and overview a process-based approach to transtheoretical clinical research and training stefan g. hofmann 1 , steven c. hayes 2 [1] department of psychology, philipps-university of marburg, marburg, germany. [2] department of psychology, university of nevada, reno, nv, usa. clinical psychology in europe, 2024, vol. 6(special issue), article e11987, https://doi.org/10.32872/cpe.11987 received: 2023-05-16 • accepted: 2023-07-17 • published (vor): 2024-04-26 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: stefan g. hofmann, department of psychology, philipps-universität marburg, schulstrasse 12, 35037 marburg/lahn, germany. tel. germany: +49 (0)172 489 2245. e-mail: stefan.hofmann@uni-marburg.de related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract background: the science and practice of psychopathology and psychological intervention of today is more like an island archipelago than it is a single land mass, and connections between different traditions are both limited and fraught with misunderstanding. method: our analysis and solution to the problem is process-based therapy (pbt). pbt defines psychopathology as failed adaptation processes to a given context. therapy involves adaptation through context-dependent or context-altering applications of biopsychosocial strategies that allows a goal to be met. results: this coherent approach to more transtheoretical and integrative concepts of clinical training and practice provides a firm foundation by targeting biopsychosocial processes of change, analyzing these processes using an idiographic complex network analytic approach, and organizing findings on the intellectual agora of multi-dimensional and multi-level evolutionary science. conclusion: pbt is a new empirical form of functional analysis, resulting in interventions and trainings that are built on elements or kernels of direct relevance to client’s specific needs. in pbt, case formulation continues as long as treatment persists. keywords psychopathology, psychotherapy, evolutionary science, adaptation, context, processes, dynamic networks this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11987&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0002-3548-9681 https://orcid.org/0000-0003-4399-6859 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • clinical psychology and psychiatry are too syndrome focused. • this limits the potential of the interventions. • an idiographic, context-sensitive approach will resolve this impasse. • process-based therapy offers such an approach. most clinical concepts in wide use in psychotherapy have emerged from particular applied theoretical positions or technological approaches, linked to specific normative measures, and clusters of treatment methods. it is not unusual for these to be especially focused on particular disorders, populations, or treatment settings. methods differ in the emphasis across dimensions of human experience: this method is more cognitive, that is more bodily focused, while another emphasizes social relationships. training occurs by experts in these clusters, and entire training programs in major universities are often readily characterized in that way. in effect, the science and practice of psychopathology and psychological intervention is more like an island archipelago than it is a single land mass, and connections between different traditions are both limited and fraught with misunderstanding. there has long been pressure and regular efforts to build a great sense of cooperation across these distinct theoretical and practical clusters, especially by practicing clinicians, but the barriers to doing so are considerable. clinical researchers and treatment developers may give lip service to the importance of transtheoretical conversations, but the methods they develop and test are often distinctive as compared to others. over the last decade, however, a new focus and analytic approach has emerged that now has a growing record of fostering evidence-based transtheoretical and inte­ grative concepts in psychotherapy research, and in clinical training and practice. this focus breaks down barriers between the various “schools” of psychological therapy, and provides a new and more functional approach to psychopathology and intervention concepts and methods. it promises to profoundly transform the future of scientifically based clinical training and practice. we named this approach process-based therapy (pbt: hayes & hofmann, 2021; hayes, hofmann, & ciarrochi, 2020; hofmann & hayes, 2019; hofmann, hayes, & lorscheid, 2021). pct is not a new therapy as such – it is a new vision of the central tasks that need to be accomplished by evidence-based intervention science. pbt has a characteristic target, analytic approach, and meta-model. its target is the understanding of biopsychosocial processes of change and how they can be modified by treatment components or kernels to help accomplish the goals of the client. its analytic approach is to measure, predict, and influence idiographically assessed processes of change with high levels of precision, scope, depth and to generate nomothetic generalizations only to the degree to which doing so increases idiographic fit within complex networks. its process-based therapy 2 clinical psychology in europe 2024, vol. 6(special issue), article e11987 https://doi.org/10.32872/cpe.11987 https://www.psychopen.eu/ meta-model is meant to create a kind of intellectual agora based on a common language of multi-dimensional and multi-level evolutionary science. pbt defines psychopathology as failed adaptation processes to a given context. pbt applies socially extended principles of contextual adaptation from evolutionary science to psychopathology and psychological interventions, hereby focusing on the human ability to adapt to or alter environmental challenges through variation (in contrast to psychology inflexibility), selection of adequate strategies, and retention of successful strategies at the psychological, biophysiological, sociocultural levels of analysis (hayes, hofmann, & ciarrochi, 2020; hayes, hofmann, & wilson, 2020). broadly defined, adap­ tation is the context-dependent or context-altering application of biopsychosocial strat­ egies that allows a goal to be met, whereas psychopathology is the maladaptation of these processes. maladaptation can include a larger failure to create a more adaptive context itself, so the focus on adaptation is not passive and it is not socially blaming or irresponsible. entire families or communities can in principle be pathological. in each level of organizational complexity, specific dimensions can be involved in healthy variation, that is selected and retained in context. for example, the biophysio­ logical level might involve genes, epigenes, brain circuits, or organ systems, among various others. a psychological level might include dimensions of affect, cognition, self, attention, motivation, and overt behavior, among other dimensions. there are no hard and fast divisions among dimensions – the point is that the extended revolutionary meta-model can accommodate a variety of useful dimensions and levels of processes of change. this model has been termed an extended evolutionary meta-model (eemm; hayes et al., 2019; see figure 1), because it can serve as a meta-model for more specific, independ­ ent psychotherapeutic schools, and because of its roots in the knowledge on evolutionary science (badcock, 2012) applied to the individual in all of its socially-situated complexity (hofmann, curtiss, & hayes, 2020; hofmann, curtiss, & mcnally, 2016; see ong et al., 2022 for a recent case description). it is important to understand that a meta-model is not a new model. it is a model of models. consider any row of the eemm – say, the cognitive dimension – to begin to explore why a meta-model is helpful to a transtheoretical appoach. a given model of psychopathology or treatment may emphasize that persons who develop psychological problems tend to have characteristic cognitive styles or modes of thinking. perhaps these styles are rigid, irrational, or over-generalized, for example. these are theoretically grounded ways of speaking about how given cognitions or cogni­ tive styles can be insensitive to the actual context or fail to vary when a wider range of possibilities need to be considered. understanding the person's history might lead to an understanding about why these styles became dominant for a particular person, that is, how they were selected and retained. for example, a person may have had hofmann & hayes 3 clinical psychology in europe 2024, vol. 6(special issue), article e11987 https://doi.org/10.32872/cpe.11987 https://www.psychopen.eu/ critical parents who modelled irrational thinking styles or who might have reverted to over-generalizations to avoid criticisms by others. figure 1 a conceptual space for the examination of adaptive and maladaptive change processes provided by modern multi-dimensional, multi-level evolution science variation selection retention context affective cognitive attentional self motivational overt behavioral physiological social/cultural maladaptive adaptive extended evolutionary meta-model (eemm) note. the bottom two rows represent nested levels of analysis relevant to the psychological level – although not the topic of this paper a full explication of these levels would require similar matrices of their own. copyright steven c. hayes and stefan g. hofmann. the eemm is not meant as a substitute for a specific model – it is instead meant as a generic way of considering them and studying them in a transtheoretical fashion. if another specific model emphasizes that cognitive rigidity comes from seeing thoughts as facts, it would be an easy matter to study this idea in comparison to cognitive over-generalization in a given instance. two theorists might feel compelled to compete if an entire model is at stake, but when specific processes are being compared, it is far easier to have shared interests in any given outcome. process-based therapy 4 clinical psychology in europe 2024, vol. 6(special issue), article e11987 https://doi.org/10.32872/cpe.11987 https://www.psychopen.eu/ idionomic versus normative “latent disease” analysis analytically, a pbt approach is a radical departure from the traditional latent disease model of psychiatry. it relies on network analysis as a form of functional analysis using the framework of evolutionary science. in a latent disease model, the signs and symptoms of psychopathology in a given syndrome for a given individual are meant to orient towards underlying entities that are assumed to be driving the particular features that are seen. latent diseases are inherently normative and categorical. the statistical methods used in traditional psycho­ metric evaluations of measures rely heavily on consistencies between people as the metric for evaluating consistencies across persons that are assumed to be driven by underlying variables that cannot be directly measured but must be inferred. clinically speaking, after assessment people are grouped in diagnostic de-individualized categories (greenhalgh et al., 2014). in line with this, particular collections of data, theories, and interventions are utilized with the intention of encompassing and benefiting the entire group. such labels are commonly found in traditional cbt protocols. the latent disease model gives priority to the prescribed symptoms and syndromes rather the psychological processes underlying psychopathology and mental health. this view tends to reduce human suffering to brain abnormalities and biological dysfunctions and de-emphasize the importance of the biopsychosocial context of the individual (greenhalgh et al., 2014). despite the increased transdiagnostic focus of cbt approaches as process-based approach gains strength (hayes & hofmann, 2021), narrow attention to the patient’s specific symptoms and normative views of presenting problems remains a main feature of cbt case formulation and treatment delivery. it is increasingly apparent that the central tendencies of groups do a very poor job of modeling individual life trajectories. statistical physics long ago proved the ergodic theorem, which suggests that the measurement of a collection of elements can adequate­ ly reflect the behavior of individual elements only if the behavior involved is stationary and all individual elements share the same dynamic model. statisticians agree that this ergodicity is an underlying assumption of common biostatistical methods but by defini­ tion processes of change are not stationary, and they unfold in different ways at different times and different people. in a pbt approach, this problem is avoided through idiographic analyses that model the relation of processes of change as they bear on particular outcomes within the person over time. only then are individual results related to those of other people. relations that become evident by extending the analysis to the nomothetic or group level are retained if and only if they improve ideographic fit for most people. this is what is meant by the neologism “idionomic analysis”, offered as a substitute for “normative analysis.” hofmann & hayes 5 clinical psychology in europe 2024, vol. 6(special issue), article e11987 https://doi.org/10.32872/cpe.11987 https://www.psychopen.eu/ functional analysis in an idionomic approach because processes of change interact, process-based therapists conduct functional anal­ yses through contextual sensitive idionomic network assessment. psychopathology is represented as an idionomic network of problems, conditions, and processes. the goal of pbt is to help clients replace their maladaptive networks with adaptive networks. this is done by strengthening processes that promote well-being while moving toward desirable goals and values. early functional analysis and later cbt case formulations (persons, 2008; persons et al., 2013) were important steps toward the translation of general processes of change to individual applications. according to pbt, we ask: what core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed? (hofmann & hayes, 2019, p. 38). pbt does not demarcate case conceptualization, assessment and treatment. pbt visualizes a client’s problem as a dynamic network that is maintained through maladaptive processes. once we understand them, we can effectively intervene. this network is not static, but dynam­ ic and changes with time and treatment. therefore, high density data monitoring are essential, such as ecological momentary assessment (ema), dynamic network analysis, and time-series analysis. examples of some available methods that can be taken in clini­ cal settings are frequent measures of processes taken in session and between sessions, and measures of social, psychological, and physical context (hayes et al., 2019). in that way, frequent, contextually focused assessment sets the stage for the creation of a comprehensive empirical form of functional analysis for each client. that is, idio­ nomic analysis of longitudinal assessments leads to the identification of relevant and controllable functional relations to an individual’s specific behavioral targets (haynes & o’brien, 1990). this is quite different from traditional forms of functional analysis that were common in the early days of cognitive and behavioral therapy. in those times, applying principles to individual patterns of behavior was more an art than a science, making replicable case analysis difficult (hayes & follette, 1992). traditional functional analysis was neglected from psychology literature for decades because of that, in addition to the fact that the range of processes considered was too limited, appropriate statistical analytic methods were under-developed, and consequently it was difficult to show superior outcomes from functional analysis for addressing human suffering. in recent decades, newer forms of cbt have reemphasized a functional approach (hayes, hofmann, & ciarrochi, 2020), and research has expanded our clarity about the key processes of change that need to be targeted (hayes, ciarrochi, hofmann, chin, & sahdra, 2022), revitalizing a functional analytic approach. additionally, interventions based on a functional-analytic assessment have demonstrated utility in improving clinical outcomes of some conditions (ghaderi, 2006; hurl et al., 2016). it is particularly worth noting that every significant mediator of a randomized control trial of a psychosocial method focused on a mental health outcome, process-based therapy 6 clinical psychology in europe 2024, vol. 6(special issue), article e11987 https://doi.org/10.32872/cpe.11987 https://www.psychopen.eu/ easily fits within the eemm (hayes, ciarrochi, et al., 2022). this means that the eemm is in fact the intellectual agora sought by pbt: it provides a stable transtheoretical ground for all current approaches to processes of change. from packages to kernels in personalized interventions pbt is based on the idea that efficient and effective intervention should be based on the individual’s unique biopsychosocial characteristics, goals, and needs. in other words, the dynamic process-based case formulation can and should lead to specific treatment elements or kernels. pbt rejects the a priori focus on symptoms from dsm or icd-de­ fined syndromes and instead focuses on processes that ameliorate problems or promote prosperity when positive goals are ascendant. rather than just reduction in symptoms, the aim of pbt is to strengthen processes that promote well-being in accordance to the clients’ values and goals. we have a great deal to learn about how well treatment elements or components modify processes of change, but systematic reviews of the ability of treatment kernels to do so are already available in some areas (e.g., levin et al., 2012). the claim that the eemm can serve as an agora for a transtheoretical approach is also strengthened by evidence that all current positive psychology methods and models also readily fit within the eemm (ciarrochi et al., 2022). concluding thoughts broadly-cast transtheoretical approaches to processes of change should lead to an in­ creased ability to share treatment methods without losing intervention coherence. said in another way, instead of vapid eclecticism, a pbt approach encourages researchers and practitioners to develop broader models of change, to communicate across theoretical boundaries about overlapping interests in processes of change, and to share intervention kernels that successfully alter idiographically relevant biopsychosocial processes. this approach allows the strengths that come from clarity about philosophical assumptions and basic or applied theory, on the one hand, while reaping the benefits that can come from theoretical consilience and cooperation, on the other. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. hofmann & hayes 7 clinical psychology in europe 2024, vol. 6(special issue), article e11987 https://doi.org/10.32872/cpe.11987 https://www.psychopen.eu/ references badcock, p. b. 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(2008). the case formulation approach to cognitive-behavior therapy. guilford. persons, j. b., beckner, v. l., & tompkins, m. a. (2013). testing case formulation hypotheses in psychotherapy: two case examples. cognitive and behavioral practice, 20(4), 399–409. https://doi.org/10.1016/j.cbpra.2013.03.004 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. hofmann & hayes 9 clinical psychology in europe 2024, vol. 6(special issue), article e11987 https://doi.org/10.32872/cpe.11987 https://doi.org/10.1016/j.cpr.2016.05.003 https://doi.org/10.1016/j.beth.2012.05.003 https://doi.org/10.3389/fpsyg.2022.1002849 https://doi.org/10.1016/j.cbpra.2013.03.004 https://www.psychopen.eu/ process-based therapy (introduction) idionomic versus normative “latent disease” analysis functional analysis in an idionomic approach from packages to kernels in personalized interventions concluding thoughts (additional information) funding acknowledgments competing interests references i’m still standing: body sway, interpersonal distance, and social anxiety – a proof of principle research articles i’m still standing: body sway, interpersonal distance, and social anxiety – a proof of principle wolf-gero lange 1 , muriel a. hagenaars 2 [1] behavioural science institute, radboud university nijmegen, nijmegen, the netherlands. [2] department of clinical psychology, faculty of social and behavioural sciences, utrecht university, utrecht, the netherlands. clinical psychology in europe, 2025, vol. 7(3), article e15365, https://doi.org/10.32872/cpe.15365 received: 2024-08-21 • accepted: 2025-02-07 • published (vor): 2025-08-29 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: wolf-gero lange, radboud university nijmegen, behavioural science institute, p.o. box 9104, 6500 he, nijmegen, the netherlands. phone: +31 (0)6 25771579. e-mail: gero.lange@ru.nl abstract background and objectives: cognitive models suggest that individuals with high degrees of social anxiety (sas) tend to incorrectly interpret (ambiguous) social cues as negative evaluations and thus justifying their fears. it is assumed that subtle behaviors of sas may give rise to factual negative evaluations, but it is unclear which kind of behaviors that may be. we tested whether automatic motivational behavior becomes disrupted when degree of social anxiety increases, expecting higher social anxiety to be associated with more threat-related ‘freezing’ (reduction of body sway) and backward leaning (avoidance). method: of 87 participants with varying degrees of social anxiety, body sway was recorded by means of a stabilometric platform, while a fe-/male experimenter was gradually approaching. results: higher levels of social anxiety were related to an increase of body sway at an interpersonal distance of 260 to 120cm. no avoidant backward-leaning occurred. limitations: predictability of set-up and knowledge of escape options may have undermined participants’ experience of the situation as highly socially threatening. unease-, rather than fearrelated behavior may have been the result. conclusions: the results indicate that sas seem to show an increase in uneasy, nervous movement when approached by strangers. whether that provokes the negative evaluation sas fear most, still needs to be investigated. keywords social anxiety, freezing behavior, interpersonal distance, stabilometric force platform, body sway, avoidance this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.15365&domain=pdf&date_stamp=2025-08-29 https://orcid.org/0000-0002-4236-0819 https://orcid.org/0000-0002-5674-6966 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • stranger approach paradigm was used to study freezing and avoidance behavior in social anxiety. • objective changes in body posture were assessed by a stabilometric force platform. • higher social anxiety was related to increased body sway during stranger approach. • freezing behavior was associated to state but not to (trait social) anxiety. social anxiety disorder (sad) is a common and highly distressing disorder (e.g., fehm et al., 2005; kennedy et al., 2009; perry et al., 2016) that is characterized by an excessive fear of negative evaluation by others in social or performance situations (american psychiatric association, 2013, 2022). until recently, it has been predominantly concep­ tualized as a condition of ‘distorted or biased information processing’ (clark & wells, 1995; hofmann, 2007; rapee & heimberg, 1997) based on the idea that individuals with high degrees of social anxiety (sas) have a tendency to see social danger where in fact there is none. this tendency is thought to cumulate and eventually maintain sad (beard & amir, 2008; heeren et al., 2012; schmidt et al., 2009). yet, there is growing evidence that sas are truly evaluated in a negative way. heerey and kring (2007) found that interactions with sas were characterized by, e.g., nervous fidgeting, or poor reciprocity of smiling (heerey & kring, 2007). as a consequence, conversations with sas evoked increased negative affect in interaction partners (alden & wallace, 1995; creed & funder, 1998; meleshko & alden, 1993; voncken & bögels, 2008). while the above-mentioned behaviors are more of a deliberate nature, the question remains whether sas show disruptions in subtle, more automatic behaviors in social interaction. research by asher et al. (2020) showed that non-verbal behavioral synchrony increased in non-anxious couples during conversation while it decreased in anxious/nonanxious dyads. as behavioral synchrony is associated with increased positive affect (tschacher et al., 2014) and increased sense of rapport (miles et al., 2009), a lack of syncing with others may actually lead to the effect that sas fear most. in a different line of research, givon-benjio and okon-singer (2020) reported that increased degrees of social anxiety were related to a preference for larger interpersonal distance (ipd) and a tendency to underestimate interpersonal distances to strangers when compared to friends (see givon-benjio et al., 2020 for replication in individuals diagnosed with sad). while keeping more ipd to others may be a means to downregulate anxiety, breaches of an sa’s personal space by others should increase anxiety (perry et al., 2013). accord­ ingly, wieser et al. (2010) showed that high social anxiety was associated with avoiding the gaze of a virtual male agent at 1.5m ipd, while the gazes of male agents were avoided irrespective of degree of anxiety at 0.5m. sas also showed avoidance in the form of subtle backward head-movements irrespective of ipd (wieser et al., 2010). in body sway, interpersonal distance, and social anxiety 2 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ addition, closer ipd and direct gaze were associated with heart rate deceleration. these last findings are particularly intriguing as decelerations have been linked to orienting and freezing responses in the past, while accelerations is thought to indicate fearful or phobic responding (klorman et al., 1977; ruiz-padial et al., 2005; for critical discussion, see barry & maltzman, 1985). it is only since this millennium, that researchers have started to investigate human freezing behavior as reflected by reduced body sway in response to threat (azevedo et al., 2005; hagenaars et al. (2014a); roelofs, 2017; volchan et al., 2017). it is proposed that a common response to imminent (unavoidable) threat is to ‘freeze’, before flight or fight responses are triggered (blanchard, 2017; bracha, 2004; fanselow, 2022; fanselow et al., 1987; hagenaars et al., 2014a). eilam (2005), however, argued that freeze and flight responses are mutually exclusive but may, nevertheless, alternate quickly, dependent on the situation. in the same line, hagenaars et al. (2014a), suggested that when freeze/fight/ flight responding had evolved for survival purposes, it must be dynamic and flexible rather than being characterized by chronological order and lack of overlap. accordingly, fanselow (2022) postulates that, under more, context, type and direction of approaching threat determines the ‘adaptive defense threshold’ and thus the timing, kind and magni­ tude of responding. a few studies investigated freezing-like behavior in response to social threat. roelofs et al. (2010a) and noordewier et al. (2020) placed healthy participants on a stabilometric force platform and/or measured their heart-rates while passively viewing neutral, angry, and happy facial expressions. viewing angry faces was associated with freezing-related behavior, e.g., a reduction in body sway. moreover, reduced body sway was associated with increased state anxiety. in patients with sad, levitan et al. (2012), found reduced body sway irrespective of stimulus type (neutral objects, social threat, generic threat). niermann et al. (2017), investigated freezing behavior after a physiological and social stress induction (smeets et al., 2012) and found associations between diminished recov­ ery from freezing and increased internalizing symptoms (such as, e.g., social anxiety). in sum, there is reason to assume that sas show distinct postural behaviors in social interactions, and in particular when their interpersonal space is breached. yet, research assessing postural changes in human beings has seldomly looked at the impact of a trait such as social anxiety. it is particularly remarkable that all studies used static stimuli while threatening situations are typically of a dynamic nature. to our knowledge, postural balance fluctuations have not, yet, been investigated when the cause of threat is gradually approaching. in this proof-of-principle study we therefore investigated at what distances between participant and an approaching research assistant (ra), avoidance behaviors and/or freezing would occur and which role social anxiety would play herein. we expected increasingly marked backward swaying of the participant when the ra would come closer. such impulsive backward swaying would indicate embodied negative evaluation lange & hagenaars 3 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ (bargh & chartrand, 1999; niedenthal et al., 2005). in addition, we expected that freezing responses, indicated by reduced body sway, would increase with a decreasing distance between ra and participant. finally, we expected that freezing and simultaneous avoid­ ance would occur earlier (at a greater distances) with higher degrees of social anxiety. the stance of the ra (moving vs still) was controlled for. method participants in total 871 students from radboud university nijmegen (67.8% female) participated in the study with a mean age of 21.75 years (sd = 3.17), ranging from 18 to 41 years. the whole sample consisted of 75.7% individuals from dutch origin, 20.9% germans and 1.1% from other countries. with 66.7%, psychology was the predominant field of studies, followed by law (10.3%) and pedagogical sciences (8%). the remaining 15% was distributed nearly even across five other fields of studies or did not indicate a direction. the experiment took about 20–25 minutes, and, after completion, participants received a candy bar or course credit. questionnaires before the personal space task, participants completed a general screening instrument to assess sociodemographic information (e.g., age, gender, native language, education) and their height in centimeters (cm). prior to the experiment some state measures were assessed by means of visual analogue scales (vass; bond & lader, 1974). participants had to indicate on a 10 cm wide slider ranging from 0 (not at all) to 100 (extremely) how anxious they were at the very moment, how tense they felt and how much they would like to escape the situation. typically, vass have good psychometric properties (wewers & lowe, 1990). in the present study cronbach’s α was .55. after the experimental task, participants were asked to answer questions to correct for possible experimenter related variables. participants had to indicate by means of four vass how friendly, sympathetic, and attractive they evaluated the research assistant (ra) ranging from 0 (not at all) to 100 (very much). in addition, they were asked to evaluate 1) in the time that the study was conducted, preregistrations and a priori power analyses were rather uncommon, and thus not done for the current study. for power estimations, it was common to rely on the sample sizes of comparable studies (lakens, 2022). for the present study, thematically related articles indicated sample sizes between 20 (rinck et al., 2010) and 148 (kaitz et al., 2004). we strove to recruit as many participants as possible within two semesters, but at least 80. post hoc power analyses indicated that with an effect size of η2 = .25 (wieser et al., 2010) and a power of α = .80 a necessary sample size of 87 was calculated with g*power (faul et al., 2009) which coincidentally is the number of participants that we recruited.” body sway, interpersonal distance, and social anxiety 4 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ the body scent of the ra, ranging from 0 (very unpleasant) to 100 (very pleasant). in the present study, cronbach’s α for these scales was .83. level of social anxiety was assessed with the dutch self-report version (van vliet, 1999) of the liebowitz social anxiety scale (lsas; liebowitz, 1987; oakman et al., 2003). the participants indicated for 24 social situations (e.g., “talking to people in authority”) on a 4-point likert-type scale, ranging from 0 (none) to 3 (severe) how anxious they would be in these situations and how much they would avoid them from 0 (never) to 3 (usually). the psychometric properties of the scale are generally considered good (dos santos et al., 2013; heimberg et al., 1999) but the dutch version has not been officially evaluated, yet (lange et al., 2024). the internal consistencies of the total score of the lsas measured by means of cronbach’s α was .93 in the present study. in order to control for depressive symptomology often associated with social anxiety (e.g., adams et al., 2016), participants completed the dutch version of center for epide­ miological studies depression scale (ces-d; ratloff, 1977). they had to indicate how often they had experienced each of the 20 listed symptoms (e.g., “i felt depressed”) in the last week on a 4-point likert scale ranging from 0 (almost never) to 3 (almost always). ces-d has good psychometric properties (bouma et al., 2012). in the present study, cronbach’s α was .92. apparatus the questionnaires were filled in online on a standard pc via the survey-platform uni­ park (www.unipark.de). the stabilometric force platform (balance board [bb]) was a 1 m × 1 m custom-made strain-gauge force plate with a sampling frequency of 4 × 100 hz, a resolution of 0.28 n/bit and a resonance frequency of 30 hz. changes in center-of-pres­ sure (cop) were recorded in anterior-posterior (ap) direction as well as the medio-lateral (ml) direction by means of four pressure-sensitive sensors at each corner of the plate. as the bb was 16 cm high, a custom-made “catwalk” (3.20 m long and 50 cm wide) was used on which the ras could approach the participants (figure 1). to mark the distance between participant and ra in the bb data, a bell-button with 5 m cable was connected to the laptop via a custom-made button box. all bb data were recorded by presentation® software (www.neurobs.com). to record the participants’ distance estimations an olympus™ digital voice recorder was used. procedure prior to a test session, each participant was randomized to be tested by either the male or the female ra. upon arrival participants were accompanied into the lab, were informed about the test session and were asked to give informed consent. after that, they filled in the sociodemographic information, while the ra left the room. after the ra’s return, participants were informed that they were to judge the distances between themselves lange & hagenaars 5 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 http://www.unipark.de http://www.neurobs.com https://www.psychopen.eu/ and the ra who would be approaching in small steps on the catwalk. participants were instructed to not look for spatial cues in the room but to focus on the (neutral) face of the ra. whenever the ra had completed a step, they were asked to speak their estimation out loud but would not receive any response. the ra also explained that s/he would eventually come very close, but that the participant was to stay on the platform. when the participants indicated that they had understood the instructions, they were asked to take off their shoes and stand loosely but straight in the middle of the bb facing towards the “cat-walk”. the ra started the software that recorded the bb signals and the voice recorder. s/he took a position on the catwalk at roughly 3.20 m from the participant (figure 1) and held the bell-button in one hand. s/he asked if the participant was ready and if s/he could give the first estimate. then the ra looked down, pressed the button to indicate the movement part of his approach in the data, moved a 20 cm step forward to a subtly marked point on the catwalk, released the button to mark the stationary part of her/his approach and looked up at the participant. after the participant had given her/his estimation of the distance, this procedure was repeated until the ra was standing right in front of the participant at a distance of about 20 cm. this led to 16 stationary and 15 movement markers. after the last estimate the ra stepped off the catwalk to stop data-recording, while the participant remained on the platform. the ra stepped back on the catwalk at about 1.5 m and asked the participant to indicate a distance that s/he would find comfortable/would prefer for an interaction, by instructing the ra to move closer or further away. this preferred interpersonal distance (pid) was marked on the catwalk. finally, the participant put on her/his shoes and was asked to fill in the remainder of the questionnaires, while the ra left the room. at the end of the experiment, participants were debriefed, compensated, and thanked. after the participant figure 1 sketch of the balance board set-up and sensor numbering body sway, interpersonal distance, and social anxiety 6 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ had left, the ra measured and noted the preferred ips and wrote down the distance estimates by listening to the recordings. data preparation the raw data from the 4 bb sensors was processed with matlab™ software (the mathworks inc., natick, ma). from every participant the first 20 data-points (0.2 sec) were deleted. to determine a baseline from the empty bb, the following 20 data points were averaged. this mean was subtracted from each data-point with the participant on the bb to calculate a value that was solely determined by the weight of the participant and not by that of the bb. the last trial, in which the ra stopped at about 20 cm from the participant, was discarded from analyses, as this trial was terminated quicker than the previous ones to minimize the discomfort of the participants. for each of the remaining 14 distances (steps of the ra), we first calculated the mean center of pressure (cop)2 in the anterior-posterior (forward-backward; copap-mean) direction and in the medio-lateral (left-right; copml-mean) direction. copap-mean was used to determine participants mean position/leaning towards the ra or backwards/away from the ra (i.e., “avoidance” per distance and per stance), copap and copml were both used to determine the general radius of body sway an indicator of the variability in body sway per distance and ra stance3. a reduction in posture mobility is typically seen as index of “freezing” responses (azevedo et al., 2005; hagenaars et al., 2012; roelofs et al., 2010a). statistical analyses to investigate whether participants respond with avoidance and/or freeze behaviors when being approached and how these behaviors relate to degrees of social anxiety, separate repeated measures mancovas were conducted: one for avoidance in ap direction with copap-mean direction as dependent variable, and one for magnitude of movement with movement radius as dependent variable. distance in steps (14 à 20 cm) and the ra’s stance (move vs still) were independent within-subject variables. the total scores of lsas and ces-d, participants’ pid, as well as their ratings of the ras' friendli­ ness, sympathy, attractiveness, and body scent were added as covariates. whenever the assumptions of univariate testing were violated in any of the analyses, more conservative tests with corrections of degrees of freedom were used (i.e., huynh-feldt). 2) cop_ap = ((f1 + f2) – (f3 + f4) / (f1 + f2 + f3 + f4)) * (1000/2). cop_ml = ((f1 + f3) – (f2 + f4) / (f1 + f2 + f3 + f4)) * (1000/2). for sensor numbering, see figure 1; 1000 represents the distance between the bb sensors in millimeters. 3) r = √(cop_x^2 + cop_y^2). we selected the radius because it provides a complete indication of changes in body sway (including diagonal movements), while the sd of, e.g, the cop_ap only indicates the radius of body sway in ap direction, deprived of the ml component. lange & hagenaars 7 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ results participants and research assistants first, randomization of participants to ras had been successful: there was no difference in gender ratio allocated to the female (28 female:14 male) or male (31 female:14 male) ra, χ2(1, n = 87) = 0.05, p = .83. in addition, a one-way-anova was used to test whether age, questionnaire-scores, and state measures differed between female and male participants. there were no significant differences on any of these measures between the genders, all f’s < 2.0, all p’s > .16 (table 1). by means of a manova it was explored whether female and male participants evaluated the ra differently, regarding friendliness, sympathy, attractiveness, or body scent. again, no significant differences emerged, all f’s < 2.18, all p’s > .08. finally, as would be expected, pearson’s correlations revealed that degree of social anxiety (lsasmin = 5, lsasmax = 93) correlated positively with self-reported state anxiety at the beginning of the test session, r(87) = .28, p = .01, with tension/arousal, r(87) = .26, p = .02, and with number of depressive symptoms, r(87) = .58, p < .001. table 1 mean (m), standard deviations (sd), of age, questionnaires, state measures and ratings of the research assistants per participant gender ♀ ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ ♂ n 59 28 59 28 59 28 59 28 59 28 age lsastotal ces-dtotal vasanx. vasarousal m 21.64 21.96 37.49 34.93 12.88 11.71 12.03 8.07 20.07 23.57 sd 3.41 2.63 17.90 13.22 10.03 8.02 16.35 7.88 17.85 21.41 vasavoid rafriend. rasymp. raattract. raodor m 11.08 8.57 73.69 74.36 68.27 69.14 37.53 42.64 58.10 54.71 sd 16.10 10.43 21.55 21.08 23.82 21.74 22.49 25.06 19.51 20.66 note. lsas = liebowitz social anxiety scale; ces-d = center of emotion scale-depression; vasanx. = visual analogue scale (vas) for state anxiety; vasarousal = vas for state arousal; vasavoid = vas for state avoidance; rafriend. = reseach assistant (ra) rating of friendliness; rasymp = ra rating of sympathy; raattract. = ra rating of attractiveness; raodor = ra rating of body odor. four participants had to be excluded from further analyses because of erroneous bb data recordings, resulting in 83 participants for testing the main research questions. body sway, interpersonal distance, and social anxiety 8 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ interpersonal distance, social anxiety and avoidance (leaning backwards) the only significant result concerned the three-way interaction of distance × ra stance × social anxiety on copap-mean, f(12.04, 902.67) = 1.82, p = .041, η2 = .024. the remaining main effects and two-way interactions were not significant, all f’s < 2.52, all p’s > .11. to explore the three-way interaction in more detail, identical analyses were conduc­ ted but for the ‘moving’ and the ‘still’ stance separately. the critical interactions of dis­ tance × social anxiety were not significant f’s < 1.26, p’s > .26. the parameter estimates reveal that numerous distances of moving ras are tendentiously related to social anxiety, while only two are for stationary ras (table 2). this difference between moving and standing still may have caused the observed three-way interaction but the conclusion must be that, neither social anxiety, distance to the participant nor the stance of the ra had any effect on the copap-mean (figure 2: for visualization purposes participants were subdivided in three groups based on their lsas scores: the 33.3% scoring lowest (score ≤ 29), 33.3% scoring highest (score ≥ 39), and those scoring in-between).4 interpersonal distance, social anxiety and body sway (freezing) there was a non-significant trend of social anxiety, f(1, 75) = 3.57, p = .063, η2 = .045, in­ dicating that increases in social anxiety were associated with more participant movement in general. the interaction of distance × social anxiety was significant, f(8.19, 614.34) = 2.33, p = .017, η2 = .03. this indicates that, with increasing levels of social anxiety, participants’ movability was increased as well, but only for some of the distances. all remaining main effects, two-way and three-way interactions were not significant, all f’s < 1.26, p’s > .10.5 the parameter estimates revealed (marginal) significant effects of social anxiety at different distances (table 3). in sum, it seems that sas tend to move about more, when being approached by an unknown other. this movability seems to peek at about 180 cm and 160 cm distance between ra and participant (for visualization see figure 3). 4) explorative analyses with these group divisions as between-subject factor revealed comparable results. in addition, based on suggestions of an anonymous reviewer, we conducted the originally planned analyses but added participant gender as between-subject factor and omitted preferred distance, ra friendliness, -sympathy, -attractiveness and -body odor as covariates. again, the results did not change considerably. 5) analyses conducted with the standard deviations of the copap yielded similar results. lange & hagenaars 9 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ table 2 parameter estimates of leaning behavior per distance and ra stance correlated with social anxiety scores stance and distance b se t p 95% ci η2ll ul still 300 cm -.262 .177 -1.478 .144 -.615 .091 .028 280 cm -.304 .170 -1.791 .077† -.643 .034 .041 260 cm -.230 .170 -1.351 .181 -.570 .109 .024 240 cm -.294 .180 -1.635 .106 -.652 .064 .034 220 cm -.316 .177 -1.785 .078† -.670 .037 .041 200 cm -.226 .176 -1.282 .204 -.577 .125 .021 180 cm -.282 .190 -1.489 .141 -.660 .095 .029 160 cm -.265 .185 -1.432 .156 -.635 .104 .027 140 cm -.288 .181 -1.591 .116 -.648 .073 .033 120 cm -.282 .184 -1.529 .130 -.650 .085 .030 100 cm -.278 .180 -1.540 .128 -.637 .081 .031 80 cm -.296 .190 -1.562 .122 -.674 .082 .032 60 cm -.235 .187 -1.259 .212 -.608 .137 .021 40 cm -.144 .186 -.770 .444 -.515 .228 .008 moving 300 cm -.271 .168 -1.607 .112 -.606 .065 .033 280 cm -.188 .166 -1.130 .262 -.519 .143 .017 260 cm -.305 .168 -1.812 .074† -.639 .030 .042 240 cm -.324 .180 -1.804 .075† -.682 .034 .042 220 cm -.332 .183 -1.810 .074† -.697 .033 .042 200 cm -.289 .169 -1.709 .092† -.626 .048 .037 180 cm -.239 .177 -1.351 .181 -.590 .113 .024 160 cm -.101 .187 -.539 .592 -.473 .272 .004 140 cm -.339 .191 -1.774 .080† -.719 .042 .040 120 cm -.311 .183 -1.699 .093† -.675 .053 .037 100 cm -.342 .175 -1.948 .055† -.691 .008 .048 80 cm -.339 .189 -1.796 .077† -.714 .037 .041 60 cm -.250 .184 -1.361 .177 -.616 .116 .024 40 cm -.229 .189 -1.212 .229 -.606 .148 .019 †p < .1. *p < .05. body sway, interpersonal distance, and social anxiety 10 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ figure 2 mean center of pressure per distance note. mean center of pressure in anterior-posterior direction (copap-mean) and standard errors per distance to participant and participants’ degree of social anxiety as measured with liebowitz social anxiety scale (lsas) for (a) research assistant (ra) moving and (b) ra standing still. a more negative score reflects more leaning backwards/away from the ra. lange & hagenaars 11 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ table 3 parameter estimates of body sway per distance and ra stance correlated with social anxiety score stance and distance b se t p 95% ci η2ll ul still 300 cm .009 .041 .215 .831 -.073 .090 .001 280 cm .011 .051 .214 .831 -.092 .114 .001 260 cm .078 .037 2.074 .042* .003 .152 .054 240 cm .010 .036 .285 .776 -.062 .083 .001 220 cm .022 .026 .821 .414 -.031 .074 .009 200 cm .008 .029 .260 .795 -.051 .066 .001 180 cm .127 .039 3.244 .002* .049 .206 .123 160 cm .072 .028 2.530 .014* .015 .129 .079 140 cm .051 .039 1.324 .189 -.026 .128 .023 120 cm .060 .025 2.401 .019* .010 .110 .071 100 cm -.019 .021 -.904 .369 -.061 .023 .011 80 cm .030 .021 1.390 .169 -.013 .072 .025 60 cm -.006 .017 -.351 .727 -.039 .028 .002 40 cm .026 .027 .980 .330 -.027 .080 .013 moving 300 cm -.004 .026 -.149 .882 -.056 .049 .000 280 cm .024 .028 .853 .396 -.032 .079 .010 260 cm .049 .023 2.138 .036* .003 .095 .057 240 cm .055 .023 2.368 .020* .009 .102 .070 220 cm .051 .027 1.938 .056† -.001 .104 .048 200 cm .024 .019 1.300 .198 -.013 .062 .022 180 cm .019 .025 .784 .436 -.030 .069 .008 160 cm .081 .039 2.107 .038* .004 .158 .056 140 cm .039 .019 2.011 .048* .000 .078 .051 120 cm .043 .022 1.991 .050† -.000 .086 .050 100 cm -.007 .029 -.229 .819 -.065 .051 .001 80 cm .001 .018 .030 .976 -.035 .036 .000 60 cm .012 .018 .689 .493 -.024 .049 .006 40 cm -.017 .018 -.927 .357 -.053 .019 .011 †p < .1. *p < .05. body sway, interpersonal distance, and social anxiety 12 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ figure 3 mean body sway per distance note. mean radius (body sway) per distance to participant and participants’ degree of social anxiety as measured with liebowitz social anxiety scale (lsas). a higher score reflects more/larger movements in body posture irrespective of moving/stationary stance. preferred interpersonal distance and social anxiety to explore the relationship between social anxiety and the preferred interpersonal dis­ tance (pid) when interacting with a stranger, pearson’s correlations were calculated, two-tailed. participants’ lsas scores were not related to pid, r(87) = -.02, p = .83 (m = 73.37 cm, sd = 16.45; ipsmin = 45, ipsmax = 157). explorative analyses to explore effects that are not (directly) related to the current research question, several additional analyses were performed. correlations pid was negatively correlated with how attractive the ra was found, r(87) = -.26, p = .02: the more attractive the ra was evaluated, the closer participants positioned the ra to indicate their comfortable interpersonal distance. with regard to body sway it was found that mobility and evaluations of the ra’s body scent were positively correlated, r(87) = .24, p = .03: the more pleasant the ra’s body scent was, the more the participants moved about. it was also found that state arousal and mobility were negatively correlated, r(87) lange & hagenaars 13 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ = -.22, p = .049: the more participants felt aroused and tense at the beginning of the test session, the less they moved about during the task. gender to explore possible influences of participant gender, we also added this variable to the above-mentioned repeated measures mancovas. this, however, had no influence on any of the statistical effects that were described above. distance estimates finally, we explored whether the distance estimates that participants gave per step of the ra, were influenced by any of the relevant factors mentioned above. as would be expected, there was a main effect of distance f(1.87, 147.7) = 5.23, p = .008, η2 = .062, indicating that participants’ distance estimates declined with each step that the ra moved closer. no other relevant effect was found. discussion we investigated if decreasing interpersonal distance was related to subtle avoidance (backward leaning) and increased freezing-like behavior (reduced body sway), as well as the role of social anxiety here in. to test this, we used a stabilometric platform to measure objective movements accurately and applied it to a dynamic stranger-approach paradigm in a proof-of-principle study. against expectations, the distance between the approaching ra and the participant had no general effect on avoidant body posture or freezing-like behavior. typically, one would have expected that an approaching, unfamiliar person would make participants retreat, at least when their personal space was breached. this was indeed partially demonstrated by wieser et al. (2010). in a vr setting, participants made backward head movements and avoided eye gaze of approaching male digital agents at an uncomfortable 50 cm distance. however, they used fixed distances where the agents stopped (0.5 and 1.5 m) instead of dynamic distance changes as used in our study and in our study gaze avoidance was undermined by instructing participant to look the ra in the eyes. yet, our study could have shown similar results as backward head movements should be readily reflected in our sensitive measure of body posture. unexpectedly, social anxiety did not have any influence on avoidant body posture when the interpersonal distance decreased. this is not in line with the results of wieser et al. (2010) and rinck et al. (2010). the embodied cognition theory suggest that automatic evaluative/emotional responses towards environmental stimuli are readily reflected in associated impulsive bodily responding (and vice versa: van dantzig et al., 2009). thus, higher degrees of social anxiety should have increased the salience of the experimental situation as social and potentially threatening, which should have been body sway, interpersonal distance, and social anxiety 14 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ reflected in automatic bodily avoidance. numerous studies using prototypical approachavoidance tasks based on joystick-movements towards social stimuli, found such auto­ matic avoidance behavior towards angry but not neutral faces in highly socially anxious individuals (e.g., heuer et al., 2007; lange et al., 2008; roelofs et al., 2010b). it is possible that particularly angry faces as representation of prototypical threat evoke threat-related avoidance responses in sas while approaching, neutral looking ras might be merely unpleasant but inapt to evoke threat responding (lange et al., 2014) as observed in our study. body sway, on the other hand, was influenced by participants’ degree of social anxiety interacting with the distance of the ra. interestingly, the pattern was opposite to what was expected: participants with high levels of social anxiety showed increased bod­ ily movement at 260cm, and between 200cm and 100cm distance, with a peak at 180cm. these results seem to contradict numerous previous studies that found reduced move­ ment in response to threat in unselected samples (e.g., azevedo et al., 2005; hagenaars et al., 2014b; roelofs et al., 2010a). studies with participants showing characteristics rela­ ted to social anxiety, however, reported more contradictory results. for example, while insecure attachment was associated with increased freezing-like responding (niermann et al., 2015), internalizing symptoms were not (niermann et al., 2017). two studies found no effects of stimulus valence but instead general reductions of body sway throughout the experiment (social anxiety disorder: levitan et al., 2012; panic disorder: lopes et al., 2009), and one study found reduced body sway for blocks with painful stimuli, but not modulated by social context (karos et al., 2020). importantly, there is also evidence for a lack of freezing behavior in psychopathology. stoffels et al. (2017), for example, reported reduced heart rate (typically associated with freezing) in response to aversive pictures in healthy controls but not in patients with borderline personality disorder. in the same line, fragkaki et al. (2017) discovered attenuated freezing responses in patients with posttraumatic stress disorder. finally, hagenaars et al. (2015) found that heart rate reductions (indicative of freezing) were absent when participants were prepared for the aversive stimuli but not when being unprepared. warning participants in the current study about the (very intimate) approach of the ra might have prevented the evaluation of the situation as threatening and may have undermined typical threat related respond­ ing. this is also compatible with fanselow’s (2022) idea that context and type of threat can influence the timing, type and degree of defensive responding. taken together with trower and gilbert's (1989) evolutionary approach that social anxiety is not so much determined by imminent threat of death but more by survival related resources, freezing may be less likely in the approaching stranger context than other behavior that signals discomfort or unease. note that higher degrees of state anxiety at baseline, irrespective of social anxiety, were associated with decreased body sway/freezing, indicating that our measure was sensible enough to pick up freezing-like behavior when participants are stressed. this is lange & hagenaars 15 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ in line with previous work from, e.g., hagenaars et al. (2014b) or roelofs et al. (2010a). it might be that particularly state assessments of subjective experiences of stress/fear are more directly linked to physiological and automatic behavioral responding. our assessment of sa, however, is more based on anxiety traits that may not necessarily be related to the stress levels in this particular situation. true is, that, in general, state stress and trait sa are positively correlated, but the predictability of our specific procedure may have evoked an attitude often observed with high functioning sas: knowing the job, getting it done, with nervous fidgeting and restless movements indicating discomfort (heerey & kring, 2007; voncken et al., 2008, 2012) but no pronounced fear reaction. in line with this notion, research has indicated that sa is a heterogeneous condition based, under more, on distorted interpretations and evaluations of environmental cues and social situations (clark, 2001; hofmann, 2007; rapee & heimberg, 1997). as indicated above, fanselow (2022) as well as trower and gilbert (1989) acknowledge that decreases in adaptive defense thresholds are highly related to subjective evaluations and interpre­ tations of the context. it is therefore thinkable that high degrees of social anxiety are generally related to increased stress in a situation, but that it is primarily the degree of sa in these healthy participants that allows for evaluating the situation as unpleasant but not threatening which then could determine their subtle behavior accordingly. it is important to note that the social anxiety levels of this particular sample were unexpect­ edly higher than is typical of a student sample. if the range between a score of 30–60 on the lsas marks mild to moderate degrees of social anxiety then about 54% of the participants fall in that range. about 10% score 60 or higher which might be indicative of a clinically relevant degree of social fears (mennin et al., 2002; rytwinski et al., 2009). in sum, increases of body sway may be more indicative of general unease with or nervousness in a situation rather than reflecting the expectation of eminent threat. for our understanding of social anxiety, this could mean that sas show subtle signs of discomfort in a social situation. once noticed by interaction partners they may feel uncomfortable themselves and may start disliking the situation, thereby fulfilling the sas ‘prophecy’ of being disliked by others (asher et al., 2020; tschacher et al., 2014). remarkably, we found differences in body sway between high and low socially anxious individuals when the ras were at a moderate distance. that is, ra-distance related changes in body sway were in the form an inverted u-shape. especially on the uncomfortably short distances, one would have expected anxiety related effects to be strongest. this may have been a floor effect: the unnaturally close interpersonal distances are likely to be perceived as highly unpleasant for everyone, irrespective of social fears (bailey et al., 1972; dosey & meisels, 1969; hayduk, 1983). but exaggerated threat interpretations and resulting anxiety responses in social anxiety become primarily apparent in ambiguous situations and not necessarily in situations that actually are highly uncomfortable or threatening. in addition, subtle signs of discomfort and unease, body sway, interpersonal distance, and social anxiety 16 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ rather than obvious ones, would manifest in a distance range where normal social interactions take place and not at a far distance, when there is clearly no social threat. irrespective of these results, a few limitations need to be considered. as indicated above, the predictability of what participants could expect may have diminished the experience of threat and related behaviors. luo et al. (2019) found indeed that task instructions can readily attenuate automatic responding to emotional stimuli. in addition, our participants were, of course, free to leave the situation whenever unbearable while freezing-like behavior may be more likely to occur without (knowledge of) escape options (compare: clark, 1993; sanderson et al., 1989). for example, buss et al. (2004) found that children responded with more freezing to an approaching stranger when they were restrained in a high-chair instead of freely playing. finally, while our setup was considerably more dynamic than, e.g., that of wieser et al. (2010), approaching participants in steps rather than in a continuous motion in combination with distance judgements may still be suboptimal and decrease ecological validity. future research should delineate specific responses to dynamic social interactions and distinguish social threat from social discomfort herein to provide the most ecologically validity when measuring subtle behavior. although not consistently supported in sa research (e.g., cheng et al., 2022), the addition of physiological measures to the current study setup may help to further the understanding of subtle behaviors in social interactions. to conclude, with our new experimental setup, we found that high degrees of social anxiety were associated with deviations from subtle ‘default’ behaviors seen as normal in social interaction: sas showed increased movement when their own personal space was intruded. future research may explore whether such behavior elicits feelings of discomfort in others, and if so, whether that would lead to true negative evaluation of sas. treatments may target these subtle behaviors to break this vicious circle. if psycho­ therapy, “primarily tackles faulty cognitions while there is a considerable probability that the fear of negative evaluation is justified, chances of substantial and sustained recovery are undermined.” (lange et al., 2014, p. 360). lange & hagenaars 17 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ funding: this research was partially supported by a grant awarded by the netherlands organization for scientific research [nwo]) to muriel a. hagenaars (veni #451-09-018) as well as additional funding by the experimental psychopathology & treatment program of the behavioural science institute at radboud university nijmegen, the netherlands. acknowledgments: we would like to thank aniek pijl and olaf van der lecq for their great effort in literally approaching (recruiting and testing) all the participants. in addition, we would also like to thank all our participants for furthering our research by enduring these close encounters. competing interests: neither of the authors has any conflict of interest regarding (the publication of) this research. ethics statement: the current study was carried out in accordance with apa ethical principles and with the provisions of the world medical association declaration of helsinki (2013). it received a general approval by the ethics committee of the faculty of social sciences of radboud university nijmegen (the netherlands) as education related research. this implies that no diagnosed, vulnerable and/or underage samples were tested, and no interventions/manipulations/stress inductions were taking place. reporting guidelines: to the best of our knowledge we adhered to the jars quant guidelines of reporting quantitative research. preregistration: in the time that the study was conducted, preregistrations and a priori power analyses were rather uncommon, and thus not done for the current study. data availability: research material and data will be available upon request. references adams, g. c., balbuena, l., meng, x. f., & asmundson, g. j. g. 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treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. lange & hagenaars 25 clinical psychology in europe 2025, vol. 7(3), article e15365 https://doi.org/10.32872/cpe.15365 https://www.psychopen.eu/ body sway, interpersonal distance, and social anxiety (introduction) method participants questionnaires apparatus procedure data preparation statistical analyses results participants and research assistants interpersonal distance, social anxiety and avoidance (leaning backwards) interpersonal distance, social anxiety and body sway (freezing) preferred interpersonal distance and social anxiety explorative analyses discussion (additional information) funding acknowledgments competing interests ethics statement reporting guidelines preregistration data availability references a systematic review of evidence-based cognitive and/or behavioural interventions targeting mental health in lgbtq+ populations systematic reviews and meta-analyses a systematic review of evidence-based cognitive and/or behavioural interventions targeting mental health in lgbtq+ populations carina tudor-sfetea 1 , raluca topciu 1 [1] cedar (clinical education development and research), university of exeter, exeter, united kingdom. clinical psychology in europe, 2024, vol. 6(3), article e11323, https://doi.org/10.32872/cpe.11323 received: 2023-02-13 • accepted: 2024-05-06 • published (vor): 2024-09-30 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: carina tudor-sfetea, washington singer laboratories, university of exeter, perry road, prince of wales road, exeter, ex4 4qg, uk. telephone number: +447990572937. e-mail: c.tudor-sfetea@exeter.ac.uk supplementary materials: data, materials, preregistration [see index of supplementary materials] abstract background: despite a minority stress-related higher risk to develop mental health difficulties, and problematic access to and treatment from healthcare providers, research into lgbtq+ mental health support is limited. the aims of this systematic review were to explore evidence-based cognitive and/or behavioural interventions and adaptations targeting mental health in lgbtq+ populations, before providing recommendations for future clinical and research directions. method: six databases were searched in february-march 2022 and risk of bias evaluated using the cochrane rob 2/robins-i tools. a narrative synthesis following the picos framework and the review questions was used to examine the results. results: sixteen studies met inclusion criteria, including various interventions and adaptations, mental health difficulties, and other emotionand minority stress-related processes/constructs. risk of bias was judged as high, and critical/serious, respectively, in all studies. outcomes included improvements in symptoms of depression (most statistically/clinically significant effects/large effect sizes), and anxiety, emotion regulation, and internalised homophobia in the pre-post studies. conclusion: cognitive/behavioural interventions and adaptations for lgbtq+ populations feature a range of therapeutic modalities and levels of adaptation, with largely positive effects, in the context of limited and heterogenous literature and risk of bias concerns, as well as limitations related to publication bias and inclusion criteria of the current work. suggestions for future clinical and research directions include a focus on generic therapeutic competencies and this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.11323&domain=pdf&date_stamp=2024-09-30 https://orcid.org/0000-0002-5494-4731 https://orcid.org/0000-0002-3242-1200 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ metacompetencies, and affirmative, potentially more holistic approaches, as well as more consistency in methodology, more focus on underserved lgbtq+ populations and intersectionality, and more detailed investigations into mechanisms of change. keywords lgbtq+, systematic review, mental health, cognitive behavioural interventions highlights • research findings on evidence-based mental health support for lgbtq+ individuals are positive, but the literature is limited, heterogenous, and there are risk-of-bias concerns. • more work is needed around affirmative approaches, consistency in methodology, mechanisms of change, and underserved lgbtq+ populations and intersectionality. rationale lgbtq+ individuals (who identify as lesbian, gay, bisexual, transgender, queer, or with any other non-heterosexual and/or non-cisgender identity) experience a disproportion­ ately higher rate of mental health difficulties compared to heterosexual and/or cisgen­ der individuals (pinna et al., 2022; plöderl & tremblay, 2015). this disparity has been attributed at least partly to stigma-related stressors, with perhaps the most important framework addressing this being the minority stress theory (brooks, 1981; meyer, 1995, 2003; reviewed in hoy-ellis, 2023; tan et al., 2020) alongside its extensions, particularly hendricks and testa’s (2012) work exploring gender identity stressors. herein, distal (external, objective) factors – victimisation, prejudice, and discrimina­ tion, and the likely resulting proximal (internal, subjective) factors – concealment of one’s identity, prejudiceand rejection-related anxiety and expectations, and internalised homoand transphobia, are thought to contribute to a set of differences in cognitions, emotions, and behaviours which drive and maintain mental health disparities transdiag­ nostically (meyer, 2003; nicholson et al., 2022; pachankis, 2015). the effects of these factors have been widely documented (gnan et al., 2019; testa et al., 2017). a complicat­ ing, yet crucial, consideration, is that of the intersection of various sexual identities with other racial, ethnic, social, and gender identities, with individuals with multidimensional minority status facing unique challenges (balsam et al., 2011; dale & safren, 2019). various mechanisms have been proposed in the context of minority stress. these include: alterations in emotion regulation, social/interpersonal dynamics (e.g., isolation), and cognitive processes (e.g., negative self-schemas; hatzenbuehler, 2009); disruptions of negative valence systems (avoidance, hypervigilance, loss), positive valence systems (ap­ proach motivation, reward learning – associated with impulsivity/addictive behaviours), social functioning (e.g., disrupted attachment, low agency, poor social communication; lgbtq+ mental health interventions 2 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ pachankis, 2015), and anticipatory emotions/behaviours as well as cognitions around the expectation of rejection (feinstein, 2020). biological mechanisms (flentje et al., 2020) and neuroimaging/neural correlates (nicholson et al., 2022) have also been documented. despite these significant vulnerabilities, access to and treatment for mental health seems to be problematic for lgtbq+ populations (e.g., mccann & sharek, 2014; steele et al., 2017). while some limited research has documented poorer psychological treatment outcomes for some lgbtq+ populations (beard et al., 2017; rimes et al., 2019), there is generally a paucity of literature (e.g., data pertaining to sexual orientation and gender identity is often omitted in research on psychological interventions for mental health – heck et al., 2017). this speaks to the need for tailored mental health interventions for this population, and crucially, thorough research into their effectiveness. others have reviewed interventions targeting mental health and/or health behav­ iour in various lgbtq+ sub-populations. in their systematic review and meta-analysis, pantalone et al. (2020) focused on behavioural interventions targeting psychosocial syn­ demics and hiv-related health behaviours for sexual minority men, reporting significant improvements with small effect sizes in mental health, while a systematic review by melendez-torres and bonell (2014) found improvements related to sexual risk behaviour following a cbt (cognitive behavioural therapy) intervention in substance-using men who have sex with men, although the evidence was evaluated to be of moderate quality. focusing on lgbtq+ youth mental health, hobaica et al. (2018) found support for the effectiveness of a range of intervention modes, including in-person, computerised, online, as well as individual and group. sheinfil et al. (2019) investigated adapted psy­ chotherapeutic interventions for depression, while van der pol-harney and mcaloon (2019) found cbt to be an effective therapeutic framework. bochicchio et al. (2022) also reported preliminary evidence for effectiveness of a variety of psychotherapeutic interventions. this work has, however, either mainly focused on health behaviour rather than mental health, therefore not including details around intervention components, outcome measures, and their relationship to minority stress (pantalone et al., 2020); on specific genders or populations known to present with unique challenges (sexual minority men including those hiv-positive or at risk – pantalone et al., 2020; substance-using sexual minority men – melendez-torres & bonell, 2014; young people – bochicchio et al., 2022; hobaica et al., 2018; van der pol-harney & mcaloon, 2019), therefore making generali­ sations limited; or on particular diagnoses rather than more widely/transdiagnostically which would be more in line with minority stress factors and mechanisms (sheinfil et al., 2019). few, if any reviews have adopted a wider/more general lens on lgbtq+ populations of any age, focusing on psychotherapies for mental health and their adaptations, their components, their outcomes, and their relationship to transdiagnostic minority stressors; this review aims to bridge this gap. as cbt has a rich evidence base for several mental tudor-sfetea & topciu 3 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ health difficulties (hofmann et al., 2012), and importantly, offers a framework by which to understand and explore minority stressors (i.e, relationships among cognition – e.g., negative self-schemas, emotion – e.g., emotion regulation, anxiety, shame, and behaviour – e.g., isolation, avoidance), the review will focus on this psychotherapeutic model. objectives the aim of this systematic review is to explore the landscape of the scientific literature on evidence-based cognitive and/or behavioural interventions and adaptations targeting mental health in lgbtq+ populations, by answering the following questions: 1. what evidence-based cognitive and/or behavioural interventions for lgbtq+ populations exist, and what, if any, specific adaptations do they involve? 2. what are the outcomes of evidence-based cognitive and/or behavioural interventions and adaptations targeting mental health in lgbtq+ populations? 3. what recommendations could be made in terms of such adaptations in clinical practice? method guidelines and registration this systematic review was carried out in accordance with the updated prisma guide­ lines (page et al., 2021), and registered on prospero (international prospective register of systematic reviews) in april 2022 (crd42022243466) – please see tudor-sfetea and topciu, 2024s, appendix a for more information regarding deviations from this preregis­ tration. no ethics approval was required due to the nature of the work. eligibility criteria studies had to be published or in press in peer-reviewed journals, in english; no time limits for publication were enforced. pre-prints were considered, while other grey litera­ ture was excluded. the studies also had to fulfil the criteria outlined in table 1, following the picos framework (population, intervention, comparison, outcomes, study designs, higgins et al., 2023). please see more details on these decisions in the discussion section, and in tudor-sfetea & topciu, 2024s, appendix b. information sources eligible studies were sourced from: embase, medline, psycinfo, psychextra, web of science, cochrane library (advanced search), via searches between 19.02.2022 and 10.03.2022. lgbtq+ mental health interventions 4 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ table 1 inclusion and exclusion criteria according to the picos framework inclusion exclusion population lgbtq+ individuals or individuals reporting distress over minority stressrelated issues, of any age, sex, gender, sexual orientation, race, and ethnicity; including people identifying as gay, lesbian, bisexual, pansexual, demisexual, asexual, queer, transgender, genderqueer, genderfluid, nonbinary studies with hiv-positive participants where no separate results for participants with negative or unclear hiv status were reported, as well as studies with people with substance dependence as a main presenting problem interventions evidence-based individual and group-based cognitive behavioural interventions; including cognitive behavioural therapy (cbt), behaviourbased interventions such as exposure or exposure and response prevention (erp), as well as third-wave cbt interventions, including acceptance and commitment therapy (act), mindfulness-based interventions such as mindfulness-based stress reduction (mbsr) and mindfulness-based cognitive therapy (mbct), dialectical behaviour therapy (dbt), behavioural activation (ba), or compassion focused therapy (cft); delivered in any settings, including outand inpatient settings, charity organisations, educational settings, or any other community or home settings; and via any medium, including in person, videoconference, telephone, live-chat interventions with only a minimal cognitive or behavioural component, and couple-specific interventions; self-help interventions with no direct therapist involvement comparison active control (i.e., other interventions for mental health; treatment-asusual), inactive control (i.e., waitlist), or no control group outcomes outcomes in the domain of common mental health difficulties; including studies with outcomes related to, e.g., symptoms of depression, anxiety and any anxiety disorders, obsessive-compulsive disorder (ocd) and body dysmorphic disorder (bdd), health anxiety, post-traumatic stress disorder (ptsd), and minority stress, as well as psychological flexibility and quality of life/subjective wellbeing, assessed via validated questionnaires studies with outcomes related solely to sexrelated health behaviour, as well as drug use study designs quantitative studies or the quantitative aspects of mixed-method studies; including randomised controlled trials (rcts), controlled/experimental studies such as controlled trials, open trials/studies/pilots, pilot trials/ studies, case-control studies, effectiveness studies without a control group (e.g., pre-post effect size), feasibility or acceptability studies qualitative studies, as well as published study protocols and reviews search strategy search terms based on the picos framework were used to determine mesh (medical subject heading) terms where applicable, and perform searches using these as well as keyword searches, combined with boolean logic, or/and – a table of the search terms, and a link to the full search strategy/history are available in tudor-sfetea and topciu, 2024s, appendix c. tudor-sfetea & topciu 5 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ results were exported into ris and microsoft excel files, before being imported into covidence (veritas health innovation, 2022), a screening and data extraction tool recommended for cochrane authors. selection process duplicates were automatically removed in covidence. reference titles and abstracts were then screened by the first author and categorised as “yes”, “no”, “maybe”, before reviewing the full texts of the “yes” and “maybe” references. a second reviewer followed the same process for a randomly-selected subset, at both stages (approximately 20%; n = 51, n = 5 respectively). disagreements (n = 5 at title and abstract screening stage, none at full text review stage) were resolved by discussion and revisiting/clarification of criteria, with consensus reached throughout. data collection process data were extracted using customised forms on covidence, based on the cochrane data collection forms for intervention reviews. the forms were piloted on one randomly selected study, and further refined. a subset (12.5%, n = 2) of the extracted data were checked for accuracy by the second reviewer; no disagreements occurred. a link to a more extensive, raw data table is available in tudor-sfetea and topciu, 2024s, appendix d. study risk of bias assessment all included studies were assessed for risk of bias. there seems to be no agreed standard to evaluate the quality of psychotherapy outcome research; instead, a heterogeneity of tools are available, with the cochrane tools or adapted versions thereof more common (munder & barth, 2018). therefore, the cochrane risk-of-bias tool for randomised trials (rob 2) (sterne et al., 2019) for randomised studies, and the risk of bias in non-rando­ mised studies of interventions (robins-i) tool (sterne et al., 2016) for non-randomised studies were used, consistent with prisma guidelines (page et al., 2021), and to align to the majority of previous research, encouraging consistency and reproducibility. the tool domains were evaluated categorically as low, high, or some concerns (rob2), or low, moderate, serious, critical, or no information (robins-i), in line with the sig­ nalling questions and guidance (sterne et al., 2019; sterne et al., 2016, respectively). customised quality assessment templates on covidence were used. a subset (12.5%, n = 2) of the studies were also evaluated by the second reviewer; no disagreements occurred. synthesis methods due to the limited number of included studies and the heterogeneity of results in terms of study designs and outcomes, following scoping/initial searches, the data were deemed lgbtq+ mental health interventions 6 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ not appropriate for quantitative synthesis. therefore, a narrative synthesis considering the “synthesis without meta-analysis" (swim) guidelines (campbell et al., 2020), as well as tables and figures, were used to summarise and explain the characteristics of the included studies. results study selection a total of 411 records were identified and imported into covidence, with 152 records au­ tomatically identified as duplicates and removed. of the remaining 259 records, 231 were excluded following title and abstract screening, resulting in 28 records eligible for full text review. twelve of these were then excluded as they did not meet the review criteria; see tudor-sfetea and topciu, 2024s, appendix e for a detailed overview. therefore, 16 records were included. the prisma flow diagram in figure 1 outlines this process. study characteristics table 2 summarises study and sample characteristics. studies have been numbered for clarity (chronologically, starting with the oldest, grouped by rcts, then non-rcts), and will be referred to by their allocated numbers from now on. please see tudor-sfetea and topciu, 2024s, appendix f for a narrative summary of study and sample characteristics. interventions, adaptations, and results table 3 summarises the interventions, adaptations, and results of each of the included studies. what evidence-based cognitive and/or behavioural interventions for lgbtq+ populations exist, and what, if any, specific adaptations do they involve? cbt-based interventions: eleven studies involved cbt-based interventions, five of which featured the esteem (effective skills to empower effective men) intervention, or interventions based on it. esteem was adapted via interviews with key stakeholders, including gay and bisexual men with depression and anxiety and expert providers, from barlow et al.’s (2011) unified protocol to improve minority stress coping through emo­ tion regulation, cognitive restructuring, and assertiveness training (identifying minority stress experiences; tracking cognitive, affective, and behavioural reactions to minority stress; attributing distress to minority stress rather than to personal failure; pachankis, 2014; pachankis et al., 2015). tudor-sfetea & topciu 7 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ figure 1 prisma flow diagram outlining the process of study selection figure 1. prisma flow diagram outlining the process of study selection. records identified from: databases (n = 411) cochrane (n = 62) embase (n = 138) medline (n = 64) psychextra (n = 15) psychinfo (n = 48) web of science (n = 84) records removed before screening: duplicate records removed by automation tools (n = 152) records screened (n = 259) records excluded by reviewer (n = 231) reports sought for retrieval (n = 28) reports not retrieved (n = 0) reports assessed for eligibility (n = 28) reports excluded (n = 12): did not meet population inclusion/exclusion criteria (n = 3) conference abstract (n = 2) unpublished/dissertation (n = 2) did not meet intervention inclusion/exclusion criteria (n = 2) not differentiating lgbt (n = 1) did not meet route of administration inclusion/exclusion criteria (n = 1) wrong study design (n = 1) reports included in review (n = 16) identification of studies via databases and registers lgbtq+ mental health interventions 8 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ ta bl e 2 st ud y an d sa m pl e c ha ra ct er is tic s st ud y; y ea r( s) o f da ta c ol le ct io n; co un tr y/ co un tr ie s of d at a co lle ct io n st ud y de si gn s; c om pa ri so ns ti m ep oi nt s of ou tc om e co lle ct io n sa m pl e si ze pa rt ic ip an ts a ge m (sd ) / br ea kd ow n g en de r (% o r n) se xu al or ie nt at io n (% o r n) et hn ic it y (% o r n) m en ta l h ea lt h 1 p ac ha nk is e t a l. (2 01 5) ; 2 01 320 14 ; u sa ra nd om is ed c on tr ol le d tr ia l (c ro ss ov er pa rt ic ip an ts w er e ra nd om is ed (s tr at if ie d ac co rd in g to r ac e/ et hn ic ity an d an xi et y/ de pr es si on ) t o ei th er im m ed ia te tr ea tm en t re ce iv ed tr ea tm en t b et w ee n ba se lin e an d 3m on th as se ss m en t , o r w ai tli st re ce iv ed tr ea tm en t b et w ee n 3m on th a nd 6 -m on th as se ss m en t ); in ac tiv e co nt ro l ( w ai tli st ) im m ed ia te co nd iti on : p re tr ea tm en t, po st tr ea tm en t, 3m on th fo llo w -u p; w ai tli st c on di tio n: 3m on th p re tr ea tm en t, pr etr ea tm en t, po st tr ea tm en t 63 (5 4 co m pl et ed a t le as t o ne se ss io n) im m ed ia te co nd iti on : 2 6. 19 (4 .2 6) ; w ai tli st co nd iti on : 2 5. 69 (4 .2 8) m al e in cl us io n cr ite ri on ; g ay /q ue er : 3 1; 27 bi se xu al : 1 ; 4 im m ed ia te c on di tio n; w ai tli st c on di tio n: a m er ic an in di an /a la sk an n at iv e: 0 ; 1 a si an : 0 ; 3 bl ac k/ a fr ic an a m er ic an : 6 ; 4 pa ci fi c is la nd er : 1 ; 1 w hi te : 1 6; 1 7 o th er /m ix ed : 9 ; 5 h is pa ni c/ la tin o: y es 12 ; 1 1; n o 2 0; 2 0 im m ed ia te p re -t re at m en t m ea n sc or es (s d ) d ep re ss io n: c es d im m ed ia te c on di tio n: 2 7. 69 (1 .8 3) , w ai tli st c on di tio n: 2 3. 19 (2 .1 4) ab ov e cu tof f 1 6 o d si s i m m ed ia te c on di tio n: 8 .1 6 (0 .7 6) , w ai tli st c on di tio n: 7 .0 8 (0 .8 8) ju st ab ov e /s lig ht ly b el ow c ut -o ff 8 a nx ie ty : o a si s i m m ed ia te c on di tio n: 8 .0 3 (0 .6 6) , w ai tli st c on di tio n: 6 .8 9 (0 .7 8) ju st a bo ve / sl ig ht ly b el ow c ut -o ff 8 2 m ill ar , w an g, & pa ch an ki s (2 01 6) ; 20 13 -2 01 4; u sa a s ab ov e a s ab ov e 63 e nr ol le d, 5 4 co m pl et ed b ot h pr e a nd p os ttr ea tm en t as se ss m en ts m = 2 6. 1 (s d = 4 .0 ) m al e in cl us io n cr ite ri on g ay /q ue er (4 9) , bi se xu al (4 ) a m er ic an in di an o r a la sk an n at iv e (1 ), a si an (1 ), bl ac k / a fr ic an a m er ic an (7 ), pa ci fi c is la nd er (2 ), w hi te (3 0) , o th er /m ix ed (1 3) h is pa ni c / la tin o y es (2 2) , n o (3 2) pr etr ea tm en t m ea n sc or es (s d ) d ep re ss io n: o d si s 7 .4 6 (4 .3 0) be lo w c ut -o ff 8 a nx ie ty : o a si s 7 .5 0 (3 .7 6) be lo w c ut -o ff 8 3 – o ’c le ir ig h et a l. (2 01 9) ; 2 00 720 11 ; u sa ra nd om is ed c on tr ol le d tr ia l; ac tiv e co nt ro l ( v c ton ly ) ba se lin e, e nd o f t he tr ea tm en t p er io d (a pp ro xi m at el y 3m on th s af te r ra nd om iz at io n) , a nd 6 a nd 9 -m on th fo llo w -u p 43 m = 3 9. 19 (s d = 1 1. 07 ) m al e in cl us io n cr ite ri on g ay (2 7) , bi se xu al (1 2) , u ns ur e (4 ) c au ca si an (2 7) , a fr ic an a m er ic an (1 1) , h is pa ni c/ la tin o (3 ), o th er (2 ) ba se lin e m ea n sc or es (s d ) pt sd : d av id so n tr au m a sc al e c on tr ol 37 .2 0 (2 5. 29 ) b el ow c ut -o ff 4 0 tr ea tm en t 4 7. 09 (2 1. 27 ) a bo ve c ut -o ff 40 re po rt a ls o st at es 3 2. 6% o f p ar tic ip an ts m et d ia gn os tic c ri te ri a fo r pt sd tudor-sfetea & topciu 9 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y; y ea r( s) o f da ta c ol le ct io n; co un tr y/ co un tr ie s of d at a co lle ct io n st ud y de si gn s; c om pa ri so ns ti m ep oi nt s of ou tc om e co lle ct io n sa m pl e si ze pa rt ic ip an ts a ge m (sd ) / br ea kd ow n g en de r (% o r n) se xu al or ie nt at io n (% o r n) et hn ic it y (% o r n) m en ta l h ea lt h 4 p ac ha nk is e t a l. (2 02 0) ; 2 01 820 19 ; u sa a s pa ch an ki s et a l. (2 01 5) an d m ill ar , w an g, & pa ch an ki s (2 01 6) a s pa ch an ki s et a l. (2 01 5) a nd m ill ar , w an g, & p ac ha nk is (2 01 6) 60 e nr ol le d, 5 8 co m pl et ed a t le as t o ne se ss io n m = 2 5. 58 (s d = 3 .2 6) w om en in cl us io n cr ite ri on ; ci sg en de r (5 6. 7% ) q ue er (5 5% ) w hi te (5 8. 3% ), ra ci al o r et hn ic m in or iti es (4 1. 7% ) im m ed ia te p re -t re at m en t m ea n sc or es (s d ) d ep re ss io n: c es d im m ed ia te c on di tio n: 2 9. 70 (1 .8 4) , w ai tli st c on di tio n: 2 6. 86 (1 .9 1) ab ov e cu tof f 1 6 o d si s i m m ed ia te c on di tio n: 6 .3 0 (0 .8 3) , w ai tli st c on di tio n: 7 .6 9 (0 .7 3) be lo w c ut of f 8 a nx ie ty : o a si s i m m ed ia te c on di tio n: 8 .8 0 (0 .6 4) , w ai tli st c on di tio n: 8 .0 3 (0 .4 6) ju st a bo ve cu tof f 8 5 m ag ue n, sh ip he rd , & h ar ri s (2 00 5) ; u nc le ar ye ar s of d at a co lle ct io n; u sa pr epo st pr e, p os t 6 m = 4 7 (s d = 9 .1 6) , ra ng e 32 -5 9 fe m al e (m tf ) n /a n /a d ep re ss io n: 67 % (4 ) s co re d ab ov e cl in ic al th re sh ol d fo r bd i a nx ie ty : 67 % (4 ) s co re d ab ov e cl in ic al th re sh ol d fo r st a i 6 y ad av ai a & h ay es (2 01 2) ; un cl ea r ye ar s of da ta c ol le ct io n; u sa c on cu rr en t, m ul tip le ba se lin e, a cr os spa rt ic ip an ts de si gn (s ev er al c oo rd in at ed si m pl e ph as e ch an ge s, in w hi ch tr ea tm en t b eg in s fo r sp ec if ic p ar tic ip an ts a t di ff er en t p oi nt s in r ea l t im e an d af te r ba se lin e pe ri od s of di ff er in g le ng th s) ; pr epo st pr e, p os t, 4w ee k an d 12 -w ee k fo llo w -u p 6 en ro lle d, 5 co m pl et ed a ge 2 124 (3 pa rt ic ip an ts ), ag e >3 0 (1 pa rt ic ip an t) , ag e 56 (1 pa rt ic ip an t) m al e (3 ), fe m al e (2 ) g ay (2 ), le sb ia n (1 ), q ue st io ni ng (1 ) o ne p pt 's da ta no t r ep or te d du e to pr ef er en ce s a si an /a fr ic an a m er ic an / c au ca si an (1 ), a fr ic an a m er ic an /c au ca si an (1 ), c au ca si an (1 ), n at iv e a m er ic an (1 ) o ne p pt 's da ta no t r ep or te d du e to pr ef er en ce s m ea n sc or es (s d ) d ep re ss io n: d a ss -d 14 .4 (8 .2 ) in di ca tin g m od er at e de pr es si on a nx ie ty : d a ss -a 5. 2 (3 .9 ) in di ca tin g no rm al an xi et y 7 c ra ig & a us tin (2 01 6) ; 2 01 4; o pe n pi lo t, pr epo st ba se lin e (< 4 w ee ks be fo re s ta rt o f 30 m = 1 6. 8, ra ng e 15 -1 8 fe m al e (5 4% ), ge nd er pa ns ex ua l (2 9% ), le sb ia n w hi te e ur op ea n (6 4% ), bl ac k/ a fr ic an /c ar ib be an m ea n sc or es (s d ) d ep re ss io n: lgbtq+ mental health interventions 10 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y; y ea r( s) o f da ta c ol le ct io n; co un tr y/ co un tr ie s of d at a co lle ct io n st ud y de si gn s; c om pa ri so ns ti m ep oi nt s of ou tc om e co lle ct io n sa m pl e si ze pa rt ic ip an ts a ge m (sd ) / br ea kd ow n g en de r (% o r n) se xu al or ie nt at io n (% o r n) et hn ic it y (% o r n) m en ta l h ea lt h un cl ea r co un tr ie s of da ta c ol le ct io n – lik el y c an ad a, po ss ib ly u sa in te rv en tio n) , p os t, 3m on th fo llo w -u p in de pe nd en t/ no nbi na ry (2 1% ), m al e (1 8% ), tr an s (1 0% ), an d/ or tw osp ir it (8 % ) (2 5% ), qu ee r (2 1% ), bi se xu al (1 8% ), un su re / qu es tio ni ng (1 1% ), ga y (1 1% ), an d/ or po ly se xu al (2 % ) (2 5% ), ea st /s ou th /s ou th ea st a si an (2 4% ), in di ge no us / fi rs t n at io ns (1 8% ), an d/ or la tin o/ a (7 % ) bd iii 25 .9 5 (1 4. 51 ) in di ca tin g m od er at e de pr es si on 8 a us tin , c ra ig , & d ’s ou za (2 01 8) ; 20 14 ; c an ad a pr epo st pr e, p os t, 3m on th fo llo w -u p 8 a ge 1 6 (1 pa rt ic ip an t) , ag e 17 (1 pa rt ic ip an t) , ag e 18 (6 pa rt ic ip an ts ) n on bi na ry (6 ), q ue er (5 ), fe m al e (2 ), tr an sg en de r (2 ), m al e (1 ), tw osp ir it (1 ), g en de r in de pe nd en t (1 ), o th er fi gu ri ng th in gs ou t ( 1) q ue er (5 ), pa ns ex ua l ( 2) , q ue st io ni ng (2 ), a se xu al (1 ) w hi te (c an ad ia n, e ur op ea n) (5 ), m ix ed (2 ), a si an (1 ), bl ac k (a fr ic an , c an ad ia n, c ar ib be an ) ( 1) , i nd ig en ou s, fi rs t n at io ns , i nu it, m et is (1 ), la tin a m er ic an (1 ) m ea n sc or es (s d ) d ep re ss io n: bd iii 37 .5 0 (1 2. 29 ) in di ca tin g se ve re de pr es si on 9 j ab so n tr ee & pa tt er so n (2 01 9) ; un cl ea r ye ar s of da ta c ol le ct io n; u sa pr epo st pr e, p os t, 12 -w ee k fo llo w -u p 24 e nr ol le d, 1 7 co m pl et ed n /a fe m al e (1 1) , m al e (6 ) bi se xu al (1 ), m os tly le sb ia n/ ga y/ ho m os ex ua l ( 2) , o nl y le sb ia n/ ga y/ ho m os ex ua l (1 2) , o th er (2 ) n /a n /a no m ea su re s re la te d to m en ta l he al th d is or de rs 10 c oh en e t a l. (2 02 1) ; u nc le ar ye ar s of d at a co lle ct io n; u sa c as e se ri es ; p re -p os t pr e, p os t 7; 6 c om pl et ed tr ea tm en t n /a n /a se xu al m in or ity u nc le ar br ea kd ow n n /a d ep re ss io n: 6 7% (4 ) s co re d ab ov e cl in ic al th re sh ol d fo r ph q -9 a nx ie ty : 5 0% (3 ) s co re d ab ov e cl in ic al th re sh ol d fo r o a si s tudor-sfetea & topciu 11 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y; y ea r( s) o f da ta c ol le ct io n; co un tr y/ co un tr ie s of d at a co lle ct io n st ud y de si gn s; c om pa ri so ns ti m ep oi nt s of ou tc om e co lle ct io n sa m pl e si ze pa rt ic ip an ts a ge m (sd ) / br ea kd ow n g en de r (% o r n) se xu al or ie nt at io n (% o r n) et hn ic it y (% o r n) m en ta l h ea lt h 11 h ar t e t a l. (2 02 0) ; u nc le ar ye ar s of d at a co lle ct io n; u nc le ar co un tr ie s of d at a co lle ct io n – c an ad a or u sa pr epo st p ilo t ba se lin e, p os t, 3, an d 6m on th fo llo w -u p 29 s ta rt er s, 2 1 co m pl et er s m = 3 2. 81 (s d = 8 .9 5) m al e in cl us io n cr ite ri on g ay (1 8) , bi se xu al (3 ) w hi te (1 2) , b la ck (2 ), ea st / so ut he as t a si an (0 ), m id dl e ea st er n/ n or th a fr ic an (2 ), la tin a m er ic an /h is pa ni c (2 ), m ix ed r ac e (3 ) m ea n sc or es (s d ) so ci al a nx ie ty : li eb ow itz s oc ia l a nx ie ty s ca le 62 .8 6 (2 2. 76 ) in di ca tin g m od er at e so ci al an xi et y si a s 4 7. 38 (1 2. 31 ) a bo ve c ut -o ff 3 4/ 36 sp s 3 3. 57 (1 8. 81 ) a bo ve c ut -o ff 2 4 bf n es 3 0. 28 (7 .1 1) ab ov e cu tof f 2 5 re po rt a ls o st at es 9 5% o f p ar tic ip an ts m ee tin g di ag no st ic c ri te ri a fo r so ci al an xi et y d ep re ss io n: c es d 25 .8 1 (1 2. 76 ) a bo ve c ut -o ff 1 6 re po rt a ls o st at es 2 4% o f p ar tic ip an ts m ee tin g di ag no st ic c ri te ri a fo r m aj or de pr es si ve d is or de r, cu rr en t e pi so de 12 bl ut h et a l. (2 02 3) ; 2 02 020 21 (p re su m ed d ue to m en tio n of c ov id -1 9 pa nd em ic an d 20 21 y ea r of pu bl ic at io n) ; un cl ea r co un tr ie s of da ta c ol le ct io n – u sa o r c an ad a pr epo st pr e, p os t, 3m on th fo llo w -u p 41 m = 1 4. 5 (s d = 1 .4 9) tr an sg en de r m -f (9 ), tr an sg en de r fm (1 8) , n on bi na ry (1 2) , g en de rf lu id (3 ), q ue st io ni ng (2 ), a ge nd er (1 ) n /a w hi te (3 3) , b la ck /a fr ic an a m er ic an (4 ), a si an (1 ), h is pa ni c/ la tin o/ a (5 ), o th er : m ix ed (1 ) m ea n sc or es (s d ) p re -i nt er ve nt io n a nx ie ty : st a i 5 0. 77 (1 3. 58 ) a bo ve c ut -o ff 4 0 d ep re ss io n: ph q -9 15 .1 2 (6 .7 7) ab ov e cu tof f 1 0 13 c ra ig e t a l. (2 02 1) ; 2 02 0; un cl ea r co un tr ie s of da ta c ol le ct io n, n on -r an do m is ed ex pe ri m en ta l s tu dy ; i na ct iv e co nt ro l pr e, p os t 46 c om pl et er s m = 2 1. 17 (s d = 4 .5 2) n on -b in ar y (1 7) , tr an sg en de r (1 4) , c is w om an (8 ), q ue er (1 2) , le sb ia n (1 0) , bi se xu al (6 ), g ay (6 ), pa ns ex ua l ( 6) , w hi te (3 5) , a si an (5 ), bl ac k (4 ), m id dl e ea st er n (2 ), in di ge no us (1 ), la tin x (0 ), m ul tiet hn ic /r ac ia l ( 5) , o th er (6 ) m ea n sc or es (s d ) d ep re ss io n: bd iii co nt ro l: 19 .4 8 (1 0. 67 ), in te rv en tio n: 1 9. 30 (1 1. 15 ) in di ca tin g m ild -m od er at e de pr es si on lgbtq+ mental health interventions 12 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y; y ea r( s) o f da ta c ol le ct io n; co un tr y/ co un tr ie s of d at a co lle ct io n st ud y de si gn s; c om pa ri so ns ti m ep oi nt s of ou tc om e co lle ct io n sa m pl e si ze pa rt ic ip an ts a ge m (sd ) / br ea kd ow n g en de r (% o r n) se xu al or ie nt at io n (% o r n) et hn ic it y (% o r n) m en ta l h ea lt h lik el y c an ad a or u sa q ue er (3 ), a ge nd er (2 ), c is m an (1 ), tw osp ir it (0 ), o th er (1 ) a se xu al (3 ), q ue st io ni ng (2 ), d em i ( 1) , o th er (0 ) 14 pa n et a l. (2 02 1) ; u nc le ar ye ar s of d at a co lle ct io n; c hi na pr epo st ba se lin e, 1 -m on th fo llo w -u p 8 a ge 1 620 (2 pa rt ic ip an ts ), ag e 21 -3 0 (3 pa rt ic ip an ts ), ag e >3 0 (3 pa rt ic ip an ts ) m al e in cl us io n cr ite ri on g ay (6 ), bi se xu al (2 ) a si an /c hi ne se (a s pe r ar tic le tit le ) ba se lin e m ea n sc or es (s d ) d ep re ss io n: ph q -9 10 .4 3 (3 .4 6) ab ov e cu tof f 1 0 a nx ie ty : g a d -7 7. 43 (2 .5 7) be lo w c ut -o ff 8 15 ja ck so n et a l. (2 02 2) ; 2 01 820 19 ; u sa pr epo st ba se lin e, 3 -m on th fo llo w -u p 21 s ta rt er s, 1 7 co m pl et ed th e 3m on th fo llo w -u p a ge 1 823 (4 pa rt ic ip an ts ), ag e 24 -2 9 (1 1 pa rt ic ip an ts ), ag e 30 -3 5 (6 pa rt ic ip an ts ) m al e in cl us io n cr ite ri on ; c is ge nd er m an (2 0) , tr an sg en de r m an (1 ) g ay (1 6) , bi se xu al (3 ), q ue er (2 ) la tin o/ la tin x (h is pa ni c) (7 ), w hi te (h is pa ni c) (5 ), bl ac k (h is pa ni c) 5 , b la ck (n on h is pa ni c) (4 ) ba se lin e m ea n sc or es (s d ) d ep re ss io n: c ed s 2 2. 10 (1 1. 89 ) a bo ve c ut -o ff 1 6 o d si s 1 1 (4 .7 9) ab ov e cu tof f 8 a nx ie ty : o a si s 1 2. 05 (3 .5 4) ab ov e cu tof f 8 16 po on e t a l. (2 02 2) ; u nc le ar ye ar s of d at a co lle ct io n; u sa pr epo st ; lg bq -n on -l g bq pr e, p os t 39 m = 1 5. 21 (s d = 1 .6 5) fe m al e (8 6. 8% ) lg bq (1 6) , h et er os ex ua l (2 3) n on -h is pa ni c w hi te (7 1. 1% ), h is pa ni c (2 2. 9% ), bi o r m ul tir ac ia l ( 13 .1 % ), a si an , a fr ic an -a m er ic an , o r ot he r (7 .9 % ) pr et re at m en t m ea n sc or es (s d ) d ep re ss io n: bd iii 28 .6 4 (1 4. 61 ) in di ca tin g m od er at ese ve re d ep re ss io n tudor-sfetea & topciu 13 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ ta bl e 3 in te rv en tio ns , a da pt at io ns , a nd r es ul ts st ud y in te rv en ti on s a ny l g bt q +sp ec if ic ad ap ta ti on s r el ev an t o ut co m es (c om pl et e na m es an d re fe re nc es in t ud or -s fe te a & to pc iu , 2 02 4s , a pp en di x i) r el ev an t a na ly se s; n um be r of pa rt ic ip an ts in cl ud ed th er ei n r el ev an t r es ul ts s um m ar y 1 p ac ha nk is e t a l. (2 01 5) c bt : e st ee m in te rv en tio n 10 in di vi du al ly -d el iv er ed se ss io ns , b as ed o n ba rl ow e t al .’s u ni fi ed p ro to co l f or th e tr an sd ia gn os tic t re at m en t o f em ot io na l d is or de rs ye s f oc us o n th e im pa ct o f m in or ity s tr es s on m en ta l he al th , i nt er pe rs on al fu nc tio ni ng , u nh el pf ul be ha vi ou rs ; a im o f i m pr ov in g m in or ity s tr es s co pi ng th ro ug h em ot io n re gu la tio n, c og ni tiv e re st ru ct ur in g, a ss er tiv en es s tr ai ni ng c en te r fo r ep id em io lo gi ca l s tu di es d ep re ss io n sc al e (c es d ); o ve ra ll d ep re ss io n se ve ri ty & im pa ir m en t s ca le (o d si s) ; o ve ra ll a nx ie ty s ev er ity & im pa ir m en t sc al e (o a si s) ; m ea su re o f g ay -r el at ed s tr es s (m o g s) ; g ay -r el at ed r ej ec tio n se ns iti vi ty s ca le (g rs ); in te rn al iz ed h om op ho bi a sc al e (i h s) ; se xu al o ri en ta tio n c on ce al m en t s ca le (s o c s) ; ru m in at iv e re sp on se s sc al e (r rs ); d iff ic ul tie s of e m ot io n re gu la tio n sc al e (d er s) ; ra th us a ss er tiv en es s sc he du le (r a s) li ne ar m ix ed m od el s w ith m ax im um lik el ih oo d es tim at io n 1) c on di tio n co m pa ri so n 2) g en er al iz ed li ne ar m ix ed m od el s pr ed ic tin g th e od ds o f m ee tin g cl in ic al cu tof fs o n c es d , o d si s, o a si s 3) p oo le d da ta (p re -t re at m en t m ea su re s fr om th e ba se lin e as se ss m en t f or th e im m ed ia te p ar tic ip an ts a nd th e th re em on th a ss es sm en t f or th e w ai tli st pa rt ic ip an ts , a nd p os ttr ea tm en t m ea su re s fr om th e th re em on th a ss es sm en t f or th e im m ed ia te p ar tic ip an ts a nd th e si xm on th as se ss m en t f or th e w ai tli st p ar tic ip an ts ) ch an ge c om pa ri so n ac ro ss a ll pa rt ic ip an ts fr om im m ed ia te p re -t re at m en t t o po st tr ea tm en t 4) f ol lo w -u p as se ss m en t; 63 in te nt -t otr ea t a pp ro ac h 1) s ig ni fi ca nt im pr ov em en ts in d ep re ss iv e sy m pt om s (o n o d si s, n ot c es d ), m ar gi na lly s ig ni fi ca nt im pr ov em en ts in an xi et y (o a si s) in im m ed ia te v s w ai tli st co nd iti on (m ed iu m -l ar ge e ff ec ts s iz es ), no si gn if ic an t c on di tio n t im e in te ra ct io n ef fe ct s fo r co gn iti ve , a ff ec tiv e, a nd be ha vi ou ra l m in or ity s tr es s pr oc es se s or fo r un iv er sa l p ro ce ss es (s m al l e ff ec t s iz es ) 2) s tr on ge r de cr ea se s in th e pr op or tio n of im m ed ia te v er su s w ai tli st p ar tic ip an ts w ho c on tin ue d to e xc ee d th e cu tof f a t th re e m on th s (o n c es d , n ot o d si s or o a si s) 3) s ig ni fi ca nt r ed uc tio ns in a ll pr im ar y ou tc om es , s ig ni fi ca nt (a pa rt fr om s o c s) re du ct io ns in a ll m in or ity s tr es s pr oc es se s an d un iv er sa l p ro ce ss es fr om im m ed ia te pr etr ea tm en t t o po st -t re at m en t ( la rg e ef fe ct s iz es ) 4) t re at m en t e ff ec ts g en er al ly m ai nt ai ne d at fo llo w -u p, fe w s ig ni fi ca nt d iff er en ce s be tw ee n po st -t re at m en t a nd fo llo w -u p, ru m in at io n sc or es c on tin ui ng to si gn if ic an tly d ec re as e fr om p os ttr ea tm en t 2 m ill ar , w an g, & pa ch an ki s (2 01 6) c bt : e st ee m in te rv en tio n ye s d es cr ib ed a bo ve se xu al o ri en ta tio n im pl ic it a ss oc ia tio n te st ; li ne ar m ix ed m od el s w ith m ax im um lik el ih oo d es tim at io n, p oo le d da ta a s d ep re ss io n an d an xi et y sh ow ed si gn if ic an t r ed uc tio ns ; lgbtq+ mental health interventions 14 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y in te rv en ti on s a ny l g bt q +sp ec if ic ad ap ta ti on s r el ev an t o ut co m es (c om pl et e na m es an d re fe re nc es in t ud or -s fe te a & to pc iu , 2 02 4s , a pp en di x i) r el ev an t a na ly se s; n um be r of pa rt ic ip an ts in cl ud ed th er ei n r el ev an t r es ul ts s um m ar y in te rn al iz ed h om op ho bi a sc al e (i h s) ; o ve ra ll d ep re ss io n se ve ri ty & im pa ir m en t s ca le (o d si s) ; o ve ra ll a nx ie ty s ev er ity & im pa ir m en t sc al e (o a si s) ab ov e, tw o se pa ra te m od el s w ith im pl ic it ih a nd e xp lic it ih , a nd th ei r re sp ec tiv e in te ra ct io ns w ith ti m e; 54 (w ho c om pl et ed p re a nd p os ttr ea tm en t a ss es sm en ts ) pa rt ic ip an ts h ig he r in im pl ic it ih a t ba se lin e sh ow ed n ea rl y th re e tim es gr ea te r re du ct io ns th an th os e lo w er in im pl ic it ih o n de pr es si on a nd a nx ie ty ; a t p os ttr ea tm en t, th os e hi gh er in im pl ic it ih s ho w ed r ed uc tio ns o n de pr es si on a nd a nx ie ty r ou gh ly eq ui va le nt to o ne s ta nd ar d de vi at io n 3 o ’c le ir ig h et a l. (2 01 9) c bt : 1 0se ss io n in te gr at ed c bt fo r tr au m a an d se lfc ar e (c bt -t sc ) i nt er ve nt io n w ith h iv v ol un ta ry c ou ns el in g an d te st in g (v c t ) o r v c t a lo ne (v c ton ly ) ye s p ar tic ip an ts in b ot h co nd iti on s re ce iv ed h iv /s t i vo lu nt ar y co un se lin g an d te st in g (v c t ) a t b as el in e m in iin te rn at io na l n eu ro ps yc hi at ri c in te rv ie w (m in i) to a ss es s sy m pt om s an d a di ag no si s of p t sd d av id so n pt sd s ca le h lm (h ie ra rc hi ca l l in ea r m od el in g) 43 d av id so n tr au m a sc al e im m ed ia te ly p os ttr ea tm en t: s ig ni fi ca nt ly g re at er r ed uc tio ns in po st tr au m at ic s ym pt om s ev er ity fo r th e c bt -t sc c on di tio n fo r th e to ta l s co re an d th e a vo id an ce s ub sc al e t re nd fo r a di ff er en ce b et w ee n th e co nd iti on s fo r th e in tr us io ns s ub sc al e fo llo w -u p: t re nd fo r a st at is tic al ly s ig ni fi ca nt di ff er en ce b et w ee n th e ra nd om iz at io n co nd iti on s on th e to ta l s co re s ig ni fi ca nt r ed uc tio ns in tr au m a sy m pt om s ev er ity fo r th e a vo id an ce su bs ca le t re nd fo r a m ea ni ng fu l d iff er en ce be tw ee n th e co nd iti on s fo r th e in tr us io ns su bs ca le 4 p ac ha nk is e t a l. (2 02 0) c bt : e q ui p (e m po w er in g q ue er id en tit ie s in ps yc ho th er ap y) , a 1 0se ss io n in te rv en tio n ad ap te d fo r se xu al m in or ity w om en fr om th e es t ee m p ro to co l ye s a da pt ed fr om th e es t ee m p ro to co l, de sc ri be d ab ov e, w ith a fo cu s on s ex ua l m in or ity w om en ’s u ni qu e ex pe ri en ce s c en te r fo r ep id em io lo gi ca l s tu di es d ep re ss io n sc al e (c es d ); br ie f s ym pt om in ve nt or y (b si ); o ve ra ll d ep re ss io n se ve ri ty & im pa ir m en t s ca le (o d si s) ; a s pa ch an ki s et a l. (2 01 5) ; 60 (i nt en tto -t re at ) 1) s ig ni fi ca nt im pr ov em en ts in d ep re ss iv e sy m pt om s (o n c es d , o d si s) a nd a nx ie ty (o a si s) in im m ed ia te v s w ai tli st co nd iti on (l ar ge e ff ec t s iz es ), no si gn if ic an t c on di tio n t im e in te ra ct io n tudor-sfetea & topciu 15 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y in te rv en ti on s a ny l g bt q +sp ec if ic ad ap ta ti on s r el ev an t o ut co m es (c om pl et e na m es an d re fe re nc es in t ud or -s fe te a & to pc iu , 2 02 4s , a pp en di x i) r el ev an t a na ly se s; n um be r of pa rt ic ip an ts in cl ud ed th er ei n r el ev an t r es ul ts s um m ar y o ve ra ll a nx ie ty s ev er ity & im pa ir m en t sc al e (o a si s) ; se xu al m in or ity w om en 's re je ct io n se ns iti vi ty s ca le (s m w -r ss ); se xu al o ri en ta tio n c on ce al m en t s ca le (s o c s) ; le sb ia n, g ay , a nd b is ex ua l i de nt ity s ca le in te rn al iz ed h om on eg at iv ity s ub sc al e; se xu al o ri en ta tio n im pl ic it a ss oc ia tio n te st ; d iff ic ul tie s of e m ot io n re gu la tio n sc al e sh or t f or m (d er ss f) ; ru m in at iv e re sp on se s sc al e b ro od in g su bs ca le (r rs ); si m pl e ra s s ho rt f or m (s ra ssf ) ef fe ct s fo r m in or ity s tr es s pr oc es se s or fo r un iv er sa l p ro ce ss es (s m al l e ff ec t s iz es ) 2) s tr on ge r de cr ea se s in th e pr op or tio n of im m ed ia te v er su s w ai tli st p ar tic ip an ts w ho c on tin ue d to e xc ee d th e cu tof f a t th re e m on th s (o n o d si s, n ot c es d , a nd on o a si s) 3) s ig ni fi ca nt im pr ov em en ts in a ll pr im ar y ou tc om es (l ar ge e ff ec t s iz es ), si gn if ic an t i m pr ov em en ts in e m ot io n re gu la tio n di ff ic ul tie s an d ru m in at io n an d m ar gi na lly s ig ni fi ca nt r ed uc tio ns in re je ct io n se ns iti vi ty (s m al l e ff ec t s iz es fo r m in or ity s tr es s pr oc es se s, s m al lm ed iu m ef fe ct s iz es fo r un iv er sa l p ro ce ss es ) 4) t re at m en t e ff ec ts g en er al ly c on tin ue d to d ec re as e at fo llo w -u p fo r m en ta l a nd be ha vi ou ra l h ea lth o ut co m es , m in or ity st re ss p ro ce ss es , a nd u ni ve rs al p ro ce ss es , bs i a nd r um in at io n co nt in ui ng to si gn if ic an tly d ec re as e fr om p os ttr ea tm en t 5 m ag ue n, sh ip he rd , & h ar ri s (2 00 5) c bt : 1 2 w ee kl y 60 -m in ut e se ss io ns ye s s es si on d ed ic at ed to ho rm on e m ai nt en an ce , su rg er ie s, h ea lth c ar e; s es si on de di ca te d to d is cl os ur e, pa ss in g, s oc ia lis at io n; s es si on de di ca te d to b od y is su es a nd in tim at e re la tio ns hi ps e tc . be ck d ep re ss io n in ve nt or y (b d i) st at e an d tr ai t a nx ie ty in ve nt or y (s ta i) n et w or k o ri en ta tio n sc al e (n o s) ut ili si ng s oc ia l s up po rt n et w or ks in ti m es of n ee d li fe s at is fa ct io n in de x (l si ) n /a in di vi du al s co re s; 6 o ve ra ll: a nx ie ty a nd d ep re ss io n m ea su re s: im pr ov em en t s oc ia l s up po rt : i nc re as es in 4 /6 pa rt ic ip an ts l ife s at is fa ct io n in di ce s: d ec re as ed fo r th e m aj or ity o f p ar tic ip an t, pe rh ap s du e to th e m ul tit ud e of li fe c ha ng es , i nc lu di ng be co m in g un em pl oy ed a nd h om el es s lgbtq+ mental health interventions 16 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y in te rv en ti on s a ny l g bt q +sp ec if ic ad ap ta ti on s r el ev an t o ut co m es (c om pl et e na m es an d re fe re nc es in t ud or -s fe te a & to pc iu , 2 02 4s , a pp en di x i) r el ev an t a na ly se s; n um be r of pa rt ic ip an ts in cl ud ed th er ei n r el ev an t r es ul ts s um m ar y 6 y ad av ai a & h ay es (2 01 2) a c t : 6 -1 0 w ee kl y 50 -m in ut e a c t s es si on s ye s e xp lic itl y ad dr es si ng s el fst ig m a ar ou nd s ex ua l or ie nt at io n/ in te rn al is ed ho m op ho bi a pr im ar y: d ai ly r at in gs o f t ho ug ht s a bo ut s ex ua l o ri en ta tio n ((a ) t he d eg re e to w hi ch ne ga tiv e th ou gh ts a bo ut s ex ua l or ie nt at io n in te rf er ed in th e pa rt ic ip an t's lif e, (b ) t he d is tr es s as so ci at ed w ith th os e th ou gh ts , ( c) th e be lie va bi lit y of th e th ou gh ts , a nd (d ) t he ir fr eq ue nc y) ; se co nd ar y: d ep re ss io n, a nx ie ty , a nd s tr es s sc al es -2 1 (d a ss -2 1) ; s ho rt in te rn al iz ed h om on eg at iv ity s ca le (s ih s) ; l es bi an in te rn al iz ed h om op ho bi a sc al e (l ih s) ; w h o q o lbr ef (w or ld h ea lth o rg an iz at io n q ua lit y of l ife a bb re vi at ed v er si on ); a a q -i i ( a cc ep ta nc e an d a ct io n q ue st io nn ai re -i i) h ie ra rc hi ca l l in ea r m od el in g (h lm ); m ix ed m od el r ep ea te d m ea su re s; 5 d ai ly r at in gs o f t ho ug ht s a bo ut s ex ua l o ri en ta tio n: im pr ov em en ts in in te rf er en ce a nd d is tr es s fr om b as el in e to th e la te r tim e po in ts in al l p ar tic ip an ts ; s im ila r pa tt er n fo r be lie va bi lit y ra tin gs ; i nc on si st en t a nd sm al le r ch an ge s fo r fr eq ue nc y ra tin gs d ur in g ba se lin e: n o si gn if ic an t t im e ef fe ct s fo r tim e fo r an y of th e ra te d di m en si on s d ur in g tr ea tm en t: fr eq ue nc y of th ou gh ts di d no t c ha ng e, b ut b el ie va bi lit y de cl in ed si gn if ic an tly , a s di d di st re ss a nd s el fre po rt ed in te rf er en ce ih : i m pr ov em en t o n si h s an d li h s fr om pr etr ea tm en t b y po st -t re at m en t ( 23 % ), by th e 4w ee k fo llo w -u p (3 2% ), an d by th e 12 -w ee k fo llo w -u p (4 0% ) d ep re ss io n, a nx ie ty s tr es s: n o si gn if ic an t ch an ge o n an xi et y (f ro m n or m al r an ge a t ba se lin e) ; s ig ni fi ca nt r ed uc tio n in de pr es si on a nd s tr es s (f ro m m od er at e an d m ild r an ge , r es pe ct iv el y, a t b as el in e) b y fo llo w -u p; im pr ov em en ts in q ua lit y of li fe an d ps yc ho lo gi ca l f le xi bi lit y at 4 -w ee k fo llo w -u p 7 c ra ig & a us tin (2 01 6) c bt : a ff ir m in te rv en tio n: ei gh t m od ul e, m an ua lis ed af fi rm at iv e co gn iti ve be ha vi ou ra l i nt er ve nt io n ye s i nc or po ra tin g af fi rm at iv e pr ac tic es in to tr ad iti on al c bt m od el s be ck d ep re ss io n in ve nt or y (b d iii ); st re ss a pp ra is al m ea su re fo r a do le sc en ts (s a m a ) 3 s ub sc al es (c ha lle ng e, th re at , re so ur ce s) ; re pe at ed m ea su re s a n o va ge ne ra l lin ea r m od el (g lm ); t 1t 2 = 30 ; t 1t 3 = 17 d ep re ss io n: s ta tis tic al ly s ig ni fi ca nt re du ct io n fr om t 1 to t 2, a nd fr om t 1 to t 3 re fle ct iv e co pi ng : n on -s ig ni fi ca nt in cr ea se fr om t i t o t 2; s ig ni fi ca nt di ff er en ce s be tw ee n t 1 an d t 3 tudor-sfetea & topciu 17 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y in te rv en ti on s a ny l g bt q +sp ec if ic ad ap ta ti on s r el ev an t o ut co m es (c om pl et e na m es an d re fe re nc es in t ud or -s fe te a & to pc iu , 2 02 4s , a pp en di x i) r el ev an t a na ly se s; n um be r of pa rt ic ip an ts in cl ud ed th er ei n r el ev an t r es ul ts s um m ar y a do le sc en t p ro ac tiv e c op in g in ve nt or y (p c ia ) r ef le ct iv e c op in g su bs ca le (r c s) st re ss a pp ra is al : t hr ea t a pp ra is al : s ig ni fi ca nt d ec re as e fr om t 1 to t 2, p er si st ed to t 3 c ha lle ng e ap pr ai sa l: si gn if ic an t i nc re as e fr om t i t o t 2, d id n ot r et ai n st at is tic al si gn if ic an ce to t 3 re so ur ce a pp ra is al : s ig ni fi ca nt in cr ea se fr om t 1 to t 2, d id n ot r et ai n si gn if ic an ce to t 3 8 a us tin , c ra ig , & d ’s ou za (2 01 8) c bt : 2 -d ay r et re at a ff ir m , de sc ri be d ab ov e ye s d es cr ib ed a bo ve be ck d ep re ss io n in ve nt or y (b d iii ); a do le sc en t p ro ac tiv e c op in g in ve nt or y (p c ia ) r ef le ct iv e c op in g su bs ca le (r c s) pa ir ed -s am pl e tte st s (t 1t 2, t 1t 3, t 2t 3) ; t 1t 2 8 , t 1t 3, t 2t 3 6 d ep re ss io n: st at is tic al ly s ig ni fi ca nt r ed uc tio n fr om t 1 to t 2, fr om t 1 to t 3, n on si gn if ic an t re du ct io n fr om t 2 to t 3; m ea n sc or es a t t 2 an d t 3 re m ai ne d in th e bd iii s ev er e ra ng e c op in g: n o si gn if ic an t d iff er en ce s fr om t 1 to t 2 or fr om t 2 to t 3 9 j ab so n tr ee & pa tt er so n (2 01 9) o nl in e m bs r 8 w ee ks , pa ra lle le d k ab at -z in n' s in pe rs on m bs r n /a pe rc ei ve d st re ss s ca le (p ss ); d ai ly e xp er ie nc es w ith h et eo se xi sm q ue st io nn ai re (d eh q ) 1) p ai re d sa m pl es tte st s fo r ch an ge s in st re ss fr om b as el in e to p os tp ro gr am a nd ba se lin e to fo llo w -u p 2) r ep ea te dm ea su re s a n o va te st ed m ea n va lu es fo r ea ch m ea su re o f s tr es s ag ai ns t o ne a no th er a t t he 3 ti m e po in ts ; 17 w om en : p er ce iv ed s tr es s (p ss ): si gn if ic an t de cr ea se p re -p os t a nd p re -f ol lo w -u p o ve ra ll d eh q a nd v ig ila nc e su bs ca le : n on -s ig ni fi ca nt d ec re as e pr epo st , si gn if ic an t d ec re as e pr efo llo w -u p v ic ar io us tr au m a su bs ca le o f t he d eh q : si gn if ic an t d ec re as e pr epo st a nd p re fo llo w -u p s im ila r bu t l es s dr am at ic r es ul ts o n it t an al ys es o ve ra ll m en : p er ce iv ed s tr es s (p ss ): si gn if ic an t de cr ea se p re -p os t, bu t n ot p re -f ol lo w -u p, lgbtq+ mental health interventions 18 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y in te rv en ti on s a ny l g bt q +sp ec if ic ad ap ta ti on s r el ev an t o ut co m es (c om pl et e na m es an d re fe re nc es in t ud or -s fe te a & to pc iu , 2 02 4s , a pp en di x i) r el ev an t a na ly se s; n um be r of pa rt ic ip an ts in cl ud ed th er ei n r el ev an t r es ul ts s um m ar y si m ila r bu t l es s dr am at ic r es ul ts o n it t an al ys es d eh q : n o si gn if ic an t d iff er en ce in ei th er p er -p ro to co l o r it t a na ly se s 10 c oh en e t a l. (2 02 1) d bt ; o th er : w ee kl y 90 -m in ut e se ss io n ov er 1 0 co ns ec ut iv e w ee ks ; p ar tic ip an ts w er e en ro lle d in in di vi du al ps yc ho th er ap y an d/ or m ed ic at io n m an ag em en t co nc ur re nt ly ye s i nc or po ra te s m in or ity st re ss th eo ry a nd a da pt s th e te ac hi ng p oi nt s of e xi st in g d bt s ki lls to c re at e a ff ir m at iv e d bt s ki lls tr ai ni ng ; i nc lu di ng ps yc ho ed uc at io n on th e m in or ity -s pe ci fi c ps yc ho lo gi ca l p ro ce ss es o f re je ct io n se ns iti vi ty , in te rn al iz ed s tig m a, a nd s ex ua l or ie nt at io n co nc ea lm en t d iff ic ul tie s of e m ot io n re gu la tio n sc al e (d er s) ; o ve ra ll a nx ie ty s ev er ity & im pa ir m en t sc al e (o a si s) ; pa tie nt h ea lth q ue st io nn ai re d ep re ss io n m od ul e (p h q -9 ); g ay -r el at ed r ej ec tio n se ns iti vi ty s ca le (g rs ); se xu al m in or ity w om en 's re je ct io n se ns iti vi ty s ca le (s m w -r ss ); in te rn al iz ed h om op ho bi a sc al e (i h s) ; se xu al o ri en ta tio n c on ce al m en t s ca le (s o c s) c lin ic al ly s ig ni fi ca nt r el ia bl e ch an ge , w ith no rm at iv e da ta u se d to c al cu la te r c i ac qu ir ed th ro ug h th e sc al es o ri gi na l ar tic le s; rc i n ot c al cu la te d fo r th e g rs , s m w rs s, ih s, a nd s o c s, a s re le va nt d at a w er e no t a va ila bl e; 6 em ot io n re gu la tio n: im pr ov em en ts in 5 /6 pa rt ic ip an ts (s ta tis tic al ly s ig ni fi ca nt fo r ~5 0% o f t he p ar tic ip an ts ); d ep re ss iv e sy m pt om s: im pr ov em en ts in 4/ 5 of th e pa rt ic ip an ts w ho r ep or te d a cl in ic al le ve l o f d ep re ss io n at b as el in e (s ta tis tic al ly s ig ni fi ca nt fo r ~5 0% o f t he pa rt ic ip an ts ; a nx ie ty s ym pt om s: im pr ov em en ts in 3 /4 of th e pa rt ic ip an ts w ho r ep or te d a cl in ic al le ve l o f a nx ie ty a t b as el in e; g rs /s m w -r ss , i h s, a nd s o c s: im pr ov em en ts in th e m aj or ity o f pa rt ic ip an ts 11 h ar t e t a l. (2 02 0) c bt : t en 1 -h ou r, w ee kl y se ss io ns o f c bt fo r tr ea tm en t of s oc ia l a nx ie ty , r el at ed su bs ta nc e us e in s ex ua l si tu at io ns , a nd h iv p re ve nt io n ye s f oc us o n pa rt ic ip an ts ' se xu al a nd r el at io ns hi p hi st or y, go al s fo r sa tis fy in g re la tio ns hi ps a nd s ex e tc . t he m in i i nt er na tio na l n eu ro ps yc hi at ri c in te rv ie w v er si on 6 .0 (m in i 6 .0 ); a nx ie ty d is or de rs in te rv ie w s ch ed ul eiv li fe tim e (a d is -i v ), so ci al p ho bi a se ct io n; li eb ow itz s oc ia l a nx ie ty s ca le (l sa s) ; t he s oc ia l i nt er ac tio n a nx ie ty s ca le (s ia s) a nd s oc ia l p ho bi a sc al e (s ps ); c en te r fo r ep id em io lo gi c st ud ie sd ep re ss io n sc al e (c es d ); u c la l on el in es s sc al e ve rs io n 3 (u c la ); br ie f f ea r of n eg at iv e ev al ua tio n sc al e, st ra ig ht -f or w ar d it em s (b fn es) g en er al iz ed e st im at in g eq ua tio ns w ith ro bu st e st im at or s an d un st ru ct ur ed co rr el at io n m at ri x ad dr es si ng no ni nd ep en de nc e of d at a ac ro ss ti m e po in ts ; be ta e st im at es fo r co nt in uo us m ea su re s an d re la tiv e ri sk r at io s (r r) fo r bi na ry ou tc om es si m ila r pa tt er n of r es ul ts u si ng b ot h in te nt -t otr ea t ( n = 32 ) a nd c om pl et er (n = 21 ) s am pl es ; t he re fo re , r es ul ts o f l at te r re po rt ed so ci al a nx ie ty : s ig ni fi ca nt r ed uc tio ns in th e pr op or tio n of p ar tic ip an ts w ho m et d ia gn os tic cr ite ri a fo r so ci al a nx ie ty d is or de r fr om ba se lin e to a ll tim ep oi nt s s ig ni fi ca nt r ed uc tio ns in m ea n sc or es o n th e ls a s, s ia s, s ps , b fn es be tw ee n ba se lin e an d al l t im e po in ts d ep re ss io n an d lo ne lin es s: tudor-sfetea & topciu 19 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y in te rv en ti on s a ny l g bt q +sp ec if ic ad ap ta ti on s r el ev an t o ut co m es (c om pl et e na m es an d re fe re nc es in t ud or -s fe te a & to pc iu , 2 02 4s , a pp en di x i) r el ev an t a na ly se s; n um be r of pa rt ic ip an ts in cl ud ed th er ei n r el ev an t r es ul ts s um m ar y s ig ni fi ca nt r ed uc tio n in th e pr op or tio n of p at ie nt s w ith c ur re nt m aj or d ep re ss iv e ep is od es p re -p os ttr ea tm en t, no nsi gn if ic an t d iff er en ce s fo r 3 a nd 6 -m on th fo llo w -u p; s ig ni fi ca nt r ed uc tio n in m ea n sc or es o n th e c es d b et w ee n ba se lin e an d al l tim ep oi nt s; s ig ni fi ca nt r ed uc tio n in m ea n sc or es o n th e u c la b et w ee n ba se lin e an d al l tim ep oi nt s 12 bl ut h et a l. (2 02 3) m in df ul s el fc om pa ss io n fo r te en s (m sc -t ) 8 x1 .5 h se ss io ns o nl in e, h el d ov er 8 da ys (1 /d ay ) f or th e fi rs t co ho rt , t he n 2x /w ee k fo r 4 w ee ks fo r th e se co nd tw o co ho rt s ye s s lig ht m od if ic at io ns to ac co m m od at e th e ne ed s of tr an sg en de r ad ol es ce nt s e. g. , om m is si on o f b od y sc an pr ac tic e se lfco m pa ss io n sc al e: y ou th (s c sy) st ud en t l ife s at is fa ct io n sc al e (s ls s) sp ie lb er ge r st at e a nx ie ty s ca le sh or t fo rm pa tie nt h ea lth q ue st io nn ai re -d ep re ss io n m od ul e (p h q -9 ) in te rp er so na l n ee ds q ue st io nn ai re (i n q ) br ie f r es ili en ce s ca le (b rs ) o ne -w ay r ep ea te d m ea su re s a n o va s; 26 o ve ra ll, m ai n ef fe ct o f t im e fo r al l co ns tr uc ts a cr os s th e st ud y d ep re ss io n: s ig ni fi ca nt d ec re as e pr epo st an d pr e3m on th fo llo w -u p a nx ie ty : s ig ni fi ca nt d ec re as e pr epo st (n ot o bs er ve d at 3 -m on th fo llo w -u p) re si lie nc e: s ig ni fi ca nt in cr ea se p re -p os t (n ot o bs er ve d at 3 -m on th fo llo w -u p) m in df ul ne ss : s ig ni fi ca nt in cr ea se p re -p os t an d pr e3m on th fo llo w -u p se lfco m pa ss io n: s ig ni fi ca nt in cr ea se p re po st a nd p re -3 -m on th fo llo w -u p 13 c ra ig e t a l. (2 02 1) c bt : a ff ir m , d es cr ib ed a bo ve o nl in e gr ou ps (e ig ht w ee kl y se ss io ns ) w ith 6 -1 4 di st in ct pa rt ic ip an ts in e ac h ag eap pr op ri at e (1 418 , 1 924 , 2 5+ ) gr ou p ye s a ff ir m , d es cr ib ed a bo ve be ck d ep re ss io n in ve nt or y (b d iii ); br ie f c o pe in ve nt or y (b c i) ; pr oa ct iv e c op in g in ve nt or y fo r a do le sc en ts -a (p c ia )re fle ct iv e c op in g su bs ca le (r c s) ; st re ss a pp ra is al m ea su re fo r a do le sc en ts (s a m a ); h op e sc al e (h s) li ne ar m ul til ev el m od el s w ith r es tr ic te d m ax im um li ke lih oo d es tim at io n (r em l) to te st th e ef fe ct s of t im e, c on di tio n, a nd t im e x c on di tio n fo r al l o ut co m es ; a ge (c en tr ed a t t he m ea n of th e w ho le s am pl e = 22 .3 4) in cl ud ed a s a co va ri at e in th e m od el ; in te rv en tio n (4 6) , c on tr ol (5 0) c om pa re d to w ai tli st c on tr ol , in te rv en tio n co nd iti on p ar tic ip an ts ex pe ri en ce d: s ig ni fi ca nt ly r ed uc ed d ep re ss io n s ig ni fi ca nt ly im pr ov ed li ke lih oo d to ap pr ai se s tr es s as c ha lle ng e an d to ap pr ai se th at th ey h ad e no ug h re so ur ce s to d ea l w ith th e st re ss lgbtq+ mental health interventions 20 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y in te rv en ti on s a ny l g bt q +sp ec if ic ad ap ta ti on s r el ev an t o ut co m es (c om pl et e na m es an d re fe re nc es in t ud or -s fe te a & to pc iu , 2 02 4s , a pp en di x i) r el ev an t a na ly se s; n um be r of pa rt ic ip an ts in cl ud ed th er ei n r el ev an t r es ul ts s um m ar y s ig ni fi ca nt ly im pr ov ed a ct iv e co pi ng , em ot io na l s up po rt , p os iti ve fr am in g, pl an ni ng m ar gi na lly s ig ni fi ca nt d ec re as e in s el fbl am e; n o si gn if ic an t d iff er en ce s be tw ee n th e in te rv en tio n an d co nt ro l c on di tio ns fo r su bs ta nc e us e an d be ha vi ou ra l di se ng ag em en t i nc re as es fo r re fle ct iv e co pi ng o r ho pe , bu t n ot s ta tis tic al ly s ig ni fi ca nt 14 pa n et a l. (2 02 1) c bt : e st ee m , a da pt ed fo r ne w c on te xt s or p op ul at io ns ye s e st ee m , d es cr ib ed ab ov e, b ut w ith a d iff er en t (a si an /c hi ne se ) p op ul at io n c hi ne se v er si on o f t he p h q -9 c hi ne se v er si on o f t he g a d -7 pa ir ed s am pl e tte st s; 7 re du ct io n in th e av er ag e sc or e of de pr es si on a nd a nx ie ty s ym pt om s by ap pr ox im at el y 7 an d 5, r es pe ct iv el y (m ed iu m -t ola rg e im pr ov em en t) 15 ja ck so n et a l. (2 02 2) c bt : w ee kl y 90 -m in g ro up tr ea tm en t s es si on s ov er 1 0 w ee ks ye s e st ee m , d es cr ib ed ab ov e, b ut a da pt ed to re co gn is e th e in te rs ec tio na lit y of r ac is m a nd h om op ho bi a c en te r fo r ep id em io lo gi ca l s tu di es d ep re ss io n sc al e (c es d ); o ve ra ll d ep re ss io n se ve ri ty & im pa ir m en t s ca le (o d si s) ; o ve ra ll a nx ie ty s ev er ity & im pa ir m en t sc al e (o a si s) ; g ay -r el at ed r ej ec tio n se ns iti vi ty s ca le (g rs ); se lfc on ce al m en t s ca le a s pr ev io us ly m od if ie d fo r us e w ith g bm ; in te rn al iz ed h om op ho bi a sc al e (i h s) ; pr ol on ge d a ct iv at io n an d a nt ic ip at or y ra ce -r el at ed s tr es s sc al e p sy ch ol og ic al su bs ca le a nd p er se ve ra tiv e c og ni tiv e su bs ca le ; ra ci sm -r el at ed v ig ila nc e sc al e; h et er os ex is m in r ac ia l e th ni c m in or ity c om m un iti es s ub sc al e of th e lg bt tte st s f oc us in g on h ed ge 's g ef fe ct s iz es 21 (b as el in e) , 1 7 (3 -m on th fo llo w -u p) d ep re ss io n sy m pt om s an d se ve ri ty , an xi et y, p sy ch ol og ic al d is tr es s, s ui ci da l id ea tio n: d ec re as e (v er y sm al l e ff ec t si ze s) ; re je ct io n se ns iti vi ty a nd c on ce al m en t: d ec re as e (s m al l e ff ec t s iz es ), bu t n ot in te rn al is ed h om op ho bi a; ra ci al m in or ity s tr es s ou tc om es , in cl ud in g de cr ea se d an tic ip at or y st re ss , ra ce -r el at ed r um in at io n, a nd r ac ere la te d vi gi la nc e, a nd in te rs ec tio na l s tr es s, in cl ud in g ho m op ho bi a w ith in o ne ’s ra ci al /e th ni c co m m un ity , r ac is m w ith in th e lg bt c om m un ity , a nd r ac is m in da tin g an d cl os e re la tio ns hi ps : d ec re as e (v er y sm al l t o sm al l e ff ec t s iz es ) tudor-sfetea & topciu 21 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ st ud y in te rv en ti on s a ny l g bt q +sp ec if ic ad ap ta ti on s r el ev an t o ut co m es (c om pl et e na m es an d re fe re nc es in t ud or -s fe te a & to pc iu , 2 02 4s , a pp en di x i) r el ev an t a na ly se s; n um be r of pa rt ic ip an ts in cl ud ed th er ei n r el ev an t r es ul ts s um m ar y pe op le o f c ol or (p o c ) m ic ro ag gr es si on sc al e 16 po on e t a l. (2 02 2) d bt : 1 8w ee k co m pr eh en si ve d bt -a (a da pt at io n of d bt m od el fo r ad ol es ce nt s an d th ei r fa m ili es ) o ut pa tie nt pr og ra m o ff er ed to a do le sc en ts be tw ee n th e ag es o f 1 318 , de liv er ed w ith fi de lit y to th e st an da rd m od el , i nc lu di ng a w ee kl y m ul ti fa m ily s ki lls tr ai ni ng g ro up , i nd iv id ua l th er ap y, 2 4/ 7 ph on e co ac hi ng , an d a th er ap is t c on su lta tio n te am n /a d iff ic ul tie s of e m ot io n re gu la tio n sc al e (d er s) ; be ck d ep re ss io n in ve nt or y (b d iii ); be ck a nx ie ty in ve nt or y; t he d ia le ct ic al b eh av io ur th er ap y w ay s of co pi ng c he ck lis t ( d bt -w c c l) ; bo de rl in e sy m pt om s lis t ( bs l) 1) r ep ea te dm ea su re s bo ot st ra pp ed tte st s (t w ota ile d 0. 05 p -v al ue s fo r tr ea tm en t ef fe ct s) fo r lg bq p ar tic ip an ts o nl y 2) 2 x2 m ix ed -m od el a n o va to te st g ro up (l g bq /n on -l g bq ) e ff ec ts o n th e ou tc om es ; 16 lg bq fo r 1) , 1 6 l g bq + 23 no nlg bq fo r 2) 1) s ig ni fi ca nt im pr ov em en ts o n al l ou tc om es , a pa rt fr om a nx ie ty (m os tly la rg e ef fe ct s iz es ) 2) n o si gn if ic an t g ro up tim e in te ra ct io n ef fe ct s on a ny o f t he o ut co m es (c ha ng es ov er ti m e di d no t d iff er b et w ee n lg bq an d no nlg bq p ar tic ip an ts ); st at is tic al ly no ns ig ni fi ca nt , b ut s m al l t o m ed iu m in te ra ct io n ef fe ct s iz es o n th e d er s, b d iii , a nd w c c lsk ill u se (s ex ua l m in or iti es m ay b en ef it sl ig ht ly m or e fr om d bt -a w ith r es pe ct to e m ot io n re gu la tio n, de pr es si on , a nd e ff ec tiv e sk ill u se ) n ot e. a ll in fo rm at io n w as p re se nt ed a s fo un d in th e re sp ec tiv e re su lts s ec tio ns o f t he p ri m ar y re po rt s; th e sa m e ap pl ie s fo r ev al ua tio ns o f w ha t i s co ns id er ed st at is tic al ly o r cl in ic al ly s ig ni fi ca nt , a nd e ff ec t s iz es (a lth ou gh g en er al ly , s ta tis tic al ly s ig ni fi ca nt p er ta in s to p < .0 5, c lin ic al ly s ig ni fi ca nt p er ta in s to r ed uc tio ns in sc or es th at e ith er d ec re as e to b el ow c lin ic al th re sh ol d of th e re sp ec tiv e sc al e or e xc ee d th e m ea su re m en t e rr or o f t he s ca le s, a nd e ff ec t s iz es a re c on si de re d sm al l (d /g = 0 .2 ), m ed iu m (d /g = 0 .5 ), an d la rg e (d /g ≥ 0 .8 ) a cc or di ng to c oh en (1 96 9) , a nd th e in cl ud ed s tu di es s ee m to h av e ad he re d to th is ). lgbtq+ mental health interventions 22 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ interventions based on esteem included equip (empowering queer identities in psy­ chotherapy), which, following interviews with sexual minority women and expert clini­ cians, revised intervention contents to, for example, focus on sexual minority women’s unique experiences, including the intersection of sexism with other forms of oppression, exposure to sexual assault and harassment, or impact of gender norms (pachankis et al., 2020). esteem was also adapted to more diverse contexts, populations, and ethnicities, with a view to address cultural contexts such as prioritisation of family needs and limited support from the health system (pan et al., 2021), or to recognise intersectionality of racism and homophobia (jackson et al., 2022). adaptations occurred via key stakehold­ er feedback and by following the assessment-decision-administration-production-topi­ cal experts-integration-training-testing (adapt-itt) model (wingood & diclemente, 2008), a prescriptive method for adapting existing evidence-based interventions for new contexts or populations (pan et al., 2021), as well as based on prior empirically supported group treatments for gbm of colour and guidance on psychotherapy for individuals who are both racial and sexual minorities (jackson et al., 2022). three studies featured the affirm intervention, a manualised affirmative cognitive behavioural intervention developed using case studies and community-based research, and participant feedback. affirm targets young people with sexual and/or gender iden­ tity minority identities, focusing on improving coping and reducing depression. this occurs by explicitly acknowledging and validating the unique experiences of these pop­ ulations, providing opportunities to understand and modify cognition (self-awareness, identifying risk, e.g., development of realistic alternative ways of thinking and behaving that affirm identities while integrating healthy ways of coping with internal/external stressors), mood (recognising the link between thoughts and feelings, e.g., how partici­ pants have learned to cope with identity-specific stressors), and behaviour (identifying strengths and ways of coping, e.g., connection to peer and adult allies) (craig & austin, 2016). furthermore, one study featured cbt for trauma and self-care (cbt-tsc) including hiv counselling, another featured cbt for social anxiety including a focus on goals for satisfying relationships and sex, and a last study featured cbt with sessions dedicated to transgender-specific issues. dbt, mindfulness, act: two studies used dbt, one adapted by explicitly including minority stress psychoeducation; two studies featured mindfulness-based interventions (mbsr; mindful self-compassion for teens, msc-t – with slight modifications to ac­ commodate the needs of transgender adolescents). a final study featured act, explicitly addressing self-stigma around sexual orientation/internalised homophobia. see tudor-sfetea and topciu, 2024s, appendix g for more details. tudor-sfetea & topciu 23 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ what are the outcomes of evidence-based cognitive and/or behavioural interventions and adaptations targeting mental health in lgbtq+ populations? condition differences post-intervention — four studies, three of which were rcts with inactive controls (#1, #3, #4) and one of which was a non-randomised experimental study (#13), all cbt-based, reported condition differences; #2, although an rct, focused primarily on the effects of internalised homophobia. mental health; depression and anxiety — three studies (#1, #4, #13) reported significant improvements in depressive symptoms – although on different measures, and the two rcts also at least marginally significant improvements in anxiety, all of which had medium-large effect sizes, maintained at follow-up where available. the fourth study (#3) focused on ptsd and showed significant improvements on all measures related to this, bar one subscale which showed a trend for significant difference; these effects were maintained or were trending towards this at follow-up. mental health; other processes/constructs and minority stress-related processes/constructs — no significant differences were reported in any of the studies. pre-post differences — the remaining 11 studies reported pre-post intervention dif­ ferences for variables of interest – however, three of the rcts (#1, #2, #4) and the non-randomised experimental study (#13) also reported pre-post differences. mental health; depression and anxiety — fourteen studies reported results related to symptoms of depression, all of which showed improvements on at least one measure, ten of which (#1, #2, #4, #6, #7, #8, #11, #12, #13, #16) statistically or clinically significant, with medium-large effect sizes, generally maintained at follow-up. ten studies reported results related to symptoms of anxiety, eight of which showed improvements, four of which (#1, #2, #4, #12) were at least marginally statistically or clinically significant, with medium-large effect sizes, of which two maintained the effects at follow-up. the study that focused on social anxiety (#11) showed significant improvements on all measures related to this. mental health; other processes/constructs — two studies reported results related to emo­ tion regulation, one of which (#16) showed significant improvements with large effect sizes, maintained at follow-up. three studies reported results related to coping, only two of which (#7, #13) showed significant improvements between at least two timepoints, on different measures. minority stress-related processes/constructs — six studies reported results related to in­ ternalised homophobia, three of which reported improvements on at least one analysis, lgbtq+ mental health interventions 24 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ one of which (#1) was statistically significant, with a large effect size, maintained at follow-up. four studies reported results on rejection sensitivity, all of which showed improvements, but only one of which (#1) reported a significant result, with a large effect size. finally, four studies reported results related to sexual orientation concealment, two of which reported improvements, none of which appeared to be significant, with small effect sizes. risk of bias in studies all four rcts were judged to be at high risk of bias using the rob 2 (sterne et al., 2019), particularly due to high risk being identified in the measurement of outcome and missing data domains, respectively. of the 12 non-randomised studies, nine (#5, #7, #8, #9, #10, #11, #12, #14, #15) were judged to be at critical risk of bias using the robins-i (sterne et al., 2016), and three (#6, #13, #16) were judged to be at serious risk of bias. this was mostly due to critical scores in the confounding domain, as well as serious scores in the measurement of outcomes domain. half of the studies also scored as serious on the selection of participants domain. see figures 2 and 3, generated using the cochrane visualisation tool robvis, mcguinness et al., 2021), and further details, in tudor-sfetea and topciu, 2024s, appendix h. discussion this review investigated evidence-based cognitive and/or behavioural interventions and adaptations for lgbtq+ populations, complementing previous work (bochicchio et al., 2022; sheinfil et al., 2019; van der pol-harney & mcaloon, 2019) by focusing specifically on cognitive and/or behavioural interventions and broadening the criteria to include participants of any age. summary and interpretation of evidence what evidence-based cognitive and/or behavioural interventions for lgbtq+ populations exist, and what, if any, specific adaptations do they involve? the studies included in the review featured a range of therapeutic modalities (cbt – 11 studies; dbt – two studies; act – one study; mindfulness-based interventions – two studies). of the cbt studies, eight involved versions of two protocolised interven­ tions aimed specifically at lgbtq+ individuals (esteem, interventions based on it such as equip, or adaptations to more diverse contexts or populations – five studies, and affirm – three studies; see table 3). another four studies explicitly referred to lgbtq+-specific adaptations, including a focus on stigma around sexual orientation, tudor-sfetea & topciu 25 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ incorporating minority stress theory, or slight modifications to accommodate lgbtq+ needs. what are the outcomes of evidence-based cognitive and/or behavioural interventions and adaptations targeting mental health in lgbtq+ populations? when considering post-intervention differences between groups, of the four studies (three rcts, one non-randomised experimental study) which reported this, three repor­ ted significant improvements in depressive symptoms, and the two rcts also at least marginally significant improvements in anxiety. the fourth study, which focused on ptsd, showed significant improvements on most measures related to this. no significant differences were reported in terms of other mental health or minority stress-related processes/constructs. when considering pre-post differences, these were reported in the remaining 11 studies as well as in three of the rcts and the non-randomised experimental study. all the 14 studies investigating this showed improvement on at least one measure, ten being statistically/clinically significant. for anxiety, eight out of ten studies showed improve­ ments, four thereof at least marginally statistically/clinically significant. the study that focused on social anxiety showed significant improvements on all measures related to this. reflections studies were heterogenous in terms of study designs, outcome measures, and analyses. although the studies showed general improvements in certain areas such as depression, this is based on a variety of outcome measures (e.g., in some studies, significant improve­ ments are seen on one outcome measure and not another, and viceversa – pachankis et al., 2015, and pachankis et al., 2020, respectively), as well as types of analysis (statistical significance, effect sizes, clinically significant reductions). this, together with the limita­ tions of the studies (see below), raises questions about the strength and consistency of the evidence base. the included studies also featured a heterogeneity of lgbtq+ populations, such that the results cannot be generalised to any specific lgbtq+ population without discussing the intersection of various identities (sexual, gender, racial, ethnic, social). indeed, six studies focused on men, of which four included both gay and bisexual men, one included gay and bisexual men of colour, and one included sexual minority men in china. one study only focused specifically on women, three specifically on transgender individuals; moreover, most studies were conducted in north america. therefore, findings may apply more to particular populations such as sexual minority men in north america, raising the question of whether other populations are the focus of enough relevant research. lgbtq+ mental health interventions 26 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ moreover, while a variety of transdiagnostic elements were featured in the studies’ interventions, mechanisms of change are not clearly differentiated such that the role of the minority stress-based adaptations remains largely unclear. indeed, the most notable effects were observed for depression, while measures of minority stress (that is, proximal factors such as internalised homophobia, concealment, rejection sensitivity) showed less reliable improvements – or were not even explored at all (of the 16 included studies, only seven included such measures). measures of other processes/constructs proposed to interact with minority stress (e.g., emotion regulation, unhelpful behaviours) were included in some studies, yet again, yielded unreliable results. while some authors (e.g., pachankis et al., 2015) discuss that larger sample sizes would reveal such effects, it seems that certain components of non-empirically based treatment may also lead to improvements (van der pol-harney & mcaloon, 2019). findings of this review were consistent with those of previous systematic reviews in that positive effects on mental health were reported, particularly in terms of symp­ toms of depression (bochicchio et al., 2022; sheinfil et al., 2019; van der pol-harney & mcaloon, 2019), with comparable results for various modes of administration, including in-person, online, individual, or group (bochicchio et al., 2022; hobaica et al., 2018), and particularly for interventions based on cbt (van der pol-harney & mcaloon, 2019). furthermore, previous reviews also noted the paucity and heterogeneity of existing liter­ ature. however, while the cited reviews only explored interventions for young people, the current review expanded these to all ages, providing some evidence that results can be generalisable to adults as well, yet the intersection of these various characteristics and identities necessitates more in-depth exploration. what recommendations could be made in terms of such adaptations in clinical practice? the heterogeneity in the studies leads to a limited ability to draw more precise con­ clusions about the effects of particular interventions for particular groups. therefore, generic therapeutic competencies and metacompetencies (e.g., around engagement, ther­ apeutic alliance and grasping clients’ ‘world views’, adapting interventions in response to client feedback, formulating and applying cbt models to the individual client etc., roth & pilling, 2007) may be especially important. indeed, such competencies have been deemed important by some lgbtq+ populations (mcnamara & wilson, 2020). applying these competencies to the needs of lgbtq+ populations may also specifi­ cally mean adopting an affirmative approach, with clinicians being aware of lgbtq+ issues (o’shaughnessy & speir, 2018), including minority stress, and receiving ongoing training on this (boroughs et al., 2015; mcnamara & wilson, 2020). this may also mean adopting a more holistic approach, as lgbtq+ individuals may benefit from addressing minority stress regardless of the format and drawing from social support to build resil­ ience or reframe unhelpful beliefs (alessi, 2014). tudor-sfetea & topciu 27 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ limitations of evidence/summary and interpretation of risk of bias evaluation searches yielded only 16 studies despite broad inclusion criteria. only four studies used an rct design, with the majority using a pre-post design with no control group, there­ fore not being able to establish a causal effect of the interventions. moreover, sample sizes varied considerably, with some studies featuring very small sample sizes and some studies relying on the same sample, bringing into question statistical power and the relevance, reliability, and generalisability of results where statistical tests were not even used. risk of bias was evaluated as high in all four rcts, and critical in nine of the non-randomised studies, with the remaining three non-randomised studies evaluated as serious. however, due to the nature of psychological interventions, domains regarding blinding participants and study personnel and measuring outcomes are intrinsically restricted. nonetheless, almost all uncontrolled pre-post studies were evaluated as pre­ senting critical risk of confounding, based on the robins-i detailed guidance (sterne et al., 2016), which recommends this where confounding is “inherently uncontrollable”. this may have led to a flooring effect. limitations of the review process only english language and peer-reviewed studies were included, which limited the range of articles, potentially raising publication bias (cuijpers et al., 2010). our intention was to focus on the “gold standard” (peer-reviewed) literature as a first step, and research has found that “any unpublished studies identified in a given review may be an unrepresen­ tative subset of all the unpublished studies in existence” (higgins et al., 2023). a funnel plot was considered, but this was not possible, as treatment effects were not available for all included studies. additionally, we excluded certain populations (e.g., hiv-positive persons) and studies with outcomes related solely to drug use, and did not explicitly address outcomes related to suicidality or eating disorders. these areas were considered beyond the scope of this review due to the added complexity they would have brought. see tudor-sfetea and topciu, 2024s, appendix b for more details on these decisions. finally, while our search terms were developed in line with our inclusion/exclusion criteria, using the picos framework, and in collaboration with a university of exeter librarian specialising in with psychology, as well as via terms identified during the scop­ ing search, we acknowledge that their use in their current form may have led to some potentially eligible studies not being retrieved. this is because terms such as “minority stress” encompass heterogenous sets of constructs which may have led to studies not being retrieved unless the constructs were explicitly part of the search string. this, of lgbtq+ mental health interventions 28 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ course, may in turn limit the representativeness of the studies and paint a relatively different picture of the landscape of the literature. our rationale for keeping terms rather broad was to keep a similar “detail level” of terms, one which was most likely to retrieve the most relevant results. indeed, as dis­ cussed above, our findings are broadly in line with those of previous systematic reviews in the area, suggesting that the retrieved studies were mostly representative of the topic at hand. we provide a more extensive explanation in tudor-sfetea and topciu, 2024s, appendix b. the limited and heterogeneous nature of the evidence also restricted the possibility of exploring the data via meta-analyses and drawing more robust conclusions. implications and future research directions to allow for more robust and more generalisable conclusions to be drawn, more consis­ tency in outcome measures and general methodology is needed. this would allow for more meta-analyses to be conducted, and these should consider the impact of publication bias (cuijpers et al., 2010). however, less strict methodologies may also offer pragmatic information on how interventions are administered and received in a variety of health­ care settings. moreover, as certain lgbtq+ populations seem to be focused on more than others in the literature, more research needs to be carried out focusing on other lgbtq+ popu­ lations, as well as discussing the intersection of various identities. more detailed investi­ gations into specific mechanisms of change could also provide invaluable information as to the role of minority stress-based adaptations and what intervention aspects and therapeutic competencies are most important in producing positive outcomes, allowing for more investment and/or training in those areas. conclusion the review investigated evidence-based cognitive and/or behavioural interventions and adaptations for lgbtq+ populations, revealing a range of therapeutic modalities and levels of adaptation. findings showed largely positive effects, in line with previous systematic reviews – however, in the context of a paucity of the literature, with hetero­ geneity in terms of study designs, outcome measures, and analyses, as well as risk of bias evaluated as high or critical/serious (despite the possibility of a flooring effect). limitations in terms of included studies and possible publication bias, as well as limited opportunity for generalisability and further exploration of the evidence to draw more robust conclusions are recognised. suggestions for clinical practice are around the im­ portance of generic therapeutic competencies and metacompetencies, and affirmative, potentially more holistic approaches. suggestions for future research directions include more consistency in methodology, more focus on underserved lgbtq+ populations and intersectionality, and more detailed investigations into mechanisms of change. tudor-sfetea & topciu 29 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. social media accounts: @cts504 reporting guidelines: this systematic review was carried out in accordance with the updated prisma guidelines (page et al., 2021). preregistration: the work was registered on prospero (international prospective register of systematic reviews) in april 2022 (crd42022243466) (tudor-sfetea & topciu, 2022s). data availability: for this article, a data set is freely available (tudor-sfetea, 2023s). supplementary materials the supplementary materials contain the following items: • the preregistration (tudor-sfetea & topciu, 2022s) • online appendices ◦ appendix a – further explanation regarding deviations from the prospero protocol (tudor-sfetea & topciu, 2024s) ◦ appendix b – further explanation regarding inclusion/exclusion criteria (tudor-sfetea & topciu, 2024s) ◦ appendix c – search terms and full search strategy/history (tudor-sfetea, 2023s) ◦ appendix d – full extracted data table (tudor-sfetea, 2023s) ◦ appendix e – overview of records excluded at full text review stage (tudor-sfetea & topciu, 2024s) ◦ appendix f – narrative summary of study and sample characteristics (tudor-sfetea & topciu, 2024s) ◦ appendix g – further details around study session numbers and duration (tudor-sfetea & topciu, 2024s) ◦ appendix h – further information regarding risk of bias in studies (tudor-sfetea & topciu, 2024s) ◦ appendix i – measures referenced in the data extraction table(s) (tudor-sfetea & topciu, 2024s) index of supplementary materials tudor-sfetea, c. (2023s). a systematic review of evidence-based cognitive and/or behavioural interventions targeting mental health in lgbtq+ populations [search terms, full search strategy/ history, and full extracted data table]. osf. https://osf.io/zbu6r lgbtq+ mental health interventions 30 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://x.com/cts504 https://osf.io/zbu6r https://www.psychopen.eu/ tudor-sfetea, c., & topciu, r. (2022s). a systematic review of evidence-based cognitive and/or behavioural interventions targeting mental health in the lgbt+ community [preregistration]. prospero. https://www.crd.york.ac.uk/prospero/display_record.php?id=crd42022243466 tudor-sfetea, c., & topciu, r. 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(2019). rob 2: a revised tool for assessing risk of bias in randomised trials. bmj, 366, article i4898. https://doi.org/10.1136/bmj.l4898 tan, k. k. h., treharne, g. j., ellis, s. j., schmidt, j. m., & veale, j. f. (2020). gender minority stress: a critical review. journal of homosexuality, 67(10), 1471–1489. https://doi.org/10.1080/00918369.2019.1591789 testa, r. j., michaels, m. s., bliss, w., rogers, m. l., balsam, k. f., & joiner, t. (2017). suicidal ideation in transgender people: gender minority stress and interpersonal theory factors. journal of abnormal psychology, 126, 125–136. https://doi.org/10.1037/abn0000234 van der pol-harney, e., & mcaloon, j. (2019). psychosocial interventions for mental illness among lgbtqia youth: a prisma-based systematic review. adolescent research review, 4(2), 149– 168. https://doi.org/10.1007/s40894-018-0090-7 wingood, g. m., & diclemente, r. j. (2008). the adapt-itt model: a novel method of adapting evidence-based hiv interventions. journal of acquired immune deficiency syndrome, 47(suppl 1), s40–s46. https://doi.org/10.1097/qai.0b013e3181605df1 *yadavaia, j. e., & hayes, s. c. (2012). acceptance and commitment therapy for self-stigma around sexual orientation: a multiple baseline evaluation. cognitive and behavioral practice, 19(4), 545– 559. https://doi.org/10.1016/j.cbpra.2011.09.002 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. lgbtq+ mental health interventions 36 clinical psychology in europe 2024, vol. 6(3), article e11323 https://doi.org/10.32872/cpe.11323 https://doi.org/10.1136/bmj.i4919 https://doi.org/10.1136/bmj.l4898 https://doi.org/10.1080/00918369.2019.1591789 https://doi.org/10.1037/abn0000234 https://doi.org/10.1007/s40894-018-0090-7 https://doi.org/10.1097/qai.0b013e3181605df1 https://doi.org/10.1016/j.cbpra.2011.09.002 https://www.psychopen.eu/ lgbtq+ mental health interventions (introduction) rationale objectives method guidelines and registration eligibility criteria information sources search strategy selection process data collection process study risk of bias assessment synthesis methods results study selection study characteristics interventions, adaptations, and results risk of bias in studies discussion summary and interpretation of evidence limitations of evidence/summary and interpretation of risk of bias evaluation limitations of the review process implications and future research directions conclusion (additional information) funding acknowledgments competing interests social media accounts reporting guidelines preregistration data availability supplementary materials references attitudes towards digital health interventions in germany: findings from a population-based representative survey research articles attitudes towards digital health interventions in germany: findings from a population-based representative survey lena sophia steubl 1 , rebekka büscher 2,3 , lasse bosse sander 2 , amit baumel 4 , katja barck 1, cedric sachser 5 , jörg michael fegert 5 , elmar brähler 6,7 , harald baumeister 1 , matthias domhardt 1 [1] department of clinical psychology and psychotherapy, institute of psychology and education, ulm university, ulm, germany. [2] medical psychology and medical sociology, medical faculty, university of freiburg, freiburg im breisgau, germany. [3] department of clinical, neuro and developmental psychology, vrije universiteit amsterdam, amsterdam, the netherlands. [4] department of community mental health, university of haifa, haifa, israel. [5] department of child and adolescent psychiatry/psychotherapy, medical faculty, ulm university, ulm, germany. [6] department of psychosomatic medicine and psychotherapy, university medical center mainz, mainz, germany. [7] medical psychology and medical sociology, medical faculty, university of leipzig, leipzig, germany. clinical psychology in europe, 2025, vol. 7(3), article e15233, https://doi.org/10.32872/cpe.15233 received: 2024-08-01 • accepted: 2025-06-12 • published (vor): 2025-08-29 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: lena sophia steubl, department of clinical psychology and psychotherapy – institute of psychology and education, ulm university, lise-meitner-straße 16, 89081 ulm, germany. tel.: +49-(0)731/50 32834. e-mail: lena.steubl@uni-ulm.de supplementary materials: materials [see index of supplementary materials] abstract background: digital (mental) health interventions have the potential to address barriers in mental health care. however, attitudes towards these interventions are a crucial factor to their successful implementation. therefore, this study aims to assess those in a representative sample of the german adult population. method: a total of n = 2,519 participants took part in the survey as part of a larger study. following a structured face-to-face interview, participants completed a self-administered questionnaire under the supervision of the interviewer. the questionnaire was based on the e-therapy attitudes measure (etam) and the attitudes towards psychological interventions questionnaire (apoi). results were analyzed by means of pearson's product moment correlation coefficients and spearman's ρ statistics. supplementary open-ended questions explored this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.15233&domain=pdf&date_stamp=2025-08-29 https://orcid.org/0000-0002-8508-5271 https://orcid.org/0000-0001-8931-0942 https://orcid.org/0000-0002-4222-9837 https://orcid.org/0000-0002-7043-8898 https://orcid.org/0000-0002-9353-7936 https://orcid.org/0000-0001-6070-4323 https://orcid.org/0000-0002-2648-2728 https://orcid.org/0000-0002-2040-661x https://orcid.org/0000-0002-3243-8926 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ participants' utilization of digital health interventions for specific conditions, the conditions they perceived as suitable for those, and the perceived barriers to their adoption. replies on open-ended questions are summarized descriptively. results: while a majority of participants (34.0%–41.5%) indicated partial agreement with the potential usefulness and advantages of digital health interventions (items 1-3), a substantial proportion (45.8%, 95% ci [43.8%, 47.7%]) expressed an entire refusal to use them for future psychological problems (item 4). older individuals and those with lower educational status expressed particular critical views. key barriers identified by participants comprised the absence of personal contact, technical issues, and concerns related to data privacy and security. conclusion: the results of this study indicate that while participants acknowledge the potential benefits of digital health interventions, the observed limited acceptance rates and identified barriers are to be addressed, in order to fully harness their potential. keywords e-health, acceptance, utaut, digital psychotherapy, online therapy highlights • a substantial proportion expressed an absolute reluctance to use digital health interventions. • this reservedness decreases with younger age and higher educational status. • key barriers include the absence of personal contact, technical issues, and data privacy and security concerns. • there was, however, a subsample that would rather use digital than regular face-toface treatment. while the precise prevalence rates of common mental conditions differ across countries, they are consistently high worldwide – with female gender, younger age, living without a partner, and low socio-economic status representing important risk factors (baumeister & härter, 2007; gbd 2019 mental disorders collaborators, 2022; jacobi et al., 2014; world health organization, 2022). mental conditions are associated with substantial individual and societal costs and efficacious interventions to treat them are theoretically present, but only a fraction of affected individuals receive an evidence-based treatment (mack et al., 2014; wang et al., 2007). possible reasons for the low uptake rates of mental health care include logistical barriers, fear of stigmatization, and a shortage of actually available treatment options (brakemeier & herpertz, 2019; hansen et al., 2002; lambert, 2017). expanding the provision of digital health interventions has repeatedly been linked to the promise to overcome these barriers (andersson & titov, 2014; domhardt, cuijpers, et al., 2021; torous et al., 2021). digital health interventions, defined as interventions using the internet as a medium for the delivery of psychotherapeutic treatment, have been found to be efficacious and effective for a variety of mental conditions in a variety attitudes towards digital health interventions in germany 2 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ of populations (domhardt et al., 2019, 2020; domhardt, schröder, et al., 2021; edge et al., 2023; kolaas et al., 2024; lecomte et al., 2020; moshe et al., 2021; plessen et al., 2025; steubl et al., 2021). these interventions make therapeutic content available digitally – with the help of for example audios, videos, texts, downloads, and questions. a recent framework provides information on how to implement and study them (smith et al., 2023). of note, while video-based psychotherapy (i.e., synchronous therapy via videocon­ ferencing) is also internet-delivered, it differs from the types of digital interventions primarily referred to in this study and is therefore not the main focus of the present analysis. compared to conventional face-to-face treatments, digital health interventions may be easier to access, integration into the patients’ daily lives may be more flexible and the provision may be easily scalable and cost-efficient (at least compared to non-bonafide comparisons) once developed (andersson & titov, 2014; gega et al., 2022; kählke et al., 2022; titov et al., 2015; warmerdam et al., 2010). however, there are two issues that have been repeatedly associated with limited implementation success of digital health interventions into routine health care: low uptake and low adherence (kählke et al., 2022; lambert, 2017). one suggested reason for these issues may be the possible low level of patients’ acceptance of digital health interventions. this is in line with the basic assumption of the so-called unified theory of acceptance and use of technology (utaut), an overarching framework that combines eight models and postulates that acceptance is a direct predictor of the future use of digital interventions (venkatesh et al., 2003). along with several moderators (e.g., gender, age, voluntariness), utaut hypothesizes four determinants of intention to use as a predictor of behavior (i.e., usage): 1) the degree to which an individual believes that the technology will help them (performance expectancy), 2) the expected effort of using the technology (effort expectancy), 3) the influence of the opinion of significant others (i.e., peers or others, social influence), and 4) the degree to which necessary resources and support are seemingly available (facilitating conditions; venkatesh et al., 2003). the utaut concept has been widely and successfully used in multiple areas, including digital health (dwivedi et al., 2020). a scoping review found evidence that digital health interventions were perceived as less beneficial compared to traditional face-to-face interventions (apolinário-hagen, kemper, et al., 2017). furthermore, the intentions to utilize digital health interventions in the future were generally lower in comparison to face-to-face services. damerau et al. (2021) assessed the acceptance of digital health interventions following the utaut model in patients with diabetes in germany, resulting in moderate acceptance ratings. hereby, gender and having a mental disorder had a significant influence on acceptance, with participants with mental disorders having a significantly higher acceptance than those without. more broadly, philippi et al. (2021) conducted secondary analyses on primary data of ten studies from germany that examined participants' acceptance of steubl, büscher, sander et al. 3 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ digital health interventions using the utaut framework. it was found that the most appropriate model resembled the fundamental structure of utaut, with performance expectancy emerging as the most influential predictor (philippi et al., 2021). on average, the level of acceptance observed was categorized as low to moderate, primarily being drawn from a segment of the population that was close to hand (i.e., convenience sampling; philippi et al., 2021). all included studies focused on specific disorders or populations (i.e., depression, diabetes and comorbid depression, chronic pain, well-being and health in the elderly, gastrointestinal problems, aftercare for inpatients, multiple sclerosis, psychotherapists’ acceptance towards blended therapy; philippi et al., 2021). however, another recent study on the acceptance of digital health interventions for depression care in germany focusing on the perspective of patients, their relatives, and health professionals resulted in general openness towards the use of those interventions (hafner et al., 2022). more precisely, about 80% of the participants reported being open to using a digital health intervention for depression (hafner et al., 2022). similar results have been found in two survey studies in germany (apolinário-hagen et al., 2018; apolinário-hagen, vehreschild, et al., 2017) concluding that the majority of participants regard digital health interventions as potentially helpful. nevertheless, intentions to use are low and face-to-face treatments are preferred overall (apolinário-hagen et al., 2018; apolinário-hagen, vehreschild, et al., 2017). while these results shed some light on the attitudes towards digital health interven­ tions – in the german population and in other western countries – they are still limited and inconclusive regarding attitudes towards digital health interventions in specific pop­ ulation groups, where acceptance levels are particularly high or low, and how this corre­ lates with sociodemographic characteristics. not only do the rates of acceptance diverge, there are also important limitations when it comes to the recruitment of survey partic­ ipants. in particular, even recruitment for studies focusing on the general population was often convenienceand web-based and took place through digital advertisements (apolinário-hagen et al., 2018; apolinário-hagen, vehreschild, et al., 2017) potentially leading to biased findings of prior research. this may restrict the generalizability of these findings to the general population. therefore, this study aims to assess general attitudes towards digital health interventions exemplified in the german population by means of a representative and randomly chosen sample, in order to inform future efforts to integrate those interventions into routine health care. method the present study analyzes relevant parts of the data from a large, representative survey conducted in germany. the survey was approved by the ethics committee of the medical faculty of the university of leipzig (approval number: 298/21‐ek). the implementation of the survey and data collection was performed by an independent attitudes towards digital health interventions in germany 4 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ institute (usuma, berlin) between december 2020 and march 2021. to put the data collection period into perspective, it is important to note that the first diga (i.e., a certified health application that can be reimbursed by german health insurances) was available in october 2020 (ludewig et al., 2021). regional areas were first predefined using the adm-sampling-system (heckel & hofmann, 2014). next, target households were selected by means of a random route procedure. for multi-person households, one person was randomly selected. this multi-stage recruitment strategy ensures representa­ tivity of included individuals (heckel & hofmann, 2014). no financial compensation or other incentives were provided to participants. all randomly selected participants were first informed verbally about the research background of the study as well as the volun­ tary nature and the right of later withdrawal of their own participation. experienced and trained interviewers then conducted face-to-face interviews with 2,519 participants representative for the german population over the age of 15 and supervised also the accomplishment of the self-report questionnaires after participants gave their informed consent. the data predominantly relevant for this study was obtained in the self-report questionnaires. measures relevant sociodemographic information (i.e., age, gender, marital status, level of educa­ tion, religious affiliation, current stress, prior experience with digital health interven­ tions) was collected from all participants. attitudes towards digital health interventions were assessed using four items (items 1-4; 5-point likert scale; 1 = absolutely no, 2 = rather no, 3 = partly, 4 = rather yes, 5 = absolutely yes) that were based on the “e-therapy attitude measure” (etam; apolinário-hagen, vehreschild, et al., 2017) and the “attitudes towards psychological interventions questionnaire” (apoi; schröder et al., 2015) following the utaut model. additionally, they were asked if they would use routine face-to-face psychotherapy for psychological problems in the future (5-point likert scale, item 5). furthermore, three open questions were included in order to complement the quantitative measures and pro­ vide further exploratory insights. they assessed (1) the conditions for which participants already use digital health interventions, (2) the conditions participants could imagine to use digital health interventions in the future, and (3) possible barriers for the personal usage of digital health interventions. all questions were administered in german. to make sure patients understood what we conceive as digital health interventions, a short explanation was prefaced stating that the interventions in question are administered via the internet (e.g., pc, tablet, smartphone) and can be used for the treatment of mental disorders, such as anxiety and depression, but also for other (mental and somatic) conditions. a translation of the full questionnaire, including the initial instruction, can be found in the supplementary materials (see steubl et al., 2025s). steubl, büscher, sander et al. 5 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ statistical analyses statistical analyses were performed using r studio (version 4.2.2; r core team, 2022). to classify attitudes towards digital health interventions descriptive analyses were used. potential predictors (i.e., age, gender, highest level of education, current stress) were explored using pearson's product moment correlation coefficients and spearman's ρ statistics. hereby, the four questions assessing attitudes towards digital health interven­ tions were combined to one sum score. results from open questions were qualitatively analyzed using a structured approach informed by conventional content analysis. one rater developed a coding scheme based on the content of the responses (lss), which was then independently applied by a second rater (af). disagreements were resolved through discussion until consensus was achieved. results of the 2,519 study participants, 1,322 participants self-rated their gender as female (52.5%), 1,130 as male (47.4%), and four as diverse (0.2%). the mean age was 50.3 years (sd = 18.1). further characteristics of the study sample are described in table 1. table 1 characteristics of the study sample variable n (%) or m (sd) age (m, sd) 50.3 (18.1) gender (n, %) male 1,193 (47.4) female 1,322 (52.5) diverse 4 (0.2) marital status (n, %) married, living together 1,076 (42.7) married, living apart 65 (2.6) single 757 (30.1) divorced 370 (14.7) widowed 243 (9.7) german citizenship (n, %) 2,425 (96.3) highest level of education (n, %) in school 47 (1.9) no graduation 57 (2.3) year 9 lower secondary school certificate) 679 (27.0) year 10 lower secondary school certificate 822 (32.7) graduated from polytechnical high school 240 (9.6) attitudes towards digital health interventions in germany 6 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ variable n (%) or m (sd) graduated from technical college with no accreditation 101 (4.0) entrance qualification for technical college/university 277 (11.0) college/university studies completed 274 (10.9) other 3 (0.1) currently stressed (n, %) absolutely no 1,388 (55.1) rather no 507 (20.1) partly 364 (14.5) rather yes 189 (7.5) absolutely yes 51 (2.0) previous usage of digital health interventions (n, %) yes 17 (0.7) no 2,497 (99.1) not stated 5 (0.2) heard of digital health interventions (n, %) yes 873 (34.7) no 1,593 (63.2) not stated 53 (2.1) attitudes towards digital health interventions the distribution of responses with regard to attitudes towards digital health interven­ tions can be found in figures 1, 2, 3, 4, and 5. figure 1 attitudes towards digital health interventions: item 1 item 1: "i rate digital health interventions as positive and helpful" (in %) 0 20 40 60 absolutely no rather no partly rather yes absolutely yes pe rc en ta ge steubl, büscher, sander et al. 7 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ figure 2 attitudes towards digital health interventions: item 2 item 2: "digital health interventions will be able to reach more patients and help them" (in %) 0 20 40 60 absolutely no rather no partly rather yes absolutely yes pe rc en ta ge figure 3 attitudes towards digital health interventions: item 3 item 3: "the anonymity of digital health interventions makes it easier to talk openly and honestly" (in %) 0 20 40 60 absolutely no rather no partly rather yes absolutely yes pe rc en ta ge attitudes towards digital health interventions in germany 8 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ figure 4 attitudes towards digital health interventions: item 4 item 4: "i would seek treatment via digital health interventions in the future" (in %) 0 20 40 60 absolutely no rather no partly rather yes absolutely yes pe rc en ta ge figure 5 attitudes towards routine face-to-face psychotherapy: item 5 item 5: "i would seek routine psychotherapy in the future" (in %) 0 20 40 60 absolutely no rather no partly rather yes absolutely yes pe rc en ta ge in detail, when asked if they would agree that they rated digital health interventions positively and as helpful, a majority of participants indicated partial agreement (i.e., rated item 1 with 3 = partly, n = 1,046, 41.5%, 95% ci [39.6%, 43.4%]). likewise, the statement that digital health interventions will reach and help more patients was approved partly by the majority of the participants (i.e., rated item 2 with 3 = partly, n = 959, 38.1%, 95% steubl, büscher, sander et al. 9 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ ci [36.2%, 40.0%]). the majority also indicated partial agreement towards the statement that the anonymity of digital health interventions makes it easier to speak openly and honestly about important problems (i.e., rated item 3 with 3 = partly, n = 854, 34.0%, 95% ci [32.1%, 35.8%]). nevertheless, the majority of participants stated that they will “absolutely not” use digital health interventions for future psychological problems (i.e., rated item 4 with 1 = absolutely no, n = 1,153, 45.8%, 95% ci [43.8%, 47.7%]). in contrast, the majority absolutely agreed that they would use routine face-to-face psychotherapy in case of future psychological problems (i.e., rated item 5 with 5 = absolutely yes, n = 760, 30.2%, 95% ci [28.4%, 32.0%]). of note, 10.2% of the participants (n = 256, 95% ci [9.0%, 11.3%]) rated item 4 higher than item 5, which indicates a preference for digital health interventions over routine face-to-face psychotherapy. the mean age of the subsample preferring digital health interventions was 42.8 (sd = 16.1). correlational analyses of attitudes towards digital health interventions there was no significant correlation between attitude towards digital health interven­ tions and gender (i.e., sum score of items 1-4; r = .002, p = .937) or current psychological stress (r = 0.000, p = .998). the correlation between age and attitude was moderate (r = -0.296, p < .001), with younger age being associated with higher acceptance of digital health interventions. the correlation between highest level of education and attitude towards digital health interventions showed a small positive association (rho = 0.14, p < .001). responses to all individual items depending on gender and categorized by age groups can be found in the supplementary materials (see steubl et al., 2025s). open questions out of the total number of participants, 17 (0.7%) stated that they have previously used a digital health intervention. conditions mentioned included borderline personality disorder (n = 2; 11.8%), anxiety disorders (n = 2; 11.8%), depression (n = 2; 11.8%), obsessive-compulsive disorder (n = 2; 11.8%), addiction (n = 1; 5.9%), migraine (n = 1; 5.9%), burnout (n = 1; 5.9%), kleptomania (n = 1; 5.9%), and stroke (n = 1; 5.9%). the remaining six participants (35.3%) did not specify for which condition. a total of 582 (23.1%) participants listed one or more conditions for which digital health interventions were considered as suitable treatment options. most frequently listed were depression (n = 225, 38.7%) and anxiety disorders (n = 123, 21.1%). other conditions mentioned were medical conditions (e.g., cancer, diabetes; n = 96, 16.5%), addictive disorders (n = 55, 9.5%), psychotic disorders (n = 15, 2.6%), obsessive-compulsive disorders (n = 13, 2.2%), eating disorders (n = 11, 1.9%), suicidal ideation (n = 8; 1.4%), personality disorders (n = 6, 1.0%), somatoform disorders (n = 4, 0.7%), and trauma-rela­ attitudes towards digital health interventions in germany 10 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ ted disorders (n = 3, 0.5%). additionally, 111 (19.1%) participants mentioned psychosocial problems not directly associated with medical or mental conditions. altogether, 822 participants (32.6%) stated possible barriers to initiating treatment via digital health interventions. most commonly stated barriers were the absence of personal contact (e.g., no personalization, no therapeutic relationship, anonymous treatment, n = 285, 34.7%), technical aspects (e.g., no softand hardware, no internet connection, prob­ lems with internet in general, n = 164, 20.0%), and mistrust because of data privacy and security concerns (n = 124, 15.1%). other mentioned barriers were not enough experience or competence in the use of such interventions or the internet in general (n = 106, 12.9%), integrity of interventions (n = 98, 11.9%), costs of digital health interventions (n = 27, 3.3%), limited offer of digital health interventions (n = 23, 2.8%), limited perceived effectiveness (n = 23, 2.8%), health reasons (e.g., symptom severity, n = 7, 0.9%), and assessments that need to take place in-person (e.g., electrocardiogram; n = 3, 0.4%). discussion this representative study shows that attitudes towards digital health interventions in germany are rather restrained. this holds particular significance because even the most effective digital interventions have limited impact if they are underutilized due to nega­ tive attitudes and lack of acceptance. specifically, 45.8% of the representative sample in this study explicitly expressed an absolute reluctance to use digital health interventions for mental health in the future. in particular, older people and people with a lower level of education rated digital health interventions for mental health problems with reservation. this is in line with previous results suggesting that especially older adults experience a variety of barriers to the uptake of digital health interventions for mental conditions including the lack of trusted facilitators (pywell et al., 2020; wykes & brown, 2016). however, even though there are concerns, there is still considerable acceptance in certain groups that also offers the opportunity to bring more individuals with mental conditions into treatment. for example, when looking at the youngest age group (< 20 years) this percentage drops to 27.3% with the majority (28.4%) stating that they would partly seek treatment via digital health interventions in the future (for details see supplementary materials [steubl et al., 2025s]). additionally, there is also a subsample (n = 256, 10.2%) that seems to prefer digital health interventions over routine face-to-face psychotherapy and a considerable number of participants (n = 595, 23.6%) listed mental health conditions they could see digital health interventions being used for. accordingly, the frequently expressed barriers assessed within the survey (i.e., absence of face-to-face therapeutic relationship with personalization, technical aspects, and data privacy and security concerns) are of particular importance. hereby, the primary concern lies in the absence of a genuine therapeutic relationship and the perception that digital health interventions are unable to provide the same steubl, büscher, sander et al. 11 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ level of personalized treatment as traditional face-to-face psychotherapy. however, it is well established that it is indeed possible to form a therapeutic relationship in (guided) digital health interventions (berger, 2017; flückiger et al., 2018; pihlaja et al., 2018). additionally, emerging viewpoints suggest that while a stable therapeutic relationship is of importance in conventional treatment, digital health interventions may extend beyond this and be applied for alternative purposes (e.g., micro interventions or to support significant others; baumel et al., 2020; baumel & tamir, 2022). these novel applications appear to diminish the significance of the therapeutic relationship, as perceived by patients (baumel & tamir, 2022). moreover, there is a variety of new approaches to make digital health interventions more personalized and engaging with possible approaches include just-in-time adaptive interventions, gamification, chatbots, and interventions that are personalized and tailored to the individual (baumeister et al., 2023; baumeister & montag, 2023; domhardt, cuijpers, et al., 2021; torous et al., 2021). while the issue of missing technical prerequisites (e.g., an internet connection) cannot be solved that easily, the ubiquitous digital change may lessen this issue in the future. finally, privacy and security concerns are certainly to be taken very seriously as digital health interventions are dealing with private and sensitive data. however, this problem may be of special relevance when using digital health interventions from un­ known sources. fortunately, there is a wide range of digital health interventions from reputable and well-established sources with a high level of data protection efforts on the market. additionally, there are platforms available online that rate interventions with re­ gard to for example data privacy and security details (e.g., mobile health app database, mhad.science [stach et al., 2020] or https://onemindpsyberguide.org/). moreover, patients in germany have the opportunity to use so-called digas. these digital interventions are subject to certain data privacy and security regulations to protect users' personal health information (ludewig et al., 2021). patients can obtain digas with a prescription by their consulting physician, medical doctor or psychotherapist and use them as part of their treatment plan (ludewig et al., 2021). nevertheless, the exemplary regulation of digital interventions in germany and other countries like sweden or australia does not refer to all available digital health interventions and many reviews of publicly available mobile health apps show considerable limitations when it comes to data privacy and security (domhardt, messner, et al., 2021; simon et al., 2023; steubl et al., 2022). taken together, the barriers seem to reflect low scores on the utaut dimensions fa­ cilitating conditions and effort expectancy. interestingly, only a minority of participants explicitly questioned the effectiveness of digital mental interventions (2.8%) and none mentioned the influence or opinions of others as a reason for non-use (0.0%), despite performance expectancy and social influence being core factors within the utaut model. while the emphasis on the absence of personal contact could also reflect a broader skepticism regarding the performance of digital interventions, and thus relate to perform­ ance expectancy, these findings suggest that efforts to increase acceptance and uptake attitudes towards digital health interventions in germany 12 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://onemindpsyberguide.org/ https://www.psychopen.eu/ may benefit from a focus on improving perceived usability, trust, and the integration of relational elements, rather than solely emphasizing efficacy. of note, the majority of participants (67.4%) did not provide any response when asked about potential barriers to using digital health interventions. this may reflect a lack of specific concerns among many respondents, but it could also be due to the open-ended nature of the question, which typically yields lower response rates compared to closed questions with multiple choice answers provided. additionally, participants may have lacked detailed knowledge about such interventions, which could limit their ability to anticipate barriers. nevertheless, it seems evident from the aforementioned points that there exist valid reasons for patients to hold a more positive stance towards reputable digital health inter­ ventions than it is currently the case. fortunately, there are numerous ways to influence and develop patients’ attitudes positively (bauer & kirchner, 2020). for example, as a persuasive strategy, proponents have advocated the incorporation of future users and in­ dividuals with lived-experience in the developmental and implementation phases of digi­ tal health interventions (i.e., participatory development; geirhos et al., 2021; hochmuth et al., 2020). moreover, there have been successful efforts to offer acceptance-facilitating interventions to both patients and therapists (baumeister et al., 2014; ebert et al., 2015). in general, it seems likely that a (corrective) experience with a digital intervention or more knowledge on the matter (e.g., through educational campaigns) is necessary to alleviate concerns or apprehensions. this should be addressed in depth in future studies and efforts. in addition to promoting acceptance of digital health interventions, our findings may also inform future strategies on how to implement these interventions within the healthcare system. specifically, the results highlight the importance of offering a variety of treatment formats (e.g., face-to-face/on-site, video-based/remotely delivered, fully digital/stand-alone) in routine mental health care. given that individual preferences – such as the desire for personal contact – can shape attitudes and acceptance, providing freedom of choice and for example blended therapy formats (baumeister et al., 2018) may help align treatment settings with patients’ expectations and increase engagement. it is worth highlighting that in contrast to attitudes toward digital interventions, a substantially larger proportion of participants indicated that they would be willing to use routine face-to-face psychotherapy in the case of future psychological problems. these results reflect the alignment between public attitudes and the current organization of the mental health care system, in which face-to-face psychotherapy remains the standard form of service delivery next to (rudimentary) mental healthcare provided by general practitioners (e.g., with medication). it also shows greater familiarity and comfort with traditional treatment modalities, as well as a general preference for direct personal contact, which was also a commonly cited barrier to using digital intervention formats. these results further underscore the continued importance of offering and extending steubl, büscher, sander et al. 13 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ face-to-face treatment options – while addressing some limitations of on-site treatments like long waiting times at the same time – and highlight that digital health interventions may complement, rather than replace, conventional care in mental health services (e.g., as in blended therapy formats; baumeister et al., 2018) and may represent a low-thresh­ old component in stepped mental healthcare (domhardt & baumeister, 2018). limitations while the results of this study shed light on the acceptance of digital health interven­ tions, there are some important limitations to consider. first and foremost, the term digital health intervention is very broad and participants were only provided with a concise description comprising two sentences. in the following, some participants might have had a very limited or unrealistic understanding of the concept resulting in differen­ ces in attitudes. additionally, blended therapy approaches (i.e., the combination digital health interventions with traditional face-to-face therapy) were not explicitly mentioned in the survey. given that such formats are generally associated with higher acceptance compared to stand-alone digital interventions (schuster et al., 2018), the incorporation of this treatment format into the survey might have had an additional influence on partici­ pants’ responses. while the decision not to prime participants with specific interventions may have certain advantages (e.g., not focusing on one certain intervention), it might be beneficial for future studies to actually present participants with one or two examples (similar to the aforementioned acceptance-facilitating studies; baumeister et al., 2014; ebert et al., 2015). this is especially important, as a considerable amount of the replies to the open questions might have focused on video-based therapy. while this is certainly an important and already widely used form of a digital intervention as outlined previ­ ously in this paper, it might not provide the same advantages (e.g., cost-effectiveness, scalability) and disadvantages (e.g., limited guidance, concerns regarding therapeutic relationship) as other digital health interventions (i.e., imis) and might have to be viewed separately (for a more detailed discussion on this issue: steubl & baumeister, 2023). second, the reported statistical analyses provide predominantly a descriptive picture of the gathered data. longitudinal designs and examining changes over time would be high­ ly worthwhile. third, potentially relevant individual characteristics were not assessed (e.g., digital literacy, stigmatization of mental conditions, ethnic background) due to the broader scope of the overall study of which our survey represents a specific sub-analysis. as a result, our ability to examine how these factors may influence attitudes towards digital interventions is limited, and this may affect the generalizability of our findings to all segments of the population. last, this study assesses attitudes towards digital health interventions, but considering the use of certain offers in a questionnaire might be different to actually using them. however, the utaut model on which the employed questionnaires are based strongly suggests that assessed acceptance is a direct predictor of use of digital offers (venkatesh et al., 2003). attitudes towards digital health interventions in germany 14 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://www.psychopen.eu/ conclusion this study suggests that a majority of adults in germany would (rather) not use digital health interventions. however, this reservedness decreases with younger age and there is a subsample of individuals who would rather use digital health interventions than reg­ ular face-to-face treatment. the identified barriers for the usage of digital interventions (i.e., absence of personal contact, technical issues, and concerns related to data privacy and security) need to be addressed in order to fully harness the potential of digital health interventions in routine care. funding: the authors have no funding to report. acknowledgments: the authors wish to thank elisa könig and anna früchtl (af) for their contributions to the study preparation and the coding of text replies. competing interests: lbs, ab, hb, and md have received payments for talks and workshops in the context of digital health interventions. ab and hb are principal investigators of several third party funded projects on digital health interventions. all other authors declare no competing interests. previously presented: parts of the results presented in this article were previously shared in a poster presentation at the eabct 2023 conference in antalya, turkey (https://social.hse.ru/data/2023/11/01/2051848124/ eabct2023-book.pdf). the current manuscript expands upon that presentation. ethics statement: the study was approved by the ethics committee of the medical faculty of the university of leipzig (approval number: 298/21‐ek). social media accounts: lena sophia steubl: linkedin. preregistration: the present study analyzes selected data from a large, population-based representative survey conducted in germany. as the analyses were conducted retrospectively based on an existing dataset, the study was not preregistered. reporting guidelines: the paper follows the jars–quant guidelines for quantitative research. data availability: data, code, and materials can be obtained by contacting the first author upon reasonable request. supplementary materials the supplementary materials contain the following items (for access, see steubl et al., 2025s): • table 1. full questionnaire (translated) • figure 1. attitudes towards digital health interventions depending on gender • figure 2. attitudes towards routine face-to-face psychotherapy depending on gender steubl, büscher, sander et al. 15 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://social.hse.ru/data/2023/11/01/2051848124/eabct2023-book.pdf https://social.hse.ru/data/2023/11/01/2051848124/eabct2023-book.pdf https://social.hse.ru/data/2023/11/01/2051848124/eabct2023-book.pdf https://www.linkedin.com/in/lena-sophia-steubl-314025137 https://www.psychopen.eu/ • figure 3. attitudes towards digital health interventions depending on age group • figure 4. attitudes towards routine face-to-face psychotherapy depending on age group index of supplementary materials steubl, l. s., büscher, r., sander, l. b., baumel, a., barck, k., sachser, c., fegert, j. m., brähler, e., baumeister, h., & domhardt, m. 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(2016). over promised, over-sold and underperforming? e-health in mental health. journal of mental health, 25(1), 1–4. https://doi.org/10.3109/09638237.2015.1124406 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. steubl, büscher, sander et al. 21 clinical psychology in europe 2025, vol. 7(3), article e15233 https://doi.org/10.32872/cpe.15233 https://doi.org/10.1016/j.beth.2014.09.008 https://doi.org/10.1002/wps.20883 https://doi.org/10.2307/30036540 https://doi.org/10.1016/s0140-6736(07)61414-7 https://doi.org/10.1016/j.jbtep.2009.10.003 http://hdl.handle.net/10713/20295 https://doi.org/10.3109/09638237.2015.1124406 https://www.psychopen.eu/ attitudes towards digital health interventions in germany (introduction) method measures statistical analyses results attitudes towards digital health interventions correlational analyses of attitudes towards digital health interventions open questions discussion limitations conclusion (additional information) funding acknowledgments competing interests previously presented ethics statement social media accounts preregistration reporting guidelines data availability supplementary materials references eaclipt statement on the importance of science and evidence-based treatment for mental health editorial eaclipt statement on the importance of science and evidence-based treatment for mental health chantal martin-soelch 1 , claudi bockting 2,3,4 , josefien breedvelt 5 , lisbeth frostholm 6,7 , nina heinrichs 8 , colette hirsch 9 , agnieszka popiel 10 , winfried rief 11 [1] department of psychology, university of fribourg, fribourg, switzerland. [2] amsterdamumc, department of psychiatry, amsterdam public health, university of amsterdam, amsterdam, the netherlands. [3] the centre for urban mental health, university of amsterdam, amsterdam, the netherlands. [4] institute for advanced study, university of amsterdam, amsterdam, the netherlands. [5] department of child and adolescent psychiatry, institute of psychiatry, psychology and neuroscience, king's college london, london, united kingdom. [6] department of clinical medicine, aarhus university, aarhus, denmark. [7] department of functional disorders, aarhus university hospital, aarhus, denmark. [8] department of psychology, bielefeld university, bielefeld, germany. [9] department of psychology, king’s college london, london, united kingdom. [10] institute of psychology, swps university, warsaw, poland. [11] department of clinical psychology and psychotherapy, university of marburg, marburg, germany. clinical psychology in europe, 2025, vol. 7(2), article e18031, https://doi.org/10.32872/cpe.18031 published (vor): 2025-05-28 corresponding author: chantal martin-soelch, university of fribourg, department of psychology, rue p.-a.-defaucigny 2, 1700 fribourg, switzerland. phone: +41 26 300 7687. e-mail: chantal.martinsoelch@unifr.ch the european association for clinical psychology and psychological treatment (eaclipt) expresses deep concern regarding current trends concerning science, evi­ dence-based treatment, and the potential threats to mental health. recent developments have highlighted a troubling trend of undermining and censur­ ing scientific research and evidence-based practices and propagating false information in medical and psychological care. this shift poses significant risks to the well-being of individuals who rely on scientifically validated treatments for their mental health conditions. it is crucial to ensure that mental health care remains grounded in rigorous scientific evidence to provide the best possible outcomes for those in need. the spread of false or misleading information can undermine public trust in legiti­ mate medical research and treatments, leading individuals to seek unproven or harmful alternatives. this is especially concerning for mental disorders, where the complexity of conditions and treatments already makes it challenging to identify solid, evidence-based this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.18031&domain=pdf&date_stamp=2025-05-28 https://orcid.org/0000-0003-3859-9023 https://orcid.org/0000-0002-9220-9244 https://orcid.org/0000-0003-1864-1861 https://orcid.org/0000-0002-9683-7416 https://orcid.org/0000-0002-8301-5798 https://orcid.org/0000-0003-3579-2418 https://orcid.org/0000-0001-9990-4971 https://orcid.org/0000-0002-7019-2250 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ research. disinformation can exacerbate these difficulties, creating confusion and skepti­ cism around scientifically validated therapies. consequently, patients may struggle to access effective care, and healthcare providers may face increased barriers in delivering accurate information and support. combating disinformation requires robust efforts to promote media literacy, enhance transparency in research, and ensure that credible sources are easily accessible to the public. we are also deeply concerned about the impact of the current geopolitical situation worldwide on the mental health of individuals. the heightened political tensions, di­ visive rhetoric, armed conflicts and climate changes have created an environment of uncertainty and stress, which can exacerbate mental health issues. we call for a renewed commitment to science and the well-being of individuals affec­ ted by mental health issues. together, we can ensure that mental health care remains effective, compassionate, and grounded in the best available evidence. eaclipt stands in solidarity with mental health professionals and advocates who are working tirelessly to protect and promote evidence-based practices. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: winfried rief is an editor-in-chief and colette hirsch is a subject editor for clinical psychology in europe. the other authors declare no conflicts of interest that could have influenced the content of this editorial. clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. eaclipt statement on evidence-based mental health 2 clinical psychology in europe 2025, vol. 7(2), article e18031 https://doi.org/10.32872/cpe.18031 https://www.psychopen.eu/ the effects of mindfulness-focused internet-based cognitive behavioral therapy on elevated levels of stress and symptoms of exhaustion disorder: a randomized controlled trial research articles the effects of mindfulness-focused internet-based cognitive behavioral therapy on elevated levels of stress and symptoms of exhaustion disorder: a randomized controlled trial kristofer vernmark 1 , timo hursti 2 , victoria blom 3 , robert persson asplund 1,3 , elise nathanson 2, linda engelro 2, ella radvogin 4, gerhard andersson 1,5,6 [1] department of behavioural sciences and learning, linköping university, linköping, sweden. [2] department of psychology, uppsala university, uppsala, sweden. [3] the swedish school of sport and health sciences, stockholm, sweden. [4] psykologpartners ab, linköping, sweden. [5] department of biomedical and clinical sciences, linköping university, linköping, sweden. [6] department of clinical neuroscience, karolinska institute, stockholm, sweden. clinical psychology in europe, 2024, vol. 6(3), article e12899, https://doi.org/10.32872/cpe.12899 received: 2023-09-29 • accepted: 2024-05-06 • published (vor): 2024-09-30 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: kristofer vernmark, department of behavioural sciences and learning, campus valla, ihuset, 3:430, 581 83, linköping, sweden. phone: +46733211074. e-mail: kristofer.vernmark@liu.se abstract background: internet-based cognitive behavior therapy (icbt) and mindfulness interventions are commonly used to treat elevated levels of stress. there are however few high-quality studies that examine icbt with integrated mindfulness components for symptoms of stress and exhaustion, and the role of mindfulness exercises in digital treatment. method: the aim of the present study was to evaluate if a mindfulness-focused icbt-program could reduce symptoms of stress and exhaustion, and increase quality of life, in a randomized controlled trial including 97 self-referred participants between 18 and 65 years who experienced elevated levels of stress. results: the intervention group had significantly reduced symptoms of stress and exhaustion, and increased quality of life, compared to the control group. compared with the controls, participants in the intervention group showed a significant improvement with moderate to large effects on the primary outcome measure perceived stress (d = 0.79), and the secondary outcomes, exhaustion (d = 0.65), and quality of life (d = 0.40). participants in the icbt group also increased their level of this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12899&domain=pdf&date_stamp=2024-09-30 https://orcid.org/0000-0003-4250-8868 https://orcid.org/0000-0003-1990-5785 https://orcid.org/0000-0002-0079-124x https://orcid.org/0000-0001-7627-1729 https://orcid.org/0000-0003-4753-6745 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mindfulness (d = 0.66) during the program. the amount of mindfulness training was significantly associated with an increased level of mindfulness, which in turn was significantly associated with reduced stress symptoms. conclusions: mindfulness-focused icbt can be an effective method to reduce stress-related mental health problems and the amount of mindfulness training seems to be of importance to increase the level of experienced mindfulness after treatment. keywords cbt, icbt, stress, mindfulness, exhaustion, internet-based highlights • combining mindfulness with icbt is effective when treating individuals with elevated stress. • mindfulness-based icbt can decrease symptoms of exhaustion and increase quality of life. • the amount of mindfulness training during treatment has an impact on self-rated mindfulness. • increased mindfulness is associated with decreased levels of stress. perceived stress is conceptualized as an individual’s feelings or thoughts about how much stress one is experiencing at a given point in time or during a period of time. to experience stress is a fundamental feature of human beings and can be an adaptive response to various stressors in everyday life. stress becomes an issue when the body is forced to mobilize energy for an extended period of time without sufficient recovery. during the last decades, rapid advancements in society have transformed how we live, work, and interact, resulting in higher exposure to mental strain (atroszko et al., 2020). elevated stress over longer periods of time can have a negative impact on daily life and is associated with other physical and psychological problems such as anxiety, impaired sleep, depression, and exhaustion (cohen et al., 2007; grossi et al., 2015). increased levels of stress are also associated with a negative impact on quality of life (parsaei et al., 2020), a wider construct of self-perceived satisfaction with important life areas such as work, friendship, creativity, and leisure, that should be measured separately from other mental health symptoms (lindner et al., 2016). consequently, stress-related health issues have increasingly been recognized as a significant health issue with prevalence ranging between 4% and 16% (glise et al., 2010; höglund et al., 2020). even though the most common diagnostic manuals icd-11 and dsm-v contain definitions and categorizations such as post-traumatic stress, acute stress reaction and adjustment disorder, there is still a lack of consensus and well-defined terminology related to stress induced problems that are associated with relational conflicts, economic hardship, or work-related stressors. another diagnosis close to stress-related disorders is exhaustion disorder (ed), which is mindfulness-focused icbt for stress and exhaustion 2 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ similar to the concept of clinical burnout (van dam, 2021). it is characterized by severe mental and physical fatigue, in combination with lack of initiative and endurance. mental and physical effort in daily activities lead to long recovery periods and it is a common cause for workplace sick leave in sweden (lindsäter et al., 2022). prolonged exposure to stress has direct effects on people’s well-being and leads to immense costs for society (grossi et al., 2015; hassard et al., 2018; kivimäki & steptoe, 2018; melchior et al., 2007). despite these well-known and detrimental consequences, a majority of all individuals suffering from stress and other mental health-related disorders, remain untreated (ebert et al., 2016). this calls for further development and evaluation of interventions that are accessible, cost-effective, and have the potential in reducing stress. two established methods for the treatment of mental health problems are cognitive behavior therapy (cbt) and mindfulness interventions. cbt is considered an evidencebased and cost-effective treatment method for common mental health problems that is often provided individually in face-to-face settings (bhattacharya et al., 2023; butler et al., 2006; myhr & payne, 2006). it incorporates behavioral and cognitive strategies with the addition of homework assignments between sessions (wenzel et al., 2016). to this date it is the most researched psychotherapy method, although its effects for stress related problems have been less studied (nakao et al., 2021). mindfulness has its roots in buddhist traditions and can be described as the psychological process of purposefully focusing attention on experiences occurring in the present moment (kabat‐ zinn, 2003). the ability to be mindful is considered a skill that can be trained through practice (bishop et al., 2004) and mindfulness-based interventions are commonly used to increase wellbeing and treat mental health problems (sverre et al., 2023). there are also correlational studies examining the role of mindfulness in relation to stress and quality of life (javaid et al., 2023), some of which are showing that higher levels of present moment awareness and mindful attention can lead to lower levels of perceived stress and increased wellbeing (hepburn et al., 2021). further examinations of the amount and duration of mindfulness training and its effects on dispositional mindfulness scale measurements are also warranted (quaglia et al., 2016). there is a growing body of evidence to support the efficacy of stress management interventions (smi) in different populations and on a wide range of outcomes, such as perceived stress, burnout, recovery, and quality of life (bhui et al., 2012). smis based on cbt, have yielded the largest effect sizes (cohen's d = 1.16), followed by mindfulness and relaxation-based interventions (cohen's d = 0.50; richardson & rothstein, 2008). common components in stress-focused cbt vary but interventions commonly include a rationale about stress and how to manage stressors, relaxation techniques, coping and activation techniques, cognitive restructuring, problems solving, and skills training in assertiveness and time management (ghazavi et al., 2016). mindfulness-based stress reduction, focusing on mindfulness techniques (e.g., direc­ ted attention to bodily sensations, thoughts, feelings, and daily activities) has been vernmark, hursti, blom et al. 3 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ found to reduce stress symptoms in non-clinical and clinical samples (chiesa & serretti, 2009; shapiro et al., 2005; smith et al., 2008) as well as in employees (janssen et al., 2018) and students (deshpande et al., 2023). mindfulness has shown similar effects as cbt and pharmacological treatment for stress symptoms (khoury et al., 2013). mindful­ ness has also been incorporated into modern third-wave cognitive behavior therapy approaches, such as acceptance and commitment therapy (act; hayes, 2016), where it is used together with other concepts such as values and acceptance, aimed at increasing psychological flexibility and quality of life. there is data showing that incorporating value-based action in mindfulness interventions could enhance the effects of mindfulness (christie et al., 2017). previous trials (e.g., michel et al., 2014) have also suggested that mindfulness could be an effective segmentation strategy to promote work–life balance for employees struggling with stress-related rumination and psychological preoccupation with work concerns. although studied separately, few studies have examined the com­ bined effects of integrated cbt and mindfulness-based stress reduction interventions. internet-based cbt (icbt) is a well-established treatment format that offers in­ creased access to effective psychological interventions for a wide range of mental health problems (andersson, titov, et al., 2019). since one of the first studies on internet-based stress interventions (zetterqvist et al., 2003) a growing body of literature has provided evidence of the efficacy in various populations (andersson, carlbring, et al., 2019). it has several advantages compared to face-to-face cbt, including being cost-effective by consuming less therapist time and reducing waiting times (catarino et al., 2023), as well as being less emotionally stressful and bringing variety to a therapist’s daily work (weineland et al., 2020). the effects are long-lasting (andersson et al., 2018) and similar to face-to-face treatment (hedman‐lagerlöf et al., 2023). meta-analyses have yielded small to moderate effects on outcomes of perceived stress, burnout, exhaustion, depression, and anxiety (heber et al., 2016; svärdman et al., 2022). subgroup analyses have revealed greater improvement in guided interventions (heber et al., 2017) and recent trials have suggested that icbt stress interventions could have long-lasting effects (12 months post-treatment) and accelerate recovery and return to work (asplund et al., 2023). there are examples of studies on other disorders that have added mindfulness com­ ponents in icbt-programs (carlbring et al., 2013) but to our knowledge few studies have evaluated the full integration of cbt and mindfulness components delivered in a concise internet-based format for perceived stress and symptoms of exhaustion. there is also a need for further knowledge about the association between the amount and length of mindfulness training in shorter treatment programs, and if increased mindfulness is associated with lower levels of perceived stress. the aim of the present study was to evaluate a six-week mindfulness-focused icbt program for stress and its effects on stress, exhaustion, quality of life, and mindfulness, and the impact of mindfulness train­ ing in reducing stress and increasing experienced mindfulness. we hypothesized that mindfulness-focused icbt for stress and exhaustion 4 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ the internet-based recovery program would produce greater improvements in perceived stress (primary outcome) compared with a waitlist control group. we also hypothesized that the intervention group would differ with regard to stress-related exhaustion and quality of life. finally, we hypothesized that the icbt mindfulness training would be associated with increased mindfulness levels and reduction in perceived stress. method design in this randomized controlled trial, participants were randomized to an internet-based mindfulness-focused icbt program or a waitlist control group (wlc). the study fol­ lowed consolidated standards of reporting trials (consort) guidelines (schulz et al., 2010) and was conducted between january 2017 and march 2017. estimates of sample size were based on calculations in previous controlled trials on icbt for stress (ly et al., 2014) where a minimum of 66 participants was needed to achieve a power of 0.80 and detect an effect size of d = 0.50 (α level = .05). self-report outcome measures were collected at preand post-treatment (six weeks). participants who met the study criteria and provided informed consent were allocated randomly by an independent researcher using an online random generator (www.randomizer.org). participants were randomized to either intervention or to a waitlist control condition. in addition to the preand post-assessment, participants reported the intensity of their mindfulness training every week. the study was part of a larger project investigating icbt for stress and ethical approval was obtained from the local ethics committee (reference no. 353-31). participants and recruitment participants were recruited by self-referral. information was distributed by information on websites and social media and by emailing student health centers and human resource staff in some organizations. those interested in participating were invited to contact the research team by email to receive further information about the study and a link leading to a website with information about the study. following the link enabled the possibility to give informed consent and answer questions for screening purposes as well as the forms included in the pre-treatment assessment. the questionnaire also included questions about if participants had been diagnosed with exhaustion disorder or another psychiatric diagnose in routine care. exclusion criteria were ongoing alcohol or drug abuse, ongoing psychological treatment, and a rating of 3 or higher on item 9 (life desire) on the montgomery åsberg depression rating scale (madrs-s; svanborg & åsberg, 2001), indicating suicidal ideation. of the 127 persons completing this phase, 30 were excluded mainly due to ongoing treatment or suicidal ideation. the flowchart of the study is displayed in figure 1. individuals with suicidal ideation that were excluded from vernmark, hursti, blom et al. 5 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 http://www.randomizer.org https://www.psychopen.eu/ the study were informed about appropriate help within the swedish health care system. participants did not receive any compensation for their participation in the study. figure 1 flow diagram of participants in the study assessed for eligibility (n = 127) randomized (n = 97) flow diagram of participants in the study figure 1 excluded (n = 30) • ongoing treatment (n = 16) • madrs-s suicide item >3 (n = 14) provided data (n = 40) dropout (n = 8) allocated to waitlist control (n = 49)allocated to intervention (n = 48) provided data (n = 49) dropout (n = 0) analyzed (n = 48) analyzed (n = 49) enrollment allocation post-treatment analysis in total 97 persons from different parts of sweden were included. inclusion criteria were an age between 18 and 65 years, fluency in swedish, basic computer skills, and the subjective experience of elevated levels of stress. the sample consisted predominantly of females with a mean age around forty years. roughly one out of four participants reported that they had been diagnosed with stress-induced exhaustion disorder and among other self-reported diagnoses, depression was most prevalent. more detailed demographic information about the sample is shown in table 1. during the intervention phase eight participants (8.2%) in the treatment group dropped out and none in the control group. mindfulness-focused icbt for stress and exhaustion 6 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ table 1 demographic characteristics of participants at pre-treatment baseline characteristics intervention group (n = 48) control group (n = 49) m sd m sd age 38.33 11.13 42.22 10.78 n % n % sex female 41 85 42 86 male 7 15 7 14 comorbiditya exhaustion disorder 12 25 14 29 depression 8 17 7 14 depression and gad 5 10 6 12 sleep disorder 1 2 1 2 bipolarity and panic disorder 1 2 0 0 occupation student 9 19 3 6 full-time employee 23 48 32 65 part-time employee 6 13 6 12 job seeker 1 2 1 2 student and employee 3 6 4 8 sick leave (full time) 4 8 2 4 sick leave (part time) 2 4 2 4 level of education elementary school 0 0 1 2 upper secondary education, 1-2 years 0 0 4 8 upper secondary education, 3-4 years 14 30 10 20 universityor college education, 3 years or less 9 18 8 16 universityor college education, >3 years or more 25 52 26 53 country region northern sweden 8 17 16 33 central sweden 24 50 20 40 southern sweden 13 27 11 22 overseas 3 6 2 4 aself-rating in pre-treatment questionnaire of being diagnosed in routine care. vernmark, hursti, blom et al. 7 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ primary outcome measure the perceived stress scale (pss; cohen et al., 1983) was used as primary outcome measure to assess the level of experienced stress. the pss measures the degree to which situations in one’s life are being perceived as stressful. the version used in the study had 14 items which focus on perceived stress during the last month. individual scores can range from 0 to 56 with higher scores indicating higher perceived stress. the swedish version of pss-14 has shown to have good internal consistency (α = .84 – .90; eklund et al., 2014). versions of the scale are commonly used in research studies and it has been shown to be responsive to psychological treatment in internet-based interventions for stress (svärdman et al., 2022; zetterqvist et al., 2003). while normative population data for sweden is unavailable, studies conducted in other countries have indicated mean scores ranging between 20.93 and 25.63 for the pss-14 in various non-clinical sample groups (gonzález-ramírez et al., 2013). secondary outcome measures karolinska exhaustion disorder scale (keds; besèr et al., 2014) was used to assess ex­ haustion related consequences of prolonged stress. keds is designed to measure symp­ toms typical in exhaustion disorder, such as exhaustion, cognitive problems, poor sleep and reduced tolerance to further stress. the scale has 9 items, and each item is answered on a 7-point scale (0 – 6). verbal descriptions are given to answering alternatives 0, 2, 4, and 6. the maximum score is 54 while the cut-off score for incidence of exhaustion dis­ order is 19. keds has good overall psychometric properties including excellent internal consistency (cronbach’s alpha, α = .94). further, keds is able to discriminate between exhaustion, depression and anxiety (besèr et al., 2014). brunnsviken brief quality of life (bbq; lindner et al., 2016) is a self-rating scale for assessment of subjective quality of life. it consists of 12 statements within six areas of life considered relevant for the experience of quality of life. all items are answered on a 5-point scale (0 = don’t agree at all to 4 = agree completely), but for a given area of life, satisfaction is rated first and then the importance of the area. afterwards, scores for satisfaction and importance within respective area are multiplied. the maximum score is 96 implying a high level. the psychometric evaluation of the scale suggests good concurrent and convergent validity. internal consistency is adequate (cronbach’s alpha, α = .76) and test-retest reliability is high (icc = .82). the five facets mindfulness questionnaire – swedish version (ffmq-swe; baer et al., 2008; lilja et al., 2011) has been developed to assess the level of mindfulness. ffmq-swe has 29 items distributed on five subscales: nonreactivity to inner experience, observing, acting with awareness, describing and nonjudging of experience. the items are rated on a 5-grade likert scale (1 = never or very seldom to 5 = always). the internal mindfulness-focused icbt for stress and exhaustion 8 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ consistency for the global scale is good (cronbach’s alpha, α = .81). and it also has a high content validity (lilja et al., 2011). montgomery åsberg depression rating scale (madrs-s; svanborg & åsberg, 1994) is a widely used self-rating scale measuring depression. in this study, only item nine was used to allow exclusion due to suicidal ideation or low level of life desire. in addition to the evaluation of treatment effects, the participants’ experience consid­ ering the functionality of the internet treatment system was assessed by the system usability scale (sus; brooke, 1996). sus is a 10-item scale composed of 10 statements scored on a 5-point scale with a final score ranging from 0 to 100. a higher score on the scale indicates better usability of a given product or service. a large empirical evaluation of sus (bangor et al., 2008) provided support for the validity of the scale as well as guidelines for the interpretation of the results. a swedish version of the scale have existed and been used since 2011. there are currently no publications on the swedish version, but translations to other languages have shown retained psychometric properties and conceptual equivalence (hvidt et al., 2020). the intervention the treatment program, stresshjälpen, was developed by the private swedish psychology company psykologpartners. it contains cbt-components for the treatment of stress-re­ lated problems such as psychoeducation about stress, functional analysis of stressful situations, strategies for self-care and healthy habits, time-management strategies, how to handle perfectionism and setting up a plan for setbacks. mindfulness components and weekly mindfulness exercises are integrated into the treatment from module two and onwards. the modules and their content are further described in table 2. the intervention is delivered through six online modules containing text, video, audio, and free-form text input boxes. in the beginning of each new module, participants were asked to reflect upon the previous module and how they managed the homework assignments. to keep track of the participants’ mood and motivational level, a few short questions in the end of each module were included covering quality of life, stress, compliance with the treatment and sleep problems. the two therapists had access to the treatment content in advance and could fa­ miliarize themselves with the material. therapists also underwent a two-day training program in internet-based cbt and had regular supervision with an icbt-proficient clinical psychologist during the whole study. the study participants were instructed to complete one module per week, and they had access to the treatment website for eight weeks. two-factor authentication was used for logging in and accessing the material. the communication between the therapists and the participants took place via a secure messaging function in the portal. once a week the participants received a message with comments on their previous work and further instructions. therapists aimed to motivate participants, validate and reinforce functional behavior, answer questions and solve vernmark, hursti, blom et al. 9 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ problems. participants who had not been logged in for a longer period were reminded by email or telephone. table 2 description of the content in stresshjälpen module content module 1 – what is stress? • psychoeducation about stress • stressful situations • reactions in stressful situations • homework: map current experiences of stress and coping strategies, and a 7-day diary with ratings of stress level module 2 – functional analysis and mindfulness • functional analysis of stressful situations • introduction to mindfulness • homework: functional analysis and mindfulness exercises module 3 – mindfulness and values • mindfulness • values and valued living • homework: values in specified life domains and mindfulness exercises module 4 – self-care • committed action • healthy habits: sleep, exercise, and healthy eating • mindfulness to create healthy habits • homework: change an important habit module 5 – time-management and setting boundaries • time-management strategies • values, functional analysis and strategies for setting boundaries • homework: setting boundaries and mindfulness exercises module 6 – maintaining treatment effects • how to handle perfectionism • summarize the treatment: lessons learned, obstacles and important behaviors • create a maintenance plan and a plan for setbacks • valued living procedure there was no face-to-face contact between therapists and participants and all activities were conducted online. the intervention was delivered through a website and the as­ sessments were done via an encrypted website. the randomization via randomizer.org resulted in 48 participants in the intervention group and 49 in the waitlist control group. the treatment started in january 2017 and continued to march 2017. after the post-assessment, participants in the control group were offered the online treatment. mindfulness-focused icbt for stress and exhaustion 10 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ all data analyses were carried out using ibm spss statistics v.29 software. pretreat­ ment differences on demographic and outcome variables were analyzed with t-test and chi2-test. intention to treat (itt) was employed by using multiple imputation to handle missing data including 20 imputations, as recommended by enders (enders, 2017). anal­ ysis of covariance (ancova) was used with pre-treatment scores as covariates for all the self-report measures to investigate treatment effects (vickers & altman, 2001). effect sizes with cohen’s d with confidence intervals were calculated based on the post-treat­ ment imputed means. the relationship between mindfulness training (assessed weekly) and the change in the level of mindfulness from preto post-treatment was analyzed using spearman’s rho, due to the skewed distribution of the number of training sessions and the total duration of training. the association between changes in mindfulness levels and experienced stress was analyzed using the pearson correlation coefficient. results baseline differences, ratings of usability, and adherence there were no differences between the study groups at the pretreatment considering demographic or outcome variables. the overall rating for the internet treatment system assessed by sus was 86 points which is considered excellent (bangor et al., 2008). the average number of completed modules in the intervention group was 4.7 of six modules (sd = 2.26, range 0-6) and 71% (n = 34) of the participants completed all modules. the self-estimated number of times engaging in mindfulness sessions during the course of treatment was 18.7 (sd = 14.52, range 0-62) and the self-estimated time in minutes engaging in mindfulness was 73.68 minutes (sd = 78.76, range 0-376). treatment effects means and standard deviations including ancova f-values and effect sizes are presen­ ted in table 3. a large between-group effect size was found at posttreatment, d = 0.79, 95% ci [0.36, 1.23], on the primary outcome pss-14 measuring perceived levels of stress. the secondary outcome measure keds assessing exhaustion-related symptoms demon­ strated a similar change. the ancova was statistically significant with a moderate effect size of d = 0.65, 95% ci [0.24, 1.06]. for the bbq measuring quality of life the ancova was statistically significant, but with a smaller effect size of d = 0.40, 95% ci [0.03, 0.81]. regarding the ffmq-swe measuring mindfulness there was an effect in favor of the treatment group with a moderate effect size of d = 0.66, 95% ci [0.26, 1.07]. the reported increase in the level of mindfulness was positively correlated with both the number of training sessions (rho = .38, p = .016) and the total duration of training (rho = .31, p = .049). there was also a significant negative correlation between reported changes in the level of mindfulness and experienced level of stress, respectively. those achieving vernmark, hursti, blom et al. 11 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ a higher level of mindfulness reported a larger decrease in their stress level (r = .36, p = .023). table 3 means (m), standard deviations (sd), effect sizes (cohen’s d), and ancova results for stress, exhaustion, quality of life, and mindfulness measures in treatment (n = 48) and control (n = 49) groups measure / group pre post cohen's d ancova f(1, 96)m sd m sd pss 0.79 28.4*** treatment 33.09 6.66 23.46 8.98 control 33.96 6.24 29.82 7.04 keds 0.65 25.3*** treatment 26.06 8.94 18.33 9.17 control 27.45 8.14 23.95 7.93 bbq 0.40 6.4* treatment 44.90 18.22 54.37 19.89 control 42.82 16.78 46.80 17.27 ffmq-swe 0.66 19.9*** treatment 83.79 12.00 93.18 9.60 control 84.12 9.40 86.10 11.42 note. ancova = analysis of covariance; pss = perceived stress scale; keds = karolinska exhaustion disorder scale; bbq = brunnsviken brief quality of life; ffmq-swe = five facets of mindfulness, swedish version. *p < .05. ***p < .001. discussion the present study evaluated the effects of a mindfulness-focused icbt program on elevated stressand exhaustion symptoms, and quality of life. the study also investigated the effect of the number of mindfulness sessions and the total amount of training with regard to changes in the level of mindfulness, as well as the association between changes in the level of mindfulness and symptoms of stress. the study results show that the treatment group reduced their perceived levels of stress, such as experiences of not having control and feelings of being overloaded, significantly more than the waitlist control group. this is in line with previous research on cbt-based stress management (richardson & rothstein, 2008), mindfulness interventions (khoury et al., 2013), and results from other icbt-studies, showing that digital interventions for stress related problems can be effective with moderate to large effect sizes (svärdman et al., 2022). re­ sults also showed that the intervention group had significant effects in comparison with the control group on symptoms of exhaustions, such as memory, ability to concentrate mindfulness-focused icbt for stress and exhaustion 12 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ and fatigue. in sweden, exhaustion disorder accounts for more instances of long-term sick leave than any other diagnose and there is a limited amount of treatment research and limited evidence (lindsäter et al., 2022) the findings in this study adds to the literature showing that icbt interventions have the potential to influence work related outcomes such as levels of exhaustion (asplund et al., 2023) and can be a cost-effective treatment option (lindsäter et al., 2019). we also investigated if the treatment program would increase quality of life compared to the waitlist control group, which it did. the significant small to moderate effect on quality of life is in line with the effects usually obtained in cbt-studies on this measure (kolovos et al., 2016). despite the short period of time for the intervention, participants in the treatment group increased their level of mindfulness significantly compared to the waitlist during the program. this is interesting as mindfulness is known to take long time and much effort to practice before effects can be shown (brand et al., 2012). we found that the amount of mindfulness training, both number of sessions and total length, was signifi­ cantly associated with increased self-reported mindfulness. this finding is confirmed by meta-analytic evidence showing that training in mindfulness can affect the dimensions of mindfulness captured by ffmq (quaglia et al., 2016). it should be mentioned that there could be a methodological problem as the measure of amount of mindfulness practice was self-estimated and could be influenced by social desirability. we also found that the level of mindfulness was significantly associated with reduced levels of perceived stress symptoms. this may be because individuals who improve their ability to have a non-reactive approach to inner experiences, and the ability to observe and describe the present situation in a non-judging manner, experience less stress symp­ toms. this is in line with previous literature (chiesa & serretti, 2009; shapiro et al., 2005; smith et al., 2008) showing an effect of mindfulness techniques on reduced level of perceived stress symptoms in a clinical as well as a non-clinical population. nevertheless, due to the absence of information regarding the direction of this association, it is equally plausible that reduced stress symptoms heighten individuals' awareness of their internal context. compared to other internet-based treatment programs, the intervention used in this study was less text-driven, shorter in length (length and number of modules) and developed to be interactive and motivating to work with for participants. there is indicative evidence that more condensed internet-based interventions are equally as effective (karlsson-good et al., 2023) and it could also be that the user experience had an effect on motivation and the use of treatment content, which is supported by the fact that the overall rating of the user experience was considered excellent by participants (bangor et al., 2008). this topic needs to be further investigated, as the use of technology for increased effect and compliance in digital interventions are still under-researched (balcombe & leo, 2022; wildeboer et al., 2016). vernmark, hursti, blom et al. 13 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://www.psychopen.eu/ the limitations and strengths in the present study should be mentioned. first, there were no follow-up measurement. thus, long-term effects were not measured which should be valuable to investigate in future studies. however, the robust design of rct and the high number of individuals who completed the program are strengths in the study. the study also has high generalizability to the clinical population as the inclusion criteria for individuals recruited in the study were broad and there were no exclusions of individuals due to comorbidity. a possible limitation is the inclusion of a subclinical population as there are no norms available for pss-14 and we did not exclude partic­ ipants based on a certain lower threshold on the scale, although the data from this sample shows that the participants experienced elevated levels of perceived stress and exhaustion comparable to what is seen in other studies (asplund et al., 2018). other limitations are the possibility of selection bias using an open recruitment strategy and that we have no information on the direction of the associations being studied and they should therefore be interpreted with caution. the present randomized controlled study provides knowledge that a mindfulness-fo­ cused icbt stress program can reduce perceived stress and symptoms of exhaustion, and also increase quality of life and the experience of mindfulness. this shows that short internet-based interventions combining cbt and mindfulness have the potential to lessen the burden of stress-related problems. funding: the authors have no funding to report. acknowledgments: the authors would like to thank psykologpartners for providing the icbt-program stresshjälpen that was used in this study. competing interests: ella radvogin and kristofer vernmark were employed by psykologpartners at the time of the study. ethics statement: the study protocol was approved by the local ethics board (reference no. 353-31). preregistration: the trial was not preregistered. reporting guidelines: the study followed consolidated standards of reporting trials (consort) guidelines. data availability: data, material and analysis methods from the trial can be made available for other researchers upon request. references andersson, g., carlbring, p., titov, n., & lindefors, n. 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(2003). randomized controlled trial of internet-based stress management. cognitive behaviour therapy, 32(3), 151–160. https://doi.org/10.1080/16506070302316 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. mindfulness-focused icbt for stress and exhaustion 20 clinical psychology in europe 2024, vol. 6(3), article e12899 https://doi.org/10.32872/cpe.12899 https://doi.org/10.1016/s0165-0327(00)00242-1 https://doi.org/10.1016/j.invent.2022.100553 https://doi.org/10.1016/j.cpr.2022.102234 https://doi.org/10.1080/1359432x.2021.1948400 https://doi.org/10.1136/bmj.323.7321.1123 https://doi.org/10.1016/j.invent.2020.100356 https://doi.org/10.1037/14936-001 https://doi.org/10.1016/j.ijmedinf.2016.04.005 https://doi.org/10.1080/16506070302316 https://www.psychopen.eu/ mindfulness-focused icbt for stress and exhaustion (introduction) method design participants and recruitment primary outcome measure secondary outcome measures the intervention procedure results baseline differences, ratings of usability, and adherence treatment effects discussion (additional information) funding acknowledgments competing interests ethics statement preregistration reporting guidelines data availability references youth, the new adolescence: a challenge and a window of opportunity for early mental health interventions editorial youth, the new adolescence: a challenge and a window of opportunity for early mental health interventions simone munsch 1,2 , tina in-albon 3 , nadine messerli-bürgy 4 [1] department of psychology, clinical psychology and psychotherapy, university of fribourg, fribourg, switzerland. [2] food research and innovation center, fric, cluster food and mental health / psychology, university of fribourg, fribourg, switzerland. [3] clinical child and adolescent psychology and psychotherapy, university of mannheim, mannheim, germany. [4] family and development research center, institute of psychology, university of lausanne, lausanne, switzerland. clinical psychology in europe, 2025, vol. 7(1), article e16951, https://doi.org/10.32872/cpe.16951 published (vor): 2025-02-28 corresponding author: simone munsch, department of psychology, clinical psychology and psychotherapy, university of fribourg, rue p.-a.-de-faucigny 2, 1700 fribourg, switzerland. phone: +41 26 300 7657. e-mail: simone.munsch@unifr.ch at the beginning of 2025, we invite you to focus on some of the mental health challenges that lie ahead. our attention is focused on youth, particularly those between the ages of 12 and 25 (insel & fenton, 2005), a period often referred to as the "new adolescence" (sawyer et al., 2018). while there is evidence on an earlier onset of puberty and on continued growth well into the 20s, there is also knowledge on a delayed timing of role transitions, including the completion of education and parenthood which let to the new conceptualization of this period as the new adolescence (sawyer et al., 2018). it is also essential to recognize that despite advances in psychotherapy, in neuroscience and psychopharmacological approaches, there are no quick solutions to stop or slow down the global increase of mental health problems in youth. in recent years, this increase has been particularly evident among children and adolescents, driven by factors such as uncertainty, crises, and conflicts in our world. however, we all wish childhood and adolescence to be a period of positive devel­ opment that is, at times, maybe feeling shaky but happy, with most young people overcoming perceived challenges and growing out of any problems. while this is still the case for the majority of children, adolescents and young adults, we cannot ignore the fact that the peak age of onset of mental disorders in the general population is around 5.5 and 15.5 years for anxiety disorders, 14.5 years for obsessive-compulsive disorder, 15.5 years for eating disorders, 19.5 years for substance use disorders, 20.5 years for schizophrenia/psychotic disorders and personality disorders, and 20.5 years for mood this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.16951&domain=pdf&date_stamp=2025-02-28 https://orcid.org/0000-0002-6187-8912 https://orcid.org/0000-0002-2070-8458 https://orcid.org/0000-0001-8619-5950 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ disorders (solmi et al., 2022). in other words, by the age of 24 years, 75% of all mental disorders an individual might experience in his life had already occurred for the first time (kessler et al., 2001). why should the period of adolescence be expanded to ‘new adolescence’? this idea is not a tiktok move or of any other social media, but an evidence-based strategy to address the challenges of today’s world of children, adolescents and young adults and besides this, not to let windows of opportunity go unused that allow early intervention and prevention improving mental health. therefore, youth is not only a critical period but a period of meaningful development that allows long-term changes in an individual’s functioning. does that get you excited? we fully understand that for you—the active members of this community —enthusiasm alone is not enough, but independently of your specialization in child, adolescent, or adult mental health, you probably agree that reliable data is needed to show that this period is not only critical for emotional, social, cognitive and occupational development (thompson et al., 2023), but that it can be influenced in a meaningful way. let’s start with the term “window of opportunity” which is a sensitive period in the child’ and adolescent’s development of neurobiological systems such as systems related to threat, reward, social cognition and stress and generally the formation of multiple complex neural systems enabling an individual to live through, and therefore perceive and process a given situation in the context of multiple, at best, coping-oriented experiences and neurobiological systems. research shows that in addition to data on the importance of youth for the devel­ opment of mental disorders (solmi et al., 2022), we also have data on the sensitivity of the underlying biological systems up to the age of 25 years (uhlhaas et al., 2023). although this is good news, it is not enough for us as psychologists because we all know that youth is a time of more complex interplay of different factors. besides the impact of changes in parent-child and peer interactions, the adolescent’s living context (degree of urbanization, economic background, access to education) but also the levels of stigmatization of mental health problems within adolescent’s environment and limited access to mental health support all impact on an adolescent’s mental wellbeing (orben et al., 2020; speyer et al., 2022; van der wal et al., 2021). it’s up to us to highlight the importance of this developmental window and mobilize ourselves, our colleagues, and policymakers to support and improve mental health in this critical period of youth. while some aspects of today's 12-25-year-olds’ daily lives are new to us, we must acknowledge that a person’s integration into society has long been recognized as a developmental period (erikson, 1959). let’s face it. the idea that adolescence doesn’t neatly end at the age of 18 has been around for decades and is sometimes consistent with our own “lived experience”. yet, despite this, mental health systems, diagnostics and research efforts worldwide have been slow to fully reflect this understanding and consider it consistently in diagnostics, treatment and prevention. youth, the new adolescence 2 clinical psychology in europe 2025, vol. 7(1), article e16951 https://doi.org/10.32872/cpe.16951 https://www.psychopen.eu/ we do not want to waste precious time in the early year of 2025, and we therefore call on you to contribute to the idea of making the most of these windows of opportunity in your daily research and clinical work, which means: • broaden the age range of your research: include experts who are skilled in adapting questionnaires, clinical interviews, and interventions for this age group. even if "youth" ranges from 12 to 25, it’s important to recognize that instruments need to be adapted because cognitive and emotional development limit the assessment of youth. • broaden your treatment approach: when treating children, adolescents and young adults with or at risk for mental health problems, use your expertise in developmental psychopathology to anticipate future needs. ask yourself: what will this child’s mental health look like at the age of 16? where should we intervene to support their well-being at the age of 22? how might the family system be able to adapt to the child or young person’s needs and promote positive change? • educate parents: help parents to better understand their evolving role in the modern world and provide parental training to help them model resilience, cope with daily challenges, and promote mental well-being in their children. • advocate for mental health policies: advocate for policies that view youth mental health as a critical window of opportunity, which should be recognized and promoted wherever and whenever possible. • include youth in your research: youth with lived experience or youth in the same age range as your research samples can provide valuable feedback and help to advance the understanding of mental health problems in youth. we thank you for your patience if you find our enthusiasm is too strong at the beginning of this year. however, we have long been committed to contributing to the youth mental health paradigm and would like to do so more this year in our new role as editor-in-chief and editors of cpe. we look forward to your contributions and to the exchange with you on this topic. we thank the publishers and the reviewers for their excellent contribution to open science and look forward to the upcoming cpe volumes with the same enthusiasm. we thank you for your critical commitment and for including a developmental psychology perspective in your research and clinical work. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: simone munsch and tina in-albon are subject editors and nadine messerli-bürgy is editorin-chief of clinical psychology in europe. munsch, in-albon, & messerli-bürgy 3 clinical psychology in europe 2025, vol. 7(1), article e16951 https://doi.org/10.32872/cpe.16951 https://www.psychopen.eu/ references erikson, e. h. (1959). identity and the life cycle. international universities press. insel, t. r., & fenton, w. s. (2005). psychiatric epidemiology: it’s not just about counting anymore. archives of general psychiatry, 62(6), 590–592. https://doi.org/10.1001/archpsyc.62.6.590 kessler, r. c., avenevoli, s., & ries merikangas, k. (2001). mood disorders in children and adolescents: an epidemiologic perspective. biological psychiatry, 49(12), 1002–1014. https://doi.org/10.1016/s0006-3223(01)01129-5 orben, a., tomova, l., & blakemore, s. j. (2020). the effects of social deprivation on adolescent development and mental health. the lancet child & adolescent health, 4(8), 634–640. https://doi.org/10.1016/s2352-4642(20)30186-3 sawyer, s. m., azzopardi, p. s., wickremarathne, d., & patton, g. c. (2018). the age of adolescence. the lancet child & adolescent health, 2(3), 223–228. https://doi.org/10.1016/s2352-4642(18)30022-1 solmi, m., radua, j., olivola, m., croce, e., soardo, l., salazar de pablo, g., il shin, j., kirkbride, j. b., jones, p., kim, j. h., kim, j. y., carvalho, a. f., seeman, m. v., correll, c. u., & fusar-poli, p. (2022). age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. molecular psychiatry, 27(1), 281–295. https://doi.org/10.1038/s41380-021-01161-7 speyer, l. g., ushakova, a., hall, h. a., luciano, m., auyeung, b., & murray, a. l. (2022). analyzing dynamic change in children’s socioemotional development using the strengths and difficulties questionnaire in a large united kingdom longitudinal study. journal of psychopathology and clinical science, 131(2), 162–171. https://doi.org/10.1037/abn0000714 thompson, e. j., richards, m., ploubidis, g. b., fonagy, p., & patalay, p. (2023). changes in the adult consequences of adolescent mental ill-health: findings from the 1958 and 1970 british birth cohorts. psychological medicine, 53(3), 1074–1083. https://doi.org/10.1017/s0033291721002506 uhlhaas, p. j., davey, c. g., mehta, u. m., shah, j., torous, j., allen, n. b., avenevoli, s., bellaawusah, t., chanen, a., chen, e. y. h., correll, c. u., do, k. q., fisher, h. l., frangou, s., hickie, i. b., keshavan, m. s., konrad, k., lee, f. s., liu, c. h., . . . wood, s. j. (2023). towards a youth mental health paradigm: a perspective and roadmap. molecular psychiatry, 28(8), 3171– 3181. https://doi.org/10.1038/s41380-023-02202-z van der wal, j. m., van borkulo, c. d., deserno, m. k., breedvelt, j. j. f., lees, m., lokman, j. c., borsboom, d., denys, d., van holst, r. j., smidt, m. p., stronks, k., lucassen, p. j., van weert, j. c. m., sloot, p. m. a., bockting, c. l., & wiers, r. w. (2021). advancing urban mental health research: from complexity science to actionable targets for intervention. the lancet psychiatry, 8(11), 991–1000. https://doi.org/10.1016/s2215-0366(21)00047-x youth, the new adolescence 4 clinical psychology in europe 2025, vol. 7(1), article e16951 https://doi.org/10.32872/cpe.16951 https://doi.org/10.1001/archpsyc.62.6.590 https://doi.org/10.1016/s0006-3223(01)01129-5 https://doi.org/10.1016/s2352-4642(20)30186-3 https://doi.org/10.1016/s2352-4642(18)30022-1 https://doi.org/10.1038/s41380-021-01161-7 https://doi.org/10.1037/abn0000714 https://doi.org/10.1017/s0033291721002506 https://doi.org/10.1038/s41380-023-02202-z https://doi.org/10.1016/s2215-0366(21)00047-x https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. munsch, in-albon, & messerli-bürgy 5 clinical psychology in europe 2025, vol. 7(1), article e16951 https://doi.org/10.32872/cpe.16951 https://www.psychopen.eu/ transdiagnostic network mapping of psychopathology in daily life: rationale and research protocol research articles transdiagnostic network mapping of psychopathology in daily life: rationale and research protocol guðrún r. guðmundsdóttir 1 , anne roefs 1 , alberto jover martínez 1 , anita jansen 1 , eiko i. fried 2 , esmée groot 1 , lotte h. j. m. lemmens 1 [1] department of clinical psychological sciences, maastricht university, maastricht, the netherlands. [2] department of clinical psychology, leiden university, leiden, the netherlands. clinical psychology in europe, 2025, vol. 7(4), article e15939, https://doi.org/10.32872/cpe.15939 received: 2024-11-02 • accepted: 2025-03-24 • published (vor): 2025-11-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: guðrún r. guðmundsdóttir, department of clinical psychological science, maastricht university, universiteitssingel 40, maastricht, 6211lk, the netherlands. e-mail: gudrun.gudmundsdottir@maastrichtuniversity.nl supplementary materials: materials, preregistration [see index of supplementary materials] abstract background: the burden of mental health problems and the need for more effective interventions is well established. one path towards treatment improvement involves more effective (evidencebased) tailoring, which requires a deeper understanding of differences in individual profiles of psychopathology. the network approach to mental disorders has emerged as a promising framework in this regard, as it sees and assesses psychopathology as individual networks of interacting symptoms and other variables and uses analysis methods that allow fine-grained analyses of (differences in) individual processes. method: we describe the protocol of a 6-week ecological momentary assessment (ema) study in a broad clinical population, designed to capture various transdiagnostic psychopathology relevant states. participants are dutch adults (desired = 600) who are currently awaiting intakeor start of treatment for psychopathology. in addition to ema self-reports, we collect digital phenotyping data, a broad range of baseline data on symptomatology and transdiagnostic traits, and diagnostic classifications after intake. the study’s primary aims are to estimate individualand group networks of psychopathology (identifying), explore what factors can explain individual differences in networks (linking), and identify potential subgroups based on the networks (clustering). finally, we plan to evaluate the measures and procedures to facilitate future transdiagnostic ema (network) research. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.15939&domain=pdf&date_stamp=2025-11-28 https://orcid.org/0000-0002-0912-6414 https://orcid.org/0000-0002-9935-1075 https://orcid.org/0009-0003-9653-9050 https://orcid.org/0000-0001-5101-8778 https://orcid.org/0000-0001-7469-594x https://orcid.org/0009-0002-0518-9415 https://orcid.org/0000-0002-2037-1808 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ discussion: the prospective study findings have the potential to advance the description, prediction, and assessment of psychopathology and to evaluate the utility of the network framework in achieving these aims. the insights gained may facilitate the evaluation and refinement of current classifications of mental health conditions and alternative transdiagnostic approaches. keywords network approach, mental disorders, ecological momentary assessment, transdiagnostic, individual differences, diagnostic classifications highlights • the network approach is a promising way to conceptualise, study and treat mental health problems. • however, more research is needed to assess its utility, especially related to dynamic individual processes. • we present a momentary assessment study protocol for network research in a broad clinical sample. • key aims involve mapping and comparing transdiagnostic individualand group-level networks. mental health problems are increasingly recognised as a major global concern, with significant personal and societal impacts across health care, the economy, education, and overall well-being (prince et al., 2007; walker et al., 2015; wu et al., 2023). although much progress has been made in developing effective treatments for various forms of psychopathology, treatment efficacy and high relapse (~60% within 1 year) leave much to be desired (clark, 2018; holmes et al., 2018). the modest treatment outcomes have been attributed to a limited understanding of the structure and mechanisms of psycho­ pathology and treatment processes, together with insufficient translation from research to clinical practice (holmes et al., 2014; rief et al., 2024). beyond general mechanisms, a better understanding of individual differences is also needed for adequate treatment tailoring (wright & woods, 2020). currently, treatment protocols are mostly based on disorder classification categories (e.g., those of the dsm-5; american psychiatric association, 2022) which have been shown to consist of very heterogeneous symptom profiles (allsopp et al., 2019; fried & nesse, 2015; newson et al., 2021). this means that each individual’s profile can be substantially different to that of others sharing the same diagnostic label. individual pro­ files also frequently contain characteristics of multiple different disorders (allsopp et al., 2019; forbes et al., 2024). indeed, comorbid diagnoses appear to be the rule rather than the exception (al-asadi et al., 2015; roefs et al., 2022). yet, much of the evidence used to guide treatment tailoring is based on these categories and often excludes individuals transdiagnostic network mapping of psychopathology 2 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ with comorbid diagnoses (shean, 2014), threatening the representativeness of the popu­ lations under study. it follows that classification-informed approaches are likely to be suboptimal for many individuals. these issues highlight the need for more individualised (i.e., idiographic) approaches that transcend diagnostic boundaries (i.e., transdiagnostic) to underpin effective treatments that are tailored to the individual, not the disorder. a novel and promising framework that has rapidly gained traction in recent years and that may be well-suited to address these challenges is the network approach to mental disorders (borsboom, 2008, 2017). here, the emphasis is on studying idiosyncratic ‘sys­ tems’ of interacting symptoms and other relevant variables rather than typical ‘syndro­ mes’ or disorder categories presumed to share a common (biological) underlying cause (borsboom, 2017; bringmann et al., 2022; fried, 2022). this protocol paper describes a large-scale ecological momentary assessment (ema) study in a clinical sample embedded within a larger initiative to evaluate the scientific and clinical utility of this approach (roefs et al., 2022). in the following, we outline the overarching aims and guiding principles of this study and describe the design and its development, followed by a reflection on the project’s strengths and challenges. in doing so, we respond to recent calls for more open and transparent practices in clinical psychology research (rief et al., 2024) and hope to stimulate and help guide future efforts using ema and transdiagnostic network approaches in mental health research. the network approach to psychopathology the network approach to mental disorders is often described as a paradigm shift in how psychopathology has long been conceptualised, studied, and practised – as it moves away from the prevailing common-cause and latent-variable models. these latter mod­ els see the disorder as explaining its symptoms and assume some underlying, often biological, common cause of these symptoms (roefs et al., 2022). however, diagnostic categories are descriptive labels, not causal explanations (borsboom & cramer, 2013), and despite much research, there is little evidence to suggest that specific mental disorders can be predicted or explained by neurobiological factors (scull, 2021). nevertheless, this often termed ‘medical model’ of mental disorders is a prevailing narrative reinforced by leading (mental) health institutions’ causal and disease-laden language (kajanoja & valtonen, 2024). inspired by a wider framework of complex systems science (e.g., olthof et al., 2023), the network approach sees the symptoms not as outcomes of the disorder or some common underlying cause. instead, it sees psychopathology as an emergent and dynamic property arising from the symptom interactions themselves (borsboom, 2008, 2017; borsboom & cramer, 2013). importantly, recent theoretical advances pose that a ‘symptom’ in this context can be any biopsychosocial element (e.g., emotions, appraisals, behavioural tendencies, contextual factors) that contributes to the development and maintenance of a state of psychopathology, and not only ‘symptoms’ as defined by guðmundsdóttir, roefs, jover martínez et al. 3 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ diagnostic manuals (fried & cramer, 2017; roefs et al., 2022). as such, the network approach is transdiagnostic, seeing each individual’s problem as an idiographic system that may contain elements (i.e., nodes) associated with various diagnostic labels. the application of the network approach to mental disorders has sparked much interest among researchers and practitioners (kashihara et al., 2025; roefs et al., 2022), and empirical studies utilising it are accumulating quickly. initial results are promising but also highlight that much work is still needed for the approach to mature and realise its scientific and clinical potential (for reviews, see contreras et al., 2019; kashihara et al., 2025; robinaugh et al., 2020). importantly, much of the existing empirical work has been cross-sectional. albeit informative, cross-sectional networks cannot address the dynamic nature of psychopathology or nuanced individual differences in the dynamic interactions that – according to the network approach – drive the disorder (borsboom, 2017; bringmann et al., 2022). although some work has been done using time-series networks (e.g., levinson et al., 2022; mcghie & mcnally, 2025), these studies have pri­ marily focused on a few specific mental disorders. therefore, more work is needed using time-series data to uncover within-person networks across the broader psychopathology spectrum. some first steps have been taken towards this aim through work carried out by mem­ bers of the dutch research consortium new science of mental disorders (nsmd), which was set up to advance the study of psychopathology from the network perspective and in which the current project is embedded. examination of the network structures among undergraduate students with high vs. low levels of general psychopathology revealed consistent differences in node averages, small differences in the structure of average within-person networks, but considerable heterogeneity in individual networks overall (jover martínez et al., 2024a, 2024b). the lack of differences in group-level networks, in contrast to the heterogeneity observed in individual-level networks, aligns with prior work to suggest limited translatability from the group to the individual level of analysis (levinson et al., 2022; reeves & fisher, 2020). other recent work has also found consider­ able heterogeneity in networks within the same disorder category (i.e., major depressive disorder), even when analysed separately by severity levels (ebrahimi et al., 2024). these findings highlight the need to study individual– in addition to group-level processes. further, we propose to start at the individual level and use bottom-up approaches to identify more homogenous groups of psychopathology profiles that better translate to the individuals within these groups. such subgroups can help evaluate current classifica­ tion systems and identify common patterns that can potentially serve as more insightful heuristics in clinical practice and research compared to common classifications. to assess this most adequately and stretch the network mapping space to a broader range and severity of psychopathology, the next step involves extending this line of transdiagnostic research to a broad clinical population. transdiagnostic network mapping of psychopathology 4 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ the network mapping study central objectives the overarching aim of the network mapping study (nms) is mapping (individual) networks of psychopathology in a broad clinical population of individuals awaiting treat­ ment. through this mapping, we seek to achieve the following three central objectives: (1) identifying differences across people in individual transdiagnostic networks of psy­ chopathology; (2) linking these individual differences to transdiagnostic traits (e.g., selfcontrol), variables in the external field (i.e., contextual factors, such as social support), and disorder classifications (e.g., dsm diagnoses); and (3) clustering individuals based on their networks to see whether network similarities can point to meaningful subgroups and whether network-based clusters overlap with common disorder classifications (e.g., dsm). table 1 presents an overview of example research questions we aim to examine using these data. table 1 overview of research questions objective example research questions identifying • what do individual networks of psychopathology look like in a broad clinical population (i.e., within-person level)? • how do the networks differ across individuals (i.e., between-person level)? linking • how do between-person differences in the networks relate to differences in scores on standard questionnaires of psychopathology, transdiagnostic traits, and other (e.g., contextual) factors (i.e., mediating or moderating associations)? • what are the similarities and differences between network structures of individuals with a similar clinical presentation (e.g., dsm diagnosis)? clustering • can individual networks be used to derive more homogeneous subgroups based on their similarities through clustering methods? • how do the identified subgroups differ in terms of their network structures, standard questionnaires of psychopathology, transdiagnostic traits, and other (e.g., contextual) factors? • how do the identified subgroups align with common disorder classifications (i.e., dsm diagnoses) and alternative taxonomies of psychopathology (e.g., hitop spectra and symptom components; see kotov et al., 2017)? achieving a better understanding of the dynamic interactions of mental health problems in individuals’ daily lives and how individuals differ in these processes is an important step in bridging the network-informed understanding of psychopathology and its poten­ tial clinical applications. beyond evaluating the usefulness for advancing mental health science and research practices, the findings can facilitate potential applications of ema guðmundsdóttir, roefs, jover martínez et al. 5 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ and network-derived insights for diagnosis, case conceptualisation and treatment tailor­ ing; and can help evaluate the viability of such approaches in clinical practice. guiding principles the main principles guiding our research efforts are four-fold. first, in achieving our primary goal of gaining an overview of what individual networks look like in a wide variety of mental disorders, we strive for both breadth – via transdiagnostic measures and a broad range of pathology, and depth – via studying idiosyncratic processes. second, we strive to bridge the nomothetic and idiographic levels of analysis by studying group– as well as individual networks and focusing both on the trait– and state aspects of psy­ chopathology. we agree with recent calls to distinguish between these levels (deyoung et al., 2022; lunansky et al., 2020; rief et al., 2024) and believe that a holistic picture of psychopathology emerges when the insights gained across levels are integrated. it is clear that processes at the different levels often do not converge (fisher et al., 2018), not only because of individual differences that get lost when aggregating data but also because different aspects of psychopathology occur at different time scales. psychopa­ thology is not only a system of daily dynamics in emotions, thoughts and behaviour (i.e., states) but also of a more stable (yet malleable) aspect of the self, reflected in personality characteristics and identity (i.e., traits; klimstra & denissen, 2017; lunansky et al., 2020; wright & hopwood, 2022). thus, we intend to explicitly link dynamic state interactions (i.e., captured through momentary assessment) with more stable trait representations of psychopathology (i.e., captured using trait questionnaires). third, for all analyses of the resulting data, we aim to use state-of-the-art analysis methods, keeping track of the latest developments in network analysis and always striving to use the most optimal and fit-for-purpose methods. this also means considering alternative models (other than networks) in case they turn out to be superior. importantly, the consortium is devoted to assessing whether there is added value in the network approach, not in confirming it. this is directly linked to our fourth principle: to keep sight of the ultimate aim, which is to better explain and predict psychopathology in a way that can be useful for both research and practice, balancing complexity and specificity (methodological/statistical perspective) on one hand and practicality and generalisability on the other (applied/clini­ cal perspective). to foster such a balanced approach, the consortium comprises statistical scientists, (clinical) psychological scientists, and clinical practitioners who continually share expertise and perspectives. transdiagnostic network mapping of psychopathology 6 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ method design figure 1 depicts a schematic overview of the study design. the study involves a baseline measure and a 6-week ecological momentary assessment (ema) protocol in a dutch clinical population with a wide range of psychopathology. the baseline questionnaire intends to provide a comprehensive picture of psychopathology using common measures of mental disorder symptomatology and various transdiagnostic traits. the ema consists of brief surveys capturing a broad range of state-like symptoms and contextual variables. in addition, passive data is collected from participants’ smartphones during the ema phase. after the ema, participants also complete a short evaluation survey asking about their experiences with the study. figure 1 graphical overview of the study design the design is largely based on a previous study within the consortium (the student mapping study; sms) specifically developed with transdiagnostic network research in mind jover martínez et al., 2024a) and validated in a student population (n = 262; jover martínez et al., 2025). the ema battery in the sms included the full range of psychopa­ thology and was informed by expert opinion collected with a survey and focus groups. clinicians were queried on the variables most relevant for the mental disorders they spe­ cialise in, what transdiagnostic variables they would ask individuals of any disorder and to what extent they believe these variables fluctuate (i.e., momentarily, daily or weekly). we built on and adapted the sms protocol based on differences in study aims and target guðmundsdóttir, roefs, jover martínez et al. 7 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ groups, insights gained from analyses of the sms data (e.g., compliance, variabilities in item scores), review of the literature, and follow-up expert meetings among researchers with either methodological or clinical backgrounds (mostly within the consortium). the project is funded by the dutch ministry of education, culture and science (nwo gravitation grant number 024.004.016) and received ethical approval by maas­ tricht university ethics review committee psychology and neuroscience (ercpn; [nr. 225.97.07.2020]). the study complies with regulations at the university of maastricht and gdpr guidelines. the entire study protocol was preregistered before data collection started (guðmundsdóttir et al., 2024s). data collection is currently ongoing (n enrolled at submission = 6). participants and recruitment participants are individuals referred to the adult care units (‘volwassenzorg’; 18-65 years of age) of participating (specialised) mental health care clinics in the netherlands who are currently awaiting intakeor start of treatment. to participate, individuals need to be proficient in dutch and own a smartphone. we include the full range of psychopathology and only exclude those who are already receiving treatment elsewhere, those with symp­ toms that require immediate (crisis) care (e.g., severe suicidality) or that could severely impact the understanding of the ema items (e.g., symptoms of psychosis). potentially eligible participants will be informed about the study by the clinics during the registra­ tionand intake phase (through flyers, video, website, information letter, word of mouth). after reading the recruitment materials, individuals express their interest by contacting the research team via phone, email or the project website. after a screening phone call to ensure inclusion and exclusion criteria are met, eligible participants receive a link to the online informed consent form. we will consider additional routes of recruitment if necessary. procedure participants first complete the (~80 min) online baseline questionnaire, followed by the ema phase and, finally, the evaluation survey. the ema phase starts with a registration in which participants respond to a set of questions that will be used to personalise the ema. this personalisation involves 1) aligning the triggering of surveys to participants’ waking times and 2) preventing the inclusion of (almost) completely non-applicable items for specific participants (e.g., purging, wish to die), thus reducing unnecessary burden. participants proceed with one practice day in which they can get familiar with the protocol before data collection starts. through the avicenna smartphone app (avicenna research inc., 2025), participants are prompted to answer surveys seven times per day for a total of 42 days (294 surveys in total). each day, participants receive three types of ema surveys triggered at different transdiagnostic network mapping of psychopathology 8 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ frequencies: one morning survey, six momentary surveys, and one evening survey. the first measurement of the day includes both the morning survey and the first momentary survey (see figure 1). the evening survey is triggered separately after the last momenta­ ry survey. the survey notifications are prompted semi-randomly in intervals of 2 hours. for all ema surveys, participants receive in-app notifications when they are due and reminders when they are about to expire. after the initial prompt, participants have 45 minutes to complete each morning and evening survey but 20 minutes for each momentary survey. each survey should take about 3-6 minutes to complete, depending on survey type, number of personalised items, and responses to items with skip logic. participants receive an evaluation phone call after the first and fourth week and a motivational e-mail after the fifth week (in addition to the screening and initial evaluation phone call). to further improve ema compliance, participants receive reminder e-mails or a phone call when responding deviates from their usual compliance and when responding drops below 50%. participants are compensated with up to €100 based on compliance with the ema protocol (€0.33 per ema survey and €10 for the baseline survey), and those interested can receive a personalised report of their ema data. during the entire study period, participants can contact researchers if they have questions, and they can withdraw from the study at any time without providing a reason and without any effect on their treatment or waiting time. waiting time will never be extended for participation, and if treatment starts earlier than anticipated (which we do not expect to occur often considering the standard waiting time and recruitment strategies), participants will, by default, drop out of the study. participants can continue the monitoring phase at their own wish, but any data collected after the start of treatment will not be used for the primary analyses. measures in the following, we provide an overview of the measurement battery. a comprehensive overview of all measures, scoring information, translation information and references, and a list of all ema items in both english and dutch is available in guðmundsdóttir et al., 2025s-a). baseline measures and diagnostic information the baseline measurement battery consists of demographic and related information and 19 scales measuring psychopathology and transdiagnostic traits. the measures employed are validated scales commonly used to measure symptoms and specific mental health disorders in line with the dsm-5, and wherever possible, validated dutch translations of these scales. some scales were translated by the research team (see guðmundsdóttir et al., 2025s-a). additionally, we will receive diagnostic and intake information from the guðmundsdóttir, roefs, jover martínez et al. 9 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ participating mental health institutions from which participants are recruited. table 2 contains an overview of the baseline and diagnostic measures. table 2 overview of baseline self-report measures and diagnostic information category variables demographics age, gender, nationality anthropometrics height, weight education and employment highest achieved level of education, current student status, current employment status relationship and children current relationship status, number of children general mental health and treatment primary mental health complaint leading to seeking treatment, previous pharmacotherapy, general symptom severity measures of specific psychopathology general depression severity, stress and anxiety, depressive disorder symptoms, attention deficit hyperactivity disorder symptoms, autism spectrum disorder symptoms, disordered eating symptoms, post-traumatic stress symptoms, symptoms of substance use disorders (alcohol and drug use, respectively), obsessive-compulsion disorder symptoms transdiagnostic psychopathology sexual dysfunction, insomnia severity, levels of personality functioning, dysfunctional personality traits, self-esteem, fear of negative evaluation, dichotomous thinking, self-control, workand social adjustment, stressful life experiences, trauma diagnostic informationa official dsm-5 diagnosis (primary and comorbid classifications), health of the nation outcome scale (honos+) scores and outcomes, dates of intake, diagnosis, and start of treatment note. for the full measurement battery, see guðmundsdóttir et al., 2025s-a). areported by mental health institutions. ema items items from the sms were translated and (when applicable) adapted (e.g., due to differen­ ces in target population and language, or to improve clarity), and additional items were formulated by a team of native dutch speakers. in the morning survey, participants rate sleep quality, nightmares, and how they feel about the upcoming day. the momentary surveys are of central interest for network estimation and capture a broad range of transdiagnostic states relevant to modelling psychopathology as a system. items include transdiagnostic network mapping of psychopathology 10 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ affective states, physical and physiological states, cognitions, cravings, behaviours and interpersonal context that are likely to show sufficient variability within days, which is necessary for network estimation. the evening survey (like the momentary survey) also consists of psychopathology-relevant states, but ones that either concern specific events, have a low daily base rate, or are less likely to fluctuate throughout the day. for example, participants report their perceived social support, deficits in functioning, (urge to) self-harm or harm others and sense of meaning in life. here, participants are also asked to report in an open format the most unpleasant and pleasant event that day and when it happened. these items can provide important context for interpreting the momentary patterns at both the withinand between-person levels (e.g., what might explain shifts in patterns across days or stable differences across individuals), even if not used as nodes in the (momentary) networks. most ema items are answered on a visual analogue scale (vas; no tick marks but labels on either side [e.g., “very much” and “not at all”] and a dot with an integer between 0 and 100). the vas format was preferred over the 7-point likert scale used in the sms based on recent (currently unpublished) results suggesting that vas may be better suited for capturing affective states and in the presence of floor or ceiling effects (haslbeck et al., 2024). in addition to the self-report surveys and with the informed permission of partici­ pants, passive data is also collected from their smartphones via the avicenna app. this contains information on their device status, location, motion and app usage (see table 3). it is emphasised to participants that at no point is the content of their text messages, phone calls, social media or other online activity accessible to the researchers. table 3 contains an overview of the ema measures, and the full list of items can be found in guðmundsdóttir et al., 2025s-a. statistical approaches the arsenal of network analytic approaches is rapidly growing as the field advances (for a recent overview, see briganti et al., 2024). for this reason, combined with the explora­ tory nature of this project, we do not, at this stage, outline in detail or preregister any specific models. instead, we provide a general summary and examples (see table 4) for the three central objectives based on the state-of-the-art at the time of writing. for the identifying, we plan to estimate individualand group-level networks using variations of vector autoregressive models (e.g., bringmann et al., 2013; epskamp, 2020; epskamp et al., 2018; haslbeck & waldorp, 2020) and assess heterogeneity in individual models (e.g., hoekstra et al., 2023). for the linking, we plan to conduct moderation analyses of the networks (e.g., haslbeck et al., 2023; proppert et al., 2025). for the clustering, we plan to run data-driven clustering algorithms to derive subgroups based on the networks (e.g., ernst & haslbeck, 2025; gates et al., 2017; ntekouli et al., 2023; park et al., 2024). going beyond the more traditionally used models developed in psychology and psychometrics in the last years, such as the vector autoregressive models mentioned above, we are guðmundsdóttir, roefs, jover martínez et al. 11 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ table 3 overview of ema self-report and passive measures category variables morning sleep sleep quality, nightmares perceptions about the upcoming day nervousness about what could happen during the day, looking forward to the day momentary affect states general negative and positive affect, cheerfulness, sadness, guilt, anxiety, irritability, gloom, loneliness, stress, anger, hopelessness, shame, emptiness*, disgust* physical/physiological states fatigue, pain or other physical discomfort, nausea*, trembling*, heart palpitations* self-satisfaction satisfaction with self, satisfaction with physical appearance cognition/appraisal concentration, worry, intrusive thoughts, specific cravings/urges (e.g., cigarettes, drugs, sex), enjoyment of activity, detachment* behaviour type of activity engaged in (e.g., work, rest, exercise), giving into/losing control over cravings/urges, avoidance (e.g., thoughts, activities, people), impulsivity, compulsions, body scanning*, scanning environment* interpersonal context being alone or with others, type of company (e.g., friends, family), enjoyment of company, perceived stress due to company evening day reflection general satisfaction with the day cognition/appraisal perceived deficits in functioning, perceived social support, perceived meaning in life, wish to die*, urge to self-harm*, urge to harm others* behaviour self-harm*, aggression*, binge eating*, compensation behaviours* daily events events perceived as most pleasant and most unpleasant, brief description (openended) and timing of these events continuous / passive digital phenotyping device status (battery status, screen state), location and motion (geolocation, step count and type of activity), frequency and duration of using specific apps a (e.g., youtube, instagram; but only possible for android users) note. *starred variables are only presented to participants who indicated in the registration phase that they apply to them at least some of the time. for the full measurement battery, see guðmundsdóttir et al., 2025s-a. ano app content is collected (e.g., messages, contact details). transdiagnostic network mapping of psychopathology 12 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ generally interested in modelling frameworks that can be leveraged to model data as systems, including but not limited to dynamic structural equation modelling, complex dynamic systems modelling, and machine learning. study potential and challenges the current project has some noteworthy potential, both within and beyond the network approach. its strengths lie in the transdiagnostic focus, the sampling from a clinical population with a broad range of psychopathology, and the adoption of state-of-the-art methodology and complex systems thinking. as far as we are aware, this is one of the largest transdiagnostic ema studies in a clinical population to date. of course, a project like this also faces several important challenges. table 4 overview of potential network analysis approaches for the central objectives objective example analytical approaches identifying …differences across people in individual transdiagnostic networks of psychopathology • (multilevel) graphical var (bringmann et al., 2013; epskamp, 2020; epskamp et al., 2018) • time-varying mixed graphical var (haslbeck et al., 2021; haslbeck & waldorp, 2020) • individual network invariance test (init; hoekstra et al., 2023) linking …individual differences in networks to transdiagnostic traits, variables in the external field and disorder classifications • group comparison for multilevel var (haslbeck et al., 2023) • two-step approaches regressing individual network parameters on predictors (proppert et al., 2025) • multilevel var with continuous moderators of network parameters clustering …individuals based into subgroups on their networks and assessing whether these subgroups overlap with common disorder classifications • latent class var, mixture multilevel var (lcvar; mmvar; ernst et al., 2020, 2024; ernst & haslbeck, 2025) • chain graphical var (park et al., 2024) • group iterative multiple model estimation (gimme; gates et al., 2017) • model-based approaches using (non-)linear machine learning models (ntekouli et al., 2023) • individual network invariance test (init; hoekstra et al., 2023) to assess network heterogeneity within and across clusters • regressing cluster membership on predictors note. the examples presented here are approaches that can be utilised for the three central objectives – based on the state-of-the-art at the time of writing. we will keep track of the latest developments in the field and always strive to use the most optimal methods. we are also interested in exploring how the data can be leveraged within other modelling frameworks. guðmundsdóttir, roefs, jover martínez et al. 13 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ in a sea of relevant constructs and measures, selecting the final measurement battery is difficult, particularly when the goal is to map a wide range of psychopathology. aside from including a representative set of items, we need to consider participant burden, compliance, response biases, and the timescale with which the variables fluctuate. for this project, these challenges were addressed by combining multiple sources of infor­ mation – both qualitative and quantitative. the initial protocol was based on clinical experts’ views collected through focus groups and survey data, and then refined based on insights from a validation study in a student sample (jover martínez et al., 2025), differences in population and study goals and a review of the literature. as always, there is room for improvement, but one of the values of this project involves the insights gained (e.g., via participant feedback and psychometric analyses) that can help further refine and adapt this and similar protocols for future transdiagnostic (network) research. a measurement challenge lies in determining the amount of data needed that bal­ ances reliable and well-powered analyses on the one hand and participant burden on the other. there are no clear guidelines on how many observations are needed to estimate individual networks, but early simulation work suggests that small networks (six variables) can be reliably estimated with approximately 100 observations (mansueto et al., 2023). based on that, the current studies should provide adequate reliability and statistical power despite missingness. note, however, that reliability and power are de­ pendent on various other factors, such as networkand item characteristics (e.g., number of nodes, network density, item variability, type of missingness) and whether group (multilevel) or individual networks are estimated. thus, any network estimation using these data needs to be made with an eye to such factors. although more observations are always desirable, a longer ema phase would not be feasible given the study context (i.e., waitlist for clinical intervention) and analysis aims (i.e., many classic network estimation techniques rely on the assumption of stationarity, which is more likely to be violated for longer timespans; jordan et al., 2020). further, a more intense scheduling procedure would likely lead to worse compliance (eisele et al., 2022; vachon et al., 2019). we also foresee challenges on the analysis front. for example, there are concerns (both methodological and conceptual) attached to combining variables at different ‘lev­ els’ (de boer et al., 2021; wichers et al., 2021), whether it be different time scales (e.g., momentary vs daily, state vs trait), data types (e.g., self-report vs passive data, internal vs external factors), or construct breadth (e.g., discrete emotional states vs broad metaconstructs). current network models for ema data cannot easily incorporate different data types and variables that fluctuate at different rates (bringmann, 2024), but this may become possible with methodological advancements (e.g., through ‘multi-layered’ networks; riese & wichers, 2021). until then, we advocate caution in estimating and interpreting networks with different types of nodes, starting with more homogenous self-report elements measured at the momentary level, which this study is specifically designed for. transdiagnostic network mapping of psychopathology 14 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ another analytical challenge is that if the goal is to explore inter-individual differen­ ces and subgroups, all networks must contain the same nodes. however, the relevance and fluctuations of nodes likely differ across individuals. to tackle this, we plan to select a generally representative set of nodes for individual comparisons and consider alternative nodes for specific subgroups or when exploring individual networks. this highlights again the need to consider both the nomothetic and idiographic levels of analysis, one of our central objectives. conclusion the network mapping study is a research initiative primarily conducted to expand cur­ rent knowledge on the structure and dynamics of psychopathology and evaluate the utility of the network approach. in addition to the clinical population, its key strengths lie in the transdiagnostic measurement battery and rich information on individuals’ psychopathology at both the trait and state levels, providing ample opportunity for collaboration and exploring novel research questions. the amount and richness of the data should lend themselves well to various types of analyses, addressing the nuances of psychopathology from different angles and approaches. when combined with evidence from experimental and intervention studies and work within other (transdiagnostic) frameworks, the insights gained may be integrated into larger knowledge structures that can help move the field forward and achieve the urgent goal of improving measurement, classification and personalised treatment of mental health problems. guðmundsdóttir, roefs, jover martínez et al. 15 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://www.psychopen.eu/ funding: this study is part of the project ‘new science of mental disorders’ (www.nsmd.eu), supported by the dutch research council and the dutch ministry of education, culture and science (nwo gravitation grant number 024.004.016). acknowledgments: we would like to thank lindy dullens and nina aussems for coordinating the recruitment, screening, and monitoring of data collection. we would also like to extend our gratitude to participants, participating clinics, nsmd consortium members, and student assistants for their valuable contributions, time, and effort. competing interests: the authors have declared that no competing interests exist. ethics statement: this research received ethical approval by maastricht university ethics review committee psychology and neuroscience (ercpn; [nr. 225.97.07.2020]). social media accounts: guðrún r. guðmundsdóttir: bluesky, linkedin, alberto jover martínez: linkedin, lotte h. j. m. lemmens: linkedin, anne roefs: linkedin, eiko i. fried: x reporting guidelines: we follow the jars-quant (reporting standards for studies using no experimental manipulation). preregistration: the study is preregistered (https://osf.io/93cwz). data availability: the project's osf repository (https://osf.io/keth3/) contains a comprehensive overview of the study measures, including the full ecological momentary assessment battery in both dutch and english (see also supplementary materials accompanying this publication). relevant materials, including procedures on personalised reports, analysis code, and publications, will be uploaded to this repository. the consortium is currently developing a data-sharing policy with the goal of fostering open collaboration and data sharing. supplementary materials the supplementary materials contain the following items: • the preregistration for the study (guðmundsdóttir et al., 2024s) • the full ecological momentary assessment battery in both dutch and english (guðmundsdóttir et al., 2025s-a) • the project's osf repository (guðmundsdóttir et al., 2025s-b) index of supplementary materials guðmundsdóttir, g. r., roefs, a., groot, e., jover martínez, a., jansen, a., & lemmens, l. h. j. m. (2024s). network mapping of psychopathology: estimation of individual and group networks in a clinical sample [preregistration]. osf registries. https://osf.io/93cwz guðmundsdóttir, g. r., roefs, a., groot, e., jover martínez, a., jansen, a., fried, e. i., & lemmens, l. h. j. m. (2025s-a). supplementary materials to "transdiagnostic network mapping of transdiagnostic network mapping of psychopathology 16 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 http://www.nsmd.eu https://bsky.app/profile/grgudmundsdottir.bsky.social https://www.linkedin.com/in/grgudmundsdottir/ https://www.linkedin.com/in/albertojover/ https://www.linkedin.com/in/lemmenslotte/ https://www.linkedin.com/in/anne-roefs-02b5a18/?originalsubdomain=nl https://x.com/eikofried https://osf.io/93cwz https://osf.io/keth3/ https://osf.io/93cwz https://www.psychopen.eu/ psychopathology in daily life: rationale and research protocol" [measurement]. osf. https://osf.io/w4sef guðmundsdóttir, g. r., roefs, a., groot, e., jover martínez, a., jansen, a., fried, e. i., & lemmens, l. h. j. m. (2025s-b). the network mapping study [project repository]. osf. https://osf.io/keth3 references al-asadi, a. m., klein, b., & meyer, d. 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(2023). changing trends in the global burden of mental disorders from 1990 to 2019 and predicted levels in 25 years. epidemiology and psychiatric sciences, 32, article e63. https://doi.org/10.1017/s2045796023000756 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service provided by the leibniz institute for psychology (zpid), germany. transdiagnostic network mapping of psychopathology 22 clinical psychology in europe 2025, vol. 7(4), article e15939 https://doi.org/10.32872/cpe.15939 https://doi.org/10.1155/2014/561452 https://doi.org/10.2196/14475 https://doi.org/10.1001/jamapsychiatry.2014.2502 https://doi.org/10.3389/fpsyt.2021.719490 https://doi.org/10.1111/jopy.12671 https://doi.org/10.1146/annurev-clinpsy-102419-125032 https://doi.org/10.1017/s2045796023000756 https://www.psychopen.eu/ transdiagnostic network mapping of psychopathology (introduction) the network approach to psychopathology the network mapping study method design participants and recruitment procedure measures study potential and challenges conclusion (additional information) funding acknowledgments competing interests ethics statement social media accounts reporting guidelines preregistration data availability supplementary materials references effectiveness of attachment-based family therapy for suicidal adolescents and young adults: a systematic review and meta-analysis systematic reviews and meta-analyses effectiveness of attachment-based family therapy for suicidal adolescents and young adults: a systematic review and meta-analysis poul m. schulte-frankenfeld 1,2 , josefien j. f. breedvelt 3,4 , marlies e. brouwer 1 , nadia van der spek 1 , guy bosmans 5 , claudi l. bockting 1,4,6 [1] department of psychiatry, amsterdam university medical center, university of amsterdam, amsterdam, the netherlands. [2] department of pediatric neurology, charité – universitätsmedizin berlin, berlin, germany. [3] department of child and adolescent psychiatry, institute for psychiatry, psychology & neuroscience, king’s college london, london, united kingdom. [4] centre for urban mental health, university of amsterdam, amsterdam, the netherlands. [5] department of clinical psychology, ku leuven, leuven, belgium. [6] amsterdam public health, amsterdam university medical center, university of amsterdam, amsterdam, the netherlands. clinical psychology in europe, 2024, vol. 6(4), article e13717, https://doi.org/10.32872/cpe.13717 received: 2024-01-15 • accepted: 2024-08-12 • published (vor): 2024-12-20 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: claudi l. bockting, meibergdreef 5, 1105 az amsterdam, the netherlands. phone: +31 20 566 9111. e-mail: c.l.bockting@amsterdamumc.nl supplementary materials: code, data, materials, preregistration [see index of supplementary materials] abstract background: suicide is a leading cause of death among adolescents and young adults. while only few evidence-based treatments with limited efficacy are available, family processes have recently been posed as a possible alternative target for intervention. here, we review the evidence for attachment-based family therapy (abft), a guideline-listed treatment targeting intrafamilial ruptures and building protective caregiver-child relationships. method: pubmed, psycinfo, embase, and scopus were searched for prospective trials on abft in youth published up until november 6th, 2023, and including measures of suicidality. results were independently screened by two researchers following prisma guidelines. risk of bias was assessed using the cochrane rob-2 framework. a random effects meta-analysis was conducted on suicidal ideation and depressive symptoms post-intervention scores in randomized-controlled trials (rcts). results: seven articles reporting on four rcts (n = 287) and three open trials (n = 45) were identified. mean age of participants was mpooled = 15.2 years and the majority identified as female this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.13717&domain=pdf&date_stamp=2024-12-20 https://orcid.org/0000-0003-0244-9226 https://orcid.org/0000-0003-1864-1861 https://orcid.org/0000-0002-9972-9058 https://orcid.org/0000-0003-4767-6553 https://orcid.org/0000-0001-9057-6027 https://orcid.org/0000-0002-9220-9244 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ (~80%). overall, abft was not significantly more effective in reducing youth suicidal ideation, gpooled = 0.40, 95% ci [-0.12, 0.93], nor depressive symptoms, gpooled = 0.33, 95% ci [-0.18, 0.84], compared to investigated controls (waitlist, (enhanced) treatment as usual, family-enhanced nondirective supportive therapy). conclusion: evidence is strongly limited, with few available trials, small sample sizes, high sample heterogeneity, attrition rates, and risk of bias. while not generally superior to other treatments, abft might still be a clinically valid option in specific cases and should be further investigated. clinicians are currently recommended to apply caution when considering abft as stand-alone intervention for suicidal youth and to decide on a case-by-case basis. keywords suicide, suicidal ideation, adolescents, young adults, psychotherapy, family therapy highlights • current evidence on the comparative effectiveness of abft is strongly limited. • meta-analysis showed no improved effect on suicidal ideation nor depressive symptoms compared to other treatments. • abft might still be a clinically valid option in specific cases and should be further investigated. • implications and recommendations for researchers and practitioners are discussed in the article. suicide is the fourth most prevalent cause of death in adolescents and young adults worldwide (world health organization, 2021). in 2019, more than 157.700 youths aged 15 to 29 died prematurely by intentional self-harm, accounting for about 8% of all deaths and the majority of years of life lost in this cohort (castelpietra et al., 2022; world health organization, 2020). many of these cases are preceded by risk factors and early warning signs such as depressive symptoms, being part of a sexual minority group, expression of suicidal ideas, previous self-harm, or contact with primary health services, and could thus potentially be prevented through targeted treatment (bachmann, 2018; chiang et al., 2021; fergusson et al., 2005; jackman et al., 2021; liu et al., 2020; walby et al., 2018). several psychological interventions that might help to attenuate the suicidal trajectory are available (e.g., cognitive behavioral therapy (cbt), dialectical behavior therapy (dbt)). however, efficacy of these interventions for adolescent populations was found to be low overall and has stagnated for decades (busby et al., 2020; fox et al., 2020; franklin et al., 2017; kothgassner et al., 2020; robinson et al., 2018; tarrier et al., 2008). thus, developing more effective interventions to prevent adolescent suicide is warranted (holmes et al., 2018). increasing attention has recently been paid to the role that early childhood interper­ sonal and relational factors might play in the development and trajectory of mental abft for suicidal youth: review and meta-analysis 2 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ health problems and suicidal thoughts and behaviors (chu et al., 2017; franzoi et al., 2024; van orden et al., 2010). having strong and positive interpersonal connections to family members and friends was found to be protective in this regard, and the absence of such resulting in feelings of loneliness was a risk factor respectively (gunn et al., 2018; mcclelland et al., 2020). at the same time, disturbing aspects of interpersonal relations and familial environments, such as conflicts, constant negative evaluation, childhood trauma, physical abuse, and neglect, can be perceived as major stressors by individuals at risk and contribute to the suicidal trajectory (carballo et al., 2020; king & merchant, 2008). although accumulating evidence suggests that interpersonal relations, specifically in the context of adolescents’ family environments, could be strong targets for preventive interventions, there are only few family-focused interventions available (frey et al., 2022; sullivan et al., 2023). one such family-focused intervention for suicidal youths is attachment-based family therapy, which targets interpersonal ruptures between youth at risk of suicide and their primary caregivers (g. s. diamond, 2022; g. s. diamond et al., 2014). developed upon the assumption that the quality of familial relations can trigger, exacerbate, and buffer against suicide trajectories, this 16-week treatment protocol addresses interperso­ nal traumata and dysfunctional interaction patterns in a therapist-guided systematic process. in contrast to currently prevalent treatments mainly targeting patients’ thought patterns and behavior (e.g., cognitive behavioral therapy, dialectical behavior therapy), the five critical treatment tasks in abft focus on identifying factors that damaged intrafamilial trust, motivating patients and caregivers to rediscover their innate desire for mutual closeness, and building mature, regulated, and empathic interaction patterns. adolescents’ autonomy and developmental responsibility are encouraged, and caregivers are supported in developing an empathic, empowering, and unconditionally accepting stance toward their youths. by the end of treatment, attachment security is expected to be improved, building the foundation for future positive development and alleviation of symptoms. a full description of underlying theory and mechanisms can be found in the original manual and a more recent review (g. s. diamond et al., 2014, 2016). attachment-based family therapy is currently listed as a ‘promising’ intervention for youth depression and suicidal ideation at the california evidence-based clearing house for child welfare, with ratings based on three randomized-controlled trials and four moderation studies published up until 2018 (g. s. diamond et al., 2002, 2010, 2012; shpigel et al., 2012; israel & diamond, 2013; feder & diamond, 2016; ibrahim et al., 2018; cebc, 2020). it is further mentioned as a possible intervention for youth suffering from moderate to severe depression in the nice guidelines (national institute for health and care excellence, 2019). in recent years, increasing interest in interpersonal treatments for youth suicide bore new evidence, and new results ought to be considered in clinical guidelines and practice. importantly, more recently published reviews on abft remain mostly narrative and do not provide a systematic approach to its evaluation, or do schulte-frankenfeld, breedvelt, brouwer et al. 3 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ not examine the efficacy of abft for youth suicidality specifically (g. s. diamond et al., 2016, 2021; sullivan et al., 2023; van aswegen et al., 2023). one recently published meta-analysis on the effect of family-based treatments in youth finds a significant overall treatment benefit of family-therapy over comparator therapies for suicidal ideation, but not depressive symptoms (waraan et al., 2023). however, this review pools together different types of family-based therapies (e.g. family-focused cognitive behavioral ther­ apy, systems integrative family therapy), thus not allowing to assess the individual efficacy of abft. therefore, this systematic review and meta-analysis aims to summarise and assess the current evidence for the effectiveness of attachment-based family thera­ py in treating suicidal adolescents and young adults. method search strategy and selection criteria this review follows the prisma guidelines, was initially performed in august 2021 and updated on november 6th, 2023, and preregistered at prospero (crd42021271731, see schulte-frankenfeld et al., 2024s-a). pubmed (ovid medline® all 1946 to november 03, 2023), psycinfo (apa psycinfo 1806 – october week 4 2023), and embase (embase classic + embase, 1946 – 2023 november 03) were searched for trials indexed for the search term “attachment-based family therapy” up until november 06th, 2023, using the ovid interface (version 05.09.00.005). scopus (november 06, 2023) was searched in titles, abstracts, and keywords. no further filters were applied. snowballing was performed to identify non-indexed studies by examining published reviews, reference lists of included trials, and contacting expert authors. search results were deduplicated using proquest refworks. two reviewers independently screened all records based on titles and abstracts using rayyan (ouzzani et al., 2016). studies were eligible if they fulfilled the following criteria: (1) sample of adolescents and young adults aged ten years and older; (2) abft treatment; (3) suicidality measured at post-treatment through diagnostic methods (e.g., clinical interviews, siq-jr, bss, sidas); (4) longitudinal or prospective design; (5) written in english, dutch, or german. review papers, expert opinions, and case reports were exclu­ ded. potentially eligible records were further assessed on a full-text basis. risk of bias of eligible records was assessed using the cochrane rob-2 framework (appendix a, schulte-frankenfeld et al., 2024s-c). consensus about deviant decisions was reached by unblinded discussion and consulting a senior author. a list of screened articles (schultefrankenfeld et al., 2024s-b) and a prisma flow diagram (figure 1) are available. abft for suicidal youth: review and meta-analysis 4 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ figure 1 prisma flow diagram for the systematic review data extraction and statistical analysis primary outcome was the difference in suicidality severity at post-treatment between abft and respective control conditions. further measures of the patient’s idiosyncratic condition (e.g. bdi-ii, ham-d) were collected if available. demographic information (population type, age, country), study characteristics (n, design, conditions), outcome measures, and statistical factors necessary to calculate effect sizes were extracted by one author and independently checked by two others. all authors of included articles were contacted to request individual participant data, and additionally summary sta­ tistics when reported outcome data was insufficient to calculate effect sizes. when schulte-frankenfeld, breedvelt, brouwer et al. 5 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ measurement data from multiple post-baseline timepoints was given, the timepoint most immediate to the end of treatment was used. recalculating effect sizes based on means and standard deviations was preferred, and data transformations were applied following cochrane guidelines where necessary (higgins et al., 2023). calculations were performed using rstudio in version 2023.03.0+386 following guide­ lines by harrer and colleagues (harrer et al., 2021; rstudio team, 2021). hedge’s g was used as effect size measure to correct for small sample bias, expressing the magnitude of difference between group means in units of pooled standard deviation. although it is commonly interpreted with cut-offs (small (< 0.2), medium (~0.5), and large (> 0.8)) these thresholds are arbitrary and lack solid statistical and empirical foundations. therefore, they should be interpreted only as rough guidelines within this review (cuijpers et al., 2014). a random effects model using the hartung-knapp method was applied as consid­ erable heterogeneity among studies was expected (van aert & jackson, 2019; zeraatkar et al., 2020). cochran’s q was used to assess homogeneity (α < .05), and i 2 to quantify how much variability can be attributed to between-study heterogeneity (low: ≤ 25%, medium: 26%–50%, high: > 50%). a prediction interval (95% pi) was calculated to estimate the range in which true effect sizes of future replication studies are expected to fall (inthout et al., 2016). publication bias was assessed through visual inspection of colour-enhanced funnel plots. the {tidyverse} package v2.0.0 was used for data processing, and the {esc} package v0.5.1 for calculating effect sizes (lüdecke, 2019; wickham et al., 2019). pooled effect sizes and 95% cis, measures of heterogeneity, forest plots, and funnel plots were calculated using the {meta} package v6.5-0 (balduzzi et al., 2019). risk of bias plots were created using the {robvis} package v0.3.0 (mcguinness, 2019). all data and calculation scripts are publicly available (schulte-frankenfeld et al., 2024s-b). results study selection pubmed, psycinfo, embase, and scopus were searched for prospective trials indexed for “attachment-based family therapy”, measuring suicidality at post-treatment in a sample of adolescents and young adults aged ten years or older, up until november 06th, 2023. out of 370 records identified, seven articles met the inclusion criteria (n = 332), of which four were included in the meta-analysis (n = 287) (g. m. diamond et al., 2012; g. s. diamond et al., 2002, 2010, 2019; russon et al., 2022; van der spek et al., 2024; waraan et al., 2021). see figure 1 for the selection process. individual participant data were requested from all authors, though only provided by one team despite repeated outreach attempts. thus, an individual participant data meta-analysis was not performed. one study reported siq-jr data deviating between text, figures, and appendix, which only matched after multiplying reported summary scores by the number of items in the un­ abft for suicidal youth: review and meta-analysis 6 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ derlying scale (waraan et al., 2021). another study reported confidence intervals instead of standard deviations, for which a t-distribution conversion following the cochrane handbook was applied (g. s. diamond et al., 2010; higgins et al., 2023). study characteristics characteristics of included studies are depicted in table 1. included trials recruited a total of 332 participants (rcts n = 287, open trials n = 45) with a mean age of 15.2 years (sdpooled = 1.65, range: 12 – 25 years) and the majority identifying as female (~80%). baseline levels of suicidal ideation, siq(-jr), mpooled = 46.26, sdpooled = 17.91, and depressive symptoms bdi(-ii), mpooled = 31.59, sdpooled = 9.00, were high across trials. het­ erogeneity between studies regarding populations, treatment protocols, study designs, and implemented control conditions was considerable. four of the seven studies were randomized-controlled trials using the 12-week (k = 2) (g. s. diamond et al., 2002, 2010) or 16-week (k = 2) (g. s. diamond et al., 2019; waraan et al., 2021) abft protocol, and a waitlist group (k = 1) (g. s. diamond et al., 2002), treatment as usual (tau) (waraan et al., 2021), directly referred “enhanced” usual care (enhanced usual care; euc) (g. s. diamond et al., 2010), or a nondirective supportive therapy augmented with psychoeducative sessions for primary caregivers (family-enhanced nondirective supportive therapy; fe-nst) (g. s. diamond et al., 2019) as control condition. tau and euc trials did not follow-up participants for the type of treatment received (g. s. diamond et al., 2010; waraan et al., 2021). the open non-controlled trials consisted of one study using the 16-week abft protocol, and two applying lgbtq+ sensitive variants of abft to sexual minority youths (g. m. diamond et al., 2012; russon et al., 2022; van der spek et al., 2024). clinically significant scores of suicidal ideation were a recruitment criterion in five studies (rcts k = 2; open trials k = 3), while two rcts primarily recruited adolescents with depressive symptoms (g. s. diamond et al., 2002; waraan et al., 2021). overall, trials were small, with samples ranging from 10 to 129 participants. a priori calculated recruitment targets were only met by one study (g. s. diamond et al., 2019). one study presented a post-intervention attrition rate of ~80%, raising concerns about its validity (waraan et al., 2021). after conducting a sensitivity analysis, we kept it for completeness. risk of bias was high in most studies, with non-blinded assessment and selective data reporting as major issues (appendix a and b, schulte-frankenfeld et al., 2024s-c). effect sizes and meta-analyses suicide attempts and suicidal ideation, as assessed through the suicidal ideation ques­ tionnaire (siq), were the only shared measure of suicidality between studies. since the number of recorded attempts was too low for statistical analysis (see table 1), siq scores were used to compare effect sizes. schulte-frankenfeld, breedvelt, brouwer et al. 7 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ ta bl e 1 c ha ra ct er is tic s of s tu di es in cl ud ed in th e sy st em at ic r ev ie w st ud y po pu la ti on in cl us io n cr it er ia n a ge , m (s d, ra ng e) g en de r, % fe m al e lo ca ti on d es ig n c on di ti on s m ea su re o f ef fe ct se co nd ar y ou tc om es a tt ri ti on ra te a dh er en ce , m (s d, ra ng e) ba se lin e se ve ri ty , m (sd ) ef fe ct si ze ,g, [9 5% c i] c lin ic al r ec ov er y su ic id al be ha vi or c on cl us io n r is k of bi as d ia m on d et a l., 20 02 a d ep re ss ed yo ut h, r ef er re d by s ch oo ls a nd ca re gi ve rs m d d pr im ar y di ag no si s ac co rd in g to d sm -i ii -r   32 14 .9 (1 .5 , ra ng e: 1 3 17 ) 78 % u sa pi lo t r c t a bf t: 1 2 w ee ks a bf t co nt ro l: 6 w ee ks w ai tli st si q bd i, h a m d , b h s, st a ic 3% n a si q : 32 .1 0 (2 0. 37 ) bd i: 25 .9 (7 .4 5) tim e: 0 .6 6 [0. 05 , 1 .3 8] gr ou p: 0 .3 7 [0. 34 , 1 .0 8] n a n a n o ef fe ct o ve r tim e, n ot su pe ri or to w ai tli st h ig h d ia m on d et a l., 20 10 a su ic id al y ou th , re fe rr ed b y pr im ar y ca re an d em er ge nc y ro om s si q -j r > 31 , bd iii > 2 0 66 15 .1 (1 .5 , ra ng e: 1 2 17 ) 83 % u sa rc t a bf t : 1 2 w ee ks a bf t co nt ro l: 12 w ee ks e u c si q -j r ss i, bd iii 9% a bf t: 9 .7 1 (5 .2 6) co nt ro l: 2. 87 (3 .3 ) si gn if ic an t g ro up di ff er en ce (z = -4 .7 4, p < .0 01 )* si q -j r: 51 .0 7 (1 3. 45 ) bd i-i i: 33 .0 0 (9 .0 3) tim e: 3 .9 1 [3 .0 8, 4 .7 4] * gr ou p: 0 .8 3 [0. 30 , -1 .3 2] * re m is si on (≤  1 3) : 8 7. 1% o r = 6. 30 [1 .7 6 – 22 .6 1] * su ic id e at te m pt s (u p to 6 m on th s af te r ba se lin e) : a bf t: 1 1% (n = 4) co nt ro l: 23 % (n = 7)   ef fe ct o ve r tim e, s up er io r to e u c h ig h g . m . d ia m on d et a l., 2 01 2 su ic id al l g b yo ut h lg b id en tif ic a­ tio n, s iq -j r ≥ 31   10 15 .1 (1 .3 7, ra ng e: 1 4 18 ) 80 % u sa o pe n tr ia l a bf t: 1 2 w ee ks a bf tlg b si q -j r bd iii 20 % a bf t: n a (r an ge : 8 – 16 ) si q -j r: 51 .0 0 (1 3. 00 ) bd i-i i: 28 .1 0 (1 3. 63 ) tim e: 3 .8 6 [2 .2 4, 5 .4 7] * re m is si on (≤  1 3) : 8 7. 5% n a ef fe ct o ve r tim e n a d ia m on d et a l., 20 19 a su ic id al y ou th , re fe rr ed b y pr im ar y an d em er ge nc y ca re , i np at ie nt cl in ic s, s ch oo ls , an d se lfre fe rr al   si q -j r ≥ 31 , bd iii > 2 0 12 9 14 .8 7 (1 .6 8, ra ng e: 1 2 18 ) 81 .9 % u sa rc t a bf t: 1 6 w ee ks a bf t co nt ro l: 16 w ee ks f en st si q -j r bd iii 18 % a bf t: 1 4. 34 (7 .5 8) co nt ro l: 12 .6 7 (5 .7 4) n o si gn if ic an t g ro up di ff er en ce , t 12 7 = -1 .4 3, p = .1 6 si q -j r: 49 .8 3 (1 5. 08 ) bd i-i i: 30 .5 9 (7 .9 4) tim e: 1 .9 1 [1 .4 7, 2 .3 4] * gr ou p: 0 .1 7 [0. 21 , 0 .5 5] re m is si on (<  1 2) : 3 2. 7% vs . 2 4. 4% su ic id e at te m pt s (d ur in g tr ea tm en t) : a bf t: 3 % (n = 2) co nt ro l: 8% (n = 4) ef fe ct o ve r tim e, n ot su pe ri or to f en st so m e co nc er n w ar aa n et a l., 20 21 a d ep re ss ed yo ut h, r ef er re d to m en ta l he al th c lin ic s c ur re nt m d e ac co rd in g to cl in ic al in te rv ie w , g ri d h a m d > 1 5   60 14 .9 (1 .3 5, ra ng e: 1 3 18 ) 87 % n or w ay rc t a bf t: 1 6 w ee ks a bf t co nt ro l: 16 w ee ks t a u si q -j r g ri d h a m d , bd iii 80 % n a si q -j r: 43 .0 9 (2 2. 96 ) bd i-i i: 35 .2 2 (8 .6 6) tim e: 0 .6 4 [0. 32 , 1 .6 1] gr ou p: 0 .1 0 [0. 66 , 0 .8 6] n a n a n o ef fe ct o ve r tim e, n ot su pe ri or to ta u h ig h ru ss on e t a l., 20 22 su ic id al lg bt q + yo ut h lg bt q + id en tif ic a­ tio n, s iq -j r ≥ 31 , b d iii ≥ 21 10 18 .2 (n a , ra ng e: 1 5 25 ) n a u sa o pe n tr ia l a bf t: 1 6 w ee ks a bf tlg bt q + si q -j r bd iii 0% a bf t: 1 5. 3 (r an ge : 1 1 – 23 ) si q -j r: 52 .7 0 (1 9. 36 ) bd iii : 35 .4 0 (1 1. 92 ) tim e: 1 .4 5 [0 .4 0, 2 .5 0] * re m is si on (≤  1 3) : 1 1% su ic id e at te m pt s (d ur in g tr ea tm en t) : a bf t: 1 1% (n = 1)   ef fe ct o ve r tim e n a va n de r sp ek e t al ., 20 24 d ep re ss ed an d/ or s ui ci da l yo ut h re fe rr ed to a n ou tp at ie nt cl in ic   c lin ic al as se ss m en t, de pr es si ve an d su ic id al sy m pt om s 25 17 .1 (n a , ra ng e: 1 2 23 ) 74 .2 % n et he r­ la nd s o pe n tr ia l a bf t: 1 6 w ee ks a bf t si q -j r c d i2 32 % a bf t: 8 9% c om pl et ed 10 o r m or e se ss io ns si q -j r: 36 .3 1 (1 1. 93 ) c d i2: 3 2. 07 (1 1. 48 ) tim e: 0 .7 2 [0 .0 9, 1 .3 5] * n a su ic id e at te m pt s (d ur in g tr ea tm en t) : a bf t: 1 4% (n = 4) ef fe ct o ve r tim e n a n ot e. ef fe ct s iz es fo r pr im ar y ou tc om es c al cu la te d as w ith in -g ro up e ff ec t o ve r tim e fo r th e a bf t g ro up (t im e) a nd b et w ee n gr ou ps a t p os ttr ea tm en t ( gr ou p) . s am pl e si ze (n ) r ep re se nt s th e to ta l n um be r of p ar tic ip an ts in cl ud ed in th e re sp ec tiv e tr ia l, th e nu m be r of a va ila bl e da ta po in ts p er m ea su re u se d to c al cu la te e ff ec t s iz es c an d ev ia te . a bf t in di ca te s va lu es fo r th e a bf t in te rv en tio n gr ou p, c on tr ol fo r th e co nt ro l g ro up r es pe ct iv el y. a tt ri tio n ra te w as c al cu la te d as th e nu m be r of d at ap oi nt s at p os ttr ea tm en t c om pa re d to b as el in e fo r th e si q (jr ) s ca le a s th e pr im ar y ou tc om e. a dh er en ce w as a ss es se d as th e am ou nt o f c om pl et ed tr ea tm en t s es si on s. b as el in e se ve ri ty r ep re se nt s ou tc om e st at is tic s fo r th e to ta l s am pl e es tim at ed fr om g ro up -w is e ba se lin e sc or es . a bf t = a tt ac hm en tba se d fa m ily t he ra py ; a bf tlg b = lg b se ns iti ve v ar ia nt o f a bf t ; a bf tlg t bq + = lg bt q + se ns iti ve v ar ia nt o f a bf t ; b d iii i = b ec k d ep re ss io n in ve nt or yii ; c d i2 = c hi ld re n’ s d ep re ss io n in ve nt or y 2nd e di tio n; e u c = e nh an ce d u su al c ar e; f en st = f am ily -e nh an ce d n on di re ct iv e su pp or tiv e tr ea tm en t; g ri d -h a m d = g ri d h am ilt on r at in g sc al e fo r d ep re ss io n; l g b = le sb ia n, g ay a nd b is ex ua l; m d d = m aj or d ep re ss iv e d is or de r; m d e = m aj or d ep re ss iv e ep is od e; n a = n ot a va ila bl e; s iq -j r = su ic id al id ea tio n q ue st io nn ai re -j un io r; s si = s ca le fo r su ic id al id ea tio n; t a u = t re at m en t a s u su al . a s tu di es in cl ud ed in th e m et aan al ys is . *c on fi de nc e in te rv al e xc lu di ng z er o in di ca tin g si gn if ic an ce o r p < .0 5. abft for suicidal youth: review and meta-analysis 8 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ the siq scale is a commonly applied self-administered questionnaire appropriate for adolescents around grade 10 – 12, consisting of 30 items measuring mental distress and suicidal intend. participants receive a list of “thoughts that people sometimes have” and are instructed to “indicate which of these thoughts [they] have had in the past month” on a scale from 0 “i never had this thought” to 6 “almost every day” (reynolds, 1987). the siq-jr scale is an adapted version of the siq, consisting of a 15-item subset appropriate for adolescents around grade 7 – 9 (reynolds & mazza, 1999). scores consist of summed item responses, thus ranging from 0 to 180 for the siq and 0 to 90 for the siq-jr respectively, with higher scores indicating higher levels of mental distress and suicidal intend. out of seven studies, four trials presented moderate to large within-group changes in siq(-jr) scores over time, g = 0.72 to 3.91 (g. m. diamond et al., 2012; g. s. diamond et al., 2002, 2019; van der spek et al., 2024). when compared with controls at post-treat­ ment, a significant difference between treatment and comparator groups was present in one out of four rcts, g = 0.83, 95% ci [0.30, 1.36], whereby the pooled effect size was large and reported to remain stable after 24 weeks (g. s. diamond et al., 2010). trials utilizing other comparators did not reveal significant group differences in siq(-jr) scores at post-treatment, and follow-up data was unavailable (g. s. diamond et al., 2002, 2019; waraan et al., 2021). a meta-analysis was performed on siq(-jr) scores. four trials (n = 287) were included in this synthesis, the results of which are depicted in figure 2. the pooled effect size was gpooled = 0.40 with a confidence interval including zero, 95% ci [-0.12, 0.93], indicating that siq(-jr) scores of participants in the abft conditions did not significantly differ from those in the associated control conditions at post-intervention. the prediction in­ terval spanning zero, 95% pi [-0.88, 1.69], suggests that abft will likely not benefit some patients in future trials with similar conditions based on current evidence. variation between effect sizes attributed to study heterogeneity was moderate, with i 2 = 26% and cochran’s q being non-significant, p = 0.25. visual inspection of the colour-enhanced funnel plot (appendix c, schulte-frankenfeld et al., 2024s-c) did not indicate asymmetry. a sensitivity analysis restricted to active-control trials (euc, fe-nst, tau) yielded similar results, gpooled = 0.42, 95% ci [-0.55, 1.39], i 2 = 51%, and cochran’s q being non-significant, p = 0.13. subgroup analyses were not performed due to the low number of included studies (cuijpers et al., 2021). since all studies also measured the intervention's effect on depressive symptoms, performing a secondary meta-analysis on bdi(-ii) scores was possible. the beck’s depression inventory (bdi) and its revised version, the bdi-ii scale, are widely used 21-item self-report rating inventories measuring characteristic attitudes and symptoms of depression (beck, 1961; beck et al., 1996). ratings per item range from 0 (not present) to 3 (strongly present) and scores are calculated by summing all item ratings, with higher scores indicating higher levels of depressive attitudes and symptoms. in this schulte-frankenfeld, breedvelt, brouwer et al. 9 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ meta-analysis of post-intervention bdi(-ii) scores across trials, the pooled effect size was gpooled = 0.33 with a confidence interval including zero, 95% ci [-0.18, 0.83], indicating that bdi(-ii) scores of participants in the abft condition did not significantly differ from those in the associated control conditions. the prediction interval includes zero, 95% pi [-0.83, 1.49]. heterogeneity was moderate, with i 2 = 24% and cochran’s q non-sig­ nificant, p = 0.27. a sensitivity analysis restricted to active-control trials (euc, fe-nst, tau) yielded similar results, gpooled = 0.23, 95% ci [-0.43, 0.88], i 2 = 2.8%, cochran’s q p = 0.36. discussion this study is the first to systematically review the efficacy of attachment-based family therapy (abft), a psychotherapeutic treatment for pediatric patients focussing on intra­ familial attachment dynamics, for treating youth who are suicidal. out of 370 records, four randomized-controlled trials (n = 287) and three open trials (n = 45) measuring suicidality were identified. in the meta-analysis covering four rcts, attachment-based family therapy was not superior in reducing suicidal ideation or depressive symptoms compared to investigated controls (waitlist, fe-nst, euc, tau), and these results re­ mained stable when restricting the analysis to active control interventions only. none­ theless, most studies (5 out of 7) reported significant reductions in suicidal ideation and depression within the abft treatment group over time. overall, experimental evidence is limited, with few available trials, small sample sizes, limited follow-up data, high sample heterogeneity, attrition rates, and risk of bias. figure 2 forest plot on the effect of abft versus control treatments for reducing siq(-jr) scores note. effect sizes for siq(-jr) scores calculated between groups at post-treatment as hartung-knapp corrected hedges’ g values. euc, enhanced usual care; fe-nst, family-enhanced nondirective supportive therapy; tau, treatment as usual. abft for suicidal youth: review and meta-analysis 10 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ currently, only four controlled trials including 287 participants exist, which might be insufficient to robustly establish or rule out superiority in a comparison with anticipated small effect sizes. follow-up data was only available for one out of four rcts, limiting the interpretability of clinical effects and their sustainability over time (g. s. diamond et al., 2010). a priori defined recruitment targets were only met in one trial, indicating that most studies were underpowered (g. s. diamond et al., 2019). loss-to-follow-up was heterogeneous, with one study exhibiting a pre-post loss rate of ~80% for the primary outcome (waraan et al., 2021). attrition rates in the other randomized-controlled trials were moderate (3%–18%) and in line with estimates from other psychotherapy trials for depression in children and youth (cooper & conklin, 2015; wright et al., 2021). siq(-jr) and bdi(-ii) scales were used in most trials to assess suicidality and depressive symptoms, introducing some risk of instrument bias. additionally, the siq(-jr) scale has recently been criticized for its insufficient psychometric properties (courtney et al., 2024). emerging evidence further suggests that severity of suicidal ideation strongly fluctuates short-term, for which multiple assessments might be necessary to measure state suicidality reliably (czyz et al., 2019; kleiman et al., 2017). there was also consid­ erable design heterogeneity between trials. two studies in the meta-analysis used the 12-week abft protocol, while others applied the treatment for 16 weeks. comparator treatments differed strongly, with trials using waitlist control, (enhanced) treatment as usual (euc, tau), or family-enhanced nondirective supportive therapy (fe-nst), which interestingly has been found to be effective for adult depression (cuijpers et al., 2012). actual type of treatment delivered was not assessed and adequately described in euc and tau trials, which might contribute to unexplained heterogeneity (burns, 2009; witt et al., 2018). further so, three out of four included rcts were conducted by researchers associated with the treatment development group. primary allegiance of care providing professionals was only reported in one rct, potentially introducing allegiance bias. unfortunately, extending the meta-analysis through subgroup analyses for hetero­ geneity factors was not feasible due to the limited number of included trials and lack of individual participant data. as a result, it was not possible to assess the respective impact of these sources of bias on the potential underestimation or overestimation of the comparative effect. narrative reviews of previous trials suggested that attachment-based family therapy might be more effective in reducing suicidal ideation and depressive symptoms in youth than the current standard of care, which was not confirmed by this meta-analysis (g. s. diamond et al., 2016, 2021; ewing et al., 2015). although restrained in validity due to the described limitations, these findings are in line with systematic reviews on the effect of other family-based interventions on depressive symptoms and a large meta-analysis on the effect of all-type treatments (e.g., medication, psychotherapy, combined) on several measures of suicidality (e.g., ideation, (non-)suicidal self-injury, death) in adolescents, which neither found significant treatment effects, regardless of outcome measure and schulte-frankenfeld, breedvelt, brouwer et al. 11 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ intervention type (harris et al., 2022; van aswegen et al., 2023; waraan et al., 2023). simi­ lar patterns can be observed with treatments for youth depression, which generally tend to yield lower effects than interventions for adults, and to which a substantial amount of patients do not respond within time (cuijpers et al., 2020, 2023). for preventative approaches, data availability is currently strongly limited, and individual reports suggest that universal approaches might even lead to adverse effects on at-risk youth (breedvelt et al., 2018; montero-marin et al., 2022). in contrast to these results, it should be noted that one other meta-analysis did identify a small positive effect of various family-based interventions on youth suicidal ideation, which upon closer inspection appears to be due to a discrepancy in data extraction for one specific trial (waraan et al., 2023). as retrieving underlying data from this meta-analysis was not possible, we verified our ex­ tracted data with the author team of the trial in question to ensure correctness. overall, effectiveness of current treatment options for youth suicidality is strongly limited and a major concern in pediatric healthcare. considering the high burden of disease implicated by continued suicidal ideation, attempts, and completed suicide in youth, developing more effective treatments is im­ perative. previous discussions of this challenge suggested that integrating insights on the dynamics of youth, characterized by strong psychological, biological, and social vo­ litions, might improve efficacy (harris et al., 2022; robinson et al., 2018). while attach­ ment-based family therapy was, in contrast to more commonly applied psychological interventions (e.g., cognitive behavioral therapy, dialectical behavior therapy), devel­ oped explicitly for a pediatric population, it being non-superior to compared alternative treatments raises the question if other factors, such as patient baseline characteristics or therapeutic modalities, might influence treatment efficacy. recent investigations on moderating factors in previous abft trials suggest, that patients with higher baseline levels of parent-teen conflict and underserved family backgrounds particularly benefit from treatment, and that more change in family cohesion during the intervention period was related to better treatment outcomes (ibrahim et al., 2022; zisk et al., 2019). target­ ing attachment-based family therapy at high-yield subgroups, e.g., lgbtqi+ youth with non-accepting parents, could thus be beneficial (g. m. diamond et al., 2022; russon et al., 2023). another area of improvement could be to intensify treatment components contributing to family cohesion, and disrupt negative feedback dynamics early on by e.g. implementing supervised exposure exercises to reduce patients’ fear of the caregiver’s emotional rejection (bosmans et al., 2022). other reviews pointed out that participants with higher baseline levels of depression, non-suicidal self-injury, perceived burdensome­ ness, and anxiety profited less from the treatment (abbott et al., 2019; herres et al., 2021). this might indicate that other interventions could have suited these patients better, or that sequential or multimodal approaches addressing their comorbidities and family dy­ namics simultaneously might have had better effects, e.g., combining attachment-based family therapy and cognitive behavioral therapy for patients with anxiety (herres abft for suicidal youth: review and meta-analysis 12 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ et al., 2023). considering given evidence for moderating factors, it is thus conceivable that abft might potentially lead to better treatment outcomes compared to the current standard of care when applied to patients whose condition is strongly linked to dynamics of intrafamilial relations, and whose comorbid disorders are concurrently addressed – that is, when the right patient receives the right treatment at the right time. given the limitations of current evidence on the efficacy of attachment-based family therapy for treating youth who are suicidal, future research should focus on delivering high-quality evidence with more adequately powered samples, longer follow-up times, and more consistent and rigorous measurements. at the time of review, two adequately powered randomized-controlled clinical trials evaluating its performance and cost-effec­ tiveness were registered at clinicaltrials.gov (bockting et al., 2023; pachankis et al., 2023). additionally, with the weight of evidence suggesting that abft yields varying degrees of benefit for different patient groups – on average not exceeding the effective­ ness of alternative interventions such as tau or fe-nst – a better understanding of underlying active ingredients and treatment-induced mechanisms of change might be helpful to dismantle contexts and conditions under which specific treatment components lead to better treatment outcomes (cuijpers et al., 2019; hofmann & hayes, 2019). pre­ viously, limited evidence for the role of therapeutic alliance as a common factor, and guided emotional processing, improved parenting, and reattachment as treatment-specif­ ic factors was found (g. s. diamond et al., 2021). future research could further focus on disentangling these specific factors from common factors also activated in alternative treatments such as tau or fe-nst, understanding the underlying processes of change involved, identifying therapeutic components that activate these changes in a cost-effi­ cient manner, and providing clinicians with informed guidelines on implementing these components within a process-based therapy framework (hofmann & hayes, 2019; rief et al., 2024). finally, a key challenge is to establish predictive factors for when individual treat­ ment components of attachment-based family therapy might be feasible for a patient. while tailoring therapy plans and manualized treatments to the needs of individual patients and their presenting condition is common practice among clinicians, the appli­ cation of prediction and personalization models in research remains scarce (meehan et al., 2022). meanwhile, research indicates that such personalized medicine approaches could result in substantial benefits for patients, and it might therefore be valuable to investigate further ‘what works for whom’ when it comes to dynamicity-embracing treatments for suicidal youth (deisenhofer et al., 2024; derubeis et al., 2014; robinson et al., 2018). ultimately, prioritizing investment into larger cohort studies and analyses of individual patient data to develop and improve targeted preventative approaches in adolescence is crucial, as this special developmental stage provides a unique window of opportunity to stimulate long-lasting positive life trajectories (breedvelt et al., 2018, 2024; dahl et al., 2018). schulte-frankenfeld, breedvelt, brouwer et al. 13 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://www.psychopen.eu/ funding: cb is funded by the centre for urban mental health, university of amsterdam, amsterdam, the netherlands. the funding source was not involved in any processes or decisions related to this study. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: gb is head and founder of the ku leuven attachment-based family therapy (abft) training centre. all other authors report no conflict of interest. preregistration: this systematic review was preregistered at the international prospective register of systematic reviews, prospero: crd42021271731. reporting guidelines: this systematic-review and meta-analysis was conducted in accordance with the prisma guidelines. the cochrane rob-2 framework was applied to assess the risk of bias in randomized-controlled trials. author contributions: cb is the guarantor. all authors contributed to the development of the research question and review design. ps performed the search, review, data extraction, analysis, and drafted the manuscript. mb provided expertise on systematic reviews, contributed to the review of articles, and verified extracted data. jb provided expertise on meta-analyses, verified extracted data and analysis, and contributed to the manuscript. ns and gb provided expertise on the intervention. all authors contributed by reading, providing feedback, and approving the final manuscript. social media accounts: @poschfeld, @josefienumh, @clbockting, @mebrouwer abbreviations:   abft – attachment-based family therapy cbt – cognitive behavioral therapy dbt – dialectical behavior therapy euc – enhanced usual care fe-nst – family-enhanced nondirective supportive therapy tau – treatment as usual data availability: all data and calculation scripts for this study are publicly available (see schulte-frankenfeld et al., 2024s-b). supplementary materials the supplementary materials contain the following items: • the preregistration for the study (schulte-frankenfeld et al., 2024s-a). • all collected summary statistics per study, analysis scripts, and a list of all articles screened (schulte-frankenfeld et al., 2024s-b) • online appendices: additional information on the meta-analysis, namely detailed risk-of-bias scores per study and category, weighted overall risk-of-bias scores, and a color-enhanced funnel abft for suicidal youth: review and meta-analysis 14 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://x.com/poschfeld https://x.com/josefienumh https://x.com/clbockting https://x.com/mebrouwer https://www.psychopen.eu/ plot on the distribution of effect sizes of included studies [supplements 1] (schulte-frankenfeld et al., 2024s-c). index of supplementary materials schulte-frankenfeld, p. m., breedvelt, j. j. f., brouwer, m. e., van der spek, n., bosmans, g., & bockting, c. l. (2024s-a). the effectiveness of attachment-based family therapy for suicidal adolescents and young adults: a systematic review and meta-analysis [preregistration]. prospero. https://www.crd.york.ac.uk/prospero/display_record.php?id=crd42021271731 schulte-frankenfeld, p. m., breedvelt, j. j. f., brouwer, m. e., van der spek, n., bosmans, g., & bockting, c. l. (2024s-b). attachment-based family therapy for suicidal adolescents and young adults: a systematic review and meta-analysis [summary statistics, analysis scripts, list of screened articles]. osf. https://doi.org/10.17605/osf.io/2swe8 schulte-frankenfeld, p. m., breedvelt, j. j. f., brouwer, m. e., van der spek, n., bosmans, g., & bockting, c. l. 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(2019). parent–teen communication predicts treatment benefit for depressed and suicidal adolescents. journal of consulting and clinical psychology, 87(12), 1137–1148. https://doi.org/10.1037/ccp0000457 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. schulte-frankenfeld, breedvelt, brouwer et al. 23 clinical psychology in europe 2024, vol. 6(4), article e13717 https://doi.org/10.32872/cpe.13717 https://doi.org/10.1177/1359104520980776 https://doi.org/10.1177/13591045221125005 https://doi.org/10.21105/joss.01686 https://doi.org/10.1016/j.jad.2018.04.025 https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death https://doi.org/10.1016/j.jad.2020.11.039 https://doi.org/10.1002/14651858.cd201901 https://doi.org/10.1037/ccp0000457 https://www.psychopen.eu/ abft for suicidal youth: review and meta-analysis (introduction) method search strategy and selection criteria data extraction and statistical analysis results study selection study characteristics effect sizes and meta-analyses discussion (additional information) funding acknowledgments competing interests preregistration reporting guidelines author contributions social media accounts abbreviations data availability supplementary materials references all i want for christmas is a loo: visualizations of sex and gender on toilet doors editorial all i want for christmas is a loo: visualizations of sex and gender on toilet doors judith rosmalen 1,2 , ilona plug 3 , aranka ballering 1 [1] department of psychiatry, university medical center groningen, university of groningen, groningen, the netherlands. [2] department of internal medicine, university medical center groningen, university of groningen, groningen, the netherlands. [3] department of communication and cognition, tilburg school of humanities and digital sciences, university of tilburg, tilburg, the netherlands. clinical psychology in europe, 2024, vol. 6(4), article e16159, https://doi.org/10.32872/cpe.16159 published (vor): 2024-12-20 corresponding author: aranka ballering, interdisciplinary center psychopathology and emotion regulation (icpe), department of psychiatry, university medical center groningen, p.o. box 30.001, internal code cc72, 9700 rb, groningen, the netherlands. e-mail: a.v.ballering@umcg.nl supplementary materials: data, materials [see index of supplementary materials] preface ah, christmas eve. a time for carols, cozy fires, and, of course, culinary excellence. you’ve secured a reservation at one of your city’s best restaurants, ready to pamper your taste buds with gastronomic delights, until it all takes an unexpected turn. you want to run from the table and not because of your eating companion’s endless debates. rather, your gut is staging a revolt, hinting at an encore performance of your prawn appetizer. channeling your inner olympic sprinting champion, you run to the restroom, breaking records and social decorum alike. and now, in front of the restroom doors, you face the ultimate dilemma: which door to choose? while your gut is rumbling along with mariah carey’s song playing in the background, you can only think: “all i want for christmas is a clue…” we are all confronted with the importance of a nuanced understanding of both sex and gender when facing a toilet door in dire times, but this day-to-day realization does not always find its way into the realm of health research (ballering et al., 2023). although health-related research is becoming increasingly sex-sensitive (i.e., attentive towards the biology of intersex, male, and female bodies), sensitivity towards gender (i.e., attentiveness towards psychosocial factors related to being a woman, man, or non-binary identity) in research remains scarce (ballering et al., 2024). this is problematic, as it ham­ this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.16159&domain=pdf&date_stamp=2024-12-20 https://orcid.org/0000-0002-6393-0032 https://orcid.org/0000-0002-5429-7810 https://orcid.org/0000-0002-3491-8990 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ pers the validity of conclusions drawn from these studies, as recent studies show that sex and gender independently affect health outcomes (ballering et al., 2020; mauvais-jarvis et al., 2020). multiple resources are available to increase sex and gender-sensitivity in research, with the sager guidelines being most prominent (heidari et al., 2016). however, we consider one key resource to be underused in raising gender-sensitivity in research: toilets. after all, we all choose on a daily basis which toilet door to open. this sensitivity to (the difference between) sex and gender in daily life, is ought to find its way to health research. therefore, this study identified visual loo clues on toilet doors that guide the decision on which toilet to enter. we thematically analyzed, and subsequently quanti­ fied, whether these clues are related to sex or gender. we aim to sharpen the reader’s understanding of sex and gender, thus facilitating increased sex and gender sensitivity in research. also, this will aid readers so that the next time they find themselves in front of those puzzling restroom doors, they confidently choose the clue for the right loo without breaking a sweat (or a sprinting record). method data collection we collected pictures of international toilet doors in the period of 2020 to 2022. initially, we visited and photographed as many toilet doors as possible whenever we were outside of our homes. we did not seek permission from an ethical committee, nor from the owners of the toilet doors. consequently, we had to endure confused looks of others while we were taking these pictures – ah, the things we do in the name of science. we also searched online using a search string in google containing commonly used dutch and english variants of the terms ‘toilet door(s)’, ‘toilet door sticker(s)’, toilet icon(s)’ and ‘toilet entrance’. duplicates were defined as different doors having exactly the same visual clues; these were excluded from the analyses. all raw visual data are available from osf (rosmalen et al., 2024s-a). coding of visual decision clues as related to sex and/or gender each set of toilet doors was independently analyzed by three female coders (mean age 35 [sd = 13.9]). the coders identified all visual elements on a given set of toilet doors that would aid the decision of which door to open in times of need. in some cases, predominantly for gender-neutral or gender-inclusive toilet doors, there was only one door to assess. open coding of visual elements was used, followed by a thematic analysis. consensus discussion resulted in a final definition of the visual clues per toilet door. visual clues were considered neutral, if these did not consistently represent either sex or gender, or as referring to either sex or gender. the three coders extensively visualizations of sex and gender on toilet doors 2 clinical psychology in europe 2024, vol. 6(4), article e16159 https://doi.org/10.32872/cpe.16159 https://www.psychopen.eu/ discussed all themes in order to reach consensus on their categorization as neutral, sex, or gender clues. interrater agreement was assessed by means of free-marginal multi-rater kappa using the online kappa calculator (http://justusrandolph.net/kappa/). the overall agreement between the three raters was 85.5%; the free-marginal kappa was 0.78 (95% ci [0.61, 0.95]). analysis ms office excel was used to analyze the total number of clues and per set of doors. results study sample appendix 1 in the supplementary materials shows the prisma statement. our final study sample included 97 sets of toilet doors. of these doors, six were sex-or-gender-neu­ tral (i.e., not specifically related to women or men), unisex (i.e., specifically related to both female and male individuals) or even universal with visual clues that moved beyond sex and gender, as these depicted aged people, tattooed people, queer people, the grim reaper, people with various religions, aliens, fairies and mermaids. thematic analysis on the 97 doors, we identified a total of 260 visual decision clues that were categorized in 23 themes. the minimum and maximum number of clues per door were 1 and 8, with a median of 2 (iqr 1-4). the 23 themes were subdivided into neutral (n = 2), or related to sex (n = 9) or gender (n = 12). the identified visual themes and concomitant frequencies can be found in appendix 2. of the 260 clues, 52.7% were gender-related and 30.0% were sex-related. the remain­ ing 17.3% included text and icons that were categorized as neutral. sex clues were found on 54.1% of all doors, gender clues on 72.4%. neutrality and naughty nomenclature two themes, namely text elements and icons, were coded as neutral, since these did not consistently represent either sex or gender. textual sex clues included variants of ‘male-female’ or synonyms in different languages (e.g., ‘miehet-naiset’, ‘femei-barbati’ or ‘vrouwtjes-mannetjes’), or in different species (e.g., ‘bulls-cows’). we also categorized the text element ‘sausage-eggs’ as a sex clue, assuming that decision clues on toilet doors are not reflecting food preferences. gendered textual clues include names (‘adam-eve’), cognitions (‘shopping-football’), communication (‘bla-blablablabla’), and assumed capa­ bilities (‘men to the left, because women are always right’)1. rosmalen, plug, & ballering 3 clinical psychology in europe 2024, vol. 6(4), article e16159 https://doi.org/10.32872/cpe.16159 http://justusrandolph.net/kappa/ https://www.psychopen.eu/ icons predominantly included symbolic representations of the male and female repro­ ductive organs (i.e., sex; figure 1). discussion was required for the doors in figure 1b that contain a sophisticated symbol of the words used; an n = 1 pilot test in a young man suggested that these clues on the toilet door would take up too much time than preferred. one of the authors did not understand these doors either until the consensus discussion; as a linguist she interpreted these doors as representing gendered behavior: cocky (i.e., men-like) and catty (i.e., women-like). figure 1 toilet doors with icons a b c d e f peeing with precision and the angle of male confidence some visual clues required some more extensive discussion. an example hereof is the urinary stream theme (figure 2). we initially assumed that the urinary stream was a sex clue, since it would be related to anatomical characteristics of men and women. however, it appeared more complex. we assessed the initial angle of the male urinary stream, based on the visual prostate symptom score (vpss) (stothers et al., 2017). most male icons in figure 2 depicted an angle that exceeds the highest possible score on the vpss, namely a strong horizontal or even sky-facing stream. potentially, this indicates male (over)confidence, which would be gender-related. a validated female equivalent of the vpss is unfortunately not known to the authors. however, we noted a women-specific aspect that might influence a urinary stream: the women sit, bend and even jump while peeing (figure 2). we hypothesize that this is due to the female practice of urinating without trying to touch the public toilet seat, which may be related to gender. 1) clearly, the three coders, who identify as women, fully agree with the assumptions made on this toilet door. visualizations of sex and gender on toilet doors 4 clinical psychology in europe 2024, vol. 6(4), article e16159 https://doi.org/10.32872/cpe.16159 https://www.psychopen.eu/ figure 2 urinary streams a b c d e a case of the jingle balls a second example that required somewhat more extensive discussion on the sex versus gender dimension of visual clues on toilet doors is provided in figure 3. we initially assumed that the text element ‘balls-no balls’ in figure 3a referred to sex (or potential­ ly to how to decorate a christmas tree). however, when studying doors with more direct graphical representations of balls, our interpretation appeared to be incorrect: figure 3b shows similar balls for him and her, figure 3c shows similar numbers of balls but qualitative differences, and figure 3d suggests that no balls refers to men, which contrasts with figure 3a. since all graphical representations show that women have at least as many, or even more, balls than men, we assume that ‘balls-no balls’ in figure 3a refers to feminine gender and masculine gender respectively, in which case we -as three womenwould like to point out that the owner of the doors misplaced the male/female icons. discussion our study found that loo clues are primarily based on gender, as 52.7% of the clues depicted on toilet doors related to gender, while 30.0% related to sex. twelve of the 23 rosmalen, plug, & ballering 5 clinical psychology in europe 2024, vol. 6(4), article e16159 https://doi.org/10.32872/cpe.16159 https://www.psychopen.eu/ identified themes related to gender and nine related to sex. clues related to gender were found on 72.4% of the included toilet doors and sex clues on 54.1%. figure 3 toilet doors with balls a b c d before interpreting our results, the following limitations need to be taken into account. first of all, data collection was performed by three women. we assume this has not influ­ enced the offline search strategy, since we collected visual clues outside of the restrooms. one could argue that the female-oriented online search histories would have influenced the online search results, but the searches were done on computers that were also used by men. secondly, selection bias may have occurred: it is likely that either extremely gendered or sexed toilet doors that were considered funny or interesting enough to be put online were found via our online searches. lastly, the embodiment of gender, and what is considered feminine and masculine, depends strongly on time, place, and culture potentially affecting the interpretation of loo clues. to the best of our knowledge, little to no previous studies have systematically as­ sessed and quantified the clues present on toilet doors with regards to differentiating sex and gender (iio, 2023). it has been previously argued that many toilet signs have a symbolic function (iio, 2019). in our study, the majority of signage does not depict the visualizations of sex and gender on toilet doors 6 clinical psychology in europe 2024, vol. 6(4), article e16159 https://doi.org/10.32872/cpe.16159 https://www.psychopen.eu/ toilet itself (only 4 clues) or the activity of using the facility (7 clues related to urinary stream and 10 to urinating position, often combined). therefore, the signage of toilets frequently involves learned behavior and culturally accepted conventions that tie closely with gendered segregation of men and women, and use of toilet facilities (ciochetto, 2003). previous research argues that explicitly showing the act of urinating or defecating it­ self is seldom reflected in toilet signage. potentially, this may be culturally inappropriate (ciochetto, 2003). however, our results contrast with this view. especially with regards to the vpss, the results also suggest that toilets are not very inclusive for men with prostate problems. this may be attributed to the stoicism related to masculinity, which results in men not easily admitting physical complaints or bodily disturbances (ballering et al., 2021; maclean et al., 2010). toilet signage involving men with prostate problems may not be attractive for men without problems. we conclude that current toilet signage predominantly uses gender clues to indicate who should enter. further studies could investigate the amount of time it takes to make a decision based on sex and gender clues, in relation to attitudes towards sex and gender characteristics. as a practical implication, we suggest for all to take a second look at the loo clues and try to identify the sex and/or gender clues before entering a toilet, if the urgency allows the time investment2. this facilitates a learning experience about the difference between sex and gender and may subsequently increase sex and gender sensitivity in research as well. but, perhaps more importantly, you can now enjoy your holiday dinner in peace, knowing that the only dilemma left to solve this christmas is whether to indulge in another slice of pie—without a hint of restroom anxiety in sight. 2) if the urgency is relatively low, please consider snapping pictures of interesting toilet doors and send these to the corresponding author. especially doors with christmas trees, santa claus, and reindeers are very welcome. rosmalen, plug, & ballering 7 clinical psychology in europe 2024, vol. 6(4), article e16159 https://doi.org/10.32872/cpe.16159 https://www.psychopen.eu/ funding: jr, ab and ip have received funding from zonmw (gender and health project number 849200013), ab additionally received funding from zonmw (project number: 849800001, 50018423 and 04520232330002). acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have no conflicts of interest to declare. author contributions: jr had the original idea, conducted the statistical analysis and wrote a first draft of the article. jr, ip and ab together conducted the qualitative analysis. ip and ab helped to interpret results. ab edited the final version of the paper. ethics statement: the study used routinely collected, non-identifiable data, and ethics approval was not required. data availability: all raw visual data are available from osf (see rosmalen et al., 2024s-a). supplementary materials the supplementary materials contain the following items: • all raw visual data (rosmalen et al., 2024s-a) • the online appendices (rosmalen et al., 2024s-b): ◦ appendix 1: prisma flow chart ◦ appendix 2: frequency and categorization of the identified themes on toilet doors index of supplementary materials rosmalen, j., plug, i., & ballering, a. (2024s-a). all i want for christmas... [research data]. osf. https://osf.io/gyqek/ rosmalen, j., plug, i., & ballering, a. (2024s-b). supplementary materials to "all i want for christmas is a loo: visualizations of sex and gender on toilet doors" [online appendices]. psychopen gold. https://doi.org/10.23668/psycharchives.15751 references ballering, a. v., bonvanie, i. j., olde hartman, t. c., monden, r., & rosmalen, j. g. m. (2020). gender and sex independently associate with common somatic symptoms and lifetime prevalence of chronic disease. social science & medicine, 253, article 112968. https://doi.org/10.1016/j.socscimed.2020.112968 ballering, a. v., burke, s. m., maeckelberghe, e. l. m., & rosmalen, j. g. m. (2023). how to ensure inclusivity in large-scale general population cohort studies? lessons learned with regard to including and assessing sex, gender, and sexual orientation. archives of sexual behavior, 52(5), 2163–2172. https://doi.org/10.1007/s10508-023-02600-y visualizations of sex and gender on toilet doors 8 clinical psychology in europe 2024, vol. 6(4), article e16159 https://doi.org/10.32872/cpe.16159 https://osf.io/gyqek/ https://doi.org/10.23668/psycharchives.15751 https://doi.org/10.1016/j.socscimed.2020.112968 https://doi.org/10.1007/s10508-023-02600-y https://www.psychopen.eu/ ballering, a. v., muijres, d., uijen, a. a., rosmalen, j. g. m., & olde hartman, t. c. (2021). sex differences in the trajectories to diagnosis of patients presenting with common somatic symptoms in primary care: an observational cohort study. journal of psychosomatic research, 149, article 110589. https://doi.org/10.1016/j.jpsychores.2021.110589 ballering, a. v., olde hartman, t. c., & rosmalen, j. g. m. (2024). gender scores in epidemiological research: methods, advantages and implications. the lancet regional health – europe, 43, article 100962. https://doi.org/10.1016/j.lanepe.2024.100962 ciochetto, l. (2003). toilet signage as effective communication. visible language, 37(2), 208–221. heidari, s., babor, t. f., de castro, p., tort, s., & curno, m. (2016). sex and gender equity in research: rationale for the sager guidelines and recommended use. research integrity and peer review, 1, article 2. https://doi.org/10.1186/s41073-016-0007-6 iio, j. (2019). the semiotics of toilet signs. in m. kurosu (ed.), human-computer interaction: design practice in contemporary societies (pp. 285–293). https://doi.org/10.1007/978-3-030-22636-7_20 iio, j. (2023). the restroom sign database. bulletin of human centered design organization, 19(1), 57–62. https://doi.org/10.34404/hcd.19.1_57 maclean, a., sweeting, h., & hunt, k. (2010). ‘rules’ for boys, ‘guidelines’ for girls: gender differences in symptom reporting during childhood and adolescence. social science & medicine, 70(4), 597–604. https://doi.org/10.1016/j.socscimed.2009.10.042 mauvais-jarvis, f., bairey merz, n., barnes, p. j., brinton, r. d., carrero, j.-j., demeo, d. l., de vries, g. j., epperson, c. n., govindan, r., klein, s. l., lonardo, a., maki, p. m., mccullough, l. d., regitz-zagrosek, v., regensteiner, j. g., rubin, j. b., sandberg, k., & suzuki, a. (2020). sex and gender: modifiers of health, disease, and medicine. lancet, 396(10250), 565–582. https://doi.org/10.1016/s0140-6736(20)31561-0 stothers, l., macnab, a., bajunirwe, f., mutabazi, s., & lobatt, c. (2017). comprehension and construct validity of the visual prostate symptom score by men with obstructive lower urinary tract symptoms in rural africa. canadian urological association journal, 11(11), e405–e408. https://doi.org/10.5489/cuaj.4589 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. rosmalen, plug, & ballering 9 clinical psychology in europe 2024, vol. 6(4), article e16159 https://doi.org/10.32872/cpe.16159 https://doi.org/10.1016/j.jpsychores.2021.110589 https://doi.org/10.1016/j.lanepe.2024.100962 https://doi.org/10.1186/s41073-016-0007-6 https://doi.org/10.1007/978-3-030-22636-7_20 https://doi.org/10.34404/hcd.19.1_57 https://doi.org/10.1016/j.socscimed.2009.10.042 https://doi.org/10.1016/s0140-6736(20)31561-0 https://doi.org/10.5489/cuaj.4589 https://www.psychopen.eu/ visualizations of sex and gender on toilet doors preface method data collection coding of visual decision clues as related to sex and/or gender analysis results study sample thematic analysis neutrality and naughty nomenclature peeing with precision and the angle of male confidence a case of the jingle balls discussion (additional information) funding acknowledgments competing interests author contributions ethics statement data availability supplementary materials references structured diagnostic interviews in psychotherapy training: trainees’ beliefs about interviews and their relationship to overall interview satisfaction research articles structured diagnostic interviews in psychotherapy training: trainees’ beliefs about interviews and their relationship to overall interview satisfaction sebastian palmer 1,2 , bertram walter 1 , christiane hermann 2,3 , rudolf stark 1,2 , andrea hermann 1,2 [1] department of psychotherapy and systems neuroscience, justus liebig university giessen, giessen, germany. [2] cognitive-behavioral psychotherapy outpatient clinic, justus liebig university giessen, giessen, germany. [3] department of clinical psychology, justus liebig university giessen, giessen, germany. clinical psychology in europe, 2025, vol. 7(4), article e17321, https://doi.org/10.32872/cpe.17321 received: 2025-03-18 • accepted: 2025-08-27 • published (vor): 2025-11-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: sebastian palmer, cognitive-behavioral psychotherapy outpatient clinic, justus liebig university giessen, südanlage 30, 35390 giessen, germany. phone: +49 641 99 26547. e-mail: sebastian.palmer@psychol.uni-giessen.de supplementary materials: materials, preregistration [see index of supplementary materials] abstract background: structured diagnostic interviews (sdis) are frequently used in science and are highly recommended for diagnosing mental disorders in clinical practice. however, the actual sdi familiarity and use among psychotherapy practitioners is limited. to identify opportunities for training improvement and ensure a frequent sdi application by future practitioners, data on sdi experiences and beliefs among current psychotherapy trainees is essential. method: n = 233 psychotherapy trainees completed an online survey that included questions about their sdi experiences, use, beliefs, and their estimation of patient sdi satisfaction and acceptance. in addition, adherence to psychotherapeutic orientation and personality factors were assessed. correlation between sdi satisfaction and familiarity was computed. multiple linear regression analysis was performed to predict trainees’ sdi satisfaction by beliefs about sdis. exploratory correlations between sdi satisfaction, adherence to psychotherapeutic orientations, and personality factors were analyzed. results: sdi familiarity was significantly related to trainees’ overall sdi satisfaction. both positive (e.g., “sdis are efficient”) and negative (e.g., “sdis disturb the relationship to patients”) beliefs this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.17321&domain=pdf&date_stamp=2025-11-28 https://orcid.org/0000-0002-5567-2897 https://orcid.org/0000-0003-0254-5322 https://orcid.org/0000-0001-5969-2898 https://orcid.org/0000-0003-4299-5280 https://orcid.org/0000-0003-3186-7777 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ about sdis predicted trainees’ overall satisfaction. small relationships were found between sdi satisfaction and adherence to psychotherapeutic orientation, but none to personality factors. conclusion: psychotherapy training programs should provide sufficient opportunity for sdi practice to promote trainee satisfaction. training providers should address trainees’ beliefs and concerns, underline advantages of sdis, and inform about actual sdi acceptance among patients to resolve prejudice. trainees’ personality appears to be less relevant to sdi satisfaction, but further investigations are needed. the findings have important implications for overcoming barriers to the use of structured diagnostic interviews. keywords structured diagnostic interviews, psychotherapy training, interview satisfaction, psychotherapeutic orientation, personality highlights • most psychotherapy trainees encounter sdis, but experiences and use vary. • trainees’ level of sdi satisfaction is medium on average, but it positively relates to familiarity. • satisfaction is higher when sdis are viewed as reliable and efficient. • the views that sdis are confusing and threaten the therapeutic relationship raise dissatisfaction. diagnostic decisions of mental health practitioners often deviate from the criteria of classification systems, increasing the risk for inaccurate diagnoses and suboptimal treat­ ment recommendations (rettew et al., 2009; wolkenstein et al., 2011; zimmerman & mattia, 1999). structured diagnostic interviews (sdis) have been repeatedly proposed as a standard procedure to help diagnostic decision-making (basco et al., 2000; joiner et al., 2005; miller et al., 2001). while broader sdis, such as the structured clinical interview for dsm-5 (scid-5, first et al., 2016) assess a range of diagnoses, diagnosis-specific sdis, like the clinician-administered ptsd scale for dsm-5 (caps, weathers et al., 2013) focus on a single disorder. previous evidence indicates that sdis have high reliability, validity, and acceptance among patients (margraf et al., 2017; neuschwander et al., 2017; osório et al., 2019; suppiger et al., 2009). despite the advantages of sdis, a substantial number of clinicians refrains from their regular use in clinical practice (bruchmüller et al., 2011; cook et al., 2017; hatfield & ogles, 2004; jensen-doss & hawley, 2010). a survey by bruchmüller et al. (2011) on the sdi practices of licensed psychotherapists revealed that, on average, sdis are used in only 15% of patient encounters. the most common arguments against the use of sdis include their lack of usefulness compared to clinicians’ own judgement, their length, and their potential harm to the therapeutic relationship, all of which predicted practitioners’ actual use of sdis. in light of the acceptance and satisfaction rates among patients trainees’ beliefs about structured interviews 2 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ (suppiger et al., 2009), bruchmüller et al. (2011) concluded that practitioners tend to overestimate the negative and underestimate the positive impact of sdis. interestingly, actual knowledge of sdis among practitioners is limited. more than a third of the bruchmüller et al. (2011) sample was barely or not at all familiar with sdis, with sdi familiarity predicting sdi use. similarly, cook et al. (2017) found that practitioners who predominantly endorsed unstructured assessment practices were less likely to report training in standardized assessment, including standardized diagnostic interviews. these findings suggest that implementation of sdis into early professional training is not only important for fostering competence, but also for ensuring their regu­ lar use. psychotherapy training guidelines consider assessment competencies as crucial, yet they do not necessarily recommend specific diagnostic methods (hatcher et al., 2013; wright, 2022). surveys among psychotherapy trainees and training providers indicate that a considerable number of trainees do not receive formal practical sdi training (ingram et al., 2022; mihura et al., 2017; ponniah et al., 2011). accordingly, there is a need for information about trainees’ actual experiences with and beliefs about sdis that may help identifying facilitators and barriers to sdi training. another finding from the bruchmüller et al. (2011) study is that a primary orientation in cognitive-behavioral therapy (cbt) positively predicted sdi use. most likely, this is accounted for by cbt therapists’ more positive attitude towards symptom-based classification systems (raskin et al., 2022). additionally, the preferred theoretical orienta­ tions of psychotherapists have been found to be related to their personality. poznanski and mclennan (2003) reported higher neuroticism in psychodynamic psychotherapists compared to cbt therapists, whereas the latter showed lower levels of openness. ogunfowora and drapeau (2008) found that conscientiousness positively predicted a cbt orientation in psychotherapy students and psychotherapists. to clarify whether trainees’ personality not only relates to broader theoretical orientation preferences, but also to evaluations of sdis directly, a combined investigation is necessary. results could inform the development of sdi training schedules that consider trainees’ individual differences, especially with respect to their personality. as personality has been shown to relate to professional development and well-being throughout training (chapman et al., 2009; evers et al., 2019), it might also be worth considering it when training and supervising student therapists in conducting an sdi. building upon previous findings on sdi practices and beliefs of practitioners (bruchmüller et al., 2011; cook et al., 2017), the present study investigated experiences with sdis among german psychotherapy trainees. participants completed an online survey on their sdi use, overall satisfaction, their beliefs about sdis, their estimation of patients’ sdi satisfaction and acceptance, as well as personality factors and adherence to psychotherapeutic orientations. extending the findings by bruchmüller et al. (2011), the present study examined the relationships of psychotherapy trainees’ overall sdi palmer, walter, hermann et al. 3 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ satisfaction with specific positive and negative beliefs about sdis and sdi familiarity. the following main hypotheses were tested: 1. there is a significant relationship between overall sdi satisfaction and sdi familiarity. 2. overall sdi satisfaction is related to psychotherapy trainees’ agreement to positive and negative beliefs about sdis. in addition, exploratory analyses were performed to investigate the relationship between trainees’ sdi satisfaction, their adherence to psychotherapeutic orientations, and person­ ality factors. method participants participants were recruited among training institutions for post-graduate psychotherapy training in germany (for further information see procedure). figure 1 shows participant flow. figure 1 participant flow chart excluded for analyses (n = 20) • unusual values (n = 2) • incorrect answer to careless response check (n = 18) began survey (n = 309) completed survey (n = 253) premature discontinuation and exclusion (n = 56) • terminated by participant (n = 50) • not enrolled in psychotherapy training (n = 2) • unfamiliar with term „structured diagnostic interview“ (n = 4) analysed (n = 233) the final sample for analysis consisted of n = 233 psychotherapy trainees. the mean age was m = 31.05 years (sd = 5.72). on average, participants were enrolled for m = 3.05 (sd = 2.02) years into their current training program and had m = 3.96 (sd = 3.39) years trainees’ beliefs about structured interviews 4 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ of experience in working with patients, with six participants reporting no prior patient experience. for further participant information see table 1. table 1 demographic and training information of psychotherapy trainees variable n % gender female 202 86.7 male 30 12.9 diverse 1 0.4 type of training psychological psychotherapy 171 73.4 child and adolescent psychotherapy 61 26.2 other 1 0.4 training orientation behavioral therapy 208 89.3 psychodynamic psychotherapy 10 4.3 psychoanalytic psychotherapy 2 0.9 systemic psychotherapy 9 3.9 more than one orientation 4 1.7 study course prior to training psychology 204 87.6 medicine 1 0.4 social pedagogy 11 4.7 educational sciences 12 5.2 other 10 4.3 type of training institute university-based 119 51.1 private 112 48.1 other 2 0.9 note. n = 233. surveys and measurements at the beginning, the survey explained the term “structured diagnostic interview” and gave examples of common interview schedules (see supplement 1). subsequently, partic­ ipants were asked about the context in which they learned or practiced sdis, the total number of sdis conducted, their familiarity with sdis (1 = “not at all familiar” to 9 = “very familiar”), and their overall satisfaction with sdis (0 = “not at all satisfied” to 100 = “totally satisfied”). the latter rating was adapted from the interviewer acceptance ques­ tionnaire (suppiger et al., 2009). furthermore, participants rated their current frequency palmer, walter, hermann et al. 5 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ of use of different diagnostic information and methods to assess diagnoses during patient encounters (1 = “never” to 9 = “always”), and their estimated use of sdis for diagnosing patients after completing training (1 = “never” to 9 = “always”). the therapist version of the patient acceptance questionnaire (paq, bruchmüller et al., 2011; suppiger et al., 2009) was included to measure participants’ estimation of patients’ sdi satisfaction and acceptance. first, participants estimated patients’ overall sdi satisfaction (0 = “not at all satisfied” to 100 = “totally satisfied”). second, ten single items assessed participants’ estimate of patients’ acceptance. the single items include both positive (e.g., “in an sdi patients feel that the interviewer takes their problems seriously”) and negative statements (e.g., “patients find sdis exhausting”). participants rated their endorsement of each item on a four-point scale (0 = “does not apply at all”, 1 = “somewhat applies”, 2 = “quite completely applies”, 3 = “completely applies”). additionally, participants rated their agreement to six positive and nine negative beliefs about sdis (see supplement 2). eleven items (e.g., “sdis help not to overlook anything”, “sdis take too long”) were adapted from bruchmüller et al. (2011). the first author formulated four additional items (e.g., “sdis help to broaden one’s own diagnostic competence”, “learning sdis takes too much time”) based on feedback from participants of a psychotherapy training course. participants rated their agreement to the presented beliefs on a nine-point scale (1 = “i totally disagree” to 9 = “i totally agree”). in addition, participants could provide further statements on sdis. participants’ personality factors were measured using the german short version of the big five inventory (bfi-k, rammstedt & john, 2005). based on the five-factor model of personality, the bfi-k contains the scales extraversion, agreeableness, conscientious­ ness, neuroticism, and openness. it consists of 21 items which participants rate on a five-point scale (1 = “strongly disagree” to 5 = “strongly agree”). the bfi-k has sufficient validity and reliability across different samples (kovaleva et al., 2013; rammstedt & john, 2005). finally, participants’ demographic information, including age, gender, previous study courses, and information on their current training program were assessed. additionally, participants rated their adherence to different psychotherapeutic orientations (psychody­ namic/ analytic, cognitive/ behavioral, and systemic psychotherapy) on a nine-point scale (1 = “not at all” to 9 = “very strongly”). these orientations were chosen because they are offered by state-approved post-graduate training institutes in germany. the survey included two instructed response items to check for careless responding. in the first item, participants were instructed to choose the option “slight agreement” on a five-point rating scale (“strong disagreement”, “slight disagreement”, “neutral”, “slight agreement”, “strong agreement”). the second item used a multiple-choice format with four options numbered 1 to 4, where participants were instructed to choose “option 4”. trainees’ beliefs about structured interviews 6 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ procedure the data were collected between february and june 2023. the online survey was created using sosci survey (leiner, 2024) and was made available on http://www.soscisurvey.de. the link to the survey was sent via e-mail to 172 state-approved training institutions for post-graduate psychotherapy training in germany from all four major psychotherapeutic orientations (behavioral, psychodynamic, psychoanalytic, and systemic psychotherapy). institutions were contacted either directly through the contact information on their web­ site or through a mailing list. contact persons were asked to disseminate the information and link to the survey among the institutions’ current psychotherapy trainees. upon accessing the link, participants received participant information and actively consented to survey participation. participants could enter a personal e-mail address for a chance to win one of five 20€ online vouchers after survey completion. e-mail addresses were saved separately from participants’ survey data to ensure anonymity. statistical analysis all analyses were performed using ibm spss statistics (version 28). the main analyses were preregistered at aspredicted (https://aspredicted.org/n3f_9t3). secondary analyses as well as descriptive analyses regarding a further student sample, as described in the pre-registration, will not be reported in the present manuscript. due to the composition of the sample and the results of the correlational analyses, the pre-registered test of regression and mediation models concerning personality factors and adherence to orien­ tation were not computed. only the results from exploratory correlational analyses are reported (see results). significance level was set at α = .05 for all analyses. a two-tailed test of correlation between sdi familiarity and overall sdi satisfaction was computed. additionally, a mul­ tiple linear regression model of overall sdi satisfaction on the agreement to 15 beliefs about sdis was computed. all predictors were entered in a single step. a priori power analysis using g*power (faul et al., 2009) indicated that a minimum of n = 143 partici­ pants was needed for the regression analysis to detect a medium effect with power = .80. small to moderate intercorrelations were observed between predictors, but mean vif = 1.75 indicated no multicollinearity (see supplement 3). exploratory correlations between overall sdi satisfaction, the bfi-k subscales (rammstedt & john, 2005), and the ratings of adherence to psychotherapeutic orientations were computed. due to the negatively skewed distribution for the cognitive/behavioral and the positively skewed distribution of the psychoanalytic/psychodynamic orientation ratings, non-parametric kendall’s tau c correlations are reported. the answers to the open question about further beliefs about sdis were categorized by the first author. first, specific entries were categorized into positive and negative palmer, walter, hermann et al. 7 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 http://www.soscisurvey.de https://aspredicted.org/n3f_9t3 https://www.psychopen.eu/ arguments. second, specific topics were identified. the most frequent topics for both positive and negative arguments, along with examples of participant entries are reported. results sdi experience, use, and satisfaction participants commonly reported treatment of outpatients (70%) as a context for sdi encounters, followed by courses during their master’s program and training (67.4%), treatment of inpatients (50.6%), and research (28.3%). the estimated number of sdis conducted by psychotherapy trainees ranged from zero to 200 interviews. most trainees (42.1%) conducted 10 or fewer sdis, with 13 participants reporting that they had never conducted an sdi before. the majority (66.5%) of participants stated that conducting sdis was mandatory during their training program. on average, trainees reported a medium level of overall sdi satisfaction (m = 60.43, sd = 20.83, range: 0 – 100) and endorsed a moderate level of sdi familiarity (m = 6.03, sd = 1.78, range: 1 – 9). a moderate positive correlation between overall sdi satisfaction and sdi familiarity was observed, r(231) = .41, p < .001. concerning estimated sdi use after training (m = 5.79, sd = 1.81, range: 1 – 9), 2.6% of trainees stated that they would “never”, while 6.4% stated that they would “always” use an sdi for diagnosing patients. for diagnosing patients, trainees with patient expe­ rience (n = 227) reported to use clinical history taking most frequently, followed by questionnaires, classification systems, and sdis (see figure 2). trainees’ estimation of patients’ sdi satisfaction and acceptance psychotherapy trainees estimated a medium level of overall sdi satisfaction among patients (m = 55.60, sd = 20.62, range: 0 – 95). the positive statements with the highest mean agreement ratings were the statement: “during an sdi, patients feel that the interviewer takes their problems seriously” (m = 1.82, sd = 0.86) and the statement: “after an sdi, patients think that the interviewer asked for enough detail to get an appropriate understanding of their situation” (m = 1.82, sd = 0.87). in contrast, psycho­ therapy trainees tended to only partially agree or disagree with the statement: “patients have the feeling that they understand themselves and their problems better after an sdi” (m = 0.84, sd = 0.77). among the negative items, the estimation that patients find sdis exhausting received the highest mean agreement (m = 1.50, sd = 0.80). descriptive statistics on all paq items are shown in supplement 4. trainees’ beliefs about structured interviews 8 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ prediction of psychotherapy trainees’ sdi satisfaction by beliefs about sdis the regression model of overall sdi satisfaction on beliefs about sdis was significant, f(15, 217) = 17.01, p < .001. the whole model explained 54% of variance. descriptive and regression statistics for all beliefs are shown in table 2. two of the positive beliefs (“sdis are reliable sources of information”, “sdis are efficient”) positively predicted overall sdi satisfaction, whereas two of the negative beliefs (“sdis disturb the relationship to patients”, “sdis are too confusing”) negatively predicted overall sdi satisfaction. trainees’ answers to open question participants entered 31 further arguments for and against sdis. among the positive arguments, the identified topics were: benefit for patients and the therapeutic relation­ ship (e.g., “the diagnosis [using an sdi] induces confidence that the therapist relies on scientific evidence, and not arbitrary; the patient can rely on the result”), and benefit for determining accurate diagnoses (e.g., “in particular cases [the sdi] uncovered symp­ toms in the past”). among the negative arguments, the most common topics included: weakness of the interview itself (e.g., “structured interviews are too undynamic”), lack of benefit for determining a diagnosis (e.g., “[…] the interview only showed that there is figure 2 psychotherapy trainees’ use of diagnostic sources for diagnosing patients 1 2 3 4 5 6 7 8 9 clinical history taking questionnaires classification systems sdis third party information diagnostic check lists performance/ intelligence tests fr eq ue nc y of u se diagnostic sources note. n = 227; sdi = structured diagnostic interview; frequency of use was rated from 1 (“never”) to 9 (“always”); error bars indicate standard deviations. palmer, walter, hermann et al. 9 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ psychological distress, it was not helpful diagnostically”), detrimental effect on patients and the therapeutic relationship (e.g., “sdis can irritate patients ([they create the] im­ pression that one’s very sick if one has to answer such different questions)”), high effort (e.g., “sdi require a lot of time/resources, that, to my experience, are not available in the table 2 multiple linear regression of psychotherapy trainees’ overall sdi satisfaction on beliefs about sdis predictor m (sd) b (se) 95% ci β t positive beliefs sdis help to not overlook anything. 7.33 (1.51) 0.80 (0.79) [-0.76, 2.36] 0.06 1.02 sdis help to broaden one’s own diagnostic competence. 6.67 (1.88) 0.21 (0.63) [-1.04, 1.45] 0.02 0.33 sdis are reliable sources of information. 6.49 (1.47) 3.01 (0.97) [1.09, 4.93] 0.21 3.1** sdis secure the quality of treatment. 6.12 (1.99) 0.21 (0.69) [-1.14, 1.56] 0.02 0.31 sdis help with treatment planning. 5.67 (2.07) -0.33 (0.59) [-1.49, 0.83] -0.03 -0.56 sdis are efficient.   5.19 (1.72) 2.60 (0.73) [1.15, 4.04] 0.21 3.54*** negative beliefs sdis take too long. 6.73 (1.86) -1.34 (0.71) [-2.75, 0.06] -0.12 -1.89 my clinical judgment is more useful to me than an sdi. 4.61 (2.12) -0.87 (0.62) [-2.10, 0.35] -0.09 -1.40 sdis are too confusing. 4.58 (2.10) -1.74 (0.61) [-2.94, -0.55] -0.18 -2.87** sdis are unpleasant for patients. 4.50 (1.95) 1.08 (0.67) [-0.23, 2.4] 0.10 1.62 sdis are too detailed. 4.40 (1.95) 1.16 (0.65) [-0.13, 2.44] 0.11 1.78 learning sdis requires too much time. 4.11 (2.13) -0.94 (0.50) [-1.93, 0.06] -0.10 -1.86 sdis disturb the relationship to patients. 3.73 (2.10) -2.36 (0.66) [-3.67, -1.06] -0.24 -3.57*** sdi questions are barely understandable. 3.36 (1.67) -0.47 (0.70) [-1.84, 0.90] -0.04 -0.68 information from sdis are not relevant for treatment. 2.27 (1.58) -0.58 (0.77) [-2.09, 0.93] -0.04 -0.76 note. n = 233; r 2 = .540; se = standard error; ci = confidence interval; sdi = structured diagnostic interview; trainees’ beliefs about structured diagnostic interviews were rated on a scale from 1 (“i totally disagree”) to 9 (“i totally agree”). **p < .01. ***p < .001. trainees’ beliefs about structured interviews 10 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ daily clinic routine”), and lack of appropriate compensation (e.g., “structured interviews are not sufficiently rewarded during training (neither monetary, nor for the progress of training), which can be frustrating”). relationship between personality factors, adherence to psychotherapeutic orientations, and sdi satisfaction the exploratory correlational analysis included only participants that reported experi­ ence in working with patients (n = 227). a small negative relationship was found between psychotherapy trainees’ overall sdi satisfaction and the adherence to a psycho­ analytic/psychodynamic orientation, τc = -.14, p = .005. in contrast, a small positive relationship was found between psychotherapy trainees’ overall sdi satisfaction and the adherence to a cognitive/behavioral orientation, τc = .11, p = .005. no relationships were found between overall sdi satisfaction and any personality factor. full results of the correlational analyses are reported in supplement 5. discussion the results of the present study indicate that current psychotherapy trainees have encountered sdis in different contexts throughout training, predominantly during outpa­ tient treatment. compared to the practitioner sample from bruchmüller et al. (2011), the degree of familiarity with sdis was higher, which might reflect a growing importance of sdis in clinical practice and corresponding changes in the curricula of psychotherapy training. still, one third of the trainees reported that they were not required to use sdis during training, and the number of conducted sdis varied considerably. in line with findings from us samples, sdis are less frequently used than self-report question­ naires, possibly due to the availability and feasibility of the latter, even though they lack usefulness for diagnostic classification (ingram et al., 2022; mihura et al., 2017). the relationship between sdi satisfaction and sdi familiarity underlines the importance of sufficient sdi coverage during training. however, further longitudinal investigations need to clarify the direction of the relationship: while a higher sdi familiarity could lead to higher satisfaction, it is also plausible that a satisfying initial sdi experience could motivate trainees to become more familiar with sdis. the results on the beliefs about sdis show that trainees recognize the advantages of sdis for practice and professional development, but negative beliefs persist to some extent. moreover, regression analysis revealed that beliefs differed in their impact on trainees’ overall sdi satisfaction. the positive association between sdi satisfaction and the beliefs that sdis are reliable and efficient implies that educating trainees about the existing evidence on the reliability and validity of sdis, ideally in the early phases of training, could strengthen their trust in the method and their confidence in their clinical palmer, walter, hermann et al. 11 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ decisions (margraf et al., 2017; osório et al., 2019). in contrast, sdi satisfaction was negatively related to the belief that sdis harm the therapeutic relationship. additionally, trainees estimated patients’ overall sdi satisfaction as moderate, on average, which is similar to the practitioner estimation reported by bruchmüller et al. (2011). furthermore, 45.9% of the trainees quite or completely agreed that patients find sdis exhausting. given these results, it is crucial that trainees learn about evidence of patients’ sdi satisfaction and acceptance. particularly, the finding that most patients view the relation­ ship to interviewers as positive might challenge the misconception that sdis inherently interfere with the therapeutic relationship (neuschwander et al., 2017; suppiger et al., 2009). additionally, individual patients’ sdi acceptance and satisfaction ratings might help trainees and supervisors to identify difficulties and opportunities for improvements in future sdi applications. furthermore, a negative relationship was observed between sdi satisfaction and the belief that sdis are too confusing. the confusion and related dissatisfaction may partly arise from reservations about standard classification systems. even though classification systems are widely used and considered helpful, many practitioners would prefer concise manuals with fewer diagnostic categories (evans et al., 2013; reed et al., 2011). moreover, the definition and validity of diagnostic criteria of certain disorders, e.g. generalized anxiety disorder, have been repeatedly challenged and debated (andrews et al., 2010; ruscio et al., 2024). confusion could be reduced if trainees receive ongoing support during the study of the diagnostic criteria and the structure of sdis. moreover, trainees should have the opportunity to start practicing with non-clinical interviewees. the combination of theoretical and role play sessions in an sdi course for clinical psychology master’s students has already proven to be highly accepted by participants (bonnin et al., 2024). subsequently, a guided and supervised approach could ensure that trainees gradually move from clearly circumscribed to more complex cases (e.g., with higher comorbidity). notably, institutions should also consider how trainees could be remuner­ ated more adequately (e.g., additional therapy sessions and credit for training, provide sdi-specific supervision), thus encouraging regular sdi use. lastly, the belief that sdis take too long did not significantly predict sdi satisfaction but had a high mean agreement in the present sample. similarly, additional participant statements criticized sdis as being too effortful for clinical practice. the perceived impracticability of sdis is a common argument against their use, yet many practitioners are barely familiar with sdis (bruchmüller et al., 2011; cook et al., 2017). as interview duration likely decreases along with sdi experience and familiarity, the view that sdis take too long might change accordingly. building on the present finding that sdi famili­ arity positively relates to overall satisfaction, future studies might prospectively assess the duration of individual sdis and trainees’ estimated sdi practicability over the course of training. trainees’ beliefs about structured interviews 12 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ in addition to the impact of trainees’ beliefs, the exploratory correlational analyses revealed relationships between sdi satisfaction and adherence to cognitive/behavioral as well as psychodynamic/psychoanalytic orientations. the positive relationship between satisfaction and adherence to a cognitive/behavioral orientation is in line with the re­ sults reported by bruchmüller et al. (2011). as noted earlier, the relationship is likely accounted for by cbt therapists’ more positive attitude towards the underlying classifi­ cation systems (raskin et al., 2022). for a direct test of this assumption, future studies should jointly assess therapists’ attitudes towards classification systems and beliefs about sdis. in contrast to orientation adherence, trainees’ personality appeared to be of less importance for their sdi evaluation, as no significant relationships were found. while personality factors relate to orientation preferences and the underlying general approach to psychotherapy, endorsement and evaluation of sdis could be more closely related to specific behaviors and skills that are relevant in the therapeutic process. for instance, since the application of an sdi is a form of therapist-patient-interaction, interpersonal behaviors of psychotherapy might be worth investigating in this context. it is important to note that comparisons to previous studies are limited by the high proportion of cbt trainees in the present sample (bruchmüller et al., 2011; poznanski & mclennan, 2003), and the small effects from exploratory analyses need to be interpreted with caution. study limitations the present study has limitations that need to be considered. first, the cross-sectional design does not allow for conclusions regarding possible long-term effects of sdi train­ ing (e.g., on actual sdi use after training). second, certain survey items might have been insufficient. even though most sdi beliefs were endorsed previously (bruchmüller et al., 2011), the additional arguments reported by participants suggest that there are more issues relevant to sdi satisfaction. single items of adherence to psychotherapeutic orientations were used as ecological and integrative measures but may have failed to capture all aspects relevant to orientation adherence. trainees that are at an early stage of training might have had more difficulties providing accurate answers due to little experience. third, correlational and exploratory analyses somewhat limit the conclusions that can be drawn. however, the present study has important implications for clinical practice and future research despite this methodological limitation, as it is the first to provide evidence on sdi beliefs and satisfaction among trainees. finally, as most partic­ ipants were psychologists in cbt training, the present results may not generalize to trainees with other training orientations and professional backgrounds. yet, importantly, the present sample is still representative of the current trainee population in germany, as most psychologists choose a post-graduate training in cbt (rabe-menssen et al., 2021). palmer, walter, hermann et al. 13 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ summary and perspective the present study is the first to provide evidence for the impact of beliefs about sdis on psychotherapy trainees’ overall sdi satisfaction. the results imply that training pro­ grams need to increase their efforts to implement sdi training and provide opportunities for sdi application in different settings to strengthen trainees’ sdi familiarity. while considering trainees’ needs and concerns (e.g., time constraints, limited compensation), programs need to inform trainees about the evidence on sdis that highlight diagnos­ tic advantages and common misconceptions, especially regarding their impact on the therapeutic relationship (neuschwander et al., 2017; suppiger et al., 2009). longitudinal studies are needed to determine the impact of sdi training experiences on practitioners’ sdi use following training. in addition to overall sdi satisfaction, it would be informa­ tive to assess trainees’ immediate response to individual sdis, thus allowing for direct comparisons to previous studies on interviewer satisfaction (neuschwander et al., 2017; suppiger et al., 2009). this approach would also enable tracking changes in sdi satisfac­ tion and help determine the number of conducted sdis required for sufficient experience to benefit from sdis’ advantages. when investigating relations of sdi endorsement and evaluations with individual characteristics of trainees, research might focus more on specific behaviors and skills, as they are possibly more relevant than personality factors, and can be directly addressed and monitored during training. finally, future evaluations of sdi satisfaction should include trainees with different professional backgrounds and orientations to account for a wider trainee population. trainees’ beliefs about structured interviews 14 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://www.psychopen.eu/ funding: this work was supported by the dynamic center, which is funded by the loewe program of the hessian ministry of science and arts (grant number: loewe1/16/519/03/09.001(0009)/98) and the deutsche forschungsgemeinschaft (german research foundation, dfg) under germany’s excellence strategy (exc 3066/1 “the adaptive mind”, project no. 533717223). acknowledgments: the authors wish to thank raphaela zimmer, marie kristin neudert, susanne fricke, annkathrin noll and rosa seinsche for their contributions to the preparation and proofreading of the online survey. competing interests: the authors declare no potential conflicts of interest with respect to the research, authorship, and publication of this article. ethics statement: the study was approved by the local ethics committee of the department of psychology at the justus liebig university giessen, germany (no. 2021-0015) on july 30, 2021. survey respondents gave written informed consent prior to participation. reporting guidelines: the present manuscript was written in accordance with the jars-quant reporting standards for non-experimental designs. preregistration: the main analyses of the present study were preregistered at aspredicted: https://aspredicted.org/n3f_9t3 data availability: the data and materials of this study are available on request from the corresponding author. supplementary materials the supplementary materials for the present manuscript include: • preregistration (palmer et al., 2022s) • additional information (palmer et al., 2025s): ◦ supplement 1: survey introduction ◦ supplement 2: beliefs about structured diagnostic interviews ◦ supplement 3: predictor intercorrelations and multicollinearity statistics for multiple linear regression of overall sdi satisfaction on beliefs about sdis ◦ supplement 4: descriptive statistics for the patient acceptance questionnaire – therapist version ◦ supplement 5: correlations between psychotherapy trainees’ overall sdi satisfaction, personality, and adherence to theoretical orientations index of supplementary materials palmer, s., walter, b., hermann, c., stark, r., & hermann, a. 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(2009). acceptance of structured diagnostic interviews for mental disorders in clinical practice and research settings. behavior therapy, 40(3), 272–279. https://doi.org/10.1016/j.beth.2008.07.002 weathers, f. w., blake, d. d., schnurr, p. p., kaloupek, d. g., marx, b. p., & keane, t. m. (2013). the clinician-administered ptsd scale for dsm-5 (caps-5). u. s. department of veterans affairs. https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp wolkenstein, l., bruchmüller, k., schmid, p., & meyer, t. d. (2011). misdiagnosing bipolar disorder – do clinicians show heuristic biases? journal of affective disorders, 130(3), 405–412. https://doi.org/10.1016/j.jad.2010.10.036 wright, a. j. (2022). master’s-level psychological assessment competencies and training. training and education in professional psychology, 16(3), 272–279. https://doi.org/10.1037/tep0000339 zimmerman, m., & mattia, j. i. (1999). psychiatric diagnosis in clinical practice: is comorbidity being missed? comprehensive psychiatry, 40(3), 182–191. https://doi.org/10.1016/s0010-440x(99)90001-9 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service provided by the leibniz institute for psychology (zpid), germany. palmer, walter, hermann et al. 19 clinical psychology in europe 2025, vol. 7(4), article e17321 https://doi.org/10.32872/cpe.17321 https://doi.org/10.1016/j.beth.2008.07.002 https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp https://doi.org/10.1016/j.jad.2010.10.036 https://doi.org/10.1037/tep0000339 https://doi.org/10.1016/s0010-440x(99)90001-9 https://www.psychopen.eu/ trainees’ beliefs about structured interviews (introduction) method participants surveys and measurements procedure statistical analysis results sdi experience, use, and satisfaction trainees’ estimation of patients’ sdi satisfaction and acceptance prediction of psychotherapy trainees’ sdi satisfaction by beliefs about sdis trainees’ answers to open question relationship between personality factors, adherence to psychotherapeutic orientations, and sdi satisfaction discussion study limitations summary and perspective (additional information) funding acknowledgments competing interests ethics statement reporting guidelines preregistration data availability supplementary materials references empirically informed, idiographic networks of concordant and discordant motives: an experience sampling study with network analysis in non-clinical participants research articles empirically informed, idiographic networks of concordant and discordant motives: an experience sampling study with network analysis in non-clinical participants thies lüdtke 1,2 , fabian steiner 3 , thomas berger 3 , stefan westermann 4 [1] department of human medicine, msh medical school hamburg, hamburg, germany. [2] institute of sustainability psychology, leuphana university lüneburg, lüneburg, germany. [3] department of clinical psychology and psychotherapy, institute of psychology, university of bern, bern, switzerland. [4] department of psychology and psychotherapy, witten/herdecke university, witten, germany. clinical psychology in europe, 2025, vol. 7(2), article e12305, https://doi.org/10.32872/cpe.12305 received: 2023-06-30 • accepted: 2024-11-24 • published (vor): 2025-05-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: stefan westermann, chair of clinical psychology and psychotherapy, department of psychology and psychotherapy, witten/herdecke university, alfred-herrhausen-straße 44, 58455 witten, germany. phone: +49 2302 92 6789. e-mail: stefan.westermann@uni-wh.de supplementary materials: materials [see index of supplementary materials] abstract background: case formulations and treatment planning mostly rely on self-reports, observations, and third-party reports. we propose that these data sources can be complemented by idiographic networks of motive interactions, which are empirically derived from everyday life using the experience sampling method (esm). in these networks, positive edges represent concordance of motives whereas negative edges indicate discordance. based on consistency theory, which states that discordance emerges when the activity of one motive (e.g., ‘affiliation’) is incompatible with the activity of another motive (e.g., ‘autonomy’), we hypothesized that discordance would be associated with subclinical depressive symptoms. method: fifty-one undergraduates completed a six-day esm assessment period with 6 assessments of motive satisfaction per day. based on the esm data, idiographic networks of the seven most important motives per person were computed using mlvar (https://doi.org/10.32614/cran.package.mlvar). we extracted indices of motive dynamics from each person’s network, namely the strength of negative edges compared to the overall network this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12305&domain=pdf&date_stamp=2025-05-28 https://orcid.org/0000-0003-2019-3842 https://orcid.org/0009-0003-6361-9783 https://orcid.org/0000-0002-2432-7791 https://orcid.org/0000-0002-4785-0024 https://doi.org/10.32614/cran.package.mlvar https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ strength as well as the values of the single most negative and positive edges. these indices were then used to predict subclinical depressive symptoms, controlling for overall motive satisfaction. results: discordant, conflicting motive relationships made up only 6% of network strengths, indicating high concordance overall. neither conflict index predicted subclinical depressive symptoms but maximum concordance was associated with lower subclinical depressive symptoms. motive satisfaction was a significant predictor across models. conclusion: the applicability and clinical utility of the motive network approach was promising. insufficient variance due to a healthy sample and the small number of observations limit the interpretability of findings. keywords consistency theory, approach, avoidance, motive, concordance, conflict highlights • a novel approach to estimating idiographic networks of motives is introduced. • network links between motives indicate discordance (= conflict) or concordance (= compatibility). • motive satisfaction and concordance were associated with lower subclinical depressive symptoms. • unexpectedly, motive conflicts were not associated with subclinical depressive symptoms. theoretical background for decades, therapists have relied on the same data sources for case conceptualization and treatment planning (eells, 2007), namely questionnaires or clinical interviews, ob­ servations (e.g., nonverbal behavior), and information from third parties, such as fami­ ly members. these data are undoubtedly indispensable but their ‘ecological validity’, meaning the applicability to real-world situations (kihlstrom, 2021), can be questioned. one way to supplement traditional methods of case conceptualization is the structured assessment of patients’ experiences and behaviors in daily life, a method referred to as the experience sampling method (larson & csikszentmihalyi, 2014), which relies on repeated self-report assessments, for example using smartphones. the feasibility of person-specific esm studies has been demonstrated (bak et al., 2016; thonon et al., 2020; wichers et al., 2016) and the necessary assessment tools (i.e., smartphones) are widely available (vuma, 2023). nonetheless, therapists seldom make use of this method beyond paper-pencil diaries in clinical practice, likely due to heavy caseload and lack of financial incentives. experience sampling results in datasets which allow the estimation of both groupbased and idiographic (molenaar, 2004) models. one statistical approach, which is appli­ cable to both types of models, is the so-called network approach (borgatti et al., 2009), motive networks 2 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ which has gained popularity within psychological research over the past years (fried et al., 2017; robinaugh et al., 2020). in network models, constructs are represented as nodes and edges. nodes are the variables of interest, often symptoms (borsboom, 2017), whereas edges represent statistical relationships between them, computed, for example, as partial correlations. such networks can take many forms, such as social networks in which nodes represent people (tabassum et al., 2018) or semantic networks in which nodes represent semantic or lexical units (christensen & kenett, 2023). in the present study, nodes represent psychological constructs whereas edges represent the partial cor­ relations between these constructs. one of their major advantages is that networks can be graphically visualized, making them accessible to health professionals and patients alike (bak et al., 2016). as bak et al. (2016) phrase it, “discussing esm results with a patient offers clues as to why and when symptoms vary, given certain stressors and contexts, with clues for protective mechanisms or coping strategies” (p. 8). why are esm-based, idiographic assessments of patients’ experiences and behaviors in daily life not already a standard tool for therapists? we argue that – in addition to above-mentioned reasons – the information that is usually assessed in idiographic networks is not useful enough in aiding the conceptualization and individualization of psychotherapy. although symptom-focused networks help to understand the centrality of certain symptoms and strength of symptom associations (e.g., beard et al., 2016), they provide limited information about the underlying processes that may have led to their formation or maintenance. given that psychological interventions are often targeted at mechanisms rather than symptoms (e.g., metacognitive biases; moritz & woodward, 2007), symptom networks may have limited clinical utility (current network approaches have other shortcomings, too, such as limited utility in ordinal data, see borsboom et al., 2021). in line with that, scholten, lischetzke, and glombiewski (2022) recently proposed a combination of functional analytic and experience sampling approaches. here, we use network theory to assume a motive-focused view that answers questions such as does the patient value independence or confirmation by others, does the patient seek intimacy and does she/he receive it, and most importantly do the patient’s motivational goals clash? against this background (westermann et al., 2019) we propose that a more instructive source of information for therapists is the interplay of patients’ motives in their daily life, particularly when these are in conflict. the term ‘motive’ can be conceptualized as an active process that directs attention, cognition, and action (e.g., schultheiss & brunstein, 2005). according to grawe (2004), motives serve as means to satisfy basic needs, such as the need for relatedness or autonomy (deci & ryan, 2000), and to protect them from violation. one can distinguish between approach and avoidance motives. approach motives aim at creating or main­ taining appetitive, need-satisfying experiences, such as being liked by others (affiliation). in contrast, avoidance motives are directed towards preventing or ending aversive, needviolating experiences, such as being criticized (self-esteem), that a person wants to avoid lüdtke, steiner, berger, & westermann 3 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ (coats et al., 1996; grosse holtforth, 2008). according to consistency theory, motive satis­ faction (i.e., ‘congruence’; grawe, 2004) describes a state in which an approach motive is fulfilled (e.g., experiencing oneself as belonging) or the aversive experience is averted (e.g., avoiding being criticized), whereas motivational incongruence is characterized by the dissatisfaction of one’s motive, the latter being associated with mental health issues, such as loneliness (gable, 2006) or the risk of chronicity of anxiety disorders (struijs et al., 2018). when the satisfaction of one motive supports satisfaction of another motive, they are in a concordant relationship with each other. in contrast, a discordant relationship emerges when the satisfaction of one motive reduces the satisfaction of another motive. for example, belonging and being autonomous can be mutually exclusive, as assertive behavior can be accompanied by discontent of others whereas overly cooperative behav­ ior can violate one’s self-determination. such motivational conflicts due to competing motives give rise to what is called ‘discordance’ within the framework of consistency theory. discordance, in turn, is hypothesized to function as an ‘internal’ stressor (similar to cognitive dissonance; festinger, 1957) that can facilitate the formation and mainte­ nance of psychopathology (grawe, 2004). in line with this, psychotherapy is accompa­ nied by a reduction of incongruence (e.g., berking et al., 2003) and psychological conflicts of goals (more broadly defined and not restricted to motives) are inversely associated with psychological well-being (gray et al., 2017). we propose that esm-based measurements of motive satisfaction and conflict are ideally suited to augment established methods of treatment planning because they allow assessing motivational dynamics in vivo and in personally relevant situations, unaffected by retrospective recall biases (ben-zeev & young, 2010; urban et al., 2018). according to our approach, the interplay of motives in daily life can be represented as an idiographic network, in which nodes depict motives and edges constitute concordant (i.e., positive) versus discordant (i.e., negative) relationships between motives, potentially providing information that helps to personalize treatment and improve the therapeutic relationship (caspar, 1997). importantly, we propose that motivational conflicts can be empirically assessed even when participants are not able to report those associations in self-reports (e.g., due to a simple lack of explicit representation or due to defense mechanisms in a psychodynamic sense, see blanco et al., 2023). table 1 provides an overview of relevant motive-related terms and how they were operationalized in the network methodology. the clinical utility of motive dynamics is not limited to a certain diagnosis or symp­ tom spectrum (grosse holtforth & grawe, 2004). however, for the first-time validation of the proposed motive network approach, we focus on depressive symptoms. accord­ ing to the reinforcement theory of depression (ferster, 1973; lewinsohn & graf, 1973; lewinsohn & libet, 1972), a low rate of response-contingent positive reinforcement through rewarding activities is a key factor in the development and maintenance of depressive symptoms (lewinsohn, 1974, p. 151). within our motive network approach, motive networks 4 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ activities are perceived as rewarding if they satisfy an individual’s motives (brockmeyer et al., 2015), but if the satisfaction of one motive is accompanied by the dissatisfaction of another motive (i.e., motivational discordance), activities may lose their reinforcing properties. enduring states of conflict due to discordant motives could lead to diminished reinforcement and thus depressive symptoms whereas motivational concordance may be a protective factor. in sum, we hypothesized that individuals with higher subclinical depressive symp­ toms would display stronger motive conflicts, operationalized as the proportion of nega­ tive edges, as well as the magnitude of the largest negative edge within the individual’s network. relatedly, we hypothesized that concordance, operationalized as the magnitude of the strongest positive edge would be associated with reduced subclinical depressive symptoms. we excluded avoidance motives from the analyses because they are empiri­ cally associated with psychopathology (grosse holtforth, 2008), which may confound analyses. method recruitment we recruited undergraduate psychology students who were compensated with course credits. participants were eligible for participation if they were at least 18 years of age table 1 motive-related terms and their network operationalization term network operationalization motive node (in)congruence momentary value of node (0: incongruence, 9: congruence) motive interaction edge concordant motives (mutualistic interaction of two motives over time) positive edge discordant/conflicting motives (competitive interaction of two motives over time) negative edge concordance / discordance summary statistics of edge weights in the network (e.g., negative edge weights divided by all edge weights; see methods section) lüdtke, steiner, berger, & westermann 5 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ and did not report any mental disorder. the ethics committee of the faculty of human sciences at the university of bern approved the study (#2016-05-00006). the present study was part of a larger project (lüdtke & westermann, 2023). sample size considerations were based on recommendations for multilevel modelling (maas & hox, 2005) given the nested data structure of repeated measurements within participants. the target sample size was set to n = 50 level two cases (i.e., participants) to avoid biased estimates of second-level standard errors (maas & hox, 2005). no stopping rule for data collection was applied. given that our initial power analysis focused on maximizing level two cases, the number of data points within participants (up to 36 assessments) was limited when compared to recommendations for within-person network estimation (mansueto et al., 2023). procedures assessments were conducted between august and november 2016. all participants pro­ vided written informed consent prior to participation. the baseline assessment consis­ ted of an online survey as well as a face-to-face meeting. the online survey covered sociodemographic and clinical variables, approachand avoidance motives, as well as subclinical depressive symptoms (see baseline measures section). during the face-to-face meeting, participants received a study smartphone and were instructed to carry it with them for six consecutive days. all functions of the smartphones were disabled except for the esm survey application ‘movisensxs’, version 0.8.4211 (movisens gmbh, germany). measures baseline measures the german version of the depression anxiety stress scales (dass-21; nilges & essau, 2015) was used to measure subclinical depressive symptoms. participants rated how much each item applied to them over the past week (e.g., “i felt that life was meaning­ less”), with response options ranging from not at all to very much, or most of the time on a four-point scale. internal consistencies ranged from α = .79 for the anxiety subscale to α = .87 for the depression subscale in the present sample. the dass-21 can be used both in clinical and non-clinical samples (antony et al., 1998). the inventory of approach and avoidance motivation (iaam; grosse holtforth & grawe, 2000) measures the importance of motives from not at all to extremely important. the questionnaire was developed in a ‘bottom-up’ process based on patients’ case formu­ lations (grosse holtforth, 2008) covering 14 approachand nine avoidance motives on 94 items. for approach motives, internal consistencies range from .62 (self-reward) to .90 (affiliation) in psychology students (grosse holtforth & grawe, 2000). whereas the iaam measures motive importance, the incongruence questionnaire (inc; grosse holtforth & grawe, 2003) measures the extent to which motives are motive networks 6 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ implemented/satisfied in participants’ interactions with their environment (recoded to represent the degree of incongruence). internal consistencies of inc subscales range from .71 to .89 in healthy participants (grosse holtforth & grawe, 2003). for the present study, only approach motives were considered. the short version of the scale (inc-s; grosse holtforth & grawe, 2003) consists of one item per motive and was used in the esm assessment phase (see esm assessments section). esm assessments participants completed six assessments of momentary motive satisfaction per day, for a period of six days, resulting in a maximum of 36 assessments per participant. entries were defined as missing if they were dismissed, ignored, discontinued, or completed more than 30 minutes after the prompt. each esm assessment comprised 36 items. esm assessments occurred at pseudo-random times between 9:30 a.m. and 9:30 p.m. with a minimum inter-assessment distance of 60 minutes. in addition, we offered the possibility to access the esm assessment manually in case of a missed prompt. each esm assessment took approximately one minute to answer. participants completed a total of 1,481 assessments, of which 1,406 assessments were prompted by the smartphone (95%), whereas 75 assessments were manually accessed by the participant within 30 minutes after a missed/ignored prompt (5%). full adherence would have resulted in 36 x 51 = 1,836 datapoints, so 1,481 assessments correspond to 81% adherence. on average, participants responded to a prompt after 301 seconds (sd = 427 seconds, range = 1 to 1761 seconds, median = 27 seconds). the distribution was skewed with half of the responses occurring within the first 30 seconds after the prompt. most participants (n = 48; 94%) used the study smartphone for 6 days as intended. after completing the esm phase, participants returned the study smartphones and completed a debriefing session. motive satisfaction was assessed six times per day using the short version of the incongruence questionnaire (inc-s; grosse holtforth & grawe, 2003). we made slight adjustments to the inc-s. first, a ten-point likert scale was administered to allow for a more fine-grained assessment of motive satisfaction while retaining the endpoints of the scale. second, we adjusted the wording to capture momentary motive satisfaction rather than general motive satisfaction: “below you will find a list of different pleasant and unpleasant experiences. please indicate how sufficiently you have been able to realize the more pleasant ones since the last survey (part 1) and how much the more unpleasant ones apply to you since the last survey (part 2)” (translated from german). the internal consistency of approach motive satisfaction has been reported as good (.84; grosse holtforth & grawe, 2003) and the correlation between the short and the long version of the inc was high in the present sample (r = .62, p < .001), illustrating the validity of the inc-s in the esm setting (for both scales, the seven most important motives based on the iaam were used). lüdtke, steiner, berger, & westermann 7 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ the inc-s was accompanied by a short version of the positive and negative affect scales (panas; watson et al., 1988), as well as items on the situational context (see lüdtke & westermann, 2023). we used only one of the panas items in exploratory analyses to examine the effect of momentary motive satisfaction on concurrent sadness, namely “in the present moment, i feel…” with the response options ranging from unhap­ py to happy on a seven-point scale. analyses first, we computed idiographic networks of motive satisfaction separately for each par­ ticipant. to do so, we identified the seven most important motives that participants endorsed in the iaam and entered the corresponding inc-s items into a network. selecting the most important motives per participant ensured that potential motive conflicts were personally relevant and it helped to reduce model complexity (i.e., fewer nodes), which is recommended for low numbers of observations (mansueto et al., 2023). conceptually, the resulting networks represented concordant or discordant interactions (i.e., edges) between the satisfaction of idiosyncratically relevant motives (i.e., nodes) within a participant across the esm period. hence, a positive edge indicated that the satisfaction of one motive was accompanied by the concomitant satisfaction of another motive, whereas a negative edge indicated that whenever one motive was satisfied, another motive was less satisfied. network estimation was conducted using the mlvar package in r, version 0.5.1 we computed contemporaneous networks, which indicate how the satisfaction of one motive is associated with the satisfaction of another goal at the same time (i.e., partial correlations). the mlvar package estimates these networks by extracting the residuals of time-lagged temporal models based on non-correlated random effects. model estimation relied on linear mixed effects (lmer), the contemporaneous network estimation was set to “orthogonal”, without prior standardization. node-specific fit indices provided are presented in the supplementary materials. in the second step of the analysis, we extracted network parameters on motive concordance versus discordance from each model and examined their association with subclinical depressive symptoms on a group level (i.e., between persons). first, we calcu­ lated the proportion of negative edges relative to total edge strength in the network, henceforth referred to as conflict proportion. to do so, we added up the absolute values of negative edge weights and divided them by the absolute values of all edge weights. the resulting index of discordance can be interpreted as the proportion of conflicting edge strength relative to the overall strength of edges within the network. additionally, we ex­ tracted the strongest negative edge from each network, referred to as maximum conflict, as well as the strongest positive edge, referred to as the maximum concordance. the ra­ 1) cran link: http://cran.r-project.org/package=mlvar github link (developmental): http://www.github.com/sachaepskamp/mlvar motive networks 8 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 http://cran.r-project.org/package=mlvar http://www.github.com/sachaepskamp/mlvar https://www.psychopen.eu/ tionale for estimating the maximum conflict parameter was that one strong motivational conflict may have detrimental consequences because the conflicting motives cannot both be satisfied at the same time, resulting in over-active motives with ongoing activity and an overall lower level of congruence (e.g., boudreaux & ozer, 2013). for example, while autonomy and affiliation are in conflict, the self-esteem motive has fewer opportunities to become satisfied. the rationale for the maximum concordance parameter was that one strong concordant relationship between important motives allows for efficient behavior that results in high decreases of incongruence. network parameters of motive discordance and concordance were then used to pre­ dict subclinical depressive symptoms (dass-d; nilges & essau, 2015) in ols regression models. motive satisfaction across the esm period (inc-s; grosse holtforth & grawe, 2003) was added as a covariate to all models. a check of model assumptions revealed that the outcome was skewed due to a large proportion of participants reporting hardly any subclinical depressive symptoms, and a visual inspection of residuals indicated problems with heteroscedasticity and non-normality. as a log-transformation could not resolve the issue, we resorted to bias-corrected and accelerated (bca) bootstrap confidence intervals and corresponding p-values (based on 5000 samples), which are robust to violations of assumptions, such as non-normality (field, 2009, p. 163). all tests were two-sided with conventional p-values of .05. following confirmatory analyses, we conducted an exploratory linear mixed model (lmm) analysis to examine the moment-to-moment effects of motive satisfaction on concurrent mood. lmm allowed us to examine how the level of motive satisfaction, that is (in)congruence, relates to momentary affective states measured concomitantly. thus, the lmm analyses answered the question whether – within participants – a moment in which motives were more strongly satisfied was associated with better mood as compared to a moment in which motives were less satisfied (and vice versa). lmm analyses account for the clustering of time points nested within individuals (twisk, 2019, p. 150). the model included a random intercept, and it relied on maximum likelihood estimation. averaged as well as momentary person-mean-centered motive satisfaction were entered as predictors (a so-called hybrid model; twisk, 2019, p. 139). results participant characteristics and adherence a priori it was determined that participants with fewer than 12 completed assessments (i.e., 33%) would be excluded from analyses. out of n = 55 participants, four (7%) completed less than 12 timely esm assessments, leaving n = 51 participants. baseline characteristics are presented in table 2. lüdtke, steiner, berger, & westermann 9 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ table 2 baseline characteristics (n = 51) baseline characteristic age; m (sd) 21.8 (2.1) gender; female/male 45/6 years of education; m (sd) 14.3 (1.8) dass-21-d; m (sd) 1.6 (0.6) note. dass-21-d = dass-21 depression subscale. importance, satisfaction and conflict of motives the motives that were most often represented in the idiographic networks were ‘confi­ dence’ and ‘variety’ (both part of 43 idiographic networks; 78%), followed by ‘intimacy’ (76%), ‘autonomy’ (65%), and ‘self-reward’ (64%). the ‘status’ goal was the least promi­ nent, as it was represented only in one idiographic network (2%). the mean-ratings in the iaam support the importance of the aforementioned motives, with ‘self-confidence’ receiving the highest average rating (m = 4.28 on the 5-point scale, sd = 0.51), followed by ‘autonomy’ (m = 4.21, sd = 0.53) and ‘intimacy’ (m = 4.20, sd = 0.65), whereas ‘status’ received the lowest rating (m = 2.47, sd = 0.56). across the esm period, the motive with the highest grand-mean satisfaction was autonomy (m = 7.18 on the 10-point scale, sd = 1.95), followed by control (m = 7.03, sd = 1.87). however, a variance component analysis (‘null model’) revealed that participants differed significantly in terms of motive satisfaction across the esm-period (wald z tests: p’s < .001). figure 1 depicts four exemplary idiographic motive networks. across the sample, motives were mostly concordant, with an average conflict propor­ tion of 6.2% (sd = 6.7%; range = 0 to 29%). of note, n = 10 participants showed no conflict at all, and the distribution was skewed due to low values. for maximum conflict, the resulting distribution was skewed towards zero as well, with a mean of r = -.09 (sd = .09; range: 0 to -.33). exemplary time series of motivational conflict versus cooperation are presented in the supplementary materials. associations between motive concordance as well as discordance and subclinical depressive symptoms we conducted three linear regression analyses (see table 3). the first model examined whether the conflict proportion predicted subclinical depressive symptom severity, whereas the remaining two models examined the effect of the maximum conflict and maximum concordance, respectively. in all models, motive satisfaction was entered as a covariate. motive networks 10 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ figure 1 four exemplary idiographic motive networks notes. network graphs of four participants are depicted for illustrative purposes. green lines (i.e., edges) represent concordant relationships between motives whereas red lines represent discordant relationships. the thickness of edges is determined by the strength of the association. motive network a (participant 72) depicts uniformly positive edges, indicating no conflict, motive network b (participant 71) depicts multiple moderately negative edges (29% conflict proportion), motive network c (participant 41) shows few but strong negative edges (-.33 maximum conflict), and motive network d shows a case of maximum concordance (.61 maximum concordance). contrary to our hypotheses, neither conflict proportion nor maximum conflict predicted subclinical depressive symptoms (see table 3). in contrast, the maximum concordance predicted subclinical depressive symptoms in that higher maximum concordance was as­ sociated with reduced subclinical depressive symptoms in models using robust bootstrap­ ping. motive satisfaction, which was added as a covariate, was a significant predictor of subclinical depressive symptoms across models in that more satisfaction was associated with less subclinical depressive symptoms. lüdtke, steiner, berger, & westermann 11 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ table 3 network-derived motive satisfaction, concordance and discordance as predictors of subclinical depressive symptoms predictor b se t (df) p bootstrap 95%-ci; p motive satisfaction -0.139 0.059 2.358 (48) .023 [-0.258, -0.013]; p = .047 proportion of negative edges 0.374 1.269 0.295 (48) .770 [-2.341, 3.014]; p = .792 motive satisfaction -0.167 0.057 2.921 (48) .005 [-0.286, -0.052]; p = .012 most negative edge 0.995 0.940 1.058 (48) .295 [-0.517, 2.405]; p = .198 motive satisfaction -0.165 0.054 3.072 (48) .003 [-0.285, -0.051]; p = .008 most positive edge -1.136 0.643 1.765 (48) .084 [-2.119, -0.038]; p = .021 note. intercept coefficients not displayed; due to heteroskedasticity and non-normality of residuals, bootstrap confidence intervals and p-values are provided. exploratory analyses it was surprising that the maximum concordance was associated with subclinical depres­ sive symptoms whereas the maximum conflict was not. our conjecture was that the null effects regarding motivational conflict might be related to a lack of discordant motivational relations (and thus variance). when we excluded participants from the analyses who displayed not one subclinical depressive symptom or motive-conflict (n = 15), maximum conflict was associated with subclinical depressive symptoms according to bootstrapping (b = 1.744, 95% bootstrap-ci [0.054, 3.329]), but not conventional signifi­ cance testing (p = .131). tentatively, these findings suggest that a lack of variance may have contributed to null results at least partly and that it may be worthwhile to examine effect of maximum conflict in participants who display more motive conflicts. confirmatory analyses indicated that participants with higher average motive satis­ faction across the six-day esm period reported lower subclinical depressive symptoms. possibly, this effect emerged because motive satisfaction was immediately related to positive mood on a moment-to-moment level. thus, we examined whether momentary within-person fluctuations of motive satisfaction were associated with contemporane­ ous affect (i.e., unhappy to happy) in a lmm analysis. the model controlled for the mean level of motive satisfaction (i.e., a ‘hybrid model’) to disentangle betweenfrom within-person variance. results suggested that, on a within-person level, an increase in motive satisfaction predicted more happiness (fixed effect: b = 0.406, se = .024, p < .001), meaning that when a person felt that their motives were satisfied more than usually, they felt in fact happier. motive networks 12 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ discussion the present study demonstrated the feasibility and, in part, the clinical utility of a novel network-based approach to quantifying motive concordance and discordance in participants’ everyday lives using experience sampling. adherence (81%) was relatively high compared to other esm studies (e.g., 76.8% in psychosis research; deakin et al., 2022), and only four participants had to be excluded because of too few assessments. these data suggest that the proposed esm-based motive network approach could be a feasible tool for therapists to learn about patients’ idiographic motivational conflicts in order to aid treatment planning. the clinical utility of the derived indices of concordance and discordance was supported partly, as higher maximum concordance (i.e., strong concordant relationships between at least two motives) and overall motive satisfaction were associated with reduced subclinical depressive symptoms whereas motive conflicts were not. in terms of validity, the assessment method has proven to be promising because the correlation between trait incongruence assessed via self-report and the average incongruence in daily life was high but not redundant (r = .62). visual representations of aggregated motive conflict (figure 1) could serve as valuable sources of information for both therapists and patients. inter-individual differences in idiographic network com­ position and everyday-life motive satisfaction support the usefulness of the idiographic approach. whereas network-derived concordance may be a protective factor, motivational con­ flicts showed no associations with subclinical depressive symptoms. it is possible that null effects were the result of the low number of observations within participants (i.e., 36 given full adherence) in combination with a low probability of occurrence of motivational discordance in the healthy student sample. a clinical sample would likely increase the likelihood of detecting more severe motive conflicts, which might be better suited to predict depressive symptoms. for example, edges and centrality strength show stronger correlations between internalizing symptom networks from the same popula­ tion than between networks from clinical versus non-clinical samples (funkhouser et al., 2020). alternatively, when explaining the null finding one has to take into account that incongruence and discordance overlap empirically and theoretically, because discordance actually results in incongruence. therefore, testing that discordance explains variance in depressive symptoms over and above incongruence is particularly conservative. finally, an alternative psychological explanation for the null finding is, of course, that the motive conflicts that are related to depression are not captured with our network operationaliza­ tion of motive conflict (e.g., due to motive incongruence not being consciously accessible due to avoidance motives and/or defense mechanisms). lüdtke, steiner, berger, & westermann 13 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ the role of motive satisfaction esm-derived motive satisfaction emerged as a significant predictor of subclinical depres­ sive symptoms across models. interestingly, exploratory post hoc analyses suggest that momentary fluctuations in approach motive satisfaction were associated with momenta­ ry happiness. this result is in line with theoretical accounts of approach and avoidance motivation (carver & scheier, 2000), and it adds to findings that a lack of motive satisfaction is associated with reduced well-being, self-esteem, or joie de vivre (grosse holtforth & grawe, 2003) between persons but also on a moment-to-moment level. in addition, this finding provides further evidence for the importance of resource activation in psychotherapy and a salutogenetic perspective on mental health in general (e.g., munder et al., 2019). consequently, the clinical utility of the assessment might lie in the identification of how an individual motive network can be driven to more concordance during psychotherapy. limitations and future directions first, the number of observations was low. even 75 or 100 assessments are associated with low sensitivity (mansueto et al., 2023), so 36 assessments in the present sample may have been too few to reliably estimate network parameters. however, we have made several design choices that were aimed at reducing the impact of small numbers of observations (mansueto et al., 2023), namely limiting the number of nodes by selecting the seven most important motives per person, constraining analyses to contemporaneous networks, and using full information maximum likelihood estimation. one might argue that a more robust measure of motive interactions, such as simple correlations between motives, would be more appropriate. we decided against this option because, conceptual­ ly, the isolated relationship between two motives is not as informative as the interplay of all motives, which is illustrated by the fact that motivational (in)congruence is as­ sessed using a combination of all approach and avoidance motives, respectively (grosse holtforth & grawe, 2003). unlike simple correlations, partial correlation networks repre­ sent associations between two nodes while controlling for all other information possible (epskamp & fried, 2018), which we consider a much more appropriate representation of overall concordance/discordance among motives. second, the student sample was educated, healthy, and mostly unaffected by motiva­ tional conflict according to our approach, resulting in skewed data and non-normally distributed errors. we addressed these issues with robust bootstrapping procedures but could not overcome the conceptual problem of floor effects. third, the method of motive networks must be critically discussed. a motive network is based on an individual’s transaction with their environment. a conflict between motives might occur due to motive-related conflicts, but also due to challenges imposed by the environment, a skill deficit, or a combination of such factors. in the current study, it is not possible to motive networks 14 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ partition those sources of variance, and it would be worthwhile to qualitatively assess how conflicts emerged and how they were experienced by participants in future studies. fourth, the theoretical framework we drew upon – consistency theory (grawe, 2004) – is only one amongst many that are capable of informing motive conflicts. in the domain of psychodynamics, there are many theories that address motives and conflicts between motives. for example, the two-polarities model of personality development (blatt, 2007) assumes two motivational processes: interpersonal relatedness and self-def­ inition. in this model, psychopathology such as a depressive disorder can stem from a too strong focus on one of these processes accompanied by a neglect of the other. however, if one motivational process is active and the other is inactive all the time – in contrast to alternating activity –, there is no variance to be captured as motive conflict in experience sampling data. thus, the theoretical perspective adopted here, and the resulting operationalization cannot capture the entirety of motive conflicts, limiting the interpretation of the findings. lastly, the slightly adapted version of the inc-s which we used to assess congruence in daily life was not validated prior to the study. there are several avenues for future research. first, the convergent validity of motive networks could be assessed using other data sources such as clinical interviews (e.g., opd; arbeitskreis zur operationalisierung psychodynamischer diagnostik, 2023). sec­ ond, the test-retest reliability could be determined through repeated experience sampling phases (e.g., a month apart). lastly, the qualitative evaluation of motive networks could be achieved by interviewing participants about their personal motive networks (e.g., individual concordant and conflicting pairs of motives and their face validity for the interviewees). lüdtke, steiner, berger, & westermann 15 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://www.psychopen.eu/ funding: stefan westermann received funding from the unibe initiator grant. the study did not receive further funding. the funding had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: we have no conflicts of interest to disclose. ethics statement: this study was performed in line with the principles of the declaration of helsinki. the ethics committee of the faculty of human sciences at the university of bern approved the study (#2016-05-00006). all participants provided written informed consent prior to participation. preregistration: the study was not pre-registered. reporting guidelines: the manuscript was prepared in accordance with the jars-quant guidelines for quantitative research. an overview of approach motives as well as fit indices of the network’s nodes are provided in the supplementary materials. data availability: the data that support the findings of this study as well as the code are available from the corresponding author, stefan westermann, upon reasonable request. supplementary materials the supplement contains a table which lists all approach motives that were assessed in the present study including respective intraclass correlation coefficients (iccs), a table with fit indices for each node of the idiographic network models, as well as a figure with exemplary depictions of congruence of the autonomy and the affiliation motive over time for two participants (for access, see lüdtke et al., 2025s). index of supplementary materials lüdtke, t., steiner, f., berger, t., & westermann, s. 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(2016). critical slowing down as a personalized early warning signal for depression. psychotherapy and psychosomatics, 85(2), 114–116. https://doi.org/10.1159/000441458 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. lüdtke, steiner, berger, & westermann 21 clinical psychology in europe 2025, vol. 7(2), article e12305 https://doi.org/10.32872/cpe.12305 https://doi.org/10.1093/oxfordhb/9780190666453.013.23 https://doi.org/10.1093/oxfordhb/9780190666453.013.23 https://doi.org/10.1093/oxfordhb/9780190666453.013.23 https://doi.org/10.1159/000441458 https://www.psychopen.eu/ motive networks (introduction) theoretical background method recruitment procedures measures analyses results participant characteristics and adherence importance, satisfaction and conflict of motives associations between motive concordance as well as discordance and subclinical depressive symptoms exploratory analyses discussion the role of motive satisfaction limitations and future directions (additional information) funding acknowledgments competing interests ethics statement preregistration reporting guidelines data availability supplementary materials references the clinical role of euthymia in mental health editorial the clinical role of euthymia in mental health jenny guidi 1 [1] department of psychology ‘renzo canestrari’, university of bologna, bologna, italy. clinical psychology in europe, 2024, vol. 6(2), article e14349, https://doi.org/10.32872/cpe.14349 published (vor): 2024-06-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: jenny guidi, department of psychology ‘renzo canestrari’, university of bologna, viale berti pichat 5, 40127 bologna, italy. e-mail: jenny.guidi2@unibo.it the concept of euthymia was defined in the psychiatric literature essentially in negative terms, and extensively used to refer to the absence of mood disturbances meeting the threshold for a mental disorder based on diagnostic criteria or on cut-off points of dimensional assessment tools. however, in both unipolar and bipolar mood disorders, psychological distress may fluctuate considerably over time, even during the so-called ‘euthymic’ periods, and residual symptoms appear to be exceedingly common, indicating that the disorder is still present even though its intensity may vary (dunner, 1999; fava, 1999; judd et al., 2002). this, in turn, could negatively impact on vulnerability to relapse in the long term (fava, 1999). the concept of euthymia in 2016, fava and bech introduced a novel definition of euthymia, according to specific clinimetric criteria, as a state characterized by the lack of mood disturbances that can be subsumed under diagnostic rubrics and the presence of features such as positive affect and balanced levels in psychological well-being dimensions (namely, autonomy, environmental mastery, positive relations with others, personal growth, purpose in life and self-acceptance), leading to flexibility, consistency, and resistance to stress (i.e., anxietyor frustration-tolerance and resilience) (fava & bech, 2016). these psychological well-being dimensions, that were derived from marie jahoda’s model of positive mental health (jahoda, 1958), have a bipolar nature, ranging from suboptimal to excessively elevated levels, and interact with each other through a compensatory, or eventually dysfunctional, dynamic balance. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.14349&domain=pdf&date_stamp=2024-06-28 https://orcid.org/0000-0001-6815-2738 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ this unifying concept of euthymia was subsequently refined by fava and guidi (2020) and further elaborated (guidi & fava, 2020, 2022), with particular regard to its relationships with other clinical constructs (e.g., individual characteristics, concurrent distress and other psychological attributes), and its associations with lifestyle behaviors and allostatic load. allostatic load can be conceived as a result of the cumulative effects of daily life experiences encompassing both major challenges (i.e., life events) and ordinary events (i.e., subtle and/or repeated sources of chronic stress) (mcewen & stellar, 1993). when environmental challenges exceed the individual ability to cope, then allostatic overload ensues, with a number of negative consequences on both physical and mental health (fava et al., 2019; guidi et al., 2021). according to mcewen’s (2020) viewpoint, ‘euthymia means using allostatis optimally and maintaining a healthy balance that promotes positive aspects of brain and body health through health-promoting be­ haviors’. such behaviors include not only healthy eating habits, but also adequate and good-quality sleep, regular physical activity, refraining from smoking, alcohol and drug consumption, as well as positive social interactions and features of physical environment, which contribute to reduce allostatic load. clinical assessment of euthymia exclusive reliance on diagnostic criteria (i.e., dsm-5-tr, icd-11) often does not allow to capture the complexity of several manifestations that are encountered in clinical practice. a comprehensive clinical assessment requires appropriate collection and integration of a number of clinical variables, according to a clinimetric framework (fava, 2022). clinical interviewing should encompass evaluation of euthymia (guidi & fava, 2022), allostatic load/overload (fava et al., 2019; guidi & fava, 2022) and lifestyle habits according to a longitudinal perspective. instruments for assessing euthymia according to clinimetric principles have been developed. the clinical interview for euthymia (cie; guidi & fava, 2022) is a 22-item observer-rated clinimetric tool for gathering information on pos­ itive affect, both impaired and excessive levels in psychological well-being dimensions, flexibility, consistency and resistance to stress. further, the semi-structured interview for the diagnostic criteria for psychosomatic research (ssi-dcpr; guidi & fava, 2022) permits to assess, among other psychosomatic syndromes, allostatic overload and related constructs, such as demoralization. as to self-rated clinimetric measures, the 10-item euthymia scale (es; fava & bech, 2016; carrozzino et al., 2019) represents an expanded version of the who-5 well-being index (who-5; topp et al., 2015) to evaluate positive affect and jahoda’s well-being dimensions (i.e., flexibility, consistency and resistance to stress). other clinimetric instru­ ments that may be used jointly are the psychosocial index (psi; piolanti et al., 2016) encompassing aspects related to allostatic load, and the symptom questionnaire (sq; benasi et al., 2020) for assessing both distress symptoms and well-being. euthymia in mental health 2 clinical psychology in europe 2024, vol. 6(2), article e14349 https://doi.org/10.32872/cpe.14349 https://www.psychopen.eu/ euthymia as a treatment target euthymia can be regarded as a therapeutic target, particularly when pre-planned sequen­ tial treatment strategies are implemented (e.g., psychotherapy after pharmacotherapy, or the sequential combination of two psychotherapeutic strategies) to decrease vulnerability to relapse in affective disorders, increase the level of recovery, and modulate mood (guidi & fava, 2021). well-being therapy (wbt; fava, 2016; guidi & fava, 2020) is a manualized, shortterm psychotherapeutic approach specifically aimed at modulating psychological wellbeing and pursuing a state of euthymia. wbt has introduced a clinical revolution in self-observation: patients are encouraged to identify episodes of well-being and their situational contexts. this systematic monitoring of well-being by using a structured diary represents a key, distinct therapeutic ingredient of wbt (fava, 2016; guidi & fava, 2020), facilitates interaction between patients and therapists, and stimulates cognitive restructuring and homework (e.g., optimal experiences) based on the individual’s account and material. psychotherapeutic strategies geared to euthymia, such as wbt, should be applied within a clinimetric framework, based on clinical reasoning and case formulation accord­ ing to macroand micro-analysis, and staging (fava, 2022). the treatment plan should be filtered by clinical judgment and integrate a number of clinical variables, such as severity and features of psychiatric disturbances, co-occurring symptoms and problems, medical comorbidities, patient’s history and preferences, and psychological well-being (fava, 2022). clinical applications and new developments there are several potential clinical applications of treatments that target euthymia, including relapse prevention in depressive disorders, improving recovery in affective and other psychiatric disorders, modulating mood in bipolar-spectrum disorders, managing treatment resistance as well as discontinuation of psychotropic drugs, treating suicidal behavior and post-traumatic stress disorder (guidi & fava, 2020). further, more recent findings support the clinical relevance of euthymia and lifestyle modification in improv­ ing medical outcomes, particularly in the setting of chronic medical diseases (rafanelli et al., 2020). indeed, a personalized approach targeting psychological well-being and euthy­ mia may effectively improve patients’ health attitudes and behavior, and promote endur­ ing lifestyle changes (fava et al., 2023). potential technical developments of wbt may derive from its application to couples, families, and groups, whereas computerized/digital methods of delivery could also be feasible, yet to be tested. guidi 3 clinical psychology in europe 2024, vol. 6(2), article e14349 https://doi.org/10.32872/cpe.14349 https://www.psychopen.eu/ conclusions the clinical role of euthymia supports innovative approaches to the assessment and treatment of mental disorders, and provides new, important insights in their psychother­ apeutic management by modifying customary psychiatric approach, still unbalanced towards psychological dysfunction. funding: the author has no funding to report. acknowledgments: the author has no additional (i.e., non-financial) support to report. competing interests: prof. jenny guidi has no competing interests, financial or otherwise to declare. related versions: this editorial is based on prof. jenny guidi’s oral presentation at the eaclipt x umh conference 2024 in amsterdam. references benasi, g., fava, g. a., & rafanelli, c. 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(2015). the who-5 well-being index: a systematic review of the literature. psychotherapy and psychosomatics, 84(3), 167–176. https://doi.org/10.1159/000376585 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. guidi 5 clinical psychology in europe 2024, vol. 6(2), article e14349 https://doi.org/10.32872/cpe.14349 https://doi.org/10.1016/j.cpr.2020.101941 https://doi.org/10.1001/jamapsychiatry.2020.3650 https://doi.org/10.1159/000524279 https://doi.org/10.1159/000510696 https://doi.org/10.1001/archpsyc.59.6.530 https://doi.org/10.1002/wps.20720 https://doi.org/10.1001/archinte.1993.00410180039004 https://doi.org/10.1159/000447760 https://doi.org/10.1159/000510006 https://doi.org/10.1159/000376585 https://www.psychopen.eu/ euthymia in mental health (introduction) the concept of euthymia clinical assessment of euthymia euthymia as a treatment target clinical applications and new developments conclusions (additional information) funding acknowledgments competing interests related versions references a remote adapted physical activity intervention for women with breast cancer and severe depressive or anxiety symptoms: series of n-of-1 trials with ecological momentary assessment research articles a remote adapted physical activity intervention for women with breast cancer and severe depressive or anxiety symptoms: series of n-of-1 trials with ecological momentary assessment johan caudroit 1 , samuel st-amour 2 , josyanne lapointe 3,4, ahmed jerôme romain 4,5 , alain steve comtois 3 , guillaume chevance 6 , paquito bernard 6 [1] laboratoire sur les vulnérabilités et l’innovation dans le sport, université claude bernard lyon 1, villeurbanne, france. [2] health sciences department, université du québec à rimouski, rimouski, qc, canada. [3] physical activity sciences department, université du québec à montréal, montreal, qc, canada. [4] research centre, university institute of mental health in montreal, montreal, qc, canada. [5] school of kinesiology and physical activity sciences, faculty of medicine, université de montréal, montreal, qc, canada. [6] ehesp, inserm, irset (institut de recherche en santé, environnement et travail) – umr_s, 1085, université de rennes, rennes, france. clinical psychology in europe, 2025, vol. 7(3), article e14851, https://doi.org/10.32872/cpe.14851 received: 2024-06-17 • accepted: 2025-04-14 • published (vor): 2025-08-29 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: paquito bernard, irset (institut de recherche en santé, environnement et travail), avenue professeur léon bernard, rennes 35000, france. +33 2 23 23 69 11. e-mail: paquito.bernard@inserm.fr supplementary materials: code, data, materials, preregistration [see index of supplementary materials] abstract background: women with breast cancer live with the burden of the disease, its treatment, and the psychosocial consequences of illness, often contributing to the experience of psychological distress. at this end, physical activity (pa) is an evidence-based strategy to decrease depressive and anxiety symptoms. however, no study has yet investigated how those psychological symptoms fluctuate and vary during a pa intervention at the individual level, especially for individuals with severe psychological distress. thus, the aim of the present study was to examine the short-term effects of a 12-week remote pa intervention on daily level of depressive and anxiety symptoms among women with breast cancer and severe depressive or anxiety symptoms. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.14851&domain=pdf&date_stamp=2025-08-29 https://orcid.org/0000-0002-5994-1337 https://orcid.org/0000-0002-6282-7885 https://orcid.org/0000-0003-1690-1375 https://orcid.org/0000-0002-6159-3220 https://orcid.org/0000-0002-8926-4816 https://orcid.org/0000-0003-2180-9135 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ method: a n-of-1 study followed an aba’ design was conducted. each a phase (2-week) represents preand post-intervention phase and b phase (12-week) represents the intervention phase. for the whole 16 weeks, participants received a daily prompt to report their depressive and anxiety levels. the intervention combined two to three (un)supervised remote pa sessions per week coupled with weekly text messages. results: sixteen participants completed the intervention. a significant decrease of depressive and anxiety symptoms was found for nine and seven participants, respectively. different temporal patterns of depressive and anxiety were observed during and after the intervention. interestingly, the impact of pa intervention was generally not immediate and gradual. conclusion: this study supports the utility of remote pa intervention to improve depressive and anxiety symptoms in women with breast cancer and poor mental health. keywords psychological distress, cancer, physical exercise, tele-health, single case experimental study highlights • a remote physical activity intervention is beneficial for adults experiencing severe psychological distress. • n-of-1 coupled with ema is a solid method to observe the fluctuation of mental health symptoms. • physical activity benefits on mental health symptoms are not immediate but gradual. poor mental health is a major clinical issue during and post-breast cancer treatment (caruso et al., 2017; kissane, 2014; niedzwiedz et al., 2019). previous meta-analyses have reported that the prevalence of anxiety and depressive symptoms among women with breast cancer (bc) reached 44.2% and 28.9% for moderate levels and 20% and 13.2% for severe level, respectively (hashemi et al., 2020; pilevarzadeh et al., 2019). severe depressive or anxiety symptoms are associated with higher risk of mortality and cancer recurrence (wang et al., 2020) but also with lower cancer treatments adherence, higher health related costs and impaired quality of life (mausbach et al., 2015, 2018; mitchell et al., 2013). regarding treatment options, psychological therapies and antidepressants can de­ crease the symptoms' intensity among women with a bc and moderate levels of depres­ sive and anxiety symptoms. however, the effectiveness of these interventions is very modest (vita et al., 2023; xiao et al., 2017) and, in most cases, women with severe depressive and anxiety symptoms were excluded from clinical trials (carvalho et al., 2014). therefore, new interventional strategies must be explored and applied to women with bc and moderate to severe depressive and anxiety symptoms. at this end, high level of evidence revealed that physical activity (pa) interventions are effective treatments to help adults with moderate or severe depressive or anxiety dis­ exercise for mental health in breast cancer 2 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ orders (ravindran et al., 2016). for bc, the american college of sport medicine (acsm)’s guideline highlighted that pa interventions are an evidence-based strategy to decrease the risk of depressive or anxiety symptoms (campbell et al., 2019). meta-analyses in­ cluding more than thirty randomized controlled trials, suggested that pa interventions decrease the depressive and anxiety symptoms during and after bc treatment (carayol et al., 2013, 2015). however, none of these trials included women with a severe level of depression or anxiety (bernard & carayol, 2015). one reason is that designing an adapted pa intervention for those women is very challenging because the presence of depressive and anxiety symptoms decreases the pa engagement and adherence rate (bullard et al., 2019). so, it is crucial to individualize and personalize the pa intervention, according to preferred pa modalities in women with bc (schmitz et al., 2019) and in using behavioral change techniques during the intervention. furthermore, the daily fluctuations of those symptoms are complex to observe with a simple preand post-intervention measurement (bentley et al., 2019). an appropriate method, such as single case experimental study (or n-of-1) is necessary to examine the evolution of depressive and anxiety symptoms during the intervention (bentley et al., 2019). n-of-1 has received an increasing interest in oncology (sequeira et al., 2023), pa (lapointe et al., 2023), and mental health research (st-amour et al., 2024). this design consists in collecting data regularly form participants as they progress through different phases of the study, i.e., the first phase measures the baseline of the interest variables and the subsequent phase serve to introduce the intervention. the data from the inter­ vention phase are compared to the baseline phase, providing strong internal validity for each participant. in addition, conduction n-of-1 combined with ecological momentary assessment (ema) is a solid methodological approach to examine the effects of a clinical intervention on depressive and anxiety symptoms at individual level. ema has been recommended to improve the ecological validity and reduce recall bias (st-amour et al., 2024). the goal of the present study was to examine the short-term effects of a 12-week supervised adapted pa intervention on daily levels of depressive and anxiety symptoms among women with bc and severe depressive or anxiety symptoms. we hypothesize that (1) daily level of depressive and anxiety symptoms will decrease during the intervention and (2) intervention effects were maintained 2 weeks after its end. method this research protocol has been approved by the ethics boards of the eastern montreal integrated university health and social services centre (2022-4319). this manuscript was written according to the single-case reporting guideline in behavioural interventions (scribe; tate et al., 2016). the scribe checklist is provided in the supplementary materials (bernard, 2025s). caudroit, st-amour, lapointe et al. 3 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ study design this n-of-1 study followed an a-b-a design (representing the three phases of the study) and lasted 16 weeks. no randomization nor blinding were used due to the nature of the study. each a phase (2-week each) represents the preand post-intervention baseline measures, and the b phase (12-week) represents the intervention phase. for the whole 16 weeks, participants received a daily ema prompt to report their depressive and anxiety levels. the intervention (b phase) included two to three (un)supervised remote pa sessions per week coupled with motivational and educational text messages. recruitment participants were recruited from maisonneuve rosemont or santa cabrini hospitals (montreal, canada). flyers, outlined the study aims, inclusion criteria and contact infor­ mation for the research coordinator, were distributed through psycho-oncology consulta­ tions and shared to patients on the psycho-oncology unit waitlist and on the oncology center website and social networks. potential participants were screened by telephone and included if they: 1) were diagnosed with a non-metastatic bc and currently complet­ ing treatment or completed treatment at least three months prior; 2) reported a high level of self-reported depressive (patient health questionnaire score ≥ 15) or anxiety symptoms (general anxiety disorder’s questionnaire score ≥ 15); 3) were aged 18 to 65 years; 4) were considered inactive (less than 150 minutes per week or godin’s ques­ tionnaire score < 23; amireault et al., 2015); 5) possessed a smartphone. participants were excluded if they: 1) reported a psychotic or schizophrenia disorder diagnostic; 2) answered positively to the pa readiness questionnaire for everyone; 3) received a weekly psychological treatment from a clinician; 4) reported a major functional or physical disability; 5) were unable to provide consent. the consent form was sent via e-mail before the initial evaluation. participants were rewarded $150 ca upon study completion. physical activity intervention the intervention combined a remote adapted pa intervention, supervised by a kinesiol­ ogist, coupled with weekly text messages for 12 weeks. the characteristics of this inter­ vention were based on the acsm recommendations, identified behavioral change techni­ ques and pa preferences in interventional context among women with bc (caudroit, chevance, et al., 2025). the detailed description of the intervention development and content have been previously published (caudroit, lapointe, et al., 2025). this interven­ tion has been found as feasible, acceptable, and associated with high adherence rates (caudroit, lapointe, et al., 2025). participants had three supervised remote pa sessions from week three to six. from week seven to 14, participants had two supervised remote pa sessions, with the choice exercise for mental health in breast cancer 4 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ between supervised or unsupervised sessions for the third weekly session. the super­ vised pa sessions included: 1) combination of behavioral change techniques and aerobic exercise with resistance or yoga exercises (participants’ choice); 2) the durations of sessions ranged from 30 (weeks 3-6) to 60 minutes (weeks 7-14) but actual durations were adaptable based on participants’ self-reported fatigue level; 3) the effort intensity was selected by the participant, guided by the proposed intensity of the day provided by the kinesiologist, explained through the rate of perceived exertion, progressively increasing, and varying between 1 and 8 (different for aerobics, resistance, yoga) on a scale of 10 during the 14 weeks. the unsupervised pa sessions could be based on previous supervised sessions or personalized after discussions with the participant (e.g., 2 weekly walks of 30 minutes). measures online questionnaires and ema were used to measure our variables of interest during the phases of our study. in line with the scribe, we used validated questionnaires to describe participants demographic characteristics and clinical features (tate et al., 2016). a research-oriented app was installed (ethicadata) on participants’ smartphones to obtain self-measured daily rating of depressive and anxiety symptoms. questionnaires before the intervention, online questionnaires collected information on age, educational achievements, marital status, income, number of children, date of diagnosis, treatments, current medications, and history of cancer. according to the scribe recommendations, generalization measures were also performed to increase the external validity of the study. thus, gad-7 and phq-9 were filled by participants three times during the study (details in figure 1; tate et al., 2016). the respective validated thresholds of these scales were used to describe the individual scores (see details in the supplementary materials [bernard, 2025s]). the patient health questionnaire (phq-9) is a screening instrument with nine items, developed to assess the severity of depression (kroenke et al., 2001). for each item, the respondent is asked to rate how often each symptom occurred over the last two weeks, on a likert scale ranging from 0 “not at all” to 3 “nearly every day”. the sum score (range to 0 to 27) indicates the degree of depression with score of ≥ 15 representing severe levels of depression (howell et al., 2015). the generalized anxiety disorder (gad-7) is a one-dimensional instrument created to detect symptoms of generalized anxiety disorders (spitzer et al., 2006). core symptoms within the past two weeks were queried with seven items on a four-point likert scale rated from 0 (not at all) to 3 (nearly every day). the total gad-7 score can range from 0 to 21 and a score ≥ 15 represents severe anxiety symptoms levels (howell et al., 2015). phq-9 and gad-7 caudroit, st-amour, lapointe et al. 5 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ are both recommended questionnaires by the canadian association of psychosocial oncology (howell et al., 2015). figure 1 study design daily assessments every day during the phase b, participants rated the severity of depressive and anxiety symptoms using a 0-100 visual analog slider (0: not at all – 100: as much as possible). participants rated the severity of depression symptoms with 8 adapted items from the patient health questionnaire (phq-9, kroenke et al., 2001). the severity of anxiety symptoms was measured with 6 adapted items from the gad-7 (spitzer et al., 2006). all ema items are presented in table 1. internal validity single case experimental studies may be subject to rival hypotheses that can explain changes in the dependent variables like maturation, question-behavioral effect, and other external factors (st-amour et al., 2024). to ensure the internal validity (i.e., the observed change is attributable to the intervention rather than other factors), participants were questioned at the end of phase b about important event having occurred in their life during the phase they just finished that could have a prolonged (positive or negative) impact on their mental health symptoms. statistical analyses a piecewise linear regression has been performed for each participant. this analysis is particularly well-suited for time series with gaussian or poisson distribution (lapointe et al., 2023; wilbert, 2021). we considered the auto-correlation between symptoms data only for models with a gaussian distribution because it was implemented only for the exercise for mental health in breast cancer 6 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ latter in the scan package (wilbert, 2021). through those analyses, we compared the daily depression and anxiety level during and after the intervention to baseline measures. each piecewise regression was carried out to examine the level effects (i.e., the difference between the mean of symptoms in phase a with phase b and a’, divided by the standard deviation of the residuals) and test the slope effects (i.e., the continuous change of symptom levels due to the pa intervention). two models were systematically compared by including or not the trend. the model with the highest r 2 was finally selected for each dependent variable. transparency and openness the study protocol was registered a priori with osf registries (see supplementary mate­ rials [bernard et al., 2022s]). analyses and graphics have been performed with r 4.3 and ggplot2, and scan packages. data, open materials, and r scripts are available online (bernard, 2024s-a). table 1 ecological momentary assessment items variable / item depressive symptoms today, i feel depressed today, i feel guilty today, i had difficulties in concentrating today, i feel tired today, i feel like i am in slow motion today, i have a good appetite today, i felt hopeless today, i have little interest or pleasure in what i am doing anxiety symptoms today, i have a feeling of fear today, i feel angry today, i feel worried today, i feel restless today, i feel irritable today, i am feeling muscle tension caudroit, st-amour, lapointe et al. 7 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ results participants characteristics between 2022 may and 2023 june, 18 participants (10 during treatment and eight posttreatment) were included. baseline sociodemographic, health and cancer-related informa­ tion, and pa adherence sessions rates are in table 2. two participants were dropped during this study. some participants postponed the beginning of their intervention phase due to events out of their control making some a phases longer for some than others. regarding scores on phq-9 and gad-7, all participants experienced severe psychological distress (score ≥ 15 on, at least, one scale) with 13 patients who had severe depressive disorders, one who had severe anxiety disorders and four who had severe depressive and anxiety disorders. the ema adherence rates were ranged from 48% to 88%, with eight participants with a rate above 70%. table 2 study participant characteristics id age marital status education working status incomes (k$) bmi cancer stage in treatmenta smoking gad7 phq9 adherence id1 44 single coll sl 40-60 23 i yes no 13 17 62 id2 43 single coll sl 40-60 dk iii no no 15 17 100 id3 59 married coll ftw >80 25 ii yes no 14 16 85 id4 29 married high s sl >80 48 iv yes no 10 18 97 id5 38 married univ sl 20-40 30 ii yes no 12 15 94 id6 44 married univ sl >80 27 i yes no 12 15 88 id7 61 single univ ptw 40-60 14 i yes no 13 21 82 id8 45 single coll ftw 60-80 55 iii no yes 12 18 91 id9 30 married univ sl >80 37 iii yes no 15 19 97 id10 50 other coll sl 40-60 32 ii yes no 17 18 100 id11 52 married coll ptw 20< 40 i yes yes 22 13 32 id12 47 single univ sl 40-60 14 dk yes no 11 17 91 id13 29 single colle ftw >80 21 ii no no 9 16 88 id14 37 divorced coll sl 20< 28 ii no no 11 19 94 id15 45 divorced univ sl 40-60 41 ii no no 18 18 94 id16 60 other coll sl 20-40 74 ii no no 11 21 38 note. dk = don’t know; univ = university; coll = college; high s = high school; sl = sick leave; ftw = full-time work; ptw = part-time work; bmi = body mass index; phq = patient health questionnaire; gad = general anxiety disorder; adherence = number of adapted physical activity sessions realized. achemotherapy or radiotherapy. intervention effects figures 2 and 3 present the daily mean of depression and anxiety symptoms for all par­ ticipants and local regressions. table 3 and 4 present the results of piecewise regressions. the level regression coefficient indicates a mean level change after the beginning of exercise for mental health in breast cancer 8 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ intervention. the slope regression coefficient indicates the daily decrement following the beginning of intervention. a significant decrease of depressive symptoms during the intervention has been found among 10 participants (id2, id3, id4, id5, id8, id13, id10, id11, id12, id15, see details in table 2). as presented in figure 2, different patterns of symptom reduction can be observed. for id4, id5, id8, id12, a negative and significant effect was found for level and slope. in other words, benefits from our intervention were quick and progressive. for id2, id3, id13, the beginning of intervention was associated with a significant higher level of symptoms, however, these symptoms gradually decreased (i.e., negative slope) during the intervention. a significant reduction of daily depressive symptoms was observed only for the level (id10, id15) or slope (id11). figure 2 depression scores in three conditions with regression lines for each phase caudroit, st-amour, lapointe et al. 9 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ figure 3 anxiety scores in three conditions with regression lines for each phase a significant decrease of anxiety symptoms following the introduction of the interven­ tion has been found for nine participants (id1, id2, id3, id4, id5, id10, id11, id12, id13, see details in table 3). different patterns of symptom reduction have also been found (see figure 3). for id12, a negative and significant effect was found for level and slope. for id3, the beginning of intervention was associated with significant a higher level of anxi­ ety symptoms, however, these symptoms gradually decreased during the intervention. a significant reduction of daily anxiety symptoms was observed only for the level or slope for id10, id11, and id1, id2, id4, id5, id13, respectively. in summary, a significant reduction of depression and anxiety symptoms was found among seven participants (id2, id3, id4, id5, id10, id12, id13). a no significant effect of our intervention on mental health symptoms was found for four participants (id6, id9, id14, id16). also, id6 showed a significant progressive increase of depressive and anxiety symptoms during the follow-up phase. exercise for mental health in breast cancer 10 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ table 3 results of piecewise regressions for depressive symptoms id phase b vs a phase a2 vs a level slope level slope b 2.5% 97.5% b 2.5% 97.5% b 2.5% 97.5% b 2.5% 97.5% 1 14.36 -9.73 38.45 1.19 -.06 2.45 68.32 -27.02 163.66 3.14 -1.04 7.32 2 15.27* 4.81* 25.73* -.48* -.63* -.33* -16.67 -37.32 3.98 -.88 -4.46 2.71 3 9.62* 2.48* 16.76* -.30* -.43* -.17* -17.86* -29.59* -6.14* -.58 -1.47 .31 4 -.40* -.56* -.23* -.03* -.04* -.02* -3.38* -4.45* -2.32* -.03 -.07 .01 5 -.66* -.84* -.48* -.08* -.09* -.05* -7.46* -9.26* -5.65* -.05* -.09* -.01* 6 .40 -18.73 19.53 .15 -1.13 1.42 -10.76 -131.59 110.07 3.37* .98* 5.76* 7 -9.99 -22.93 2.94 -.08 -.27 .11 -32.09* -55.81* -8.37* .30 -3.42 4.02 8 -.17* -.32* -.03* -.01* -.01* -.01* -.94* -1.21* -.68* -.01 -.03 .01 9 -3.60 -13.23 6.04 -.52 -1.67 .62 -41.06 -95.19 13.06 1.84 -7.65 11.33 10 -15.81* -20.70* -10.91* -.01 -.08 .06 -19.95* -26.85* -13.05* -.21 -.68 .26 11 2.26 -5.91 10.42 -.86* -1.03* -.69* -39.12* -51.51* -26.73* .39 -.94 1.72 12 -12.99* -16.80* -9.18* -.36* -.50* -.22* -20.94* -38.72* -3.17* 4.35 -7.43 16.14 13 7.00* .58* 13.43* -.35* -.45* -.26* -22.92* -33.91* -11.93* -.07 -1.44 1.29 14 -2.59 -19.37 14.18 -.08 -.31 .15 2.19 -23.44 27.81 -.49 -2.71 1.74 15 -23.85* -43.17* -4.53* .47* -.05 1.00 3.10 -18.50 24.70 -.96 -2.26 .34 16 1.29 -12.16 14.73 -.25 -1.28 .79 -25.21 -118.30 67.88 .31 -1.22 1.84 *p < .05. significant slope changes were observed more often than level changes (8/10 for depres­ sive and 7/9 anxiety symptoms), indicating that the impact of pa on mental health was generally gradual. seven participants with a significant reduction of depressive symp­ toms during the intervention showed maintained benefits during the follow-up phase (id, 3, id4, id5, id8, id11, id12, id13). four women experienced maintained benefits in terms of anxiety (id1, id4, id5, id13). the statistical modeling of time series explained 15% to 74%, and 12% to 54% of the variance for depressive and anxiety symptoms, respectively (more details are provided in the supplementary materials [(bernard, 2025s]). a visual analysis of repeated phq-9 and gad-7 scores (see figure s.1. and s.2. in the supplementary materials [bernard, 2024s-b]) shows that most of the participants (with complete data) had a score below the clinical cut-off at the end of intervention. caudroit, st-amour, lapointe et al. 11 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ table 4 results of piecewise regressions for anxiety symptoms id phase b vs a phase a2 vs a level slope level slope b 2.5% 97.5% b 2.5% 97.5% b 2.5% 97.5% b 2.5% 97.5% 1 7.70 -7.68 23.08 -.96 -1.70 -.21 -80.52 -138.72 -22.33 2.20 -.87 5.28 2 2.81 -8.38 13.99 -.23* -.41* -.06* -8.18 -28.24 11.88 -1.03 -4.22 2.16 3 19.86* 10.50* 29.23* -.27* -.41* -.13* -2.47 -17.16 12.23 -.77 -2.02 .49 4 -.16 -.35 .03 -.05* -.06* -.04* -3.98* -5.23* -2.73* -.05* -.09* .00* 5 -.10 -.32 .12 -.06* -.08* -.03* -5.48* -7.63* -3.32* -.04* -.08* .00* 6 6.80 -5.74 19.33 -.03 -.20 .15 -8.73 -28.43 10.96 3.38* 1.45* 5.31* 7 -2.56 -13.39 8.26 -.14 -.30 .02 -11.71 -33.53 10.11 -3.75* -7.27* -.23* 8 4.84 -4.43 14.11 -.01 -.30 .27 .81 -35.27 36.90 .01 -.49 .51 9 6.78 -2.22 15.78 -.89 -1.92 .14 -40.63 -89.36 8.11 3.83 -5.02 12.68 10 -17.71* -24.55* -10.88* -.17 -.68 .33 -37.82 -83.46 7.82 -.28 -.95 .40 11 -11.82* -19.83* -3.81* .43 -.46 1.33 20.40 -44.40 85.20 .41 -.74 1.56 12 -21.19* -27.05* -15.34* -.72* -1.23* -.20* -45.22* -85.39* -5.06* -1.19 -11.24 8.86 13 .06 -.20 .09 -.02* -.02* -.02* 2.57* -3.22* -1.99* .08* .01* .15* 14 4.94 -6.39 16.28 -.02 -.17 .13 1.24 -17.48 19.97 1.44 -.25 3.13 15 -10.21 -22.74 2.32 -.14 -.46 .17 -9.41 -23.57 4.76 -.75 -1.85 .34 16 -.79 -8.00 6.41 -.08 -.20 .04 -14.47 -28.91 -.04 .08 -1.48 1.64 *p < .05. personal event during intervention eleven participants were available for the short interview at the end of intervention. the reported personal events are presented in the supplementary materials (bernard, 2025s). discussion the primary aim of this study was to evaluate the short-term effects a 12-week remote adapted pa intervention on daily levels of depressive and anxiety symptoms among women with bc and severe depressive or anxiety symptoms. we hypothesized that daily level of depressive and anxiety symptoms would decrease during the intervention and that these benefits would be maintained two weeks after intervention. our findings show that our program progressively decreases the depressive and anxiety symptoms among 10 and nine participants, respectively. this significant decrease of symptoms could be considered as clinically relevant because observed benefits were corroborated with the decrease phq-9 and gad-7 after the intervention. after phase b, most of our patients showed improvement, moving from a severe to a moderately severe or moderate depression score, and from a moderately severe to a moderate anxiety score. overall, this study supports the utility of remote pa intervention to improve depressive exercise for mental health in breast cancer 12 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ and anxiety symptoms in women with bc and poor mental health. it is difficult to compare our results to previous studies as no other study has examined the effect of pa in this specific population. however, our positive findings are in line with previous meta-analyses suggesting significant benefits of physical activity on mental health in women with breast cancer (carayol et al., 2013, 2015). the remote format of our intervention is particularly promising because physical dis­ tance from care and the disproportionate distribution of mental healthcare providers are two major barriers for patients with cancer and severe psychological distress (deshields et al., 2021). another important finding is that the benefits from pa were generally not immediate, i.e., not associated with the beginning of intervention. it is in line with the canadian treatment guidelines for mood disorders concluding that pa interventions length has to be superior to 10 weeks to decrease the depression severity (ravindran et al., 2016). this progressive effect is also in line with previous n-of-1 studies examining the benefits of pa in young adults with high depressive symptoms (mcfadden et al., 2017) or women with major depressive disorders (doyne et al., 1983). our intervention did not show significant effect for all included women. the absence of mental health benefits from our intervention could be partially explained by personal events during the intervention: cancer treatment (id16) or mourning experiences (id14). other factors could also be associated with responsiveness to the intervention such as a low adherence rate (e.g., id16), intensity of pa session (bernard et al., 2013), or type of exercise. indeed, carayol et al. (2015) suggested that yoga related activities led to greater decrease of depressive and anxiety symptoms rather than aerobic/resistance-pa during bc treatment. the fear of cancer recurrence (savard & ivers, 2013) might also play a moderating role in the effectiveness of pa intervention for this population. future studies should consider this factor as a judgment or inclusion criterion to optimize the benefits of pa program. to our knowledge, this is the first study examining the effects of a pa intervention among women with bc and severe depressive or anxiety symptoms. although this study employed a robust method, our results have to be replicated with a larger sample to understand the pa intervention response heterogeneity. also, more complex models should also be used to examine the daily dynamic of mental health outcomes (batley, 2024). while our results are promising, this study is not without limitations. firstly, repeat­ edly asking study participants about their mental health symptoms with ema may increase their awareness about them (runyan et al., 2013), thus influence outcomes and threat the internal validity in our n-of-1. secondly, women with metastatic bc were excluded from our study because we could not fully guarantee the safety of these patients during remote pa sessions. future studies should investigate how to implement a safe remote pa intervention for this population, who is less aerobically fit, more symptomatic and report higher levels of fatigue and dyspnea (yee et al., 2014). thirdly, caudroit, st-amour, lapointe et al. 13 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://www.psychopen.eu/ the collection of information regarding impactful life events that could influence our result was missing for 4 participants. consequently, we could not check the internal validity our findings. in conclusion, the present study is the first to report on the short-term effect of remote adapted pa for the treatment of severe depressive or anxiety symptoms. future investigations could assess the efficacy of several strategies to improve the maintenance of mental health benefits, such as offering additional booster sessions as needed. our findings are relevant for clinical practice, as they suggest that our intervention can be easily implemented for women with bc living far to psycho-oncology services. funding: this research received a grant of fondation cancer du sein du québec. ajr is supported by a fellowship grant of fonds québec recherche santé. acknowledgments: the authors would like to thank arnaud delagrave, julien gagnon, lucie edorh, guillaume montpetit, sandie oberoi, celia kingsbury, marc lanovaz, clarisse defer, and chiappara rosangela for their involving in this study. competing interests: no potential conflict of interest was reported by the author(s) ethics statement: the research protocol has been approved by the ethics boards of the eastern montreal integrated university health and social services centre (2022-4319). social media accounts: paquito bernard: mastodon, bluesky preregistration: the study protocol was registered a priori (see bernard et al., 2022s). reporting guidelines: this manuscript was written according to the single-case reporting guideline in behavioural interventions. data availability: data, open materials, and r scripts are available online (see bernard, 2024s-a, 2024s-b, 2025s). supplementary materials the supplementary materials contain the following items: • preregistration (bernard et al., 2022s) • research data and r code (bernard, 2024s-a) • additional figures (bernard, 2024s-b) • additional information: ◦ detailed statistic findings (bernard, 2025s) ◦ scribe checklist (bernard, 2025s) ◦ interview findings (bernard, 2025s) exercise for mental health in breast cancer 14 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://masto.ai/@paquitobernard https://bsky.app/profile/paquitobernard.bsky.social https://www.psychopen.eu/ index of supplementary materials bernard, p. (2024s-a). a remote adapted physical activity intervention for women with breast cancer and severe depressive or anxiety symptoms: series of n-of-1 trials with ecological momentary assessment: data + r code [research data and r code]. osf. https://osf.io/m7xpu/ bernard, p. (2024s-b). a remote adapted physical activity intervention for women with breast cancer and severe depressive or anxiety symptoms: series of n-of-1 trials with ecological momentary assessment: figures [additional figures]. osf. https://osf.io/z7tm5/ bernard, p. (2025s). a remote adapted physical activity intervention for women with breast cancer and severe depressive or anxiety symptoms: series of n-of-1 trials with ecological momentary assessment: supplementary files [additional information]. osf. https://osf.io/tmfub/ bernard, p., lapointe, j., caudroit, j., comtois, a. s., & lanovaz, m. j. 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(2014). physical activity and fitness in women with metastatic breast cancer. journal of cancer survivorship: research and practice, 8(4), 647–656. https://doi.org/10.1007/s11764-014-0378-y clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. caudroit, st-amour, lapointe et al. 19 clinical psychology in europe 2025, vol. 7(3), article e14851 https://doi.org/10.32872/cpe.14851 https://doi.org/10.1007/s11764-014-0378-y https://www.psychopen.eu/ exercise for mental health in breast cancer (introduction) method study design recruitment physical activity intervention measures questionnaires daily assessments internal validity statistical analyses transparency and openness results participants characteristics intervention effects personal event during intervention discussion (additional information) funding acknowledgments competing interests ethics statement social media accounts preregistration reporting guidelines data availability supplementary materials references assessing perinatal psychiatric morbidity: implications for maternal mental health care in italy research articles assessing perinatal psychiatric morbidity: implications for maternal mental health care in italy giulia ciuffo 1 , marta landoni 2 , chiara ionio 1 [1] cridee, trauma research unit, department of psychology, faculty of psychology, catholic university of the sacred heart, milan, italy. [2] cridee, department of psychology, faculty of psychology, catholic university of the sacred heart, milan, italy. clinical psychology in europe, 2025, vol. 7(3), article e15117, https://doi.org/10.32872/cpe.15117 received: 2024-07-15 • accepted: 2025-03-08 • published (vor): 2025-08-29 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: giulia ciuffo, cridee, unità di ricerca sul trauma, dipartimento di psicologia, università cattolica del sacro cuore, largo gemelli, 1, 20123 milano (italy). +390272343642. e-mail: giulia.ciuffo@unicatt.it supplementary materials: materials [see index of supplementary materials] abstract background: traumatic births impact women’s long-term health, family dynamics, and healthcare systems, underscoring the need for prevention and effective interventions. despite italy's universal healthcare, perinatal mental health services and guidelines, especially for childbirth-related ptsd (cb-ptsd), remain underdeveloped. this study aims to investigate the prevalence of cb-ptsd, postpartum depression (ppd), and anxiety in italian women 6-12 weeks postpartum, and assess the impact of comorbidities on mother-child bonding. method: the study was part of a broader longitudinal research that involved 175 italian mothers 6-12 weeks postpartum, recruited from birthing centers. participants completed measures for childbirth-related ptsd (city bits-it), depression (epds), anxiety (psas-it), and mother-child bonding (pbq). results: prevalence rates were 1.1% for cb-ptsd, 18.6% for depression, and 30.2% for anxiety. depression was significantly associated with anxiety (χ2(1, n = 159) = 9.131, p = .003) and cb-ptsd (χ2(1, n = 171) = 11.689, p < .001). hierarchical regression showed that depression and general ptsd symptoms significantly impaired mother-child bonding, explaining 36.3% of the variance (r2 = 0.363). conclusion: the findings highlight the prevalence and complexity of perinatal psychiatric morbidity, emphasizing the critical need for comprehensive assessment tools tailored to the italian context. these results contribute to a deeper understanding of maternal mental health challenges during the perinatal period. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.15117&domain=pdf&date_stamp=2025-08-29 https://orcid.org/0000-0003-4031-0890 https://orcid.org/0000-0003-0082-1565 https://orcid.org/0000-0002-0163-3841 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ keywords post-traumatic stress disorder, birth, recommendations, policy, perinatal, screening highlights • 1.1% met full diagnostic criteria for childbirth-related ptsd, 68.4% had one or more symptoms. • cb-ptsd was associated with depression and comorbidity impaired mother-infant bonding. • screening for cb-ptsd is often neglected. this paper offers a validated screening tool. pregnancy and childbirth bring significant physical, psychological, and social changes. the perinatal period, which extends from the beginning of pregnancy to one year postpartum, is a complex and vulnerable time that presents various challenges for both women and men in the transition to parenthood (parfitt & ayers, 2014). research suggests that approximately 1 in 3 births are perceived as psychologically traumatic (alcorn et al., 2010) and meta-analyses show that 4% of women who give birth later develop childbirth-related ptsd (cb-ptsd), while clinically significant cb-ptsd symptoms are observed in 17% of women (heyne et al., 2022). the mother-child bond, the emotional and cognitive connection between a mother and her child, is of central importance for the child's development and the mother's well-being. previous research has shown that poor parent-child attachment has been associated with impaired emotional, behavioural and cognitive development in the child, as well as affective disorders in adulthood (dekel et al., 2020). although previous studies have shown how postpartum depression and anxiety can affect mother-infant bonding (dekel et al., 2020), less is known about the potential impact of birth-related ptsd. traumatic birth experiences and the resulting cb-ptsd symptoms can cause consid­ erable distress and have a significant long-term impact on the health of women, their ba­ bies and their families. it is now well established that maternal cb-ptsd can affect both maternal and spousal relationships (garthus-niegel et al., 2018; hairston et al., 2018) and can also lead to long-term negative effects on child behaviour and development (e.g. cook et al., 2018). traumatic births can also affect medical staff (uddin et al., 2022), resulting in sig­ nificant costs to healthcare systems and potential economic consequences for society (bauer et al., 2014). therefore, the prevention of traumatic births and cb-ptsd is a global priority. this mandate is in line with the united nations millennium and sustain­ able development goals for better health for women, mothers and children (united nations desa, 2022), the world health organisation’s call for dignified and respectful maternity care for every woman (who, 2015) and the council of europe and european parliament’s resolution on the importance of women’s sexual and reproductive rights (european parliament, 2022). although a recent systematic review of the cost-effective­ assessing perinatal psychiatric morbidity in italy 2 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.psychopen.eu/ ness of interventions for perinatal disorders, including cb-ptsd, concluded that screen­ ing, psychological or social support and specialised treatment programs are all effective and cost-effective interventions to address these issues (verbeke et al., 2022), screening for cb-ptsd is often neglected among perinatal mental disorders (pmds). currently, only a handful of countries have developed strategies to prevent traumatic births and treat cb-ptsd (thomson et al., 2021). even in the world health organisation’s recom­ mendations on maternal and newborn care for a positive postnatal experience (who, 2022), only depression and anxiety are mentioned in the few lines dedicated to mental health. the lack of clear policies or guidelines means that many people have limited access to the services they need (sperlich et al., 2017). since 1978, the italian national health service (servizio sanitario nazionale, ssn) has guaranteed universal access to healthcare. the central government determines the national core benefits package and provides funding for the regional healthcare systems. the 19 italian regions and two autonomous provinces are responsible for funding, plan­ ning and providing services at the local level, supported by a network of around 100 local health authorities (signorelli et al., 2020). significant differences exist in the provision of healthcare services across the country (cicchetti & gasbarrini, 2016). in italy, there is no specialised service for perinatal mental health, so mental health care for women of childbearing age is provided by mental health departments (mhds; grussu et al., 2020). family care centres (fccs), which are integrated into ssn community services, provide free support to women during pregnancy and in the postnatal period and focus on the early identification of perinatal mental health problems (grussu et al., 2020). a national guideline for perinatal mental health care is currently not available (lega et al., 2024). in addition, healthcare providers often have limited training in selecting the most appropri­ ate screening tool and determining the appropriate cut-off point for specific time periods (cena et al., 2020). despite these findings, recent research suggests that the prevalence of perinatal mental disorders (pmds) in italy is similar to other european countries (e.g. camoni et al., 2023; ciuffo et al., in preparation), so there is currently a lack of knowledge about how the national mental health service supports women during the perinatal period. the first study providing insights into the availability of evidence-based best practices for perinatal mental health (pmh) within the italian mental health service dates back to 2024 (lega et al., 2024). however, recommendations on prevention and screening for cb-ptsd are still lacking. the predominant perinatal mental disorders that occur in women during pregnancy and postpartum are depressive syndromes and anxiety syndromes (cena et al., 2020). comorbidity of these disorders is common, reaching 40% in some studies (i.e., misri & swift, 2015). research indicates that cb-ptsd is often comorbid with depression and anxiety disorders (i.e., horesh et al., 2017), which increases the likelihood of postpartum psychiatric problems in women with cb-ptsd. of women diagnosed with ptsd, 65% also exhibit symptoms of postpartum depression (ppd), while 22% of women with ppd ciuffo, landoni, & ionio 3 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.psychopen.eu/ also exhibit symptoms of ptsd (söderquist et al., 2006). due to the frequent overlap of these syndromes, it is important to consider how these factors interact with maternal mental health (grisbrook & letourneau, 2021). the failure to include recommendations for cb-ptsd screening in existing guidelines may be due to a failure to recognise the prevalence and impact of cb-ptsd on maternal quality of life and family functioning, and the need for validated screening tools (grisbrook & letourneau, 2021). against this background, the present study aims to investigate the prevalence of cb-ptsd, ppd, and anxiety, along with their comorbidity, in a sample of italian women 6–12 weeks postpartum, as well as to assess the impact of potential comorbidities on mother-child bonding. materials and method ethics ethical approval was granted by the ethics committees of the catholic university of the sacred heart (reference: 05-22) and the s. giuseppe hospital in milan (reference: 550/2022). before starting the survey, participants had to read an information sheet and electronically sign a consent form with qualtrics. data collection was conducted according to the principles of the declaration of helsinki and in accordance with the ethical guidelines of the irb. procedure and participants the city bits-it was included in a wider international project, the international survey of childbirth-related trauma (intersect), which has been registered at: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/ 5ffc7453702012001b80a58c/ in italy, the intersect project was conducted by the trauma psychology research unit of the catholic university of the sacred heart in milan. the italian component followed a longitudinal design with three waves of data collection. in the initial phase (t1), participants were recruited in birth centers, hospitals or clinics and completed the questionnaire via qualtrics. they were then contacted 6-12 weeks after the birth (t2) and again 6 months after the birth (t3) for a follow-up survey. no social media or other online methods were used during recruitment to avoid self-selection bias. the inclusion criteria were: (i) participants in the third trimester of pregnancy, (ii) aged 18 years or older, (iii) with informed consent and (iv) proficient in italian. measures alongside socio-demographic and obstetrical information, participants completed the following measures. assessing perinatal psychiatric morbidity in italy 4 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5ffc7453702012001b80a58c/ https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5ffc7453702012001b80a58c/ https://www.psychopen.eu/ the city birth trauma scale (city bits) cb-ptsd was assessed using the validated italian version of the city birth trauma scale (bits; ayers et al., 2018; ciuffo et al., in preparation). the bits assesses ptsd symptoms based on dsm-5 criteria, including exposure to traumatic stressors, intrusive symptoms, avoidance, negative cognitions and mood, hyperarousal, and dissociative symptoms. the scale also assesses symptom occurrence, duration, distress, impact on daily life and possible physical causes. the total score resulting from criteria b-e ranges from 0 to 60. you can find more detailed information about the bits in the supplementary materials (ciuffo et al., 2025s). the edinburgh postnatal depression scale (epds) maternal depression was assessed using the italian version of the edinburgh postnatal depression scale (epds; cox et al., 1987; benvenuti et al., 1999). this self-report ques­ tionnaire assesses the severity of maternal depression during the postpartum period. scores range from 0 to 30, with a score between 9 and 10 indicating clinically significant depression. the internal reliability was ω = 0.84. detailed information on the evaluation can be found in the supplementary materials (ciuffo et al., 2025s). the postpartum specific anxiety scale (psas) the mothers' anxiety was assessed using the italian version of the postpartum specific anxiety scale (psas; fallon et al., 2016; ionio et al., 2023). this questionnaire comprises 51 items that were developed to assess anxiety symptoms in the postpartum phase. the scale measures four areas of anxiety. scores range from 51 to 204, with a threshold score of 112 indicating clinically significant anxiety. further details about the psas can be found in the supplementary materials (ciuffo et al., 2025s). the postpartum bonding questionnaire (pbq) maternal and paternal attachment was assessed using the italian adaptation of the post-birth attachment questionnaire (pbq; brockington et al., 2001; busonera et al., 2017). the questionnaire comprises four subscales and uses a six-point likert scale to assess attachment difficulties. further information about the pbq can be found in the supplementary materials (ciuffo et al., 2025s). statistical analyses the analyses were carried out with ibm spss statistics version 29.0. descriptive statis­ tics (means, standard deviations, frequencies) were calculated to summaries the charac­ teristics of the sample and the prevalence rates of psychiatric disorders. recommended cut-offs were used to analyse the rates of depression and anxiety. diagnostic criteria were used to calculate the prevalence of ptsd. participants were categorised based on ciuffo, landoni, & ionio 5 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.psychopen.eu/ their scores. comorbidity of cb-ptsd, ppd and anxiety was analysed using cross-tabula­ tions and chi-square tests to determine the proportion of women suffering from multiple disorders simultaneously. hierarchical regression analyses were performed to examine the influence of cb-ptsd, ppd and anxiety (independent variables) on mother-infant at­ tachment (dependent variable). previous mental disorders, complications for the mother or child during labour and mode of delivery were included as covariates in the model. results the sample consisted of 175 italian women with a mean age of 32.75 years (sd = 4.68). the majority were either married or cohabiting (93.7%), and 60.6% had attained higher education. in terms of employment, most participants were engaged in profes­ sional, office, or technical occupations, while a small percentage were unemployed or homemakers. all participants were primiparous, and the majority (74.0%) had a vaginal birth, with 34.7% experiencing minor maternal complications during delivery. infant complications were reported in 11.1% of cases. additionally, 28.2% had experienced a previous pregnancy loss, and 12.8% reported uncertainty regarding a past diagnosis of mental illness. table s1 (supplementary materials – see ciuffo et al., 2025s) summaries the main demographic characteristics and obstetric information of the mothers. table 1 shows the prevalence rates of psychiatric disorders and the distribution of specific diagnostic criteria to provide a comprehensive understanding of symptom patterns and diagnostic thresholds. the cross-tabulation analysis between postnatal depression and anxiety showed a significant correlation. of the 175 participants, 159 gave valid responses (90.9%), while 16 were missing (9.1%). of the women with valid data, 84 met the criteria for either depression or anxiety: 46 women met the criteria for anxiety but not for depression, 27 women met the criteria for depression but not for anxiety, and two women met the requirements for both. the remaining nine cases were women who did not fulfil the criteria for either disorder. the chi-square test for independence showed a statistically significant relationship between depression and anxiety, χ2(1, n = 84) = 9.131, p = .003. this was further confirmed by the likelihood ratio, χ2(1, n = 159) = 11.258, p < .001, and fisher’s exact test, p (bilateral) = .002. these results suggest that the presence of de­ pression is significantly associated with an increased likelihood of anxiety in postpartum women. the association between cb-ptss and anxiety was examined in 158 valid cases (90.3%) and 17 missing cases (9.7%). the distribution was as follows: 33 women met criteria for neither cb-ptss nor anxiety, 19 women met criteria for anxiety but did not have cb-ptss, 78 women met criteria for cb-ptss but not anxiety, and 28 women met criteria for both. the chi-square test showed no statistically significant association between ptss and anxiety, χ2(1, n = 158) = 1.711, p = .191. the likelihood ratio, χ2(1, assessing perinatal psychiatric morbidity in italy 6 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.psychopen.eu/ n = 158) = 1.680, p = .195, and fisher’s exact test, p (bilateral) = .200, also showed no significant association. this suggests that the presence of ptsd symptoms related to childbirth was not significantly correlated with anxiety in this sample. table 1 distribution of psychiatric disorder diagnostic criteria and prevalence rates characteristic percentage cb-ptsd criterion a: exposure to traumatic stressor 14.3 cb-ptsd criterion b: re-experiencing 58.6 cb-ptsd criterion c: avoidance symptoms 12.6 cb-ptsd criterion d: negative cognitions and mood 35.6 cb-ptsd criterion e: hyperarousal 61.1 cb-ptsd criterion f: duration 53.1 cb-ptsd criterion g: distress or impairment 57.5 having one or more symptoms of trauma 68.4 full criteria for cb-ptsd met 1.1 depression above the cutoff 18.6 anxiety above the cutoff 30.2 note. the total sample for this table included 175 participants. for the relationship between cb-ptss and postnatal depression, there were 171 valid cases (97.7%) and 4 missing cases (2.3%). the results of the contingency table were as follows: 52 women did not meet criteria for either cb-ptss or depression, two women met criteria for depression but not cb-ptss, 87 women met criteria for cb-ptss but not depression, and 30 women met criteria for both. the chi-square test showed a statistically significant association between cb-ptss and depression, χ2(1, n = 171) = 11.689, p < .001. the likelihood ratio, χ2(1, n = 171) = 14.541, p < .001, and fisher’s exact test, p (bilateral) < .001, confirmed this significant association. these results suggest that women with postnatal depression are more likely to experience ptsd symptoms related to childbirth. finally, a hierarchical regression model was developed to examine the effects of individual and comorbid disorders on mother-infant attachment 6-12 weeks postpartum. in step 1, depression was used as a predictor of attachment, in step 2 anxiety was integrated, in step 3 the cb-ptss (birth-related symptoms and general symptoms) and in step 4 the covariates were added. depression was found to be a significant predictor of disturbed mother-infant attachment and explained 28% of the variance. this suggests that higher levels of postpartum depression are associated with poorer attachment. the addition of anxiety did not significantly improve the model, suggesting that anxiety is not a strong predictor of mother-infant attachment in this sample. when birth-related ciuffo, landoni, & ionio 7 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.psychopen.eu/ and general ptsd symptoms were added, the model improved significantly, with general ptsd symptoms being a particularly strong predictor. this model explained 34.8% of the variance, suggesting that trauma-related symptoms play a significant role in moth­ er-infant attachment. the inclusion of additional covariates (such as type of birth and pre-existing mental health diagnoses) did not further improve the model, suggesting that these variables do not have a significant impact on mother-infant attachment in this context. the following table (table 2) summaries these results. table 2 hierarchical regression predicting mother-child bonding predictor b se b β t p step 1 (r 2 = 0.280) depression 1.073 0.137 .529 7.836 < .001 step 2 (r 2 = 0.280) depression 1.072 0.138 .529 7.741 < .001 anxiety -0.002 0.032 -.004 -0.055 .957 step 3 (r 2 = 0.348) depression 0.740 0.167 .365 4.435 < .001 anxiety 0.015 0.031 .031 0.465 .643 birth-related ptsd symptoms -0.257 0.187 -.100 -1.374 .171 general ptsd symptoms 0.592 0.148 .337 4.002 <.001 step 4 (r 2 = 0.352) depression 0.753 0.171 .371 4.412 < .001 anxiety 0.015 0.032 .031 0.461 .645 birth-related ptsd symptoms -0.255 0.193 -.099 -1.323 .188 general ptsd symptoms 0.565 0.152 .322 3.708 < .001 vaginal delivery 1.350 2.466 .062 0.547 .585 assisted vaginal delivery -0.257 3.517 -.006 -0.073 .942 emergency cs 2.276 2.999 .079 0.759 .449 pre-existing diagnosis -0.623 1.943 -.022 -0.321 .749 note. mode of delivery includes four categories: vaginal delivery, assisted vaginal delivery, emergency cs, and planned cs. dummy coding was applied, with planned cs as the reference category. pre-existing mental health diagnosis is a binary variable (yes/no). discussion perinatal mental disorders are widespread and represent a major health problem. aware­ ness, prevalence rates and treatment of these mental disorders vary greatly from country to country (i.e., dikmen-yildiz et al., 2017). the present study aimed to investigate the prevalence and comorbidity of cb-ptsd, ppd and anxiety in a sample of italian assessing perinatal psychiatric morbidity in italy 8 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.psychopen.eu/ women 6-12 weeks postpartum. in addition, the effects of these potential comorbidities on mother-infant bonding were investigated. in terms of prevalence rates, depression and anxiety were similar to previous liter­ ature (i.e., hahn-holbrook et al., 2018), while cb-ptsd was slightly lower than the observed global pooled prevalence (heyne et al., 2022), albeit similar to previous studies (i.e., dikmen-yildiz et al., 2017). although only 1.1% of women met the full diagnostic criteria for cb-ptsd, the vast majority of mothers (68.4%) had one or more cb-ptss, demonstrating how prevalent this pathology is in this population. in addition, the results confirmed the co-occurrence of childbirth-related ptsd symptoms and depression in 17.54% of the sample, similar to previous research in this field (dekel et al., 2020), sug­ gesting that women with depression are more likely to have cb-ptss and vice versa. in our sample, we found no significant association between cb-ptss and anxiety. however, previous studies (dikmen-yildiz et al., 2017) have found increased comorbidity between these disorders 6 months postpartum. this suggests that the co-occurrence of these dis­ orders becomes more evident later in the postpartum period as conditions become more structured. longitudinal studies are needed to investigate these associations throughout the postpartum period. the presence of comorbidities indicates that if depression or ptsd is suspected, it is important to look at other symptoms for treatment purposes. it may also be beneficial to consider these disorders as part of a continuum of stress and to use the term ‘postnatal mood disorders’ proposed by matthey et al. (2003), which includes birth-related ptsd. there is extensive evidence that early assessment of ppd can predict maternal attachment difficulties up to one year postpartum (e.g. kasamatsu et al., 2020), but there is considerably less research examining the relationship between attachment and other psychopathologies such as cb-ptsd. women with comorbid men­ tal disorders are more likely to have impaired functioning and experience higher levels of stress than women with only one disorder (e.g. horesh et al., 2017). although ppd is widely recognised as a significant risk factor for poor attachment, the relationship be­ tween cb-ptsd and attachment is less well understood. some studies have found a clear association between cb-ptsd and impaired attachment (parfitt et al., 2014), while others have not observed such an association (nakić radoš et al., 2020). this inconsistency may be due to differences in the definition of cb-ptsd, the methods used to measure it, and the consideration of other factors, such as comorbid depression (davies et al., 2008). our findings suggest that the effects of cb-ptsd on attachment may vary from person to person. in particular, symptoms of cb-ptsd, especially when combined with depression, appear to disrupt emotional bonding between mothers and their infants. in contrast, birth-related ptsd symptoms alone appear to have less of an impact on attachment. this is consistent with recent research that distinguishes between birth-related and more general ptsd symptoms (e.g. nakić radoš et al., 2020), with general ptsd symptoms showing a stronger association with impaired attachment. ciuffo, landoni, & ionio 9 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.psychopen.eu/ as mentioned above, the lack of recommendations for cb-ptsd screening in existing guidelines may be due to a lack of awareness of the prevalence and impact of cb-ptsd on maternal quality of life and family functioning, as well as the need for validated screening tools (grisbrook & letourneau, 2021). indeed, a recent systematic review (ciuffo et al., 2025) highlighted that a challenge in screening for cb-ptsd is the limited availability of validated questionnaires specifically designed to assess this disorder. the lack of customised instruments also makes it difficult to determine the true prevalence of the disorder, which remains poorly researched and overlooked in italian maternity facilities (ciuffo et al., in press). screening needs to take into account organisa­ tional factors that affect implementation as well as the availability of valid measurement tools to accurately identify the disorder. to date, the city birth trauma scale (city bits; ayers et al., 2018) is the only self-report specifically designed to measure cb-ptsd according to dsm-5 diagnostic criteria and validated for the italian population (ciuffo et al., in press). the city bits-it has good reliability and strong psychometric properties. it is a quick and straightforward instrument, making it highly recommended for the early detection of childbirth-related ptsd (ciuffo et al., in press). in 2019, an international consortium of researchers and clinicians specialising in traumatic birth and cb-ptsd was established to advance knowledge and practise in this area (european commission cooperation in science and technology (cost action grant ca18211). this group developed recommendations for practise, research and policy (ayers et al., 2024). in terms of research, the use of “cb-ptsd validated, diagnosis-based instruments is required. to determine diagnoses and prevalence, cut-off values need to be established and adapted to different cultural settings”. substantial evidence of the prevalence and consequences of cb-ptsd will facilitate the assessment of the economic burden associated with this condition, thus providing a sound rationale and financial motivation for prioritising prevention and intervention efforts in areas that are currently under-supported in health systems worldwide (ayers et al., 2024). strengths and limitations of the study this study has several limitations. first, it relies on self-reported measures, which may be subject to response biases such as social desirability or memory distortions, which could affect the accuracy of reported symptoms and experiences. on the other hand, the ques­ tionnaires are easy to administer and score, making them ideal for early assessment and prevention of pmds. second, the cross-sectional design limits the possibility of establish­ ing causal links between psychiatric disorders and disrupted mother-child attachment. while our results suggest significant associations, the direction of these associations remains unclear. for example, it is unclear whether psychiatric symptoms directly af­ fect attachment or whether attachment difficulties exacerbate maternal psychological distress. longitudinal data would provide a more comprehensive understanding of the trajectory of maternal mental health and attachment over time. future research should assessing perinatal psychiatric morbidity in italy 10 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.psychopen.eu/ use longitudinal studies to track the development of symptoms, identify potential medi­ ators or moderators in this relationship, and assess the long-term impact on maternal and infant well-being. second, the cross-sectional design may limit the ability to draw causal conclusions. future research should consider longitudinal studies to better under­ stand possible pathways of comorbidity of these disorders as well as their long-term effects on family functioning. finally, study participants were recruited in birth centers, hospitals and clinics without using social media or other online methods. while this approach helps to reduce self-selection bias, it may also exclude women who do not seek inpatient care or are less familiar with these healthcare facilities. this study uses validated measures, ensuring a reliable and standardised assessment. furthermore, to the best of the authors’ knowledge, this is the first study to investigate the prevalence and impact of cb-ptsd and its comorbidities in the italian context, providing new insights into perinatal mental health in italy. conclusions the high rates of mental disorders after birth emphasise several important implications for policy and clinical practice. effective perinatal screening is crucial for identifying women with mental health problems. early detection and intervention can reduce the likelihood of postnatal mental disorders. timely treatment of women affected by these disorders is important to ensure their mental well-being and that of their families and to prevent these disorders from becoming chronic. national and international guidelines on maternal mental health are needed to raise awareness of perinatal mental health problems, including cb-ptsd, and to present evidence-based, practical strategies for detection, prevention and treatment. future research and policy statements should also include men and/or other birth partners. this review adds to the literature highlighting the great need to prioritise women’s mental health in both research and clinical practice, and reflects calls for greater atten­ tion to this area within the psychological community (e.g. ayers et al., 2024). our study, which focuses on the prevalence of perinatal psychiatric disorders and their impact on mother-infant attachment, provides a foundation for future research and policy decisions aimed at improving women's mental health. this could be a first step in addressing a historically overlooked aspect of public health and ensuring that women receive the support they need during this critical stage of life. overall, this research has shown that a significant number of women in italy suffer from significant depression, anxiety, cb-ptsd or a combination of these conditions during the perinatal period. healthcare providers and policy makers should recognise the significant psychological distress experienced by italian women during the perinatal period and the potential long-term impact on women and their families. ciuffo, landoni, & ionio 11 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.psychopen.eu/ funding: this research received no external funding. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors declare that the research was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest. author contributions: conceptualisation: [gc, ci]; methodology: [gc, ci]; formal analysis: [gc]; investigation: [ci, gc] writing – original draft: [gc]; writing – review & editing: [gc, ml, ci]; supervision: [ci]. ethics statement: women who chose to participate in the study gave their informed consent. all procedures used in human subjects research followed the ethical requirements of the institutional and/or national research committee and the 1964 declaration of helsinki and its subsequent revisions or comparable ethical standards. related versions: this research was conducted as part of the international survey of childbirth-related trauma (intersect, www.intersectstudy.org). reporting guidelines: this paper was written following strobe reporting guidelines (strengthening the reporting of observational studies in epidemiology). social media accounts: chiara ionio: linkedin preregistration: this study is part of the broader international project international survey of childbirth-related trauma (intersect), which was preregistered on the research registry. the preregistration includes the general study aims and methodological framework of the international survey and is publicly accessible at: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5ffc7453702012001b80a58c. however, the analysis of the italian subsample and the specific research questions addressed in the present article were not preregistered. data availability: the raw data supporting the conclusions of this article, as well as the code used for data analysis and the materials employed during the study are available from the authors upon reasonable request. these resources will be provided directly to researchers who contact the corresponding author, without undue reservation. supplementary materials supplementary file 1 – table 1 and measures (see ciuffo et al., 2025s): this supplementary material includes a table summarizing the demographic characteristics and obstetric information of the 175 italian mothers who participated in the study. it provides details such as maternal age, region of residence, marital status, occupation, educational attainment, and various obstetric variables, including mode of delivery and maternal/infant complications during birth. additionally, the supplementary material offers detailed information on the self-report ques­ tionnaires used in the study: the city birth trauma scale (city bits), the edinburgh postnatal depression scale (epds), the postpartum specific anxiety scale (psas), and the postpartum assessing perinatal psychiatric morbidity in italy 12 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 http://www.intersectstudy.org https://www.linkedin.com/in/chiara-ionio-a6584364/ https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5ffc7453702012001b80a58c https://www.psychopen.eu/ bonding questionnaire (pbq). each measure is described in terms of its structure, scoring, and internal reliability. index of supplementary materials ciuffo, g., landoni, m., & ionio, c. 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(2022). who recommendations on maternal and newborn care for a positive postnatal experience. https://www.ncbi.nlm.nih.gov/books/nbk579657/pdf/bookshelf_nbk579657.pdf assessing perinatal psychiatric morbidity in italy 16 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://doi.org/10.1016/s1701-2163(15)30150-x https://doi.org/10.1016/j.jad.2020.03.006 https://doi.org/10.1002/imhj.21443 https://doi.org/10.1080/02646838.2014.956301 https://doi.org/10.1016/j.healthpol.2019.11.002 https://doi.org/10.1080/01674820600712172 https://doi.org/10.1111/jmwh.12674 https://doi.org/10.1186/s12913-021-07238-x https://doi.org/10.1016/j.midw.2022.103460 https://unstats.un.org/sdgs/report/2022 https://doi.org/10.1111/birt.12623 https://apps.who.int/iris/bitstream/handle/10665/134588/who_rhr_14.23_eng.pdf https://www.ncbi.nlm.nih.gov/books/nbk579657/pdf/bookshelf_nbk579657.pdf https://www.psychopen.eu/ appendix: list of abbreviations cb-ptsd – childbirth-related posttraumatic stress disorder cb-ptss – childbirth-related posttraumatic stress symptoms ppd – postpartum depression pmds – perinatal mental disorders pmh – perinatal mental health mhds – mental health departments clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. ciuffo, landoni, & ionio 17 clinical psychology in europe 2025, vol. 7(3), article e15117 https://doi.org/10.32872/cpe.15117 https://www.psychopen.eu/ assessing perinatal psychiatric morbidity in italy (introduction) materials and method ethics procedure and participants measures statistical analyses results discussion strengths and limitations of the study conclusions (additional information) funding acknowledgments competing interests author contributions ethics statement related versions reporting guidelines social media accounts preregistration data availability supplementary materials references appendix: list of abbreviations growing (up) in times of multiple crises – a call for mental health (research) action editorial growing (up) in times of multiple crises – a call for mental health (research) action julia asbrand 1, tanja michael 2, hanna christiansen 3,4, gerhard reese 5 [1] department of psychology, friedrich-schiller-university jena, jena, germany. [2] department of psychology, saarland university, saarbrucken, germany. [3] department of psychology, university of marburg, marburg, germany. [4] deutsches zentrum für psychische gesundheit (dzpg), bochum/marburg, germany. [5] department of psychology, rptu kaiserslautern-landau, campus landau, landau, germany. clinical psychology in europe, 2023, vol. 5(3), article e12713, https://doi.org/10.32872/cpe.12713 published (vor): 2023-09-29 corresponding author: julia asbrand, friedrich-schiller-university jena, department of psychology, semmelweisstr. 12, 07743 jena, germany. e-mail: julia.asbrand@hu-berlin.de the rock band fury in the slaughterhouse sang that “every generation got its own disease”, however, remaining in that wording, the current generation of children and adolescents in europe has to cope with several severe “diseases” at the same time: the war of russia against ukraine, the social and mental health consequences of the covid-19-pandemic, the economic downturn, societal polarization, and last but not least, the twin crises of biodiversity loss and climate change. each of these crises have visible and measurable consequences, and some crises mutually reinforce each other. the climate crisis, for instance, has already brought irreversible damage to some societies and natural habitats around the world. according to the intergovernmental panel on climate change (ipcc, 2023), weather phenomena such as droughts, storms and floods will become more likely and more intense. it is estimated that people who are born today will experience heat waves up to seven times more often than people who are in their forties to sixties today (thiery et al., 2021). furthermore, climate change is linked to macroeconomic consequences negatively affect­ ing the economic situations of states and individuals and is thus a driving force behind increasing poverty (e.g., kotz et al., 2021). the climate crisis also accelerates biodiversity loss. further, both environmental degradation as well as climate change undermine peace and increase the likelihood for conflict between groups, representing additional stressors for development both on an individual and a societal level (e.g., palmer, 2022). unsurpris­ ingly, a recent meta-analysis shows that climate events are negatively correlated with mental health (cuijpers et al., 2023), and a recent review demonstrates that the risk for this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12713&domain=pdf&date_stamp=2023-09-29 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mental health problems among young people is particularly high (ma, moore, & cleary, 2022). the covid-19 pandemic decreased mental health in the general population, and younger age groups in particular (santomauro et al., 2021). furthermore, several studies show that the worsened mental health of young people remained up to two years after the onset of the pandemic (hansen et al., 2023). a recent study among german adolescents also shows that both pandemic-related and climate-related distress are linked to more depression and anxiety symptoms and to reduced health-related quality of life. distress related to the russia-ukraine war was associated with greater anxiety. critically, these associations remained significant when controlling for important covariates (e.g., gender, distress caused by personal problems), showing that the crisis measures have incremental predictive value (lass-hennemann et al., 2023). however, self-efficacy and, though to a lesser extent, expressive flexibility were associated with better mental health. there are no studies yet examining how the war influences mental health of children and adolescents living in an area directly exposed to the war. despite the increased need to address mental health problems among young people (e.g. deng et al., 2023), sufficient in-patient and outpatient mental health care systems are yet to be implemented. actually, waiting times have doubled during the pandemic and low-threshold effective interventions are lacking (e.g. overhage et al., 2023). in sum, the current evidence suggests that global crises impact the mental health and healthy upbringing of young people. therefore, policies should include interventions that help children and adolescents in particular to cope with the stress caused by the crises. the systemic structure underneath: what can we (not) do? however, it is not enough to only develop strategies to help individuals to cope better with stress or to increase mental health care capacities. large scale crises, as the ones depicted above, have in common that they are usually a result of collective (in-)action and as such, these crises cannot be remedied by individual action alone: as an individual, i can neither address the pandemic, solve the climate crisis nor end a war all by myself. in other words: an individual can hardly experience self-efficacy when faced with these challenges. these challenges can only be addressed by collective efforts, and these efforts must be implemented on various societal levels. for example, the multilevel model of societal change introduced by geels and schot (2007) represents a framework that helps to understand how and which levels of society need to be addressed to achieve societal change. in short, the model suggests that certain pressures such as climate change or resource scarcity open windows of opportunity within a political regime. networks of growing (up) in times of multiple crises 2 clinical psychology in europe 2023, vol. 5(3), article e12713 https://doi.org/10.32872/cpe.12713 https://www.psychopen.eu/ innovators and groups with joint ideas can then use such a window to engender change within society. for example, the fridays-for-future movement did so, and changed the way climate change is treated in politics and society. recent psychological models sug­ gest the pathways through which collective and participatory efficacy beliefs can foster such collective actions (hamann et al., 2023). building on these systemic considerations, clinical psychology and psychotherapy, both at the level of care and research, urgently need to move away from an exclusively individual approach to a consideration of the individual in the system, its structures, and their relevant life-environments such as schools or the work-place. how could this look like? a call for health(y) action first of all, broader prevention structures focusing on systemic levels of mental health as well as self-efficacy (lass-hennemann et al., 2023) and adaptive coping are necessary (mah et al., 2020). these need to be implemented and institutionalized within structural levels, and have to provide an outreach service – independent of youth’s knowledge about health care structures or individual resources. second, these prevention structures must also be flanked by measures that mitigate major risk factors for mental health and a negative trajectory when growing up. specifically, these are all measures targeting financial and social injustices and inequity, i.e. installing appropriate climate protection measures, providing access to education and living above the poverty line is part of health care. third, our research must do justice to the complex interplay between the individual and society, also in the field of mental health. this means that research approaches must be promoted in clinical psychology and psychotherapy that situate the individual in society and clarify the effects of society on the individual, e.g. which systemic structures limit treatment success? how do societal crises affect mental health? we believe that the current age of multiple crises holds several challenges for mental health care and research, foremost the fact that we are affected by these crises as health care professionals and researchers. to adequately address these challenges, we need to expand (preventive) healthcare, intensify our research efforts and at the societal level to help young people grow up healthy. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. asbrand, michael, christiansen, & reese 3 clinical psychology in europe 2023, vol. 5(3), article e12713 https://doi.org/10.32872/cpe.12713 https://www.psychopen.eu/ references cuijpers, p., miguel, c., ciharova, m., kumar, m., brander, l., kumar, p., & karyotaki, e. 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(2021). intergenerational inequities in exposure to climate extremes. science, 374(6564), 158–160. https://doi.org/10.1126/science.abi7339 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. asbrand, michael, christiansen, & reese 5 clinical psychology in europe 2023, vol. 5(3), article e12713 https://doi.org/10.32872/cpe.12713 https://doi.org/10.1038/s41893-022-00973-x https://doi.org/10.1016/s0140-6736(21)02143-7 https://doi.org/10.1126/science.abi7339 https://www.psychopen.eu/ growing (up) in times of multiple crises (introduction) the systemic structure underneath: what can we (not) do? a call for health(y) action (additional information) funding acknowledgments competing interests references transtheoretical psychological therapy – new perspectives for clinical training and practice editorial transtheoretical psychological therapy – new perspectives for clinical training and practice wolfgang lutz 1 , winfried rief 2 [1] clinical psychology and psychotherapy, university of trier, trier, germany. [2] clinical psychology and psychotherapy, philipps university marburg, marburg, germany. clinical psychology in europe, 2024, vol. 6(special issue), article e13891, https://doi.org/10.32872/cpe.13891 published (vor): 2024-04-26 corresponding author: wolfgang lutz, clinical psychology and psychotherapy, department of psychology, university of trier, d-54286 trier, germany. tel.: +49 (0)6 51 / 2 01 28 83. e-mail: lutzw@uni-trier.de related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si in this special issue of clinical psychology in europe on "transtheoretical psychological therapy – new perspectives for clinical training and practice", we focus on new evi­ dence-based transtheoretical concepts of clinical training and practice. a transtheoretical perspective offers a new framework for integrating evidence-based psychological treat­ ment techniques that can have theoretical roots in different theories. thus, it represents an umbrella that encourages the consideration of all research results and evidence-based treatment proposals, and a fruitful stimulation of insights across traditional orientations. transtheoretical psychotherapy aims to use findings from mechanisms, outcome, proc­ ess, and feedback research as conceptual frameworks for clinical practice and training. the history of psychotherapy (now often referred to as psychological therapy to include the various newer theoretical concepts) is characterized by a growing number of clinical theories, approaches, and methods with their psychopathological concepts, psy­ chological models of change, and, as a result, the growth of a heterogeneous landscape of professional therapy associations. the major schools of therapy that have emerged from this development have contributed to the establishment of the field and advances in patient care around the world. however, a scientifically sound and clearly defined causal network between mechanisms of change and treatment outcomes has been lacking (lutz et al., 2022). in addition, service systems around the world are very heterogeneous in the definition and delivery of psychological therapy, and not all treatment concepts applied in clinical practice are scientifically evaluated (rief et al., 2022). this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.13891&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0002-5141-3847 https://orcid.org/0000-0002-7019-2250 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ simultaneously, an emphasis on treatment approaches and therapeutic schools re­ sulted in inflexibilities and conflicts among colleagues. this frequently resulted in a constricted view of scientific and clinical perspectives, impeding the dynamic advance­ ment of the field in terms of psychotherapy research and finding common ground (e.g. goldfried, 1980; hofmann et al., 2022; lutz et al., 2023). furthermore, while for example in germany the official state-wide guidelines prohibit combining procedures in outpatient practice, such combinations are at the same time prevalent in outpatient and inpatient settings both nationally and internationally (twomey et al., 2023). in this special issue, transtheoretical concepts and practical implications that go be­ yond the boundaries of traditional psychotherapeutic procedures and aim for a broader, scientifically based understanding of psychotherapy are discussed. transtheoretical is understood here as a broader concept, as originally introduced by prochaska and di clemente (1982). this includes an orientation towards evidence-based treatment procedures and strat­ egies as well as multimethod and multidimensional diagnostic concepts and data-in­ formed decision tools, which can form the basis for transtheoretical and evidence-based clinical training and practice in the future. from our point of view, it is now time to de­ velop broader transtheoretical and scientifically supported concepts for clinical training and practice of psychological therapy, and this special issue wants to contribute to this process. the papers cover a wide range of issues in the current debate on transtheoretical and integrative concepts as well as specific interventions, clinical methods, or strategies. several papers present important new developments in transtheoretical metamodels and provide new researchand process-based conceptual frameworks, such as babl et al. (2024); boswell et al. (2024); caspar and berger (2024); flückiger et al. (2024); hofmann and hayes (2024); lutz et al. (2024); mcnally (2024); rafaeli and rafaeli (2024); rief et al. (2024) and taubner and sharp (2024). in addition, several papers discuss transtheoretical clinical case conceptualization and interventions, competencies, and core processes, such as case conceptualization (gilboa-schechtman, 2024), homework (ryum & kazantzis, 2024), deliberate practice, marker response sequences, and responsiveness (babl et al., 2024; boswell et al., 2024), mentalization (taubner & sharp, 2024), alliance ruptures (zilcha-mano & muran, 2024), needs and internal self-states (rafaeli & rafaeli, 2024), strength (flückiger et al., 2024), outcome monitoring (lutz et al., 2024), central processes (hofmann & hayes, 2024); disorder-specific knowledge and dynamic networks (hofmann & hayes, 2024; mcnally, 2024; rief et al., 2024). while the authors were mostly trained in traditional approaches such as psychodynamic therapy or cbt, they share the intention to search for the common ground of psychotherapy, the basic mechanisms of change, and to foster the development of a common language of psychological treatments. our vision is a vibrant scientific and practical discipline, optimizing the surplus of integration and progress of treatments, and overcoming artificial boundaries. transtheoretical psychological therapy – introduction to the special issue 2 clinical psychology in europe 2024, vol. 6(special issue), article e13891 https://doi.org/10.32872/cpe.13891 https://www.psychopen.eu/ funding: no funding that could have influenced the content of this paper. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: wolfgang lutz is guest editor of this special issue. winfried rief is editor-in-chief of clinical psychology in europe. twitter accounts: @lutzpsychres, @riefwinfried references babl, a., eubanks, c. f., & goldfried, m. r. (2024). a 21st century principle-based training approach to psychotherapy: a contribution to the momentum of transtheoretical work. clinical psychology in europe, 6(special issue), article e11925. https://doi.org/10.32872/cpe.11925 boswell, j. f., constantino, m. j., gaines, a. n., & smith, a. e. (2024). responding to key process markers as a focus of psychotherapy training and practice. clinical psychology in europe, 6(special issue), article e11967. https://doi.org/10.32872/cpe.11967 caspar, f., & berger, t. (2024). four versions of transtheoretical stances, and the bernese view. clinical psychology in europe, 6(special issue), article e12453. https://doi.org/10.32872/cpe.12453 flückiger, c., willutzki, u., grosse holtforth, m., & wampold, b. e. (2024). psychotherapy works – an inclusive and affirming view to a modern mental health treatment. clinical psychology in europe, 6(special issue), article e11971. https://doi.org/10.32872/cpe.11971 gilboa-schechtman, e. (2024). case conceptualization in clinical practice and training. clinical psychology in europe, 6(special issue), article e12103. https://doi.org/10.32872/cpe.12103 goldfried, m. r. (1980). toward the delineation of therapeutic change principles. the american psychologist, 35(11), 991–999. https://doi.org/10.1037/0003-066x.35.11.991 hofmann, s. g., barber, j. p., salkovskis, p., wampold, b. e., rief, w., ewen, a.-c. i., & schäfer, l. n. (2022). what is the common ground for modern psychotherapy? a discussion paper based on eaclipt’s 1st webinar. clinical psychology in europe, 4(1), article e8403. https://doi.org/10.32872/cpe.8403 hofmann, s. g., & hayes, s. c. (2024). a process-based approach to transtheoretical clinical research and training. clinical psychology in europe, 6(special issue), article e11987. https://doi.org/10.32872/cpe.11987 lutz, w., deisenhofer, a.-k., weinmann-lutz, b., & barkham, m. (2023). data-informed clinical training and practice. in l. g. castonguay & c. e. hill (eds.), becoming better psychotherapists: advancing training and supervision (pp. 191–213). american psychological association. https://doi.org/10.1037/0000364-010 lutz & rief 3 clinical psychology in europe 2024, vol. 6(special issue), article e13891 https://doi.org/10.32872/cpe.13891 https://twitter.com/lutzpsychres https://twitter.com/riefwinfried https://doi.org/10.32872/cpe.11925 https://doi.org/10.32872/cpe.11967 https://doi.org/10.32872/cpe.12453 https://doi.org/10.32872/cpe.11971 https://doi.org/10.32872/cpe.12103 https://doi.org/10.1037/0003-066x.35.11.991 https://doi.org/10.32872/cpe.8403 https://doi.org/10.32872/cpe.11987 https://doi.org/10.1037/0000364-010 https://www.psychopen.eu/ lutz, w., schwartz, b., deisenhofer, a.-k., schaffrath, j., eberhardt, s. t., bommer, j., vehlen, a., moggia, d., poster, k., weinmann-lutz, b., rubel, j. a., & hehlmann, m. i. (2024). from theory to practice: a transtheoretical treatment and training model (4tm). clinical psychology in europe, 6(special issue), article e12421. https://doi.org/10.32872/cpe.12421 lutz, w., schwartz, b., & delgadillo, j. (2022). measurement-based and data-informed psychological therapy. annual review of clinical psychology, 18, 71–98. https://doi.org/10.1146/annurev-clinpsy-071720-014821 mcnally, r. j. (2024). psychological clinical science: meeting the challenge of public mental health. clinical psychology in europe, 6(special issue), article e12067. https://doi.org/10.32872/cpe.12067 prochaska, j. o., & diclemente, c. c. (1982). transtheoretical therapy: toward a more integrative model of change. psychotherapy, 19(3), 276–288. https://doi.org/10.1037/h0088437 rafaeli, e., & rafaeli, a. k. (2024). needs, modes, and stances: three cardinal questions for psychotherapy practice and training. clinical psychology in europe, 6(special issue), article e12753. https://doi.org/10.32872/cpe.12753 rief, w., kopp, m., awarzamani, r., & weise, c. (2022). selected trends in psychotherapy research: an index analysis of rcts. clinical psychology in europe, 4(2), article e7921. https://doi.org/10.32872/cpe.7921 rief, w., wilhelm, m., bleichhardt, g., strauss, b., frostholm, l., & von blanckenburg, p. (2024). competence-based trainings for psychological treatments – a transtheoretical perspective. clinical psychology in europe, 6(special issue), article e13277. https://doi.org/10.32872/cpe.13277 ryum, t., & kazantzis, n. (2024). between-session homework in clinical training and practice: a transtheoretical perspective. clinical psychology in europe, 6(special issue), article e12607. https://doi.org/10.32872/cpe.12607 taubner, s., & sharp, c. (2024). mental flexibility and epistemic trust through implicit social learning – a meta-model of change processes in psychotherapy with personality disorders. clinical psychology in europe, 6(special issue), article e12433. https://doi.org/10.32872/cpe.12433 twomey, c., o’reilly, g., & goldfried, m. r. (2023). consensus on the perceived presence of transtheoretical principles of change in routine psychotherapy practice: a survey of clinicians and researchers. psychotherapy, 60(2), 219–224. https://doi.org/10.1037/pst0000489 zilcha-mano, s., & muran, j. c. (2024). thinking transtheoretically about alliance and rupture: implications for practice and training. clinical psychology in europe, 6(special issue), article e12439. https://doi.org/10.32872/cpe.12439 transtheoretical psychological therapy – introduction to the special issue 4 clinical psychology in europe 2024, vol. 6(special issue), article e13891 https://doi.org/10.32872/cpe.13891 https://doi.org/10.32872/cpe.12421 https://doi.org/10.1146/annurev-clinpsy-071720-014821 https://doi.org/10.32872/cpe.12067 https://doi.org/10.1037/h0088437 https://doi.org/10.32872/cpe.12753 https://doi.org/10.32872/cpe.7921 https://doi.org/10.32872/cpe.13277 https://doi.org/10.32872/cpe.12607 https://doi.org/10.32872/cpe.12433 https://doi.org/10.1037/pst0000489 https://doi.org/10.32872/cpe.12439 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. lutz & rief 5 clinical psychology in europe 2024, vol. 6(special issue), article e13891 https://doi.org/10.32872/cpe.13891 https://www.psychopen.eu/ the context of covid-19 at 18 months in relation to depression, anxiety, insomnia: the emerging role of post covid-19 symptoms research articles the context of covid-19 at 18 months in relation to depression, anxiety, insomnia: the emerging role of post covid-19 symptoms karin c. brocki 1 , monica buhrman 1 , farzaneh badinlou 2 , lance m. mccracken 1 [1] department of psychology, uppsala university, uppsala, sweden. [2] department of clinical neuroscience, karolinska institutet, stockholm, sweden. clinical psychology in europe, 2025, vol. 7(3), article e13243, https://doi.org/10.32872/cpe.13243 received: 2023-11-14 • accepted: 2025-01-19 • published (vor): 2025-08-29 handling editor: cornelia weise, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany corresponding author: karin c. brocki, department of psychology, uppsala university, box 1225, 751 42 uppsala, sweden. phone: +46184712117. e-mail: karin.brocki@psyk.uu.se abstract background: the covid-19 pandemic naturally raised concerns about mental health and wellbeing around the world. as time passed, persisting physical and mental symptoms of post covid-19, referred to as post covid condition (pcc), have become an increasing concern. the aim of this study was to investigate the stability of symptoms of mental ill health in sweden in the late phase of the pandemic and the prevalence of persistent symptoms post covid-19 and interrelations between them. method: we measured depression, anxiety, and insomnia, through a one-time online survey in sweden (n = 1,482, mean age 47.6 years; 89.5% women) and used correlation and regression analysis to study potential predictors and their interrelations with pcc symptoms. results: compared to our previous study during the pandemic (may – june 2020), a marginal decrease was found for depression (27% versus 30%), a larger decrease for anxiety (16% vs 24%), and an increase for insomnia (45% vs 38%). persistent symptoms were frequently reported, with 84.5% reporting at least one symptom, and 49.7% attributing one or more of these to covid-19 infection. a history of poor mental health and covid-19 related worry appeared as the strongest risk factors for mental ill health. persistent symptoms also predicted these outcomes. conclusions: based on comparison with pre-pandemic rates, it appears that the pandemic continued to exert a negative impact on mental health in sweden. persistent symptoms, associated with covid-19 exposure, appear common and may represent a vulnerability factor for mental ill this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.13243&domain=pdf&date_stamp=2025-08-29 https://orcid.org/0000-0002-4310-3224 https://orcid.org/0000-0002-1722-3505 https://orcid.org/0000-0002-6438-3800 https://orcid.org/0000-0002-9734-0153 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ health, along with other factors, including history of a mental ill health and specific pandemic worries. keywords covid-19, pandemic, mental health, depression, anxiety, insomnia, post covid-19 condition highlights • mental health problems persist 18 months post-pandemic. • high rates of depression, anxiety, and insomnia are documented. • symptoms of post covid-19 condition appear highly prevalent, notably fatigue. • risk factors for persistent symptoms include health history and pandemic-related worries. background during the covid-19 pandemic mental health and wellbeing was a concern, especially for the most vulnerable (world health organization, 2020; yu et al., 2021). global mental health was rapidly studied during the early pandemic, documenting considerable suffer­ ing (mukherjee et al., 2021). years following the pandemic the question becomes what does the picture look over time? did mental health and wellbeing worsen, or did people demonstrate resilience and adjust? tentative evidence suggests that some recovery took place (manchia et al., 2022; yarrington et al., 2021). on the other hand, there is also evidence of persistent impacts 6 and 12 months later in covid-19 survivors (mazza et al., 2022; taquet et al., 2021) suggesting long lasting effects. thus, more careful study is needed to determine what has happened and what to do about it (gruber et al., 2021; o’connor et al., 2021; tegnell, 2021). during may and june 2020, we conducted a survey in sweden with the purpose to assess mental health and wellbeing and factors related to these (mccracken et al., 2020). based on responses from 1,212 adults we found high rates of depression, anxiety, and insomnia, at 30%, 24%, and 38%, respectively. we further found that these outcomes were associated with poor self-rated overall health, a history of mental health problems, presence of covid-19 symptoms, and specific worries around health and finances (see also rondung et al., 2021). it is not known whether circumstances improved or declined for mental health, in sweden or globally, during the years that followed. an unexpected result from the pandemic is a high rate of post covid-19 condition or pcc (fernández-de-las-peñas et al., 2021; nalbandian et al., 2021). this includes per­ sisting symptoms potentially involving multiple organ systems, including fatigue, breath­ ing problems, cognitive disturbance, problems with the gastrointestinal tract, joints, skin, problems with mood and sleep, and other problems, that follow infection by the coronavirus (carfì et al., 2020; hayes et al., 2021; sbu, 2020). the prognosis of persisting depression, anxiety, insomnia and covid-19 2 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ symptoms remains unclear, and it appears that additional research and new models of care are needed (nalbandian et al., 2021). it is unknown how these symptoms correlate with, or perhaps contribute to, mental health outcomes. the purpose of this study was to repeat our study conducted in sweden during june 2020 and reassess the state of mental health and wellbeing 18 months following the start of the pandemic using an independent population sample. the outcomes were levels of depression, anxiety, and insomnia as they are sensitive to stressful events and serve as important predictors of both emotional and physical health. the second purpose was to examine the prevalence of pcc (i.e., symptoms lasting for at least six weeks following in­ fection (e.g., physical, and mental dysfunctions and cognitive impairments – see method section for full description) and their relations with mental health outcomes. additional questions addressed included the identification of risk factors previously associated with health outcomes, such as a previous history of mental health problems and covid-19 related worry. method data collection for this one-time cross-sectional survey in sweden occurred from june to august 2021. participants were recruited online via notices on social media and uppsala university hospital and uppsala university homepages. it was only required that participants were adults, living in sweden, and able to respond to survey material online in swedish. study data were collected and managed using research electronic data capture (redcap), a widely used electronic survey tool hosted locally at uppsala university (harris et al., 2009, 2019). recruitment of participants continued until the rate of recruitment reduced and before the recruitment interval became extended beyond two months. participants initially, 1,657 people provided their consent and entered the survey. in general, there was an increase in missing data with each subsequent measure in the survey, due to dropout, as opposed to skipped or missed items. there was a 10.6% non-completion rate of the three mental health outcome measures and the sample size retained was n = 1,482. however, sample size varied slightly from analysis to analysis due to small amounts of missing data on other individual variables. participant characteristics are included in table 1. notably, the percentage of women who participated was 89.5%. mean age of the total sample was 47.6 years, sd = 11.7, and range was 18 to 81. the participants were well educated with 61.1% having completed university or post graduate education. the vast majority of participants were from sweden or another scandinavian country, 90.1%. most were married or in a relationship, brocki, buhrman, badinlou, & mccracken 3 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ 75.0%, or single, 18.3%, and a little less than half had young children, 45.9%. most partic­ ipants were working either full or part time, 80.3%, and the next largest category was retired, 6.8%. a substantial proportion reported a history of mental health difficulties, 43.2%. fewer, 27.9% of the total sample, were currently experiencing these, and 23.9% reported they had a formal diagnosis. measures demographic variables included those detailed in table 1. to further clarify, participants were also asked whether they (a) lived in suburbs, city, or countryside; (b) had children living at home; and (c) the number of people living in their home in total; whether (d) they had received a formal diagnosis of a mental health condition; (e) were experiencing one of these currently; or (f) were suffering with any of the identified conditions placing people at risk of a poor outcome from covid-19, including age over 70, hypertension, angina, stroke, heart disease, diabetes, cancer, smoking, respiratory disease, and immune suppressant. specific worries about covid-19 were assessed with items used in our previous study (mccracken et al., 2020). here participants rated their worries about their own health, others’ health, their personal finance, world economy, and the future, on a 5-point scale from 1 (not at all worried) to 5 (extremely worried). the respondents’ answers to the five worry items were summed up to calculate a total worry score (α = .77). persistent symptoms persistent symptoms were defined as symptoms lasting for at least six weeks in one or more of 25 different domains. these were based on the pcc report from the swedish agency for health technology assessment and assessment of social services (sbu, 2020) based on available literature at the time and reported on 21 december 2020. the following symptoms were included: fatigue, sleeping problems, problems with attention, joint pain, memory difficulties, depression, headache, impaired daily functioning, anxi­ ety, shortness of breath, pins and needles, gut problems, heart palpitations, changes in smell, changes in taste, decreased lung function, chest pain/pressure, cough, nausea, skin changes, appetite loss, sore throat, weight loss, fever, and reduced quality of life. participants were presented with the following: “do you have one or more of the fol­ lowing long-term symptoms? with long-term symptoms we mean symptoms that have persisted for at least six weeks”. if the participant answered “yes” to any of the symptom questions, they were further asked whether they attributed symptoms they experienced to a previous covid-19 infection. standardized measures three well-established, widely used, and properly validated measures were utilized to assess depression, anxiety, and insomnia (see previous report for full descriptions; depression, anxiety, insomnia and covid-19 4 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ mccracken et al., 2020, 2021). these measures included the patient health questionnaire (phq-9; kroenke & spitzer, 2002) for depression, the generalized anxiety disorder scale (gad-7; kroenke et al., 2007) for anxiety, and the insomnia severity index (isi; bastien et al., 2001) for insomnia. the phq-9 scores range from 0 to 21, with recommended cutoff points for depression severity set at 5 (mild), 10 (moderate), 15 (moderately severe), and 20 (severe) (kroenke & spitzer, 2002). in addition to the nine items on the phq-9, an additional global rating item assesses functional impairment. the gad-7 scores also range from 0 to 21, with a cutoff score of 10 identified as optimal for sensitivity and specificity (kroenke et al., 2007). the isi total score ranges from 0 to 28 and is categorized as follows: absence of insomnia (0-7), sub-threshold insomnia (8-14), moderate insomnia (15-21), and severe insomnia (morin et al., 2011). statistical analysis data were analyzed using ibm spss version 26.0. first, sample characteristics includ­ ing rates of infection, vaccination, other health-related descriptors, and rates of cases meeting clinical cutoffs for depression, anxiety, insomnia, and persistent physical symp­ toms were analyzed. next pearson correlation coefficients were calculated to identify background or health status factors significantly associated with depression, anxiety, and insomnia scores. categorical background variables, such as work and relationship status, were dichotomized as labelled, for example, into “out of work” versus not, and “in a relationship” or not. a second set of correlation analyses included depression, anxiety, and insomnia with each of the individual persistent physical symptom reports and the summary of the total number reported, excluding sleep, depression, anxiety, quality of life, and daily functioning, to avoid inflating the correlations. additional correlation analyses examined relations between participant attributions of symptoms to a covid-19 infection, this time analyzing the full symptom set again examining whether the symptom was regarded as a direct result of infection with the covid-19 virus or not. finally, hierarchical multiple regression analyses were conducted, with depression, anxiety, and insomnia scores as the criterion variables. in these analyses, age, being in a relationship, being out of work, and having above average financial status were included as background variables in the first block of predictors, based on the correlation analy­ ses. the second block of predictors included relevant health status variables, including self-rated physical health, reported mental health history, and a summary score of risk factors for poor covid-19 outcome. the third block included reported infection with covid-19. the fourth block included the summary score for covid-19-related worry. and finally, a selected set of persistent physical symptom reports plus the summary total of symptoms reported was included in the final block of predictors. the included individual symptoms were selected based on having achieved a medium sized correlation or larger with either depression, anxiety, or insomnia in the correlation analyses. brocki, buhrman, badinlou, & mccracken 5 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ results descriptive statistics table 1 includes descriptive statistics on covid-19 infection and vaccination related data. table 1 sample characteristics (n = 1,657) and mental health results variable n % sample characteristics gender female 1483 89.5 male 154 9.4 non-binary 6 0.4 education pre-secondary 39 2.3 secondary 326 19.8 university 1206 73.5 post graduate 71 4.3 country of birth sweden 1430 87.1 other scandinavian country 49 3.0 other european country 121 7.4 other 41 2.6 domestic status married 742 45.2 in a relationship 411 25.0 single 301 18.3 divorced/separated 99 6.0 living apart 79 4.8 widowed 10 0.6 work status working full time 1072 65.3 working part time 247 15.0 retired 111 6.8 student 77 4.7 sick leave 69 4.2 unemployed 31 1.9 parental leave 29 1.8 unpaid work 6 0.4 depression, anxiety, insomnia and covid-19 6 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ variable n % self-rated economic status average 762 46.4 above average 584 35.6 below average 185 11.3 much below average 58 3.5 much above average 53 3.2 self-rated health status good 595 37.0 average 568 35.3 very good 239 14.9 poor 177 11.0 very poor 30 1.9 history of a mental health condition no 927 56.8 yes 705 43.2 covid-19 vaccine two dose 862 53.6 one doses 407 25.3 three doses 339 21.1 infected with covid-19 no 784 48.8 yes, diagnosed 580 36.1 yes, unconfirmed 242 15.1 physical risk factorsa none 1065 66.5 one 380 23.7 two 118 7.4 three or more 39 2.4 mental health outcome results depression (phq-9; m = 6.8, sd = 5.9) minimal (range 0 – 4) 630 44.7 mild (range 5 – 9) 393 27.9 moderate (range 10 – 14) 221 15.6 moderately severe (range 15 – 19) 107 7.6 severe (range 20 – 27) 59 4.2 anxiety (gad-7; m = 4.9, sd = 4.8) none (range 0 – 4) 810 57.0 mild (range 5 – 9) 380 26.8 moderate (range 10 – 17) 190 13.4 severe (range 15 – 21) 30 2.8 brocki, buhrman, badinlou, & mccracken 7 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ variable n % insomnia (isi; m = 9.4, sd = 6.5) none (range 0 – 7) 629 44.5 sub-threshold (range 8 – 14) 474 33.6 moderate (range 15 – 21) 235 16.6 severe (range 22 – 28) 75 5.3 asum of risk factors: age over 70, hypertension, angina, stroke, heart disease, diabetes, cancer, smoking, respiratory disease, and immune suppressant. mental health results table 1 includes summary results from the measures of depression, anxiety, and insom­ nia. mean values fall in the mild or subthreshold range, and most people fall below the clinical cutoff in each case. on the other hand, 27.4%, 16.2%, and 45.0%, met criteria for clinically significant depression, anxiety, and insomnia, respectively, based on cutoff scores > 10. further, 13.6% reported some frequency of thoughts of being better off dead or self-harm (phq-9 item 9), and 67.3% reported that depression symptoms were associated with some level of difficulty in work, home, or social activities (phq-9 item 10). for potential comorbid presentations of these three conditions, 50.6% met criteria for at least one, 25.6% for at least two, and 12.7% for all three. naturally these measures are intercorrelated, with depression and anxiety scores correlated at r = .82, depression and insomnia at r = .67, and anxiety and insomnia at r = .65. data on worries about own health, health of friends or family, own finances, national or international finances, or the future, was provided on a scale from 1 to 5, from not at all worried to extremely worried. the highest area of worry was around health of friends or family, m = 2.85, sd = 1.25, followed by national or international economy, m = 2.68, sd = 1.19, and the future, m = 2.68, sd = 1.30. worry about own health, m = 2.43, sd = 1.91, and own finances, m = 1.99, sd = 1.23, were lowest ranked. pcc results overall, 84.5% of survey participants reported at least one persisting covid-19 symptom from the set of 25 and the mean number of symptoms reported was m = 6.5, sd = 5.3. at least one symptom was reported by 78.0% of those who reported they were never infected with covid-19 and 90.5% of those who reported that they had been. these percentages, although both high, were significantly different, χ2(1, n = 1,552) = 46.3, p < .001. with the removal of the symptom items related to sleep, depression, anxiety, quality of life, and daily functioning, high percentages of participants reported at least one of the remaining 20 symptoms, including 73.1% of those who reported never having covid-19 and 88.2% of those who reported having it, χ2(1, n = 1,552) = 57.0, p < .001. depression, anxiety, insomnia and covid-19 8 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ figure 1 includes the percentages for persons reporting each of the 25 persistent symptoms potentially associated with covid-19 infection. the figure includes both the percentage reporting the symptom and the percentage of those who attributed the symp­ tom to covid-19. the most frequent persistent symptom overall was fatigue, reported by 55.4% and 48.0% of those (24.9% of the overall sample), attributed the fatigue directly to covid-19. a total of nine symptoms were reported by 30% or more of respondents, and these included, in addition to fatigue, sleep disturbance, difficulties with attention, reduced quality of life, joint pain, difficulties with memory, depression, headache, and reduced daily functioning. for about half of the respondents who reported decreased quality of life or daily functioning these effects were attributed to covid-19. for all the other symptoms the percentage was lower. there were several symptoms where the majority of those who reported the symptom also attributed it to covid-19, at rates all greater than 67%. these included shortness of breath, reduced sense of smell, reduced sense of taste, and reduced lung function. figure 1 reported rates (%) of 25 symptoms potentially linked to covid-19 note. the downward arrow symbol (↓) indicates a reduction in that domain (e.g., ↓attention = reduced attention, ↓daily func = reduced daily functioning, ↓appetite = reduced appetite, ↓qual life = reduced quality of life). brocki, buhrman, badinlou, & mccracken 9 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ factors associated with mental health outcomes table 2 includes correlations between the depression, anxiety and insomnia scores with participant background and health status variables. alpha was set at p < .001, given the large sample size and large number of correlations calculated. table 2 correlations addressing potential predictors of depression, anxiety, and insomnia potential predictor depression (phq-9) anxiety (gad-7) insomnia (isi) age -.17* -.21* -.04 gender (female) .07 .06 .09 education (university graduate) -.06 -.04 -.09 married or in a relationship -.11* -.04 .10* unemployed .20* .16* .18* city dwelling .05 .05 .02 children at home -.03 .01 .02 self-rated finance above average -.15* -.13* -.07 self-rated health above average -.52* -.43* -.40* history of a mental health condition .33* .35* .25* current mental health condition .55* .57* .35* infected with covid-19 .15* .10* .13* risk factors for poor covid-19 outcomea .10* .07 .12* worry about own health .39* .38* .31* worry about others health .28* .34* .26* worry about personal finance .48* .45* .39* worry about world economy .21* .21* .21* worry about the future .45* .41* .34* worry total .50* .49* .42* note. correlations that reflect medium or large effect sizes in bold text. asum of risk factors: age over 70, hypertension, angina, stroke, heart disease, diabetes, cancer, smoking, respiratory disease, and immune suppressant. *p < .001. there were several factors that were unrelated to the mental health outcomes, including gender, education, home setting (city versus suburbs or country), or having children at home. there were several other factors that achieved significant but small or inconsistent correlations, including age, relationship status, employment status, self-rated financial status, covid-19 inflection, number of medical conditions increasing risk for poor cov­ id-19 outcomes, and worry about the world economy. factors that achieved mediumsized or larger correlations included self-rated health, history of mental health problems, depression, anxiety, insomnia and covid-19 10 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ current mental health, and worries about own health, others health, personal finances, and the future. amongst all of these, reported history of mental health problems was the strongest correlate. table 3 includes correlations between depression, anxiety, and insomnia with the 25 persistent symptoms. every symptom correlated with all three outcomes at p < .001, except for changes in sense of smell which failed to significantly correlate with anxiety. table 3 correlations of persistent symptoms during covid-19 and depression, anxiety, and insomnia symptom depression (phq-9) anxiety (gad-7) insomnia (isi) fatigue .53* .43* .43* shortness of breath .35* .29* .29* cough .16* .13* .19* heart palpitations .35* .33* .26* weight loss .19* .20* .18* gut problems .31* .27* .29* memory problems .48* .39* .38* attention problems .55* .48* .40* chest pain or pressure .30* .27* .19* sleep difficulties .49* .45* .67* skin changes .21* .17* .16* changes to sense of taste .14* .09* .11* changes to sense of smell .11* .07 .11* joint pain .29* .23* .30* pins and needles in extremities .29* .27* .26* nausea .34* .31* .24* decreased lung function .18* .15* .17* headache .35* .32* .30* decreased appetite .37* .27* .23* fever .19* .15* .13* sore throat .18* .12* .11* depression .63* .56* .43* anxiety .53* .60* .34* decrease quality of life .51* .41* .36* decreased daily functioning .46* .36* .36* total number of symptomsa .59* .49* .48* note. correlations that reflect medium or large effect sizes in bold text. atotal number of symptoms here excludes items related to sleep, depression, anxiety, quality of life, and daily functioning. *p < .001. brocki, buhrman, badinlou, & mccracken 11 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ there were several symptoms that achieved medium or large correlations across all three outcomes. these included fatigue, memory problems, attention problems, sleeping difficulties, headache, depression, anxiety, decreased quality of life, decreased daily func­ tioning, and the total number of symptoms. multivariate prediction analyses three separate hierarchical multiple regression analyses were conducted with depres­ sion, anxiety, and insomnia as dependent variables (see table 4). these were to examine the combined role of background, health status, covid-19 infection, worry, and persis­ tent post-covid-19 symptoms in accounting for variance in these outcomes. amongst these blocks of variables, history of covid-19 infection was the least informative, accounting for less than 1% of variance in all cases. the four background variables, including age, relationship status, employment status, and self-rated financial status, accounted for 8.4%, 7.6%, and 4.1% of variance in depression, anxiety, and in­ somnia, respectively. older age significantly predicted lower scores for depression and anxiety, and being single, unemployed, and, unexpectedly, being well off financially, each contributed significantly to higher score for insomnia, although the variance accounted for was modest. the health status block including self-rated health, mental health history, and the summary score of physical conditions representing risks for poor covid-19 accounted for 27.0%, 21.0%, and 17.0% of variance. here the health rating and mental history were significant predictors, but the physical risk factors were not. the single best variable in the equations was the total covid-related worry scores, accounting for 9.2%, 10.0%, and 7.5% of variance in the outcomes. with all other potential predictors included, on average the twelve persistent physical symptoms with medium effect sizes and the sum­ mary score for the number reported (adjusted to exclude depression, anxiety, sleeping problems or reduced quality of life or daily functioning) were relatively good predictors of outcomes as a set, accounting for 14.0% or variance in depression, 9.0% for anxiety, and 7.7% for insomnia. the specific symptoms most strongly related to the three outcomes were fatigue and headache, which both significantly predicted all three, and attention problems, which was a relatively strong predictor of both depression and anxiety, but not insomnia. finally, we reran the regression analyses selecting only the participants who had reported a history of covid-19 infection and the results did not change appreciably. for example, the variance accounted for by the persistent physical symptoms remained similar or the same, 14.0% for depression, 8.4% for anxiety, and 7.5% for insomnia. depression, anxiety, insomnia and covid-19 12 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ table 4 multiple regression analyses of depression, anxiety, and insomnia block predictor dependent variable depression anxiety insomnia δr 2 β δr 2 β δr 2 β 1 background .084** .076** .041** age -.080** -.11** .010 in a relationship -.061** -.00 -.068* unemployed .046 .027 .064* finances above average .023 .021 .067* 2 health status .27** .21** .17** health above average -.17** -.12** -.11** mental health history .12** .17** .11** physical risk factors -.00 -.00 .00 3 covid .005* .002 .005* covid infection -.021 -.024 .010 4 worry .092** .10** .075** worry total .23** .26** .23** 5 persistent symptoms .14** .090** .077** fatigue .13** .073* .12** shortness of breath .078* .069 .040 heart palpitations .045 .094** .010 gut problems -.025 .010 .041 memory problems .081* .024 .067 attention problems .20** .21** .054 chest pain/pressure .035 .024 .050 joint pain .039 .017 .076* nausea .065* .078** .010 headache .081** .094** .075* decreased appetite .17** .081** .037 total number symptoms .12 .12 .040 total r 2 .59 .48 .37 note. regression coefficients that reflect significant effect sizes across all three dependent variables in bold text. *p < .01. **p < .001. brocki, buhrman, badinlou, & mccracken 13 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ discussion >the purpose of this study was to examine levels of depression, anxiety, and insomnia, in sweden at 18 months following the start of the pandemic and compare to our findings from an independent population sample in 2020. we also examined persistent covid-19 symptoms in terms of prevalence and associations with the mental health outcomes, as well as risk factors known to increase vulnerability for mental ill health in the pandemic context (mccracken et al., 2020; zvolensky et al., 2020). compared to previous reports of mental health from the early pandemic, we found a decrease in level of depression and anxiety and an increase for insomnia. we found a high rate of persistent covid-19 symptoms, with 84.5% of the sample reporting at least one persistent symptom, with fatigue being the most common. it appears that at the late phase of the pandemic, people in sweden were still suffering from mental health problems, and from persistent symptoms. in addition, these persistent symptoms seemed to play a role in mental health over and above risk factors such as demographics, general health status, and covid-19 related worry. we found that 27% of our sample reported clinically significant levels of depression, whereas the rates for anxiety and insomnia were 16% and 45%, respectively. in our previous study (mccracken et al., 2020), the rates for the same mental health problems, were 30% for depression, 24% for anxiety, and 38% for insomnia. although we observed a decrease for depression, this change is small and may be practically non-significant. on the other hand, the results for anxiety are in line with other reports indicating that the world is beginning to slowly recover from the mental health impacts associated with the pandemic (manchia et al., 2022; yarrington et al., 2021). the high rate of significant insomnia was unexpected, and the cause for this increase is unclear. in one study, insomnia during the pandemic was more common in women (goncalves et al., 2022) and considering that 89.5% of our sample identified as women could be a factor. we note that the percentage meeting criteria as having significant insomnia is the same as the 44% who endorse sleeping problems in the list of persistent symptoms, the second most frequent complaint. perhaps not surprisingly, our regression analyses showed that covid-19-related worries were a strong predictor of insomnia. the higher rates of depression, anxiety, and insomnia in sweden are consistent with global prevalence of these identified in a systematic review and meta-analysis, calling prevalence rates “very high compared to normal times” (mahmud et al., 2021) and with longitudinal data suggesting long term psychological disturbances in covid-19 survi­ vors (mazza et al., 2022). practically speaking, 67% of the participants meeting criteria for depression reported that this was having an impact on their daily functioning suggesting significant real-life consequences for the individual and society. as a whole, the persistent symptoms assessed occurred very frequently, with 84.5% of the participants reporting at least one symptom lasting for at least six weeks, and there was a high rate of these symptoms even among those who reported no prior infection depression, anxiety, insomnia and covid-19 14 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ with covid-19, 78%. important to note is that some of the symptoms are likely entirely coincidental to the covid-19 infection, but we have no clear way to specifically identify those that are and those that are not. in our study, fatigue was the most common persistent symptom, with a prevalence of 55.4% and approximately half of these, 48%, attributing it directly to covid-19. this finding corroborates consistent results across european studies on persistent covid-19 symptoms, with prevalence rates of fatigue between 50-70% (fernández-de-las-peñas et al., 2021; lopez-leon et al., 2021). this is not to lose sight of the wider range of symp­ toms and that 30% of the participants reported having all of a total of nine symptoms including fatigue, sleep disturbances, difficulties with attention, reduced quality of life, joint pain, difficulties with memory, depression, headache and reduced daily functioning. looking at potential vulnerability factors, numerous participant characteristics were associated with at least one of the three mental health outcomes, including age, relation­ ship status, employment status, financial status, risk for poor covid-19 outcome, and worry about the world economy (see table 3). given the small correlations, practical implications for these results may be limited and findings should be replicated. how­ ever, factors that appeared more robustly linked to depression, anxiety and insomnia, presenting medium effect sizes, were self-rated overall health, history of mental health problems, current mental health status, and current worries. amongst these, reported current mental health status was the strongest correlate. the results from the multivariate analyses showed that history of covid-19 infection was the least informative in explaining variance for depression, anxiety and insomnia, accounting for less than 1% of all three outcomes. thus, contracting covid-19 infection did not seem to impact on level of mental health in the pandemic context perhaps pointing to other contextual factors as more important. background variables – age, relationship status, employment status, and self-rated financial status –, as a set, signif­ icantly predicted all of the three mental health outcomes, explaining 8.4%, 7.6%, and 4.1% of the variance in depression, anxiety, and insomnia, respectively. older age seemed to function as a protective factor against increased levels of depression and anxiety. this also suggests that younger people are more vulnerable to mental ill health in the pandemic context, a result which has been well documented throughout the pandemic (mccracken et al., 2020; pierce et al., 2020). the health status variables, including, overall rated health, mental health history, and a summary score of physical conditions was the strongest predictor of risk for poor outcome in depression, anxiety and insomnia, accounting for close to half of the explained variance for each outcome. overall health and mental history appeared similarly important whereas physical risk did not contribute at all. the relation between a previous history of mental ill health and higher levels of poor mental health in all outcomes, suggests increased vulnerability for mental ill health during the pandemic in those already burdened with the impacts of mental ill health brocki, buhrman, badinlou, & mccracken 15 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ we found that the best single predictor of the mental health outcomes was cov­ id-19-related worry scores, accounting for 9.2%, 10.0%, and 7.5% of variance in depres­ sion, anxiety and insomnia. this finding may mean that for many people cognitive and emotional responses to the pandemic situation represent an underlying mechanism of the elevated levels of significant depression, anxiety, and insomnia. controlling for all other predictors, the 12 selected persistent symptoms and the sum­ mary score for the number reported (adjusted to exclude depression, anxiety, sleeping problems or reduced quality of life or daily functioning) accounted for 14.0% or variance in depression, 9.0% for anxiety, and 7.7% for insomnia. the symptoms most strongly related to the three outcomes were fatigue and headache, which both significantly predicted all three, and attention problems, which was a relatively strong predictor of both depression and anxiety, but not insomnia. we attempted to examine whether it mattered if the symptoms seemed to emerge directly from diagnosed covid-19 exposure or not. we did this in two ways, by analyzing the covid-19 attributions related to the symptoms and by analyzing the specific covid-19 diagnosis groups. in either case it did not make any difference whether there was a direct link with covid-19 infection or not. this may mean that these symptoms are not specific or uniquely linked to covid-19 infection but may be caused by people’s experiences in the pandemic context, as men­ tioned before, in combination with other vulnerability factors. in fact, the nature of many of the symptoms included is that they are frequently associated with stress. these persistent symptoms are interesting, because their link with mental health outcomes seems stronger than their links with covid-19 itself. we hasten to add that none of this is to deny the legitimacy of the symptoms nor to express an opinion on their genesis in any particular case. one obvious limitation of this study is the relative absence of men, with 89.5% of participants identifying as women. this result was unexpected. one explanation may be related to the reported gender gap in covid-19 risk perceptions, with men having lower estimates of their covid-19 related risks compared to women (lewis & duch, 2021). this could lead to greater interest in pandemic research among women and, consequently, increased participation. nevertheless, the uneven gender distribution limits what we can say about the experience of men. however, analyses of gender differences in mental ill health based on data from our previous pandemic survey (mccracken et al., 2020, 2021) showed no gender difference in the prevalence of the same mental health outcomes. yet another unexpected result was the 100% vaccination rate in participants, leaving us unable to examine the role of this variable or to assume generalizability to those who are unvaccinated. this survey, like our previous one (mccracken et al., 2020) is a cross sectional study and did not technically track the same people prospectively. there could be differences in the samples recruited that confound our comparison despite our intention to avoid these. either way, we are unable to assess any direction in relations observed. finally, we depression, anxiety, insomnia and covid-19 16 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.psychopen.eu/ must acknowledge the inherent bias of self-report measures and the potential selective recruitment bias entailed through the use of social media. in fact, it may be this social media context that led to the recruitment of more women than men. in light of these limitations our results reported here need to be regarded as provisional. to summarize, about 18 months after the pandemic began swedish people continued to report a great deal of suffering and reduced health. half of those who responded in this study appeared to suffer significant problems in at least one of the domains of depression, anxiety, or insomnia. in addition, many participants, 84.5%, reported one or more persistent symptom defined as potential effects of covid-19. the most apparent risk factors for lower mental health included negative overall self-rated health, history of mental health problems, worries related to the pandemic, and persistent physical symptoms. it may be important to study whether symptoms and other negative health outcomes persist long term post pandemic, whether these represent a significant health burden, and might need to be addressed. in conclusion, this study emphasizes the need for comprehensive, long-term mental health strategies that address both psychological and physical health issues, particularly for vulnerable populations, as the world contin­ ues to recover from the covid-19 pandemic. funding: this research was supported by the swedish research council (2019–02978) to karin c. brocki. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. ethics statement: the study was approved by the swedish national ethical board (dnr 2021-01647) and informed consent was obtained from all participants. preregistration: the study 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(2020). psychological, addictive, and health behavior implications of the covid-19 pandemic. behaviour research and therapy, 134, article 103715. https://doi.org/10.1016/j.brat.2020.103715 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. depression, anxiety, insomnia and covid-19 20 clinical psychology in europe 2025, vol. 7(3), article e13243 https://doi.org/10.32872/cpe.13243 https://www.sbu.se/en/publications/sbu-bereder/long-term-symptoms-of-the-disease-covid-19/ https://doi.org/10.1016/s2215-0366(21)00084-5 https://doi.org/10.1111/apm.13112 https://www.who.int/publications/i/item/978924012455/ https://doi.org/10.1016/j.jad.2021.02.056 https://doi.org/10.1016/j.jpain.2021.02.011 https://doi.org/10.1016/j.brat.2020.103715 https://www.psychopen.eu/ depression, anxiety, insomnia and covid-19 (introduction) background method participants measures statistical analysis results descriptive statistics mental health results pcc results multivariate prediction analyses discussion (additional information) funding acknowledgments competing interests ethics statement preregistration reporting guidelines data availability references thinking transtheoretically about alliance and rupture: implications for practice and training scientific update and overview thinking transtheoretically about alliance and rupture: implications for practice and training sigal zilcha-mano 1 § , j. christopher muran 2 § [1] department of psychology, university of haifa, haifa, israel. [2] gordon f. derner school of psychology, adelphi university, new york, ny, usa. §these authors contributed equally to this work. clinical psychology in europe, 2024, vol. 6(special issue), article e12439, https://doi.org/10.32872/cpe.12439 received: 2023-07-19 • accepted: 2023-10-01 • published (vor): 2024-04-26 handling editor: wolfgang lutz, department of psychology, university of trier, trier, germany corresponding author: sigal zilcha-mano, department of psychology, university of haifa, mount carmel, haifa 31905, israel. telephone: 972-4-8249047. e-mail: sigalzil@gmail.com related: this article is part of the cpe special issue “transtheoretical psychological therapy – new perspectives for clinical training and practice”, guest editors: wolfgang lutz & winfried rief, clinical psychology in europe, 6(special issue), https://doi.org/10.32872/10.32872/cpe.v6.si abstract repairing alliance ruptures has the potential to serve as a powerful mechanism of change in psychotherapy. in this article, a transtheoretical individual-specific framework for repairing alliance ruptures is proposed. according to the proposed framework, at the intake session, the therapist evaluates the trait-like tendencies of individual patients to face ruptures in interpersonal relationships. we propose a typology based on which patients are assigned to one of the following therapeutic strategies: (a) a treatment where alliance rupture and repair is the main mechanism of change (type a), (b) an added module that augments another treatment, focusing on rupture and repair (type b), or (c) treatment where no rupture resolution work is carried out (type c). the proposed framework is based on cumulative clinical knowledge, and its validity and utility need to be assessed in future research. keywords rupture and repair, alliance, mechanism of change, trait-like, state-like this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12439&domain=pdf&date_stamp=2024-04-26 https://orcid.org/0000-0002-5645-4429 https://orcid.org/0000-0002-6522-7551 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ highlights • repairing alliance ruptures is considered an important mechanism of change in the psychotherapeutic process. • a transtheoretical and individual-specific framework for repairing alliance ruptures is proposed. • based on an individual’s trait-like tendencies to face ruptures in interpersonal settings, the therapist may choose among three different therapeutic approaches. the alliance used to be an “analytic construct,” developed to address the real and practical aspects of the patient-therapist interaction (greenson, 1967), but it eventually took on transtheoretical relevance. this was in large part due to bordin’s (1979, 1994) reformulation, which defined it as composed of purposeful collaboration (agreement on tasks and goals) and affective bond (mutual trust and respect) between patient and therapist. it is now widely considered an integral “common factor” (wampold & imel, 2015), a “principle of change” (castonguay et al., 2019), and a “quintessential integrative variable” (wolfe & goldfried, 1988). in contrast to previous conceptualizations, bordin placed greater emphasis on mutuality rather than adherence to the therapist’s agenda or organizing capacity, and pointed out the inextricable tie between therapist technique and the therapeutic relationship. bordin’s reformulation provided the basis for an “intersub­ jective elaboration” by safran and muran (2000, 2006), which recognized the negotiation between patient and therapist regarding motivational needs for agency and communion. bordin’s definition describes the “explicit collaboration” between patient and therapist; safran and muran’s describes the “implicit negotiation” (see muran, 2022). decades of empirical research support the importance of the patient-therapist alli­ ance for successful treatment, regardless of theoretical orientation. four of the most commonly used measures for assessing the alliance are (flückiger et al., 2018): the california psychotherapy alliance scale (calpas; gaston & marmar, 1991), the helping alliance questionnaire (haq; luborsky et al., 1996), the vanderbilt psychotherapy proc­ ess scale (vpps; suh et al., 1989), and the working alliance inventory (wai; horvath & greenberg, 1986). the alliance can be assessed based on patient or therapist reports, or may be rated by an external observer watching videotaped sessions or reading session transcripts. the various alliance measures developed over the years have been significantly informed by bordin’s conceptualization. a recent meta-analysis suggests that a stronger alliance is significantly associated with better treatment outcome, and a weakened alli­ ance can lead to premature termination of treatment (flückiger et al., 2018). indeed, the significant alliance-outcome correlation is among the most replicated findings in psycho­ therapy research, perhaps in psychology science in general. there is also a growing body of evidence suggesting a potential causal relation of the alliance to outcome, supporting thinking transtheoretically about alliance and rupture 2 clinical psychology in europe 2024, vol. 6(special issue), article e12439 https://doi.org/10.32872/cpe.12439 https://www.psychopen.eu/ the consideration of the alliance as a “change mechanism” (e.g., barber et al., 2000; zilcha-mano, 2017; zilcha-mano et al., 2019; zilcha-mano & fisher, 2022). to translate this empirical knowledge into clinical practice methods of improving alliance to achieve better treatment outcome, it is critical to address the question of whether the alliance is a facilitative condition for change or a change mechanism in itself. correlational research efforts support the former but other work suggests the latter, including mediational, within-individual effects, and task analyses. change can be understood as involving movement on multiple levels or including multiple processes, and as noted, alliance has been defined as inherently integrated in all change processes of which collaboration and trust are a part. as a change process, the alliance can be un­ derstood to involve both skill development and a new relational or corrective experience, that is, how to negotiate one’s motivational needs with another and how to be intimate with another (expressive and understood). one of the most studied and supported perspectives of the alliance as a change mechanism concerns rupture repair. ruptures have been defined as (a) disagreements about tasks or goals or deterioration in trust or respect (bordin’s formulation) and (b) breakdowns in the negotiation of the patient’s and therapist’s implicit needs for agency or communion according to safran and muran’s elaboration (see safran & muran, 2000, 2006). more specifically, ruptures have been defined based on patient or therapist markers of withdrawal or confrontation: withdrawal markers are “movements away” from self or the other that can be understood as pursuits of communion at the expense of agency (e.g., shutting down, avoiding, masking experience); confrontation markers are “movements against” the other that can be understood as pursuits of agency at the expense of communion (e.g., complaining about the other, defending the self, controlling the other; eubanks, muran, & samstag, 2023; muran & eubanks, 2020a). at the heart of the rupture is the negotiation of individual differences and relationship ambiguities, which result in objectifications to control and feel agentic, but also reflect a struggle to recognize respective subjectivities, define oneself, and feel connected (muran, 2007; muran & eubanks, 2020b). a recent meta-analysis on rupture repair (eubanks et al., 2019) that included self-re­ port and observer-based methods demonstrated a similar significant relation between rupture repair episodes and treatment outcome (as ratings of the alliance quality). several task analytic studies provided empirical support for stage-process models that define rupture repair as a change event: one example defines an exploratory model in which ruptures are acknowledged and explored and implicit needs clarified as expressions of resolution (safran & muran, 1996); another defines a renegotiation of tasks or goals, which includes the application of various strategies, such as acknowledging ruptures, ex­ plaining rationales, clarifying obstacles, discussing alternatives, redirecting attention, and making modifications (muran, 2022). other similar mixed-method efforts (quantitative and qualitative) have sought to elucidate the processes by which alliance ruptures are zilcha-mano & muran 3 clinical psychology in europe 2024, vol. 6(special issue), article e12439 https://doi.org/10.32872/cpe.12439 https://www.psychopen.eu/ repaired (hill, 2010; muran, 2019) and to train therapists to better recognize and resolve ruptures (e.g., muran et al., 2018; see eubanks et al., 2019, for a meta-analysis). the present article aims to provide further understanding of how repairing alliance ruptures can be tailored to the individual patient to improve treatment outcome across theoretical orientations. it has been suggested that any change mechanism in treatment, including the alliance, consists of distinct trait-like and state-like components (zilchamano, 2021). the trait-like component of alliance refers to individual differences between patients in their ability to form satisfying relationships with others, which may translate into an ability to form satisfying alliances with their therapists as well. the state-like component refers to within-individual changes in alliance strength occurring from one moment of the therapy session to the next (zilcha-mano, 2017). a synthesis of the availa­ ble empirical literature disentangling the trait-like and state-like components of alliance suggests that its trait-like component is a product of the patients’ and therapists’ traitlike characteristics. by contrast, the state-like component of alliance is associated with in-treatment therapeutic processes, such as corrective relational experiences between patients and their therapists (zilcha-mano & fisher, 2022). the proposed individual-specific framework for repairing alliance ruptures integrating the rich theoretical, clinical, and empirical literature on repairing alliance ruptures (muran & eubanks, 2020a; safran & muran, 2000) with the trait-like state-like model (zilcha-mano, 2021), we proposed an individual-specific framework for repairing alliance ruptures. the proposed framework is based on our experience as clinicians, trainee supervisors, and researchers. in the proposed transtheoretical framework, at the intake sessions, the therapist evaluates the trait-like tendencies of the patient to face ruptures in interpersonal relationships. this evaluation process may result in a systematic formulation of the individuals’ main interpersonal strengths and weaknesses (zilcha-mano, 2024). the resulting formulation can then serve as a guide for selecting whether and how to implement a treatment or a module for repairing alliance ruptures. the evaluation includes the frequency of such ruptures, their nature and intensity, generalizability across types of relationships, as well as the patient’s awareness of the ruptures and insight regarding their origins. these trait-like tendencies can be assessed both through the collection of specific relational episodes occurring outside the therapy room, in the individual’s daily life, and based on the in-session relational moment-to-mo­ ment interactions between patient and therapist in the therapy room. an example of a structured interview that can be used to collect specific relational episodes occurring outside the therapy room is the self-understanding of interpersonal patterns scales– interview (suip-i; gibbons & crits-christoph, 2017; yaffe-herbst et al., 2023). the suip-i is a semi-structured interview, in which patients are asked to share five stories about thinking transtheoretically about alliance and rupture 4 clinical psychology in europe 2024, vol. 6(special issue), article e12439 https://doi.org/10.32872/cpe.12439 https://www.psychopen.eu/ relational exchanges with significant others that they view as problematic. structured questions are used to give patients the opportunity to verbalize their understanding of each interaction without leading them. the interviewer evaluates the patients’ ability to recognize, understand, and describe their conflictual pattern. the information collected using the suip-i can be used to formulate the trait-like tendencies to show ruptures, their nature, severity, and manifestations, their generalizability across types of relationships and the patient's awareness of the ruptures and insight regarding their origins. other measures that can be implemented to explore the patients’ trait-like tendencies may include structured interviews of personality disorders (e.g., structured interview for dsm-iv personality; pfohl et al., 1997) and self-report questionnaires of interpersonal problems (e.g., horowitz et al., 1988). following this initial relational-based evaluation, the therapist can develop a ther­ apeutic program tailored to the individual patient’s relational needs, difficulties, and capabilities. the key decision about the therapeutic program in this context is whether a rupture and repair manual should be implemented as the recommended treatment (type a below), a module augmenting another treatment manual should be used (type b), or no rupture resolution work is needed (type c). during the pre-treatment evaluation phase, the therapist seeks to map the trait-like capacities of the patient to negotiate interpersonal needs. overall, three main “types” of such trait-like abilities can be delineated. type c – mature: individuals with mature capa­ bilities to negotiate interpersonal needs are able to form satisfying intimate relationships with others, which balance needs for agency and communion. across their interpersonal interactions, those individuals form satisfying relationships in which both their needs for agency and for communion are met most of the time. these individuals come to treatment with relational strengths and may not require deep relational therapeutic work. their therapists can build on those relational strengths and invest in strengthening other mechanisms of changes, such as adaptive cognitive schemas. they can build on the patient’s abilities to form a strong helpful alliance early in the course of treatment, and maintain it throughout with little or no direct work on building relational capabilities during treatment. few ruptures are expected with these patients during the course of treatment, and they are likely to be easily repaired using surface-based repairing techni­ ques (e.g., explaining misunderstanding). type b – functioning but with some struggles: some patients are able to form satis­ fying relationships with others but are still struggling to meet their needs for agency or communion. they may either be able to establish and maintain relatedness with others but struggle with self-definition and individualization, or may be able to maintain autonomy but at the cost of relatedness with others. these individuals may form a good enough alliance with their therapist early in treatment with some investment by the therapist in the form of implementing active supportive techniques of alliance formation. later in the course of treatment, when challenges appear, because of the zilcha-mano & muran 5 clinical psychology in europe 2024, vol. 6(special issue), article e12439 https://doi.org/10.32872/cpe.12439 https://www.psychopen.eu/ patient’s frustrations in the process of building a helpful intimate relationship with the therapist, because of other struggles resulting from the therapeutic process, or because of interpersonal struggles outside of the therapy room, a rupture and repair module may be required to augment the treatment. the concrete points in which challenges occur may differ as a function of the type of treatment, treatment duration, patient and therapist characteristics, the fit between them, etc. for example, in short-term supportive-expres­ sive psychodynamic treatment, some patients may face challenges at the end of the treat­ ment, when by definition, the therapists can no longer actualize the patients’ interperso­ nal needs and therefore may be seen as a rejecting other (ben david-sela et al., 2020). such an augmentation module is aimed at facilitating state-like improvements in the individual’s ability to negotiate interpersonal needs (e.g., castonguay et al., 2004). each episode in which the therapist implements techniques for repairing alliance ruptures results in state-like strengthening of the patients’ ability to negotiate their interpersonal needs. similarly to fredrickson’s (2004) broaden-and-build model of positive emotions, the repetitive state-like improvements in the individual’s ability to negotiate their inter­ personal needs in the alliance with the therapist result in a gradual improvement in the individual’s trait-like ability to negotiate interpersonal needs. over time, this expanded interpersonal negotiation repertoire builds useful skills and psychological resources that become available for the individual in any interpersonal interaction. type a – major interpersonal struggles: some patients either come to treatment be­ cause of severe interpersonal struggles or the interpersonal struggles are main contribu­ tors to their suffering and the mechanisms underlying their anxiety, depression, or other mental health symptoms. therapists may initially perceive the formation of a strong alliance that can support the work of treatment as an unattainable goal. these patients may distrust the therapist’s goodwill or ability to help. any therapeutic intervention the therapist may wish to implement, such as challenging thoughts or implementing a behavioral hierarchy of goals, may become an interpersonal struggle with the patient. assigning such patients to treatment containing a mixture of both indirect and direct techniques for repairing alliance ruptures (safran & muran, 2000) may be more effective. the implementation of indirect techniques may produce a corrective relational experi­ ence in which, during the rupture, the therapist identifies the patient’s suffering and dis­ tress and uses implicit techniques (e.g., changing therapy tasks) that help the patient feel understood, appreciated, and validated. through the implementation of direct techniques for negotiating interpersonal needs in the therapist-patient relationship, the patients learn, by direct participation, how interpersonal needs can be expressed and negotiated. for individuals belonging to types b and a, the recommended techniques should be based on the therapists’ evaluation of whether the trait-like interpersonal difficulties are of the self-definition or relatedness kind. based on safran and muran (2000, 2006), it is suggested that individuals may differ in their trait-like tendencies to cope with the tension between needs for agency and for relatedness. different trait-like interpersonal thinking transtheoretically about alliance and rupture 6 clinical psychology in europe 2024, vol. 6(special issue), article e12439 https://doi.org/10.32872/cpe.12439 https://www.psychopen.eu/ tendencies are expected to be reflected in the tendencies to show withdrawal vs. confron­ tational ruptures. safran and muran (2000) provided elaborated models of how to work with each that can help choose the right approach and technique for repairing ruptures, according to their type. for example, when the needs for agency are generally not being met in the patients' lives, and the patients may tend to respond to the therapists with withdrawal ruptures, a stage of qualified assertion may follow a stage of disembedding and attending to the rupture, which may finally result in an increase in self-assertion. summary and future research the proposed individual-specific framework for repairing alliance ruptures is based on theoretical conceptualizations and empirical findings. but it has never been tested directly, therefore clinical trials are needed in which patients are assigned to treatment according to their receptive “type.” although the proposed typology refers to relatively stable trait-like characteristics of individuals, it may also be subject to change as a result of transformative and formative experiences. it is important to take into account that therapists have their own trait-like tendencies toward self-definition vs. relatedness, which can be used to better match patients with therapists (e.g., constantino et al., 2021). alternatively, this information can be used to tailor therapists’ training to focus on their trait-like interpersonal tendencies and the ways in which those tendencies are reflected in their interactions with their patients and affect them, as may be manifested, for example, in therapist-initiated ruptures or unsuccessful repair efforts. after being empirically validated, the proposed typology can be further elaborated to account for and be sensitive to the socio-cultural experiences and characteristics of individuals. its utility should also be evaluated for children, after making the relevant adaptations. for the proposed conceptualization to become useful for clinical practice, after its merit and utility receive empirical support, it should be incorporated into the skill set imparted to trainees in training programs. given the great consistency in empirical findings showing the importance of a strong alliance for treatment success, many training programs worldwide are already teaching their trainees how to identify ruptures and repair them. therapists trained in such programs already possess these skills, and the added value of the typology lies in how to integrate these skills into their practice and how to tailor the implementation of the skills to the individual patient’s characteristics using the proposed typology. it is recommended that all programs teach these skills, given the cumulative empirical evidence concerning the adverse effects of unrepaired ruptures and the therapeutic effects of those that are repaired. helpful resources are available to support a large-scale implementation (e.g., eubanks-carter et al., 2015; muran & eubanks, 2020a; muran et al., 2010). zilcha-mano & muran 7 clinical psychology in europe 2024, vol. 6(special issue), article e12439 https://doi.org/10.32872/cpe.12439 https://www.psychopen.eu/ funding: the writing of this article was supported in part by grant mh071768 from the national institute of mental health (principal investigator: j. christopher muran) and by the israeli science foundation grant no. 186/15 and 395/19. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: j. christopher muran receives royalties from guilford press and american psychological association books. references barber, j. p., connolly, m. b., crits-christoph, p., gladis, l., & siqueland, l. 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(2022). distinct roles of state-like and trait-like patient-therapist alliance in psychotherapy. nature reviews psychology, 1, 194–210. https://doi.org/10.1038/s44159-022-00029-z thinking transtheoretically about alliance and rupture 10 clinical psychology in europe 2024, vol. 6(special issue), article e12439 https://doi.org/10.32872/cpe.12439 https://doi.org/10.1037/ccp0000284 https://doi.org/10.1037/0022-006x.64.3.447 https://doi.org/10.1037/0033-3204.43.3.286 https://doi.org/10.1891/0889-8391.3.2.123 https://doi.org/10.1037/0022-006x.56.3.448 https://doi.org/10.1037/pst0000491 https://doi.org/10.1037/a0040435 https://doi.org/10.1037/amp0000629 https://doi.org/10.1177/17456916231226308 https://doi.org/10.1037/ccp0000397 https://doi.org/10.1038/s44159-022-00029-z https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. zilcha-mano & muran 11 clinical psychology in europe 2024, vol. 6(special issue), article e12439 https://doi.org/10.32872/cpe.12439 https://www.psychopen.eu/ thinking transtheoretically about alliance and rupture (introduction) the proposed individual-specific framework for repairing alliance ruptures summary and future research (additional information) funding acknowledgments competing interests references trajectories of depressive symptoms and associated risk factors from late adolescence to emerging adulthood research articles trajectories of depressive symptoms and associated risk factors from late adolescence to emerging adulthood simone pfeiffer 1 , philipp alt 2 , sabine walper 2,3 [1] clinical child and adolescent psychology and psychotherapy, rptu kaiserslautern-landau, landau, germany. [2] department of education and rehabilitation, ludwig-maximilians university of munich, munich, germany. [3] german youth institute (dji), munich, germany. clinical psychology in europe, 2025, vol. 7(4), article e15801, https://doi.org/10.32872/cpe.15801 received: 2024-10-10 • accepted: 2025-05-15 • published (vor): 2025-11-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: simone pfeiffer, clinical child and adolescent psychology and psychotherapy, rptu, university of kaiserslautern-landau, landau, ostbahnstraße 12, d-76829 landau, germany. phone: +49 6341 280 35615. e-mail: simone.pfeiffer@rptu.de supplementary materials: materials [see index of supplementary materials] abstract background: this study addresses a research gap by identifying depressive symptom trajectories from adolescence to emerging adulthood in a german community sample using a person-centered approach. method: the sample consisted of 3,682 adolescents and young adults (49.3% self-identified as female; age at t1: 15–19 years, m = 17.03, sd = 0.88) assessed in seven annual waves of the german family panel pairfam. latent class growth analysis was conducted with sociodemographic variables (gender, family status, parental education, economic deprivation, immigration background) and depressive symptoms, as assessed by the state-trait depression scales. results: five depressive symptom trajectories were identified: stable low symptoms (34%), intermediate onset with decreasing symptom trajectory (8%), intermediate onset with slow increasing symptom trajectory (46%), intermediate onset with strong increase symptom trajectory (9%) and stable high symptoms (4%). female gender and economic deprivation were predictors for all four classes associated with higher depressive symptoms with reference to the class with stable low depressive symptoms. family status and immigration status lost their predictive impact for membership in depressive symptom trajectories when economic deprivation was included. conclusions: interventions should target the underlying etiological factors of female gender and economic deprivation being risk factors for trajectories of depression, taking into consideration the this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.15801&domain=pdf&date_stamp=2025-11-28 https://orcid.org/0000-0002-6866-8221 https://orcid.org/0000-0001-7523-3077 https://orcid.org/0000-0002-6212-5242 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ complexity and interaction of biopsychosocial and political variables in the development of depressive disorders. keywords depressive symptom trajectories, adolescents, emerging adulthood, risk factors highlights • five depressive symptom trajectories were identified from adolescence to emerging adulthood (15-25 years) in a german sample. • female gender and economic deprivation are risk factors and should be targeted in preventions measures for depression. • economic deprivation mediates the effects of family status and immigration status on depressive symptoms. emerging adulthood is considered a distinct period between the ages of 18 and 25 years (arnett, 2000) in which the successful handling and accomplishments of developmental milestones is associated with the transition into adulthood. the conditions under which individuals cope with these developmental milestones serve as risk factors for the devel­ opment of mental health problems (baggio et al., 2017; ladhani et al., 2019). the onset of depression increases significantly in this period with a peak at the age of 15–17 years (schubert et al., 2017) with prevalence rates of depressive disorders at 3–18% (kessler et al., 2012; polanczyk et al., 2015). after the peak in adolescence, depressive symptoms tend to decrease and seem to remain relatively stable during adulthood (salk et al., 2017). however, these overall trends do not reflect individual trajectories, which may comprise stable courses of high or low depressiveness as well as increases or recoveries. identifying types of detrimental trajectories, their prevalence, and their related risk factors can provide important information for health services and the development of targeted prevention programs. understanding risk and protective factors in the development of depressive disorders is highly relevant, as untreated depressive disorders in adolescence are associated with, among other outcomes, the development of chronic depressive symptoms, suicide, sub­ stance abuse, lower educational outcome, and lower income as an adult (chen & kaplan, 2003; hawton et al., 2012). this is the first study investigating trajectories of depressive symptoms from adoles­ cence to emerging adulthood in a german community sample, where mental disorder treatment is covered by mandatory health insurance. accordingly, by taking into ac­ count dimensional indicators of depressive symptoms and adopting a person-centered approach, we aimed to identify trajectories of depressive symptoms from adolescence to young adulthood and to investigate sociodemographic risk factors for detrimental trajectories. depressive symptom trajectories 2 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ depressive symptom trajectories from adolescence to emerging adulthood interindividual differences in the dynamics of symptom development over time are best captured by person-centered approaches, which reflect the heterogeneity of symptom development across time. in a systematic review focusing on trajectory studies of de­ pressive symptoms in late adolescence and emerging adulthood (15–24 years), the vast majority of studies found three to four trajectories, with a lower number of trajectories being more likely among younger adolescents (schubert et al., 2017). in most studies, 40–55% of the assessed subjects fell into the trajectories with stable low or no depressive symptoms (stable low/absence of symptoms). a second reoccurring trajectory was found for a group of subjects (5–15%) with constantly high depressive symptoms (persistent depression/stable high). furthermore, there was at least one group with less severe and less stable symptoms with varying increasing or decreasing slopes over time. in these intermediate trajectories external factors might play a more important role compared to the trajectories with low and high persistent symptoms (schubert et al., 2017). only a few studies investigated trajectories of depressive symptoms from adolescence to emerging adulthood in european samples, where mental disorder treatment is often covered by mandatory public health insurance. evidence for depressive symptom trajectories has been reported for samples in the united kingdom (gaysina et al., 2011; st clair et al., 2012), the netherlands (diamantopoulou et al., 2011; lubke et al., 2016; maciejewski et al., 2019), and sweden (lallukka et al., 2019). it is known that specific demographic factors are associated with higher depressive burden. the identification of risk and protective factors might be useful for understand­ ing the etiological factors in different symptom trajectories. female adolescents, for example, have a higher incidence of major depression, a more chronic trajectory, an earlier age of onset, and a higher increase in depressive symptoms compared to male adolescents (crockett et al., 2020; edwards et al., 2014; hargrove et al., 2020; mezulis et al., 2014). in a meta-analysis of depressive symptom trajectories in children and adolescents, high or increasing depressive symptom trajectories were also predominantly predicted by female gender (shore et al., 2018). there is evidence for a decrease of gender differences in emerging adulthood and a stabilization during adulthood (salk et al., 2017). other predictors of increased depressive symptoms in adolescence and young adult­ hood include lower parental income and poverty, often preceded by lower parental education (korhonen et al., 2017; najman et al., 2010; quesnel-vallée & taylor, 2012; wickrama et al., 2009). however, evidence suggests stronger associations between socio­ economic status and externalizing problems compared to internalizing problems. when family income increased, externalizing symptoms of children (e.g., aggressive behavior) seemed to decrease, but internalizing symptoms persisted (costello et al., 2003). further­ more, cross-sectional and longitudinal findings suggest that female adolescents may be more vulnerable to economic deprivation than their male peers regarding their depres­ pfeiffer, alt, & walper 3 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ siveness (walper, 2009). higher education, being associated with higher family income, may also be a protective factor (mendolicchio & rhein, 2011). family type has also been shown to matter, with results indicating higher depressive symptoms among young people from single-parent households (björkenstam et al., 2017; laukkanen et al., 2016; sieh et al., 2013), whereas living in a two-parent household was identified as a protective factor for developing a depressive disorder (costello et al., 2008). however, stepfamilies can bear increased risks of children’s and adolescents’ adjustment problems (jeynes, 2006). increased stress in the context of parental separation and/or stepfamily formation and compromised family relationships may contribute to a higher risk of depression (jensen & lippold, 2018; shafer et al., 2017). finally, there is evidence that adolescents with an immigration background and those who belong to an ethnic minority experience higher levels of depressive symptoms and an earlier age of onset compared to people with a nonimmigrant background, not only in u.s. samples (brown et al., 2007; costello et al., 2008), but also in european samples (belhadj kouider et al., 2014). an immigration background and membership in an ethnic minority is considered a risk factor for experiencing acculturation distress, facing discrimination, racism, and struggles in the process of identity development, which are, in turn, associated with an increased risk of the development of depressive symptoms (desalu et al., 2019; meca et al., 2019). we sought to replicate these findings in the present study. current study this is the first study investigating trajectories of depressive symptoms from adolescence to emerging adulthood in a german community sample. the first aim of this study was to investigate whether subgroups of adolescents transitioning into young adulthood differ in their course of depressive symptoms, using longitudinal data drawn from seven annual waves of the german family panel (pairfam). taking prior research (schubert et al., 2017) into consideration, we expected to identify four to six trajectories, including trajectories with stable low and stable high symptoms of depression and at least two trajectories with intermediate symptoms with variations in slope (intermediate increasing and intermediate decreasing). a second aim was to analyze whether and to what extent sociodemographic variables that have been identified as risk factors for depressive symp­ toms (gender, family type, education, immigration, and economic deprivation) predict trajectory membership. the results of earlier studies led us to expect that female gender, lower level of education, economic deprivation, single-parent and stepfamily status, and immigration background would be associated more with trajectories of higher depressive symptoms with reference to trajectories with no, low, or decreasing depressive symp­ toms. depressive symptom trajectories 4 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ method procedure and design our analyses are based on waves 2–8 of the pairfam study. a detailed description of the study has been provided by huinink et al. (2011). the pairfam study started in 2008/2009 with a nationally representative sample of three birth cohorts (1971–1973, 1981–1983, and 1991–1993). a total of more than 12,000 computer-assisted personal interviews for all cohorts were conducted in pairfam’s wave 1 (2008/2009), followed by annual reinterviews. for the present study, only the cohort born in 1991–1993 was considered, as adolescents and their subsequent course of development were our focus. the first wave was not included because depressive symptoms were assessed only from the second wave onward. all participants of the respective birth cohort who completed waves 2 (15-19 years) until wave 8 (21-25 years) were considered with a 30% tolerance of missing data (collins et al., 2001). the sociodemographic predictors were selected according to their last assessment date. participants participants were 3,682 adolescents and young adults who participated in the pairfam study (49.3% female). their age ranged from 15 to 19 years in wave 2, that is, t1 in our analyses (m = 17.03 years, sd = 0.88) with 96.8% of the sample being in late adolescence (16-18 years). at t1, 95.7% of the participants reported living with their parents, and 4.2% had already moved out (three missing values). most participants were german natives (76.3%), with the remaining having some form of immigrant background (21.9%) or missing data (1.8%). at t1, 7.9% of the participants had left school without a degree or were currently enrolled in a lower-level secondary school (hauptschule), 34.7% were enrolled in a middle-level secondary school (realschule), 42.4% were enrolled in a higher level secondary school (gymnasium), and 15.0% were enrolled in some other type of school. thirty percent of the parents (wave 2) had completed a lower education level, 40% a middle education level, and 30% a higher education level. at t1, 65.2% of the youth were living in nuclear families, 11.6% were living in stepfamilies, and 21.3% were living with a single parent (2% missing data). the mean value for economic deprivation was m = 2.3 (sd = 1.0; range = 1-5) with a median of 2. measures depressive symptoms depressiveness was assessed using the trait scale of the adapted german version of the state-trait depression scales (stds; krohne et al., 2002). the trait scale instructs participants to report how they ‘‘generally’’ feel by rating themselves on a four-point frequency scale (1 = almost never, 4 = almost always). the scales had good reliability pfeiffer, alt, & walper 5 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ for all measurement occasions (cronbach’s α ranged from .83 to .90 across waves) and a good external validity (krohne et al., 2002). a sum score of > 25 with a range of 0-45 is defined as a cutoff for clinically relevant depressive symptoms. family type using young people’s information regarding their biological parents’ partnership and current household composition in wave 5 adolescents’ family type was defined as nu­ clear (both biological parents living together), single parent (parents separated or one parent deceased, no new partner in the adolescent’s household), or stepfamily (parents separated or one parent deceased, new partner in the adolescent’s household). economic deprivation the economic deprivation scale comprises three items indicating the size of the house­ hold budget for ordinary living expenses: 1) we have enough money for everything we need; 2) we often have to forego something because we have to watch our budget; 3) we are mostly short of money. the items were derived from the economic deprivation scale described in (schwarz et al., 1997) and assessed in wave 4. the response format ranged from 1 (not at all correct) to 5 (completely correct). higher scores reflect higher economic deprivation. migration background young people and/or their parents who were born outside of germany and had non-ger­ man nationality were considered immigrants (first or second generation). the item was assessed in wave 2. analytic strategy and model building analyses were conducted in mplus version 7.0 (muthén & muthén, 2017) using full information maximum likelihood. we chose the modeling techniques of latent class growth analysis (lcga) and growth mixture modeling (gmm), to capture heterogeneity of depressive symptom trajectories. the main difference between lcga and gmm lies in the modeling of the variance for intercept and slope. in lcga, a special form of gmm, the variance for intercept and slope within the classes is fixed at 0, which allows for fewer parameters to be estimated (berlin et al., 2014). we estimated a series of models (see supplemental table 1) with up to six trajectories for each modeling techni­ que (lcga vs. gmm). for the selection of the most suitable model, we used multiple fit indices as well as prior empirical evidence (schubert et al., 2017). the relevant fit indices included information criteria such as the akaike information criterion (aic), where better fitting models have a lower aic. further, we implemented likelihood ratio tests where we assessed the relative fit of the model by comparing it to structurally similar models with one less class. entropy was used to assess distinctiveness of classes, depressive symptom trajectories 6 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ where higher entropy signals higher distinctiveness and more accurate assignment of individuals to classes (infurna & grimm, 2018). further analyses were performed with r 2022.07.1. once latent classes were identified, multinomial logistic regression was used to determine whether and to what extend sociodemographic variables predict a trajectory membership (dependent variable). one category of the dependent variable is chosen as the reference category, and other categories are compared to the reference. to correct for multiple comparisons, p-values were adjusted using the benjamini-hochberg procedure with a false discovery rate (fdr) set at 10%. this threshold was chosen in line with common practice in exploratory and multivariate research, where a more liberal fdr is acceptable to increase sensitivity and avoid type ii errors (benjamini & hochberg, 1995; storey & tibshirani, 2003). the correction was applied across all analyses, including those reported in the supplementary materials. results trajectories of depressive symptoms the model comparisons are shown in table 1. the entropy values for the lcga solu­ tions were generally higher than those for the gmm solutions, which speaks for a better assignment of the individuals to the trajectories within the lcga solutions. table 1 model comparisons for lcga and gmm for depressive symptom trajectories measure class 1 class 2 class 3 class 4 class 5 class 6 linear lcga aic 23,727.87 18,771.84 17,393.61 16,866.48 16,607.66 16,446.48 bic 23,793.77 18,846.37 17,486.77 16,978.28 16,738.10 16,595.55 ssa-bic 23,765.17 18,808.24 17,439.11 16,921.09 16,671.37 16,519.29 entropy 0.82 0.71 0.68 0.68 0.65 lmr p < .01 < .01 < .01 < .01 .16 linear gmm aic 16,839.03 16,250.47 16,072.48 16,037.59 bic 16,913.57 16,356.06 16,209.13 16,205.29 ssa-bic 16,875.44 16,302.04 16,139.22 16,119.50 entropy 0.45 0.49 0.51 lmr p < .01 < .01 .07 note. lcga = latent class growth analysis; gmm = growth mixture modeling; aic = akaike information criterion; bic = bayesian information criterion; ssa = sample size adjusted; lmrp = lo mendell rubin likelihood ratio test-p-values. pfeiffer, alt, & walper 7 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ on the other hand, the lower (= better) information criteria (aic, bayesian information criterion [bic], and sample-size-adjusted bic) within each class were obtained with gmm, which indicates a better model quality. the likelihood ratio tests show that the lcga approach offers a five-class solution as optimal, whereas the gmm approach produces a three-class solution as most suitable. when analyzing these two models in more detail, only the lcga solution identified the characteristic trajectories of very high and very low burden. in summary, the entropy and the consistency with previous empirical data support the five-class solution of the lcga, so the classification of this model was used for further analyses. figure 1 shows the final class solution with the associated gradients and the respec­ tive sizes of the classes. class 1 comprises young people with stable low depressive symptoms (34%); class 5 depicts the small group with stable high depressive symptoms (4%). figure 1 lcga model of final five-class solution with size (%) of each class note. stds = state-trait depression scales. depressive symptom trajectories 8 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ in addition, three classes have an intermediate starting point at t1, showing either a slight decrease (class 2: 8%), a slow increase that levels off at the starting point of those with a strong increase (class 3: 4%), or a strong increase across time that rises up to the level of the stable high group (class 4: 9%), class 2 has the highest starting point among all three intermediate groups and drops to a final level close to those with a slow increase. predicting membership in trajectories by sociodemographic variables since economic deprivation is associated with family type and immigration status, we first calculated a model without economic deprivation as a predictor variable (see supplemental table 2). the group with stable low symptoms was used as a reference group. female gender was a significant predictor for all four classes associated with depressive symptoms. living in a stepfamily and having an immigration background were predictors for membership in the groups with strongly increasing symptoms and chronic trajectory. living in a single-parent family was also a predictor for a chronic trajectory. multicollinearity was low with a variance inflation factor (vif) ranging from 1.64 to 4.27, with a model fit of aic = 4,969.26. second, we included economic deprivation in the model with a better model fit of aic = 3,764.56 and revealed high multicollinearity with a vif of 9.90. table 2 reports the descriptive statistics of sociodemographic variables for each tra­ jectory. the results of the four multinomial logistic regressions for all four models with odds ratios are reported in table 3, 4, and 5. table 2 descriptive statistics of sociodemographic variables for each trajectory variable class 1 stable low class 2 intermediate decrease class 3 intermediate slow increase class 4 intermediate strong increase class 5 stable high n 1,241 292 1,678 317 154 gender (% female) 40 60 50 58 73 family type (%) nuclear family 56 46 52 45 38 stepfamily 26 28 31 31 33 single-parent family 19 27 18 23 28 parental education level (%) lower 30 33 30 30 34 middle 40 40 42 43 36 higher 31 27 28 27 30 economic deprivation (m, sd) 2.17 (0.99) 2.64 (1.07) 2.30 (0.98) 2.70 (1.14) 2.99 (1.09) immigration background (%) 19 28 20 25 27 pfeiffer, alt, & walper 9 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ table 3 multinomial regressions analyzing sociodemographic variables as predictors of trajectory membership: model 1 variable model 1 class 2 vs. class 1 class 3 vs. class 1 class 4 vs. class 1 class 5 vs. class 1 or [95% ci] p or [95% ci] p or [95% ci] p or [95% ci] p intercept 0.06 [0.03, 0.12] < .001* 0.74 [0.51, 1.08] .12 0.05 [0.03, 0.09] < .001* 0.01 [0.00, 0.02] < .001* gender: female (ref. = male) 2.70 [1.73, 4.20] < .001* 1.47 [1.16, 1.86] .01* 2.20 [1.52, 3.18] < .001* 3.54 [1.97, 6.36] < .001* family type (ref. = nuclear family) stepfamily 0.99 [0.57, 1.72] .98 1.27 [0.95, 1.69] .10 1.30 [0.83, 2.01] .25 1.24 [0.64, 2.38] .52 single-parent family 1.19 [0.64, 2.20] .59 0.86 [0.60, 1.24] .41 1.20 [0.71, 2.03] .50 0.94 [0.42, 2.14] .89 parental education level (ref. = lower) middle 0.63 [0.38, 1.07] .09 1.08 [0.82, 1.43] .57 1.16 [0.75, 1.79] .50 1.16 [0.60, 2.22] .66 higher 0.87 [0.50, 1.51] .62 1.07 [0.78, 1.45] .68 1.05 [0.64, 1.74] .83 1.19 [0.56, 2.53] .64 economic deprivation 1.45 [1.17, 1.80] .001* 1.15 [1.01, 1.30] .03* 1.43 [0.91, 2.25] < .001* 2.08 [1.60, 2.70] < .001* immigration background (ref. = no immigration) 1.32 [0.77, 2.25] .31 1.28 [0.94, 1.74] .12 1.69 [1.41, 2.02] .12 1.64 [0.86, 3.14] .13 note. class 1: stable low; class 2: decrease; class 3: slow increase; class 4: strong increase; class 5: stable high. ci = confidence interval; or = odds ratio. *significant results for adjusted p-value thresholds. table 4 multinomial regressions analyzing sociodemographic variables as predictors of trajectory membership: model 2 variable model 2 class 3 vs. class 2 class 4 vs. class 2 class 5 vs. class 2 or [95% ci] p or [95% ci] p or [95% ci] p intercept 12.70 [6.34, 25.43] < .001* 0.82 [0.35, 1.91] .65 0.12 [0.04, 0.39] < .001* gender: female (ref. = male) 0.54 [0.35, 0.84] .001* 0.82 [0.49, 1.36] .43 1.31 [0.66, 2.60] .43 family type (ref. = nuclear family) stepfamily 1.28 [0.75, 2.18] .36 1.31 [0.70, 2.43] .39 1.25 [0.57, 2.73] .58 single-parent family 0.72 [0.40, 1.32] .29 1.01 [0.50, 2.04] .97 0.80 [0.31, 2.02] .63 parental education level (ref. = lower) middle 1.71 [1.03, 2.83] .04 1.83 [1.01, 3.31] .05 1.82 [0.84, 3.93] .13 higher 1.23 [0.72, 2.10] .45 1.21 [0.63, 2.33] .57 1.37 [0.58, 3.24] .47 economic deprivation 0.79 [0.64, 0.97] .03* 1.16 [0.92, 1.48] .22 1.43 [1.06, 1.94] .02* immigration background (ref. = no immigration) 0.97 [0.58, 1.63] .99 1.08 [0.59, 1.98] .79 1.25 [0.59, 2.65] .57 note. class 1: stable low; class 2: decrease; class 3: slow increase; class 4: strong increase; class 5: stable high. ci = confidence interval; or = odds ratio. *significant results for adjusted p-value threshold. in model 1, female gender and higher economic deprivation were significant predictors for all four classes associated with higher depressive symptoms with reference to the depressive symptom trajectories 10 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ class with stable low depressive symptoms. education, family type, and immigration background were not associated with memberships in trajectory classes. in model 2, female gender and economic deprivation were associated with a lower likelihood of a slow increase in depressive symptoms (class 3) with reference to the class with decreasing symptoms (class 2). economic deprivation was a predictor for membership in the class with stable high symptoms (class 5) with reference to the class with decreasing symptoms (class 2). in model 3, female gender and economic deprivation were predictors for being in a trajectory with intermediate strong increasing symptoms (class 4) with reference to the intermediate slow increasing trajectory (class 3). in model 4, odds ratios were non-significant for the trajectory with stable high symptoms (class 5) with reference to the trajectory with strong increasing symptoms (class 4). table 5 multinomial regressions analyzing sociodemographic variables as predictors of trajectory membership: model 3 and 4 variable model 3 model 4 class 4 vs. class 3 class 5 vs. class 3 class 5 vs. class 4 or [95% ci] p or [95% ci] p or [95% ci] p intercept 0.06 [0.04, 0.12] < .001* 0.01 [0.00, 0.03] < .001* 0.15 [0.05, 0.44] < .001* gender: female (ref. = male) 1.50 [1.05, 2.13] .02* 2.42 [1.36, 4.29] .001* 1.61 [0.85, 3.03] .14 family type (ref. = nuclear family) stepfamily 1.02 [0.67, 1.55] .93 0.97 [0.52, 1.84] .94 0.96 [0.47, 1.94] .90 single-parent family 1.40 [0.84, 2.32] .20 1.10 [0.49, 2.45] .82 0.79 [0.33, 1.88] .60 parental education level (ref. = lower) middle 1.07 [0.71, 1.62] .75 1.07 [0.56, 2.02] .84 1.00 [0.49, 2.02] .99 higher 0.99 [0.61, 1.60] .96 1.12 [0.54, 2.34] .77 1.13 [0.50, 2.57] .77 economic deprivation 1.47 [1.24, 1.74] < .001* 1.81 [1.41, 2.34] < .001* 1.23 [0.93, 1.63] .14 immigration background (ref. = no immigration) 1.12 [0.73, 1.71] .60 1.29 [0.69, 2.41] .42 1.15 [0.57, 2.30] .65 note. class 3: slow increase; class 4: strong increase; class 5: stable high. ci = confidence interval; or = odds ratio. *significant results for adjusted p-value threshold. discussion as expected, lcgas of longitudinal data on depressive symptoms revealed subgroups of different trajectories, which were in the range of three to six trajectories, as schubert et al. (2017) review indicated. specifically, we found five trajectories, including as expected one trajectory with participants who experienced only minimal depressive symptoms (stable low/absence of symptoms) and one trajectory of adolescents who suffered from chronically high depressive symptoms (stable high/chronic). furthermore, we found, as pfeiffer, alt, & walper 11 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ expected, intermediate trajectories with less severe depressive symptoms, which changed across time (negative and positive slopes). when the five trajectories are sorted by size, almost half of the adolescents (46%) reported moderate depressive symptoms with a slow increase across time (”intermediate slow increase”); a third (34%) indicated stable absence or low depressive symptoms (stable low); almost every 10th young person (9%) experienced intermediate depressive symptoms with a strong increase (intermediate strong increase); a similar-sized group (8%) indicated intermediate depressive symptoms tending to decrease; and 4% experienced chronic depressive symptoms (stable high). in contrast to our study, the majority of previous studies found four trajectories of depressive symptoms in community samples. however, these studies typically started assessments at a younger age, and studies with a starting point at early adolescence (10–14 years) tended to find fewer trajectories compared to studies assessing depressive symptoms between late adolescence and middle adulthood. additionally, the prevalence of stable high depressive symptoms (4%) was marginally lower compared to other find­ ings (5–15%), which was also the case for the absence of depressive symptoms (34%), which deviated from previous findings (40–55%; schubert et al., 2017). there is also a great heterogeneity in studies analyzing trajectories of depressive symptoms regarding measures of depressive symptoms, age span, and sociodemographic variables (schubert et al., 2017). studies with six trajectories found a trajectory with an adult onset with severe symptoms, however the sample consisted of a larger age span in adulthood compared to our sample. as expected, trajectories with higher depressive symptoms with reference to a trajec­ tory with the absence of symptoms were associated with female gender, which is in line with previous research (crockett et al., 2020; edwards et al., 2014; hargrove et al., 2020; mezulis et al., 2014). female gender was also a stronger predictor for the trajectory of intermediate symptoms with strong increase than for the trajectory of intermediate symptoms with slow increase. those results are consistent with findings that by late adolescence girls are more likely to develop depression at an earlier onset than boys (rohde et al., 2013), which might explain the stronger increase of depressive symptoms. in their integrative model to explain gender differences in the prevalence of depressive symptoms, (hyde et al., 2008) emphasized the interaction between biological vulnera­ bility (e.g., genetic vulnerability, hormonal changes in puberty), affective vulnerability (e.g., temperament), cognitive vulnerability (e.g., negative cognitive style, internalizing of gender stereotypes), and negative life events (e.g., sexual harassment), which were shown in a longitudinal study (mezulis et al., 2014). gender stereotypes and unequal gender norms are also associated with depressive symptoms among adolescents (koenig et al., 2021) and should be considered as etiological factors for gender differences. there is also evidence that youth identifying with male gender report different symptoms (e.g., more attention deficits, anhedonia) compared to youth identifying as female (depressive mood, sleep problems), which might also be a factor in gender differences in depressive depressive symptom trajectories 12 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ symptoms (crockett et al., 2020). female gender was also a stronger predictor for the trajectory of intermediate symptoms with strong increase than for the trajectory of inter­ mediate symptoms with slow increase. interestingly, we found that female participants were also more likely to be in the intermediate trajectory with decreasing symptoms with reference to the trajectory with slowly increasing symptoms. the results might indicate that adolescents and young adults with subclinical symptoms of depression who identify as female might have a higher probability of coping with symptoms compared to those who identify as male. one explanation might be that youth identifying as female have a higher probability of seeking help for mental health problems (zwaanswijk et al., 2003), which in this case might contribute to a decrease in symptoms over time. fur­ thermore, biological vulnerability might have less impact on transitioning into adulthood (hyde et al., 2008). measures should target the reduction of female gender discrimination (e.g. strengthening legal protections, economic empowerment initiatives, cultural and awareness campaigns and political representation). exploratively we analyzed if family type was a predictor for trajectories with higher depression levels given that living in a single-parent family has been identified as a risk factor for the development of depressive symptoms (björkenstam et al., 2017; laukkanen et al., 2016). when economic deprivation was not included, family status was a predictor for trajectories with intermediate increasing or chronic depressive symptoms. however, this effect disappeared completely when economic deprivation was included as a predic­ tor in the model. overall, it appears that in our sample, family status and immigration status were not risk factors per se, but only if they were associated with higher economic deprivation. the results are consistent with evidence that family type is associated with variables that might be considered independently (e.g., parental communication, coping with parental separation, lower family income) and that are not valid for every nonnuclear family system. the results are consistent with evidence that a higher risk for depression and behavioral problems is associated with other factors (e.g., children’s problems adjusting to divorce-related circumstances rather than the family structure itself; amato, 2000). our findings with regard to the role of parental education differed from expectations based on other research (korhonen et al., 2017; quesnel-vallée & taylor, 2012), as paren­ tal education was not a predictor for trajectories with higher depression levels. the more relevant predictor of trajectories with higher depressive symptoms was economic deprivation, perhaps mediating weak effects of educational resources. as expected, tra­ jectories with higher depression levels were associated with higher economic deprivation (costello et al., 2003; wickrama et al., 2009). participants with economic deprivation were also more likely to be in the group with stable high symptoms than decreasing symp­ toms, emphasizing the chronicity of stress levels in families with low income (najman et al., 2010). they were also more likely to be in the group with intermediate strong increasing symptoms than in the group with intermediate slow increasing symptoms pfeiffer, alt, & walper 13 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ demonstrating the early impact of economic deprivation. there are multiple reasons why low family income is associated with higher psychopathology. families with low income report higher stress levels and are more vulnerable to further stress events (e.g., not living in a safe environment) and traumatic events, and there are more limited parenting resources as they also have a higher burden of parental psychopathology (butler, 2014). the chronicity of stress levels in families with low income was also visible when com­ paring trajectories with each other, as we found a higher association with the stable high trajectory than in the intermediate decreasing trajectory. there is also evidence that higher socio-economic status is a facilitator for the achievement of developmental milestones associated with transitioning into adulthood, such as educational attainment (johnson & reynolds, 2013) and lower socioeconomic status associated with higher resource deprivation such as less parental and financial support (prince et al., 2018). the findings emphasize the need for further political and societal measures to reduce economic deprivation as a risk factor. evidence based measures to reduce economic deprivation include the investment in education, expansion of social safety nets, imple­ menting progressive taxation, investment in infrastructure and affordable health care (banerjee & duflo, 2011; oecd, 2015). economic deprivation was also a predictor for a group membership in the intermediate decreasing symptom trajectory with reference to the trajectory with slow increasing symptoms. in addition to the reduction of risk factors, the strengthening of protective factors also plays an important role in coping with higher stress levels. stable employment and financial security alleviate the stress associated with poverty, reducing the risk of depression in emerging adulthood (murali & oyebode, 2004). the last sociodemographic variable we considered was young people’s immigration background, asking if it was associated with trajectories of higher depression levels. comparable to family status, immigration was no longer a predictor when deprivation was included in the model. overall, the findings suggest that it is not immigration per se that is a risk factor, but the circumstances associated with it, which should be addressed accordingly to prevent the development of depressive disorders. limitations and strengths the person-centered approach based on longitudinal data of a community sample, which covered the time span from late adolescence to emerging adulthood, is one particular strength of our study. although this approach represents a reduction in complexity, as measurement points of depressive symptoms were limited to a 1-year time span, there is evidence that depressive symptoms in adolescents remain rather stable over a 1-year time span (mclaughlin & king, 2015). lcga is a powerful tool for identifying latent subpopulations (depressive symptom trajectories) within a sample according to patterns of responses to observed variables (muthén & muthén, 2017) but class assignment is based on probabilities and may neglect infrequent patterns in the course of depressive depressive symptom trajectories 14 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ symptom. trajectories might also vary according to methodological differences in study design. it can further be discussed whether the low-stable and intermediate-slow increase groups are in fact meaningfully different, as the differences between these two trajectory groups for gender and economic disadvantage are much smaller than for the compari­ sons between the low-stable group and the other groups. overall, however, our findings are well in line with previous research and provide new evidence pertaining to the phase from adolescence to emerging adulthood, which represents an important time window of development. another limitation is the use of the measurement instrument to assess depressive symptoms. a measure that enables greater comparability with other studies (e.g. ces-d) would have been of advantage. we assessed gender, family type, parental education, economic deprivation, and immigration background as predictors for depressive symptom trajectories, but there may be other predictors that were not consid­ ered in the current study but could be important in understanding the development of depressive symptoms. examples include family support, school climate, peer belonging (gregory et al., 2020), and—not least—treatment use. the analyzed predictors are also not independent of each other. the risk of poverty is higher for single parents and income depends on the level of education (oecd, 2024). the fact that we did not control for possible changes in the predictors (e.g., economic deprivation, family status) across the different waves is also a limitation of the study. sociodemographic variables do not cover the complexity of risk factors as risks can arise from the interplay of multiple factors within the guise of the analyzed variables. the fdr rate of 10%, which was used for alpha error inflation instead of the more conservative rate of 5%, can also be discussed critically. although links between trajectories of depressive symptoms and adolescents’ help-seeking behavior would be of great interest, such issues require a different strategy of data analysis and will be addressed in future analyses. the data analysis was not preregistered, which should be considered for future analysis. conclusion understanding trajectories of depressive symptoms as well as risk and protective factors in the development of depressive disorders is crucial for identifying youths at risk for depression and increasing the probability of receiving adequate treatment. longitudinal data on depressive symptoms in late adolescence transitioning into adulthood have dem­ onstrated heterogeneous trajectories, enabling us to identify female gender and economic deprivation as risk factors for group membership in trajectories associated with higher and more stable levels of depressive symptoms. on an intermediate subclinical level of depressive symptoms, female gender was also associated with a higher probability of membership in a trajectory with decreasing symptoms over time than in one with increasing symptoms, suggesting more protective factors among females for coping with subclinical depressive symptoms. family status and immigration status were not significant risk factors per se but were instead mediated by economic deprivation. it pfeiffer, alt, & walper 15 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.psychopen.eu/ is of great importance to take measures to reduce female gender discrimination and economic deprivation as risk factors to mitigate the risks of developing depressive disor­ ders. such measures (e.g., political and societal initiatives) should target the underlying etiology of both constructs, taking into consideration the complexity and interaction of biopsychosocial variables. these results also emphasize the need for early detection and treatment of depressive symptoms, especially in the trajectories of stable high and strongly increasing symptoms. funding: the pairfam study was funded as long-term project by the german research foundation (dfg). funding number: ha 5865/2-6. acknowledgments: this study uses data from the german family panel pairfam, coordinated by josef brüderl, karsten hank, johannes huinink, bernhard nauck, franz neyer, and sabine walper. competing interests: the authors report no conflict of interests. ethics statement: pairfam was approved by the ethics committee of the faculty of management, economics and social sciences of the university of cologne. preregistration: this data analysis was not preregistered. reporting guidelines: this manuscript follows the apa journal article reporting standards for quantitative research (jars–quant), including the extended guidelines for longitudinal studies. data availability: data of the pairfam study are available at https://www.pairfam.de on request. supplementary materials the supplementary materials contain the following items (for access, see pfeiffer et al., 2025s): • supplement 1. results of lcga and gmm analyses for depressive symptom trajectories this supplement provides detailed results of latent class growth analysis (lcga) and growth mixture modeling (gmm) examining trajectories of depressive symptoms. for each model specification (linear, latent base course, quadratic, and lcga linear), the supplement includes density plots, estimated trajectories, trajectories overlaid with raw data, and model fit indices (aic, bic, abic, entropy, vlmr/lmr p-values, and class sizes). these materials offer transparency regarding model selection and facilitate evaluation of alternative class solutions. • supplemental table 2. multinomial regression analyses of trajectory membership predictors this table presents results from multinomial regression models examining sociodemographic variables (gender, family type, parental education, immigration background) and treatment use as predictors of depressive symptom trajectory membership. odds ratios (or), 95% confidence intervals (ci), and p-values are reported for each class comparison. depressive symptom trajectories 16 clinical psychology in europe 2025, vol. 7(4), article e15801 https://doi.org/10.32872/cpe.15801 https://www.pairfam.de https://www.psychopen.eu/ index of supplementary materials pfeiffer, s., alt, p., & walper, s. 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[2] department of psychology, university of salzburg, salzburg, austria. [3] department of methods and evaluation / quality assurance, free university berlin, berlin, germany. clinical psychology in europe, 2025, vol. 7(2), article e14527, https://doi.org/10.32872/cpe.14527 received: 2024-05-01 • accepted: 2025-01-16 • published (vor): 2025-05-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: michaela bruckbauer-schwed, department of psychiatry, kardinal schwarzenberg klinikum, kardinal schwarzenbergplatz 1, 5620 schwarzach im pongau, austria. phone number: +436643320183. email: michaela.bruckbauer-schwed@ks-klinikum.at supplementary materials: preregistration [see index of supplementary materials] abstract background: non-suicidal self-injury (nssi) is a major health problem. functionally, it is related to affect instability and increased affective intensity. the role of negative emotions has already been extensively explored, only few studies have focused on positive emotions. the concept of dynamic complexity (dc) is particularly well suited to differentially analyze the dynamics of affect collected by ecological momentary assessment (ema). this study examines dc of positive and negative emotions in individuals with and without nssi history in an ema setting. method: participants from a clinical nssi group (n = 28) and a comparable clinical non-nssi control group (n = 33) completed the positive and negative affect schedule (panas) once a day between six to 37 days (m = 15.60, sd = 5.80). dc was calculated for the assessed time-series of daily affect. additionally, we fitted a linear mixed model to predict positive and negative dynamic complexity with length of stay and group. results: compared to controls, individuals with a history of nssi showed significantly more positive affect and had significantly higher dc in affect in general. no significant difference for negative affect was found. conclusion: our results suggest that it is important to assess dynamic emotional patterns and to analyze in detail the role of positive and negative affect in individuals with nssi in order to better this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.14527&domain=pdf&date_stamp=2025-05-28 https://orcid.org/0009-0004-8912-3433 https://orcid.org/0000-0002-6307-5347 https://orcid.org/0000-0001-6038-6775 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ understand the complex interplay between the different emotional states and to be able to use it for diagnostic purposes and clinical interventions. keywords non-suicidal self-injury (nssi), affect instability, positive affect, dynamic complexity, ecological momentary assessment highlights • the nssi group showed a higher dc in positive and negative emotions than clinical controls. • the nssi group showed higher mean levels of positive emotions than clinical controls. • within-person variation in dc explains more variance than survey period or group differences. non-suicidal self-injury (nssi) is a serious psychiatric phenomenon characterized by the direct, intentional destruction of bodily tissues without the intent to die (nock & favazza, 2009). it is a growing public health concern worldwide due to its high preva­ lence rates (muehlenkamp et al., 2012) and increased emergency department utilization (olfson et al., 2005). in inpatient samples, 21% of adults report a history of nssi (briere & gil, 1998). it is now well established from various studies that emotion regulation (gratz & roemer, 2008) is one of the most commonly endorsed functions of nssi. emotion regulation refers to the methods individuals use to manage their emotions, including determining which emotions they experience, when they occur, and how they are felt and expressed (gross, 1998). klonsky (2009) found that 85% of participants engaged in nssi to alleviate negative emotions, such as sadness, frustration, and pain and reported feeling calm and relieved afterwards. claes et al. (2010) also found similar results, where participants reported a decrease in negative high arousal emotions, such as anxiety and depression, and an increase in positive-low arousal emotions, such as relief. in addition to emotion regulation, affect instability also plays an important role in nssi (kerr & muehlenkamp, 2010). affect instability is defined as rapid and intense mood swings with difficulties in controlling these swings and their outcomes (marwaha et al., 2014). many studies (e.g., peters et al., 2016; santangelo et al., 2017) reported an increased affect instability in individuals with nssi compared to controls. furthermore, affect instability predicts the onset and continuation of non-suicidal self-injury (peters et al., 2016). another aspect of impaired emotion regulation is variability of positive and negative affect. affect variability pertains to the extent or magnitude of an individual's affective states over a period of time. if someone exhibits higher levels of affective variability, he/she experiences emotions that are more intense and deviate more significantly from dynamic complexity of positive and negative affect in nssi 2 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ his/her typical affective state (houben et al., 2015). ong and steptoe (2020) reported that greater variability in positive affect increased mortality risk in older adults. converse­ ly, in younger adults, instability in positive affect was related to better mental health (spindler et al., 2016). victor et al. (2021) demonstrated that variability in negative affect was associated with nssi, suicidal ideation, and suicidal behavior assessed concurrently as well as prospectively. there is also limited knowledge about changes in emotion dysregulation over the course of inpatient hospitalization. few studies have examined this issue in adult inpa­ tients. for example, fowler et al. (2016) found significant improvements in experiential avoidance and emotion dysregulation with large effect sizes following intensive inpatient psychiatric treatment over a period of six to eight weeks. a common idea in various theoretical models is that individuals engage in nssi in response to intense emotional distress aiming to regulate or alleviate these distressing states by modifying, reducing, or diverting attention from them in some way (e.g., nock & prinstein, 2004; selby & joiner, 2009). an approach to explain the development and maintenance of self-injury has been proposed by nock and prinstein (2004) with their four-factor model based on learning theory. this functional approach describes four reinforcement processes: automatic negative reinforcement when nssi is performed to alleviate negative states, automatic positive reinforcement when nssi is followed by an increase in positive affect, social negative reinforcement when nssi is performed to reduce or stop interpersonal demands, and social positive reinforcement when nssi is performed to seek attention or receive help. much of the research to date has focused on the negative reinforcements associated with nssi. only a few studies have found an association between positive affect and nssi. some studies have found an increase in positive affect following nssi (jenkins & schmitz, 2012; kranzler et al., 2018) however, these self-report and ecological momentary assessment data on positive affect need to be replicated. in addition, motives for engag­ ing in nssi behaviors seem to include attempts to reduce negative affect and increase positive affect (claes et al., 2010; selby et al., 2014). regarding the four-factor model, yen et al. (2016) reported that adolescents in psychiatric inpatient settings who endorsed automatic positive reinforcement as a motive for nssi were more likely to continue with nssi. turner et al. (2012) reported that 92% of an adult sample with a history of nssi engaged in self-injury as a means of generating positive emotions. other studies have found no support for an increase in positive affect after engaging in nssi (armey et al., 2011) and no group differences in positive emotional reactivity in individuals with nssi compared to controls (mettler et al., 2021). jenkins and schmitz (2012) showed that positive, but not negative affect, was significantly associated with a higher frequency of lifetime nssi acts in college students. bruckbauer-schwed, kaiser, keglevic, & laireiter 3 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ dynamic complexity (dc) a growing body of literature investigated the relationship between nssi and affect with correlational and anova-based analyses (e.g., victor & klonsky, 2014). however, no previous study was grounded in a nonlinear-dynamic systems framework where it is important to consider dynamic characteristics (such as fluctuations or critical slowing down) of affect and its relation to nssi. according to the synergetic approach to psychology, human change processes are characterized by non-linearity and non-stationarity of their dynamics (schiepek & strunk, 2010). when the relationship between input and output of a dynamic system is not directly proportional, the system is considered nonlinear (stam, 2005). it is typical for nonlinear dynamic systems that, depending on the state of the system, even high levels of negative affect (input) do not lead to non-suicidal self-injury (output). in contrast, when the system is in an unstable state, even minor increases of negative affect can trig­ ger self-injurious behavior. nonstationarity, on the other hand, denotes changes in de­ scriptive statistics, including (moving) averages and variance, over time. nonstationarity is consistent with discontinuous phase transitions caused by the nonlinear mechanisms inherent in complex systems. phase transitions are defined as a change from one pattern to another pattern, caused by internal and external conditions. almost invariably, phase transitions are preceded and facilitated with critical instabilities (schiepek & strunk, 2010). critical instabilities preceding phase transitions can be assessed with the dynamic complexity (dc), which was developed for short time series typical in psychological research (schiepek et al., 2014). dc is the product of two parameters, fluctuation (f) and distribution (d). f quantifies the intensity of change with respect to frequency and amplitude of a time-series (figure 1). f is maximal when the variable in the time-series jumps between the minimum and maximum value as often as possible. d quantifies the scattering of the time-series within the range of possible values. d maximizes when values are irregular and chaotically distributed (for a detailed description and formula, see schiepek & strunk, 2010). consequently, high dc indicates frequent, large, and irregular fluctuations (olthof et al., 2020). f and d and their product dc indicate critical instabilities in self-organizing process­ es and non-stationary phenomena in time series (schiepek & strunk, 2010). during periods of fluctuation, the system is destabilized and oscillates between old and new patterns until the system stabilizes in a new state (attractor) and variability decreases (kelso, 1995; thelen & smith, 1994). typically, dc is computed by looking at a window of data consisting of seven measurement points that are shifted from one day to the next throughout the time series. applying this procedure produces a time series that includes dc values for each item (schiepek & strunk, 2010). a manifestation of nonlinear dynamics and phase transitions is the rise and fall in affect intensity over time. individu­ als engaging in nssi typically show high affective variability (victor et al., 2021), which dynamic complexity of positive and negative affect in nssi 4 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ reflects the overall amplitude of affective changes. affective changes (from positive to negative affective states) can be considered as order transitions. the typical high affect fluctuations in individuals engaging in nssi could be recognized by the presence of more critical instabilities in their affect data. therefore, we hypothesize that an order transi­ tion phenomenon like affective change is accompanied by phases of critical instabilities (fluctuations in affect) of the time series resulting in an increase of dynamic complexity in individuals with a history of nssi compared to controls. figure 1 diagrammatic illustration of various modes of distribution, fluctuation, and dynamic complexity in one individual note. distribution describes how the time series data is distributed across the scale range, fluctuation: frequency and amplitude of changes in time series, dynamic complexity: multiplicative product of a fluctuation measure and a distribution measure, b illustrates the highest fluctuation, while a illustrates the lowest one. c and d illustrate the highest distribution, a illustrates the lowest distribution. b and d show high dynamic complexity, whereas a shows low dynamic complexity. to summarize, research has proposed that nssi is associated with intense negative affect and affective instability. although the evidence has highlighted the role of emotion regu­ bruckbauer-schwed, kaiser, keglevic, & laireiter 5 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ lation in nssi through negative reinforcement of aversive affect (e.g., nock & prinstein, 2004), some research has examined positively reinforcing effects (e.g., jenkins & schmitz, 2012). present study based on the literature described above, the present study is the first to apply the concept of dc to the description and analysis of nssi. we are particularly interested in the following three hypotheses: first, we expect individuals engaging in nssi to show a higher dc than controls without a history of nssi. the resulting high dc in the nssi group should be represented by frequent, large, and irregular fluctuations in time series. second, we aim to examine mean levels of positive and negative affect in the nssi group compared to controls. previous research mostly focused on the role of negative affect and negative reinforcement in nssi. therefore, one could assume that participants with nssi also show higher negative affect. however, we also wanted to investigate whether positive affect might be present as well. so, investigating dc in affective states that differ between individuals with and without a history of nssi may be an opportunity to identify potential maintaining or risk factors of nssi. third, we investigate whether the average values of dynamic complexity change over time. we assume that the dynamic complexity should decrease during the course of the hospital stay, as therapeutic and pharmacological interventions should lead to the stabilization of the patients. method daily assessments ecological momentary assessment (ema) enables an assessment of behavior and psycho­ logical processes in everyday life. ema reduces the influence of recall biases, enhances research findings' ecological validity, and tracks changes in intra-individual psychologi­ cal processes (stone & shiffman, 1994). another advantage of ema is the distinction between state affect and trait affect. participants inclusion criteria were a) suffering from a mental disorder; b) aged between 18 and 65 years; c) having adequate language skills in german to understand and follow instruc­ tions and give informed consent; d) non-suicidal self-injury in the last year for the nssi-group and no such behavior in the control-group. exclusion criteria were a) acute episodes of psychosis, psychotic or manic episodes, rapid cycling, and acute substance use; b) missing cognitive skills to complete assessment. 61 subjects selected according to the procedure described below met the required cri­ teria, 33 (54.1%) of them did not show nssi and constitute the control group (22 women, dynamic complexity of positive and negative affect in nssi 6 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ 11 men) with a mean age of 35.0 (sd = 10.73) years. in this group, 18 (54.5%) met the diagnostic criteria (icd-10) of a depressive disorder, ten (30.3%) of an anxiety disorder, two (6.1%) of an obsessive-compulsive disorder, two (6.1%) of a personality disorder (avoidant and dependent personality disorder), and one (3.0%) of insomnia. the nssi group consisted of 28 (45.9%) participants (26 females, two males) with a mean age of 26.69 (sd = 8.73) years. of these, 12 (42.9%) met icd-10 criteria for a depressive disorder, eight (28.6%) for a post-traumatic stress disorder, five (17.9%) for a primary diagnosis of borderline personality disorder, and three (10.7%) for an eating disorder. in addition, eight (28.6%) were diagnosed with comorbid borderline personality disorder. the diagnoses were initially assigned by the treating psychiatrist based on the clinical picture and confirmed in a second step by the researcher using the icd-10 research criteria. procedure subjects were recruited from an austrian adult inpatient psychiatric unit (“kardinal schwarzenberg klinik”) located in the southern area of the federal state of salzburg. patients meeting inclusion criteria were invited to participate in the study and were informed about the studies’ procedure in detail and written informed consent was obtained. additionally, the phone number was recorded for being able to contact sub­ jects during the study. prior to commencement, the study procedure was approved by the ethics committee of the province of salzburg (ec number: 415-e). only the third hypothesis was preregistered (see bruckbauer-schwed et al., 2023s), as the data for the first and second hypotheses had already been analyzed at the time of registration. data collection started with a general questionnaire asking for age, gender, professional and family status and nssi. with respect to that, subjects were asked if ever in their lives they had performed any nssi-behavior; if yes, they were additionally asked about its frequency over their lifetime. positive and negative affect was recorded by using the positive and negative affective schedule (panas) in an ema-design over a period of at least six days. participants received no compensation for their participation. ema was initiated by an invitation by a sms-message. the questionnaire could be retrieved and completed in sosci survey (https://www.soscisurvey.de) on the subjects’ mobile phones. due to technical problems, data acquisition had to be changed to the mobile piel app (jessup et al., 2012). with a wake-up function subjects were prompted to answer their questionnaires at 6 p.m. daily taking approximately five minutes to be completed. for assistance participants could contact the researcher at any time during the study period. it was also possible to complete the questionnaire in a paper-pencil-for­ mat. two participants choose this option for some of their entries. bruckbauer-schwed, kaiser, keglevic, & laireiter 7 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.soscisurvey.de https://www.psychopen.eu/ positive and negative affective schedule (panas) the positive and negative affective schedule (panas; watson et al., 1988; german: krohne et al., 1996) consists of two 10-item scales, one for positive and one for negative affect. participants rated, how they generally felt during each day with respect to each emotion on a 5-point likert-like intensity scale (1 = very slightly/not at all, 5 = extremely). the internal consistency of the panas is high, with cronbach alpha’s of 0.90 for positive and 0.87 for negative affect (watson et al., 1988). statistical analyses dynamic complexity (dc) (schiepek & strunk, 2010) was computed for the panas´s positive and negative affect subscales. dc is a measure for identifying critical instabilities and fluctuations in short, coarse-grained, time series like those obtained in typical diary studies. it is calculated from two parameters: fluctuation intensity and distribution (see section on dc above). the fluctuation measure is highest when the time series fluctuates widely between its minimum and maximum, while the distribution measure is larger when it takes many different values. both parameters are then multiplied by each other, resulting in a total dynamic complexity measure. both parameters were calculated in moving windows. like other studies using this method (e.g., schiepek et al., 2014), we chose a moving window size of seven days. to identify local complexity peaks, we calculated the difference between the average and maximum complexity of each panas item. peak complexity values for individual positive and negative affect items were averaged to obtain scale-level peak complexity values. we then used t-tests to compare the peak complexity values for the positive and negative affect scales of patients with nssi to those of controls. finally, to test whether average dynamic complexity values change over time, we fitted linear mixed models to predict dynamic complexity of the positive and negative affect scales from number of days since admission and group (nssi vs. controls). models included random intercepts for each participant and an interaction effect of the group by time. the linear mixed models were included to determine whether there were temporal trends in the development of dynamic complexity. missing values were imputed using kalman filter imputation. results the assessment period for the nssi group was between 8 and 37 days (mdn = 16.5, m = 17.21, sd = 5.56) and between 6 and 32 days for the control group (mdn = 14.0, m = 14.24, sd = 5.73). the frequency of nssi acts during their lifetime was classified in intervals. eleven participants indicated more than 60 nssi acts, three between 31 and 60, seven between 30 and 16, three between six and 15, and four between two and five acts. in the nssi group, a median number of 2.5 assessments (interquartile range: 5.25) were missing dynamic complexity of positive and negative affect in nssi 8 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ and had to be imputed. in the control group, a median of 3 assessments (interquartile range: 4) were missing. on average, patients engaged in nssi showed significantly higher peak complexity scores than controls (figure 2). this was true for both positive (t(44.89) = 2.88, p = .006) and negative affect (t(57.65) = 2.08, p = .042). the effect sizes of these differences were medium for positive affect (d = 0.77, 95% ci [0.23, 1.30]) and medium for negative affect (d = 0.54, 95% ci [0.01, 1.06]). as a robustness analysis, we repeated the comparisons after excluding four patients reporting only between two and five nssi acts during their lifetime. this led to slightly higher group differences. for positive affect complexity, the difference was significant and large (t(42.42) = 3.21, p = .002, d = 0.86). for negative affect complexity, the difference was significant and medium (t(56.26) = 2.17, p = .034, d = 0.56). in addition, nssi patients had higher mean levels of positive affect: the mean panas positive affect score in the nssi group was 2.41 (sd = 0.34) compared to 2.16 (sd = 0.36) in the non-nssi group. this difference was significant (t(55,02) = 2,36, p = .022; d = .61). there was no evidence of differences in negative affect: in the nssi group, the mean panas negative emotion score was 2.26 (sd = 0.41), compared to a mean of 2.27 (sd = 0.48) in the non-nssi group (t(58.98) = -0.12, p = .906). figure 3 shows the distribution of mean-max complexity in positive and negative affect. the nssi group has higher scores for both positive and negative affect, demonstrating that the nssi group generally has higher emotionality than the control group. furthermore, we fitted a linear mixed model to predict positive complexity (= dc of positive affect) from time (in days) and group (nssi vs. control) as predictors. the model included a random intercept for each participant. the model's total explanatory power was substantial (conditional r 2 = 0.50), and the part related to the fixed effects alone (marginal r 2) was 0.02. the second linear mixed model predicted negative complexity (= dc of negative affect) from the same variables as the first model. the total explanatory power was substantial (conditional r 2 = 0.57), and the part related to the fixed effects alone (mar­ ginal r 2) was 0.08. standardized parameters of the models were obtained by fitting the model on a standardized version of the dataset. 95% confidence intervals (cis) and p-values were computed using a wald t-distribution approximation. we did not find an association of length of stay with dynamic complexity. the models are summarized in table 1 and table 2. the average reported nssi frequency was not related to the average positive affect, r(26) = -.10, and the average negative affect, r(26) = -.04, both p > .05. similarly, there was no significant correlation between the number of nssis and the peak complexity for positive (r(26) = -.06) and for negative (r(26) = .08) emotions, both p > .05. bruckbauer-schwed, kaiser, keglevic, & laireiter 9 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ figure 2 raw affect scores over the period of assessment for all participants note. coloured lines represent individual subject’s daily affect assessments; x-axis: number of days of assessment; y-axis: affect intensity. dynamic complexity of positive and negative affect in nssi 10 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ figure 3 distribution of mean max complexity note. (a) distribution of mean max complexity of positive affect. (b) distribution of mean max complexity of negative affect. table 1 coefficients for the linear mixed model predicting the dynamic complexity of positive affect from time and group estimates 95% ci p predictors (intercept) 0.03 0.02; 0.05 < .001 days -0.00 -.00; .00 0.132 group [nssi] 0.01 -.01; .03 .333 days x group [nssi] 0.00 -.00; .00 .616 random effects σ2 0.00 τ00 code 0.00 icc 0.49 ncode 59 observations 671 marginal r 2 .02 conditional r 2 .50 note. 95% ci = 95% confidence interval; nssi = non-suicidal self-injury; σ2 = variance of intercepts; τ00 code = standard deviation of intercepts; icc = intraclass correlation; ncode = number of participants; marginal r 2 = variance explained by fixed effects; conditional r 2 = variance explained by both fixed and random effects. bruckbauer-schwed, kaiser, keglevic, & laireiter 11 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ table 2 coefficients for the linear mixed model predicting the dynamic complexity of negative affect from time and group estimates 95% ci p predictors (intercept) 0.02 0.01; 0.03 < .001 days -0.00 -.00; .00 0.141 group [nssi] 0.02 .00; .04 .041 days x group [nssi] 0.00 -.00; .00 .274 random effects σ2 0.00 τ00 code 0.00 icc 0.53 ncode 59 observations 671 marginal r 2 .08 conditional r 2 .57 note. 95% ci = 95% confidence interval; nssi = non-suicidal self-injury; σ2 = variance of intercepts; τ00 code = standard deviation of intercepts; icc = intraclass correlation; ncode = number of participants; marginal r 2 = variance explained by fixed effects; conditional r 2 = variance explained by both fixed and random effects. discussion the current study is, to our knowledge, the first to examine dc and the role of positive affect in nssi, particularly in an adult clinical sample. consistent with our first hypoth­ esis, participants in the nssi group showed higher dc in affect – both positive and negative – than controls. this study impressively demonstrated that only a few days are sufficient to show the typical dynamic pattern of high affect fluctuation in individu­ als with a history of nssi. although nssi is generally associated with an increase in negative affect in most other studies, in our study individuals with a history of nssi specifically showed more positive affect than controls. we could not find significant dif­ ferences in mean levels of negative affect. previous studies have reported mixed findings regarding positive affect in nssi (e.g., armey et al., 2011; jenkins & schmitz, 2012). we did not find a significant relationship between change in dynamic complexity of affect and length of inpatient stay in either the nssi or the control group. the finding that individuals with a history of nssi showed increased dc for both positive and negative affect is consistent with previous research showing higher affect variability / instability in the nssi group compared to controls (santangelo et al., 2017; victor et al., 2021). the advantage of using dc instead of, for example, classical variance as a measure of varying degrees of fluctuations is that variance is indifferent to the shape of the time series, unlike f and d, which are influenced by it. variance specifically dynamic complexity of positive and negative affect in nssi 12 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ indicates the magnitude of fluctuations without regard to the frequency or sequence of system states. we were also able to show that the nssi group generally has higher emotionality than the control group. this result is consistent with other studies based on emotional experience (e.g., victor & klonsky, 2014). according to the study by victor and klonsky (2014), self-injurers show higher negative emotions than non-injurers. to explain our finding of increased positive affect in our nssi group, several explan­ ations can be considered: first, some authors emphasize the addictive nature of nssi (e.g., buser & buser, 2013), including compulsivity, loss of control, and continuation despite negative consequences. in this sense, engagement in nssi may activate the eos (endogenous opioid system), which contributes to the experience of analgesia by releasing opiates in response to tissue damage. this physiological process can lead to an improvement in mood (sandman & touchette, 2002). second, positive reinforcement is an important general motive for maintaining nssi, as demonstrated in previous studies (e.g., selby et al., 2014). selby et al. (2014) found that more than 50% of their sample reported at least one instance of nssi for automatic positive reinforcement (apr) reasons, with "satisfaction" as the most frequently endorsed motivation. in addition, self-injurers with apr motives reported more frequent nssi. third, we used a psychiatric control group with a higher proportion of depressed patients (54.55% vs. 42.9%). depressives typically show elevated levels of negative affect compared to non-depressives. although we did not test this assumption statistically, it is plausible to assume that the higher proportion of depressives in the control group accounts for the lower levels of positive affect in this group. fourth, 13 (46.43%) participants in the nssi group met criteria for a borderline personality disorder diagnosis (primary or comorbid). borderline personality disorder and nssi overlap in some criteria (e.g. impaired emotion regulation). therefore, it could also be possible that the group differences are not due to nssi, but to other psychopa­ thological characteristics. future studies should definitely investigate this possibility. furthermore, stapleton and wright (2019) reported that psychiatric inpatients diagnosed with borderline personality disorder indicate positive experiences with inpatient care for many reasons: the opportunity to talk to someone and be listened to, time away from everyday life, feeling safe, and gaining control over their recovery. in our opinion, this argument is particularly important for our study, because almost 50% of the nssi group consisted of patients with borderline personality disorder, while not a single patient in the control group had this diagnosis. it can therefore be assumed that the patients with borderline personality disorder in our study had similar positive experiences during their inpatient stay. the increased level of positive affect found in our nssi sample could therefore be attributed to this. finally, we examined whether average dynamic complexity changed over time. the association was not significant. the average length of stay in the psychiatric department of the kardinal schwarzenberg clinic is between 2 and 3 weeks, and the average assessment period was 17 days for the nssi group and 14 days for the control group. perhaps the length of stay or assessment period was too short bruckbauer-schwed, kaiser, keglevic, & laireiter 13 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ to detect a change in dynamic complexity over time. fowler et al. (2016) found significant improvements in experiential avoidance and emotion dysregulation only after 6-8 weeks of intensive inpatient psychiatric treatment. limitations our study has several limitations. the first is that our sample size is not very large, which limits generalizability. on the other hand, the results suggest that intra-individual differences in dynamic complexity explain significantly more variance than differences in assessment duration or between-group differences. future studies with larger sam­ ples and, thus, higher power to detect smaller effects, should be done to replicate our findings. a second major limitation is that we made only one measurement per day. normally, affective changes occur several times per day, especially in emotionally unsta­ ble subjects. consequently, a single assessment per day may not have been sufficient to capture the dynamics of emotional change. typical ambulatory assessment studies therefore perform several measurements per day. however, this limitation may also be an advantage, as studies have found lower compliance rates in these designs. in their systematic review, hepp et al. (2020) found an average compliance rate of 64.9% with prompts for more than one daily measurement, while a single daily measurement resul­ ted in an average compliance rate of 78.9%. to minimize the risk of low response rates and early study termination, we chose to use a single measurement per day design. a third possible limitation is that participation in our study was not incentivized. hepp et al. (2020), in their systematic review of daily life studies of nssi, found that incentivized studies resulted in higher compliance rates. a fourth limitation is the assessment of the frequency of nssi. we could only ask our participants for a retrospective estimate of the number of times they had injured themselves in their lifetime. this type of assessment is problematic because individuals may have had difficulties in recalling the exact number of lifetime self-injurious acts. in addition, many members of the nssi sample have engaged in nssi continuously over a long period of their lives. in this case, the exact number of nssi events is likely to be impossible to assess. due to the lack of compliance, it was not possible to assess individual acts of nssi during the clinic stay or the survey period. thus, we could not directly examine associations between acts or attempts of nssi and affective states. as a result, we could not examine the relationship between emotions and nssi acts, e.g., whether positive (or negative) affect occurs before or, in the case of a positive act, after an nssi act. we were unable to assess the effects of the medications that participants received during their stay, as well as the effects of their psychological treatments on their affect fluctuations. dynamic complexity of positive and negative affect in nssi 14 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ conclusion and implications the results of our study illustrate that individuals with a history of nssi show greater dynamic complexity for positive as well as negative affect and higher mean levels of positive affect. future studies should explicitly consider this possibility and explore the dynamics of positive emotions in the context of nssi more intensively, especially with larger samples, but also in individual case studies as a second very insightful strategy. the higher variance explained at the individual level suggests that the application of dynamic complexity is more meaningful when considered at the individual case level. regarding prevention and treatment, future research should also focus on specific pat­ terns of affect dynamics to identify early warning signs of critical instability and order transitions in individuals with a history of nssi. knowledge of these phenomena offers the possibility of early intervention in affective change. for example, van de leemput and colleagues (2014) reported that specific dynamic patterns of emotions are associated with the onset and offset of episodes of major depression. in addition, anticipating and observing order transitions in affect may be useful for clinical assessment of mental disorders and treatment planning (e.g., dialectical behavior therapy (dbt)) to reduce affective instability). funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: anton-rupert laireiter is a subject editor of clinical psychology in europe but played no editorial role in this particular article or intervened in any form in the peer review process. ethics statement: this research was approved by the ethical committee of the country of salzburg (ec number: 415-e/2147). all subjects gave written informed consent in accordance with the declaration of helsinki (2013). reporting guidelines: jars-quant guidelines for quantitative research data availability: the data that support the findings of this study are available on request from the corresponding author, michaela bruckbauer-schwed. supplementary materials the supplementary materials contain the preregistration for the study (for access, see bruckbauerschwed et al., 2023s). bruckbauer-schwed, kaiser, keglevic, & laireiter 15 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://www.psychopen.eu/ index of supplementary materials bruckbauer-schwed, m., kaiser, t., plöderl, m., & laireiter, a.-r. 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(2016). predicting persistence of nonsuicidal self-injury in suicidal adolescents. suicide & life-threatening behavior, 46(1), 13–22. https://doi.org/10.1111/sltb.12167 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. bruckbauer-schwed, kaiser, keglevic, & laireiter 19 clinical psychology in europe 2025, vol. 7(2), article e14527 https://doi.org/10.32872/cpe.14527 https://doi.org/10.1073/pnas.1312114110 https://doi.org/10.1016/j.beth.2021.01.003 https://doi.org/10.1002/jclp.22037 https://doi.org/10.1037/0022-3514.54.6.1063 https://doi.org/10.1111/sltb.12167 https://www.psychopen.eu/ dynamic complexity of positive and negative affect in nssi (introduction) dynamic complexity (dc) present study method daily assessments participants procedure positive and negative affective schedule (panas) statistical analyses results discussion limitations conclusion and implications (additional information) funding acknowledgments competing interests ethics statement reporting guidelines data availability supplementary materials references letter to the editor: on the critical nature of psychosomatics in clinical practice letter to the editor, commentary letter to the editor: on the critical nature of psychosomatics in clinical practice emanuele maria merlo 1 , liam a. m. myles 2 , gabriella martino 3 [1] department of biomedical and dental sciences and morphofunctional imaging, university of messina, messina, italy. [2] department of experimental psychology, university of oxford, oxford, united kingdom. [3] department of clinical and experimental medicine, university of messina, messina, italy. clinical psychology in europe, 2025, vol. 7(3), article e16309, https://doi.org/10.32872/cpe.16309 published (vor): 2025-08-29 corresponding author: emanuele maria merlo, department of biomedical and dental sciences and morphofunctional imaging, university of messina, via consolare valeria 1, 98124, messina, italy. phone: 0039-3288024346. e-mail: emerlo@unime.it highlights • scientific dialogue on current trends referred to psychosomatics results necessary. • fostering dialogue and dissemination represents scientific advancement. • clinical psychology deepening psychosomatics provides multifactorial results. dear editors, acknowledging this journal's substantial commitment to advancing diverse applica­ tions in clinical psychology, this contribution aspires to cultivate a scientific dialogue within the psychosomatic domain. building upon this journal’s publication concerning the work of kleinstäuber et al. (2024), which highlighted the paucity of systematic contributions on comprehensive ap­ proaches and biopsychosocial models to inform the identification of aetiological factors, fostering dialogue and dissemination remains of paramount importance. the current trends in clinical psychology seem to recognize the need for a multidisci­ plinary approach and increased communication (kleinstäuber et al., 2023). these areas of interest have been addressed by the journal, thereby inspiring opportunities for initiating an innovative and international scientific discourse. the works of fischer and ehlert (2019), frostholm and rask (2019), as well as weigel et al. (2022), have demonstrated considerable sensitivity to topics such as diagnosis, intervention, aetiological factors, and multidisciplinary approaches. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.16309&domain=pdf&date_stamp=2025-08-29 https://orcid.org/0000-0001-6041-9186 https://orcid.org/0000-0002-7050-8112 https://orcid.org/0000-0001-9488-2021 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ differentiation between organic and endogenous causes, as well as psychological and ecological factors, is frequently observed. while these distinctions may still hold necessi­ ty, epistemological considerations remind us of their unitary status. despite this, there remains a prevalent and persistent inclination to divide domains, thereby overlooking inherently inseparable unitary realities. systems of thought continue to exist in which the notion of a dominant metaphysics over physics remains a common inclination. a compelling illustration of this trend is evident in the psychosomatic field, par­ ticularly regarding genuine psychosomatic and chronic conditions. the concept of psy­ chological factors exerting influence on biological systems is traditionally regarded as accurate within the classical framework of psychosomatic theory. nonetheless, this conceptual accuracy may still align with a system of thought that historically regarded psychological factors as extrinsic to the physical dynamics of a suffering body, perceiving them as mere epiphenomena. epistemologically sustainable reconfigurations are warranted, as exemplified by contemporary neuroscientific integra­ tive approaches. this contribution seeks to underscore the fundamental importance of fostering a debate on these prevailing trends. it aims to establish a platform for dialogue through which processes may be refined to enhance the precision and relevance of daily scientific practice. in conclusion, insights and exchange between clinical contexts belonging to different realities produces scientific advancement that emerges necessary. funding: the authors have no funding to report. acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. references fischer, s., & ehlert, u. (2019). psychoneuroendocrinology and clinical psychology. clinical psychology in europe, 1(2), article e33030. https://doi.org/10.32872/cpe.v1i2.33030 frostholm, l., & rask, c. u. (2019). third wave treatments for functional somatic syndromes and health anxiety across the age span: a narrative review. clinical psychology in europe, 1(1), article e32217. https://doi.org/10.32872/cpe.v1i1.32217 kleinstäuber, m., diefenbach, m. a., & rief, w. (2024). “it is not just in your mind” – improving physician-patient communication in individuals with persistent somatic symptoms. journal of psychosomatic research, 185, article 111580. https://doi.org/10.1016/j.jpsychores.2023.111580 kleinstäuber, m., schröder, a., daehler, s., pallesen, k. j., rask, c. u., sanyer, m., van den bergh, o., weinreich petersen, m., & rosmalen, j. g. (2023). aetiological understanding of fibromyalgia, psychosomatics in clinical practice 2 clinical psychology in europe 2025, vol. 7(3), article e16309 https://doi.org/10.32872/cpe.16309 https://doi.org/10.32872/cpe.v1i2.33030 https://doi.org/10.32872/cpe.v1i1.32217 https://doi.org/10.1016/j.jpsychores.2023.111580 https://www.psychopen.eu/ irritable bowel syndrome, chronic fatigue syndrome and classificatory analogues: a systematic umbrella review. clinical psychology in europe, 5(3), article e11179. https://doi.org/10.32872/cpe.11179 weigel, a., dantoft, t. m., jørgensen, t., carstensen, t., löwe, b., weinman, j., & frostholm, l. (2022). symptom perceptions in functional disorders, major health conditions, and healthy controls: a general population study. clinical psychology in europe, 4(4), article e7739. https://doi.org/10.32872/cpe.7739 clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. merlo, myles, & martino 3 clinical psychology in europe 2025, vol. 7(3), article e16309 https://doi.org/10.32872/cpe.16309 https://doi.org/10.32872/cpe.11179 https://doi.org/10.32872/cpe.7739 https://www.psychopen.eu/ worry postponement from the metacognitive perspective: a randomized waitlist-controlled trial research articles worry postponement from the metacognitive perspective: a randomized waitlist-controlled trial clara krzikalla 1 , ulrike buhlmann 1 , janina schug 1, ina kopei 1, alexander l. gerlach 2 , philipp doebler 3 , nexhmedin morina 1 , tanja andor 1 [1] institute of psychology, university of münster, münster, germany. [2] department of psychology, institute of clinical psychology and psychotherapy, university of cologne, cologne, germany. [3] department of statistics, technical university of dortmund, dortmund, germany. clinical psychology in europe, 2024, vol. 6(2), article e12741, https://doi.org/10.32872/cpe.12741 received: 2023-09-07 • accepted: 2024-03-19 • published (vor): 2024-06-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: clara krzikalla, fliednerstraße 21, d-48149 münster, germany. phone: +49 251 83-34140. email: clara.krzikalla@uni-muenster.de supplementary materials: materials, preregistration [see index of supplementary materials] abstract background: pathological worry is associated with appraisals of worrying as uncontrollable. worry postponement (wp) with a stimulus control rationale appears to be effective in non-clinical samples. however, preliminary research in participants with generalized anxiety disorder (gad) does not support its efficacy in reducing negative metacognitions or worry. the aim of this study was to investigate the efficacy of wp with a metacognitive rationale. method: participants with gad (n = 47) or hypochondriasis (hyp; n = 35) were randomly assigned to either an intervention group (ig) or waitlist (wl). the ig received a two-session long wp intervention aiming at mainly reducing negative metacognitions concerning uncontrollability of worrying. participants were instructed to postpone their worry process to a predetermined later time during the six days between the two sessions. participants completed questionnaires of negative metacognitions and worry at pre-assessment, post-assessment, and follow-up. results: we observed a significant time*group interaction for negative metacognitions and worry. post-hoc analyses on the total sample and separately for gad and hyp revealed significantly lower worry scores in the treated gad sample compared to the wl, representing the only significant effect. in the gad group, pre-post-effect sizes were small for negative metacognitions and large for worry. effects persisted to a four-week follow-up. this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.12741&domain=pdf&date_stamp=2024-06-28 https://orcid.org/0000-0002-8598-5106 https://orcid.org/0000-0003-4997-3236 https://orcid.org/0000-0001-6794-5349 https://orcid.org/0000-0002-2946-8526 https://orcid.org/0000-0002-2331-9140 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ conclusion: wp with a metacognitive rationale seems to be effective in reducing worry in participants with gad. the effectiveness for hyp seems limited, possibly due to the small sample size. keywords worry postponement, metacognitive therapy, generalized anxiety disorder, hypochondriasis, stand-aloneintervention highlights • negative metacognitions about the uncontrollability of worrying maintain pathological worry. • wp reduced negative metacognitions in participants with generalized anxiety disorder (gad). • wp further reduced worry in participants with gad, with a recovery rate of 40%. • evidence for efficacy of wp in hypochondriasis is limited. excessive and uncontrollable worry represents the core symptom of generalized anxiety disorder (gad) and it also plays an important role in other mental disorders, including hypochondriasis (hyp; chelminski & zimmerman, 2003; ehring & behar, 2020; janssonfröjmark et al., 2020). metacognitive theory for gad (wells, 2009) defines worrying as a coping strategy triggered by intrusive negative thoughts about potential future events. the development and perpetuation of gad depend on the emergence of negative meta­ cognitions concerning the uncontrollability of worrying, or its detrimental and perilous consequences. previous research supports the influence of negative metacognitions on gad symptoms (e.g., nordahl et al., 2023; penney et al., 2013; wells, 2010). metacognitive therapy (mct) addresses negative metacognitions using techniques such as attention training (att), detached mindfulness (dm), and worry postponement (wp). while the overall effectiveness of mct has been demonstrated in a wide range of disorders (normann & morina, 2018; sharma et al., 2022), investigating individual components of the treatment allows for a better understanding of its mechanism and therapeutic potential. distinguishing between active and inactive treatment components can improve treatment efficacy, patient retention, and treatment dissemination. att and dm are effective even when applied as stand-alone-interventions (gkika & wells, 2015; knowles et al., 2016; rochat et al., 2018; rupp et al., 2019). further research on the efficacy of wp is needed. in wp with a metacognitive rationale, patients are instructed to challenge their uncontrollability beliefs by consciously delaying worrisome thoughts to a predefined later time, rather than engaging with them whenever they arise (wells, 2006). this should increase patients’ control over the worry process and enable more functional metacognitions and behaviors. historically, wp has been employed in cognitive behavio­ worry postponement from the metacognitive perspective 2 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ ral therapy with a stimulus control rationale. borkovec et al. (1983) noted that worry can become associated with a variety of stimuli. striving to reduce stimulus generalization and uncontrollable worry, patients are asked to postpone their worry to a predefined worry period at the same time and location every day. this approach has shown promis­ ing results with effects particularly on worry duration in kids and psychology students (borkovec et al., 1983; brosschot & van der doef, 2006; jellesma et al., 2009; mcgowan & behar, 2013; verkuil et al., 2011). however, in a study with gad patients (tallon, 2019), wp showed no effect on worry or metacognitions compared to control conditions. none of these studies explicitly addressed negative metacognitions. consequently, the efficacy of wp with a metacognitive rationale remains unknown. against this background, we aimed to assess the efficacy of wp with a metacognitive rationale in its original target population – patients with gad. as mct is considered a transdiagnostic treatment (wells, 2009), we included another clinical sample – patients with hyp – to test if this transdiagnostic property of mct applies to wp. in hyp, illness worries and preoccupation with fears of having a serious disease are common symptoms (american psychiatric association, 2013; fink et al., 2004; noyes, 1999). previ­ ous research suggests that metacognitions, in particular the belief of uncontrollability, may also play an important role in health anxiety (bailey & wells, 2016; melli et al., 2018). there is some preliminary evidence that mct and/or att may be helpful in treating hyp (bailey & wells, 2014; papageorgiou & wells, 1998). therefore, we opted to include this patient sample in our study. based on these findings, we hypothesized that wp would reduce negative metacogni­ tions and worry in both gad and hyp from preto post-assessment compared to a waitlist control group. furthermore, we anticipated a sustained reduction in symptoms from pre-assessment to the 4-week follow-up assessment for the clinical samples. method recruitment this randomized wait-list controlled trial was conducted between 2011 and 2014 at the psychotherapy outpatient clinic at the university of münster. it was approved by the institutional review board of the department of psychology and sport science at the university of münster. participants were recruited via newspaper advertisements, brochures in medical prac­ tices, the website of the specialized unit for the treatment of gad of the psychotherapy outpatient treatment center at the university of münster, and by informing patients during consultation appointments in the psychotherapy outpatient treatment center. inclusion criteria were: diagnosis of gad as assessed with the structured clinical inter­ view for dsm-iv axis i disorders (wittchen et al., 1997) or hyp according to the criteria krzikalla, buhlmann, schug et al. 3 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ proposed by fink et al. (2004), age between 18 and 65 years, and sufficient german language skills. due to criticism of the strict dsm-iv criteria for hyp (weck et al., 2014) and the fact that the dsm-5 (american psychiatric association, 2013) was not yet available, we used the preliminary criteria of fink et al. (2004). this is also the reason why we use the term hypochondriasis throughout the manuscript, as it reflects the diagnostic criteria used at the time of data collection. fink et al. (2004) emphasized uncontrollability, as their first criterion is obsessive rumination with intrusive thoughts, ideas, or fears of harboring an illness that cannot be stopped or can be stopped only with great difficulty. in contrast to dsm-iv (american psychiatric association, 1994), both fink et al. (2004) and the dsm-5 (american psychiatric association, 2013) dropped the criterion that the preoccupation with a serious illness persists despite appropriate medi­ cal evaluation and reassurance. however, the dsm-5 (american psychiatric association, 2013) requires six months of symptom duration, whereas fink et al. (2004) require only two weeks. exclusion criteria were: current psychotherapy, a dsm-iv diagnosis of alcohol or substance abuse, psychotic symptoms, active suicidal ideation, or any change in psychotropic medications within the last three months. procedure participants were randomized using simple randomization to either an intervention group (ig) or waitlist control group (wl) when first contacting the outpatient treatment center. the diagnostic criteria were initially assessed through a telephone screening. subsequently, another investigator performed a detailed diagnostic examination face to face. participants in the ig received a two-session-long wp intervention based on the metacognitive model of gad one week after the diagnostic session. the wl also received the intervention after post-assessment. data were collected prior and one week after the intervention/waiting period. participants received a short telephone session with information about further treatment options, if necessary, after returning the ques­ tionnaires. part of the post-assessment data collection were also ecological momentary assessment data over one week. these were published elsewhere (thielsch et al., 2015). all participants received follow-up (fu) questionnaires four weeks after the intervention. an overview of participant flow and assessment points can be seen in figure 1. worry postponement from the metacognitive perspective 4 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ figure 1 consort flow diagram note. gad = generalized anxiety disorder; wp = worry postponement. krzikalla, buhlmann, schug et al. 5 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ worry postponement therapists were psychologists (m.sc.) in advanced stages of their formal training to become licensed cognitive behavioral therapists. treatment consisted of two sessions, one week apart, based on wp with a metacognitive rationale (wells, 2004, 2007). thera­ pists followed a detailed manual which was adapted for this study to focus on the modification of uncontrollability beliefs by wp as a behavioral experiment. the first session (90 minutes) consisted of psychoeducation about worry and the diagnosis. a simplified individual case conceptualization was developed focusing on the belief that worry is uncontrollable, the subsequent attempts to control thoughts, and the resulting vicious cycle of worrying. therapists used guided discovery techniques, hypothetical questions, and behavioral and thought experiments to socialize participants to the meta­ cognitive model. wp was introduced as a behavioral experiment allowing to make new experiences with worrying and test uncontrollability beliefs. specifically, participants were instructed to postpone worry throughout the day to a time frame not exceeding 30 minutes at a predefined time later in the day for the next six days. participants were instructed to face worries throughout the day with an attitude of acceptance, to not get involved with the worry process, but to also not try to control worrying with previously used strategies. they composed a statement aimed at facilitating this endeavor (e.g., “another worry arises, i acknowledge it, and now i let it go.”). the second session (60 minutes) focused on the evaluation of wp. after recapturing the insights of the first session, the experiences with wp were discussed. participants were encouraged to devise new metacognitions and to adopt a new approach to managing worry (e.g., “i cannot control whether a worrisome thought comes to my mind, but i can control how i deal with it”). measures to assess negative metacognitive beliefs as our main outcome, we applied a subscale of the short german version of the metacognitions questionnaire (mcq; arndt et al., 2011). this self-report questionnaire is rated on a 4-point likert-type scale ranging from “do not agree” to “agree very much”. for this study, we only used the negative beliefs about uncontrollability and danger subscale (mcq-neg), which consists of six items (example items: “my worrying thoughts persist‚ no matter how i try to stop them”, “my worrying is dangerous for me”). the mcq-neg has good psychometric properties (arndt et al., 2011; wells & cartwright-hatton, 2004); in the current sample the internal consistency at pre-assessment was cronbach’s α = .77 for gad and α = .86 for hyp. worry was assessed with the german version of the penn state worry questionnaire (pswq; stöber, 1995) with the instruction to rate the intensity of worry during the last seven days. the pswq consists of 16 items rated on a 5-point likert-type scale ranging from “not typical of me” to “very typical of me” (example item: “i worry all the worry postponement from the metacognitive perspective 6 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ time”). the pswq has good psychometric properties (fresco et al., 2002; glöckner-rist & rist, 2014); the internal consistency was α = .73 for gad and α = .86 for hyp at pre-assessment. data analyses our statistical approach was preregistered on the open science framework prior to data analysis (see krzikalla et al., 2022). data were analyzed using the statistical processing language r (r core team, 2021). missing data patterns were inspected with little’s mcar test (little, 1988; χ2 = 453, df = 458, p = .556) and visual inspection. the assump­ tion of a missing at random pattern was made due to the absence of contradictory evidence. missing data on item-level was imputed by median-imputation. when post-as­ sessment data was missing completely, we imputed by multiple imputation using predic­ tive mean matching in the r package mice (van buuren & groothuis-oudshoorn, 2011) to generate 20 imputed data sets. auxiliary variables were identified using correlation analyses, univariate analyses of variance (anova) and t-test comparisons (enders, 2010). statistical analyses were performed separately on each dataset and then pooled into a single set of results (rubin, 1987). if not indicated otherwise, we report the results of the completer sample as results did not differ from the multiply imputed data (see supplementary materials). comparability of groups at baseline was analyzed by calculating independent t-tests for continuous variables and χ2-tests for categorical variables. indicating partial failure of randomization, in the hyp group, the ig had significantly higher worry scores (pswq) at pre-assessment than wl (see table 1). next to the preregistered analyses, we added three further analyses to the supplementary materials of this article that take into account baseline differences. to test the effect of the intervention, we calculated 2x2x2 mixed anovas with the within-subjects factor time (pre/post), and the between-subjects factors treatment group (ig/wl) and disorder (gad/hyp). due to violations of homogeneity of variance, we calculated a robust anova using the r package manova.rm (friedrich et al., 2019) and post-hoc welch’s t-tests for mcq-neg. for pswq, we calculated a mixed anova using the r package ez (lawrence, 2016) and planned contrasts. in response to an inquiry of an anonymous reviewer, we performed a post-hoc power analysis using g*power (faul et al., 2007) for the group*time interaction. based on previous research indicating small to medium effects of wp with a rationale of stimulus control on worry (dippel et al., 2023) and large effect sizes for mct (normann & morina, 2018), we calculated a power of .97 to find a medium effect (f = 0.25) with our total sample size of 80 participants. for a small effect (f = 0.1), our power would drop to .28. to test the stability of the effect in the ig, we performed paired t-tests between pre-assessment and fu. for analyses with the fu data, we only used data of the ig as equivalence tests (lakens, 2017) failed to indicate equivalence for the ig and wl krzikalla, buhlmann, schug et al. 7 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ at post-intervention. we calculated controlled effect sizes (cohen’s d = (mig-mwl)/sdwl; cohen, 1988) for the pre-post-effect and uncontrolled effect sizes for the pre-fu-effect (cohen’s d = (mpre-mfu)/sdpooled; cohen, 1988). we assessed clinical significance according to jacobson and truax (1991) by using a reliable improvement criterion (rc = x2 − x1 sdiff ) and a recovery criterion (a = m1 – 2*sd1). results sample characteristics table 1 gives an overview of demographic characteristics, comorbid diagnoses, and descriptive statistics along with tests of comparability of ig and wl at baseline separated for both clinical groups. the only significant difference between the ig and wl at baseline was in the hyp group, where participants in the ig reported higher scores on worry than participants in the wl (pswq pre). figure 2 shows the descriptive statistics graphically. adherence and competence ratings and credibility check video tapes of both sessions for 16 participants (gad n = 11, hyp n = 5) were randomly selected and rated by an advanced psychology student. due to technical issues, only 14 videos could be included for the first session, 15 videos for the second session. adherence and competence were scored on a 7-point likert-type scale for each treatment element ranging from “none” (0) to “excellent” (6). mean ratings of the total score for the first session were 5.90 (sd = 0.16) for adherence and 5.84 (sd = 0.31) for competence, for the second session 5.74 (sd = 0.37) and 5.73 (sd = 0.37) respectively. four of the videotaped two-session-treatments were also rated by one of the coauthors (i.a. or j.w.). there were no relevant differences in the ratings. participants in the ig rated the credibility of the proposed intervention on a scale of 1 (“not at all”) to 10 (“very”) with three items at the end of the first session: rationale of the intervention (gad: m = 7.26, sd = 1.91, n = 23; hyp: m = 8.47, sd = 1.55, n = 15), treatment benefit expectations (gad: m = 5.87, sd = 2.10, n = 23; hyp: m = 6.73, sd = 1.75, n = 15), and if they would recommend it to a friend (gad: m = 6.41, sd = 2.61, n = 22; hyp: m = 7.27, sd = 2.34, n = 15). efficacy of treatment the results of the 2x2x2 mixed anova for mcq-neg and pswq can be seen in tables 2 and 3. the significant time*group interactions (p = .040 for mcq-neg and p = .003 for pswq) suggest a different effect of time in ig and wl. we performed post-hoc welch’s t-tests combined and also separately for the gad and hyp group (bonferroni-corrected α = .008, respectively) to analyze the significant worry postponement from the metacognitive perspective 8 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ table 1 characteristics of participants and descriptive statistics separated by group and disorder variable gad hyp ig wl p ig wl p age, m (sd) 38.17 (13.21) 36.30 (14.36) .646 32.18 (9.70) 36.81 (13.38) .267 sex, n (%) .779 > .999 female 18 (75.00) 19 (82.61) 11 (64.71) 10 (62.50) male 6 (25.00) 4 (17.39) 6 (35.29) 6 (37.50) marital status, n (%) .663 .449 single 5 (20.83) 3 (13.04) 3 (17.65) 1 (6.25) partnered 11 (45.83) 10 (43.48) 7 (41.18) 6 (37.50) married 8 (33.33) 9 (39.13) 7 (41.18) 9 (56.25) divorced – – – – widowed – 1 (4.35) – – highest educational level, n (%) .649 .774 non-academic high school 6 (25.00) 5 (21.74) 3 (17.65) 3 (18.75) academic high school 9 (37.50) 9 (39.13) 6 (35.29) 5 (31.25) university or postgraduate degree 9 (37.50) 9 (39.13) 8 (47.06) 8 (50.00) occupational status, n (%) .640 .494 full-time 10 (41.67) 8 (34.78) 4 (23.53) 4 (25.00) part-time 5 (20.83) 4 (17.39) 4 (23.53) 4 (25.00) retired 2 (8.33) 2 (8.70) – – not-working – 2 (8.70) 3 (17.65) – pupil/student 6 (25.00) 7 (30.43) 5 (29.41) 6 (37.50) other 1 (4.17) – 1 (5.88) 2 (12.50) comorbid diagnosesa, n > .999 .616 affective disorders 6 6 4 4 anxiety disorders (other than gad) 4 5 4 4 obsessive-compulsive disorder – 1 1 1 eating disorder – 1 – – attention deficit hyperactivity disorder 1 – – – adjustment disorder 0 – – 1 none 14 13 11 8 mcq-neg pre, m (sd) 17.12 (3.18) 18.09 (3.06) .296 19.35 (2.89) 16.81 (4.56) .069 mcq-neg post, m (sd) 14.10 (3.92) 16.50 (3.43) 15.25 (3.11) 15.31 (3.98) mcq-neg follow-up, m (sd) 13.00 (4.39) 16.11 (4.34) pswq pre, m (sd) 63.21 (6.60) 64.52 (5.93) .476 64.12 (7.50) 56.50 (9.71) .018* pswq post, m (sd) 53.90 (10.93) 61.91 (8.12) 52.58 (8.86) 52.00 (11.66) pswq follow-up, m (sd) 53.00 (13.58) 56.00 (9.25) note. gad = generalized anxiety disorder; hyp = hypochondriasis; ig = intervention group; wl = waitlist; mcq-neg = negative metacognitions of the metacognitions questionnaire; pswq = penn state worry ques­ tionnaire; p = p-value for independent t-tests for continuous variables and χ2-tests for categorical variables for the difference between ig and wl. significant p-values are marked in bold. amultiple responses possible, p-value relates to total number of participants with a comorbid diagnosis. krzikalla, buhlmann, schug et al. 9 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ time*group interaction for mcq-neg (table 4). when analyzed across both diagnostic groups together, there was no significant effect (t(66.2) = -1.68, p = .049) after bonferro­ ni-correction. in the gad group, the ig had significant lower scores in mcq-neg at post-assessment compared to the ig and wl at pre-assessment. in the hyp group, the ig had significantly higher scores at pre-assessment than the ig and wl at post-assessment. the other comparisons were not significant. figure 2 change in mcq-neg and pswq throughout treatment note. mcq-neg = negative metacognitions of the metacognitions questionnaire; pswq = penn state worry questionnaire. error bars represent standard deviation. worry postponement from the metacognitive perspective 10 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ table 2 results for the 2x2x2 robust mixed anova for mcq-neg source of variation df1 df2 ats p ηg2a time 1 inf 31.72 < .001 .09 group 1 74.27 0.27 .605 .01 disorder 1 74.27 0.06 .803 < .01 time*group 1 inf 4.22 .040 .01 time*disorder 1 inf 0.27 .605 < .01 group*disorder 1 74.27 3.06 .085 .03 time*group*disorder 1 inf 0.16 .685 < .01 note. mcq-neg = negative metacognitions of the metacognitions questionnaire. significant p-values are marked in bold. aas there is currently no established protocol for obtaining ηg2 after performing a robust anova, the results after a mixed anova are displayed. table 3 results for the 2x2x2 mixed anova for pswq source of variation df1 df2 f p ηg2 time 1 66 35.48 < .001 .11 group 1 66 0.73 .396 .01 disorder 1 66 7.14 .009 .08 time*group 1 66 9.19 .003 .03 time*disorder 1 66 0.98 .326 < .01 group*disorder 1 66 4.73 .033 .05 time*group*disorder 1 66 0.02 .882 < .01 note. pswq = penn state worry questionnaire. significant p-values are marked in bold. concerning pswq, planned contrasts revealed that ig and wl differed significantly at post-assessment in the gad group (t(101) = -2.95, p = .004), but not in the hyp group (t(101) = .17, p = .863). when analyzed across both diagnostic groups together, there was no significant effect (t(99.5) = -1.95, p = .054). we also observed significant main effects of time in mcq-neg and pswq, and significant effects of disorder and the group*disorder interaction for pswq. post-hoc welch’s t-tests to analyze the significant group*disorder interaction showed the only statistically significant difference in pswq between gad and hyp in the waitlist groups (t(22.46) = 3.12, p = .005; further results in the supplementary materials). krzikalla, buhlmann, schug et al. 11 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ table 4 post hoc welch’s t-tests for mcq-neg for the total sample and separated for gad and hyp comparison total sample gad hyp df t p df t p df t p ig_post vs. wl_post 66.23 -1.68 .049 38.02 -2.10 .021 25.93 -0.05 .482 ig_pre vs. ig_post 31 4.31 < .001 19.00 2.64 .008 11.00 4.71 < .001 wl_pre vs. wl_post 37 2.95 .006 21.00 2.11 .047 15.00 2.01 .063 ig_pre vs. wl_pre 75.02 0.62 .538 45.00 -1.06 .296 25.12 1.90 .069 ig_pre vs. wl_post 73.91 2.63 .010 42.83 0.64 .526 27.30 3.32 .003 ig_post vs. wl_pre 67.09 -3.45 < .001 35.79 -3.68 < .001 25.82 -1.08 .146 note. mcq-neg = negative metacognitive beliefs of the metacognitions questionnaire; gad = generalized anxiety disorder; hyp = hypochondriasis; ig = intervention group; wl = waitlist. alpha after bonferronicorrection: α = .008. significant p-values are marked in bold. table 5 shows the controlled pre-post effect sizes, rates of response, deterioration, and recovery, separately for gad and hyp. it also presents the results for the analysis of the fu data showing a significant reduction from pre to fu for mcq-neg in the gad, but not the hyp sample, and a significant reduction in pswq for both samples. discussion to our knowledge, this is the first study that examines the efficacy of wp with a meta­ cognitive rationale. the results support the efficacy of wp in reducing negative metacog­ nitions and worry in participants diagnosed with gad. however, for participants with hyp, the intervention demonstrated only limited efficacy. we found differential effects over time between the ig and wl over both clinical groups. subsequent post-hoc analyses of the significant time*group interaction for mcq-neg were barely non-significant for the total sample (p = .049) and the gad sample (p = .021) after bonferroni-correction (bonferroni-corrected α = .008, see table 4). however, there was a significant reduction of negative metacognitions from preto post-assessment in the ig of both clinical samples, which was not evident in the wl. concerning worry, in the total sample, there was no significant difference between ig and wl (p = .054). in the gad group, the ig had significantly lower scores at post-assessment than the wl. these results extend to the analysis of the follow-up data, where significant effects were observed from preto follow-up-assessment in the gad group, demonstrating large effect sizes for negative metacognitions and worry. in the hyp group, only a significant reduction in worry was observed. worry postponement from the metacognitive perspective 12 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ ta bl e 5 ef fe ct s iz es , t -t es t o f f ol lo w -u p d at a, r es po ns e, d et er io ra tio n, a nd r ec ov er y r at es fo r g a d a nd h y p va ri ab le pr epo st r c i r ec ov er y cr it er io n r es po ns e, n (% ) d et er io ra ti on , n (% ) r ec ov er y, n (% ) pr efu da ig w l ig w l ig w l db t df p gad m c q -n eg 0. 43 [0. 20 ; 1 .0 6] 4. 15 11 .3 5 7 (3 5. 00 ) 2 (9 .0 9) 1 (5 .0 0) 0 (0 .0 0) 5 (2 6. 32 ) 1 (4 .7 7) 0. 89 [0 .1 6; 1 .6 1] 2. 95 16 .0 09 ps w q 0. 82 [0 .1 7; 1 .4 7] 9. 00 51 .3 5 7 (3 5. 00 ) 4 (1 8. 08 ) 0 (0 .0 0) 2 (9 .0 9) 8 (4 0. 00 ) 2 (9 .0 9) 0. 88 [0 .2 2; 1 .5 4] 3. 19 16 .0 06 hyp m c q -n eg 0. 67 [0. 14 ; 1 .4 8] 4. 10 10 .2 2 4 (3 3. 33 ) 1 (6 .2 5) 0 (0 .0 0) 1 (6 .2 5) 0 (0 .0 0) 1 (6 .6 7) 0. 63 [0. 34 ; 1 .6 0] 1. 51 8 .1 69 ps w q 0. 76 [.0 5; 1 .5 7] 9. 69 41 .7 4 5 (4 1. 67 ) 5 (3 1. 25 ) 0 (0 .0 0) 1 (6 .2 5) 1 (5 .0 0) 1 (6 .6 7) 0. 79 [0 .0 0; 1 .5 9] 2. 43 8 .0 41 n ot e. g a d = g en er al iz ed a nx ie ty d is or de r; h yp = h yp oc ho nd ri as is ; m c q -n eg = n eg at iv e m et ac og ni tiv e be lie fs o f t he m et ac og ni tio ns q ue st io nn ai re ; p sw q = pe nn w or ry q ue st io nn ai re ; r c i = r el ia bl e ch an ge in de x; f u = fo llo w -u p; ig = in te rv en tio n gr ou p; w l = w ai tli st ; d a = c on tr ol le d ef fe ct s iz e, c oh en ’s d ; d b = un co nt ro lle d ef fe ct s iz e, c oh en ’s d . f or r ec ov er y, o nl y pa rt ic ip an ts w ho w er e ov er th e cu tof f a t p re -a ss es sm en t w er e ev al ua te d. krzikalla, buhlmann, schug et al. 13 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ thus far, evidence has indicated the efficacy of wp in non-clinical samples with low to moderate levels of worry. contrary to the findings of the only study examining gad patients (tallon, 2019), in our study wp effectively reduced worry compared to a control condition in this population. notably, all previous studies have employed a stimulus control rationale (dippel et al., 2023; tallon, 2019). previous research demonstrated the efficacy of mct (e.g., normann & morina, 2018) and of its components att and dm (gkika & wells, 2015; knowles et al., 2016; rochat et al., 2018; rupp et al., 2019). our results suggest that wp, as a behavioral experiment with a metacognitive rationale, is effective in reducing worry in gad patients. this supports the metacognitive model regarding the importance of negative metacognitions in maintaining worry and the resulting potential to reduce worry by changing them (wells, 2009). a tendency for these effects was also evident in the hyp group with reductions in metacognitions and worry in the ig but not in contrast to the wl. previous research has shown an association between metacognitive beliefs and health anxiety (keen et al., 2022) and preliminary evidence for the effect of mct in hypochondriasis (bailey & wells, 2014). changing uncontrollability beliefs may be less important in hyp. another explanation for the lack of larger effects could be the failure of randomization, which resulted in the ig having significantly higher worry scores at pre-assessment than the wl. importantly, effects seem to be larger for worry than for negative metacognitions. this could indicate that even minor reductions in metacognitions have a significant impact on the extent of worries (change scores of the negative metacognitions and worry correlated with r = .54 across all participants). alternatively, change of negative metacog­ nitions might just represent one mechanism affected by wp. even though wp mainly addresses the negative metacognition of uncontrollability (wells, 2006), the intervention might also influence positive metacognitions. to a lesser extent, these are also linked to worry (dugas & koerner, 2005; nordahl et al., 2023; penney et al., 2013). reduction of stimuli that trigger worry (borkovec et al., 1983) or alterations of attentional control by training disengagement from worry (hirsch & mathews, 2012) might be further explanations for the reduction of worry after wp. also, mcq-neg compromises the scale negative metacognitions from the mcq (wells & cartwright-hatton, 2004). this scale includes only three items addressing uncontrollability and three items addressing danger. the intervention did not explicitly target worry-related danger, which may have attenuated the effects. this is supported by the fact that while the intervention's effects are evident in the items related to uncontrollability, they are not observed in the items related to danger (table s11 in the supplementary materials). in addition, we exploratorily analyzed a single item on the uncontrollability of worry at various points during the intervention, which also showed a significant decrease (see appendix e in the supplementary materials). it was not possible to combine the data of the ig and wl as planned due to lack of equivalence at post-intervention. the data suggest that this is not due to attrition, worry postponement from the metacognitive perspective 14 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ but rather that improvement occurred during the waiting period, resulting in a lower pre-intervention baseline of the wl. tallon (2019) also reported a reduction of self-repor­ ted past-week worry over the course of their study in two different control groups. besides regression to the mean, the repetitive measurements could have potentially altered attentional processes and shifted participants’ perspectives on their worries and thus the worries themselves. to our knowledge, this is the first publication to address the efficacy of wp with a metacognitive rationale. some limitations must be considered, when interpreting the results. we used questionnaires to measure negative metacognitions and worry, which may be biased. additionally, uncontrollability of worries was assessed with the scale negative metacognitions of the mcq, which also includes items concerning danger of worrisome thoughts. we did not include a measure of symptom severity for gad or hyp, other than worry. lastly, the results for the hyp sample must be interpreted with special caution as the sample size is somewhat small and pre-treatment difference in worries were evident. further research, with an active control group, larger sample sizes, and the inclusion of additional mediators (e.g., positive metacognitions) is necessary to better understand mechanisms of change in wp. conclusions wp significantly reduced metacognitive beliefs of uncontrollability of worries and worry intensity in participants with gad. however, a broader measure of negative metacogni­ tions did not differ significantly between ig and wl. further, we only found limited evidence for the efficacy in the hyp sample. recovery rates of 40% in worry were achieved in the gad sample, which is particularly remarkable given the short duration of the intervention. the study supports the application of wp with a metacognitive rationale for reducing negative metacognitions and worry, holding promise for further research and practical implementation. krzikalla, buhlmann, schug et al. 15 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ funding: the authors have no funding to report. acknowledgments: the authors thank prof. dr. fred rist for his support. competing interests: the authors have declared that no competing interests exist. ethics statement: the study was approved by the institutional review board of the department of psychology and sport science at the university of münster. reporting guidelines: this article follows the guidelines of consort statement. data availability: the data that support the findings of this study are available upon reasonable request from the psychotherapy outpatient unit of the university of münster (contact via pta@uni-muenster.de). the data are not publicly available due to ethical restrictions. supplementary materials the supplementary materials contain the following items: • the pre-registration protocol for the study (see krzikalla et al., 2022) • additional information (see krzikalla et al., 2024): ◦ appendix a: pooled results of the analyses with the multiply imputed data (tables s1 to s6) ◦ appendix b: additional analyses to validate the results relating to the failed randomization concerning the worry scores of the ig and wl in the hyp group at pre-assessment (tables s7 to s9) ◦ appendix c: post-hoc-t-tests for the significant group*disorder interaction in the mixed anova for pswq (table s10) ◦ appendix d: results of the 2x2x2 robust anova separately for the subitems of mcq-neg for uncontrollability and danger (table s11) ◦ appendix e: uncontrollability of worry measured with a single item (tables s12 to s13) index of supplementary materials krzikalla, c., buhlmann, u., schug, j., kopei, i., gerlach, a. l., doebler, p., morina, n., & andor, t. (2022). supplementary materials to "worry postponement from the metacognitive perspective: a randomized waitlist-controlled trial" [pre-registration protocol]. osf registries. https://doi.org/10.17605/osf.io/h48jw krzikalla, c., buhlmann, u., schug, j., kopei, i., gerlach, a. l., doebler, p., morina, n., & andor, t. (2024). supplementary materials to "worry postponement from the metacognitive perspective: a randomized waitlist-controlled trial" [additional information]. psychopen gold. https://doi.org/10.23668/psycharchives.14458 worry postponement from the metacognitive perspective 16 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://doi.org/10.17605/osf.io/h48jw https://doi.org/10.23668/psycharchives.14458 https://www.psychopen.eu/ references american psychiatric association. (1994). diagnostic and statistical manual of mental disorders (4th ed.). american psychiatric publishing. american psychiatric association. 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(1997). strukturiertes klinisches interview für dsm-iv [structured clinical interview for dsm-iv]. hogrefe. worry postponement from the metacognitive perspective 20 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://doi.org/10.32920/ryerson.14653938.v1 https://doi.org/10.1016/j.beth.2015.05.001 https://doi.org/10.18637/jss.v045.i03 https://doi.org/10.1159/000320328 https://doi.org/10.2174/1573400509666131119004444 https://doi.org/10.1002/9780470713143.ch15 https://doi.org/10.1016/j.cbpra.2006.01.005 https://doi.org/10.5127/jep.007910 https://doi.org/10.1016/s0005-7967(03)00147-5 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service by leibniz institute for psychology (zpid), germany. krzikalla, buhlmann, schug et al. 21 clinical psychology in europe 2024, vol. 6(2), article e12741 https://doi.org/10.32872/cpe.12741 https://www.psychopen.eu/ worry postponement from the metacognitive perspective (introduction) method recruitment procedure worry postponement measures data analyses results sample characteristics adherence and competence ratings and credibility check efficacy of treatment discussion conclusions (additional information) funding acknowledgments competing interests ethics statement reporting guidelines data availability supplementary materials references attitudes and expectations towards mental health interventions in the general population: comparing face-to-face counseling, blended counseling, and digital or on-paper self-help research articles attitudes and expectations towards mental health interventions in the general population: comparing face-to-face counseling, blended counseling, and digital or on-paper self-help nele a. j. de witte 1 , fien buelens 1 , jennifer apolinário-hagen 2 , tom van daele 1,3 [1] psychology & technology, centre of expertise care and well-being, thomas more university of applied sciences, antwerp, belgium. [2] institute for occupational, social and environmental medicine, faculty of medicine, centre for health and society (chs), heinrich heine university düsseldorf, düsseldorf, germany. [3] centre for technological innovation, mental health and education, queen’s university belfast, belfast, united kingdom. clinical psychology in europe, 2025, vol. 7(4), article e16235, https://doi.org/10.32872/cpe.16235 received: 2024-11-29 • accepted: 2025-07-30 • published (vor): 2025-11-28 handling editor: winfried rief, philipps-university of marburg, marburg, germany corresponding author: nele a. j. de witte, thomas more university of applied sciences, molenstraat 8, 2018 antwerp, belgium. phone number: + 32 3 432 18. e-mail: nele.dw@thomasmore.be supplementary materials: materials [see index of supplementary materials] abstract background: digital interventions are supported by a growing evidence base and have the potential to contribute to accessible and personalized mental healthcare services. when individuals seek help for mental health problems, various intervention options are available in a digital, faceto-face or on-paper format. however, it is important to understand what individuals find important for intervention selection and how they perceive different intervention options. method: the study recruited 232 individuals for a cross-sectional online survey on (1) the relevance of 12 evaluation dimensions for mental health support, (2) whether self-help books, digital interventions, face-to-face counseling, and blended interventions would meet expectations, and (3) self-reported likelihood of use. results: the most important dimensions for intervention selection were helpfulness, personal support, motivates to get better, and credibility. face-to-face counseling was evaluated favorably for dimensions linked to intervention content (e.g., helpfulness), while self-help approaches were rated more positively for practical aspects (e.g., waiting time). blended counseling received fairly this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.16235&domain=pdf&date_stamp=2025-11-28 https://orcid.org/0000-0001-6313-7256 https://orcid.org/0000-0001-6225-4979 https://orcid.org/0000-0001-5755-9225 https://orcid.org/0000-0001-9237-9297 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ similar dimension ratings as face-to-face counseling. self-reported likelihood of use differed significantly between modalities despite large individual differences. face-to-face interventions were most likely to be used, followed by blended counseling, with digital and on-paper self-help options sharing third place. conclusion: the findings suggests that mere self-help (online or on paper) does not sufficiently meet the needs and is not the preferred choice for handling mental health problems for most individuals. if presented with the choice, individuals still prefer face-to-face counseling. nevertheless, blended interventions can be a promising treatment option for the future. keywords mental healthcare, technology acceptance, self-help, digital mental health, blended care highlights • mental health services are diversifying but we need to assess attitudes to intervention options. • face-to-face support was perceived to be more helpful, motivational and credible than alternatives. • self-help approaches were rated more positively for practical aspects but were not preferred. • blended interventions were well received but relying on face-to-face support was deemed more likely. mental health problems are one of the leading causes of burden worldwide (gbd 2019 mental disorders collaborators, 2022). however, many people, especially young adults, do not seek or find professional help (bryant et al., 2022). for example, depression is a common and sever mental health complaint but moitra et al. (2022) calculated that about 39% of individuals with this disorder in high-income countries do not receive treatment. the study by mauerhofer et al. (2009) in switzerland found that only 13% of young adults identified by their gp as experiencing depression or sadness actually sought help for that issue. however, help-seeking can also occur beyond face-to-face mental health services in the realm of self-help. in the past, self-help was mainly limited to books, which have demonstrated a moderate degree of effectiveness (kavanagh & proctor, 2011; marrs, 1995). however, individuals now increasingly come across technological resources for self-help as well. a review on online help-seeking behavior in young people found that the internet can be a gateway to further mental health information and knowledge, a means of connecting with peers or professionals regarding mental health problems, and an alter­ native to offline help-seeking behavior (pretorius et al., 2019). digital self-help services come in various forms, from an informative app or website to a full online treatment program (de witte et al., 2021). digital self-help interventions can be provided in an attitudes towards mental health interventions 2 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ unguided (fully autonomous) or guided format which includes support from a professio­ nal who (a)synchronously monitors progress and/or provides feedback. there is a large body of empirical support from clinical trials for the efficacy of digital self-help, such as internet-based cognitive behavioral therapy for depression (karyotaki et al., 2021). the meta-analysis of madrid‐cagigal et al. (2025) also supported the effectiveness of digital mental health interventions for university students with mental health difficulties. whether a guided format should be preferred can be dependent on the context and intervention tagets since the study of madrid‐cagigal et al. (2025) observed a greater effect size for fully automated interventions on anxiety symptoms but not depressive symptoms (perhaps linked to deficits in intrinsic motivation linked to depressive com­ plaints). self-help applications can show very high drop-out rates. retention rates as low as 3.3% have been recorded for frequently installed, unguided mental health apps during a 30-day period “in the wild” (baumel et al., 2019). retention rates have also been noted as a challenge for the use of self-help books. while bibliotherapy drop-out rates can be acceptable in controlled research with individuals who have a personal interest in the topic, there is little evidence on book completion rates “in the wild” (0-30%; gualano et al., 2017; kavanagh & proctor, 2011). it is also relevant to assess the reach of self-help interventions, as it has been suggested that, for example, book readership might consist of more highly educated individuals and include many who are merely interested in the topic and are not using it as self-help per se (bergsma, 2008; kavanagh & proctor, 2011). while low perceived need for treatment proves to be one of the barriers to help-seek­ ing behavior in mental health (even in individuals with severe mental health problems; andrade et al., 2014), digital mental health services can face additional uptake and drop-out challenges. the uptake of digital mental health can be hindered or facilitated by technology acceptance, i.e., attitudes and expectations of end users towards technology (philippi et al., 2021; venkatesh et al., 2003). relevant predictors in the unified theory of acceptance and use of technology (utaut) are the extent to which individuals believe that a technology can help them achieve their goals (performance expectancy), the amount of effort required to use a technology (effort expectancy), and the opinions of important others regarding technology use (social influence). in line with the role of performance expectancy, the perceived quality and effectiveness of digital interventions has proven to be a key factor in the acceptance of digital mental health interventions for depression, anxiety and stress in adolescents and young adults (zhu et al., 2025). several other barriers for using online interventions have been reported. examples are difficulties with fitting the intervention into the schedule, the lack of a convenient place to perform the intervention, past experiences with an intervention, perceived credibility, and confidentiality (borghouts et al., 2021). on the other hand, young people have reported that anonymity, privacy, accessibility, inclusivity, and the ability to connect with others are benefits of online help-seeking, which could motivate people to use digital mental health services (ho et al., 2025; pretorius et al., 2019). de witte, buelens, apolinário-hagen, & van daele 3 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ alongside (guided) self-help, digital mental health services can also be used in combi­ nation with face-to-face interventions in stepped or matched care approaches in blended care. a blended care model can vary greatly in implemented therapeutic approach, objectives, and digital and face-to-face component features, which poses challenges for defining the concept and evaluating effectiveness (ehrt-schäfer et al., 2023; singh et al., 2022). reviews have provided initial indications of feasibility and effectiveness when compared to face-to-face interventions in serious mental illness (cohen et al., 2024; cooper et al., 2022; ehrt-schäfer et al., 2023; erbe et al., 2017; köhnen et al., 2021). cooper et al. (2022) documented significant symptom reduction in blended treatment for anxiety and obsessive-compulsive spectrum disorders, and this reduction was found to be greater than the comparison group in a quarter of the included studies. erbe et al. (2017) observed lower drop-out and/or greater abstinence as compared to face-to-face treatment in six out of nine studies in patients with substance abuse. while reviews focus on seri­ ous mental illness, blended approaches have also been identified as promising for mental health prevention and promotion (singh et al., 2022). however, it is relevant to note that all reviews identify a need for additional rigorous effectiveness and cost-effectiveness research. implementation of digital and blended interventions in practice is hindered by a lack of a clear concept on how technology can be embedded in the healthcare system (including funding challenges) as well as a lack of training regarding digital mental health implementation and differences in the acceptance and preferences regarding digi­ tal technology in patients or professionals (cohen et al., 2024; titzler et al., 2018). this implies that a limited number of individuals might have already come into contact with digital interventions or blended care. while several reviews and meta-analyses address the acceptance of digital health interventions (e.g., lau et al., 2024), their scope is often restricted to clinical populations and specific intervention types or indications. similar­ ly, reviews and models (e.g., utaut) exploring the drivers and barriers to adoption predominantly focus on digital interventions in isolation, neglecting comparisons with face-to-face and other modalities like self-help books. few studies directly evaluate and compare intervention modalities on the same dimensions. since individuals have diverse treatment options available, it is relevant to gain insight into the determinants that individuals deem important for mental health inter­ ventions and analyze to what extent intervention modalities are expected to fulfill these needs. in 2014, musiat and colleagues designed a study to develop a list of evaluation dimensions which influenced people’s decision to engage with a particular intervention for mental health problems (musiat et al., 2014). they subsequently investigated to what extent different interventions fulfilled participant’s needs. their findings indicated that face-to-face interventions were expected to perform well in terms of helpfulness, personal support, credibility, motivational aspects, suiting learning preferences, including feedback, appeal, and credibility. books, websites, and apps performed well in terms of attitudes towards mental health interventions 4 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ convenient location and time, anonymity, and no waiting time but were rated poorly on all other dimensions. this also resulted in the highest likelihood of using face-to-face interventions, followed by self-help books and web-based interventions. smartphone applications showed the lowest likelihood of use. the study by musiat et al. (2014) is one of the few studies incorporating such a differentiated assessment (grounded in service users’ needs) of multiple intervention modalities. however, the position of technology in society has altered and the covid-19 pandemic has resulted in large number of potential first experiences with digital mental health (parsons et al., 2023), and a decade later, an update of the work of musiat et al. (2014) seems warranted. therefore, the aim of this study was to (1) gain insight into the importance of different evaluation dimensions for mental health interventions, (2) assess to what extent individuals from a general and student population expect different intervention options (self-help books, digital interventions, blended counseling, and face-to-face counseling) to meet their expectations, and (3) compare the self-repor­ ted likelihood of use between these intervention modalities (including an exploratory subgroup analysis for existing mental health complaints). method participants first-year applied psychology students at thomas more university of applied sciences in belgium (aged 17 or older) were invited for participation in the study through e-mail and received course credits for their participation. additionally, a call for participation was launched in the general population through social media and e-mail. recruitment took place in november and december in 2023. the study was approved by the ethical committee of thomas more university of applied sciences (ectp2324_03). all partici­ pants provided informed consent. questionnaire the questionnaire was adapted from musiat et al. (2014) and was distributed (in dutch) via a link to an online survey platform questionpro (https://www.questionpro.com/). besides the translation, the questionnaire underwent some alterations based on progres­ sion in the field regarding the intervention options. the included intervention options were slightly modified to better represent current digital mental health use. web-based interventions and smartphone applications were merged into a single intervention op­ tion, ‘digital interventions,’ since they are applied in a similar way (in the capacity of (guided) self-help) and the difference between these options has grown smaller due to the rise of mobile website traffic and mobile-first web design. blended counseling, i.e., combining face-to-face and digital interventions, is a newly added intervention option. de witte, buelens, apolinário-hagen, & van daele 5 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.questionpro.com/ https://www.psychopen.eu/ self-help books and face-to-face counseling were retained. the 12 evaluation dimensions, which musiat et al. (2014) developed based on an advisory group of service users, were retained, although learning style was translated to 'matching one's own learning process' to facilitate comprehension by the participants. participants were asked to what extent they found 12 criteria or dimensions impor­ tant, on a 7-point likert scale ranging from 1 (totally unimportant) to 7 (very important), when looking for help in the broad context of interventions for common mental health problems such as anxiety or depression. these dimensions relate to both the content of the intervention or practical considerations. dimensions considered that the intervention (1) helps with the problem, (2) motivates to get better, (3) is credible, (4) is accessible without waiting time, (5) is accessible at an appropriate time, (6) provides feedback, (7) includes personal support, (8) is accessible at a convenient location, (9) is free of charge, (10) is attractive/appeals to me, (11) can be consulted anonymously, (12) connects to my own learning preferences (mainly referring to how individuals prefer to process information). as a next step, they rated to what extent they thought that face-to-face counseling, a self-help book (without additional support), blended counseling, and a digital intervention would meet these criteria (on a scale from 1 to 7). the descriptions of the four intervention options, which were provided to the participants, can be found in table 1. participants subsequently rated the likelihood of using these modalities (“how likely is it that you would use the following applications?”) on a 6-point likert scale ranging from 0 (very unlikely) to 5 (very likely). participants were asked to report whether they currently or previously faced mental health problems and had experience with one or more of the four intervention options mentioned above. finally, the questionnaire also asked for demographics (gender, age, educational level) and included a question about the frequency of using the internet and different devices (smartphone, computer or laptop, and tablet) to provide an indication of participants’ familiarity with technology use. analysis the data was analysed using spss 29. individuals with incomplete questionnaire respon­ ses were excluded. the data was non-normally distributed according to visual inspection of the data and kolmogorov-smirnov tests of normality, so non-parametric tests were used. related-samples friedman's two-way analysis of variance by ranks and dunn’s pairwise post hoc tests were used to compare the importance of the dimensions and the ratings between modalities. an independent-samples mann-witney u test was used to in an exploratory analysis to compare between subgroups. the alpha error probability used to test statistical significance was .05 and p-values were adjusted by the bonferroni correction for multiple tests. attitudes towards mental health interventions 6 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ results sample while 354 individuals accessed the questionnaire, a large number of incomplete respon­ ses resulted in a total of 232 participants from a general (n = 106; 46%) and college student (n = 126; 54%) population being included. table s1 in supplementary materials provides an overview of the demographics. apart from age and education, the subsam­ ples differed in tablet usage and gender. smartphone, internet, and computer or laptop use were high in the sample (ranging from regularly to very often). despite this being a general population sample, 65.5% of respondents reported current or past mental health problems. however, almost none had experience with any of the four intervention modalities. one participant had experience with face-to-face counseling, and two others had used a self-help book. no experience with digital or blended help was reported. table 1 descriptions of the four intervention modalities modality description face-to-face counseling face-to-face counseling is when counseling takes place in person. as a client, you see the counselor in the same physical space. you do not use technological aids in the process. self-help book a self-help book is scientifically based and offers insights into problems or challenges that you are struggling with. a self-help book often includes strategies on how to learn to cope with your symptoms. a self-help book can be used alongside other forms of therapy, or on its owna. blended counseling blended counseling is a counseling service that combines face to face and technological interventions. for example, as a client, you regularly see the health professional physically. in addition, you occasionally have conversations via computer (through online consultations). between sessions, you can also call on a website or smartphone app for additional support. digital intervention in a digital intervention, you receive information, advice or support through a website, app or online platform. you learn more about complaints or problems, complete a selftest, or carry out assignments. in some digital interventions, you also receive remote support (e.g., a health professional who supports you via chat), but this is not always the case. aparticipants were asked to reflect on stand-alone implementation of the self-help book for the ratings. de witte, buelens, apolinário-hagen, & van daele 7 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ importance of the 12 dimensions table 2 provides an overview of the median and mean importance rating assigned to the different dimensions. all dimensions were deemed important, apart from perceived costs (‘free of charge’), which received a more neutral score. related-samples friedman’s two-way analysis of variance by ranks (χ2(11) = 610.20, p < .001) showed significant differences between the importance of the dimensions. helpfulness, personal support, motivation, and credibility were deemed the most crucial, with their importance differing significantly from other dimensions, but not among these four. on the other hand, being free of charge was rated significantly least important of all the dimensions. full results of the dunn’s pairwise post hoc tests for each dimension can be found in table s2 in supplementary materials. table 2 subjective importance ratings for the 12 dimensions dimension importance mdn m (sd) helps with the problem 7 6.43 (0.84) includes personal support 6 6.24 (0.84) motivates to get better 6 6.20 (1.01) is credible 6 6.12 (1.01) is accessible without waiting 6 5.87 (1.03) is accessible at an appropriate time 6 5.84 (1.03) provides feedback 6 5.61 (1.05) is accessible at a convenient location 6 5.53 (1.12) connects to my own learning 6 5.47 (1.12) can be consulted anonymously 5 5.15 (1.61) is attractive/appeals to me 5 5.11 (1.33) is free of charge 4 4.53 (1.37) note. scale from 1 (totally unimportant) to 7 (very important). expectations regarding the four modalities participants rated the four different intervention modalities on the 12 dimensions. ta­ ble 3 provides the scores and figure 1 provides a visual overview of results. significant differences in terms of expectations across the intervention options were reported on all dimensions, 20.48 ≤ χ2s(3) ≤ 456.27, ps < .001 (specific test results can be found in table s3 in supplementary materials). attitudes towards mental health interventions 8 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ table 3 median and mean scores of the extent to which treatment options are expected to meet expectations on each dimension dimension self-help book digital intervention blended counseling face-to-face counseling mdn m (sd) mdn m (sd) mdn m (sd) mdn m (sd) helps with the problem 5 4.38 (1.492) 5 5.00 (1.348) 6 6.01 (1.017) 7 6.47 (0.732) includes personal support 2 2.85 (1.692) 5 4.63 (1.573) 6 6.05 (1.084) 7 6.41 (0.930) accessible at convenient location 6 5.63 (1.466) 6 5.78 (1.282) 6 5.62 (1.211) 5 5.25 (1.331) accessible at appropriate time 7 6.11 (1.331) 6 5.85 (1.216) 6 5.54 (1.187) 5 4.64 (1.627) can be consulted anonymously 7 6.12 (1.306) 6 5.69 (1.437) 4 4.08 (1.815) 4 3.57 (1.930) free of charge 4 3.47 (1.736) 5 5.12 (1.481) 4 3.94 (1.541) 3 3.36 (1.725) motivates to get better 5 4.73 (1.537) 5 4.88 (1.425) 6 5.92 (1.027) 6 6.33 (0.788) connects to own learning preferences 4 4.04 (1.631) 5 4.63 (1.524) 6 5.40 (1.237) 6 5.82 (1.062) provides feedback 2 2.87 (1.746) 5 5.00 (1.372) 6 5.82 (1.077) 6 6.09 (0.969) attractive/ appeals to me 4 4.03 (1.849) 5 4.44 (1.602) 5 5.08 (1.400) 6 5.50 (1.269) credible 5 4.62 (1.650) 5 4.81 (1.474) 6 5.77 (1.156) 6 6.33 (0.765) accessible without waiting 7 6.21 (1.352) 6 5.75 (1.316) 5 5.05 (1.450) 4 3.98 (1.868) several dimensions relate to the content of the intervention, namely helping with the problem, motivating to get better, including personal support, providing feedback, connecting to one’s own learning preferences, attractiveness, and credibility. pairwise comparisons were significant for helpfulness, where face-to-face was rated highest, fol­ lowed by blended interventions, digital interventions, and self-help books. for personal support, face-to-face and blended interventions were rated similarly and higher than digital interventions. self-help books were again rated least favorably. pairwise compar­ isons for the motivational nature of the interventions showed the highest ratings for face-to-face, followed by blended interventions, with digital interventions and self-help books sharing the third rank. face-to-face interventions connected most to learning preferences, followed by blended interventions, digital interventions, and self-help books (all pairwise comparisons were significant). in terms of including feedback, face-to-face and blended interventions were rated similarly and higher than digital interventions, followed by self-help books. in terms of appeal, face-to-face and blended interventions shared the first rank, followed by digital interventions and self-help books sharing the second rank. the most credible intervention option is face-to-face, followed by blended interventions, and finally digital interventions and self-help books (which shared the third rank). other dimensions are linked to implementation and practical considerations, specif­ ically waiting time, accessibility at an appropriate time or location, anonymous consul­ tation, and perceived affordability. pairwise comparisons for the convenient location dimension showed higher ratings for self-help books and digital interventions compared de witte, buelens, apolinário-hagen, & van daele 9 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ to face-to-face counseling. all pairwise comparisons, apart from blended counseling vs. digital interventions, were significant for the convenient time dimension and showed the best ratings for self-help books, followed by both digital and blended interventions, with the lowest rating for face-to-face interventions. for anonymity, both self-help books and digital interventions were rated highest (and did not differ significantly from one another), followed by blended and face-to-face interventions (which also did not differ significantly). in terms of being free of charge, pairwise comparisons showed the highest ratings for digital interventions, followed by blended interventions, and finally self-help books and face-to-face interventions (the latter two did not differ significantly). pairwise comparisons for waiting time were all significant and indicated the following order: selfhelp books, digital interventions, blended interventions, and face-to-face interventions. taken together, face-to-face counseling and self-help books generally showed oppo­ site patterns in terms of favorable dimensions. face-to-face counseling met the partici­ pants’ needs (i.e., was rated higher than 4) regarding helpfulness, motivation, credibility, figure 1 spider diagrams combining importance and expectations ratings for the four modalities attitudes towards mental health interventions 10 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ including feedback, personal support, convenient location, appeal, and learning prefer­ ences. for affordability, anonymity, and (to a lesser extent) waiting time expectations were not met. self-help books were rated very favorably on anonymity, waiting time, accessibility at a convenient time and location. however, they showed the least favorable ratings for many other dimensions and did not meet the needs for feedback, personal support, and being free of charge. similar to face-to-face counseling, blended counseling met the participants’ needs for helpfulness, motivation, credibility, including feedback, personal support, convenient location, appeal, and learning preferences (although faceto-face counseling was rated higher for helpfulness, motivation, learning, and credibil­ ity). the scores for waiting time, convenient time, and affordability were better for blended counseling as compared to face-to-face counseling. digital interventions were also rated positively on these latter criteria, but had a lower score than blended or face-to-face interventions for helpfulness, motivation, credibility, including feedback, personal support, appeal, and learning preferences. self-reported likelihood of use there were significant differences in self-reported likelihood of use between the inter­ vention modalities, χ2(3) < 239.55, p < .001. pairwise comparisons showed that partici­ pants were most likely to consider face-to-face counseling, followed by blended counsel­ ing and a shared third rank for digital interventions and self-help books (figure 2). exploration of the data did suggest substantial individual differences in self-reported likelihood of use for the intervention modalities (see also table s4 in supplementary materials). when comparing individuals with current or past mental health problems (n = 152) with individuals without lived experience (n = 63), a couple of differences stand out. a larger proportion of individuals with lived experience indicate a higher likelihood of using face to face counseling (mdn = 5; m = 4.54, sd = 0.76) as compared to those without lived experience (mdn = 4; m = 4.16, sd = 0.90), u = 3535.00, p < .001. for digital interventions on the other hand, individuals with lived experience indicate a lower likelihood of use (mdn = 3; m = 2.71; sd = 1.18) as compared to individuals without lived experience (mdn = 3; m = 3.13; sd = 1.10), u = 5772, p = .01. there are no significant differences for self-help books, u = 4516.00, p = .50, or blended counseling based on lived experience, u = 5172.00, p = .32. de witte, buelens, apolinário-hagen, & van daele 11 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ figure 2 likelihood of using an intervention modality on a scale of 0 (very unlikely) to 5 (very likely) discussion digital interventions are supported by a growing evidence base and can increasingly become part of accessible and personalized mental healthcare services. it is important to understand how individuals view different intervention options and what their preferen­ ces are. the findings of musiat et al. in 2014 indicated that face-to-face interventions were expected to perform well in terms of helpfulness, personal support, credibility, motiva­ tional aspects, suiting learning preferences, including feedback, appeal, and credibility. books, websites, and apps performed well in terms of convenient location and time, anonymity, and no waiting time but were rated poorly on all other dimensions. this also resulted in the highest self-reported likelihood of using face-to-face interventions, fol­ lowed by self-help books and web-based interventions. smartphone applications showed the lowest likelihood of use. the current study also found relevant differences between face-to-face counseling, blended counseling, digital interventions, and self-help books across twelve evaluation dimensions. participants indicated that they were most likely to use face-to-face interventions, followed by blended counseling. the results showed that digital and on-paper self-help options were not preferred by the participants. attitudes towards mental health interventions 12 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ the ratings of the twelve evaluation dimensions for mental health interventions showed that helpfulness, personal support, motivation and credibility were deemed very important for intervention selection. the importance of helpfulness aligns with the concept of performance expectancy in the utaut model, which has been identified as the strongest predictor of technology use (venkatesh et al., 2003). being free of charge showed to be least important according to the participants. overall, the importance of these dimensions resembles the findings of musiat et al. (2014). a discrete choice experiment, which forces respondents to make trade-offs, could provide further insights regarding the importance of dimensions. phillips et al. (2021) already implemented such a design with six attributes (introductory training, human contact, peer support, proven effectiveness, mode of content delivery, and costs) in germany. in line with our study, they also observed that personal contact with a psychotherapist in blended care and proven effectiveness were highly valued by participants. however, in contrast to our findings, low price was also deemed important. these dimensions inform on what potential users experience as strengths and limita­ tions of a certain modality and can therefore help researchers, developers and professio­ nals in improving intervention design and enabling informed decision making. to give an example, digital interventions and books do not meet the needs regarding credibility, which implies that implementation can benefit from promoting system credibility in clients, e.g. by relying on the principles of persuasive theory (fogg, 2002). strategies (e.g., for raising awareness) should be designed to facilitate informed decision making, ideally participatively with the target groups based on needs and preferences. for instance, vomhof et al. (2024) showed that medical students found that timing of information (early in their studies) was the most important attribute of an information strategy (more than recommendations or media channels). other dimensions might also be relevant for intervention design and predicting intervention acceptance. pretorius et al. (2019) have suggested that a sense of control over a help-seeking journey and self-reliance might be a motivation for online help-seek­ ing. sense of control might therefore be an additional dimension that could determine preferences for intervention modality and could be interesting for further research. stigma or the fear for reactions from others could also influence the help-seeking process (rowe et al., 2014). digital health literacy and mental health literacy, as well as previous (online or real-life) help-seeking behavior and experience, can also impact intervention selection. for blended interventions, clinician’s attitudes towards new interventions and technologies will also influence patient attitudes and subsequent use (cohen et al., 2024). future research should assess which dimensions most strongly predict likelihood of use and actual use of different intervention modalities. also similar to musiat et al. (2014), there was a clear difference in which dimensions were rated positively for face-to-face counseling and self-help books. face-to-face coun­ seling was evaluated very favorably for the dimensions linked to the content of the de witte, buelens, apolinário-hagen, & van daele 13 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ intervention (e.g., helpfulness, motivation, credibility and personal support), but showed practical limitations (i.e. cost, anonymity and waiting time). on the other hand, self-help books were rated most favorably for many practical circumstances but showed the least favorable ratings for many other dimensions. as compared to self-help books, digital interventions were expected to be significantly more helpful, to include more personal support, to connect to one’s learning preferences better, and to include more feedback. this differs from the original study, where digital self-help options (apps and websites) were rated more similar to self-help books. it also differs from de jesús-romero et al. (2022) who compared willingness to use self-help books and smartphone applications and found a small preference for self-help books. the study suggested that this prefer­ ence was influenced by participant education level, perceived availability, and perceived helpfulness of the intervention. a new category consisted of blended counseling, which was rated fairly similar to face-to-face counseling although self-reported likelihood of use was significantly higher for face-to-face as compared to blended counseling. blended counseling received a better rating than face-to-face counseling for waiting time, convenient time, and affordability. however, face-to-face counseling outperformed blended counseling in three top-rated dimensions, i.e., it was expected to be more helpful, motivational, credible, which could contribute to a high likelihood of use. the relevance of and preference for face-to-face contact was also documented in a general population (phillips et al., 2021) and student sample (kählke et al., 2024) in germany and could be linked to the way participants are used to receiving mental healthcare (in europe) and a potential resulting (lack of) con­ crete understanding of blended care. additionally, some external factors could contribute to a lack of (intended) use of technology-enhanced mental healthcare, as shown by butz et al. (2022) who point to factors such as technical or reimbursement issues. a substantial number of respondents experienced current (29%) or past (36%) mental health problems. exploratory analyses showed that these individuals indicated a higher likelihood of using face-to-face counseling as compared to those without lived experi­ ence (although only one individual had actual experience with this modality). individuals with lived experience indicated a lower likelihood of using digital interventions than those without mental health problems. this appears to contrast with the findings in the review by borghouts et al. (2021) which found higher willingness to use digital mental health when symptoms were more severe. however, this review also observed that certain mental health symptoms (e.g., depressive symptoms) can reduce motivation or ability to interact with interventions and severe symptoms can impede actual inter­ vention engagement (borghouts et al., 2021). to be able to compare views regarding different delivery modalities, we needed to make abstractions from specific interventions and provide a general description of what a certain modality could look like. therefore, opinions and preferences were formulated in the context of a (rather abstract) mental health delivery modality while acceptance attitudes towards mental health interventions 14 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ is not a unitary concept. when presenting more concrete interventions (and according intensities and target populations), other preferences might arise. the specific wording used in the descriptions could also impact credibility and other ratings. the current study did not differentiate between guided and unguided digital interventions. other studies which provided more concrete and tailored information about blended interven­ tions have obtained more encouraging findings regarding the acceptability of blended treatment for first-episode psychosis (valentine et al., 2020) or depression and anxiety (braun et al., 2023). it is a limitation that the current study consisted of a sample which is quite young and has very little experience with mental health services despite the relatively large number of individuals with current or past mental health problems. the study combined students and individuals from the general population and we observed differences in gender and tablet use, which is in line with statistics on technology use in flanders (northern belgium) showing elevated tablet use in adults as compared to emerging adults (de marez et al., 2025). the current study gathered data on the self-reported likelihood of using a certain modality, in line with the ‘intention to use’ concept as framed in theories such as the utaut or the technology acceptance model (tam; venkatesh et al., 2003). while it is an extensively investigated construct (e.g., wei et al., 2024), a gap between intention and behavior has been documented in these theories. measuring actual use of (self-help) services in a general sample is challenging and requires a longitudinal panel study. further adding to the complexity of assessing this concept, mere exposure to information in a questionnaire could already result in changed behavior, e.g., registration for mental health programs (apolinário-hagen et al., 2023). factors contributing to intervention selection were rated using likert scales, which is an approach relying heavily on self-reflection while participants might not always have full insight into one's own decision-making processes. future research can benefit from going beyond the questionnaire format and could implement (1) qualitative data collection to collect more in-depth information about why certain dimensions are deemed important or why certain modalities are preferred; or (2) discrete choice experi­ ments based on the current and potential additional intervention dimensions, which force respondents to make trade-offs between different features and are less sensitive to bias (e.g., based on social desirability and lacking experience). investigating perceptions of more concrete interventions (e.g., a guided self-help website for depression) or new technologies (e.g., chatbots) could also be interesting ways to extend the current work. conclusion taken together, the current study suggests that mere self-help (online or on paper) is not expected to sufficiently meet the needs and is not the preferred choice for handling mental health problems for most individuals. however, participants did show positive views towards digital resources, and a subgroup would likely use the digital and self-help options. if presented with the choice, individuals still prefer face-to-face counseling. de witte, buelens, apolinário-hagen, & van daele 15 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ nevertheless, our and related work identify blended interventions as a promising treat­ ment option for the future. informing patients about the available options, underlying mechanisms, and potential added values – a practice shown to increase acceptance in the past (ebert et al., 2019; linardon et al., 2022) – remains a meaningful strategy, as does tailoring interventions to patient preferences and needs (van daele et al., 2020). while the evidence base and technology for digital mental health services is largely there, it is important to document patient expectations and resulting acceptance. funding: this research received no specific grant from any funding agency, commercial or not-for-profit sectors. acknowledgments: we would like to thank gwenn peeters, louise smits, margot mandeville, maxence jacobs, pär sorgeloose, and tayla breuls for their help with the data collection. competing interests: the authors have declared that no competing interests exist. ethics statement: the study was approved by the ethical committee of thomas more university of applied sciences (ectp2324_03). all subjects gave written informed consent in accordance with the declaration of helsinki (2013). preregistration: the study was not preregistered. reporting guidelines: this article is written according to the jars-quant guidelines. social media accounts: nele a. j. de witte: linkedin, fien buelens: linkedin, jennifer apolinário-hagen: linkedin, tom van daele: linkedin data availability: the data that support the findings of this study are available from the corresponding author, [ndw], upon reasonable request. supplementary materials the supplementary materials contain additional graphs supporting the findings in the publication, including sample demographics and test results (see de witte et al., 2025s). index of supplementary materials de witte, n. a. j., buelens, f., apolinário-hagen, j., & van daele, t. (2025s). supplementary materials to "attitudes and expectations towards mental health interventions in the general population: comparing face-to-face counseling, blended counseling, and digital or on-paper selfhelp" [additional information]. psychopen gold. https://doi.org/10.23668/psycharchives.21309 attitudes towards mental health interventions 16 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.linkedin.com/in/nele-de-witte/ https://www.linkedin.com/in/fienbuelens/ https://www.linkedin.com/in/pd-dr-jennifer-apolin%c3%a1rio-hagen-686198ab/ https://www.linkedin.com/in/vandaeletom/ https://doi.org/10.23668/psycharchives.21309 https://www.psychopen.eu/ references andrade, l. h., alonso, j., mneimneh, z., wells, j. e., al-hamzawi, a., borges, g., bromet, e., bruffaerts, r., de girolamo, g., de graaf, r., florescu, s., gureje, o., hinkov, h. r., hu, c., huang, y., hwang, i., jin, r., karam, e. g., kovess-masfety, v., … kessler, r. c. 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(2025). facilitators and barriers to digital mental health interventions for depression, anxiety, and stress in adolescents and young adults: scoping review. journal of medical internet research, 27, article e62870. https://doi.org/10.2196/62870 attitudes towards mental health interventions 20 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://doi.org/10.1016/j.jval.2020.09.018 https://doi.org/10.2196/13873 https://doi.org/10.1177/0004867414555718 https://doi.org/10.3389/fpsyt.2022.898009 https://doi.org/10.1016/j.invent.2018.01.002 https://doi.org/10.2196/18990 https://doi.org/10.1037/int0000218 https://doi.org/10.2307/30036540 https://doi.org/10.2196/55921 https://doi.org/10.1080/07359683.2024.2316425 https://doi.org/10.2196/62870 https://www.psychopen.eu/ clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service provided by the leibniz institute for psychology (zpid), germany. de witte, buelens, apolinário-hagen, & van daele 21 clinical psychology in europe 2025, vol. 7(4), article e16235 https://doi.org/10.32872/cpe.16235 https://www.psychopen.eu/ attitudes towards mental health interventions (introduction) method participants questionnaire analysis results sample importance of the 12 dimensions expectations regarding the four modalities self-reported likelihood of use discussion conclusion (additional information) funding acknowledgments competing interests ethics statement preregistration reporting guidelines social media accounts data availability supplementary materials references a journey through time – study protocol for a randomized controlled trial testing the add-on effects of imagery rescripting to ongoing cognitive behavioural therapy in patients with depressive disorders research articles a journey through time – study protocol for a randomized controlled trial testing the add-on effects of imagery rescripting to ongoing cognitive behavioural therapy in patients with depressive disorders amelie endres 1 , anja schaich 2 , arnoud arntz 3 , eva fassbinder 4 , fritz renner 1 [1] department of clinical psychology and psychotherapy, institute of psychology, university of freiburg, freiburg, germany. [2] department of psychiatry and psychotherapy, university of lübeck, lübeck, germany. [3] department of clinical psychology, university of amsterdam, amsterdam, the netherlands. [4] clinic for psychiatry, university of kiel, kiel, germany. clinical psychology in europe, 2025, vol. 7(4), article e16709, https://doi.org/10.32872/cpe.16709 received: 2025-01-20 • accepted: 2025-07-18 • published (vor): 2025-11-28 handling editor: nadine messerli-burgy, university of lausanne, lausanne, switzerland corresponding author: amelie endres, clinical psychology and psychotherapy unit, institute of psychology, university of freiburg, engelbergerstr. 41, 79106, freiburg, germany. e-mail: amelie.endres@psychologie.unifreiburg.de supplementary materials: preregistration [see index of supplementary materials] abstract background: patients with depression often report recurring memories of stressful events from the past (e.g. experiences of rejection, emotional or physical abuse). these distressing memories, commonly dating back to childhood, can contribute to the development and maintenance of depression through their impact on cognitive schemas. the method of imagery rescripting (imrs) addresses distressing memories and the associated emotions directly: with therapeutic support, patients recall the respective memory and modify the memory during imagination in such a way that the emotional quality and meaning of the memory changes. in this randomized trial, we will assess the impact of a three-session imrs intervention within standard cognitive behaviour therapy (cbt) for depression, comparing it to an active control intervention (imagery relaxation). method: sixty-six patients with mdd who are currently receiving treatment (cbt) will be randomized to either (1) the experimental condition (imrs) or (2) the control condition (imagery this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.16709&domain=pdf&date_stamp=2025-11-28 https://orcid.org/0009-0009-1586-2686 https://orcid.org/0000-0002-7398-8756 https://orcid.org/0000-0002-7992-2272 https://orcid.org/0000-0003-3017-4514 https://orcid.org/0000-0002-1692-449x https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ relaxation). reduction of depressive symptoms, measured by the beck depression inventory (bdiii) is the primary outcome. the bdi-ii will be assessed at baseline, post-intervention, and at 4-week and 8-week follow-ups. discussion: this study will help to clarify whether adding three imrs sessions improves the effectiveness of cbt for depression. we outline the next steps for future research and highlight the potential of this novel intervention for depression. keywords imagery rescripting, major depressive disorder (mdd), distressing memories highlights • most patients with depression report distressing memories, making them a key treatment target. • imagery rescripting (imrs) may enhance cbt by reducing negative emotions tied to distressing memories. • this rct tests imrs as an add-on to cbt for depression. depression, characterized by low mood and diminished interest in previously reward­ ing activities, is a pervasive mood disorder and a global health concern (american psychiatric association, 2013; ferrari et al., 2013; james et al., 2018; whiteford et al., 2013). despite the effectiveness of established psychological treatments like cognitive behavioural therapy (cbt; beck, 1970) in alleviating depressive symptoms, approxi­ mately 40% of patients do not respond adequately, underscoring the need for innovative interventions (cuijpers et al., 2021; zhdanava et al., 2021). the gap between the number of patients in treatment and treatment success points to the importance of further improving the treatment of depression. a crucial aspect often overlooked in current psychological treatments is the presence of distressing memories, reported by about 80% of depressed patients (brewin et al., 1996; newby & moulds, 2011a; payne et al., 2019). these memories, even in the absence of traumatic events, predict depressive symptoms and persist to trouble patients who have recovered from depression (buckman et al., 2018; kuzminskaite et al., 2022; nelson et al., 2017; newby & moulds, 2011b; payne et al., 2019). thus, distressing memories are not only common in depression but could also be a significant treatment target. distressing memories are associated with unpleasant emotions such as sadness, shame, fear, or anger. while traditional cbt addresses cognitive and behavioural aspects of emo­ tional problems, recent psychotherapy research underscores the importance of bringing the patient’s emotions into focus (greenberg, 2010, 2017; peluso & freund, 2018). one technique to address both the distressing memories and the associated negative emotions is imagery rescripting (imrs; arntz & weertman, 1999). imrs, a therapeutic technique integrated into therapeutic approaches or used as a standalone intervention (kip et imagery rescripting in cbt for depression 2 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ al., 2023), addresses distressing memories in a two-step process (arntz & weertman, 1999). first, the individual vividly imagines the distressing memory, engaging various sensory modalities and experiencing the connected emotions. in the second step, the sequence of events is imaginatively transformed into a more desirable direction. this is achieved through the introduction of a supportive figure – such as the therapist or the patient’s adult self – who addresses the individual’s emotional needs. imrs does not alter original memory content but aims to reduce the memory’s emotional meaning and emotional impact (aleksic et al., 2024; arntz, 2012; arntz & weertman, 1999). arntz (2012) hypothesizes that the central mechanism of change in imrs is the modification of maladaptive schemas, with emotional changes occurring as a by-product of this process. this perspective emphasizes the cognitive restructuring aspect of imrs, where the reimagining of events leads to a shift in underlying belief systems, subsequently influencing emotional responses. experimental research supports the idea that mental imagery has a profound impact on emotion (holmes et al., 2008, 2009; ji et al., 2016) and that imrs reduces negative emotions and distress associated with negative memories (çili & stopa, 2021; nilsson et al., 2012; reimer & moscovitch, 2015; strohm et al., 2021). the positive impact of imrs on negative emotions as well as on the distressing memories seems promising for the treatment of depression. despite its early recognition in cbt (beck, 1970), the clinical applications of mental imagery within a cbt framework were relatively under-researched until recently, with pilot studies of imrs as standalone interventions for depression demonstrating signifi­ cant effects on symptom severity (brewin et al., 2009; ma & lo, 2022; pile et al., 2021; renner & holmes, 2018). additionally, research has shown that engaging in mental imagery of future positive events can increase behavioural activation in individuals with major depressive disorder, further highlighting the potential of imagery-based interven­ tions in depression treatment (renner et al., 2017). meta-analyses by kip et al. (2023) and by kroener et al. (2023) have further supported the efficacy of imrs in treating various mental disorders associated with aversive memories, including depression, revealing large pre-post effect sizes across different disorders and highlighting its potential as a transdiagnostic intervention. building on this evidence, a recent controlled pilot study by kanczok et al. (2024) investigated the combined use of cognitive restructuring (cr) and imrs compared to treatment as usual among inpatients with moderate and severe depression. the study found that patients in the intervention group (receiving cr and imrs) achieved significantly greater improvements in depressive symptoms over time compared to the treatment-as-usual group. while these findings are promising, further research is needed to investigate the specific additional effect of using imrs during regular cognitive behavioural therapy, particularly in outpatient settings and with larger sample sizes. in addition to the open research questions regarding the extent to which imrs affects depressive symptoms, there is also a lack of evidence regarding the potential endres, schaich, arntz et al. 3 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ mechanisms that play a role in imrs. studies have shown some evidence for different potential mechanisms on a cognitive level that might be responsible for the effect of imrs: one aspect that several studies point out is the positive impact of imrs on different aspects of a person’s self-representation (lee & kwon, 2013; wild et al., 2008), self-belief (cooper, 2011) and self-esteem (çili et al., 2017). there are study results that indicate that the negative core beliefs associated with the distressing memories reduce in subjects treated with imrs (reimer & moscovitch, 2015). mancini and mancini (2018) suggest that the effect of imrs is based on a reduction of the ‘meta-emotional problem’, which is linked to a better acceptance of the negative emotions associated with the distressing memories. in the treatment of posttraumatic stress disorder (ptsd) related to traumas experienced in childhood, changes in strengths of encapsulated beliefs and distress of the index trauma preceded changes of ptsd-severity in imrs (rameckers et al., 2024), supporting the theory that change in emotional meaning of the memory underlies the effects of imrs. assmann et al. (2024) investigated the role of cognitions in the treatment of childhood-related ptsd using imrs. their study found that changes in trauma-related cognitions significantly mediated the relationship between imrs and reductions in ptsd symptoms. these results highlight the critical role of cognitive processes in the effective­ ness of imrs and suggest that targeting maladaptive cognitions may be a key mechanism through which imrs facilitates therapeutic change in ptsd. further research is needed on the effects of imrs on different aspects of cognition and emotion as well as on the ‘meta-emotional problem’. current research points to the problem that the effect of imrs on depression has not been tested sufficiently in studies yet, especially not as an adjunct to regular cognitive behavioural therapy. furthermore, the mechanisms of action of imrs for depression remain unclear. this randomized controlled trial aims to expand the research on imrs in depression. the primary objective is to evaluate the effectiveness of imrs as an add-on to standard cbt for major depressive disorder (mdd). patients receiving cbt in routine care are randomized to receive either three sessions of imrs or an active control condition (imagery relaxation). we hypothesize that participants in the imrs condition will show greater reductions in depressive symptoms from pre-intervention to post-intervention and follow-up. although imrs may be applicable across a range of disorders (kip et al., 2023), we chose to focus specifically on depression in the present study for several reasons: first, the high prevalence of distressing memories among individuals with depression suggests a particularly strong clinical relevance of imrs in this context (brewin et al., 1996; newby & moulds, 2011a; payne et al., 2019). second, existing studies have primarily evaluated imrs as a standalone intervention; its potential additive effect when embedded within standard cbt for depression remains largely unexplored. third, depression continues to be among the most prevalent and burdensome mental health conditions, underlining the need for innovative adjunctive treatments. given these considerations, we see depression as a particularly meaningful imagery rescripting in cbt for depression 4 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ starting point for examining the clinical utility of imrs. importantly, comorbidities are not excluded in our study, reflecting the complex presentations often encountered in routine clinical practice. secondary objectives of this trial include examining changes in associated psychological variables (e.g., repetitive negative thinking, emotional capa­ bilities, self-compassion, self-esteem). in addition, exploratory analyses will investigate potential mechanisms underlying the effects of imrs. method design the study is a two-arm randomized controlled trial with one active intervention con­ dition (imagery rescripting, imrs) and one active control condition (imagery relaxa­ tion). participants in both conditions are invited to complete questionnaires at base­ line session (session 1), weeks 1-3 after baseline (intervention sessions 1-3) and at post and follow-up 1 and 2 (week 1, 4 and 8 after the last session). the medical ethics committee of the university of freiburg has approved the study (approval num­ ber: 22-1518-s2). the study is pre-registered at the german clinical trials register https://drks.de/search/de/trial/drks00031495. participants inclusion criteria are (a) meeting the diagnostic criteria for a current major depressive disorder (mdd), as assessed with a scid-5-cv interview (patients with comorbid disor­ ders are eligible to participate), (b) age 18 years or older, (c) sufficient proficiency of german language to complete questionnaires. patients are excluded from participation if they are at high risk of suicidality, defined as the presence of acute suicidal ideation with concrete plans or intent. this is assessed during the standard intake procedure at the outpatient clinic where the study is conducted. diagnostic information is based on the initial clinical interview (scid) conducted by the therapist at the outpatient clinic; no additional study-specific diagnostic assessment will be conducted. participants are informed about the study at the beginning of their treatment but may enrol at any point during their ongoing cbt. the number of standard cbt sessions completed at study entry will be documented and reported. it is important to note that cbt is delivered as part of routine care in the outpatient clinic and is not part of the experimental study protocol. no efforts are made to standardize or influence the content, structure, or dose of the ongoing cbt. however, information on the number of cbt sessions and the use of imagery techniques during therapy will be collected post-hoc via therapist questionnaires. endres, schaich, arntz et al. 5 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://drks.de/search/de/trial/drks00031495 https://www.psychopen.eu/ sample size previous research has demonstrated the effectiveness of imagery rescripting (imrs) in treating various mental disorders, with large effect sizes reported when compared to in­ active control conditions (morina et al., 2017). ma and lo (2022) conducted a randomized controlled trial comparing imrs to cognitive restructuring (cr) in depression treatment. their findings revealed that both imrs and cr led to significant reductions in depressive symptoms, with medium to large effect sizes observed. in the present study, we aim to build on these findings by comparing imrs to an active control condition (relaxation) in the context of ongoing cognitive behavioural therapy (cbt) for depression. since both study arms receive standard cbt and the control condition is active rather than passive, we expect smaller between-group differences than in previous trials. specifically, we anticipate moderate differences in the reduction of depressive symptoms between the two interventions. to determine the required sample size, we conducted a simulationbased power analysis using the simr package in r. the analysis was based on a linear mixed-effects model that reflects the longitudinal structure of the study, including four repeated measurement points and a random intercept for each participant. assuming a moderate group × time interaction effect (β = 0.25) at the final follow-up (fu2), the simulation indicated that a total sample size of approximately 60–70 participants would yield a statistical power of 85–90%. to account for potential dropouts while keeping the study feasible in terms of recruitment and implementation effort, we planned a total sample size of 66 participants with equal allocation to both conditions. this sample size is expected to be sufficient to detect moderate effects over time. recruitment eligible potential participants will receive written study information from their therapist in the outpatient clinic. if they are interested in participating, they are asked to return a consent form to their therapist, giving permission to be contacted by the research team. a member of the research team will then contact the patient to discuss the study, clarify any questions and see if the patient is interested in participating in the study. if interested, an appointment for the initial session (introductory session) will be scheduled. informed consent for study participation will be signed at the introductory session. therapists study therapists will be four graduated psychologists in an advanced stage of clinical training to become fully licensed psychotherapists who are working at the outpatient treatment center of the university of freiburg. before the start of the study, study thera­ pists received 15 hours of training in the imrs procedure by arnoud arntz and training imagery rescripting in cbt for depression 6 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ in the imagery relaxation procedure by fritz renner. clinical supervision meetings are planned on a regular basis throughout the study. introduction session (baseline) prior to the start of the study’s therapeutic intervention, participants will complete an online baseline assessment. subsequently, an initial 60-minute introductory session will be scheduled with each participant. in the introductory session, the participants will get to know their study therapist and distressing memories will be identified using a semi-structured interview based on the work of previous studies (ma & lo, 2022; patel et al., 2007). there will be no restriction on the timeframe where the memory originated as previous work suggests that imrs can effectively be applied to “older” childhood memories as well as more recent memories. participants will be asked to recall three distressing memories and will be asked about the content of each memory, their age at the time when the event occurred and the context in which the event occurred. core beliefs associated with the memory will be assessed by using a standardized protocol. the specific emotions and the current distress caused by the core beliefs will be assessed as well. randomization after the introduction session, patients will be randomized into one of the two condi­ tions using a computer script performing block randomization (1:1, block size = 6). randomization will be done by a researcher who is not involved in the study sessions. after the randomization, the patients will be sent a video explanation in which their study therapist explains what is going to happen in the respective condition. to ensure consistency and standardization in how each condition is introduced, participants receive a brief video following randomization in which their assigned study therapist explains the rationale, structure, and expectations of the respective intervention. these videos aim to enhance transparency, facilitate engagement, and reduce time needed for explanation during the first session, thereby allowing more time for therapeutic work. duration of the study the three intervention sessions will take place weekly so the duration of the study therapy sessions will extend over four weeks (see figure 1). eight weeks after the last study therapy session, the last follow-up measurement will take place (online). longer follow-up intervals (e.g., at three or six months) were not implemented in this trial due to feasibility constraints and methodological considerations. since participants continue to receive non-standardized cbt throughout and beyond the follow-up period, longer intervals would likely introduce greater variability in treatment exposure, making it more difficult to attribute outcomes specifically to the experimental intervention. shorter endres, schaich, arntz et al. 7 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ follow-up intervals were therefore chosen to maintain a clearer link between the exper­ imental intervention and outcome assessments. the duration of the sessions in both experimental and control conditions is comparable (60 – 90 minutes) to control for time and therapist contact. the study procedure is also presented in figure 1. participants who take part in all sessions of the study will receive €50 as compensation for their time investments. measures primary outcome changes in depressive symptom severity, assessed by the beck depression inventory-ii (bdi-ii; beck et al., 1996) will be the primary outcome. the bdi-ii is a 21-item self-report instrument assessing depressive symptoms. the items are rated from 0 to 3, with 3 for the most depressed mood. a score 0 – 13 indicates minimal depression, 14 – 19 mild depression, 20 – 28 moderate depression and 29 – 63 severe depression. the bdi-ii will be measured before randomization (baseline), one week after the last session (post-inter­ vention) and 4 weeks and 8 weeks after the last session (follow-up). the bdi-ii was chosen as the primary outcome due to its strong psychometric properties, sensitivity to change, and feasibility for repeated online assessments, thereby minimizing participant burden and facilitating efficient data collection. secondary outcomes we will use the following measures at every measurement (before randomization (base­ line), just prior to every session, one week after the last session (post-intervention) and four weeks and eight weeks after the last session (follow-up 1 and 2)): depressive symp­ tom severity, measured by the depression module of the patient health questionnaire (phq-9; kroenke et al., 2001); rating (0 – 100) of the belief that the core beliefs captured in the baseline session are true; rating (0 – 100) of the emotions that are associated with the memories and core beliefs captured in the baseline session; rating (0 – 100) of the burden of the memories for the patient. the phq-9 was included alongside the bdi-ii to allow for convergent validation of depressive symptom trajectories. in addition, due to its brevity and ease of administration, the phq-9 is used at each study session, making it possible to assess depressive symptoms at more frequent time points than with the bdi-ii. this enables a more fine-grained analysis of symptom changes across the intervention period. the following measures will be administered before randomization (baseline), one week after the last session (post-intervention) and four weeks and eight weeks after the last session (follow-up 1 and 2): repetitive negative thinking, measured by the persev­ erative thinking questionnaire (ptq; ehring et al., 2011); emotional capabilities, meas­ ured by the self-assessment of emotional capabilities (sek-27; berking & znoj, 2008); self-compassion, measured by the short version of the german self-compassion scale imagery rescripting in cbt for depression 8 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ figure 1 study procedure endres, schaich, arntz et al. 9 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ (svs-sv; hupfeld & ruffieux, 2011); self-efficacy, measured by the german global selfefficacy expectancy scale (swe; jerusalem & schwarzer, 1999); beliefs about emotions, measured by the german version of the emotion beliefs questionnaire (ebq; grüning et al., 2021); self-esteem, measured by the german version of the rosenberg self-esteem scale (rses; von collani & herzberg, 2003). at post-intervention, we will measure satisfaction with treatment, measured by the german patient satisfaction questionnaire (zuf-8; schmidt et al., 1989) adapted for the study as well as the working alliance between patient and study therapist, measured by the working alliance inventory (wai; wilmers et al., 2008). at the post-intervention assessment, the patients will also be asked in an open-response format, to what extent they think they have benefited from the study. additional measures to evaluate possible confounding variables, the following constructs are measured: childhood trauma, measured by the childhood trauma questionnaire (ctq; bernstein & fink, 1998), which will be administered during the baseline measurement as imrs interventions were originally developed for intrusive memories following traumatic events; time of intervention: time interval (in days) between the participants’ regular cbt session and the study therapy session for each of the three intervention sessions; comorbid disorders, as measured with the scid-5-cv interview at the outpatient clinic before the start of the study; therapeutic techniques used in patients’ routine therapy, as well as the amount of regular therapy sessions received during the study period, will be recorded via a ques­ tionnaire sent to the treating therapists at the outpatient clinic after the patient has completed the final follow-up assessment (fu2). the cbt conducted alongside the study intervention is part of routine clinical care and not part of the study protocol. it follows a naturalistic format without a standardized manual, predefined number of sessions, or fixed structure. consequently, the dose and content of cbt may vary between participants. to monitor potential overlap with imagery-based methods, the therapist questionnaire includes items assessing whether, and to what extent, imagery techniques or imagery rescripting were used during the course of therapy. manipulation check to check if patients in both conditions engaged in mental imagery, they will be asked to note how vivid the imagery was: after each imagery exercise in the imrs condition, the patient will be asked to note how vivid the imagery of the respective situation was on a scale from 1 (not vivid at all) to 10 (extremely vivid). to check if the session contained any deviations from protocol, the study therapists will be asked to report any deviations from protocol after each session. to ensure that the conditions are executed as intended, all sessions will be recorded on video and evaluated by two independent raters imagery rescripting in cbt for depression 10 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ for adherence to the protocol (adherence scales for both interventions were worked out by the study group). experimental condition: imrs the imrs intervention is based on previous experimental imrs protocols (arntz & weertman, 1999; ma & lo, 2022). the relaxation intervention in the control group is based on standardized relaxation protocols (toussaint et al., 2021). imrs session 1 and 2 during imrs intervention sessions 1 and 2, participants will be asked to choose one of the three distressing memories. then they will be asked to delve into the distressing (childhood) memory in their imagination. they will be asked to give a verbal narrative of the contextual and sensory details of the event by questions as for example “what do you see?”, “what do you hear?” and “who else is there?”, as well as to experience and report the emotions that are activated, to share thoughts that go through their mind, and to express what they emotionally need. when the participants’ emotions are sufficiently activated and the most difficult part of the memory is imagined, the therapist will step into the image and change the outcome to a positive ending. the therapist assists the younger self of the participant in addressing the distressing situation, which may include confronting a perpetrator if present. the therapist helps in defending and supporting the younger self of the patient. the therapist will then take care of all other emotional needs of the younger self, helping to process associated emotions and reduce the emotional distress linked to the event. this may involve introducing a sense of safety or control, and when applicable, confronting any responsible parties. examples of interventions include providing comfort, offering protection, or empowering the younger self. the therapist continues to support the child or younger self of the participant until feeling safe and having all emotional needs satisfied. imrs session 3 during imrs intervention session 3, participants will delve into their remaining (child­ hood) memory in their image and will be again asked to give a verbal narrative of the contextual and sensory details of the event, as well as to share the emotions, thoughts and needs that are activated. at the most difficult moment the patient is instructed to change perspective and imagine to enter the scene as their present adult self and help their younger self. as modelled in the two sessions by the therapist, the adult self should now intervene in the situation. this may involve addressing a perpetrator and taking care of the needs of the younger self. in the final phase, participants will be asked to once again alter their perspective, this time re-entering the scene as their younger self to experience the support and intervention of their adult self. the younger self is also encouraged to request additional interventions as needed. endres, schaich, arntz et al. 11 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ possible variations of the sessions if the participants want to rescript a distressing memory that was not explored in the introductory session, they will be allowed to use that new situation. in that case, the therapist will briefly assess the new memory using the same structure as in the introductory session (content, age, context, core beliefs, emotional impact), ensuring continuity and consistency of the intervention. if participants do not wish or feel able to personally assist their younger selves in the third session, the session can be conducted as in sessions 1 and 2. control condition: mental imagery relaxation condition the intervention in the control condition will be an imagery-based relaxation exercise based on established protocols (toussaint et al., 2021). as in the experimental condition, there will be three experimental sessions lasting between 60 – 90 minutes. guided imagery relaxation is an established technique for stress reduction. its effectiveness in reducing symptoms of depression, anxiety, and stress has been demonstrated in several studies (apóstolo & kolcaba, 2009; beizaee et al., 2018; costa & barnhofer, 2016). the intervention periods in these studies ranged from one week to four weeks, indicating its potential to produce measurable effects within a relatively short time frame. during this intervention positive imagery is used to invoke sensory experiences and physiological responses. participants will be given the choice between different topics (e.g. a beach, a forest, a lake, a sky full of stars). then they will be instructed to sit down in a comfortable manner and to imagine themselves in the scene. the therapist will read out a text about the scenery (e.g. how does the sand under their feet feel). the imagery will be combined with breathing exercises. if time permits participants might complete several relaxation imagery exercises during one session with short intermediate breaks. data analyses to address the longitudinal nature of our data and potential missing values, we will employ a multilevel approach. this method allows us to model individual trajectories of change over time while accounting for between-person differences. the multilevel model will include time as a within-subject factor and condition as a between-subject factor. the interaction effect between time and condition is of main interest, as it will indicate whether the rate of change in depressive symptoms differs between the intervention and control group. all primary analyses will be conducted using an intention-to-treat (itt) approach, including all randomized participants. missing data will be handled using mixed-effects models, which are robust to missingness under the assumption of missing at random. analysis will be conducted in r (r core team, 2025). in case of substantial differences between conditions in demographic or any of the potentially confounding variables listed previously (e.g., number of cbt sessions before intervention), the varia­ imagery rescripting in cbt for depression 12 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ ble(s) will be added as covariates to the model. for the analysis of secondary outcomes (e.g., repetitive negative thinking, emotional capabilities, self-compassion, self-esteem), we will employ a similar multilevel modelling approach. each secondary outcome will be analysed separately, with time and condition as predictors, and the time-by-condition interaction as the primary effect of interest. given the number of secondary outcomes, we will apply a correction for multiple testing to mitigate the risk of type i errors across models. effect sizes will be reported alongside p-values to aid interpretation. results will be treated as exploratory, and full model outputs (including corrected and uncorrected p-values) will be provided in the supplementary material to ensure transparency. this will allow us to examine how these outcomes change over the course of the study and whether these changes differ between the imrs and control conditions. exploratory analyses we will present the drop-out rate alongside descriptive statistics and include qualitative feedback from participants regarding their experiences with the study. to investigate potential mechanisms of the effects of imrs, we will conduct mediation analyses within the multilevel framework. specifically, we will explore whether changes in secondary outcomes mediate the relationship between the intervention condition and changes in depressive symptoms. discussion we presented a study protocol for a randomized controlled trial testing the additional effect of imrs on depressive symptoms in individuals who are already in treatment (cbt). we hypothesized that, compared to an active control condition, the participants receiving imrs would have a greater reduction of depressive symptoms. while there are pilot studies showing significant effects of imrs on depressive symp­ tom severity (brewin et al., 2009; ma & lo, 2022), this study aims to replicate and extend these promising results. importantly, no studies have yet examined the additional effect of imrs during regular cbt for depression. by investigating potential synergistic effects of imrs and cbt, this study could provide valuable insights into enhancing treatment outcomes for depression. if participants in the imrs condition show greater improve­ ments in depressive symptoms, it would suggest a promising avenue for augmenting existing therapies. this is particularly significant given that current treatment options for depression are often insufficient for many patients (cuijpers et al., 2021). another important aspect that this study attempts to clarify is the underlying mechanisms that may be involved in the effect of the imrs technique on depressive symptoms. this study contributes to the research on potential mechanisms by assessing the change of different psychological variables during the course of the study and by analysing exploratorily endres, schaich, arntz et al. 13 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ whether changes in psychological variables mediate the effect of imrs on depressive symptoms. one potential limitation of the study is that the therapists who conduct the experi­ mental interventions of this study are not the same therapists who conduct the ongoing regular cbt. the imrs and relaxation interventions are therefore not integrated into the ongoing treatment. moreover, competence and experience levels of the therapists provid­ ing the ongoing regular cbt varies. while this approach enhances the ecological validity of our research, it introduces an analytical challenge. because many therapists are in­ volved in the regular therapy, and each therapist likely sees only few study participants, we can not effectively account for how individual therapists might influence the results. we do not have enough participants grouped with each therapist to reliably measure the impact that specific therapists might have on the outcomes. one other limitation is that the study is powered to find medium to large effects but is underpowered to find small or medium effects between the two active interventions. furthermore, the effect size assumptions underlying the power calculation may be overestimated, as they are based on studies conducted without concurrent cbt, whereas in the present study, the intervention is delivered in parallel to ongoing psychotherapy. this parallel treatment setting may reduce the observable effect sizes and should be considered when interpret­ ing the results. finally, this study exclusively relies on self-report measures for primary and secondary outcomes. while this approach allows repeated, low-burden assessment, clinician-rated interviews could provide additional information on how many patients meet diagnostic criteria following the intervention. additionally, we acknowledge that some participants might no longer fulfil the criteria for a major depressive disorder diagnosis at the time of study inclusion, despite initially meeting them during screening. this should be considered when interpreting the results, as it may influence the general­ izability and observed treatment effects. overall, we aim to expand the research on innovative interventions for depressive disorders with this study. the results will contribute to a better understanding of the effects of imrs on depression, as well as its potential added value when delivered alongside ongoing cognitive behavioural therapy. given that the primary outcome is assessed before the completion of cbt, interpretations regarding additive effects should be considered exploratory. imagery rescripting in cbt for depression 14 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ funding: this work was supported by the sofja kovalevskaja award from the alexander von humboldt foundation and the german federal ministry for education and research awarded to fritz renner. acknowledgments: the authors would like to thank the participating study therapists and research assistance for their contributions to the study. competing interests: the authors have declared that no competing interests exist. ethics statement: the present study will be performed in line with ethical standards and has been approved by the medical ethics committee of the university of freiburg (22-1518-s2). reporting guidelines: this study was reported following the consort 2010 statement (schulz et al., 2010). preregistration: the study is registered at the german clinical trials register (drks; registration number: drks00031495). data availability: upon completion of recruitment and data analysis, the data of the presented study will be made available via the open science framework. alternatively, data will be made available by the authors on reasonable request. supplementary materials the supplementary materials contain the preregistration for the study (see endres et al., 2023s). index of supplementary materials endres, a., schaich, a., arntz, a., fassbinder, e., & renner, f. 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endres, schaich, arntz et al. 21 clinical psychology in europe 2025, vol. 7(4), article e16709 https://doi.org/10.32872/cpe.16709 https://www.psychopen.eu/ imagery rescripting in cbt for depression (introduction) method design participants sample size recruitment therapists introduction session (baseline) randomization duration of the study measures experimental condition: imrs control condition: mental imagery relaxation condition data analyses exploratory analyses discussion (additional information) funding acknowledgments competing interests ethics statement reporting guidelines preregistration data availability supplementary materials references dissociative experiences and substance use disorder in adulthood after childhood trauma: a systematic review of the literature systematic reviews and meta-analyses dissociative experiences and substance use disorder in adulthood after childhood trauma: a systematic review of the literature cory julien 1 , laura bernard 1 , vincent brejard 1 [1] department of clinical psychology, aix-marseille university, lpcpp, ur 3278, aix-en-provence, france. clinical psychology in europe, 2025, vol. 7(4), article e15877, https://doi.org/10.32872/cpe.15877 received: 2024-10-20 • accepted: 2025-05-12 • published (vor): 2025-11-28 handling editor: simone munsch, university of fribourg, fribourg, switzerland corresponding author: cory julien, 29 avenue robert schuman 13100 aix-en-provence, france. e-mail: julien.cory2@gmail.com supplementary materials: data [see index of supplementary materials] abstract context: childhood trauma is more prevalent among individuals with substance use disorders compared to the general population, representing a significant public health concern. the presence of comorbid dissociative symptoms poses a significant challenge for psychological care. objectives: we conducted a systematic review of the literature, using the prisma method, to establish the relationship between dissociative experiences and substance misuse in adults who have experienced traumatic childhood events. method: we used electronic databases (pubmed, psycinfo, psycarticles, web of science and proquest) up to august 2023. studies were selected which included adults over 18 years old who had been exposed to one or more traumatic events in childhood, and which jointly assessed substance use disorder (sud) and dissociation, using quantitative methodology. the review included both cross-sectional and longitudinal studies, with the risk of bias assessed using the axis tool and the qualitative assessment tool for observational cohort and cross-sectional studies. the results are entered in a table and analyzed using a narrative summary. results: among the 18 included studies, encompassing a total of 6,451 participants, the majority (n = 10) showed a significant positive correlation between dissociative experiences and sud. the studies collectively indicate a general trend: childhood traumatic antecedents can influence the severity of dissociative symptomatology and sud. discussion: these results are discussed in greater depth in relation to the two main theories explaining the link between sud and dissociation, namely self-medication and chemical dissociation this is an open access article distributed under the terms of the creative commons attribution 4.0 international license, cc by 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.15877&domain=pdf&date_stamp=2025-11-28 https://orcid.org/0000-0002-8562-2348 https://orcid.org/0000-0002-3858-5783 https://orcid.org/0000-0003-1344-0489 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ theory. this paper clarifies the relationship between dissociation and substance use in a population traumatized in childhood, although the heterogeneity of the studies necessitates a cautious interpretation of this primary finding. keywords childhood trauma, c-ptsd, dissociation, substance use disorder, adults highlights • early traumatic experiences are a high-risk factor for substance use disorder in adulthood. • the more frequent the dissociative experiences are, the more severe the substance use tends to be. • substance abuse in individuals with traumatic childhood could be explained by chemical dissociation theory. context childhood trauma is more prevalent among individuals with substance use disorders compared to the general population (garami et al., 2019; scheidell et al., 2018). the cumulative nature of childhood traumatic experiences and their impact on the severity of traumatic symptoms and the onset of substance use disorders represents a significant public health concern (zhang et al., 2020). exposure to verbal, physical or sexual abuse or neglect during childhood can lead to the subsequent development of physiological, psychological and neurological disorders in adulthood (dye, 2018; gupta, 2013; kratzer et al., 2022). the adverse childhood experience study (felitti et al., 1998) has already highlighted the impact of stressful childhood experiences on the adult lives of these individuals. this population general­ ly presents more comorbidities in adulthood, including addiction, depression, suicide attempts, endangerment and somatic illnesses (felitti et al., 1998; rogerson et al., 2023), which can lead to premature death. children who have experienced sexual trauma are the population with the most post-traumatic symptoms (study conducted on children and adolescents aged between 8 and 17, lofthouse et al., 2024). these symptoms, identified by the diagnostic term post-traumatic stress disorder (ptsd) as described in the dsm-5, include intrusion, persistent avoidance associated with the event, alterations in cognition and mood, and changes in arousal persist for more than a month (american psychiatric association, 2013). when exposure to the event is prolonged or repetitive, as is often the case with childhood traumatic experiences, other disorders may emerge involving all the criteria of ptsd just cited, but also affect/emotion regulation disorders, a sense of being diminished, coupled with feelings of shame and guilt, as well as difficulties maintaining chemical dissociation after childhood trauma 2 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ relationships (who, 2019): this condition is referred to as complex post-traumatic stress disorder (c-ptsd). individuals who experience potentially traumatic events in childhood, such as those previously mentioned, are more likely to present high levels of dissociative symptoms (fung et al., 2023; gobin & freyd, 2017). this dissociative symptomatology can manifest as depersonalization, derealization and partial or total traumatic amnesia (nijenhuis et al., 1996). the traumatic model of dissociation (dalenberg & carlson, 2012) suggests that it functions as an adaptative mechanism, according to pavlov's classical conditioning theory from 1903 (lam et al., 2024). dissociation is considered as a defense mechanism occurring preconsciously (kennedy et al., 2004). thus, dissociation, initially experienced during early traumatic experiences, continues to be used as an emotional self-regulation strategy in response to intense emotions (lam et al., 2024; smith, 2021). research on the psychopathological interactions between dissociative mechanisms and trauma is ongoing and expanding in the literature. however, when this comorbidity is present, aggravated symptomatology is clinically observed: greater symptoms of reliving (burton et al., 2018), high rates of psychiatric comorbidities (herzog et al., 2020), feelings of personal devaluation and diminished well-being (bateman et al., 2024), higher levels of substance use (thal et al., 2019). however, the presence of the dissociative mechanism predicts an unfavorable prognosis for the improvement of traumatic symptomatology during its management (ginzburg et al., 2006). various theories have attempted to explain the comorbid onset of substance use, such as biopsychosocial or biomedical models, which conceptualize addiction in its multiface­ ted nature (skewes & gonzalez, 2013; volkow et al., 2016). in clinical psychopathology, khantzian (1997) theorized the self-medication theory. substances are used to regulate negative affects that cannot be regulated by the individual and his or her personal resources. this theory has been further developed by other authors, who hypothesize that the psychotropic effects of substances could regulate negative post-traumatic affects, that individuals are unable to control (bordieri et al., 2014; kearns et al., 2019; simpson et al., 2014). each substance appears to regulate specific behaviors or affects in individuals with emotional regulation problems and maladaptive behaviors: opiates would seem to act on intense and violent affects, alcohol would reduce depressive symptoms such as isolation, and stimulants would reduce hyperactivity. however, this theory does not account for dissociative experiences. another hypothesis is proposed by somer et al. (2010), entitled the chemical dissoci­ ation theory, which posits that the effects of substances on psychological functioning enable the maintenance of the dissociative mechanism. somer's original study focuses on opioid use as a coping strategy when individual regulatory strategies are insufficient. consequently, dissociative experiences stemming from childhood trauma appear to be perpetuated into adulthood through the use of various drugs or alcohol (romano, 2015). julien, bernard, & brejard 3 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ early traumatic experiences therefore represent a risk factor for several comorbidities in adulthood, notably sud (blanco et al., 2020). the frequent co-occurrence of these three clinical disorders – traumatic childhood experiences, dissociation and sud – complicates psychotherapeutic management (bellet & varescon, 2019; camille, 2022). while previous research has extensively explored the comorbidity between ptsd and sud, the specific role of dissociative experiences in this relationship, particularly in individuals with a history of childhood trauma, remains un­ clear. to our knowledge, no systematic review has synthesized the evidence addressing this triad. the aim of this systematic review is to identify the links between dissociative experiences and sud in adults who have experienced childhood trauma. confirming these links is crucial for optimizing therapeutic care. the therapeutic management of these two concomitant disorders is still being debated in the literature, particularly regarding sequential or integrated treatment. the recent meta-analysis by hien et al. (2024) has demonstrated that sud and ptsd can be treated simultaneously (baker et al., 2012), leading us to question the place of dissociative symptomatology. incorporating dissociation into the treatment of these two disorders may prove beneficial if this review supports the existence of a relationship. method search strategy the study followed the preferred reporting items for systematic reviews and metaanalyses (prisma) guidelines and a prisma flow chart (page et al., 2021) the prisma method facilitates the writing and reading of systematic literature reviews and metaanalyses by providing 27 methodological points to follow. our article inclusion strategy followed the picots framework. the excel of eligible articles is publicly available at the osf (julien et al., 2024s). the bibliographic search was conducted on the following databases: pubmed, psycin­ fo, psycarticles, web of science and proquest, with the following keywords defined according to the medical subject headings (mesh): (substance-related disorders or chemical dependence or drug abuse or drug use disorders or substance addiction or substance use or substance use disorders) and (post traumatic stress disorder or posttraumatic stress disorder or ptsd or moral injury or chronic post traumatic stress disorder or trauma) and (dissociative disorders or dissociation or dissociative reactions). filters were: "english", "2014-2023", "adults", "articles". these keywords and filters were applied across the five databases mentioned, following the prisma method. the complete search chain comprises all these elements for each database. we opted to use keywords related to ptsd rather than childhood aversive experien­ ces based on tests conducted in our databases. using ptsd-related keywords allowed chemical dissociation after childhood trauma 4 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ us to access studies that consider childhood aversive experiences, which are often men­ tioned in the abstract rather than the title. study selection inclusion and exclusion criteria studies were included if they: (a) assessed adults who have experienced a traumatic event in childhood, (b) jointly assessed the variables childhood trauma, sud and dissociation, (c) presented comparisons with control groups, community samples as well as inpatient and outpatient clinical samples, (d) had a quantitative methodology, (e) were published in english. manuscripts and doctoral theses were excluded. the period of publication of these articles was between january 2014 and march 2023. this time frame was selected based on an assessment of the number of publications on psychological trauma in pubmed. the number of publications increases significantly from 2014 onwards, as indicated by the ‘results by year’ graph. the 2014 limit also allows us to concentrate on the last ten years in order to report on the most recent research on the subject. studies were excluded if they: (a) did not indicate the period in which trauma events were experienced (the traumatic event must have occurred in childhood), (b) dealt with the dissociative identity disorder, (c) dealt with behavioral addictions, (d) studied the ef­ fects of alcoholization in experimental situations, (e) reported on methadone substitution treatment. screening process articles were transferred to a zotero (2019) folder when the title appeared to meet our objective. utilizing its google chrome extension, zotero enabled us to save all relevant articles directly into a dedicated folder, facilitating quick access, sorting according to our inclusion and exclusion criteria by creating different sub-folders, and better identification of duplicates. subsequently, selection was performed based on abstracts. to be selected, abstracts had to present a population that had experienced childhood trauma and at least mention our two target variables, i.e., dissociation and substance misuse. finally, the articles retained were read in their entirety, refining the final selection stage. two investigators (cj and lb) carried out this selection independently. additionally, a bibliographic monitoring was established from the screening process to keep authors updated with new publications on the subject. each data base was last consulted in august 2023. the third investigator was called upon in the event of disagreement (vb). the publication search and search strategy are presented in a flowchart (figure 1). julien, bernard, & brejard 5 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ figure 1 flowchart of search strategy fig 1: flowchart of search strategy records identified from: databases (n = 5) registers (n = 1,339) records removed before screening: records marked as ineligible by automation tools (n = 847) duplicates removed (n = 52) records screened (n = 358) reports sought for retrieval (n = 113) reports assessed for eligibility (n = 68) records excluded after title screening (n = 245) reports not retrieved after abstract screening (n = 45) reports excluded: reason 1: irrelevant (n = 20) reason 2: do not indicate the period in which the trauma was experienced (n = 19) reason 3: minors included (n = 2) reason 4: drugs induced (n = 2) reason 5: qualitative studies (n = 7) studies included in review (n = 18) id en tif ic at io n sc re en in g in cl ud e data extraction the investigators developed a standardized data extraction file to compile all the essen­ tial information from the included publications: authors and year of publication, study location, sample characteristics, methodology used and main results relevant to our ob­ chemical dissociation after childhood trauma 6 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ jective (table 1). one investigator (cj) extracted the data, which were then independently verified by another investigator (vb). the selected results pertained to the link between dissociative experiences and substance use and were documented in an excel file. study risk of bias assessment the risk of bias inherent in each study was measured using the axis questionnaire for cross-sectional studies (n = 17; downes et al., 2016) and the quality-assessment-tool-forobservational-cohort-and-cross-sectionnal-studies questionnaire for longitudinal study (n = 1). axis and quality-assessment-tool questionnaires assessed the quality of studies through 20 and 12 questions respectively, which can be answered with “yes”, “no” or “i don't know”, on the clarity of objectives, method, results and discussion. results are presented in figures 2 and 3. the principal investigator carried out this risk of bias assessment (cj) and check by another researcher (vb). figure 2 results of studies’ limits according to the axis tool for cross-sectional design risk of bias fig 2: results of studies’ limits according to the axis tool for cross-sectional design risk of bias 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% abolmaged et al., 2018 altintas et al., 2018 baudin et al., 2022 blanco et al., 2020 boughner et al., 2016 chana et al., 2021 craparo et al., 2014 diasy et hien, 2014 evren et al., 2017 güleç et al., 2014 hoktem et al., 2021 klanecky et al., 2016 laoide et al., 2017 mergler et al., 2017 patel et al., 2022 schimmenti et al., 2022 somer et al., 2019 yes no don't know julien, bernard, & brejard 7 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ figure 3 results of study’ limits according to the qualitative assessment tool observational cohort and cross-sectional studies fig 3: results of study’ limits according to the qualitative assessment tool observational cohort and cross-sectional studies 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% young et al., 2017 yes no don't know results characteristics of included studies a total of 1,339 studies were identified by the five databases mentioned. 52 duplicate arti­ cles were removed, and only 358 articles were retained after filtering. the first filtering by title revealed 113 eligible articles; the second after reading of abstracts admitted 68 eligible articles. a total of 18 studies were finally included in this systematic literature review (for total of 6,451 participants): after full reading, some articles were found to be off-topic (n = 20), others to have no specification of the period in which trauma events were expe­ rienced (n = 19), to have included minors (n = 2), to have admitted researcher-induced substance use (n = 2), or to have been qualitative studies (n = 7). these results are presented in table 1. the 18 included studies were all published between 2014 and 2022, conducted in canada, egypt, france, germany, ireland, israel, italy, spain, turkey and the usa. sample heterogeneity was observed, encompassing incarcerated individuals, inpatients or outpatients from addictology and/or psychotraumatology units, students, community or homeless people. psychiatric diagnoses also varied (borderline personality, mood disorder, sud, dual disorder, etc.). the studies featured an almost equal ratio of men to women (55% women to 45% men). half of the included studies (n = 9) focused on a specific sample, while the other half (n = 9) made a group comparison, between subgroups or using a control group. the studies were mainly cross-sectional (n = 17), with only the young et al. (2017) being longitudinal, with a session every six months for three years focusing on homeless or unstably housed women. chemical dissociation after childhood trauma 8 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ ta bl e 1 in cl ud ed s tu di es a ut ho r/ ye ar c ou nt ry sa m pl e m et ho ds /m ea su re m en ts r es ul ts g ro up s m (sd ) a ge g en de r q ue st io nn ai re s ti m e pa ra di gm 1. a bo lm ag ed e t a l., 2 01 8 eg yp t g ro up a : p at ie nt s bp d (n = 4 0) g ro up b : p at ie nt s bd p + su d (n = 4 0) 24 .5 5 (6 .7 7) 31 .3 0 (1 1. 01 ) 10 0% o f w om en sc id i sc id ii bp d si -i v c tq d es si ng le s es si on g ro up a = d is so ci at iv e ex pe ri en ce s gr ea te r th an g ro up b . 2. a lti nt as & b ili ci , 2 01 8 tu rk ey pr is on in m at es (n = 2 00 ) 18 -6 5 ye ar s 50 % o f w om en in te rv ie w s c tq -2 8 d es si ng le s es si on n o di re ct li nk b et w ee n su d a nd di ss oc ia tio n. 3. b au di n et a l., 2 02 2 fr an ce pa tie nt s ho sp ita liz ed in re ha bi lit at io n ce nt er s (n = 5 68 ) 44 .5 (9 .0 ) 15 .3 % o f w om en c tq d es a u d bd i st a i pc l5 si ng le s es si on tw o w ee ks a ft er d et ox pe ri od su bj ec ts w ith h ig h di ss oc ia tio n + su d = m or e se ve re s u d , d ep re ss io n, an xi et y an d tr au m at ic s ym pt om s, m or e ch ild ho od tr au m a. 4. b la nc o et a l., 2 02 0 sp ai n h os pi ta liz ed p at ie nt s (n = 1 50 ) • d ua l d is or de r n = 10 0 • o nl y su d n = 5 0 44 (1 0) 38 % o f w om en sd s eg ep -5 c tq d es t he h ol m es -r ah e li fe s tr es s in ve nt or y d d si pr is m h d rs ym rs bp rs si ng le s es si on a ft er in iti al d et ox p er io d n o si gn if ic an t c or re la tio n be tw ee n su d a nd di ss oc ia tio n. julien, bernard, & brejard 9 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ a ut ho r/ ye ar c ou nt ry sa m pl e m et ho ds /m ea su re m en ts r es ul ts g ro up s m (sd ) a ge g en de r q ue st io nn ai re s ti m e pa ra di gm 5. b ou gh ne r & f re w en , 20 16 u sa g ro up a : o nl in e pa tie nt s (n = 5 13 ) g ro up b : c lin ic al s am pl e (n = 1 2) to ta l n = 5 25 34 .3 9 (1 1. 18 ) 54 % o f w om en (g ro up a ) 98 % o f m en (g ro up b ) le c -5 a c e pc l5 ss isa pc r sc al in g a ss is t si ng le s es si on c or re la tio n ss isa – d is so ci at io n: o nl in e sa m pl e (f em al es ): r = .1 78 ; p < .0 1 o nl in e sa m pl e (m al es ): r = .2 71 ; p < .0 1 c lin ic al s am pl e (m al es ): r = -. 02 1; n s 6. c ha na e t a l., 2 02 1 u sa w om en p ri so ne rs (n = 5 08 ) 42 .3 3 (1 1. 71 ) 10 0% o f w om en be tr ay al tr au m a tr au m a sy m pt om s c he ck lis t 4 0 a u d it d a st -1 0 si ng le s es si on a u d – d is so ci at io n: r = .0 2; n s su d – d is so ci at io n: r = .2 1; p < .0 1 7. c ra pa ro e t a l., 2 01 4 it al y o ut pa tie nt s pr og ra m fo r al co ho lde pe nd en ce (n = 2 34 ) c on tr ol g ro up (n = 1 17 ) ta rg et g ro up = 44 .8 5 (9 .9 4) c on tr ol g ro up = 43 .9 8 (9 .5 7) 60 m en a nd 5 7 w om en in e ac h gr ou p d es -i i ta s20 t ec si ng le s es si on g ro up a u d : c or re la tio n ch ild ho od tr au m a di ss oc ia tio n r = .2 2; p < .0 5 c on tr ol g ro up : r = .3 9; p < .0 1 8. d ai sy & h ie n, 2 01 4 u sa in ne r ci ty w om en (n = 1 48 ) 32 .8 (7 .9 ) 10 0% o f w om en d em og ra ph ic a nd t re at m en t h is to ry f or m sc id c tq c hi ld ho od s ex ua l a bu se in te rv ie w c t spa rt ne r d es si ng le s es si on c or re la tio n su d – d is so ci at io n st an da rd iz ed b et a = .3 4; p < .0 01 = > r = .8 4 9. e vr en e t a l., 2 01 7 tu rk ey in pa tie nt s w ith s ub st an ce u se di so rd er (n = 1 90 ): • g ro up 1 : n o ri sk (n = 5 1) • g ro up 2 : l ow r is k (n = 8 6) • g ro up 3 : h ig h ri sk (n = 5 3) 45 .1 8 (1 0. 68 ) 44 .3 5 (1 0. 41 ) 44 .7 7 (9 .5 1) 10 0% o f m en bd i a sr s c tq -2 8 d es si ng le s es si on 3 -4 w ee ks a ft er th e la st da y of d ri nk in g c or re la tio n a u d – d is so ci at io n: r2 = .3 74 ; p < .0 01 = > r = .6 12 chemical dissociation after childhood trauma 10 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ a ut ho r/ ye ar c ou nt ry sa m pl e m et ho ds /m ea su re m en ts r es ul ts g ro up s m (sd ) a ge g en de r q ue st io nn ai re s ti m e pa ra di gm 10 . g ül eç e t a l., 2 01 4 tu rk ey in pa tie nt s w ith c on ve rs io n di so rd er (n = 9 4) : • g ro up 1 : s ui ci de a tt em pt s (+ ; s a ) n = 3 3 • g ro up 2 : s ui ci de a tt em pt s (; n sa ) n = 6 1 • h ea lth y co nt ro l (n = 5 0) 30 .3 3 (1 0. 71 ) 30 .8 2 (1 0. 83 ) 34 .6 4 (1 1. 94 ) 85 % o f w om en sc id -i bd i ba i ta s20 c tq -2 8 d es tc i si ng le s es si on n o di re ct li nk b et w ee n su d a nd di ss oc ia tio n. 11 . h ok te m e t a l., 2 02 1 tu rk ey u ni ve rs ity s tu de nt (n = 3 00 ) g ro up 1 822 y ea rs an d gr ou p 22 -2 5 ye ar s 14 5 w om en o n 30 0 c tq d es a u d it d u d it si ng le s es si on c or re la tio n a u d it -d es : r = .4 86 ; p < .0 1 c or re la tio n d u d it -d es : r = .5 52 ; p < .0 1 12 . k la ne ck y et a l., 2 01 6 u sa u ni ve rs ity s tu de nt s (n = 2 13 ) 19 .5 6 (1 .1 2) 63 .4 % o f m en a u d it d er s d es -i i et isr -s f pc lc si ng le s es si on c or re la tio n a u d it -d es : r = .3 68 ; p < .0 1 13 . ó l ao id e et a l., 2 01 8 ir la nd m ed ia a nd p re ss p ar tic ip an ts (n = 7 61 ) 21 .4 6 (2 .4 5) 69 .6 % o f w om en c tq c d s ec rrs a ee d a ss -2 1 si ng le s es si on d ru gs a nd d et ec tio n of d p o r = 0. 90 → r = -.0 29 ; ns 14 . m er gl er e t a l., 2 01 7 g er m an y in pa tie nt s (n = 3 37 ) a nd o ut pa tie nt s (n = 1 22 ) f ro m a dd ic tio n ce nt er s 36 .7 (1 1. 2) 59 .7 % o f m en id c l pd s d es c tq eu ro pa si si ng le s es si on a ss oc ia tio n of th e tw o gr ou ps ar ou nd th e su d : o r = 0. 87 8; n s → r = -.0 36 15 . p at el e t a l., 2 02 2 c an ad a 33 4 in pa tie nt s ca re fo r pt sd 44 .2 9 (9 .7 7) 50 % o f w om en pc l5 m d i a u d it d er s a c es si ng le s es si on d is so ci at io n – a lc oh ol r el at ed pr ob le m : r = .1 84 ; p < .0 5 julien, bernard, & brejard 11 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ a ut ho r/ ye ar c ou nt ry sa m pl e m et ho ds /m ea su re m en ts r es ul ts g ro up s m (sd ) a ge g en de r q ue st io nn ai re s ti m e pa ra di gm 16 . s ch im m en ti et a l., 2 02 2 it al y 10 40 c om m un ity -d w el lin g ad ul ts 29 .5 5 (1 1. 37 ) 67 % o f w om en c tq -s f d es -t le ve l2 -s ub st an ce u se -a du lt si ng le s es si on c or re la tio n pa th ol og ic al di ss oc ia tio n – se ve ri ty o f s ub st an ce us e: r = .3 6; p < .0 01 17 . s om er e t a l., 2 01 9 is ra el re co ve ri ng p at ie nt s rsu d (n = 1 00 ) c on tr ol g ro up (n = 8 0) 40 .2 41 .9 10 0% o f m en c tq d es m d s16 si ng le s es si on rsu d a nd d is so ci at io n: d = 0 .5 0; p < .0 01 → r = .2 43 18 . y ou ng e t a l., 2 01 7 u sa h om el es s or u ns ta bl y ho us ed w om en (n = 3 00 ) 46 .9 9 (8 .6 2) 10 0% o f w om en se ve ri ty o f v io le nc e a ga in st w om en s ca le s d es d is o ne s es si on e ve ry 6 m on th s fo r 3 ye ar s (7 ti m e po in ts ) n o di re ct li nk b et w ee n su d a nd di ss oc ia tio n. n ot e. b pd : b or de rl in e pe rs on al ity d is or de r; s u d : s ub st an ce u se d is or de r; r -s u d : r ec ov er in g fr om s ub st an ce u se d is or de r; d p: d ep er so na liz at io n; a u d : a lc oh ol us e di so rd er ; s a : s ui ci de a tt em pt s. q ue st io nn ai re s: s c id : s tr uc tu re d cl in ic al in te rv ie w fo r d sm -i v (a xi s i a nd ii ); bp d si : b or de rl in e pe rs on al ity d is or de r se ve ri ty in de x; c tq : c hi ld ho od tr au m at ic q ue st io nn ai re ; d es : d is so ci at iv e ex pe ri en ce s ca le ; b d i: be ck d ep re ss io n in ve nt or y; s ta i: st at etr ai t a nx ie ty in ve nt or y; pc l: p t sd c he ck lis t; sd s: s ev er ity o f d ep en da nc e sc al e; e g ep : g lo ba l a ss es sm en t o f p os tt ra um at ic s tr es s q ue st io nn ai re ; d d si : d ua l d ia gn os tic s cr ee ni ng in te rv ie w ; p r is m : p sy ch ia tr ic r es ea rc h in te rv ie w fo r su bs ta nc e an d m en ta l d is or de rs ; h d r s: h am ilt on d ep re ss io n ra tin g sc al e; y m r s: y ou ng m an ia r at in g sc al e; b pr s: b ri ef p sy ch ia tr ic r at in g sc al e; l ec : l ife tim e ev en ts c he ck lis t; a c e: a dv er se c hi ld ho od e xp er ie nc e; s si -s a : s im pl e sc re en in g in st ru m en t f or su bs ta nc e a bu se ; p c r : p er ce iv ed c au sa l r el at io ns ; a ss is t: a lc oh ol , s m ok in g, a nd s ub st an ce in vo lv em en t s cr ee ni ng t es t; a u d it / d u d it : a lc oh ol / d ru g u se d is or de r id en tif ic at io n te st ; d a st : d ru g a bu se s cr ee ni ng t es t; ta s: t or on to a le xi th ym ia s ca le ; t ec : t ra um at ic e xp er ie nc e c he ck lis t; c ts -p ar tn er : c on fli ct t ac tic s sc al epa rt ne r ve rs io n; a sr s: a du lt at te nt io nde fi ci t/ hy pe ra ct iv ity d is or de r se lfre po rt s ca le ; b a i: be ck a nx ie ty in ve nt or y; t c i: te m pe ra m en t an d c ha ra ct er in ve nt or y; d er s: d iff ic ul tie s in e m ot io n re gu la tio n sc al e; e ti -s r -s f: e ar ly t ra um a in ve nt or y – se lf re po rt – s ho rt f or m ; c d s: c am br id ge d ep er so na liz at io n sc al e; e c r -r s: e xp er ie nc es in c lo se r el at io ns hi ps – r el at io ns hi p st ru ct ur es q ue st io nn ai re ; a ee : a tt itu de s to w ar d em ot io na l e xp re ss io n; d a ss : d ep re ss io n, a nx ie ty a nd s tr es s sc al e; id c l: in te rn at io na l d ia gn os tic c he ck lis t; pd s: p os tt ra um at ic d ia gn os tic s ca le ; a si : a dd ic tio n se ve ri ty in de x; m d i: m ul tis ca le d is so ci at io n in ve nt or y; a c es : a dv er se c hi ld ho od e xp er ie nc e sc al e; m d s: m al ad ap tiv e d ay dr ea m in g sc al e; d is : d ia gn os tic in te rv ie w s ch ed ul e. chemical dissociation after childhood trauma 12 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ assessment tools used dissociative symptoms were assessed in the majority of studies (n = 13) by the dissocia­ tive experience scale (des), focused on various dissociative events in the participant's daily life. one study used another version of the des, the dissociative experience scale-taxon (des-t; schimmenti et al., 2022), including so-called pathological dissocia­ tion. the remaining five studies used the multiscale dissociation inventory (mdi; patel et al., 2022), the ptsd checklist for dsm-5 (pcl-5; boughner & frewen, 2016), the cambridge depersonalization scale (cds; ó laoide et al., 2018), or the trauma symptom checklist-40 (tsc; chana et al., 2021). childhood traumas were assessed by the childhood trauma questionnaire (ctq) in most studies (n = 12), including emotional, physical and sexual abuse, as well as physical and emotional neglect. the remaining studies used the adverse childhood experiences questionnaire (ace; boughner & frewen, 2016; patel et al., 2022); the traumatic experi­ ences checklist (tec; craparo et al., 2014); the early trauma inventory – self report – short form (eti-sr-sf; klanecky et al., 2016); the severity of violence against women scale (young et al., 2017); and the childhood experiences of violence questionnaire combined with questions chosen and created by the authors (chana et al., 2021). finally, substance use was generally identified by self-report and/or urine testing (n = 8). five studies used the alcohol use disorder test (audit; baudin et al., 2022; chana et al., 2021; hoktem et al., 2021; klanecky et al., 2016; patel et al., 2022). the study by hoktem et al. (2021) also combined the audit with the drug use disorder identification test (dudit), and another study, chana et al. (2021) combined the audit with the drug abuse screening test (dast). the other studies’ assessment tools were more heterogeneous: the severity of dependence scale (sds; blanco et al., 2020); the simple screening instrument for substance abuse (ssi-sa; boughner & frewen, 2016); and the level 2-substance use-adult (schimmenti et al., 2022). two studies assessed sub­ stance use disorders with a semi-structured interview: the structured clinical interview for dsm-iv (scid; daisy & hien, 2014) and the european addiction severity index (europasi; mergler et al., 2017). the substances covered in these articles, listed in six studies, include hallucinogens or disruptors (such as cannabis and ecstasy), depressants (heroin), stimulants (ampheta­ mines, cocaine, methamphetamine), inhalants, opiates and opioids, sedatives (such as benzodiazepines) and nicotine. correlations among dissociation, sud and traumatic events in childhood of the 18 studies identified for this review, only 12 provided quantitative data on the link between dissociation and substance use disorder in adults with childhood psychotrauma. due to considerable heterogeneity among the studies, a meta-analysis could not be julien, bernard, & brejard 13 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ conducted, as it was uncorrected by various moderators tested (e.g. socio-demographic data, clinical or non-clinical population). only the three studies by ó laoide et al. (2018), mergler et al. (2017), and the male clinical subgroup of the boughner and frewen (2016) study showed a negative correla­ tion between dissociation and substance misuse in their respective study populations. these correlations (respectively r = -0.029, r = -0.036 and r = -0.021) were, however, very weak, non-significant with a negligible effect size according to cohen's criteria. significant positive correlation coefficients were found in 10 studies. only two sub­ groups did not have significant effect sizes: the alcohol subgroup in chana et al. (2021) study and the male clinical subgroup in boughner and frewen (2016) study. thus, effect sizes were greater in studies highlighting positive correlations, with correlation coeffi­ cients ranging from r = 0.178; p < .01 (boughner & frewen, 2016) to r = 0.552; p < .01 (hoktem et al., 2021). for the remaining studies, the authors documented direct links between traumatic events in childhood and dissociative experiences and/or traumatic events in childhood and sud, without specifically highlighting a direct link between dissociation and sud (altintas & bilici, 2018; güleç et al., 2014; young et al., 2017). blanco et al. (2020) acknowledged that the correlation between dissociation and sud was not significant, without mentioning its value. abolmaged et al. (2018) observed that participants with borderline personality disorder and sud had fewer dissociative experiences than the group with substance use disorder only. the authors attempted to explain this outcome in terms of cognitive disorders potentially associated with substance use, making it difficult to identify dissociative symptomatology when it occurs. however, we could also consider the use of substances and the objectives sought in this context, particularly regarding emotional dysregulation, which can be identified both in this personality dis­ order and in substance users. finally, baudin et al. (2022) noted that higher dissociative experiences among study participants were associated with more severe sud. while most studies acknowledged a positive link between dissociation and sud, a minority could not demonstrate a significant correlation. finally, four studies in this review highlighted a mediating effect of dissociation on the link between adverse childhood experience and substance use (boughner & frewen, 2016; klanecky et al., 2016; patel et al., 2022; schimmenti et al., 2022). in the study by chana et al. (2021), this result was discussed in terms of confusing the subjective experience of dissociative symptoms and substance use: in some cases, the experience of taking drugs can be like the experience of dissociation. the authors therefore recom­ mend that future studies include a qualitative interview to address this limitation when administering dissociation questionnaires. studies by baudin et al. (2022), blanco et al. (2020), evren et al. (2017) and mergler et al. (2017) highlighted the high prevalence of anxiety and depression-type comorbidities among subjects with traumatic childhood experiences, sud and dissociative experiences. chemical dissociation after childhood trauma 14 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ general trend in studies and consideration of heterogeneous data most of the studies included in this review focused on clinical populations (n = 9), particularly patients hospitalized for substance use or ptsd. the general trend revealed by these studies is that traumatic childhood experiences are associated with more severe dissociative symptoms and other severe comorbidities (traumatic, anxiety and depressive symptoms), compared to those without aversive childhood experiences (baudin et al., 2022; blanco et al., 2020; boughner & frewen, 2016; patel et al., 2022; somer et al., 2019). only mergler and collaborators (2017) did not find these results in the population treated for sud: when comparing a group of patients with dissociative symptoms and those without: there was no difference in alcohol consumption or in the history of childhood trauma (although the questionnaires used were the same as those used in previous studies). in short, whether or not the dissociative mechanism was present, or whether or not a traumatic history was present, the proportion of drug or alcohol use was the same. however, these results seem logical given the population studied, i.e. patients in a sud treatment center, who therefore have an addiction deemed severe enough to benefit from follow-up in a specialized center. this general tendency for our three variables to be intertwined is also evident in the prison population (altintas & bilici, 2018; chana et al., 2021), particularly when sud and dissociative experiences are associated with traumatic childhood experiences. more surprisingly, the same pattern of results has been found in general populations where traumatic childhood events can be identified (boughner & frewen, 2016; daisy & hien, 2014), especially in the university student population (hoktem et al., 2021; klanecky et al., 2016). however, studies among students focused on alcohol consumption only and not on drug use. the only study focusing on a general population and drug use (ó laoide et al., 2018) reports that depersonalization is closely linked to drug use, including co­ caine, ecstasy, heroin or cannabis, and non-prescription drugs such as benzodiazepines. depersonalization is identified as a marker of a childhood history of emotional and physical neglect (schimmenti et al., 2022). identifying the different types of traumatic childhood events experienced by subjects in each study is challenging. the extensive use of questionnaires such as the childhood trauma questionnaire (ctq) allows us to consider emotional and physical neglect, as well as emotional, physical and sexual abuse. physical abuse in childhood appears to be one of the most significant predictors of dual pathology (somer et al., 2019). additionally, sexual violence in childhood increases the likelihood of re-exposure to sexual and physi­ cal violence in adulthood, presenting a potential risk of revictimization according to the study of young et al. (2017). however, these results must be interpreted with caution, as this study focuses on a population of homeless women, whose precarious situation may increase their risk of experiencing violence. julien, bernard, & brejard 15 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ discussion this systematic review is the first to examine the impact of dissociative experiences on substance use in individuals with a history of childhood trauma. most of included studies support a positive correlation with substance use, suggesting that greater disso­ ciative experiences are associated with more severe substance use. articles that did not report these positive correlations showed weak and non-significant results. four studies indicate that dissociation acts as a mediator between substance use and the severity of traumatic symptoms. this mediation is supported by the adaptive role of substance use as a coping strategy, which helps suppress intrusive symptoms related to the traumatic experience (hence the clarification of the contribution of self-medication theory) and influences the association between trauma exposure and substance use (boughner & frewen, 2016). the severity of traumatic symptoms is associated with an increase in dissociation symptoms, which in turn are linked to greater alcohol or substance use problems (patel et al., 2022). according to schäfer and colleagues (2010), studies that do not find a mediation between dissociation, trauma and substance use focused solely on physical and sexual abuse, neglecting other forms of trauma, like emotional abuse. it is therefore crucial to consider the nature of the traumatic event. the studies conducted on general populations, university populations or clinical population with ptsd, but did not specifically focus on population with sud. these findings were discussed in relation to the self-medication and the chemical dis­ sociation hypotheses, raising questions about the causal link between substance misuse, dissociative experiences and traumatic events in childhood. the self-medication theory posits that substance use regulates post-traumatic symp­ toms (khantzian, 1997), without considering dissociation. conversely, the chemical disso­ ciation theory suggests that substance use maintains the dissociative process. dissocia­ tion serves as a coping strategy, enabling individuals to psychologically survive traumat­ ic events and intense emotional reactions they have not learned to manage (lam et al., 2024). when dissociative experiences are insufficient, substances fill the gap. therefore, the self-medication and chemical dissociation hypotheses are not mutually exclusive: hoktem et al. (2021), klanecky et al. (2016) and güleç et al. (2014) explored the intertwining of these hypotheses in their studies. substance use helps cope with trauma by including chemical dissociation when dissociative capacities are inadequate and alleviating post-traumatic symptoms, notably by reducing negative affects such as anxiety and depression. in our view, the chemical dissociation theory extends the logic of self-medication. the intertwining of sud and dissociative experiences in adults who have experienced childhood trauma raises questions and opens up a field that needs further exploration. articles not included in this systematic review often had the same issue: they focused solely on the relationship between c-ptsd and substance misuse, or c-ptsd and dissociative experiences. in fact, analysis of the psychological processes involved in chemical dissociation after childhood trauma 16 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ complex trauma often fails to identify relationships between sud and dissociation. this review demonstrated the importance of identifying this under-researched link. other studies have focused on different clinical samples, not presenting traumatic events in childhood but showing results consistent with this review. for example, in the study by tsai et al. (2015), the authors focused on us veterans with wartime ptsd, with or without dissociative symptoms. the dissociative ptsd subgroup presented more severe traumatic symptoms, comorbid anxiety and depressive symptomatology, as well as more problematic alcohol use than the non-dissociative ptsd subgroup. this highlighted that the positive correlations between dissociative experiences and substance misuse can be maintained in other cases of complex trauma. future research would be interesting to analyze the possibility of this link in other types of traumatic events. the study by young et al. (2017) is unique in presenting results according to each drug listed in the sample. for instance, the authors note that stimulant use can be predicted by sexual violence experienced within six months, and that amphetamine use significantly increases the odds of being a victim of physical violence. other studies listing the drugs used by participants only address substance use disorder in general. it would be beneficial for future studies to mention results according to the specific drug consumed, as different drugs have varying psychological effects. limitations this systematic review of the literature had some limitations, both in its conception and in the original studies included. this review focuses on a specific population, namely adults who have experienced traumatic events in childhood. consequently, despite a rigorous and transparent research procedure, some research may not have been included because it does not specify the age at which the traumatic event occurred. additionally, the heterogeneous results observed may be due to differences between tools for measuring dissociation and substance use. due to this heterogeneity, we were unable to conduct a meta-analysis, despite controlling for moderating variables. then, all the articles included in this review were based on selfreports, which may introduce classic social desirability or symptom minimization biases. the studies also varied in terms of socio-demographic characteristics of the sample. finally, the majority of studies included in this review were cross-sectional, with only being longitudinal. therefore, the results may reflect individual dispositions associated with a one-session assessment rather than an evolutionary process. finally, dissociation has multiple assessment tools available, resulting an heterogeneity of assessment modal­ ities. dissociative symptomatology refers to a continuum ranging from everyday experi­ ences of dissociation to dissociative identity disorder. the various measures of dissocia­ tion presented in this review addressed dissociative experiences in subjects' daily lives, although the cambridge depersonalization scale (cds) refers only to depersonalization and not to derealization. the exclusion of studies dealing with dissociative identity julien, bernard, & brejard 17 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ disorder allowed us to focus on dissociative symptoms from peritraumatic dissociation, rather than dissociation as encountered in dissociative identity disorder. a challenge for future research will be to homogenize the different assessments of complex trauma and dissociation, to make research results comparable with each other. this literature review has highlighted the importance of examining the relationship between dissociation and substance use disorder in adults with a history of childhood trauma. it enhances our understanding of the comorbid relationship between these three clinical entities—trauma, dissociation, and substance use disorders—particularly regarding the role of substances as moderators to induce a dissociative state and mitigate traumatic symptomatology. this paper clarifies the relationship between dissociation and substance use in a population traumatized in childhood, a link seldom addressed in current literature, despite its crucial importance in psychotherapeutic treatment. the strength of this review lies in the integration of diverse samples, ranging from the general population to hospitalized patients, allowing for a broader generalization of the subject. future research should aim to confirm the theoretical model of substance misuse as both a means of self-medication and a reinforcing or maintenance of chemical dissociation. moreover, it is essential to clarify the nature of the relationship between dissociation, substance misuse and traumatic symptoms. the psychological effects of substances may fill a gap in dissociative processes or enable the re-experiencing of disso­ ciative experiences. this understanding will help clinicians develop models to conceptu­ alize these relationships and derive management strategies that consider the defensive function of substance use. implications for practice and research the literature already addresses the vicious circle maintained by problematic substance use and traumatic symptomatology, particularly with the term dual pathology. however, the impact of dissociation within this cycle is often overlooked. the severity of sud is exacerbated when dissociative symptomatology is present, which must therefore become a point of vigilance for therapists (caretti et al., 2018). dissociation not only aggravates traumatic symptomatology but also strengthens our understanding of the addictive pro­ file, which is now related to maladaptive functioning such as dissociation, emotional dys­ regulation, obsessive thoughts or separation anxiety (caretti et al., 2018). moreover, sud may influence the persistence and severity of dissociative symptomatology (wegen et al., 2017). these dissociative experiences are particularly present during acute withdrawal; dissociation and traumatic symptomatology being reported as higher from the first weeks of abstinence, particularly from alcohol and cocaine (coffey et al., 2007). dissocia­ tion is therefore an important point to consider during treatment, particularly through integrative care. in subjects with sud, dissociation followed by improvement in affect regulation skills could prevent relapse (wegen et al., 2017). however, future research will need to focus on these complex treatments, while psychotherapeutic treatments for chemical dissociation after childhood trauma 18 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://www.psychopen.eu/ comorbid disorders in dual pathology (ptsd and sud) are still under consideration and constitute a major public health issue. funding: this research was supported by a doctoral grant from the ministry of higher education, research, and innovation (mesri). acknowledgments: the authors have no additional (i.e., non-financial) support to report. competing interests: the authors have declared that no competing interests exist. ethics statement: ethical approval was not required for this review, as it involved the analysis of publicly available data. preregistration: preregistration was not performed. social media accounts: cory julien: linkedin reporting guidelines: this article was prepared following the prisma guidelines. data availability: the excel of eligible articles is available at the osf (julien et al., 2024s). supplementary materials the supplementary materials contain the excel of eligible articles (julien et al., 2024s). index of supplementary materials julien, c., bernard, l., & brejard, v. 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(2019). zotero (version 5.0.85) [computer software]. corporation for digital scholarship. https://www.zotero.org clinical psychology in europe (cpe) is the official journal of the european association of clinical psychology and psychological treatment (eaclipt). psychopen gold is a publishing service provided by the leibniz institute for psychology (zpid), germany. julien, bernard, & brejard 25 clinical psychology in europe 2025, vol. 7(4), article e15877 https://doi.org/10.32872/cpe.15877 https://doi.org/10.1037/tra0000288 https://doi.org/10.1016/j.psychres.2020.113524 https://www.zotero.org https://www.psychopen.eu/ chemical dissociation after childhood trauma (introduction) context method search strategy study selection results characteristics of included studies assessment tools used correlations among dissociation, sud and traumatic events in childhood general trend in studies and consideration of heterogeneous data discussion limitations implications for practice and research (additional information) funding acknowledgments competing interests ethics statement preregistration social media accounts reporting guidelines data availability supplementary materials references